Clinical Decision Support May Link Multiple Domains to Improve Patient Care: Viewpoint

Applying human-centered design to the construction of a cirrhosis management clinical decision support system

BACKGROUND

Electronic health record (EHR)-based clinical decision support is a scalable way to help standardize clinical care. Clinical decision support systems have not been extensively investigated in cirrhosis management. Human-centered design (HCD) is an approach that engages with potential users in intervention development. In this study, we applied HCD to design the features and interface for a clinical decision support system for cirrhosis management, called CirrhosisRx.

METHODS

We conducted technical feasibility assessments to construct a visual blueprint that outlines the basic features of the interface. We then convened collaborative-design workshops with generalist and specialist clinicians. We elicited current workflows for cirrhosis management, assessed gaps in existing EHR systems, evaluated potential features, and refined the design prototype for CirrhosisRx. At the conclusion of each workshop, we analyzed recordings and transcripts.

RESULTS

Workshop feedback showed that the aggregation of relevant clinical data into 6 cirrhosis decompensation domains (defined as common inpatient clinical scenarios) was the most important feature. Automatic inference of clinical events from EHR data, such as gastrointestinal bleeding from hemoglobin changes, was not accepted due to accuracy concerns. Visualizations for risk stratification scores were deemed not necessary. Lastly, the HCD co-design workshops allowed us to identify the target user population (generalists).

CONCLUSIONS

This is one of the first applications of HCD to design the features and interface for an electronic intervention for cirrhosis management. The HCD process altered features, modified the design interface, and likely improved CirrhosisRx's overall usability. The finalized design for CirrhosisRx proceeded to development and production and will be tested for effectiveness in a pragmatic randomized controlled trial. This work provides a model for the creation of other EHR-based interventions in hepatology care.

Clinical decision support and electronic interventions to improve care quality in chronic liver diseases and cirrhosis

Significant quality gaps exist in the management of chronic liver diseases and cirrhosis. Clinical decision support systems-information-driven tools based in and launched from the electronic health record-are attractive and potentially scalable prospective interventions that could help standardize clinical care in hepatology. Yet, clinical decision support systems have had a mixed record in clinical medicine due to issues with interoperability and compatibility with clinical workflows. In this review, we discuss the conceptual origins of clinical decision support systems, existing applications in liver diseases, issues and challenges with implementation, and emerging strategies to improve their integration in hepatology care.

Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay

OBJECTIVE

Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC).

RESEARCH DESIGN AND METHODS

Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis.

RESULTS

Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019).

CONCLUSIONS

Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.

"Beyond MELD" - Emerging strategies and technologies for improving mortality prediction, organ allocation and outcomes in liver transplantation

In this review article, we discuss the model for end-stage liver disease (MELD) score and its dual purpose in general and transplant hepatology. As the landscape of liver disease and transplantation has evolved considerably since the advent of the MELD score, we summarise emerging concepts, methodologies, and technologies that may improve mortality prognostication in the future. Finally, we explore how these novel concepts and technologies may be incorporated into clinical practice.

Assessment of Architecture of the Chilean Epidemiologic Surveillance System for Notifiable Diseases: EPIVIGILA (Preprint)

BACKGROUND

To fulfill their epidemiological vigilance function, authorities require valid, complete, timely, precise, and reliable information. Advancements in new technologies have facilitated public health control through vigilance systems for notifiable diseases; these systems can gather large numbers of simultaneous notifications, process a wide array of data, and deliver updated information in real time to relevant decision-makers. A large worldwide deployment of new information technologies was seen during the COVID-19 pandemic; these technologies proved to be efficient, resourceful tools . Platform developers should seek self-evaluation strategies to optimize functionality or improve the capacity of national vigilance systems. These tools exist in the Latin American region at various development stages, although publications reporting architectural characteristics of these tools are scarce. International publications are more abundant a nd serve as a basis for comparing the standards that need to be met.

OBJECTIVE

This study aimed to assess the architecture of the Chilean epidemiological surveillance system for notifiable diseases (EPIVIGILA), as compared to that of the international systems reported in scientific publications.

METHODS

A search for scientific publications was conducted to identify systematic reviews that documented the architectural characteristics of disease notification and vigilance systems. EPIVIGILA was compared to other systems from countries in Africa, the Americas, Asia, Europe, and Oceania.

RESULTS

The following aspects of the architecture were identified: (1) notification provenance, (2) minimum data set, (3) database users, and (4) data quality control. The notifying organizations, including hospitals, clinics, laboratories, and medical consultation offices, were similar among the 13 countries analyzed; this contrasted with Chile, where the reporting agent is the physician who can belong to an organization. The minimum data set include patient identification, disease data, and general codifications. EPIVIGILA includes all these elements, in addition to symptomatology, hospitalization data, type of medicine and treatment result, and laboratory test types. The database users or data analyzers include public health organizations, research organizations, epidemiological organizations, health organizations or departments, and the Centers for Disease Control and Prevention. Finally, for data quality control, the criteria most often used were completeness, consistency, validity, timeliness, accuracy, and competencies.

CONCLUSIONS

An efficient notification and vigilance system must be capable of promptly identifying probable risks as well as incidence and prevalence of the diseases under surveillance. EPIVIGILA has been shown to comply with high quality and functionality standards, at the level of developed countries, by achieving total national coverage and by providing timely, trustworthy, and complete information at high-security levels, thus obtaining positive assessment from national and international authorities.