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User-Centered Design and Evaluation of Clinical Decision Support to Improve Early Peanut Introduction: Formative
Thinh Hoang Nguyen1,2, Priscila Pereira Cunha1, Annabelle Friedman Rowland1
1Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
Insights
A new clinical decision support (CDS) tool effectively improved adherence to early peanut introduction guidelines in primary care. This tool enhanced comprehensive care for infants with potential peanut allergy symptoms during well-child visits.
Area of Science:
- Pediatric Allergy and Immunology
- Clinical Informatics
- Health Services Research
Background:
- Peanut allergy prevalence is increasing, necessitating updated infant feeding guidelines.
- Early peanut introduction, supported by the LEAP study, contrasts with previous avoidance recommendations.
- Current guideline adherence is suboptimal, leading to missed opportunities for prevention and management.
Purpose of the Study:
- To develop and evaluate a user-centered clinical decision support (CDS) tool for primary care.
- The tool aims to enhance the implementation of early peanut introduction guidelines.
- To improve comprehensive care for infants with potential peanut allergy.
Main Methods:
- Integrated CDS prompts and point-of-care education into well-child check (WCC) electronic health record (EHR) note templates for 4- and 6-month visits.
- Conducted formative and summative usability testing with pediatric residents in a simulated EHR environment.
- Assessed task completion rates and perceived usefulness of the CDS tool by comparing EHRs with and without the CDS.
Main Results:
- Formative testing led to iterative improvements in the CDS tool's WCC note templates.
- The CDS tool significantly increased discussion of early peanut introduction at 4-month WCC visits (60% with CDS vs. 0% without).
- At 6-month WCC visits, CDS guidance improved comprehensive care for concerning peanut reactions, including referrals, epinephrine prescriptions, and emergency plans.
Conclusions:
- User-centered CDS tools can effectively improve the application of early peanut introduction guidelines.
- The developed CDS tool enhanced comprehensive care for infants with symptoms concerning for peanut allergy in a simulated setting.
- This approach holds promise for improving guideline adherence and patient outcomes in primary care.
Background:
Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities.
Objective:
In this study, we aimed to develop a user-centered clinical decision support (CDS) tool to improve implementation of the most recent early peanut introduction guidelines in the primary care clinic setting.
Methods:
We edited the note template of the well-child check (WCC) visits at ages 4 and 6 months with CDS prompts and point-of-care education. Formative and summative usability testing were completed with pediatric residents in a simulated electronic health record (EHR). We estimated task completion rates and perceived usefulness of the CDS in summative testing, comparing a test EHR with and without the CDS.
Results:
Formative usability testing with the residents provided qualitative data that led to improvements in the build for both the 4-month and 6-month WCC note templates. During summative usability testing, the CDS tool significantly improved discussion of early peanut introduction at the 4-month WCC visit compared to scenarios without the CDS tool (9/15, 60% with CDS and 0/15, 0% without CDS). All providers except one at the 4-month WCC scenario gave at least an adequate score for the ease of use of the CDS tool for the history of present illness and assessment and plan sections. During the summative usability testing with the 6-month WCC new build note template, providers more commonly provided comprehensive care once obtaining a patient history concerning for an immunoglobulin E-mediated peanut reaction by placing a referral to allergy/immunology (P=.48), prescribing an epinephrine auto-injector (P=.07), instructing on how to avoid peanut products (P<.001), and providing an emergency treatment plan (P=.003) with CDS guidance. All providers gave at least an adequate score for ease of use of the CDS tool in the after-visit summary.
Conclusions:
User-centered CDS improved application of early peanut introduction recommendations and comprehensive care for patients who have symptoms concerning for peanut allergy in a simulation.
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