Developing and Testing the Usability of a Novel Child Abuse Clinical Decision Support System: Mixed Methods Study
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Published on: June 20, 2020
Amy Thomas1, Andrea Asnes1, Kyle Libby2
1Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States.
Insights
A new Child Abuse Clinical Decision Support (CA-CDS) system helps emergency departments identify infant physical abuse. This electronic tool provides evidence-based alerts to improve recognition and evaluation of suspected child abuse cases.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Informatics
- Child Abuse Recognition
Background:
- Child physical abuse is frequently underdiagnosed, particularly in emergency settings.
- Electronic clinical decision support (CDS) systems show promise in enhancing the detection of child abuse.
Purpose of the Study:
- To develop and assess the usability of a natural language processing-based CDS system (CA-CDS) for identifying high-risk injuries suggestive of abuse in infant medical records.
- To refine the CA-CDS system based on clinician feedback.
Main Methods:
- A multidisciplinary team developed the CA-CDS prototype, incorporating user design principles and evidence-based recommendations.
- Usability was evaluated through interviews with 24 clinicians across 4 emergency departments.
- Interview data were analyzed using conventional content analysis to identify themes related to usability, barriers, and facilitators.
Main Results:
- Clinicians identified benefits such as an "extra layer of protection" and evidence-based guidance.
- User-centered design features included soft-stop alerts and integrated documentation.
- Key recommendations for improvement involved content consolidation and clearer design; barriers included alert fatigue and documentation concerns.
Conclusions:
- The CA-CDS system, with its user-centered design and evidence-based content, can assist healthcare providers in real-time recognition and evaluation of infant physical abuse.
- The system has the potential to decrease the incidence of missed child abuse cases.
Background:
Despite the impact of physical abuse on children, it is often underdiagnosed, especially among children evaluated in emergency departments (EDs). Electronic clinical decision support (CDS) can improve the recognition of child physical abuse.
Objective:
We aimed to develop and test the usability of a natural language processing-based child abuse CDS system, known as the Child Abuse Clinical Decision Support (CA-CDS), to alert ED clinicians about high-risk injuries suggestive of abuse in infants' charts.
Methods:
Informed by available evidence, a multidisciplinary team, including an expert in user design, developed the CA-CDS prototype that provided evidence-based recommendations for the evaluation and management of suspected child abuse when triggered by documentation of a high-risk injury. Content was customized for medical versus nursing providers and initial versus subsequent exposure to the alert. To assess the usability of and refine the CA-CDS, we interviewed 24 clinicians from 4 EDs about their interactions with the prototype. Interview transcripts were coded and analyzed using conventional content analysis.
Results:
Overall, 5 main categories of themes emerged from the study. CA-CDS benefits included providing an extra layer of protection, providing evidence-based recommendations, and alerting the entire clinical ED team. The user-centered, workflow-compatible design included soft-stop alert configuration, editable and automatic documentation, and attention-grabbing formatting. Recommendations for improvement included consolidating content, clearer design elements, and adding a hyperlink with additional resources. Barriers to future implementation included alert fatigue, hesitancy to change, and concerns regarding documentation. Facilitators of future implementation included stakeholder buy-in, provider education, and sharing the test characteristics. On the basis of user feedback, iterative modifications were made to the prototype.
Conclusions:
With its user-centered design and evidence-based content, the CA-CDS can aid providers in the real-time recognition and evaluation of infant physical abuse and has the potential to reduce the number of missed cases.
