Learning from Misses: Evaluating a Clinical Decision Support for Chronic Pain Management in Primary Care

This study aimed to assess the effect of a passive, opt-in electronic health record (EHR)-based clinical decision support (CDS), the Chronic Pain OneSheet, on guideline-recommended chronic pain management in primary care.A pragmatic randomized controlled trial with a parallel group design was conducted between October 2020 and May 2022. Participants were 137 primary care clinicians (PCCs) treating qualifying patients with chronic pain at 25 primary care clinics within two academic health systems in the United States. PCCs were randomized in the EHR to have access to OneSheet or usual care. OneSheet aggregates guideline-relevant information in a single view and provides shortcuts to guideline-recommended actions (e.g., ordering urine drug screening [UDS] for patients prescribed opioids). We constructed five visit-level binary outcomes: (1) documenting pain-related goals; (2) documenting pain and function via Pain, Enjoyment of Life and General Activity (PEG) scale; (3) reviewing prescription drug monitoring programs (PDMPs); (4) ordering UDS; and (5) ordering naloxone. Analysis used generalized linear mixed models for each outcome.OneSheet access minimally increased rates of pain-related goal documentation (0.2 percentage point increase, p = 0.013), PEG scale documentation (0.7 percentage point increase, p < 0.001), and UDS orders (2.2 percentage point increase, p = 0.006). OneSheet access decreased the rate of ordering naloxone (0.5 percentage point decrease, p < 0.001). OneSheet access did not affect PDMP review rates (0.5 percentage point decrease, p = 0.382).OneSheet access did not result in clinically significant improvements in guideline-recommended management of chronic pain in primary care despite a robust user-centered design incorporating clinician input and EHR integration. Several factors likely limited OneSheet effectiveness, including limited ability to target certain patient visits, workflow limits on data collection and ordering, and evolving COVID-19 and opioid epidemic-related policies and procedures. These findings highlight specific limitations of OneSheet and the broader challenges of implementing effective EHR-based CDS in complex health care environments.