Development and use of a clinical decision support tool for behavioral health screening in primary care clinics

SummaryObjective: Screening, brief intervention, and referral for treatment (SBIRT) for behavioral health (BH) is a key clinical process. SBIRT tools in electronic health records (EHR) are infrequent and rarely studied. Our goals were 1) to design and implement SBIRT using clinical decision support (CDS) in a commercial EHR; and 2) to conduct a pragmatic evaluation of the impact of the tools on clinical outcomes.Methods: A multidisciplinary team designed SBIRT workflows and CDS tools. We analyzed the outcomes using a retrospective descriptive convenience cohort with age-matched comparison group. Data extracted from the EHR were evaluated using descriptive statistics.Results: There were 2 outcomes studied: 1) development and use of new BH screening tools and workflows; and 2) the results of use of those tools by a convenience sample of 866 encounters. The EHR tools developed included a flowsheet for documenting screens for 3 domains (depression, alcohol use, and prescription misuse); and 5 alerts with clinical recommendations based on screening; and reminders for annual screening. Positive screen rate was 21% (≥1 domain) with 60% of those positive for depression. Screening was rarely positive in 2 domains (11%), and never positive in 3 domains. Positive and negative screens led to higher rates of documentation of brief intervention (BI) compared with a matched sample who did not receive screening, including changes in psychotropic medications, updated BH terms on the problem list, or referral for BH intervention. Clinical process outcomes changed even when screening was negative.Conclusions: Modified workflows for BH screening and CDS tools with clinical recommendations can be deployed in the EHR. Using SBIRT tools changed clinical process metrics even when screening was negative, perhaps due to conversations about BH not captured in the screening flowsheet. Although there are limitations to the study, results support ongoing investigation.Citation: Burdick TE, Kessler RS. Development and use of a clinical decision support tool for behavioral health screening in primary care clinics. Appl Clin Inform 2017; 8: 412–429 https://doi.org/10.4338/ACI-2016-04-RA-0068

Download Full-text

Improving Primary Care Provider Practices in Youth Concussion Management

Clinical Pediatrics ◽

10.1177/0009922817709555 ◽

2017 ◽

Vol 56 (9) ◽

pp. 854-865 ◽

Cited By ~ 19

Author(s):

Kristy B. Arbogast ◽

Allison E. Curry ◽

Kristina B. Metzger ◽

Ronni S. Kessler ◽

Jeneita M. Bell ◽

...

Keyword(s):

Primary Care ◽

Decision Support ◽

Clinical Decision Support ◽

Care Provider ◽

Decision Support Tool ◽

Clinical Decision ◽

Post Intervention ◽

Support Tool ◽

Concussion Management ◽

Clinical Decision Support Tool

Primary care providers are increasingly providing youth concussion care but report insufficient time and training, limiting adoption of best practices. We implemented a primary care–based intervention including an electronic health record–based clinical decision support tool (“SmartSet”) and in-person training. We evaluated consequent improvement in 2 key concussion management practices: (1) performance of a vestibular oculomotor examination and (2) discussion of return-to-learn/return-to-play (RTL/RTP) guidelines. Data were included from 7284 primary care patients aged 0 to 17 years with initial concussion visits between July 2010 and June 2014. We compared proportions of visits pre- and post-intervention in which the examination was performed or RTL/RTP guidelines provided. Examinations and RTL/RTP were documented for 1.8% and 19.0% of visits pre-intervention, respectively, compared with 71.1% and 72.9% post-intervention. A total of 95% of post-intervention examinations were documented within the SmartSet. An electronic clinical decision support tool, plus in-person training, may be key to changing primary care provider behavior around concussion care.

Download Full-text

The Practical Approach to Care Kit (PACK) guide: developing a clinical decision support tool to simplify, standardise and strengthen primary healthcare delivery

BMJ Global Health ◽

10.1136/bmjgh-2018-000962 ◽

2018 ◽

Vol 3 (Suppl 5) ◽

pp. e000962 ◽

Cited By ~ 15

Author(s):

Ruth Cornick ◽

Sandy Picken ◽

Camilla Wattrus ◽

Ajibola Awotiwon ◽

Emma Carkeek ◽

...

Keyword(s):

Primary Care ◽

Decision Support ◽

Clinical Decision Support ◽

Decision Support Tool ◽

Clinical Decision ◽

Practical Approach ◽

Support Tool ◽

Clinical Guidance ◽

Primary Health ◽

Clinical Decision Support Tool

For the primary health worker in a low/middle-income country (LMIC) setting, delivering quality primary care is challenging. This is often complicated by clinical guidance that is out of date, inconsistent and informed by evidence from high-income countries that ignores LMIC resource constraints and burden of disease. The Knowledge Translation Unit (KTU) of the University of Cape Town Lung Institute has developed, implemented and evaluated a health systems intervention in South Africa, and localised it to Botswana, Nigeria, Ethiopia and Brazil, that simplifies and standardises the care delivered by primary health workers while strengthening the system in which they work. At the core of this intervention, called Practical Approach to Care Kit (PACK), is a clinical decision support tool, the PACK guide. This paper describes the development of the guide over an 18-year period and explains the design features that have addressed what the patient, the clinician and the health system need from clinical guidance, and have made it, in the words of a South African primary care nurse, ‘A tool for every day for every patient’. It describes the lessons learnt during the development process that the KTU now applies to further development, maintenance and in-country localisation of the guide: develop clinical decision support in context first, involve local stakeholders in all stages, leverage others’ evidence databases to remain up to date and ensure content development, updating and localisation articulate with implementation.

Download Full-text

e-PC101: an electronic clinical decision support tool developed in South Africa for primary care in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2018-001093 ◽

2019 ◽

Vol 3 (Suppl 5) ◽

pp. e001093 ◽

Cited By ~ 2

Author(s):

Matthew Yau ◽

Venessa Timmerman ◽

Merrick Zwarenstein ◽

Pat Mayers ◽

Ruth Vania Cornick ◽

...

Keyword(s):

South Africa ◽

Primary Care ◽

Decision Support ◽

Clinical Decision Support ◽

Decision Support Tool ◽

Clinical Decision ◽

Middle Income ◽

Support Tool ◽

Middle Income Countries ◽

Clinical Decision Support Tool

Health technology is increasingly recognised as a feasible method of addressing health needs in low and middle-income countries (LMICs). Primary Care 101, now known as PACK (Practical Approach to Care Kit), is a printed, algorithmic, checklist-based, comprehensive clinical decision support tool. It assists clinicians with delivering evidence-based medicine for common primary care presentations and conditions. These assessment and treatment guides have been adopted widely in primary care clinics across South Africa. This paper focuses on the process of designing, developing, and implementing a digital version of the clinical decision support tool for use on a tablet computer. Lessons learnt throughout its development and pilot implementation could apply to the creation of electronic health interventions and the digitisation of clinical tools in LMICs.

Download Full-text