Deployment of a human-centred clinical decision support system for pulmonary embolism: evaluation of impact on quality of diagnostic decisions

Pulmonary embolism (PE) is a serious condition that presents a diagnostic challenge for which diagnostic errors often happen. The literature suggests that a gap remains between PE diagnostic guidelines and adherence in healthcare practice. While system-level decision support tools exist, the clinica...

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Bibliographic Details
Published in:	BMJ open quality Vol. 13; no. 1; p. e002574
Main Authors:	Altabbaa, Ghazwan, Flemons, Ward, Ocampo, Wrechelle, Babione, Julie Nathalie, Kaufman, Jamie, Murphy, Sydney, Lamont, Nicole, Schaefer, Jeffrey, Boscan, Alejandra, Stelfox, Henry T, Conly, John, Ghali, William A
Format:	Journal Article
Language:	English
Published:	England British Medical Journal Publishing Group 12-02-2024 BMJ Publishing Group LTD BMJ Publishing Group
Subjects:	Clinical decision making Cognition & reasoning Computer terminals Decision support systems Decision support, clinical Decision support, computerised Diagnostic tests Electronic health records Evidence-Based Practice Hospital medicine Hospitals Intervention Medical diagnosis Medical records Original Research Patients Physicians Pulmonary embolisms Quality of care Standards of care Thrombosis Usability testing Standards of care Decision support, clinical Evidence-Based Practice Decision support, computerised Hospital medicine
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Summary:	Pulmonary embolism (PE) is a serious condition that presents a diagnostic challenge for which diagnostic errors often happen. The literature suggests that a gap remains between PE diagnostic guidelines and adherence in healthcare practice. While system-level decision support tools exist, the clinical impact of a human-centred design (HCD) approach of PE diagnostic tool design is unknown.DesignBefore–after (with a preintervention period as non-concurrent control) design study.SettingInpatient units at two tertiary care hospitals.ParticipantsGeneral internal medicine physicians and their patients who underwent PE workups.InterventionAfter a 6-month preintervention period, a clinical decision support system (CDSS) for diagnosis of PE was deployed and evaluated over 6 months. A CDSS technical testing phase separated the two time periods.MeasurementsPE workups were identified in both the preintervention and CDSS intervention phases, and data were collected from medical charts. Physician reviewers assessed workup summaries (blinded to the study period) to determine adherence to evidence-based recommendations. Adherence to recommendations was quantified with a score ranging from 0 to 1.0 (the primary study outcome). Diagnostic tests ordered for PE workups were the secondary outcomes of interest.ResultsOverall adherence to diagnostic pathways was 0.63 in the CDSS intervention phase versus 0.60 in the preintervention phase (p=0.18), with fewer workups in the CDSS intervention phase having very low adherence scores. Further, adherence was significantly higher when PE workups included the Wells prediction rule (median adherence score=0.76 vs 0.59, p=0.002). This difference was even more pronounced when the analysis was limited to the CDSS intervention phase only (median adherence score=0.80 when Wells was used vs 0.60 when Wells was not used, p=0.001). For secondary outcomes, using both the D-dimer blood test (42.9% vs 55.7%, p=0.014) and CT pulmonary angiogram imaging (61.9% vs 75.4%, p=0.005) was lower during the CDSS intervention phase.ConclusionA clinical decision support intervention with an HCD improves some aspects of the diagnostic decision, such as the selection of diagnostic tests and the use of the Wells probabilistic prediction rule for PE.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	2399-6641 2399-6641
DOI:	10.1136/bmjoq-2023-002574