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An ever-growing plethora of preventive services guidelines threatens to overwhelm primary care providers who are expected to recognize and prioritize these needed services for each patient. The Child Health Improvement through Computer Automation (CHICA) system was designed to facilitate this process through a workflow-sensitive interface that gathers and distills the most relevant patient data within pediatric settings. We evaluated family responses to 21 CHICA questions that assess risk factors and health behaviors over a three month period. 3005 patients provided 15,434 responses to these questions, and 1756 or 11.3% of these suggest risk factors which merit attention. This preliminary analysis suggests that, using CHICA, families identify significant risk factors that our clinicians acknowledge are often overlooked given the realities of practicing within this setting.
Today’s primary care providers are expected to accurately and efficiently integrate a growing body of preventive services guidelines into routine patient care. This proliferation of interventions recommended by expert panels1–3 and specialty organizations4,5 threatens to overwhelm providers, who attempt to provide these services while, at the same time, addressing acute problems, chronic conditions, and other patient concerns.6,7 Juggling provision of these services is especially challenging, given the time constraints of an average 16–20 minute office visit.8 To highlight these realities, Yarnell et al demonstrated that meeting all of the US Preventive Services Task Force (USPSTF) recommendations within an average patient panel would require 7.4 hours per day.9
Perhaps as a more fundamental problem, human beings as care providers have finite capacities as information gatherers and processors. This, according to McDonald, “assures the occurrence of random errors” (including errors of omission) while providers offer preventive care.10 Multiple other studies11–14 imply that all of these perceived “bottlenecks” in the process of patient care might serve as explanations for the well-documented shortcomings in preventive service rates.15–18
Many strategies have been developed to address these realities directly. According to the USPSTF, when caregivers place the greatest emphasis on understanding each patient’s risk profile, they can significantly reduce the number of unnecessary interventions.3 As a result, many guidelines attempt to define an explicit, focused list of historical and demographic risk factors to facilitate rapid recognition of risk. To further reduce provider work burden, many of these risk factors are bundled into standardized screening instruments which can be completed by patients or their families.19–22 However, providers must sort who receives each of these instruments, and must also score and interpret the results.
Additional strategies that focus on prioritization of needed preventive services have also been well described in the literature.23, 24 A study by Medder illustrates the importance of setting priorities: In a sample of 230 adult patients, each was found to have an average of 15.4 risk factors, and 24.5 needed preventive services.25 Providers commonly have a difficult time manually sorting through the continually evolving set of preventive services, often choosing ones which lack a sufficient evidence base to support their benefit.26
It occurred to us that information technologies could help facilitate recognition and prioritization strategies. We designed the Child Health Improvement through Computer Automation (CHICA) system to provide an integrated suite of these services automatically within pediatric outpatient care settings.27 This system has been in operation in the pediatric primary care clinic at Wishard Memorial Hospital since November 5, 2004.
Anecdotally, CHICA appears to be identifying issues that had previously gone unrecognized or undetected, including highly sensitive issues (e.g., domestic violence and depression). We describe here issues that have been identified by the tailored survey instruments generated by CHICA, completed by families, and analyzed by the computer.
CHICA's primary user interface is a scannable, computer-interpreted paper form. We developed these Adaptive Turnaround Documents28,29 (ATDs) to collect the handwritten responses to generate questions and clinical reminders dynamically while integrating easily into clinic workflows. To determine what information needs to be printed on each ATD, CHICA employs a library of Arden Syntax30 rules that evaluate the underlying Regenstrief (citation here?) and CHICA databases. Since time constraints limit the number of topics which can be feasibly addressed in a given patient encounter, CHICA also employs a global prioritization scheme24 which limits the printed content to what's most effective and relevant.
The process begins when registration HL7 messages from our clinic appointment system cue CHICA to begin generating the first of two ATDs. This "pre-screening" form is designed to capture data immediately prior to the provider encounter from both nursing staff and patients. This form has a section for nurses to enter vital signs, and also contains the 20 most important questions to ask a child's family in a particular visit (fig 1). Answers extracted from this form are analyzed alongside previously existing data to generate the content for the second ATD. This provider worksheet contains reminders that provide varying levels of patient detail based on the information collected before the encounter. Each reminder also contains a series of checkboxes that allow the clinician to respond to prompts or pass other data back to the system. All data collected from both of these forms are ultimately stored as coded clinical observations which are used to drive decision support and can be analyzed retrospectively.
We searched the CHICA repository for the values of 21 pre-selected observations recorded by families or adolescents between December 1, 2004 and February 28, 2005. Observations extracted were for maternal depression symptoms, firearms in the home, domestic violence risk, hot water heater adjustment to avoid burns, sleep position to prevent sudden infant death syndrome, family history of deafness (a risk factor for congenital deafness), sickle cell disease, environmental tobacco smoke exposure, concerns regarding child abuse, smoke detector use, risk factors for tuberculosis, and adolescent psychosocial issues.
To evaluate question completion rates, we tallied the number of times each of the 21 questions was asked, along with each of the responses recorded by CHICA. Our system only had the ability to generate English questions at the time of this study; so Spanish speaking patients were usually unable to complete the form. To quantify the impact of this, we also extracted the race/ethnicity of the families who received forms during the study period. We tallied all answers to these questions to evaluate prevalence of risk factors identified by each question, and correlated these data to clinician actions whenever available.
During the three-month study period, 3005 unique children were seen in the clinic. Table 1 details the responses to the 21 selected questions and Table 2 describes each patient’s race/ethnicity. The 21 preselected family questions were posed by CHICA 28,133 times. Overall, the system received 15,434 handwritten responses, for a completion rate of 54.9%. Assuming that 40% of Hispanic patients did not complete the form, this is approximately a 90% completion rate.
We pre-screen eligible parents by asking two questions based on standard screening methods. One identifies depressed mood within the past month, and the other identifies the inability to experience pleasure (anhedonia). Among the 3006 children, there were 876 answers to these two questions: 170 (19%) of these suggested risks for maternal depression. CHICA reported that clinicians confirmed high risk for depression in 9 of these mothers, 8 received referrals to mental health.
To screen for domestic violence, parents were asked three questions. A total of 3,961 responses were collected, which yielded 65 actionable responses. When these issues were addressed by the pediatrician, CHICA recorded three cases of domestic violence that were confirmed where parents received assistance.
We chose five common risk factors related to injury prevention within pediatric populations. Families reported a 12% prevalence of guns within homes and no working smoke detector in 4% of homes. In addition, hot water heaters were potentially set too high in 37% of homes, and smoke detectors hadn’t been recently checked in 17%. Finally, smoking within households has been determined a significant fire hazard and a cause of morbidity in children. 30% of families who answered this question alerted clinicians to this information. According to physician responses, 81 of these smokers were ready to quit. This created an opportunity to provide targeted smoking cessation advice.
Children who sleep on their stomachs (prone) or on unsafe surfaces are at increased risk for sudden infant death syndrome (SIDS). CHICA asks about sleep position in three ways by gathering data on children who are allowed to sleep on their stomach or on unsafe surfaces (such as beanbags). According to data recorded within the system, parents identified these risky behaviors 356 times, creating many opportunities for counseling.
We used the CHICA screening form to assess two common risk factors based on AAP guidelines: exposure to others with TB, and recent visits to high-prevalence countries. We found that among our sample, families identified 36 of these risk factors.
Family history of deafness is a risk factor for congenital deafness, which is often missed until a child is nearly three. When we asked 177 families, 27 (15%) reported the need for a detailed hearing screen.
One of the most striking findings was that among 289 adolescent patients who were asked about symptoms of depression over the three month study period, 49 (17%) admitted to some symptoms of depression. When physicians were alerted to this finding, they found that 10 of these teens had moderate to severe depression, and one had suicidal ideation. Another teen, identified with suicidal ideation after the study period, said he had been depressed for a long time and told no one until he was given the survey.
The vast number of guidelines recommended for preventive care and the innumerable historical data needed to process them have made comprehensive preventive services impracticable within modern practice settings. The CHICA system, by collecting coded data directly from families in the waiting room and passing this information on to clinicians as reminders embedded in worksheets, creates a workflow sensitive means for implementing tailored preventive care in a practical fashion. Given that approximately 40% of this patient population was identified by our system as Hispanic, we were pleased with the 54.9% overall question response rate. We have recently completed features that add Spanish questions to our screening forms (figure 2), so we suspect that further work will yield better response rates.
The findings uncovered in just the first few months of implementation of CHICA suggest that there are significant risk factors and concerns among our population that may have been overlooked before. Overall, our study identified 1,756 risk factors in this sample, which represents 11.3% of responses that alert providers to preventive care counseling and intervention. It seems unlikely that these rates of problems would be uncovered by providers without the aid of CHICA. There is not time in the interview to address all of these issues within this high volume clinic. Furthermore, many of these questions are quite sensitive. Even if the clinician conscientiously asked these questions face-to-face, literature has shown that these questions are often more comfortably answered on a questionnaire.
These preliminary data will serve as the basis for multiple randomized-controlled trials which will study the effect of CHICA on some of these topic areas in much greater detail.