A new study from Children’s Hospital of Philadelphia (CHOP) and the Centers for Disease Control and Prevention (CDC) has demonstrated the utility and effectiveness of electronic health record (EHR)-based clinical decision support tools to improve clinician behaviors around concussion diagnosis. As reported in Clinical Pediatrics, the provision of the tools, coupled with in-person training led to an 85 percent increase in clinicians documenting a vestibular oculomotor exam and a 129 percent increase in their reporting return-to-learn and return-to-play guidelines discussion with patient families, two recommended concussion management strategies.
During the study period, July 1, 2010, to June 30, 2014, researchers identified and followed 14,527 concussion-related primary care office visits for 7,284 unique patients, mostly between the ages of 5 to 19 years old. EHR-based clinical support tools have the potential to facilitate structured screening and diagnostic assessments, as well as enable systematic documentation across a broad healthcare network.
“Historically, integrating new evidence into provider behavior can take many years. However, we demonstrated a rather robust and quick uptake of several recommended clinical strategies, even ones new to many primary care providers,” says Kristy Arbogast, PhD, lead author and co-director of CHOP’s Center for Injury Research and Prevention. “The EHR platform allowed us to provide clinical practice guidance across our geographically and socio-economically diverse network, and promote systematic implementation and documentation of emerging recommended practices. We want all patients to get ‘CHOP-level care’ no matter where they enter our system.”
The study’s results highlight that in the two years leading up to the intervention, neither management strategy was implemented and documented consistently or systematically. In the pre-intervention period, performance of the vestibular oculomotor exam was documented in the EHR for only 1.8 percent of concussion visits. In contrast, 71 percent of visits in the post-intervention period included evidence of this exam for an overall 129 percent increase from July 2012 to June 2014.
During the pre-intervention period, 19 percent of concussion visits included EHR documentation of sharing return-to-learn and return-to-play guidelines. In contrast, in the post-intervention period these phrases were found in 73 percent of EHRs for a total increase of 85 percent.
The vast majority of exams performed in the post-intervention period (95 percent) were documented within a “Concussion SmartSet” template in CHOP’s electronic health record system, EpicCare®, showing that the template facilitated performance and systematic documentation of the exam components.
“We were motivated to create the Concussion SmartSet by increasing numbers of youth seeking concussion care in primary care,” says Christina Master, MD, study co-author and a primary care sports medicine specialist. “During a provider needs assessment we identified a clear clinical need and engaged front-line clinicians in the design of the tool. We also provided hands-on, in-person provider training on the use of the tool during continuing education events at CHOP’s Care Network sites. These steps were critical to our success.”
“We are encouraged by the power of the electronic health record platform to improve best practices for concussion and other medical conditions,” says Juliet Haarbauer-Krupa, PhD, study co-author and senior health scientist at CDC’s Injury Center. “Linking these provider behaviors to better patient outcomes is one potential next step for this line of research.”
Large and small health networks and practices can use the emerging evidence base in concussion to develop their own clinical guidelines and pathways. The Concussion Care for Kids: Minds Matter website from CHOP has resources that are freely available for use. Additional resources for healthcare providers and others involved in the care of children are available from CDC through HEADS UP to Youth Sports.
Kristy B. Arbogast, PhD, Allison E. Curry, PhD, Kristina B. Metzger, PhD, Ronni S. Kessler, MS, Jeneita M. Bell, MD, Juliet Haarbauer-Krupa, PhD, Mark R. Zonfrillo, MD, Matthew J. Breiding, PhD, Christina L. Master, MD. Improving Primary Care Provider Practices in Youth Concussion Management. Clinical Pediatrics. May-19-2017. 10.1177/0009922817709555
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