Between 12 and 16% of children in the United States have a developmental disability. Early intervention programs improve outcomes in these children, and are also cost-effective. The pediatric medical community has pushed to identify children with developmental delays or disabilities as early as possible, using a standardized approach that includes both developmental surveillance and screening. Physicians, however, cite several barriers to the implementation of these recommendations. Modern computer decision support strategies (CDSS) offer the best hope of overcoming these barriers. We have developed a novel CDSS for implementing clinical guidelines in pediatric practice. CHICA (Child Health Improvement through Computer Automation) combines three elements: (1) pediatric guidelines encoded in Arden Syntax;(2) a dynamic, scannable paper user interface;and (3) an HL7-compliant interface to existing electronic medical record systems. The result is a system that both delivers """"""""just-in-time"""""""" patient-relevant guidelines to physicians during encounters, and accurately captures structured data from all who interact with it. Preliminary work with CHICA has demonstrated the feasibility of using the system to implement and evaluate clinical guidelines. We propose to expand CHICA to include a developmental surveillance and screening module. The specific research aims of this application are to (1) expand and modify an existing computer-based decision support system (CHICA) to include the 2006 American Academy of Pediatrics (AAP) developmental surveillance and screening algorithm;(2) evaluate the effect of the CHICA system on the developmental surveillance and screening practices of four pediatric clinics;(3) evaluate the effect of the CHICA system on referrals for developmental and medical evaluations as well as early developmental intervention/early childhood services for those children identified as having concerning developmental screening results;and (4) develop a cohort of children with identified developmental disabilities that can be followed over time in order to look at the end results/effects of developmental screening. This study will include a randomized trial to compare changes in surveillance, screening, diagnosis, and management of developmental disorders before and after implementation of the CHICA system. To measure the effect of the CHICA system on developmental surveillance and screening practices (aim 2), we will collect data from medical records and the CHICA system. The primary outcome of interest for aim 2 is the proportion of children at 9, 18, and 30 month visits who undergo developmental screening.
For aim 3, we will evaluate the individual components of a child's developmental disorder management program in order to determine CHICA's effect on the management of patients with developmental disorders. We will also explore qualitative aspects of a child's management plan, including family involvement in treatment decisions/planning, whether treatment decisions are based on an initial assessment and are continuously modified using data-driven decision-making, and whether the management strategies build on the strengths of the child.
Project Narrative Researchers and physician organizations such as the American Academy of Pediatrics have called on pediatric primary care providers to institute a standardized approach for the identification of developmental delays that includes both developmental surveillance and screening in order to facilitate early identification and intervention for children with developmental disorders. Physicians, however, cite several barriers to the implementation of these recommendations within their practices. Computer decision support systems, such as the Child Health Improvement through Computer Automation (CHICA) system we have developed, offer the best hope of addressing these barriers and enabling developmental surveillance and screening to fit within the workflow of busy pediatric practices.
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