Clinicians? ability to accurately diagnose pneumonia and choose appropriate treatment is enhanced by well- designed clinical decision support (CDS), thereby increasing patient safety. Pneumonia CDS has historically been focused on inpatient settings, but ambulatory care settings with high pneumonia patient volumes and different care processes also need CDS. We propose to adapt and evaluate an innovative, validated electronic clinical decision support (CDS) tool based on consensus guidelines for pneumonia (ePNa) to urgent care centers (UCC). The proposal supports four aims: 1) Adapt ePNa for UCC and after in silico testing, pilot it among ?super user? clinicians during UCC shifts and assess its usability. ePNa needs adaptation for the limited patient data available in UCC, calibration of severity measures for lower observed mortality, and a chest imaging prompt in patients with pneumonia signs and symptoms. ePNa for UCC will incorporate the artificial intelligence CheXpert model to provide real-time (within seconds) electronic classification of chest images for elements of pneumonia diagnosis and treatment (radiographic pneumonia, single vs multiple lobes, and pleural effusion). 2) Use the CFIR framework, a focus group of UCC clinicians, and workflow observations to identify barriers and facilitators to adaptation and implementation of ePNa to UCC. 3) Test the implementation strategy by deploying ePNa at one of two randomly chosen Intermountain Healthcare UCC clusters each with about 800 annual pneumonia patients - the other a usual care control. 4) Co-primary outcomes are a) Patients diagnosed with pneumonia without chest imaging will be ?50% lower in the ePNa cluster. b) Antibiotic prescribing for treatment of pneumonia will be ?90% consistent with consensus guidelines and higher in the ePNa cluster. Safety measures will be unplanned subsequent 7-day ED visits/hospitalizations and 30-day mortality. Based on this rigorous pilot study, we anticipate a subsequent multi-system cluster-randomized trial including Cerner systems outside Utah. Our work incorporates the Five Rights of CDS to ensure that the strengths of this technology are optimized in the clinical environment. We will leverage experience in innovative pneumonia research, pioneering CDS, and implementation science available at Intermountain to successfully complete this proposal. The proposal will be facilitated by and disseminated through Intermountain relationships with the PCORnet Learning Health Systems Network, PCOR CDS Learning Network, the Healthcare Services Platform Consortium, Cerner, and clinicaltrials.gov. Our innovative proposal promises to advance safety for patients suspected of pneumonia in an understudied, high-volume ambulatory care setting.
Pneumonia is the most common serious infection among adults, but diagnosis and treatment decisions vary between different clinicians. We will adapt for free standing urgent care clinics a validated, real-time, emergency department deployed, electronic pneumonia clinical decision support tool (ePNa). We hypothesize successful implementation of ePNa using the Consolidated Framework for Implementation Research into a cluster of urgent care clinics which treat about 800 pneumonia patients annually will improve care processes and patient outcomes compared to a similar cluster of usual care clinics.
