Back to the Bedside: Developing a Bedside Aid for Concussion and Brain Injury Decisions in the Emergency Department

Abstract

Context:Current information-rich electronic health record (EHR) interfaces require large, high-resolution screens running on desktop computers. This interface compromises the provider’s already limited time at the bedside by physically separating the patient from the doctor. The case study presented here describes a patient-centered clinical decision support (CDS) design process that aims to bring the physician back to the bedside by integrating a patient decision aid with CDS for shared use by the patient and provider on a touchscreen tablet computer for deciding whether or not to obtain a CT scan for minor head injury in the emergency department, a clinical scenario that could benefit from CDS but has failed previous implementation attempts.Case Description:This case study follows the user-centered design (UCD) approach to build a bedside aid that is useful and usable, and that promotes shared decision-making between patients and their providers using a tablet computer at the bedside. The patient-centered decision support design process focuses on the prototype build using agile software development, but also describes the following: (1) the requirement gathering phase including triangulated qualitative research (focus groups and cognitive task analysis) to understand current challenges, (2) features for patient education, the physician, and shared decision-making, (3) system architecture and technical requirements, and (4) future plans for formative usability testing and field testing.Lessons Learned:We share specific lessons learned and general recommendations from critical insights gained in the patient-centered decision support design process about early stakeholder engagement, EHR integration, external expert feedback, challenges to two users on a single device, project management, and accessibility.Conclusions:Successful implementation of this tool will require seamless integration into the provider’s workflow. This protocol can create an effective interface for shared decision-making and safe resource reduction at the bedside in the austere and dynamic clinical environment of the ED and is generalizable for these purposes in other clinical environments as well.

Development and Testing of Shared Decision Making Interventions for Use in Emergency Care: A Research Agenda

“…1,5,8,15 In the outpatient setting, best practices for decision aid development include iterative refinement and adaptation to the local setting, with the goal of using the decision aid to create a conversation between the clinician and the patient. 2 Specific developmental steps include (1) review and synthesis of the evidence, (2) analysis of usual practice, (3) development of an initial prototype, (4) field testing by patients and clinicians, and (5) successive iterations and refinement based on end user feedback and the quality of the conversation the tool promotes.…”

“…4,5 Further studies investigating the development and testing of decision aids to facilitate SDM in the ED for the management of pediatric and adult blunt head trauma as well as low-risk chest pain are ongoing. 4,6–8 Further research is needed to identify which clinical situations are best suited for SDM and what methods are best regarding the SDM process, as well as to develop and test SDM interventions in the ED.…”

Should US doctors embrace electronic health records?

“…They recommend using computers to shift "indirect patient care" to the bedside to improve communication and engagement. We agree that technology can and should support time at the bedside, 22 but presently it does not, and their argument misses the forest through the trees: the current system distracts and obstructs, threatening the quality of this time.…”

Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians

“…There is currently limited research on ED-based decision aids 8 but there will surely be further work in this area in the coming years. 20–22 A full discussion on the effectiveness and use of decision aids is beyond the scope of this manuscript.…”