Decision-centered design of a clinical decision support system for acute management of pediatric congenital heart disease

Abstract

Background and ObjectivesChildren with congenital heart disease (CHD), have fragile hemodynamics and can deteriorate due to common childhood illnesses and the natural progression of their disease. During these acute periods of deterioration, these children often present to their local emergency departments (ED) where expertise in CHD is limited, and appropriate intervention is crucial to their survival. Previous studies identified that determining the appropriate intervention for CHD patients can be difficult for ED physicians, particularly since key components of effective decision making are not being met. Although key components of effective decision making for ED physicians have been identified, they have yet to be transformed into actionable guidance. We used decision centered design (DCD) to translate key components of decision making into decision requirements and associated design concepts, that we subsequently incorporated into a prototype clinical decision support system (CDSS).MethodsUsing framework analysis, transcripts from Critical Decision Method interviews of CHD experts and ED physicians were inductively coded to identify key decision requirements for ED physicians that are currently not well supported, and their associated design concepts. A design workshop was held to refine the identified key decision requirements and design concepts as well as to sketch information that would satisfy the identified requirements. These were iteratively incorporated into a prototype CDSS.ResultsThree decision requirements: (1) distinguish the patient's unique physiology based on their unique cardiac anatomy, (2) explicitly consider CHD specific differential diagnoses to allow a more structured reflection of diagnosis, and (3) select CHD appropriate interventions for each patient, were identified. These requirements along with design concepts and information needs identified through the design workshop were incorporated into the CDSS prototype.ConclusionWe identified key decision requirements and associated design concepts, that informed the design of a CDSS to provide actionable guidance for ED physicians when managing CHD patients. Meeting ED physicians' decision components with a CDSS requires the translation of their key decision requirements in its design. If not, we risk creating designs that interfere with clinician performance.

Effect of clinical decision support systems on emergency medicine physicians' decision-making: A pilot scenario-based simulation study

“…Coders independently identified utterances of decisions and reviewed their decision utterances for overlap (i.e., did they both identify the same decision utterances) to come to consensus. Once all utterances of decisions were identified, coders independently coded each decision utterance for key decision components based on a priori operational definitions identified in a previous study ( Table 2 ) ( 8 ). They also coded based on whether a decision utterance was CHD-specific (e.g., choosing to start an epinephrine infusion to support the function of the heart and increase cardiac output) or a general decision component (e.g., choosing to start antibiotics to treat a potential infection) to evaluate the effect of the CDSS on participants' non-CHD specific (general) decision making (i.e., recognition, investigation, and management of the intercurrent illness and other possible differential diagnoses).…”

“…We identified a lack of actionable guidance to support ED physicians in their decision making when confronted with a patient with CHD and intercurrent acute illness ( 7 ), and developed a prototype Clinical Decision Support System (CDSS) using the critical decision method (CDM), called MyHeartPass TM ( Figure 1 ) ( 8 ). CDSS are systems that provide clinicians with disease and patient specific clinical knowledge and information to facilitate effective decision making, enhance patient care, and improve outcomes ( 9 , 10 ).…”