Computer Automated Developmental Surveillance and Screening (Indiana)

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Summary:

Approximately one in six children in the U.S. has a developmental disability. Early intervention for these children is critical, as pediatric primary care providers are in the best position to identify and refer children to intervention programs in a timely manner. However, developmental surveillance and screening programs are not routinely implemented in primary care settings, and when screening does occur, standardized protocols and tools are used infrequently. Barriers to successful programs include lack of time and staff, logistical challenges in administering screening tools, inadequate reimbursement, and language barriers.

The project sought to determine if a computer decision support (CDS) system integrated with routine care could improve standardized developmental screening during 9, 18, and 30 month well-child visits and surveillance for developmental disabilities at all pediatric visits.

The specific aims of this project were to:

  • Expand and modify an existing computer-based decision support system, the Child Health Improvement through Computer Automation (CHICA), to include the 2006 American Academy of Pediatrics developmental surveillance and screening algorithm.
  • Evaluate the effect of the CHICA system on the developmental surveillance and screening practices of four pediatric clinics.
  • Evaluate the effect of the CHICA system on referrals for developmental and medical evaluations, and for early developmental intervention and early childhood services.
  • Develop and follow a cohort of children with identified developmental disabilities to look at the end results and effects of developmental screening.

The system was evaluated with a randomized controlled trial at four primary care pediatric clinics, two of which served as intervention sites and two as control sites. A developmental surveillance and screening (DSS) module was added to CHICA, a CDS system that delivers relevant guidelines to physicians during patient visits. The control sites used CHICA without the DSS module. During the study period, more than 6,000 children of the four practices’ combined patient population of 35,782 were screened for developmental disabilities. The charts of 360 children in the developmental screening portion of the study and 120 in the developmental surveillance portion of the study were reviewed to assess screening, surveillance, and diagnosis. Additionally, 95 children had parents who agreed to participate in interview sessions and reviews of their children’s medical record.

The use of CHICA with DSS increased the numbers of children screened at 9, 18, and 30 months of age, and significantly improved consistent surveillance at other ages. The number of children diagnosed with developmental delays increased, and referrals for timely services at an earlier age increased. This study showed that using a CDS system to automate the screening of children for developmental delay significantly increased the number of children screened. Upcoming efforts include determining if the increase in screening leads to improved outcomes for children. The project team is working on moving CHICA on to commercial platforms to make it more widely available.

Computer Automated Developmental Surveillance and Screening - 2012

Summary Highlights

Summary: Developmental disabilities affect between 12 and 16 percent of the pediatric population in the United States. ‘Best practices’ guidelines require that children receive appropriate and timely screening and treatment for these disabilities. Electronic computer decision support strategies offer a promising aid for implementing a standardized approach to developmental surveillance and screening.

Prior to this grant, researchers at Indiana University developed an electronic computer decision support system for pediatric practices called CHICA—Child Health Improvement through Computer Automation—to deliver appropriate guidelines to physicians during patient visits. CHICA was modified to incorporate developmental surveillance and screening within the existing practice workflow without requiring additional time of the physician or other office staff. The CHICA system includes: 1) pediatric guidelines encoded in Arden Syntax, a common computer language representing medical conditions and recommendations; 2) a dynamic scan form interface for the user; and 3) a Health Level 7-compliant interface to existing medical record systems.

This project extends the CHICA software by incorporating the 2006 American Academy of Pediatrics (AAP) guidelines into the surveillance and screening algorithm, and evaluates the effect of the CHICA system on developmental surveillance, screening, referral, and early childhood intervention services. This evaluation follows a cohort of children with developmental disabilities through age 5 to compare the proportion of children who undergo developmental screening at 9-, 18-, and 30-month visits at four
practice sites, two of which have implemented the CHICA system and two of which have not. This evaluation will identify how implementation of the AAP recommendations into CHICA affects adherence to clinical guidelines. In addition, documentation of long-term outcomes will contribute to knowledge about the impact of early surveillance and screening on child health. Qualitative aspects of child screening surveillance will also be explored. These include elements of the child’s management plan such as family involvement in treatment decisions and planning; treatment that is based on the initial assessment versus treatment that is continuously modified using data-driven decisionmaking; and whether management strategies build on the strengths of the child.

Specific Aims:

  • Expand and modify an existing computer-based decision support system (CHICA) to include the 2006 AAP developmental surveillance and screening algorithm. (Achieved)
  • Evaluate the effect of the CHICA system on the developmental surveillance and screening practices of four pediatric clinics. (Ongoing)
  • Evaluate the effect of the CHICA system on referrals for developmental and medical evaluations, and for early developmental intervention and early childhood services. (Ongoing)
  • Develop and follow a cohort of children with identified developmental disabilities to look at the end results and effects of developmental screening. (Ongoing)

2012 Activities: The project team completed the data collection for the second and third aims of the research study. The data collection phase included a chart review at intervention practices to identify rates of diagnosis and referral for services. At the control practices, chart reviews using the Autism Screening Questionnaire identified referrals as well as developmental screening rates. The project team biostatisticians began cleaning and analyzing the data from the chart reviews.

In order to examine the effects of developmental screening, the grantee is recruiting parents of children who have confirmed developmental disabilities for participation in telephone interviews to discuss their experience with the referral process and the child’s care plan in detail. In addition to the group being interviewed, a larger cohort is being analyzed to assess the result of screening through data draws from the electronic medical record. The identification and recruitment of parents required additional time because the rate of diagnosis of children with developmental disabilities was lower than was expected. There was also some difficulty recruiting patients at the control practices because the language used to communicate a diagnosis of developmental delay was inconsistent. Parents may have been told their child is not meeting developmental milestones or is slow to meet milestones. For this reason, parents may not respond to a request to participate in an interview for a child with developmental delay because that is not how they understand their child’s condition.

The research team continued to hold meetings with providers to receive feedback on potential process improvements to CHICA. They recruited one physician from each of the four participating clinics. By recruiting CHICA-resistant physicians the team received helpful suggestions and improved physician engagement. The project also has listservs for each clinic to communicate weekly updates to physicians and staff. They are continuing the feedback reports at the two intervention sites through the no-cost
extension (NCE) period. They will continue these as long as providers wish to receive the reports and the data from their research demonstrates that the feedback reports improve the rate of developmental screening.

The 1-year NCE period has been used to extend enrollment of children and families with confirmed developmental delay in the cohort analysis and qualitative interviews. As mentioned above, the identification of these children has been difficult because the rate of diagnosis is low.

Preliminary Impact and Findings: The team originally planned auto scanning and scoring of the Autism Screening Questionnaire but found that providers prefer to score the screening tool themselves. Qualitatively, they have been looking at the factors that contribute to use of the CHICA system, such as practice type and provider characteristics. In general, they are finding that younger physicians are quicker to adopt the system.

Target Population: Pediatric*, Children with Special Health Care Needs

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ’s priority populations.

Computer Automated Developmental Surveillance and Screening - 2011

Summary Highlights

Summary: Developmental disabilities affect between 12 and 16 percent of the pediatric population in the United States. "Best practices" guidelines require that children receive appropriate and timely screening and treatment for these disabilities. Electronic computer decision support strategies offer a promising aid for implementing a standardized approach to developmental surveillance and screening.

Prior to this grant, researchers at Indiana University developed an electronic computer decision support system for pediatric practices called CHICA - Child Health Improvement Through Computer Automation - to deliver appropriate guidelines to physicians during patient visits. CHICA was modified to incorporate developmental surveillance and screening within the existing practice workflow without requiring additional time of the physician or other office staff. The CHICA system includes: 1) pediatric guidelines encoded in Arden Syntax, a common computer language representing medical conditions and recommendations; 2) a dynamic scan form interface for the user; and 3) a Health Level 7-compliant interface to existing medical record systems.

This project extends the CHICA software by incorporating the 2006 American Academy of Pediatrics (AAP) guidelines into the surveillance and screening algorithm, and evaluates the effect of the CHICA system on developmental surveillance, screening, referral, and early intervention and early childhood services. This evaluation follows a cohort of children with developmental disabilities to compare the proportion of children who undergo developmental screening at 9-, 18-, and 30-month visits at four practice sites, two of which have implemented the CHICA system and two of which have not. This evaluation will identify how implementation of the AAP recommendations into CHICA affects adherence to clinical guidelines. In addition, documentation of long-term outcomes will contribute to knowledge about the impact of early surveillance and screening on child health. Qualitative aspects of child screening surveillance will also be explored. These include elements of the child's management plan such as family involvement in treatment decisions and planning, treatment that is based on the initial assessment versus treatment that is continuously modified using data-driven decisionmaking, and whether management strategies build on the strengths of the child.

Specific Aims:

  • Expand and modify an existing computer-based decision support system (CHICA) to include the 2006 AAP developmental surveillance and screening algorithm. (Achieved)
  • Evaluate the effect of the CHICA system on the developmental surveillance and screening practices of four pediatric clinics. (Ongoing)
  • Evaluate the effect of the CHICA system on referrals for developmental and medical evaluations, and for early developmental intervention and early childhood services. (Ongoing)
  • Develop and follow a cohort of children with identified developmental disabilities to look at the end results and effects of developmental screening. (Upcoming)

2011 Activities: The project intervention including the implementation of the Ages and Stages Questionnaire to identify developmental concerns, display of data for physicians, and tracking of screened patients within CHICA is fully implemented. The team completed all the baseline evaluations of developmental screenings and is reviewing the second and third rounds of screenings. The data collection phase included a chart review at intervention practices to identify rates of diagnosis and referral for services. At the control practices, chart reviews identified referrals as well as developmental screening rates. Because developmental screening is universal at three different stages in life, this study may be powered to look at secondary outcomes such as the rates of confirmation, diagnosis, and intervention.

At the end of 2011, the research team was working on the recruitment of children and their parents to follow as a cohort and evaluate the effects of developmental screening. This recruitment process will continue in 2012. Training of research assistants who will be surveying parents was completed, and in 2012, the research team plans to recruit 20 parents per clinic.

As part of the evaluation, CHICA assembled a report card for physicians to provide feedback on their assessment and management of patients with developmental disorders. In 2011, these scorecards were distributed on a periodic basis to allow multiple rounds of feedback. Providers discuss CHICA general issues on what is working well and what needs to be improved at regularly held meetings. By sharing the feedback reports at these meetings, the research team and providers can discuss what each report says. Currently, the reports are designed to be part of the research process only.

Preliminary Impact and Findings: The team originally planned auto scanning and scoring of the Autism Screening Questionnaire but found that providers prefer to score the screening tool themselves. Qualitatively, they have been looking at the factors that contribute to use of the CHICA system, such as practice type and provider characteristics. In general they are finding that younger physicians are quicker to adopt the system. As part of the research process, the research team proposed CHICA provider user groups as a mechanism to field requests for changes to the system. Recently, the principal investigator decided to select a group of more engaged pediatricians to meet once a month separately from the original provider group. They are able to engage these pediatricians in a more informed way and receive substantive feedback on how to improve CHICA.

Target Population: Pediatric*: Age 0-5, Children with Special Health Care Needs

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Computer Automated Developmental Surveillance and Screening - 2010

Summary Highlights



Target Population: Pediatric*, Persons with Disabilities*

Summary: Developmental disabilities affect between 12 and 16 percent of the pediatric population in the United States. “Best practices” guidelines require that children receive appropriate and timely screening and treatment for these disabilities. Electronic computer decision support strategies (CDSS) offer a promising aid for implementing a standardized approach to developmental surveillance and screening.

Researchers at Indiana University have developed an electronic CDSS for pediatric practices called CHICA (Child Health Improvement Through Computer Automation) to deliver appropriate guidelines to physicians during the patient visit. CHICA will be modified to incorporate developmental surveillance and screening within the existing practice workflow without requiring additional time of the physician or other office staff. The CHICA CDSS system includes elements such as: 1) pediatric guidelines encoded in Arden Syntax, a common computer language representing medical conditions and recommendations; 2) a dynamic, scan form interface for the user; and 3) a Health Level 7-compliant interface to existing medical record systems.

The proposed work extends the CHICA software by incorporating the 2006 American Academy of Pediatrics (AAP) guidelines into the surveillance and screening algorithm, and evaluates the effect of the CHICA system on developmental surveillance, screening, referral, and early intervention and early childhood services. This evaluation follows a cohort of children with developmental disabilities to compare the proportion of children who undergo developmental screening at 9-, 18-, and 30-month visits at four practice sites, two of which have implemented the CDSS system and two of which have not. This evaluation will identify how implementation of the AAP recommendations into CHICA affects adherence to clinical guidelines. In addition, documentation of long-term outcomes will contribute to knowledge about the impact of early surveillance and screening on child health. Qualitative aspects of child screening surveillance will also be explored. These include elements of the child’s management plan, such as family involvement in treatment decisions and planning, treatment that is based on the initial assessment versus treatment that is continuously modified using data-driven decisionmaking, and whether management strategies build on the strengths of the child.

Specific Aims:
  • Expand and modify an existing computer-based decision support system (CHICA) to include the 2006 AAP developmental surveillance and screening algorithm. (Ongoing)
  • Evaluate the effect of the CHICA system on the developmental surveillance and screening practices of four pediatric clinics. (Ongoing)
  • Evaluate the effect of the CHICA system on referrals for developmental and medical evaluations, and for early developmental intervention and early childhood services. (Ongoing)
  • Develop and follow a cohort of children with identified developmental disabilities to look at the end results and effects of developmental screening. (Upcoming)

2010 Activities: The intervention using the CHICA system to facilitate screening for developmental delay at 9-, 18-, and 30-month well-child visits was initiated in 2010. At the technical level, the team made the Ages and Stages questionnaire (ASQ) into a scan document that could be fed into CHICA and scored. The two intervention and two control practices began in July 2010. The grant team collected baseline information on the participating practices, partially through chart review. These practices began surveillance at acute care visits as well as well-child visits. This type of surveillance is a significant change in process for providers. They are used to screening at regular intervals but the concept of screening at any age is new for them. Families typically self-administer the ASQ in the physicians’ waiting rooms. Screening using the ASQ has required some changes in physician workflow. If a family is positively screened, a form is auto-filled to support the referral process to further care and treatment with specialists and other services. The research team has begun the evaluation phase and has started to pull and review clinical charts to assess each practice’s screening and diagnosis practices. In 2011 they will begin giving providers feedback on their screening rates through report cards. The team is also preparing sessions for families when a child receives a diagnosis. The team currently plans to begin publishing the research findings in 2012.

The team is concurrently working on the AAP guidelines for general developmental screening and autism. These guidelines call for a comprehensive screening at the 18-month well-child visit. CHICA was designed to encourage integration and avoid duplication. Because there is need for screening of multiple conditions, there is currently a discussion weighing the various benefits of screening for autism versus general developmental screening.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The team is mostly on track with all project milestones. The one area that is somewhat behind the original schedule is the chart review process. Budget spending is on target.

Preliminary Impact and Findings: The team originally planned auto scanning and scoring of the ASQ but found that providers prefer to score the screening tool themselves. Qualitatively, they have been looking at the factors that contribute to use of the CHICA system, such as practice type, and provider characteristics. In general they are finding that younger physicians are quicker to adopt the system.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

*AHRQ Priority Population.

Computer Automated Developmental Surveillance and Screening - Final Report

Citation:
Carroll A. Computer Automated Developmental Surveillance and Screening - Final Report. (Prepared by Indiana University under Grant No. R01 HS017939). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 57.42 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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