Evaluation of the Impact of EHR-Alerts on Clinical Decision Support Pathway Use in Bronchiolitis, and the Impact of Pathway Use on the Prescription of High Flow Nasal Cannula and Other Elements of High Value Care.

Bronchiolitis

best practice advisory, clinical decision support, clinical guideline, clinical pathway, practice advisory, EHR alert

The goal of this experimental study is to learn whether different types of Electronic Health Record (EHR) alerts that direct clinicians to reference clinical guidelines embedded in the increase the use of these guidelines and the delivery of evidence-based care in children presenting to the hospital with bronchiolitis. The main questions it aims to answer are: * Do EHR-alerts increase clinicians' us of evidence-based EHR-integrated Clinical Decision Support (CDS) guidelines for the care of bronchiolitis and * Is the use of EHR-integrated CDS-guidelines for the care of bronchiolitis associated with deceases in low-value use of High Flow Nasal Cannula (HFNC) and improvement in other aspects of high-value care for this disease Patients will be randomized on the encounter-level to have the patient's treating providers receive no EHR-alert or one of two types of EHR-alert (non-interruptive or interruptive) reminding the provider that the EHR-integrated CDS guideline is available for the care or bronchiolitis. Researchers will compare the rate of use of EHR-integrated CDS guidelines in patients whose clinicians did not receive any EHR-alerts, to those whose clinicians received a non-interruptive alert and to those whose clinicians received an interruptive Best Practice Advisory (BPA). In addition, the study will evaluate whether the utilization of the EHR-integrated CDS guideline in a given encounter was associated with less low-value HFNC use, and differences in other elements of low-value care for bronchiolitis. Patients in all groups will continue to receive standard hospital care for bronchiolitis as determined by the patient's treating clinicians.

Bronchiolitis is a viral respiratory illness affecting infants and toddlers and is the most common reason for hospitalization amongst children less than 2 years old. However, many children admitted with bronchiolitis receive unnecessary treatments that do not hasten recovery and may even cause harm. Despite evidence that the best treatment for bronchiolitis is supportive care (i.e. oxygen and hydration support), clinicians continue to overuse certain therapies, leading to longer hospital stays, higher costs, and increased stress for families. The investigators will study the effects of EHR-alerts on clinical decision support (CDS) guideline use, and the effect of CDS guideline use on High Flow Nasal Cannula (HFNC) use and other clinical outcomes. EHR alerts are real-time alerts within the EHR which may be used for various purposes, but in this study are designed to remind providers that a detailed clinical decision support algorithm exists for the treatment of bronchiolitis. There are multiple BPA designs commonly used in EHRs: 1) interruptive alerts, which require clinicians to interact with the alert to continue the clinician's workflow; and 2) non-interruptive alerts, which appear as visual cues but do not require clinicians to alter workflows. When patients meet criteria for the likely presence of bronchiolitis based on Electronic Medical Records (EMR) indicators of disease, the patient will be randomized into three groups in a 1:1:1 ratio. One group (control) will receive no EHR-alerts. In one group the providers will receive interruptive EHR-alerts reminding the provider that the CDS-guideline is available in the EHR and likely to be appropriate for the patient. In the last group, providers will be exposed to a non-interruptive alert (a highlighted textual banner presented to the provider when the providers are interacting with the patient's electronic medical record) reminding the provider that the CDS-guideline is available in the EHR and likely to be appropriate for the patient. The randomized groups will be compared on an intention-to-treat basis to evaluate the impact of EHR-alert exposure on CDS-guideline usage as demonstrated by the number and nature of provider interactions with the CDS guideline tool. In addition, in a related non-randomized retrospective observational evaluation, we will compare the impact of CDS-guideline usage (the outcome of the randomized evaluation) on the provision of high-value care for bronchiolitis. Specifically, because the guideline emphasizes the use of high-value HFNC, and the avoidance of low-value HFNC treatments, this analysis with focus primarily on the use of HFNC in bronchiolitis. It will also evaluate whether CDS-guideline use impacts the rate of other low-value treatments for bronchiolitis, and outcomes such as ICU admission, length or stay and readmissions.

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