Using the Electronic Medical Record to Improve Outcomes and Decrease Disparities in Screening for Child Physical Abuse

Child physical abuse is the leading cause of trauma-related death in children younger than 4 years of age in the United States. Many of the children who are injured or die as the result of physical abuse had been previously evaluated by a physician, and the diagnosis of abuse was not recognized. Failure to recognize abuse in its less severe forms can result in repeated abuse and increased morbidity and mortality. Numerous studies demonstrate that physicians fail to consistently screen for abuse in even high-risk situations. Studies have also shown persistent and pervasive disparities in screening practices related to both patient and hospital characteristics. Recent literature demonstrates that the electronic medical record (EMR) can be used to improve screening rates in a wide variety of diseases, thereby allowing for early intervention and improved outcomes. Objectives: 1. To compare compliance rates with evidence-based screening protocols for child physical abuse before and after implementation of a trigger system within the Cerner EMR using a parallel group randomized controlled trial. 2. To compare the accuracy of screening by patient race (white vs. non-white), insurance status (private vs. public insurance), and hospital-type (community vs. academic) when physicians do and do not receive screening prompts that are embedded within the EMR. Methods: A five-step process will be used to meet the objectives. 1. Integrating of triggers into the EMR that allow physicians to screen for physical abuse. 2. Testing of the “trigger system” to assess the sensitivity and specificity of the trigger system and calculation baseline screening rates. 3. Performing usability evaluation to design prompts that fit into the workflow. 4. Training physicians/physician-extenders, nurses, and social workers to use the system. 5. “Go-Live”—Randomizing of patients to activate or not activate a prompt to complete evidence-based testing. Patient Outcome: The primary outcome is completion of the relevant quality metric(s) for patients in each group (control vs. experimental). The secondary outcome is lack of disparity of screening by patient race, insurance type, or hospital-type. Successful completion of these objectives will demonstrate the ability to use the EMR to improve evidence-based screening for child physical abuse and decrease disparities in screening.