MD/PhD student Duke University School of Medicine Duke University School of Medicine Durham, North Carolina, United States
Background: Health systems around the world are implementing screening and clinical decision support tools within electronic health records (EHR) to identify maltreatment and standardize child abuse evaluations. However, critical knowledge gaps exist regarding the impacts and feasibility of such strategies.
Objective: To conduct a systematic review on the use of EHR-based strategies for the screening and evaluation of children with suspected abuse and pair this review with key informant interviews to understand the barriers and concerns of implementing such strategies in practice.
Design/Methods: A search was conducted with assistance of a librarian (SK) to identify all articles prior to Aug 2020 that describe an EHR-based child abuse screen (CA-S) and/or clinical decision support strategy (CA-CDSS) using MEDLINE, Embase, EBSCO, Scopus, and CINAHL. We included all peer-reviewed English language articles that focused specifically on child maltreatment or abuse.
Key Informant Interviews were conducted with 20 child maltreatment experts from 4 countries and 9 US states. Interviews were coded using Nvivo to determine common themes.
Results: Nearly all studies focused on strategies implemented in an Emergency Department setting and on analyzing the specificity and sensitivity of their tool. No studies evaluated the impact of the EHR tool on children’s long-term clinical outcomes. Many interviewees cited the lack of sufficient evidence supporting the use of EHR CA-S/CA-CDSS as a major barrier to uptake, which is warranted based on the current literature. Another common concern was time-intensiveness of implementing such tools, which is also supported by this review. While many interviewees shared concerns regarding bias, the literature suggests that EHR CA-S and CA-CDSS may reduce disparities in screening/consideration of maltreatment; however, more work is necessary to ensure bias does not impact other key decisions in the evaluation process. Conclusion(s): To our knowledge, this paper represents the first systematic review focusing specifically on EHR-based CA-S and CA-CDSS. By combining interviews with a systematic review, we integrate the perspective of child maltreatment experts with scientific evidence to describe the benefits and drawbacks of using these EHR tools in practice. Future research should focus on determining the impact of false-positive screens, evaluating long-term outcomes for children, and estimating the cost-effectiveness of such strategies.
Authors/Institutions: Laura R. Stilwell, Duke University School of Medicine, Durham, North Carolina, United States; Megan Golonka, Duke University Sanford School of Public Policy, Durham, North Carolina, United States; Kristin Ankoma-Sey, Duke University, Durham, North Carolina, United States; Madeleine Yancy, Duke University, Durham, North Carolina, United States; Samantha Kaplan, Duke University School of Medicine, Durham, North Carolina, United States; Lindsay Terrell, Duke Medicine, Durham, North Carolina, United States; Elizabeth J. Gifford, Duke University Sanford School of Public Policy, Durham, North Carolina, United States
