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Objective HL7 SMART on FHIR apps have the potential to improve healthcare delivery and EHR usability, but providers must be aware of the apps and use them for these potential benefits to be realized. The HL7 CDS Hooks standard was developed in part for this purpose. The objective of this study was to determine if contextually relevant CDS Hooks prompts can increase utilization of a SMART on FHIR medical reference app (MDCalc for EHR). Materials and Methods We conducted a 7-month, provider-randomized trial with 70 providers in a single emergency department. The intervention was a collection of CDS Hooks prompts suggesting the use of 6 medical calculators in a SMART on FHIR medical reference app. The primary outcome was the percentage of provider–patient interactions in which the app was used to view a recommended calculator. Secondary outcomes were app usage stratified by individual calculators. Results Intervention group providers viewed a study calculator in the app in 6.0% of interactions compared to 2.6% in the control group (odds ratio = 2.45, 95% CI, 1.2–5.2, P value .02), an increase of 130%. App use was significantly greater for 2 of 6 calculators. Discussion and Conclusion Contextually relevant CDS Hooks prompts led to a significant increase in SMART on FHIR app utilization. This demonstrates the potential of using CDS Hooks to guide appropriate use of SMART on FHIR apps and was a primary motivation for the development of the standard. Future research may evaluate potential impacts on clinical care decisions and outcomes.

Objective The Genomic Medicine Working Group of the National Advisory Council for Human Genome Research virtually hosted its 13th genomic medicine meeting titled “Developing a Clinical Genomic Informatics Research Agenda”. The meeting’s goal was to articulate a research strategy to develop Genomics-based Clinical Informatics Tools and Resources (GCIT) to improve the detection, treatment, and reporting of genetic disorders in clinical settings. Materials and Methods Experts from government agencies, the private sector, and academia in genomic medicine and clinical informatics were invited to address the meeting's goals. Invitees were also asked to complete a survey to assess important considerations needed to develop a genomic-based clinical informatics research strategy. Results Outcomes from the meeting included identifying short-term research needs, such as designing and implementing standards-based interfaces between laboratory information systems and electronic health records, as well as long-term projects, such as identifying and addressing barriers related to the establishment and implementation of genomic data exchange systems that, in turn, the research community could help address. Discussion Discussions centered on identifying gaps and barriers that impede the use of GCIT in genomic medicine. Emergent themes from the meeting included developing an implementation science framework, defining a value proposition for all stakeholders, fostering engagement with patients and partners to develop applications under patient control, promoting the use of relevant clinical workflows in research, and lowering related barriers to regulatory processes. Another key theme was recognizing pervasive biases in data and information systems, algorithms, access, value, and knowledge repositories and identifying ways to resolve them.

Lung cancer screening with low-dose computed tomography (CT) could help avert thousands of deaths each year. Since the implementation of screening is complex and underspecified, there is a need for systematic and theory-based strategies. Explore the implementation of lung cancer screening in primary care, in the context of integrating a decision aid into the electronic health record. Design implementation strategies that target hypothesized mechanisms of change and context-specific barriers. The study had two phases. The Qualitative Analysis phase included semi-structured interviews with primary care physicians to elicit key task behaviors (e.g., ordering a low-dose CT) and understand the underlying behavioral determinants (e.g., social influence). The Implementation Strategy Design phase consisted of defining implementation strategies and hypothesizing causal pathways to improve screening with a decision aid. Three key task behaviors and four behavioral determinants emerged from 14 interviews. Implementation strategies were designed to target multiple levels of influence. Strategies included increasing provider self-efficacy toward performing shared decision making and using the decision aid, improving provider performance expectancy toward ordering a low-dose CT, increasing social influence toward performing shared decision making and using the decision aid, and addressing key facilitators to using the decision aid. This study contributes knowledge about theoretical determinants of key task behaviors associated with lung cancer screening. We designed implementation strategies according to causal pathways that can be replicated and tested at other institutions. Future research is needed to evaluate the effectiveness of these strategies and to determine the contexts in which they can be effectively applied.

Background Evidence supports streamlined approaches for inpatients with community-acquired pneumonia (CAP) including early transition to oral antibiotics and shorter therapy. Uptake of these approaches is variable, and the best approaches to local implementation of infection-specific guidelines are unknown. Our objective was to evaluate the impact of a clinical decision support (CDS) tool linked with a clinical pathway on CAP care. Methods This is a retrospective, observational pre–post intervention study of inpatients with pneumonia admitted to a single academic medical center. Interventions were introduced in 3 sequential 6-month phases; Phase 1: education alone; Phase 2: education and a CDS-driven CAP pathway coupled with active antimicrobial stewardship and provider feedback; and Phase 3: education and a CDS-driven CAP pathway without active stewardship. The 12 months preceding the intervention were used as a baseline. Primary outcomes were length of intravenous antibiotic therapy and total length of antibiotic therapy. Clinical, process, and cost outcomes were also measured. Results The study included 1021 visits. Phase 2 was associated with significantly lower length of intravenous and total antibiotic therapy, higher procalcitonin lab utilization, and a 20% cost reduction compared with baseline. Phase 3 was associated with significantly lower length of intravenous antibiotic therapy and higher procalcitonin lab utilization compared with baseline. Conclusions A CDS-driven CAP pathway supplemented by active antimicrobial stewardship review led to the most robust improvements in antibiotic use and decreased costs with similar clinical outcomes.

ObjectiveTo determine the impact of a graphical information display on diagnosing circulatory shock.Materials and MethodsThis was an experimental study comparing integrated and conventional information displays. Participants were intensivists or critical care fellows (experts) and first-year medical residents (novices).ResultsThe integrated display was associated with higher performance (87% vs 82%; P < .001), less time (2.9 vs 3.5 min; P = .008), and more accurate etiology (67% vs 54%; P = .048) compared to the conventional display. When stratified by experience, novice physicians using the integrated display had higher performance (86% vs 69%; P < .001), less time (2.9 vs 3.7 min; P = .03), and more accurate etiology (65% vs 42%; P = .02); expert physicians using the integrated display had nonsignificantly improved performance (87% vs 82%; P = .09), time (2.9 vs 3.3; P = .28), and etiology (69% vs 67%; P = .81).DiscussionThe integrated display appeared to support efficient information processing, which resulted in more rapid and accurate circulatory shock diagnosis. Evidence more strongly supported a difference for novices, suggesting that graphical displays may help reduce expert–novice performance gaps.