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CHADIS Research and Development
CHADIS Research and Development
January 3, 2017
Study to featured in the next issue of World Biomedical Frontiers because of its innovation and potential for significant impact.
Autism Screening With Online Decision Support by Primary Care Pediatricians Aided by M-CHAT/F
Raymond Sturner, Barbara Howard, Paul Bergmann, Tanya Morrel, Lindsay Andon, Danielle Marks, Patricia Rao, Rebecca Landa Pediatrics Aug 2016, e20153036; DOI: 10.1542/peds.2015-3036
CHADIS receives NICHD award aimed at reduction of child maltreatment and addressing family stress. A unique family stress "patient specific template" has been created for this purposes and is being further refined through clinical simulations with primary care pediatricians and feedback from a diverse group of parents. This module will be studied further in a large scale cluster randomized trial. Interested practices should contact Dr. Barbara Howard at firstname.lastname@example.org Click to view Family Stress Grant Summary.
CHADIS American Board of Pediatrics (ABP) Portfolio Sponsor status renewed for the Maintenance of Certification (MOC-4) program. CHADIS is unique in matching patient generated data with prompted clinician decision making so chart reviews are not needed. Portfolio Sponsors are programs recognized as having demonstrated success in creating approved quality improvement processes for formal re-certification of specialty status and are able to create their own programs on behalf of the ABP. CHADIS offers MOC-4 for the following areas: Autism Screening; Developmental Screening; Asthma; ADHD; and Family Stress.
CHADIS has been developed with the assistance of grant funding from a number of agencies and sponsors. Drs. Sturner and Howard have acted as principal investigators with the assistance of the CHADIS research staff and many other professional collaborators. These grants include support from the following granting agencies: The Abell Foundation, the Wilson Foundation, the Commonwealth Fund, The Erickson Foundation, The Cisco Foundation, The State of Maryland, and the Maternal Child Health Bureau and the National Institutes of Mental Health. In addition, eleven SBIR (Small Business Innovative Research) awards were given for purposes of CHADIS research and development through Total Child Health, including six from the National Institutes of Mental Health (NIMH) and two from the National Institute of Child Health and Development (NICHD), two from the National Heart Lung and Blood Institute (NHLBI) and one from the Center for Disease Control (CDC). In addition, we have completed subcontracts aimed at developing modules for CHADIS as co-investigators with support from the Doris Duke Charitable Foundation and Substance Abuse and Mental Health Agency (SAMSHA).
Recent Posters Presented (September 2016)
Posters Presented at The Society for Behavioral and Developmental Pediatrics Conference 2016
Current Research Projects (March, 2016):
Autism is prevalent (1 in 50 children) and impairing, but early intervention has been shown to improve outcomes prompting recommendations for screening at both two year and 18 month health check-ups. Detection of autism early is crucial, but accurate screening tools have been elusive. In Phase II, a practical method of improving accuracy of M-CHAT, the most widely used autism screen, was created by adapting the validated and recommended follow up interview, M-CHAT F/Ui (F/U), for efficient use during the visit. In the case of a positive screen, the primary care provider (PCP) can use CHADIS, a web-based questionnaire delivery, decision support and post-visit engagement system, to conduct F/U rather than requiring a visit with another professional. Phase II data showed F/U results by a PCP were equivalent to the autism center. Phase II data on the M-CHAT plus F/U via CHADIS replicated findings of the F/U authors in showing both excellent positive predictive value (PPV) 0.96 for children >20 months (thus effective for 24 month olds) and also low PPV 0.54 for <20 months. Promisingly, Phase II exploratory analyses using a decision tree including supplementary data from a routinely used standard language screen (ASQ communication scale) and an item from a language measure (MCDI) plus the standard autism screen (M-CHAT plus F/U) reached PPV of 0.95 in the <20 month group. This screen completion could be done efficiently online by parents. Phase 2B plans a replication of this screening procedure which promises to be accurate for 18 month olds and comparison to alternatives using the community network of >400 Maryland doctors where >22,000 autism screens have been done using the CHADIS system.
A more accurate screening test is of less value if it is not universally used. In Phase II an approach was developed that reduces disparities in access to screening using a “talking” tablet kiosk that was preferred by parents to alternatives, but further workflow issues will be addressed in Phase 2B. To improve screen completion we will program an automated reminder/completion confirmation text/email system in CHADIS with coupons as incentives for parents. In Phase II CHADIS was adapted to capture both patient input and doctor decision-making and Maintenance of Certification (MOC) accreditation was awarded by the American Board of Pediatrics for this program and earned by 140 pediatricians. This monthly doctor quality improvement program will be extended to a daily continuous quality improvement process for the whole office team to further assure patient participation in screening while providing other clinical and financial analytics of value to the office. The Phase 2B goal is to develop and test an innovative “screening system” not just a new test.
Notes: Data collection is underway within a network of Maryland pediatric practices. In addition to the replication of earlier work, item sets are being evaluated from collaborators from Cambridge University, England led by Dr. Simon Baron-Cohen, Brock University, Canada led by Dr. Maurice Feldman, and University of North Carolina, U.S. A., led by Dr. Linda Watson.
Web System for Engaging Families and Doctors in Continuous Asthma Quality Improvement
Asthma affects 8% of US children and is a leading cause of ED visits, hospitalization, missed school, suffering and death. It disproportionately affects low income minorities. This proposal seeks to overcome health care delivery barriers to implementation of national asthma guidelines – both clinician failure to provide guideline based care and patient adherence when appropriate treatments are offered. This project will develop and then test effectiveness of an innovative web-based decision support system (CHADIS) to support teaming doctors and patients in parallel processes of continuous quality improvement of asthma care for doctors and engagement of parents and children in their own care. CHADIS engages parents in completing pre-visit questionnaires, which trigger patient specific decision support for doctors for use in the visit. Patients will complete the Pediatric Asthma Control & Communication Instrument (PACCI ), a questionnaire of asthma symptoms recently validated across a range of demographics by one of the co-investigators, online via CHADIS pre-visit and between visits. Doctor interaction with CHADIS decision support during the visit results in both documentation for recertification credit and triggering of individualized parent education to appear in an enticing website for each child called the MemoryBook Care Portal. Patient adherence is addressed through Problem Solving Counseling by the clinician prompted by the pre-visit data on symptoms and barriers. Patients also are provided tailored default messages and alerts in the Care Portal which can also be monitored by a remote coach. Monitoring of asthma symptoms between visits is expected and CHADIS uses multiple forms of automated communication (texting, email, phone) to prompt completion of the PACCI. In addition, parents are encouraged to do questionnaires through multimodal reinforcements including: the MemoryBook, coupons for free products and “gamification” i.e. entertaining videos and quiz games for individualized patient education. In Phase I the system is built with professional and patient feedback and piloting and presented to medical specialty boards for formal QI MOC certification. In Phase II the system is further refined and then tested for effectiveness in improving asthma control by a large intervention study using a cluster randomized control design. The Phase III product will have market value as it improves and documents care for Quality Improvement, Maintenance of Certification credit, meaningful use, clinical quality measurement, pay for performance and Medical Home efforts.
Notes: Dr. Sande Okelo, pediatric pulmonologist at UCLA and author of the PACCI is a co-investigator. 22 pediatric practices representing all regions of the country are now enrolled in the intervention studies.
A Tool for Supporting and Monitoring Decision Making in ADHD
This proposal is to complete and validate a new web-based tool to assist in the screening, diagnosis and management of mental health disorders (focusing here on ADHD), quality improvement (QI) documentation and efficient large scale research. CHADIS is a screening, assessment and decision support system delivering tools online for care of health, development, and mental health conditions including ADHD. CHADIS provides online questionnaires for parents, teens and teachers to complete prior to a visit. These are automatically scored to yield conclusions on a worksheet linked to electronic chapters of clinician guidance and myriad resources for families which become handouts. Clinical data is shared securely among professionals, also forming a deidentified research database. This proposal is to adapt CHADIS tools to optimize use for ADHD care, QI and research. Proper care of ADHD (Attention Deficit Hyperactivity Disorder), a common treatable mental health condition, calls for accurate diagnosis, assessment for comorbidity and multiple observer input. Among CHADIS' tools is a comprehensive previsit parent questionnaire (CHADIS-DSM) for assessing child mental health problems based on the logic of both DSM-IV and DSM-PC and producing provisional DSM diagnoses. While pilot data on CHADIS DSM is encouraging, additional validation focusing on ADHD and its comorbidities is needed. This project also proposes creating case-specific templates (CST) within CHADIS to receive the responses from all previsit parent, teen or teacher questionnaires to provide specific guidance to clinicians. CSTs will provide the clinician with evidence-based prompts, e.g. symptoms to explore, suggested wording for questions, menus of observations from which to select, and related text to help further confirm, refute or change the presumptive conclusions from parent/teen data. CST use will document evidence of diagnostic criteria, diagnose more accurately, improve care, and compile a research database. This study will validate CHADIS-DSM for ADHD and its comorbidities and assess the impact of CSTs on accuracy of diagnoses. 1100 4-12 year olds presenting for care in 2 existing CHADIS practice networks will be screened. Those 300 seeking care for behavior problems, and all positive among 800 coming for well visits plus a random sample of those negative will complete comparison and gold standard criterion measures. Pediatricians are required to conduct a QI effort in use of evidence based practices in order tomaintain professional certification through the American Board of Pediatrics (ABP). ABP approved QI programs require chart audits for documentation of approved care, difficult for practices to implement. Another product of this proposal is making CHADIS the first system for pediatric care that collects both patient data and clinician responses thus providing automated documentation of care for QI accreditation. PUBLIC HEALTH RELEVANCE: Attention Deficit Hyperactivity Disorder (ADHD), a disorder affecting 4-12% of children, is mainly diagnosed and managed by primary care physicians yet evidence based guidelines and optimized outcomes are generally not achieved. The American Board of Pediatrics is striving to improve all pediatric care by requiring Quality Improvement (QI) activities but the recertification process is onerous. This proposal is to complete and validate additions to CHADIS, an innovative web-based system for healthcare that delivers pre-visit questionnaires online and presents results to the clinician linked to decision support and helpful resource listings, in order to overcome obstacles to implementation of QI, in this case for ADHD, by guiding and documenting clinicians' responses to parent input, to increase evidence-based care and to create a tool facilitating large scale research projects.
Notes: In addition to the above plan, in order to better adhere to AAP guidelines for identifying parent goals for care and the CHADIS emphasis on evidence-based shared decision-making early in the project data was collected from 441 parents prior to ADHD visits regarding their goals for the visit as part of a process to develop a new goal setting questionnaire (article below). This questionnaire is now one of a series of measures that are being used to trigger clinician decision support and options for guidance messages for families which can be printed or provided through the CHADIS Memorybook Careportal, a secure webpage for each child.
McGoron, L., Sturner, R., Howard, B., Barry, T. D., Seymour, K. Tomeny, T. S., Morrel, T., Ellis, B. M., Marks, D., Parents’ Goals for ADHD Care in a Clinical Pediatric Sample., Clinical Pediatrics 53, 10, 949-959., 2014