Advertisement

Electronic Health Record Tools to Identify Child Maltreatment: Scoping Literature Review and Key Informant Interviews

Published:February 04, 2022DOI:https://doi.org/10.1016/j.acap.2022.01.017

      Abstract

      Objective

      To prevent missed cases and standardize care, health systems are beginning to implement EHR-based screens (EHR-CA-S) and clinical decision supports systems (EHR-CA-CDSS) for the identification and management of child maltreatment. This study aimed to 1) document the existing research evidence on the performance of EHR-CA-S and EHR-CA-CDSS and 2) examine clinical perspectives regarding the use of such tools and factors that affect uptake.

      Methods

      We searched MEDLINE, Embase, EBSCO, Scopus, and CINAHL databases for English language articles published prior to November 2021 that describe and/or evaluated an EHR-CA-S and/or EHR-CA-CDSS involving 0 to 18-year olds. We performed semistructured interviews with 20 individuals who have experience in identifying, evaluating, and/or treating child maltreatment and/or conducting research on these topics.

      Results

      Our search identified 574 articles; 16 met inclusion criteria. Studies examined screening, alerts and triggers, and quality improvement. None evaluated long-term clinical outcomes. Sensitivity ranged from 0.14 to 1.00, specificity from 0.865 to 1.00, positive predictive value from 0.03 to 1.00 and negative predictive value from 0.55 to 1.00. A variety of EHR-CA-S and/or EHR-CA-CDSS have been implemented at institutions in our sample. Interviewees cited missed cases, policy requirements, and the lack of standardization of care as impetuses for adopting these tools, yet expressed concerns regarding insufficient evidence, bias, and time-intensiveness of implementation.

      Conclusions

      Interviewees and the literature agree that current evidence does not support adoption of a particular CA-S or CA-CDSS. Further refinement and research on EHR-CA-S and EHR-CA-CDSS is necessary for these tools to be feasibly implemented and sustained, reliable for clinical practice, and not cause any unintentional harms.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Academic Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kellogg ND
        Evaluation of suspected child physical abuse.
        Pediatrics. 2007; 119: 1232-1241
        • Sheets LK
        • Leach ME
        • Koszewski IJ
        • et al.
        Sentinel injuries in infants evaluated for child physical abuse.
        Pediatrics. 2013; 131: 701-707https://doi.org/10.1542/peds.2012-2780
        • Lindberg DM
        To recognize child physical abuse early, frontline clinicians need subspecialty expertise.
        JAMA Network Open. 2021; 4e215947
        • McTavish JR
        • Gonzalez A
        • Santesso N
        • et al.
        Identifying children exposed to maltreatment: a systematic review update.
        BMC Pediatr. 2020; 20: 113https://doi.org/10.1186/s12887-020-2015-4
        • Bailhache M
        • Leroy V
        • Pillet P
        • et al.
        Is early detection of abused children possible?: a systematic review of the diagnostic accuracy of the identification of abused children.
        BMC Pediatr. 2013; 13: 1-11
        • Cebul RD
        • Love TE
        • Jain AK
        • et al.
        Electronic health records and quality of diabetes care.
        N Engl J Med. 2011; 365: 825-833https://doi.org/10.1056/NEJMsa1102519
        • Mainous 3rd, AG
        • Lambourne CA
        • Nietert PJ
        Impact of a clinical decision support system on antibiotic prescribing for acute respiratory infections in primary care: quasi-experimental trial.
        J Am Med Inform Assoc. 2013; 20: 317-324https://doi.org/10.1136/amiajnl-2011-000701
        • Shiffman RN
        • Liaw Y
        • Brandt CA
        • et al.
        Computer-based guideline implementation systems: a systematic review of functionality and effectiveness.
        J Am Med Inform Assoc. 1999; 6: 104-114https://doi.org/10.1136/jamia.1999.0060104
        • Smythe MA
        • Mehta TP
        • Koerber JM
        • et al.
        Development and implementation of a comprehensive heparin-induced thrombocytopenia recognition and management protocol.
        Am J Health Syst Pharm. 2012; 69: 241-248https://doi.org/10.2146/ajhp110313
        • Berger RP
        • Lindberg DM
        Early recognition of physical abuse: bridging the gap between knowledge and practice.
        J Pediatr. 2019; 204: 16-23https://doi.org/10.1016/j.jpeds.2018.07.081
      1. Veritas Health Innovation. Covidence Systematic Review Software.www.covidence.org

      2. Zoom. 2021. https://zoom.us/

      3. QSR International. NVivo 12 software. https://www.qsrinternational.com

        • Egyud A
        • Stephens K
        • Swanson-Bierman B
        • et al.
        Implementation of human trafficking education and treatment algorithm in the emergency department.
        J Emerg Nurs. 2017; 43: 526-531https://doi.org/10.1016/j.jen.2017.01.008
        • Sittig JS
        • Uiterwaal CS
        • Moons KG
        • et al.
        Value of systematic detection of physical child abuse at emergency rooms: a cross-sectional diagnostic accuracy study.
        BMJ Open. 2016; 6: e010788https://doi.org/10.1136/bmjopen-2015-010788
        • Bousema S
        • Stas HG
        • van de Merwe MH
        • et al.
        Epidemiology and screening of intentional burns in children in a Dutch burn centre.
        Burns. 2016; 42: 1287-1294
        • Louwers EC
        • Korfage IJ
        • Affourtit MJ
        • et al.
        Accuracy of a screening instrument to identify potential child abuse in emergency departments.
        Child Abuse Negl. 2014; 38: 1275-1281
        • Schouten MC
        • van Stel HF
        • Verheij TJ
        • et al.
        The value of a checklist for child abuse in out-of-hours primary care: to screen or not to screen.
        PLoS One. 2017; 12e0165641
        • Teeuw AH
        • Kraan RB
        • van Rijn RR
        • et al.
        Screening for child abuse using a checklist and physical examinations in the emergency department led to the detection of more cases.
        Acta Paediatr. 2019; 108: 300-313
        • Dinpanah H
        • Pasha AA
        Potential child abuse screening in emergency department; a diagnostic accuracy study.
        Emergency. 2017; 5: e8
        • Rumball-Smith J
        • Fromkin J
        • Rosenthal B
        • et al.
        Implementation of routine electronic health record-based child abuse screening in general emergency departments.
        Child Abuse Negl. 2018; 85: 58-67https://doi.org/10.1016/j.chiabu.2018.08.008
        • Gonzalez DO
        • Deans KJ
        Hospital-based screening tools in the identification of non-accidental trauma.
        Semin Pediatr Surg. 2017; 26: 43-46https://doi.org/10.1053/j.sempedsurg.2017.01.002
        • Schouten MCM
        • van Stel HF
        • Verheij TJM
        • et al.
        A screening protocol for child abuse at out-of-hours primary care locations: a descriptive study.
        BMC Fam Pract. 2016; 17: 155https://doi.org/10.1186/s12875-016-0554-4
        • Suresh S
        • Saladino RA
        • Fromkin J
        • et al.
        Integration of physical abuse clinical decision support into the electronic health record at a tertiary care children's hospital.
        J Am Med Inform Assoc. 2018; 25: 833-840https://doi.org/10.1093/jamia/ocy025
        • Rosenthal B
        • Skrbin J
        • Fromkin J
        • et al.
        Integration of physical abuse clinical decision support at 2 general emergency departments.
        J Am Med Inform Assoc. 2019; 26: 1020-1029
        • McGinn T
        • Feldstein DA
        • Barata I
        • et al.
        Dissemination of child abuse clinical decision support: moving beyond a single electronic health record.
        Int J Med Informatics. 2021; 147104349
        • Krawiec C
        • Gerard S
        • Iriana S
        • et al.
        What we can learn from failure: an EHR-based child protection alert system.
        Child Maltreat. 2020; 25: 61-69https://doi.org/10.1177/1077559519848845
        • Riney LC
        • Frey TM
        • Fain ET
        • et al.
        Standardizing the evaluation of nonaccidental trauma in a large pediatric emergency department.
        Pediatrics. 2018; 141https://doi.org/10.1542/peds.2017-1994
        • Chung EK
        • Gubernick RS
        • LaNoue M
        • et al.
        Child abuse and neglect risk assessment: quality improvement in a primary care setting.
        Acad Pediatr. 2019; 19: 227-235https://doi.org/10.1016/j.acap.2018.09.011
        • McGovern A
        • van Vlymen J
        • Liyanage H
        • et al.
        A simple clinical coding strategy to improve recording of child maltreatment concerns: an audit study.
        Br J Gen Pract. 2014; 64: 389-390https://doi.org/10.3399/bjgp14X680881
        • van Konijnenburg EMH
        • Teeuw AH
        • Zwaard SA
        • et al.
        Screening methods to detect child maltreatment: high variability in Dutch emergency departments.
        Emerg Med J. 2014; 31: 196-200
      4. voor Gezondheidszorg I. Huisartsenposten onvoldoende alert op kindermishandeling. Inventariserend onderzoek naar de kwaliteit van de signalering van kindermishandeling op huisartsenposten (in Dutch) Den Haag: Ministerie van Volksgezondheid Welzijn en Sport. 2010;

        • Berger RP
        • Saladino RA
        • Fromkin J
        • et al.
        Development of an electronic medical record-based child physical abuse alert system.
        J Am Med Inform Assoc. 2018; 25: 142-149https://doi.org/10.1093/jamia/ocx063
        • Gilbert R
        • Widom CS
        • Browne K
        • et al.
        Burden and consequences of child maltreatment in high-income countries.
        Lancet North Am Ed. 2009; 373: 68-81
        • Ash JS
        • Sittig DF
        • Poon EG
        • et al.
        The extent and importance of unintended consequences related to computerized provider order entry.
        J Am Med Inform Assoc. 2007; 14: 415-423
        • Middleton B
        • Sittig D
        • Wright A
        Clinical decision support: a 25 year retrospective and a 25 year vision.
        Yearbook Med Inform. 2016; 25: S103-S116
        • Sutton RT
        • Pincock D
        • Baumgart DC
        • et al.
        An overview of clinical decision support systems: benefits, risks, and strategies for success.
        NPJ Digit Med. 2020; 3: 1-10
        • Abbing HR
        Medical confidentiality and patient safety: reporting procedures.
        Eur J Health Law. 2014; 21: 245-259
      5. U.S. Department of Health & Human Services. Child maltreatment 2018. 2020.

      6. Child Welfare Information Gateway. Mandated reporters of child abuse and neglect. 2019. State Statutes.

        • Fong K
        Getting eyes in the home: child protective services investigations and state surveillance of family life.
        Am Sociol Rev. 2020; 85: 610-638
        • Jenny C
        • Hymel KP
        • Ritzen A
        • et al.
        Analysis of missed cases of abusive head trauma.
        JAMA. 1999; 281: 621-626https://doi.org/10.1001/jama.281.7.621
        • Flaherty E
        • Sege R
        • Mattson C
        • et al.
        Assessment of suspicion of abuse in the primary care setting.
        Ambul Pediatr. 2002; 2: 120-126
        • Rangel EL
        • Cook BS
        • Bennett BL
        • et al.
        Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline.
        J Pediatr Surg. 2009; 44: 1229-1235
        • McLennan JD
        • McTavish JR
        • MacMillan HL
        Routine screening of ACEs: should we or shouldn’t we?.
        Adverse Childhood Experiences. Academic Press, Cambridge, Mass2020: 145-159
        • Dobrow MJ
        • Hagens V
        • Chafe R
        • et al.
        Consolidated principles for screening based on a systematic review and consensus process.
        CMAJ. 2018; 190: E422-E429
        • Castillo RS
        • Kelemen A
        Considerations for a successful clinical decision support system.
        CIN: Comput Inform Nurs. 2013; 31: 319-326
        • Tcheng JE
        • Bakken S
        • Bates DW
        • et al.
        Optimizing Strategies for Clinical Decision Support: Summary of a Meeting Series.
        National Academy of Medicine, Washington, DC2017
        • Trokel M
        • Waddimba A
        • Griffith J
        • et al.
        Variation in the diagnosis of child abuse in severely injured infants.
        Pediatrics. 2006; 117: 722-728
        • Ravichandiran N
        • Schuh S
        • Bejuk M
        • et al.
        Delayed identification of pediatric abuse-related fractures.
        Pediatrics. 2010; 125: 60-66
        • Melville JD
        • Laub N
        • Palusci VJ
        Applications of telemedicine in child abuse pediatrics.
        Clin Pediatr Emerg Med. 2020; 100789