Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record
Authors: Barbara Knox
Francesca Bullaro
Linda Park
Benjamin Eithun
David A Feldstein
Safiya Richardson
Rachel P Berger
Nicholas Kuehnel
Thomas McGinn
Emily Heineman
Amanda Palm
Isabel Barata
Dana Kaplan
Joshua Ross
Sundas Khan
Journal: International Journal of Medical Informatics (2021)
Discipline: CLINICAL MEDICINE
Keywords: Child abuse; Child maltreatment; Clinical decision support; Electronic health record; Physical abuse.
Affiliations: Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Baylor College of Medicine, Houston, Texas, United States., University of Wisconsin School of Medicine and Public Health, Madison, WI, United States., Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States., Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States., Children's Hospital at Providence/Alaska Child Abuse Response and Evaluation Services, United States; University of Washington, Seattle, Washington, United States., Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States. Electronic address: .

Abstract:  Background: Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs. Methods: Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS. Results: Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves. Conclusions: Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS. 

Retracted: No

PubPeer comments:
 In this article, the authors state that u201ca Child Protection Team (CPT) was available for 24 7 consultation at UWu201d. However, the authors chose not to state the exact role of this CPT nor who exactly was on this CPT. Hospitals do not employ Child Protection Teams to simply consult in cases of suspected abuse. The role of a CPT is to take full control of all aspects regarding cases of suspected child abuse. It is the CPT that examines the child, interrogates the family, orders Child Abuse Screenings, diagnose injuries as abuse, report cases to CPS, etc. , 
 A Child Abuse Pediatrician will see bruises on a child and diagnose that child as u201cabusedu201d. That diagnosis is then entered into the data set for this research study. However, child abuse is not a medical diagnosis, but rather, a criminal allegation. In criminal cases there are prosecutors as well as defenders, and the accused are always innocent until proven guilty. All of the researchers and stakeholders of this study appear to be heavily weighted towards the side of the prosecution; they all have a vested professional interest in diagnosing and prosecuting as many cases of child abuse as possible. The question is, what happens when the court decides the bruises on this child are not a result of abuse, but were a result of the child having leukemia, e.g.? Will the researchers go back and adjust the data, or do they take the diagnosis of one Child Abuse Pediatrician over the decision of the court of law? Do they take the diagnosis of one Child Abuse Pediatrician over that of numerous other doctors who may testify against the diagnosis of abuse? False allegations of abuse and misdiagnoses of abuse by Child Abuse Pediatricians are very common, and considerations for this fact should be taken into account in any research involving child abuse. The stakeholder committees for child abuse research should always include professionals experienced in defending families that have been wrongly accused. If even the mere possibility of innocence does not exist in this study, then this is not scientific research, but rather, propaganda, which they are using for nothing more than to justify the profession of Child Abuse Pediatrics, which otherwise canu2019t be done honestly. , 
 Below is an excerpt from the Belmont Report, the gold standard in ethical human subject research: u201cOne special instance of injustice results from the involvement of vulnerable subjects. Certain groups, such as racial minorities, the economically disadvantaged, the very sick, and the institutionalized may continually be sought as research subjects, owing to their ready availability in settings where research is conducted. Given their dependent status and their frequently compromised capacity for free consent, they should be protected against the danger of being involved in research solely for administrative convenience, or because they are easy to manipulate as a result of their illness or socioeconomic condition.u201d Children with chronic illnesses and or complicated medical needs, obviously visit ERu2019s and hospitals more frequently than healthy typically developing children. Many of these medical complications show symptoms that can mimic child abuse, such as easy bruising, atypical development, brittle bones, scars from previous medical procedures, anatomical deformities, rashes and lesions, etc. This results in a higher frequency of families of children with these conditions, being subjected to child abuse investigations, especially ones initiated during hospital and ER visits. How did the researchers of this study ensure that they are in compliance with the Belmont Report, and not overburden families of children with a chronic illness or medical condition, by including this population at a higher percentage because of administrative convenience? What protections are in place within the computer alert system, so that it is not triggered at a higher percentage because of a childu2019s chronic illness or medical condition? If these questions of ethics were never asked by the researchers from the concept stage, then one would have to conclude that this research and the computer alert system itself, was designed to simply trigger more child abuse investigations, rather than more accurate child abuse investigations. ,