Patient-Centered Decision Support: Formative Usability Evaluation of Integrated Clinical Decision Support With a Patient Decision Aid for Minor Head Injury in the Emergency Department

Background The Canadian Computed Tomography (CT) Head Rule, a clinical decision rule designed to safely reduce imaging in minor head injury, has been rigorously validated and implemented, and yet expected decreases in CT were unsuccessful. Recent work has identified empathic care as a key component in decreasing CT overuse. Health information technology can hinder the clinician-patient relationship. Patient-centered decision tools to support the clinician-patient relationship are needed to promote evidence-based decisions. Objective Our objective is to formatively evaluate an electronic tool that not only helps clinicians at the bedside to determine the need for CT use based on the Canadian CT Head Rule but also promotes evidence-based conversations between patients and clinicians regarding patient-specific risk and patients’ specific concerns. Methods User-centered design with practice-based and participatory decision aid development was used to design, develop, and evaluate patient-centered decision support regarding CT use in minor head injury in the emergency department. User experience and user interface (UX/UI) development involved successive iterations with incremental refinement in 4 phases: (1) initial prototype development, (2) usability assessment, (3) field testing, and (4) beta testing. This qualitative approach involved input from patients, emergency care clinicians, health services researchers, designers, and clinical informaticists at every stage. Results The Concussion or Brain Bleed app is the product of 16 successive iterative revisions in accordance with UX/UI industry design standards. This useful and usable final product integrates clinical decision support with a patient decision aid. It promotes shared use by emergency clinicians and patients at the point of care within the emergency department context. This tablet computer app facilitates evidence-based conversations regarding CT in minor head injury. It is adaptable to individual clinician practice styles. The resultant tool includes a patient injury evaluator based on the Canadian CT Head Rule and provides patient specific risks using pictographs with natural frequencies and cues for discussion about patient concerns. Conclusions This tool was designed to align evidence-based practices about CT in minor head injury patients. It establishes trust, empowers active participation, and addresses patient concerns and uncertainty about their condition. We hypothesize that, when implemented, the Concussion or Brain Bleed app will support—not hinder—the clinician-patient relationship, safely reduce CT use, and improve the patient experience of care.


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The purpose of the app is to help you risk stratify the patient using the Canadian CT Head Rule. Then to share the risk visualization with the patient (optional) as well as serve as a platform for discussion of risk and considerations of what to expect if you do or don't get a CT.
o Remember that the original Canadian CT Head Rule studies included patients who had LOC, amnesia, or altered sensorium as well as GCS 1315, so these risk visualizations are actually an overestimate for most of our head injury patients in the ED.
Epic smart phrases  .CCHRLOWNOCT I have used the "Concussion or Brain Bleed?" decision aid to discuss the decision about getting a CT scan with this patient. This patient's injury is low risk based on the Canadian CT Head Rule. ACEP and Choosing Wisely recommend avoiding CT of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules such as the Canadian CT Head Rule. We discussed the patient's risks of: (1) need for neurosurgical intervention to be 0.0%, (2) clinically important brain injury to be 1.1%, (3) any brain injury by CT to be 2.7%. After discussing and considering the patient's unique circumstances and the pros and cons of the alternatives, we decided the patient should go home now without a CT.
 .CCHRLOWYESCT I have used the "Concussion or Brain Bleed?" decision aid to discuss the decision about getting a CT scan with this patient. This patient's injury is low risk based on the Canadian CT Head Rule. We discussed the patient's risks of: (1) need for neurosurgical intervention to be 0.0%, (2) clinically important brain injury to be 1.1%, (3) any brain injury by CT to be 2.7%. After discussing and considering the patient's unique circumstances and the pros and cons of the alternatives, we have decided to obtain a CT scan.
 .CCHRMEDNOCT I have used the "Concussion or Brain Bleed?" decision aid to discuss the decision about getting a CT scan with this patient. This patient's injury is medium risk based on the Canadian CT Head Rule. AWe discussed the patient's risks of: (1) need for neurosurgical intervention to be 0.0%, (2) clinically important brain injury to be 3.8%, (3) any brain injury by CT to be 6.9%. After discussing and considering the patient's unique circumstances and the pros and cons of the alternatives, we decided the patient should go home now without a CT.
 .CCHRMEDNOCT I have used the "Concussion or Brain Bleed?" decision aid to discuss the decision about getting a CT scan with this patient. This patient's injury is medium risk based on the Canadian CT Head Rule. The Canadian CT Head Rule recommends obtaining a CT in medium risk patients. We discussed the patient's risks of: (1) need for neurosurgical intervention to be 0.0%, (2) clinically important brain injury to be 3.8%, (3) any brain injury by CT to be 6.9%. After discussing and considering the patient's unique circumstances and the pros and cons of the alternatives, we have decided to obtain a CT scan.
 .CCHRHINOCT I have used the "Concussion or Brain Bleed?" decision aid to discuss the decision about getting a CT scan with this patient. This patient's injury is high risk based on the Canadian CT Head Rule. We discussed the patient's risks of: (1) need for neurosurgical intervention to be 4.5%, (2) clinically important brain injury to be 21.6%, (3) any brain injury by CT to be 26.7%. After discussing and considering the patient's unique circumstances and the pros and cons of the alternatives, we decided the patient should go home now without a CT.
 .CCHRHIYESCT I have used the "Concussion or Brain Bleed?" decision aid to discuss the decision about getting a CT scan with this patient. This patient's injury is high risk based on the Canadian CT Head Rule. The Canadian CT Head Rule recommends obtaining a CT in high risk patients. We discussed the patient's risks of: (1) need for neurosurgical intervention to be 4.5%, (2) clinically important brain injury to be 21.6%, (3) any brain injury by CT to be 26.7%. After discussing and considering the patient's unique circumstances and the pros and cons of the alternatives, we have decided to obtain a CT scan.