O3194: Get the Lead Out! EHR-Facilitated Lead Screening and Follow Up in Primary Care

Purpose/Objectives: Childhood exposure to lead remains a pervasive public health problem. Unfortunately, gaps remain in adherence to local guidance on best practices to screen for lead exposure and ensure timely follow-up for children who have elevated blood lead levels (EBLLs). The electronic health record (EHR) provides natural mechanisms to support quality improvement initiatives related to lead screening and follow-up. Due to the local complexities of clinical workflow and regional variability on screening guidance, such mechanisms are not widely implemented. Our objective was to iteratively refine an EHR-based workflow to improve lead level screening and follow-up lead levels for patients with EBLLs.

Design/Methods: As part of a quality improvement project selected by pediatric residents at Children’s Hospital of Philadelphia, we held focus groups with key stakeholders to redesign clinical workflows. EHR tools related to our redesigned workflows were iteratively and rapidly deployed among a group of pilot users. Detailed documentation was maintained throughout the project in a shared online notebook, which helped ensure project continuity in the context of rotating pediatric residents. We summarized key themes from these notes regarding the strengths and weaknesses of different technical approaches and captured key stages in the iterative refinement of the proposed workflow. Feedback was collected through surveys and usability testing.

Results: 37 residents and 8 faculty participated in the project over a course of 32 focus group meetings. Key strengths of the EHR-based tools included tailored decision support based on patient data, mechanism for pre-selection of recommended orders, and standardization of guideline presentation and data collection. Concerns influencing EHR tool selection were alarm fatigue, implementation timelines, maintenance needs, and variability in workflow. Given the strengths and concerns of different approaches, our implementation included two components: (1) pre-selection of lead screening on order sets at well visits for patients where lead testing was appropriate, and (2) use of progress note templates to deliver patient-specific guidance regarding EBLL follow-up (see Figure 1). The note template includes a link to a survey to capture ongoing feedback from clinical users. To support rapid deployment and small tests of change, our current implementation involves only limited amounts of automation. We anticipate increasing automation as our workflow tools are further refined.

Conclusion/Discussion: Significant gaps remain in our ability to ensure timely screening and follow-up for populations of children at risk for lead exposure. In a resident-led quality improvement project conducted in partnership with clinical informatics experts, we combined pre-selected lead screening orders with a technically straightforward adjustment to clinical workflow that will be further refined in ongoing plan-do-study-act (PDSA) cycles. Our future work will evaluate satisfaction with these tools and the impact of these tools on adherence to guidelines.