P3.B033: Implementing a Systematic Shield in EMR to Protect All: A Qualitative Analysis of Medical Expert’ Commentary on Universal Child Abuse Screening

Background: Hospitals are mandatory reporters for child abuse, but medical providers often find it difficult to recognize and detect the signs. Therefore, pediatric cases of abuse are at high risk of un- or under- reporting. We aimed to improve the quality and fair application of child abuse screening in medical settings by developing a user-friendly universal child abuse screening tool within the electronic medical record (EMR).

Methods: We partnered with EPIC, the nation’s largest provider of EMR services, to design a screening tool that would be available to all EPIC users. To elicit multiple viewpoints from and refine ideas with medical experts, EPIC conducted and recorded nine medical expert panel discussions to cover logistics and content, including tool components and design, challenges to implementation, decision support and adequate follow-up steps. Expert clinicians were recruited by EPIC from institutions nationwide including pediatric surgeons, child abuse pediatricians, pediatric emergency medicine physicians, nurses, social workers. Meetings were audio- recorded and transcribed verbatim, then de-identified. We inductively and deductively coded transcripts and conducted thematic analysis of the experts’ feedback and opinions. Data and analysis were organized using NVivo 14.

Results: Five important themes emerged from expert discussion. First, essential content components of the universal child abuse screening tool should include: use of age as a criteria for screening, factoring chief complaint and encounter history in screening criteria, structured physical exams, integration of patients’ growth charts and imaging reports into a common accessible abuse investigation tab, and inclusion of healthcare professionals’ observations during visits. Second, although primary care settings offer critical opportunities for identifying missed abuse cases, initially focusing on building clear protocols in emergency departments and urgent care centers would be the best starting place for universal screening of physical abuse. Third, to operationalize the screening tool into the EMR, experts suggested initiatives such as note templates, internal documentation, and an abuse investigation tab to aid in abuse identification and improve consultations. Fourth, anticipated challenges included the concern that resource and staff constraints among some hospitals could negatively impact implementation. Finally, expert panelists highlighted the importance of attention to biases in protocols to avoid false positive reports.

Conclusion: This qualitative study utilizing data from 9 separate discussions by an expert panel for universal child abuse screening identified essential content and generated a descriptive list of logistical challenges to implementation. This work highlights the complexity of screening for child abuse that has potentially contributed to the lack of standardization to date.