Abstract
BackgroundRisk estimation models integrated into Electronic Health Records (EHRs) can deliver innovative approaches in psychiatry, but clinicians' endorsement and their real-world usability are unknown. This study aimed to investigate the real-world feasibility of implementing an individualised, transdiagnostic risk calculator to automatically screen EHRs and detect individuals at-risk for psychosis. MethodsFeasibility implementation study encompassing an in-vitro phase (March 2018 to May 2018) and in-vivo phase (May 2018 to April 2019). The in-vitro phase addressed implementation barriers and embedded the risk calculator (predictors: age, gender, ethnicity, index cluster diagnosis, age*gender) into the local EHR. The in-vivo phase investigated the real-world feasibility of screening individuals accessing secondary mental healthcare at the South London and Maudsley NHS Trust. The primary outcome was adherence of clinicians to automatic EHR screening, defined by the proportion of clinicians who responded to alerts from the risk calculator, over those contacted. ResultsIn-vitro phase: implementation barriers were identified/overcome with clinician and service user engagement, and the calculator was successfully integrated into the local EHR through the CogStack platform. In-vivo phase: 3722 individuals were automatically screened and 115 were detected. Clinician adherence was 74% without outreach and 85% with outreach. One-third of clinicians responded to the first email (37.1%) or phone calls (33.7%). Among those detected, cumulative risk of developing psychosis was 12% at six-month follow-up. ConclusionThis is the first implementation study suggesting that combining precision psychiatry and EHR methods to improve detection of individuals with emerging psychosis is feasible. Future psychiatric implementation research is urgently needed.
Highlights
Precision medicine and digital health are two pillars of contemporary clinical research in medicine and psychiatry (Fusar-Poli et al, 2016; Lewis and Hagenaars, 2019; Quinlan et al, 2019; Wolfe et al.,⁎ Corresponding author at: Early Psychosis: Interventions & Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, United Kingdom.2018)
Implementation barriers were identified and overcome with clinician and service user engagement, and the calculator was successfully integrated into the local Electronic Health Records (EHRs) through CogStack, an information retrieval and extraction platform for EHRs
The integration of the transdiagnostic risk calculator into the CogStack platform has been fully detailed in an associated publication (Wang et al, n.d.)
Summary
Digital health approaches can involve Electronic Health Records (EHRs) (Nielsen et al, 2019), which represent real-world clinical information (e.g. diagnoses, treatment plans, prescriptions) and are increasingly adopted across healthcare systems (Perera et al, 2016; Wachter and Cassel, 2020). Despite their potential, the use of precision medicine in EHRs has not yet entered clinical practice in psychiatry (Gómez-Carrillo et al, 2018; Stiefel et al, 2019), highlighting a clear implementation challenge.
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