Refugee Health Decision Support

Description

This artifact set includes two order sets and associated documentation templates developed for the management of the newly arriving refugee patient in the United States. These order sets were developed based upon CDC guidelines for the clinical management of newly arrived refugees. Each order set contains a list of orders, links to a documentation template, and a set of recommended diagnoses. Order set options are constrained based on the patient's age and gender.

Artifact Type
Creation Date
Version
1.1.0
Status
Experimental
False

Artifact Creation and Usage

Contributors

Authors: Orenstein E, MD; Warden C, BA; Yun K, MD, MHS; Westerhaus M, MD; Mamo B, MPH; Mirth M, MSN; Karavite D, MSI; Michel JJ, MD, MHS;

Please contact refugee.cds@email.chop.edu with any questions or if you are interested in utilizing this CDS artifact.

Special thanks to the Refugee Epic User Group members: Ingrid Attleson, Tobey Audcent, Robert Carlson, Timothy Childers, Seth Clark, Jennifer Cochran, Joel Davidson, Elizabeth Dawson-Hahn, Molly Drake, Emily Esmaili, Andrea Evans, Mary Fabio, Margaret Fitzthum, Andrea Green, Thomas Herchline, Shayla Holcomb, Betty Housey, Emily Jentes, Sarah Kimball, Fabiana Kotovicz, Ann Linde, Jasmine Matheson, Carolyn McCarthy, Melissa Moore, Suzinne Pak-Gorstein, Adam Palmer , Eliza Priest, Marisa Ramos, Ann Settgast, Dipti Shah, Meera Siddharth, Laura Smock, Kailey Urban, Shary Vang

Special thanks to the pilot test sites of the Children's Hospital of Philadelphia (CHOP) and Minnesota HealthPartners.

Funding for this project was provided by CDC Centers for Excellence in Refugee Health grant 5 NU50CK000459-02 (MN).

IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Copyrights

We ask all people who download any materials to email refugee.cds@email.chop.edu.

Development of the  Refugee Health Decision Support Module was funded by Centers for Excellence in Refugee Health grant 5 NU50CK000459-02 (MN) from the U.S. Centers for Disease Control and Prevention. As a federally funded project, it is subject to federal copyright restrictions and open access policies.

While this artifact to build an Epic SmartSet is the work of partners funded by the US Centers for Disease Control and Prevention (CDC), this artifact is not the work of CDC. The selection, omission, or content of items in the artifact does not imply endorsement or any other position taken by CDC, and CDC assumes no responsibility for accuracy. The artifact belongs to its authors and all questions should be directed to its authors. However, the “Guidelines for the U.S. Domestic Medical Examination for Newly Arriving Refugees” referenced in this artifact were developed by CDC to help state public health departments and medical professionals/clinicians in determining the best tests to perform based on evidence during routine post-arrival medical screening of refugees. These guidelines are intended as recommendations rather than as mandates. Refugee providers with any questions should contact their state refugee health coordinator. 

MeSH Topics
Implementation Details
Engineering Details

Please see the Build Documentation for complete details (see Miscellaneous Files). We have also provided a pre-implementation checklist to allow organizations to preform a readiness assessment prior to implementation (see Miscellaneous Files).

This intervention includes two order sets with accompanying documentation templates. Each order set includes links to external websites that provide access to either potentially important patient information or to evidence sources used to develop the orderset. The order sets can be obtained from the Epic Community Library directly, but will likely need to be modified locally.

We have included a sample testing spreadsheet (you will need to modify and create or identify test patients to evaluate your implementation) and our epic analyst support files to assist with implementation and debugging (see Miscellaneous Files). These can be used as guides to support your implementation.

Repository Information
Approval Date
Publication Date
Last Review Date
Knowledge Level

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage
Purpose

The purpose of this intervention is to encourage evidence-based, guideline-directed standardized care across institutions for newly arriving refugee patients while providing flexibility for local workflows. The CDC creates guidelines and makes them available on the internet at https://www.cdc.gov/index.htm.

Intended Population

These artifacts are intended for use with patients of all ages and genders who are initially arriving into the United States of America through a refugee resettlement agency program.

Usage

These artifacts are intended for use in the outpatient setting in a primary care office or public health facility.

Cautions

1) The CDC maintains and updates the guidelines used to underpin this CDS.  Updates to guidelines may occur, and organizations implementing this CDS should develop a mechanism for monitoring for changes in the underlying evidence.

Supporting Evidence
Source Description

The order sets and documentation templates were developed drawing upon the cited references. A user group including health care  providers from 20+ sites was involved in the assessment of guideline recommendations, prioritization of materials, identification of supplemental evidence, and review of CDS during development.

References

References for the DME smartset:

Primary guideline:

CDC,Guidelines for the U.S. Domestic Medical Examination for Newly Arriving Refugees, https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html.

Additional evidence sources:

  1. CDC, Guidelines for Screening for Tuberculosis Infection and Disease during the Domestic Medical Examination for Newly Arrived Refugees, https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/tuberculosis-guidelines.html.
  2. CDC, Latent Tuberculosis Infection: A Guide for Primary Health Care Providers, https://www.cdc.gov/tb/publications/LTBI/treatment.htm.
  3. CDC, Screening for Hepatitis During the Domestic Medical Examination, https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/hepatitis-screening-guidelines.html.
  4. CDC, Hepatitis B, Chronic 2012 Case Definition, https://wwwn.cdc.gov/nndss/conditions/hepatitis-b-chronic/case-definition/2012/.
  5. EthnoMed, Hepatitis Patient Education Materials, https://ethnomed.org/patient-education/hepatitis.
  6. CDC, Domestic Intestinal Parasite Guidelines, https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/intestinal-parasites-domestic.html.
  7. WHO, Map of the estimated prevalence of eye worm history in Africa, http://www.who.int/apoc/raploa/en/.
  8. WHO, Schistosomiasis: Country Maps, http://www.who.int/schistosomiasis/epidemiology/global_atlas_maps/en/.
  9. CDC, Malaria: Domestic Guidelines, https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/malaria-guidelines-domestic.html.
  10. WHO, Malaria: Global Malaria Mapper, http://www.who.int/malaria/publications/world_malaria_report/global_malaria_mapper/en/.
  11. CDC, CDC Malaria Maps, https://www.cdc.gov/malaria/travelers/about_maps.html.
  12. CDC, Management of parasitic infection for asymptomatic refugees who received complete pre-departure therapy, https://www.cdc.gov/immigrantrefugeehealth/pdf/fig3.pdf.
  13. CDC, Treatment Schedules for Presumptive Parasitic Infections, https://www.cdc.gov/immigrantrefugeehealth/guidelines/overseas/interventions/interventions.html.
  14. CDC, Non-Communicable Disease, https://www.cdc.gov/immigrantrefugeehealth/profiles/congolese/health-information/non-communicable-disease.html.
  15. CDC, Treatment of Malaria: Guidelines For Clinicians (United States), https://www.cdc.gov/malaria/diagnosis_treatment/clinicians2.html.
  16. Philadelphia Department of Health, Guide for Clinicians: Preventing Lead Exposure in Children, http://www.phila.gov/health/pdfs/ChildhoodLead/Guide%20for%20Clinicians_December%202017%20update.pdf.
  17. Pennsylvania Department of Public Health, Lead Poisoning, http://www.health.pa.gov/My%20Health/Infant%20and%20Childrens%20Health/Lead%20Poisoning%20Prevention%20and%20Control/Pages/default.aspx#.WhLbKaQo4qQ.
  18. American Dental Association, Fluoride: Topical and Systemic Supplements , https://www.ada.org/en/member-center/oral-health-topics/fluoride-topical-and-systemic-supplements.
  19. CDC, 2015 Sexually Transmitted Diseases Treatment Guidelines, https://www.cdc.gov/std/tg2015/default.htm.
  20. CDC, Clinical Presentations And Diagnostic Testing For Specific STDs, Gonorrhea, https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/sexually-transmitted-diseases/gonorrhea.html.
  21. CDC, Clinical Presentations And Diagnostic Testing For Specific STDs, Chlamydia, https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/sexually-transmitted-diseases/chlamydia.html.
  22. CDC, Gonococcal Infections, https://www.cdc.gov/std/tg2015/gonorrhea.htm.
  23. CDC, Chlamydial Infections, https://www.cdc.gov/std/tg2015/chlamydia.htm.
  24. CDC, Clinical Presentations And Diagnostic Testing For Specific STDs, Syphilis, https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/sexually-transmitted-diseases/syphilis.html.
  25. CDC, Syphilis, https://www.cdc.gov/std/tg2015/syphilis.htm.
Artifact Decision Notes

A core group from the Center for International Health at the University of Minnesota, the Minnesota Department of Health, and the Children’s Hospital of Philadelphia was responsible for closely reviewing CDC’s guidelines for the U.S. domestic medical examination for newly arriving refugees, soliciting and collating user group input, reviewing feedback from state refugee health epidemiologists, and piloting the order sets and documentation templates. Development of the artifacts was informed by direct observations of workflow at one institution and indirect data collection on workflows at 20 organizations. Informaticists and a human-factor engineer identified key steps within the workflow as targets for CDS intervention. Using an iterative process the development team worked with clinicians to develop the CDS artifacts. The CDS artifacts were tested at the primary pilot institution, further revised, and disseminated to the secondary pilot institution.

Artifact Representation
Triggers

There are two separate artifacts: The pre-visit order set and the domestic medical exam (DME) order set.

Previsit: Clinicians actively select the pre-visit order set from the list of available order sets during a pre-visit encounter.

DME: Clinicians actively select the DME order set from the list of available order sets during a DME encounter.

 

Inclusions

The CDS is intended for use in the care of refugee patients upon arrival in the United States. It is intended to support preparation for and completion of the initial health care visit (domestic medical examination) and not suggested for follow up care visits. Both order sets provide tailored CDS based on the patient's age and gender.

Exclusions

The pre-visit and DME order sets are accessible only in the outpatient EHR context. There are no absolute exclusions to the initiation of these order sets. However, activation would require a clinician to intentionally load the orderset.

Interventions and Actions

Pre-visit: This order set contains a group of preselected orders (based on patient age and gender), optional orders, diagnoses, and a documentation template that can be used to capture information available to the clinician before a refugee patient arrives in clinic. Pre-visit order set visible at https://comlib.epic.com/#?query=refugee&customers=410,&tags=&type=All&pagesize=100&pageindex=0&id=694586406

DME: This order set contains a group of preselected orders (based on patient age and gender), optional orders and referrals, diagnoses, and a documentation template for the collection of information directly from the patient. Links to the underlying evidence sources, advice on how to use the DME order set (for trainees), and support for administrative work are also included. DME order set is visible at  https://comlib.epic.com/#?query=refugee&customers=410,&tags=&type=All&pagesize=100&pageindex=0&id=694586407

Testing Experience
Pilot Experience

This intervention has been in production at CHOP since 2017. User feedback has been positive and users have reported improved efficiency and that the intervention matched the workflow. Small adjustments were made to the documentation templates and ordersets to reflect changing understanding of user needs and to better align with local workflows. A second site has implemented this CDS using the Build Guide at Minnesota HealthPartners to evaluate the intervention in adult populations and to pilot dissemination strategies for the CDS artifact.