Community-Acquired Pneumonia Clinical Decision … training slide deck includes textual and graphic...

Community-Acquired Pneumonia Clinical Decision Support Implementation ToolkitHandbook

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Table of ContentsIntroduction .................................................................................................................................................................... 2 Overview of the CAP Alert ....................................................................................................................................... 2 Objective and Relevance of the Tool ................................................................................................................... 2 How to Use this Toolkit ....................................................................................................................................... 3 Potential Users of the Toolkit .............................................................................................................................. 3 What are the CAP Alert Tools? ................................................................................................................................. 4 What are the Resources Needed?.............................................................................................................................. 5Implementing CAP Alert in Your Practice .................................................................................................................. 5Step 1: Adapt the CDS to Your Practice’s EHR ......................................................................................................... 5 BaselineWorkflowAssessment ................................................................................................................................ 5 Workflow Trigger Point Recommendations ........................................................................................................ 6 CDS Adaptation and Design ..................................................................................................................................... 7Step 2: Prepare the End-Users ...................................................................................................................................... 9 InformStaffofChanges ............................................................................................................................................ 9 Gain User Buy-In ...................................................................................................................................................... 9Step 3: Train the End-Users .......................................................................................................................................... 9 Training Approach and Content ................................................................................................................................ 9Step 4: CDS Go-Live .................................................................................................................................................... 10 ImplementationActivities ....................................................................................................................................... 10References .................................................................................................................................................................... 11

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IntroductionTheCommunity-AcquiredPneumoniaPatientSafetyClinicalDecisionSupportImplementationToolkitHandbookisaresourcetohelpprimarycaresettingsandotherambulatorysettingstoimplementandadoptthecommunity-acquiredpneumonia(CAP)clinicaldecisionsupport(CDS)alertforthemanagementofcommunity-acquiredpneumonia.ThishandbookcanalsoguidedevelopersandimplementersofclinicaldecisionsupporttoolsinadaptingtheCAPalerttoyourpractice’sEHR.

ThishandbookprovidesadescriptionoftheCAPalerttool,arationaleforitsuse,anoverviewofthetoolsinthetoolkit,andhowtousethetoolkittointegratethetoolintoaclinicalpractice.

Overview of the CAP AlertTheCAPalertisadaptedfromacommunity-acquiredpneumonia(CAP)managementtoolcalledCURB-65.TheInfectiousDiseasesSocietyofAmerica(IDSA)andtheAmericanThoracicSociety(ATS)recommendtwovalidatedtoolsforassessingtheseverityofCAPduringthediagnosticprocess.ThemostactionabletoolinanambulatorycaresettingistheCURB-65toolbecauseitisdependentupontheavailabilityofonlyfiveclinicaldataelementscommonlycollectedforpatientspresentingwithsymptomssuggestiveofpneumonia.Thistoolcalculatesaseverityscoreandrecommendedsiteofcarewhileplacinglowburdenontheclinician,andincludesthefollowingmeasures:

■ Confusion

■ Uremia

■ Respiratory rate

■ Lowbloodpressure

■ Age 65 years or older1,2

Since its initial derivation and validation study in 20033,CURB-65hasbeenstudiedandendorsedasaseverityassessmentandmanagementtoolforCAPpatientsinatleasteightvalidatingstudies.4Forprimarycarepracticesandotherambulatorysettingswithoutaccesstobloodureanitrogen(BUN)testing,CRB-65isanappropriatealternativefordecision-making.5Fortheemergencydepartment(ED)setting,wherelaboratorytestsarelikelyavailable,theCAPalertwillutilizetheCURB-65.Inprimarycaresettings,wherelaboratorytestsarelikelynotavailable,theCRB-65toolwillbeused.

AccordingtotheconsensusguidelinesfromtheIDSAandtheATS,“almostallofthemajordecisionsregardingmanagementofCAP,includingdiagnosticandtreatmentissues,revolvearoundtheinitialassessmentofseverity.”6Severityassessmentsdeterminethesiteinwhichthepatientistoreceivesubsequentcare;sitesincludethehospital—intensivecareunit(ICU)orgeneralward—orthehome.

Objective and Relevance of the ToolTheCAPalertprovidesdecisionsupporttocliniciansatthepointofcarearoundtheseverityofthecondition,particularlywhenitcomestodecisionsaboutappropriatesiteofcare.

CAPistheeighthleadingcauseofdeathintheUnitedStates,andoneofthetopmostcommonlymisseddiagnoses.7 Approximately6millioncasesarereportedannually,resultinginanestimated4.2millionambulatorycarevisits.8 Adultsage65orolderhavefourtimestheincidenceofCAPasotheragegroups;theyalsohavehigherratesofhospitalizationandaremorelikelytodiefromCAP.9Accordingtooneestimate,915,900episodesofCAPoccurin adults 65 years of age and older each year in the United States.10CAPcanbetreatedinthehospitalorathome,dependingonseverity.Hometreatmentisoftenpatients’preference,andittendstobelowerincostandprevent

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exposuretohospital-acquiredconditions.Severity-of-illnessscores,suchastheCURB-65criteria,canbeusedtoidentifypatientswithCAPwhomaybecandidatesforoutpatienttreatment.11

CDS,whenusedtomanageCAP,canassistcliniciansduringthecriticaltimeperiodwhenanassessmentofseveritymustbemadetodetermineacourseoftreatment.WhenCDSisusedinconjunctionwithanEHRsystem,itcaninfluenceclinicianbehavior,diagnostictestordering,andcostsofcare,aswellasimpactclinicaloutcomes.12,13

ThegeneralclinicaldataelementsthatmakeuptheCURB-65—demographics(i.e.,patientage);vitalsigns(i.e.,bloodpressureandrespiratoryrate),andlabtests—areallrequiredtobeincludedinEHRsaspartoftheCentersforMedicare&MedicaidEHRincentiveprogram.14ItisexpectedthatfouroffivedataelementsrequiredfortheCURB-65canbeextractedfromtheEHR.Thesedatacanbeusedtotriggeraclinicaldecisionsupporttool(CDS)tocalculateseverityofCAP.Thefifthvariable—patientconfusion—willmostlikelyneedtobeassessedbyaclinicianatthetimeofthevisitandenteredintotheEHRtofullyruntheCURB-65.GiventhattheCRB-65toolinprimarycarepracticeswillnotrequiretheBUNlabtest,clinicianswillonlyneedtoconsiderfourelements.

Assigningavalueofonepointforeachclinicalfeaturepresentatthetimeofdiagnosis,theCURB-65severityscorerangesbetween0and5,withhigherscoresrepresentingincreasedmortalityriskandneedforhospitaladmission.15 Oncethescoreiscalculated,theoutputsofthetoolincludeanestimateof30-daymortalityandarecommendedsiteofcare(homeorhospital).

ThebenefitsoftheCAPalertare:

■ Itsupportsaccurateappraisalofpneumoniaseverity

■ Itprovidessiteofcarerecommendationstoassistinclinicaldecision-making

■ Itofferseasyaccesstoevidence-basedguidelinesonmanagementviahyperlinks

How to Use this ToolkitThistoolkitshouldbeusedprimarilytoimplementtheCAPalertinanambulatorycaresetting,suchasaprimaryorspecialtycareoutpatientpracticeoranemergencyroom.ThistoolkitmayalsohelpinformyourdecisionaboutwhethertoimplementtheCDSinyourpracticebyclearlydescribingthestepsnecessaryforitsimplementation.ThetoolkithelpsexplaintheimpetusforandrelevanceoftheCAPalert,aswellasitsbenefits;itmayassistingainingclinicianbuy-inforusingthetool;anditmayserveasatrainingguideforhowtointegratethetoolintopractice.ThetoolsinthistoolkitshouldbeusedasguidestoassistwiththeimplementationanduseoftheCAPalert.ThespecificimplementationoftheCAPalertinyourelectronichealthrecordshouldbeconsideredcarefullywithinthecontextofyourpracticeandthecapabilitiesofyourelectronichealthrecordsystem,andcustomizedtoyourstaff’spreferencesandworkflows.Whereappropriate,weproviderecommendationsandguidanceonspecificaspectsofthedesignandworkflowintegrationofthetoolinyourownpractice.

Potential Users of the ToolkitPotentialusersofthetoolandtoolkitincludeclinicians(e.g.,physicians,advancedpracticeclinicians,nurses),administrators(e.g.,medicaldirectors,medicalinformationofficers,informationtechnologystaff,andpracticemanagers),andthosedevelopingandimplementingtheCDS(e.g.,informaticists,ITstaff).Ofthesegroups,thishandbookwillbeofgreatvalueforclinicianchampionsandITstaffchargedwithleadingtheadministrative,clinical,andtechnicalimplementationoftheCDSaswellasthetrainingofend-users.Thesettingsinwhichimplementationofthistoolisappropriateincludesambulatorycaresettingssuchasaprimarycarepracticeandanemergencydepartmentinahospital.

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What are the CAP Alert Tools?Table1belowdescribeseachofthefourtoolsyouwillfindinthistoolkitandtheirpurpose.Subsequentsectionsofthishandbookwillgointomoredetailonhowtointegratethesetoolsintoyourpractice’simplementationoftheCAPalerttool.Tool“a”ineachsetreferstomaterialspertinenttoemergencydepartment(ED)settings,andTool“b”ineachsetreferstomaterialsfortheprimarycaresetting.

Table 1. Tools Available in the Implementation Toolkit

Tool Use this tool to… Description and formatting

For CDS developers and implementers

Tool 1: Low-fidelity Implement the CAP The low-fidelity prototype of the CAP alert will be an EHR vendor-agnostic prototype alert in your EHR visual representation of the design of the tool. This resource could be used

■ Tool 1a: EDby CDS developers/implementers to develop a CURB/CRB-65 tool within their specific EHR.

■ Tool 1b: Primary Care

Format: PDF document. There is one version for the ED setting, and one for the primary care setting.

For end-users of CDS

Tool 2: Workflow Help end-users The workflow diagrams detail:diagrams

■ Tool 2a: ED

understand the workflow impacts of the tool

■ Current state workflows: the baseline workflow for managing CAP

■ Data Flow: a diagram that highlights the points in the clinical process ■ Tool 2b: Primary where the data relevant for the CURB-65 tool are introduced Care ■ Future state workflow: a diagram that demonstrates how the CAP alert

can be integrated into the clinical workflow.

Format: PDF document. There is one version for the ED setting, and one for the primary care setting.

Tool 3: Pamphlet Inform CDS end-users Targeting clinicians, the pamphlet provides a brief overview of the clinical

■ Tool 3a: EDrelevance of CAP and the CURB/CRB-65 tool, and the benefit of using this tool. This pamphlet will be available in digital format, but may be printed

■ Tool 3b: Primary out for distribution in practices. It can also become a part of the EHR’s Care knowledge library.

Format: Two-page PDF document. There is one version for the ED setting, and one for the primary care setting.

Tool 4: Training slide Train CDS end-users The training slide deck includes textual and graphic instructions for how and deck when to use the CAP alert in the practice’s EHR, with an explanation of how

■ Tool 4a: EDthe tool fits into the user’s workflow. It also contains background information related to the guidelines supporting the CURB/CRB-65 tool for assessing

■ Tool 4b: Primary 30-day mortality.Care Format: PowerPoint slide deck. There is one version for the ED setting, and

one for the primary care setting.

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What are the Resources Needed?Ideally,astaffliaisonorclinicianchampionwillserveasthemainresourcetodriveimplementationandadoptionoftheCDS.Heorshehelpstobringotherpotentialusersofthetoolonboardandtodisseminatethetoolsinthetoolkitattheappropriatepointsintime,andmayberesponsibleforintroducingthetooltoothercliniciansandbeingavailablefortechnicalsupport.However,becausethistoolisrelativelyintuitivetolearnanduseregardlessofambulatorycaresetting,andthematerialsprovidedinthistoolkitshouldprovideallthenecessarysupport,theroleofthestaffliaisonorclinicianchampionisnotexpectedtobetime-consuming.

Additionally,informationtechnologypersonnel,informaticists,andsupportmaybenecessarytoadaptandimplementtheCDStoolinthepractice’sEHR.

Implementing CAP Alert in Your PracticeThefollowingisanoverviewofthestepstoimplementtheCAPalertintoyourpractice.ThefourstepsoutlinedinthisimplementationhandbookcanhelpyourpracticeadaptandimplementtheCAPalert.SeeExhibit1Below.

Exhibit 1: CAP Alert Implementation Overview

Step 1: Adapt the CDS to Your Practice’s EHR

Step 2: prepare the End-Users

Step 3: Train the End-Users

Step 4: CDS Go-Live

Step 1: Adapt the CDS to Your Practice’s EHROnceyourpracticehasdecidedtoimplementtheCAPalert,theclinicianchampionswillneedtoconductaworkflowassessmenttomakesomedecisionsabouthowtoimplementthealert.

Baseline Workflow AssessmentTool 2,theWorkflowDiagrams,containstwosetsofdiagrams—onethatisapplicabletomostoutpatientclinicsettingsthatdonothaverapidavailabilityoflabtests(Tool2b),andtheotherthatisapplicabletosettingssuchasemergencydepartmentswherestatlabresultscanbeobtained(Tool2a).Ineachset,weprovidethefollowingdiagrams:

■ AviewoftheworkflowpriortotheCDSinstallation

■ Aviewwheretherequireddataelementsarelikelytobecomeavailable

■ AviewdemonstratingwheretheCDSislikelytofitintheworkflow

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Exhibit2belowprovidesasetofquestionsyourpracticecanusetoassessyourworkflowformanagingCAP.

Exhibit 2: Baseline Workflow Assessment Questions

1. How is disease severity of CAP currently assessed?

2. What are the tasks of the clinical workflow?

a. What is the most common sequence in which these tasks are performed?

b. How is the patient engaged for each task?

3. Is the CURB-65 tool used by your practice/department?

a. If yes, how is it used?

b. Who completes the tool?

c. Are the elements captured electronically?

4. If the CURB-65 tool is not used, is another tool such as the Pneumonia Severity Index (PSI) tool used?

5. Are other assessment tools integrated into the EHR?

a. If so, how effective have they been?

b. Are there preferences in presentation and layout of those?

6. To what extent do clinicians rely on CDS systems in your practice?

a. What do clinicians like about them and what would they like to see changed?

7. Would clinicians launch the CAP alert or want it to be triggered automatically?

Workflow Trigger Point RecommendationsUsingthetoolsdescribedinthesectionabove,werecommendconductingbothapre-andpost-implementationworkflowassessmentinbothsettingstoanalyzethecurrentpracticeformanagingpneumoniacasesaswellaseachstaffperson’sroleininteractingwithboththepatientandtheelectronichealthrecordsystem.ConductingaformalorinformalevaluationoftheimpactoftheCAP alertonworkflowafterithasbeenimplementedisimportanttoensurethetoolisavailableattheappropriatepointintimeforthemajorityofclinicians.

InTable2below,wepresentthesetoftriggersusedinthepilotofthistooltoascertaintheappropriatetriggerpointfordecision-making.Inyourpractice’simplementationofthistool,considerwhetherthesetriggersareappropriategiventhecurrentworkflowforseeingpatients.Werecommendavoidingnon-specificchiefcomplaints,asthebroaderthetriggersare,themoreitwilldecreasethespecificityofthealertandcontributetofiringinappropriatelyand too often.

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Table 2. Advisory Triggers in the ED and Primary Care Settings

Attribute Characteristics

Alert CURB-65 CRB-65

Patient Location Emergency department Primary care office

Age Age >= 18 years Age >= 18 years

Chief Complaints ■ Cough ■ Respiratory difficulties ■ Respiratory distress ■ Breathing problem ■ Shortness of breath

■ Cough ■ Shortness of breath ■ Malaise ■ Bronchitis ■ Confusion ■ Pneumonia ■ Recurrent pneumonia ■ Respiratory difficulties ■ Breathing problem ■ Respiratory distress

Other ■ No admission order ■ Chest X-ray marked as “Exam Completed” by radiology technician

No admission order

Types of AlertsIntheEDsetting,werecommendthattheCAPalertmanifestsasaninterruptivealertsincetypicalEDworkflowhasmultiplehandoffs,andtheuserseeingthealertwillneedtoactuponthedecisionsupportwithoutdeferringtoanotheruser.Ifpossible,providingtheEDuserwitha“snooze”optionishelpfulsothatthealertdoesnotinterferewithurgentpatientcareneeds.IntheprimarycaresettingwerecommendthattheCAPSS-CDStoolbeinformationalandnon-interruptive,i.e.,presentedinavisualdisplaybutnotnecessarilyinterruptiveworkflow.Inabriefoutpatientvisit,oftenasbriefas15minutes,itisunclearatwhatpointintimeitwouldbeappropriatetofireaninterruptivealert,thustheCAPalertshouldbemorepassiveinnature.

Considerations for the Trigger Point of the Interruptive Alert in the EDGiventheexactpointofcliniciandecision-makingforsiteofcareishighlyvariable,carefulconsiderationneedstobegiventowhentotriggerthealertsoitisoptimallyhelpfulfortheclinician.Thus,inordertoensuretheworkflowtriggerpointfortheinterruptivealertintheEDallowsforflexibility,werecommenddesigningthealertwitha“snooze”option,muchlikethatofanalarmclock.Inthisdesignthealertcanfireandtheclinicianisgivensomedegreeofcontroloverrespondingtotheinformationprovidedinthealertorselectingthe‘snoozeoption’sotheycanberemindedatalater,moreappropriatetime.

CDS Adaptation and Design Informationgatheredfromtheworkflowassessmentcaninformtheadaptationanddesignofyourpractice’simplementationoftheCAPalert.Tool 1,theLow-FidelityPrototype(seeExhibit3below),canhelpinitiatetheseconversations.TheclinicianchampionshouldmeetwiththeITdepartmentand/orEHRvendor.ThepurposeofthismeetingwillbeforyourclinicianchampiontodiscusswhichfeaturesoftheCDSwillbeappropriateforyour

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practice,potentialdesignconsiderations,andhowthetoolwillintegrateintotheclinicalworkflowbasedontheworkflowassessment.ItissuggestedthatEDsettingsutilizetheCURB-65versionofthetool,whileprimarycarepracticesutilizetheCRB-65version,giventhetypicallackofstatlabsintheprimarycaresetting.

ItisrecommendedthatinanEDsettingthetoolisinitiatedafteranylabworkhasbeencompletedandthechestX-rayismarkedas“completed”bytheradiologist,asdescribedintheprevioussection.DuetotheEDworkflowandmultiplehandoffs,thepersonmakingthedispositiondecisionislikelytobetheoneevaluatingthepatientafterthesetestresultsareavailable.Intheprimarycaresetting,theadvisorydoesnotdependuponthepresenceorabsenceoflabs,orimagingresultsasmostoftheseareavailableaftertheconclusionofthepatientvisit,andthustheCRB-65doesnotutilizetheBUNelement.Mostdecisionsaremadewithoutancillarytesting.Moreover,thedecisionsupportis not dependent on the results of such testing.

IfyourpracticeutilizestheEpicelectronichealthrecord,youmaydownloadtheCAPalertfromtheEpicUserWeblibrary.Youmayfeelfreetoadaptthealertinanywayforyourownpractice.

ForsitesthatplantoadapttheCAPalertfortheirownEHRsystemsthefollowingstepsshouldbefollowed:

■ UsepatientdatathathasalreadybeenrecordedintheEHR.

■ Displaytheinformationthatwentintothecalculationofeitherscore(CURB/CRB-65).

■ PresentguidanceonCAPseverityandwhattheconsequentactionoughttobe.

■ ProvideaccesstoCAPtreatmentguideline.

■ Requestverbalfeedbackfromrepresentativeusersonclarityandrelevanceofinformationpresented.

■ RecordtheparametersofthescoreintheEHR.

Exhibit 3: Low-Fidelity Prototype (ED Setting)

Twootherpossibleconsiderationsfordesign,ifitiswithinthecapacityandresourcesallocatedforyourownimplementation,istodesignthealertwheretheCURB/CRB-65scoreandrecommendationappeartogetherfirstforasimplifiedview,andtheniftheclinicianwantsmoreinformation,theycanclicktoviewthecriteriaandotherinformationpresentinExhibit3above.Thesecondconsiderationistoallowthealerttobe“snoozed”bytheusertore-appearinapredeterminedamountoftime.

Pneumonia acuity score and recommendations below

Agree with recommendation Disagree with recommendation

Acknowledge Reason

Recommendation: Home (30d mortality 2.7%)

CURB65 score 1 Details here

Criteria included: SBP<90, or DBP <=60

Criteria not included: Age >=65

Patient confused Last BUN > 20 mg/dL

Resp rate >=30

1

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Step 2: Prepare the End-UsersOncetheCAPalerthasbeenadaptedtoyourpractice’sEHR,itwillbetimetopreparethepotentialend-usersofthetool.

Inform Staff of ChangesTheclinicianchampionshouldinformallstaffabouttheupcomingimplementationandwhyitisimportant.Letthemknowthebenefitsofusingthetool,theexpectedimpactstoworkflow,andresourcesavailablefortraining(Step3).Herearesomepossibleavenuesforannouncingtheimplementation:

■ Email

■ Staffmeetings

■ Informalannouncementswhilesupervising

■ Postinginformationintheclinic

Itisrecommendedthatmorethanoneoftheseformatsbeusedtoensurethemessageabouttheimplementationreachesallyourstaff.Theworkflowdiagrams(Tool 1)willbehelpfulduringthisprocess.Anotherhelpfultooltoshareatthispointisthepamphlet(Tool 3).ThistoolgivesanoverviewofthebackgroundofCAPandrelevanceofthetool,aswellashowitwillimpactclinicians’work,andthebenefitsofintegratingthetoolintopractice.

Gain User Buy-InOncethepotentialend-usershavebeenintroducedtothenewtool,itwillbeimportanttoearnuserbuy-in,toensurethateveryoneisonboardwiththeimplementationandcomingchanges.Thiscanbedonethroughfrequentandopencommunication,aswellasvisualreminders.Thepamphlet(Tool 3)isadocumentthatcanbeprintedandpostedinyourclinic,orthedigitalversioncanbeemailedorpostedtoasharedlocationonyourorganization’sIntranet.

Step 3: Train the End-UsersOncetheend-usershavereceivedanintroductiontoCURB/CRB-65andtheCAPalerttheendusersarenowpreparedtotrainonthetool’suseandapplication.Thetool’suser-friendlydesignwillrequireminimaltraininginordertouseiteffectively;theguidancewillallowforrapidstartupandseamlessintegrationintotheworkflow.

Training Approach and Content Trainingshouldfollowtheorganization’sestablishedprocesses.Tools2-4areusefultrainingaids.ScreenshotsoftheactualCDSfromyourEHR,outliningthesiteworkflow,willbeessentialinusertraining.AlthoughtheCAPalertwasdesignedtobeintuitivetouse,sometrainingisrecommended.Attheveryleast,trainingshouldcoverthegoaloftheCAPalert,howitworks,andhowitwillfitintoclinicalworkflows.Ifyouweretoonlyuseonetrainingtool,Tool 4isthemostcomprehensive.

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Step 4: CDS Go-LiveUponcompletionofend-usertraining,itwillbetimetogo-livewiththeCAPalert.Atthispoint,itisimportanttokeepthetrainingmaterialsavailableduring,throughout,andafterimplementationsothatuserscanrefertothematerialsatalltimes.Theclinicianchampionshouldalsobeavailableforquestionsandassistance.

LocalEHRchangecontrolprocessesshouldbeadheredtoduringthistime.Coordinatinggo-livetimelineswithstandardchangecontrolavoidsanyconflictswithEHRaccess,disruptiontoend-userworkflow,orinadvertentcorruptionofexistingEHRtools.Go-livemaybeassimpleas“turningon”theCDSalertintheappropriatesettings.

Implementation ActivitiesImplementationactivitieswillinclude:

■ Review of the resources in the toolkit

■ CAP alert go-live

■ Postgo-liveQ&A/assistance

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References1. MandellLA,WunderinkRG,AnzuetoA,etal.InfectiousDiseasesSocietyofAmerica/AmericanThoracicSociety

ConsensusGuidelinesontheManagementofCommunity-AcquiredPneumoniainAdults.ClinicalInfectiousDiseases.2007;44(Supplement2):S27-S72.

2. JonesBE,JonesJ,BewickT,etal.CURB-65pneumoniaseverityassessmentadaptedforelectronicdecisionsupport.Chest.2011;140(1):156-163.

3. LimWS,vanderEerdenMM,LaingR,etal.Definingcommunityacquiredpneumoniaseverityonpresentationtohospital:aninternationalderivationandvalidationstudy.Thorax.2003;58:377–82.

4. LimWS,BaudouinSV,GeorgeRC,etal.;PneumoniaGuidelinesCommitteeoftheBTSStandardsofCareCommittee.BTSguidelinesforthemanagementofcommunityacquiredpneumoniainadults:update2009.Thorax.2009;64(suppl3):1-55.

5. BauerTT,EwigS,MarreR,SuttorpN,WelteT.CRB-65predictsdeathfromcommunity-acquiredpneumonia.JInternMed.2006;260(1):93-101.

6. MandellLA,WunderinkRG,AnzuetoA,etal.InfectiousDiseasesSocietyofAmerica/AmericanThoracicSocietyConsensusGuidelinesontheManagementofCommunity-AcquiredPneumoniainAdults.ClinicalInfectiousDiseases.2007;44(Supplement2):S27-S72.

7. CentersforDiseaseControlandPrevention(CDC).FastStats:Pneumonia.CentersforDiseaseControlandPreventionWebsite.Availableat:http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf.

8. WatkinsRR,LemonovichTL.Diagnosisandmanagementofcommunity-acquiredpneumoniainadults.AmericanFamilyPhysician.2011;83(11):1299-1306.

9. Stupka,J.,Mortensen,E.,Anzueto,A.,Restrepo,M.Community-Acquiredpneumoniainelderlypatients.AgingHealth.2009;5(6):763-774.



12. HorskyJ,SchiffGD,JohnstonD,MercincavageL,BellD,MiddletonB.Interfacedesignprinciplesforusabledecisionsupport:Atargetedreviewofbestpracticesforclinicalprescribinginterventions.JournalofBiomedicalInformatics.2012;45(6):1202-1216.

13. BryanC,BorenS.Theuseandeffectivenessofelectronicclinicaldecisionsupporttoolsintheambulatory/primarycaresetting:asystematicreviewoftheliterature.JournalofInnovationinHealthInformatics.2008;16(2):79-91.

14. EHRIncentiveProgram.EligibleProfessionalMeaningfulUseTableofContentsCoreandMenuSetObjectives.Stage1(2013Definition).LastUpdated:July2014.https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/EP-MU-TOC.pdf.

15. YealyDM,FineJM.Community-acquiredpneumoniainadults:Riskstratificationandthedecisiontoadmit.2015;http://www.uptodate.com/contents/community-acquired-pneumonia-in-adults-riskstratification-and-the-decision-to-admit?source=see_link.

AHRQ Pub. No. 18-0020-1-EF January 2018

www.ahrq.gov

http://www.ahrq.gov

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