Electronic health record tools to identify child maltreatment: Scoping literature review and key informant interviews

Objective: To prevent missed cases and standardize care, health systems are beginning to implement EHR-based screens (EHR-CA-S) and clinical decision supports systems (EHR-CA-CDSS) for the identification and management of child maltreatment. This study aimed to (1) document the existing research evidence on the performance of EHR-CA-S and EHR-CA-CDSS and (2) examine clinical perspectives regarding the use of such tools and factors that affect uptake. Methods: We searched MEDLINE, Embase, EBSCO, Scopus, and CINAHL databases for English language articles published prior to November 2021 that describe and/or evaluated an EHR-CA-S and/or EHR-CA-CDSS involving 0-18-year-olds. We performed semi-structured interviews with 20 individuals who have experience in identifying, evaluating, and/or treating child maltreatment and/or conducting research on these topics. Results: Our search identified 574 articles; 16 met inclusion criteria. Studies examined screening, alerts and triggers, and quality improvement. None evaluated long-term clinical outcomes. Sensitivity ranged from 0.14-1.00, specificity from 0.865-1.00, positive predictive value from 0.03-1.00 and negative predictive value from 0.55-1.00. A variety of EHR-CA-S and/or EHR-CA-CDSS have been implemented at institutions in our sample. Interviewees cited missed cases, policy requirements, and the lack of standardization of care as impetuses for adopting these tools, yet expressed concerns regarding insufficient evidence, bias, and time-intensiveness of implementation. Conclusions: Interviewees and the literature agree that current evidence does not support adoption of a particular CA-S or CA-CDSS. Further refinement and research on EHR-CA-S and EHR-CA-CDSS is necessary for these tools to be feasibly implemented and sustained, reliable for clinical practice, and not cause any unintentional harms.