Pain is among the most common patient complaints, and thus, it is vital to address it in primary care. To identify treatment options and evaluate progress, initial and follow-up pain assessments are required. Clinical decision support systems can be used to make the process of pain assessment electronic, thus integrating the data with the EHR (“Meaningful use,” n.d.). In order to achieve these goals, a CDS process for pain assessment should involve a sequenced questionnaire to record pain characteristics, as well as an algorithm for recommendations, suggestions, and alerts. The CDS should assess both chronic and acute pain so that it could be used by all providers on a regular basis.
Points of Intelligence and Initiation
There are three key points of intelligence that should be the focus of the CDS: pain characteristics, aggravating/alleviating factors and remedies, and recommendations. The information should be gathered in this sequence to support the diagnosis, plan a pain management strategy, and identify the treatment plan.
The initiation of the CDS occurs when the care provide puts “Yes” for pain on the list of symptoms in the EHR. Pain assessment CDS is thus a part of the EHR data input process (“Meaningful use,” n.d.). Questions for pain assessment are mostly drawn from the evidence-based, short-form McGill Pain Questionnaire, as well as the existing paper pain questionnaire used in the clinic (Gauthier et al., 2014)
- Q1. What is the location of the pain?
- Q2. Is the pain chronic or acute?
- If acute, go to Q4
- Q3. If the pain is chronic, how long has it persisted?
- Q4. What is the level of pain during rest? (rate from 0 [no pain] to 10 [worst pain imaginable])
- Q5. What is the level of pain during activity? (rate from 0 to 10)
- Q6. What was the worst level of pain in the last 24 hours? (rate from 0 to 10)
- If 0, go to Q
- Q7. What was the weakest level of pain in the last 24 hours? (rate from 0 to 10)
- Q8. What is the level of pain right now? (rate from 0 to 10)
- Q9. What was the average level of pain in the past 24 hours? (rate from 0 to 10)
- Q10. How frequently does the pain appear?
- more than 10 times per day
- 4 to 7 times per day
- 1 to 3 times a day
- once in 2 days
- once in 3-5 days
- less than once a week
- The first two questions focus on the location and nature of the pain. If the pain is chronic, the care provider will also be asked to indicate how long it has persisted. Questions 4 to 9 assess the level of pain at various points, such as during rest or when the pain is at its worst. These should be given in numerical form on the scale of 0 to 10 (Gauthier et al., 2014). Question 10 establishes the average frequency of pain.
- Q11. What is the pain quality (sharp, pulsating, cramping, etc.)?
- Q12. How long does the pain usually last?
- less than 5 minutes
- 5-30 minutes
- up to 1 hour
- up to 2 hours
- up to 3-4 hours
- longer than 5 hours
- Q13. What factors increase the pain?
- Q14. What factors relieve the pain?
- Q15. Has the patient used any medications to curb the pain?
- If no, go to Q12
- Q16. What medications did the patient use (name, dosage, time)?
- Q17. How does the patient rate the effectiveness of these medications? (rate from 0 [no relief] to 10 [complete relief])
- If 0, go to Q19.
- Q18. How long did the relief last (in hours)?
- Q19. Is there pain in any other locations?
- If yes, go to Q1 and repeat
- If no, end of the assessment.
Questions 11 and 12 focus on the quality of pain and its length, which allows establishing a clear pattern. Questions 13 and 14 consider aggravating and alleviating factors, whereas Questions 15 to 18 evaluate whether or not the patient used any medications and if they were effective. This information can help to guide the treatment plan. Finally, Question 19 defines if pain assessment for another location is required, and if not, the assessment ends here.
Pop-ups should appear at the end of the assessment, as well as during it in certain conditions. For instance, if the pain is chronic, the system should offer patient handouts with advice and information on chronic pain. If the results of pain assessment match previous evaluations of the patient, an alert should be created asking whether or not their pain may be chronic. If there is severe pain in the abdominal area, an alert for further examination and tests should be issued. Once the assessment is finished, the care provider should receive a list of pain management recommendations based on clinical guidelines. These may include medications, alternative remedies, lifestyle changes, and other means.
Results and Follow-up
The results of the pain assessment include pain scores, a list of probable diagnoses, further examination suggestions, and pain management recommendations based on guidelines. If there are any recommended medications that the patient has already tried and the effectiveness score was less than 5, they should be excluded from the list. During a follow-up visit, pain should be re-assessed based on questions 4 to 18.
To evaluate CDS outcomes, it is necessary to determine care providers’ satisfaction and usage, rates of alert overrides, and reported workflow disruptions (Genes et al., 2016; Health IT, n.d.). This information will help to define if the CDS design requires major improvements. Additionally, the integration of CDS and the EHR should be determined based on the share of patients with pain information in the EHR. Interviews, focus groups, surveys, and system reports may be used for data collection. Follow-up should be scheduled at 3 months to identify any design issues, suggestions for improvement, and other possible concerns. However, any functional problems should be monitored and address continuously.
Gauthier, L. R., Young, A., Dworkin, R. H., Rodin, G., Zimmermann, C., Warr, D., … Macpherson, A. (2014). Validation of the short-form McGill pain questionnaire-2 in younger and older people with cancer pain. The Journal of Pain, 15(7), 756-770.
Genes, N., Kim, M. S., Thum, F. L., Rivera, L., Beato, R., Song, C.,… & Hwang, U. (2016). Usability evaluation of a clinical decision support system for geriatric ED pain treatment. Applied Clinical Informatics, 7(01), 128-142.
Health IT. (n.d.). Measure effects and refine CDS interventions. Web.
Meaningful use and clinical decision support. (n.d.). Web.
Pombo, N., Araújo, P., & Viana, J. (2014). Applied computer technologies in clinical decision support systems for pain management: A systematic review. Journal of Intelligent & Fuzzy Systems, 26(5), 2411-2425.