Leveraging Electronic Health Records (EHR) for Concussion Surveillance

Minds Matter teamed up with the Centers for Disease Control and Prevention (CDC) to leverage CHOP's electronic health records (EHR) system. Together, they expanded concussion surveillance research to improve how clinicians manage concussion in children and adolescents. Led by Kristy Arbogast, PhD and Christina L. Master, MD, the project team has published numerous articles in peer-reviewed journals that describe characteristics of concussion in youth and how youth present for clinical care, as well as concussion management strategies.

Select Concussion Surveillance Research Publications

Menstrual Cycle Patterns Following Concussion in Adolescent Patients

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In this study, researchers sought to describe menstrual cycle patterns in concussed adolescents and investigate if menstrual cycle phase at injury influenced menstrual cycle pattern changes or concussion symptoms. In the largest study sample to date of concussed female adolescents, research participants (512 post-menarchal adolescents presenting to a specialty care concussion clinic) completed Post-Concussion Symptom Inventory (PCSI) assessments for menstrual cycle pattern change since injury, menstrual cycle phase at time of injury, and symptom endorsement and severity. Researchers found that one in ten adolescents experienced a change in their menstrual cycle pattern at 3-4 months after injury. In addition, menstrual cycle phase at injury was associated with a number of concussion symptoms endorsed by a patient. However, symptom severity and change in menstrual cycle pattern was not associated with phase at injury. The findings underscore a need to further investigate the relationship between concussions and hormones in post-menarchal adolescents.

Assault-Related Concussion in a Pediatric Population

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This study compared demographic characteristics, medical care, and outcomes among patients with assault-related concussion (ARC) versus sports and recreation–related concussion (SRC) and highlighted potential disparities in the initial evaluation and outcomes. ARC patients were less likely to receive a concussion-specific diagnostic evaluation and reported greater impact on educational outcomes suggesting differences in concussion diagnosis and management.

Characteristics of Diagnosed Concussions in Children 0-4 Years 

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In a retrospective study, the Minds Matter and CDC research team looked at 329 electronic records of 0 to-4-year-old patients who were diagnosed and received care for their concussion at CHOP over a 2-year period. The study provides details on point of entry to health care, mechanisms of injury, and symptom profile. Important considerations unique to this age group are discussed that can facilitate improvements in diagnosis and management of pediatric concussion. 

Characteristics of Concussion in Elementary School-aged Children

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A collaborative study by CHOP and CDC researchers found that vision and balance issues are common in elementary school-age children (ages 5-11) with a concussion. The study, examining close to 300 children, also observed that specific visio-vestibular assessments were not consistently performed at the time of diagnosis. Authors see an opportunity to improve concussion management for this age group through the development of clinical support tools. 

Telephone Triage in Pediatric Head Injury

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Researchers queried CHOP's integrated pediatric health care system's electronic health record (EHR) for calls to the primary care telephone triage system for suspected head injury. In a sample of approximately 2,500 calls, nearly 85% of patients who were told to follow up urgently with a provider (e.g., call emergency medical services, visit an emergency department, visit a health care provider within 24 hours) did comply with the recommendation -- among whom four in ten were diagnosed with a concussion by a provider. This study shows that triage nursing provides effective real-time guidance to get patients who suspect a concussion to proper assessment and intervention. 

Recovery Trajectories in Pediatric Female Concussion

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In a retrospective study of 117 children ages 7 to 18 years presenting to a specialty care practice for a sports-related concussion, researchers found that females took longer than males to recover and that the factor most associated with a prolonged recovery was the prolonged time to first visit as compared to males. The bottom line is that female athletes seek specialty care significantly later than their male peers, and this may contribute to longer recovery trajectories.

Risk of Repeat Concussions

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This study found that one in six children ages 5 to 15 years who have a concussion will go on to experience a repeat concussion within two years. Several characteristics of the initial concussion predicted an elevated risk of subsequent concussions, including an increased number of symptoms and longer recovery time. A recovery course of more than 28 days for the initial concussion correlated to a 65% increased risk of repeat concussion compared to patients with a recovery of less than seven days. Patients who experienced more than 10 symptoms had twice the risk of repeated injury compared to patients with less than two symptoms. This is one of the first studies to quantify the risk of a subsequent injury given a first concussion. 

Mechanisms of Injury for Pediatric Concussion 

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Researchers examined the mechanism of injury for concussion among more than 1,500 children from birth through age 17 who were seen for medical evaluation at CHOP, a large and diverse pediatric healthcare system. They found that the majority of concussions were related to sports and recreational activity (70%), and a significant 30% were due to non-sports and non-recreational mechanisms. Sports and recreation-related activities become the primary source of concussions beginning at age 6, increasing in proportion up to age 10, remaining constant until age 16, and then taking a small dip at age 17, which may be due to an uptick in motor vehicle crash injury and attrition from sports.

Overall, collision or contact activities like football or soccer were the cause of 40% of all concussions, with the remaining concussions occurring in limited or non-contact sports and recreation activities (playground, recess, gym) and non-sports and non-recreation activities (falls, motor vehicle crashes, intentional assaults). The combination of gym class, recess, and playground (all similar activities) would represent the fourth most common sports and recreation-related activity (following football, soccer, and basketball and ahead of ice hockey). 

EHR-Based Clinical Support Tools for Pediatric Concussion

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This study demonstrated that the provision of clinical decision support tools, coupled with in-person training, led to an 85% increase in clinicians documenting a visio-vestibular exam and a 129%  increase in their reporting return-to-learn and return-to-play guidelines discussion with patient families, two recommended concussion management strategies. During the study period, July 1, 2010, to June 30, 2014, researchers identified and followed 14,527 concussion-related primary care office visits for 7,284 unique patients, mostly between the ages of 5 to 19 years old. In the pre-intervention period, performance of the visio-vestibular exam was documented in the EHR for only 1.8 percent of concussion visits.

In contrast, 71% of visits in the post-intervention period included evidence of this exam for an overall 129% increase from July 2012 to June 2014. During the pre-intervention period, 19% of concussion visits included EHR documentation of sharing return-to-learn and return-to-play guidelines. In contrast, in the post-intervention period these phrases were found in 73% of EHRs for a total increase of 85%. The vast majority of exams performed in the post-intervention period (95%) were documented within a “Concussion SmartSet” template in CHOP’s electronic health record system, EpicCare®, showing that the template facilitated performance and systematic documentation of the exam components. 

Point of Entry for Youth with Concussion

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Researchers retrospectively analyzed more than 8,000 concussion diagnoses over a four-year period among children up to 17 years who receive their primary care within the CHOP network. Over the course of that period (July 2010 – June 2014), primary care visits as the point of entry increased 13%, with a corresponding 16% decrease in point of entry Emergency Department (ED) visits. Among those children who have a CHOP primary care physician and were diagnosed with a concussion within CHOP's regional pediatric network, 82% had their first concussion visit at a primary care site, 12% at the ED, 5% within specialty care (sports medicine, neurology, trauma), and 1% were directly admitted to the hospital.

Additionally, one-third were under age 12 and therefore represent an important part of the concussion population that is missed by existing surveillance systems that focus on high school athletes. This study provides direction for healthcare networks and clinicians about the critical importance of providing targeted training and resources in primary care settings.