ORCID ID
Graduation Date
Summer 8-14-2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Programs
Biomedical Informatics
First Advisor
Martina Clarke
Abstract
Clinical decision-making in pediatric acute care is characterized by significant cognitive burden, diagnostic uncertainty, and practice. Integrated care pathways (ICPs) are evidence-based, structured care plans designed to standardize clinical management and reduce unwarranted variation. The shift toward embedding ICPs directly within electronic health record (EHR) systems represents a promising evolution in clinical decision support. However, rigorous evaluation of EHR-embedded ICPs in pediatric settings remains largely absent from the literature. This dissertation addresses that gap through three complementary studies evaluating the usability, clinical effectiveness, and economic value of EHR-embedded ICPs in pediatric acute care.
Chapter 1 evaluated the usability of EHR-embedded ICPs among 16 cardiac care unit (CCU) nurses at Children's Nebraska using a prospective, simulation-based crossover design. Nurses completed task-driven simulations for junctional ectopic tachycardia (JET) and chylothorax pathways under both EHR-embedded ICP and standard workflow conditions. The EHR-embedded ICP achieved a System Usability Scale (SUS) score of 91.85 (A+ letter grade), reduced perceived cognitive load across all six NASA Task Load Index (NASA-TLX) domains (p< 0.01), and was associated with a model-estimated mean task performance score of 90.6% compared to 45.1% for standard workflow (p< 0.01).
Chapter 2 evaluated clinical outcomes associated with the EHR-embedded febrile infant pathway at Children's Nebraska using propensity score-weighted logistic and generalized linear regression models across 463 encounters. Pathway-managed encounters had significantly higher odds of guideline-concordant laboratory testing, including urinalysis (OR 16.91, 95% CI: 8.66-33.03), blood culture (OR 7.28, 95% CI: 4.64-11.42), and appropriate inflammatory marker testing (OR 5.46, 95% CI: 3.68-8.09). Risk-stratified analyses demonstrated that the pathway appropriately increased evaluation in high-risk infants while reducing unnecessary procedures in low-risk infants.
Chapter 3 compared encounter-level total charges between pathway-managed and standard care encounters using the same cohort and propensity score weights. Total charges did not differ significantly between groups ($12,830 vs. $12,600, p=0.73), indicating that improvements in guideline-concordant care were achieved without a significant economic penalty.
Together, these findings provide systematic evidence that EHR-embedded ICPs in pediatric acute care can ease clinician decision-making, standardize risk-stratified care delivery, and generate clinical value without significant cost increases, establishing a foundation for broader implementation and future research.
Rights
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Recommended Citation
Schissel, Makayla, "EHR-Embedded Integrated Care Pathways in Pediatric Care: Usability, Clinical Outcomes, and Cost Evaluation" (2026). Theses & Dissertations. 1103.
https://digitalcommons.unmc.edu/etd/1103