Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011
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“So preventive care gets pushed aside for acute care issues?” Physician: “Absolutely. That’s the nature of primary care.” Physician: “Preventive care is the first thing to go when you’re busy.” Physician: “When you’re in the middle of seeing patients, the last thing you want to do is address a preventive care issue.”
![Receiving and documenting “outside” exam results25Physician: “In the [CRC] clinical reminder [dialog] box you cannot easily document that a colonoscopy was done outside of the VA. Say the patient had an outside colonoscopy done 5 years ago- you need to enter the exact date, time, location. But the patient may only remember that he had a colonoscopy about 5 years ago.”](https://image.slidesharecdn.com/investigatingintegrationofcomputerizeddecisionsupportintoworkflowhsrdpresfeb172011-12979123870257-phpapp02/85/Investigating-Integration-Of-Computerized-Decision-Support-Into-Workflow-Hsr-amp-D-Pres-Feb-17-2011-25-320.jpg)
![Compliance issues27Physician: “They did it wrong up front – they completed the colorectal cancer screening reminder wrong. It [the reminder] says the cards were given to the patient but she [health tech] did not give him the cards. Every system has weak links. This is one of them for us.”](https://image.slidesharecdn.com/investigatingintegrationofcomputerizeddecisionsupportintoworkflowhsrdpresfeb172011-12979123870257-phpapp02/85/Investigating-Integration-Of-Computerized-Decision-Support-Into-Workflow-Hsr-amp-D-Pres-Feb-17-2011-27-320.jpg)
![Lack of coordination between primary care and GI29Physician: “GI should be able to clear out the [computerized clinical] reminder. For example, the patient we just saw…it took me a while to go through and satisfy it [the CRC clinical reminder]. The patients see lots of different people in the hospital and they all have their hands in the patient’s care. They should be satisfying some of the reminders as well.”](https://image.slidesharecdn.com/investigatingintegrationofcomputerizeddecisionsupportintoworkflowhsrdpresfeb172011-12979123870257-phpapp02/85/Investigating-Integration-Of-Computerized-Decision-Support-Into-Workflow-Hsr-amp-D-Pres-Feb-17-2011-29-320.jpg)
![Acute vs. preventive care30Physician: “If I have to choose between chest pain and hemoccult [fecal occult blood test], I am going to choose chest pain.”](https://image.slidesharecdn.com/investigatingintegrationofcomputerizeddecisionsupportintoworkflowhsrdpresfeb172011-12979123870257-phpapp02/85/Investigating-Integration-Of-Computerized-Decision-Support-Into-Workflow-Hsr-amp-D-Pres-Feb-17-2011-30-320.jpg)
Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011
- 1. Investigating Integration of Computerized Decision Support into Workflow at 3 Benchmark InstitutionsFebruary 17th, 2011Doebbeling B.N., Haggstrom, D.A., Militello, L.G., Flanagan, M.E., Arbuckle, C.L., Kiess, C.L., Saleem, J.J.VA HSR&D Center on Implementing Evidence-Based Practice;Regenstrief Institute; IU School of Medicine and Purdue School of Engineering
- 2. Acknowledgements2Supported by:Agency for Healthcare Quality and Research (AHRQ)HSA2902006000131Department of Veterans Affairs, VHA HSR&D CDA 09-024-1
- 3. Background3Colorectal cancer screeningLow screening rates; evidence for screening effectivenessClinical decision support (CDS) has been associated with improved qualityHowever, the design and workflow integration of CDS may limit its impactRecent IOM Committee calling for new paradigm in cognitive support
- 4. Study Question4Barriers to colorectal cancer (CRC) screening and follow-up?Factors influencing integration into clinical workflow
- 5. Rationale for Study Sites“Benchmark institutions” for CDS Regenstrief Institute, Partners Healthcare, Veterans Health Administration, (Intermountain Health Care)Early-adopter institutions that implemented internally developed health information technology systems, including computerized CDSWidely implemented CDS in these institutionsIdeal settings to study integration of CDS in workflow(Chaudhry et al, Ann Intern Med, 2006)Chaudhry et al., Ann Intern Med, 2006
- 6. MethodsCognitive Field ResearchEthnographic observationsOpportunistic interviewsStudy: CDS for colorectal cancer (CRC) screening in Primary care clinics2 VAMCs2 teaching hospitals (Regenstrief, Partners)
- 7. Form of CRC Screening CDS at Study Sites7VA Medical Center 1Computerized clinical reminder for CRC screeningVA Medical Center 2Suite of computerized CDS for risk stratification, screening, follow-up, and surveillanceRegenstrief InstitutePaper encounter form reminder for CRC screeningPartners HealthcareElectronic, template health maintenance list
- 8. Study Sites and Participants8Multiple outpatient clinics2-3 observers experienced in ethnographic observationParticipants: Observation & opportunistic interviews: 120 providers (physicians, NPs, PAs)118 patient encounters observedKey informant interviews: 11 providers2 Focus groups: 11 physicians
- 9. Organizations, settings, providers, patients9
- 10. Analyses10Coding template based on the sociotechnical modelSocial, technical, and external subsystemsQualitative analyses: top-down vs. bottom-up codingSummary and integrative findingsFindings integrated across sites
- 11. Barriers to colorectal cancer screening and follow-up11Lack of communication of “outside” exam resultsPoor data organization & presentationOmission of provider, patient education in CDSLack of interface flexibilityLack of coordination between primary care and GINeeded technological enhancementsUnclear role assignments
- 12. % of Coded Segments in the Technical Sub-Section by Themes & Sites12Implementing and Improving the Integration of Decision Support into Outpatient Clinical Workflow, AHRQ ACTION HSA2902006000131
- 13. 13
- 14. Sociotechnical System Primary Code Frequency By Sites14
- 15. % of Coded Segments in the Technical Sub-Section by Themes & Sites15
- 16. Practices and design features161) organizational priorities; 2) contextual structure and process;3) team role assignments & workflow;4) coordination and communication between clinics and other services; 5) integrating outside results; 6) improved data organization, presentation; 7) just-in time patient education and provider cognitive support; 8) interface and user interaction; 9) technological enhancements.
- 17. ConclusionsDespite differences between health systems, barriers were quite consistent. New CDS prototypes are needed which: 1) improve data organization and presentation; 2) integrate outside results and 3) provide just-in time education and cognitive support. Workflow variations, user-centered design and usability key to an information system that works in practice.Effective design and integration of new technologies requires mindful iteration.
- 18. Thank-you!18Haggstrom DA, Saleem JJ, Militello LG, Arbuckle N, Flanagan M, Doebbeling BN. Examining the relationship between clinical decision support and performance measurement. Proc AMIA Symp 2009; 223-7.Saleem JJ, Militello LG, Arbuckle N, Flanagan M, Haggstrom DA, Linder JA, Doebbeling BN. Provider perceptions of colorectal cancer screening decision support at three benchmark institutions. Proc AMIA Symp 2009; 558-62.
- 19. VA Computerized Patient Record SystemVAMC 119
- 20. Form of Colorectal Cancer Screening CDS at Study Sites20VA Medical Center 1Computerized clinical reminder for CRC screeningVA Medical Center 2Set of computerized clinical reminders for screening, follow-up, and surveillanceRegenstrief InstitutePaper encounter form reminder for CRC screeningPartners HealthcareElectronic, template health maintenance list
- 21. Form of Colorectal Cancer Screening CDS at Study Sites21VA Medical Center 1Computerized clinical reminder for CRC screeningVA Medical Center 2Set of computerized clinical reminders for screening, follow-up, and surveillanceRegenstrief InstitutePaper encounter form reminder for CRC screeningPartners HealthcareElectronic, template health maintenance list
- 22. Regenstrief Medical Record System22Printed paper encounter form with clinical reminders at the bottom. Paper reminders automatically generated by the CDS rules.* Annual FOBT and periodic sigmoidoscopy are recommended for all persons aged 50 or over to screen for colorectal cancer. If screening FOBT is positive, colonoscopy is recommended.* HEMOCCULT 1)Pt refused 2) Done Today (results: ___________________)
- 23. Form of Colorectal Cancer Screening CDS at Study Sites23VA Medical Center 1Computerized clinical reminder for CRC screeningVA Medical Center 2Set of computerized clinical reminders for screening, follow-up, and surveillanceRegenstrief InstitutePaper encounter form reminder for CRC screeningPartners HealthcareElectronic, template health maintenance list
- 24. Partners – Longitudinal Medical Record24
- 25. Receiving and documenting “outside” exam results25Physician: “In the [CRC] clinical reminder [dialog] box you cannot easily document that a colonoscopy was done outside of the VA. Say the patient had an outside colonoscopy done 5 years ago- you need to enter the exact date, time, location. But the patient may only remember that he had a colonoscopy about 5 years ago.”
- 26. Colorectal cancer screening CDS not accurate26Physician: “One patient was sent to GI three times for a colonoscopy. Each time they told him he wasn’t due. But the reminder keeps coming up. He had a colonoscopy recently, so I don’t know why the reminder doesn’t turn off.”
- 27. Compliance issues27Physician: “They did it wrong up front – they completed the colorectal cancer screening reminder wrong. It [the reminder] says the cards were given to the patient but she [health tech] did not give him the cards. Every system has weak links. This is one of them for us.”
- 28. Poor EHR or CDS usability28Physician AssistantPaper spreadsheet to track date and results for colonoscopiesNurse PractitionerNeed to repeat screening
- 29. Lack of coordination between primary care and GI29Physician: “GI should be able to clear out the [computerized clinical] reminder. For example, the patient we just saw…it took me a while to go through and satisfy it [the CRC clinical reminder]. The patients see lots of different people in the hospital and they all have their hands in the patient’s care. They should be satisfying some of the reminders as well.”
- 30. Acute vs. preventive care30Physician: “If I have to choose between chest pain and hemoccult [fecal occult blood test], I am going to choose chest pain.”
Editor's Notes
- #7: Two studies of the integration of clinical decision support tools Two days of observation at each site2-3 observers at each siteEach observer stayed with one provider through an average of two CDS interactions before observing another providerData analyzed using upward abstraction
- #13: Site 3 had a tool focused on coordination of care between primary and specialty careSite 2 had much on paper-electronic blend—had greatest use of paperSite 4 (PH) had more comments about functionality—was that related to positive or negative comments—comparable in advanced IT development to VA, but smaller system—huge IT research dept colocated with themUsability comments comparable across the sites similar even though very different systems—most were negativeLowest site on usability (RI) had templates, fewest negative commetns on usability probably related to using less for their jobRigidity—computer system, electronic medical record—forced you to do things, computer systemSite 1 and 3 had highest comments about rigidity (VA’s) and centrally controlled development strategyCoordination between specialty and primary care—tool developed as joint effort between primary and specialty care to foster scheduling, intake and provider and specialty and provider. Here coordination between intake and provider removed.Make a list of interpretations—do this again after we create figure from card sort and recommendations.
- #15: Interesting predominance of comments on technical system—is there an imbalance on technologically driven system, or was that the focus of the observations?Site 1 West HavenSite 2 RISite 3 Columbia VASite 4 PartnersCould this reflect frequency due to additional capturing of codesSite 1 had 2 peopleSite 2 had 3 peopleBig other data so detailed and made a point of recording all data regarding other stuff observed—for example, any time CRC mentioned, coded as other.Revised slide with only observations that were coded end of FTF session…1 page list of most important results and themesCreate graph of that card sort…4 recommendations that fell under the card sort, show proportion by siteMade up of codes under each of those strategies
- #16: Site 3 had a tool focused on coordination of care between primary and specialty careSite 2 had much on paper-electronic blend—had greatest use of paperSite 4 (PH) had more comments about functionality—was that related to positive or negative comments—comparable in advanced IT development to VA, but smaller system—huge IT research dept colocated with themUsability comments comparable across the sites similar even though very different systems—most were negativeLowest site on usability (RI) had templates, fewest negative commetns on usability probably related to using less for their jobRigidity—computer system, electronic medical record—forced you to do things, computer systemSite 1 and 3 had highest comments about rigidity (VA’s) and centrally controlled development strategyCoordination between specialty and primary care—tool developed as joint effort between primary and specialty care to foster scheduling, intake and provider and specialty and provider. Here coordination between intake and provider removed.Make a list of interpretations—do this again after we create figure from card sort and recommendations.