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February 17th, 2011
Doebbeling 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
INVESTIGATING INTEGRATION OF COMPUTERIZED DECISION SUPPORT INTO WORKFLOW AT 3
BENCHMARK INSTITUTIONS
ACKNOWLEDGEMENTS
2
• Supported by:• Agency for Healthcare Quality and Research (AHRQ)
• HSA2902006000131• Department of Veterans Affairs, VHA HSR&D
• CDA 09-024-1
BACKGROUND
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• Colorectal cancer screening
• Low screening rates; evidence for screening effectiveness
• Clinical decision support (CDS) has been associated with improved quality
• However, the design and workflow integration of CDS may limit its impact
• Recent IOM Committee calling for new paradigm in cognitive support
STUDY QUESTION
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• Barriers to colorectal cancer (CRC) screening and follow-up?
• Factors influencing integration into clinical workflow
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 CDS
• Widely implemented CDS in these institutions
• Ideal settings to study integration of CDS in workflow
Chaudhry et al., Ann Intern Med, 2006
(Chaudhry et al, Ann Intern Med, 2006)
METHODS
• Cognitive Field Research
• Ethnographic observations
• Opportunistic interviews
• Study: CDS for colorectal cancer (CRC) screening in Primary care clinics
• 2 VAMCs
• 2 teaching hospitals (Regenstrief, Partners)
FORM OF CRC SCREENING CDS AT STUDY SITES
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• VA Medical Center 1
• Computerized clinical reminder for CRC screening
• VA Medical Center 2
• Suite of computerized CDS for risk stratification, screening, follow-up, and surveillance
• Regenstrief Institute
• Paper encounter form reminder for CRC screening
• Partners Healthcare
• Electronic, template health maintenance list
STUDY SITES AND PARTICIPANTS
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• Multiple outpatient clinics
• 2-3 observers experienced in ethnographic observation
• Participants: • Observation & opportunistic interviews: 120 providers
(physicians, NPs, PAs)• 118 patient encounters observed
• Key informant interviews: 11 providers
• 2 Focus groups: 11 physicians
ORGANIZATIONS, SETTINGS, PROVIDERS, PATIENTS
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Organization Type of setting No. structured interviews
No. providers and clinic staff observed
No. patients observed
Site 1 Two primary care clinics, one psychiatric outpatient clinic in VA Medical Center Tertiary care facility
3 Physicians 6
Total 19
34
Site 2 Community based primary care clinic using Regenstrief Institute EMR
3 Physicians 10
Total 30
30
Site 3 Three primary care clinics in VA Medical Center Tertiary care facility, one affiliated CBOC
2 Physicians 11
Total 35
22
Site 4 Two community based primary care clinics, and one primary care clinic in large teaching hospital
3 Physicians 15
Total 36
32
Total 11 120 118
ANALYSES
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• Coding template based on the sociotechnical model
• Social, technical, and external subsystems
• Qualitative analyses: top-down vs. bottom-up coding
• Summary and integrative findings
• Findings integrated across sites
BARRIERS TO COLORECTAL CANCER SCREENING AND FOLLOW-UP
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• Lack of communication of “outside” exam results
• Poor data organization & presentation
• Omission of provider, patient education in CDS
• Lack of interface flexibility
• Lack of coordination between primary care and GI
• Needed technological enhancements
• Unclear role assignments
% OF CODED SEGMENTS IN THE TECHNICAL SUB-SECTION BY THEMES & SITES
12
Site 1 Site 2 Site 3 Site 40.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
CoordinationUsabilityPaper-electronic blendRigidityFunctionality
Implementing and Improving the Integration of Decision Support into Outpatient Clinical Workflow, AHRQ ACTION HSA2902006000131
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Social Subsystem• Perception of CDS•Patient barriers and facilitators• Formal and informal roles•Unintended social consequences•Impact on clinical care•Training methods
Technical Subsystem• Paper forms in combination with computer system• Usability• Functionality•Interface rigidity•Unintended technical consequences•Rigidity•Redundant entry
Integration intoWorkflow
•Coordination of outside results•Coordination between primary and specialty care•Data organization and presentation•Just-in-time provider and patient education•Interface flexibility•Technological enhancements•Workflow assignments•Organizational issues
External Subsystem• Physical environment• Workload• Staffing levels•Quality reporting
Figure 1. Coding tree framed by socio-technical systems framework
11-3-10; v3.0
SOCIOTECHNICAL SYSTEM PRIMARY CODE FREQUENCY BY SITES
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External Social Technical Other0
20
40
60
80
100
120
140
160
180
Site 1Site 2Site 3Site 4
% OF CODED SEGMENTS IN THE TECHNICAL SUB-SECTION BY THEMES & SITES
15
Site 1 Site 2 Site 3 Site 40.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
CoordinationUsabilityPaper-electronic blendRigidityFunctionality
PRACTICES AND DESIGN FEATURES
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1) 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.
CONCLUSIONS
• Despite 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.
THANK-YOU!
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• Haggstrom 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.
VA COMPUTERIZED PATIENT RECORD SYSTEM
VAMC 1
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FORM OF COLORECTAL CANCER SCREENING CDS AT STUDY SITES
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• VA Medical Center 1
• Computerized clinical reminder for CRC screening
• VA Medical Center 2
• Set of computerized clinical reminders for screening, follow-up, and surveillance
• Regenstrief Institute
• Paper encounter form reminder for CRC screening
• Partners Healthcare
• Electronic, template health maintenance list
FORM OF COLORECTAL CANCER SCREENING CDS AT STUDY SITES
21
• VA Medical Center 1
• Computerized clinical reminder for CRC screening
• VA Medical Center 2
• Set of computerized clinical reminders for screening, follow-up, and surveillance
• Regenstrief Institute
• Paper encounter form reminder for CRC screening
• Partners Healthcare
• Electronic, template health maintenance list
REGENSTRIEF MEDICAL RECORD SYSTEM
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• Printed 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: ___________________)
FORM OF COLORECTAL CANCER SCREENING CDS AT STUDY SITES
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• VA Medical Center 1
• Computerized clinical reminder for CRC screening
• VA Medical Center 2
• Set of computerized clinical reminders for screening, follow-up, and surveillance
• Regenstrief Institute
• Paper encounter form reminder for CRC screening
• Partners Healthcare
• Electronic, template health maintenance list
PARTNERS – LONGITUDINAL MEDICAL RECORD
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RECEIVING AND DOCUMENTING “OUTSIDE” EXAM RESULTS
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• Physician: “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.”
COLORECTAL CANCER SCREENING CDS NOT ACCURATE
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• Physician: “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.”
COMPLIANCE ISSUES
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• Physician: “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.”
POOR EHR OR CDS USABILITY
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• Physician Assistant
• Paper spreadsheet to track date and results for colonoscopies
• Nurse Practitioner
• Need to repeat screening
LACK OF COORDINATION BETWEEN PRIMARY CARE AND GI
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• Physician: “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.”
ACUTE VS. PREVENTIVE CARE
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• Physician: “If I have to choose between chest pain and hemoccult [fecal occult blood test], I am going to choose chest pain.”