February 17 th , 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
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Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011
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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
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
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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
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.
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.”