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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

Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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Oral Presentation from AHRQ project at VA HSR&D Annual Meeting Feb 17, 2011

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Page 1: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 2: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

ACKNOWLEDGEMENTS

2

• Supported by:• Agency for Healthcare Quality and Research (AHRQ)

• HSA2902006000131• Department of Veterans Affairs, VHA HSR&D

• CDA 09-024-1

Page 3: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 4: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

STUDY QUESTION

4

• Barriers to colorectal cancer (CRC) screening and follow-up?

• Factors influencing integration into clinical workflow

Page 5: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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)

Page 6: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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)

 

Page 7: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

FORM OF CRC SCREENING CDS AT STUDY SITES

7

• 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

Page 8: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 9: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 10: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 11: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 12: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

% OF CODED SEGMENTS IN THE TECHNICAL SUB-SECTION BY THEMES & SITES

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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

Page 13: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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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

Page 14: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

SOCIOTECHNICAL SYSTEM PRIMARY CODE FREQUENCY BY SITES

14

External Social Technical Other0

20

40

60

80

100

120

140

160

180

Site 1Site 2Site 3Site 4

Page 15: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

% 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

Page 16: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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.

Page 17: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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.

Page 18: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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.

Page 19: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

VA COMPUTERIZED PATIENT RECORD SYSTEM

VAMC 1

19

Page 20: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 21: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 22: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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: ___________________)

Page 23: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 24: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

PARTNERS – LONGITUDINAL MEDICAL RECORD

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Page 25: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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.”

Page 26: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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.”

Page 27: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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.”

Page 28: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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

Page 29: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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.”

Page 30: Investigating Integration Of Computerized Decision Support Into Workflow Hsr&D Pres Feb 17 2011

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.”