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ABSTRACT: Based on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administration's (VHA's) colorectal cancer (CRC) screening clinical reminder to compare against the VHA's current CRC reminder.
In a controlled simulation experiment, 12 primary care providers (PCPs) used prototypes of the current and redesigned CRC screening reminder in a within-subject comparison. Quantitative measurements were based on a usability survey, workload assessment instrument, and workflow integration survey. We also collected qualitative data on both designs.
Design enhancements to the VHA's existing CRC screening clinical reminder positively impacted aspects of usability and workflow integration but not workload. The qualitative analysis revealed broad support across participants for the design enhancements with specific suggestions for improving the reminder further.
This study demonstrates the value of a human-computer interaction evaluation in informing the redesign of information tools to foster uptake, integration into workflow, and use in clinical practice.
BMC Medical Informatics and Decision Making 11/2011; 11:74. · 1.48 Impact Factor
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ABSTRACT: Interventions that focus on improving computerized clinical decision support (CDS) demonstrate that successful workflow integration can increase the adoption and use of CDS. However, metrics for assessing workflow integration in clinical settings are not well established. The goal of this study was to develop and validate a survey to assess the extent to which CDS is integrated into workflow. Qualitative data on CDS design, usability, and integration from four sites was collected by direct observation, interviews, and focus groups. Thematic analysis based on the sociotechnical systems theory revealed consistent themes across sites. Themes related to workflow integration included navigation, functionality, usability, and workload. Based on these themes, a brief 12-item scale to assess workflow integration was developed, refined, and validated with providers in a simulation study. To our knowledge, this is one of the first tools developed to specifically measure workflow integration of CDS.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 01/2011; 2011:427-34.
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ABSTRACT: With the United States national goal and incentive program to transition from paper to electronic health records (EHRs), healthcare organizations are increasingly implementing EHRs and other related health information technology (IT). However, in institutions which have long adopted these computerized systems, such as the Veterans Health Administration, healthcare workers continue to rely on paper to complete their work. Furthermore, insufficient EHR design also results in computer-based workarounds. Using direct observation with opportunistic interviewing, we investigated the use of paper-and computer-based workarounds to the EHR with a multi-site study of 54 healthcare workers, including primary care providers, nurses, and other healthcare staff. Our analysis revealed several paper-and computer-based workarounds to the VA's EHR. These workarounds, including clinician-designed information tools, provide evidence for how to enhance the design of the EHR to better support the needs of clinicians.
Human Factors and Ergonomics Society Annual Meeting Proceedings 01/2011;
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ABSTRACT: The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs.
Surveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models.
For all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used.
Provider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.
Implementation Science 10/2009; 4:71. · 3.10 Impact Factor
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ABSTRACT: In concept and practice, clinical decision support (CDS) and performance measurement represent distinct approaches to organizational change, yet these two organizational processes are interrelated. We set out to better understand how the relationship between the two is perceived, as well as how they jointly influence clinical practice. To understand the use of CDS at benchmark institutions, we conducted semistructured interviews with key managers, information technology personnel, and clinical leaders during a qualitative field study. Improved performance was frequently cited as a rationale for the use of clinical reminders. Pay-for-performance efforts also appeared to provide motivation for the use of clinical reminders. Shared performance measures were associated with shared clinical reminders. The close link between clinical reminders and performance measurement causes these tools to have many of the same implementation challenges.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 01/2009; 2009:223-7.
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ABSTRACT: Implementation of computerized clinical decision support (CDS), and its integration into workflow has not reached its potential. To better understand the use of CDS for colorectal cancer (CRC) screening at benchmark institutions for health information technology (HIT), we conducted direct observation, including opportunistic interviews of primary care providers, as well as key informant interviews and focus groups, to document current challenges to CRC screening and follow-up at clinics affiliated with the Veterans Heath Administration, Regenstrief Institute, and Partners HealthCare System. Analysis revealed six common barriers across institutions from the primary care providers' perspective: receiving and documenting "outside" exam results, inaccuracy of the CDS, compliance issues, poor usability, lack of coordination between primary care and gastroenterology, and the need to attend to more urgent patient issues. Strategies should be developed to enhance current HIT to address these challenges and better support primary care providers and staff.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 01/2009; 2009:558-62.
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ABSTRACT: The widespread gap between evidence and practice for clinical and preventive services argues for a deeper understanding of effective quality improvement (QI) and system change. Using implementation and system redesign sciences, we have developed and used an effective strategy to enable robust implementation of QI initiatives, including clinical practice bundles, within a health care setting. Our program, which applies Lean and systems engineering methodologies, is specifically designed to exploit the five characteristics of effective innovations, as outlined by Berwick. This strategy has been applied in over 21 hospitals (six hospital systems) throughout the State of Indiana and is currently being used as part of the Radically Reducing methicillin-resistant Staphylococcus aureus (MRSA) initiative funded by the Agency for Healthcare Research and Quality (AHRQ). The benefits of the process redesign activities are detailed at the business level through a business case analysis. Additionally, benefits at the personal level are quantified through workflow analysis (prior to and following the interventions). The intervention strategy is integrated into the current quality framework for each organization to ensure compatibility with existing organizational programs. Our staff engagement, training, and educational programs make systems engineering methodologies and principles readily accessible to frontline staff. Additionally, each project session requires immediate application of tools and techniques. This article will discuss our implementation strategy, provide examples of Lean and systems engineering tool applications, and provide an assessment of spread adoption and sustainability as a function of this implementation strategy.
01/2008;
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ABSTRACT: The rapid spread of antimicrobial resistance (AMR) in the US hospitals poses serious quality and safety problems. Expert panels, identifying strategies for optimizing antibiotic use and preventing AMR spread, have recommended hospitals undertake efforts to implement specific evidence-based practices.
To develop and validate a measurement scale for assessing hospitals' efforts to implement recommended AMR prevention and control measures.
Surveys were mailed to infection control professionals in a national sample of 670 US hospitals stratified by geographic region, bedsize, teaching status, and VA affiliation.
: Four hundred forty-eight infection control professionals participated (67% response rate).
Survey items measured implementation of guideline recommendations, practices for AMR monitoring and feedback, AMR-related outcomes (methicillin-resistant Staphylococcus aureus prevalence and outbreaks [MRSA]), and organizational features. "Derivation" and "validation" samples were randomly selected. Exploratory factor analysis was performed to identify factors underlying AMR prevention and control efforts. Multiple methods were used for validation.
We identified 4 empirically distinct factors in AMR prevention and control: (1) practices for antimicrobial prescription/use, (2) information/resources for AMR control, (3) practices for isolating infected patients, and (4) organizational support for infection control policies. The Prevention and Control of Antimicrobial Resistance scale was reliable and had content and construct validity. MRSA prevalence was significantly lower in hospitals with higher resource/information availability and broader organizational support.
The Prevention and Control of Antimicrobial Resistance scale offers a simple yet discriminating assessment of AMR prevention and control efforts. Use should complement assessment methods based exclusively on AMR outcomes.
Medical Care 07/2007; 45(6):537-44. · 3.41 Impact Factor
