“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.”

1. Investigating Integration of Computerized Decision Support into Workflow at 3 Benchmark Institutions 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

2. Acknowledgements 2 Supported by: Agency for Healthcare Quality and Research (AHRQ) HSA2902006000131 Department of Veterans Affairs, VHA HSR&D CDA 09-024-1

3. Background 3 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

4. Study Question 4 Barriers 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 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

6. 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)

7. 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

8. Study Sites and Participants 8 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

9. Organizations, settings, providers, patients 9

10. Analyses 10 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

11. Barriers to colorectal cancer screening and follow-up 11 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

12. % of Coded Segments in the Technical Sub-Section by Themes & Sites 12 Implementing and Improving the Integration of Decision Support into Outpatient Clinical Workflow, AHRQ ACTION HSA2902006000131

13. 13

14. Sociotechnical System Primary Code Frequency By Sites 14

15. % of Coded Segments in the Technical Sub-Section by Themes & Sites 15

16. Practices and design features 16 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.

17. 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.

18. Thank-you! 18 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.

19. VA Computerized Patient Record SystemVAMC 1 19

20. Form of Colorectal Cancer Screening CDS at Study Sites 20 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

21. 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

22. Regenstrief Medical Record System 22 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: ___________________)

23. Form of Colorectal Cancer Screening CDS at Study Sites 23 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

24. Partners – Longitudinal Medical Record 24

25. Receiving and documenting “outside” exam results 25 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.”

26. Colorectal cancer screening CDS not accurate 26 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.”

27. Compliance issues 27 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.”

28. Poor EHR or CDS usability 28 Physician Assistant Paper spreadsheet to track date and results for colonoscopies Nurse Practitioner Need to repeat screening

29. Lack of coordination between primary care and GI 29 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.”

30. Acute vs. preventive care 30 Physician: “If I have to choose between chest pain and hemoccult [fecal occult blood test], I am going to choose chest pain.”