Jason Slides from AHRQ Kick-Off

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Published on January 9, 2008

Author: ShawnHoke

Source: slideshare.net

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Approaches to CDS Development for Effective Workflow Integration

Approaches to CDS Development for Effective Workflow Integration January 8 th , 2008 Jason J. Saleem, PhD & Laura Militello, MA LEADERS SYMPOSIUM “ Strategic Planning to Inform a Funded Project on how to Achieve Workflow Integration in Developing and Implementing CDS for CRC Screening”

Significance – Workflow Integration The implementation of health IT and its integration into workflow has been slow to reach its potential. (e.g., Garg et al., JAMA, 2005; Doebbeling et al., GJIM, 2005; Osheroff et al., JAMIA 2007; Linder et al., AIM, 2007; Sittig et al., JBI, 2007) Multiple recent studies and reviews have specifically identified integration of CDS into clinical workflow as a key failing of current CDS efforts. (e.g., Bates et al., JAMIA, 2003; Militello et al., HFES Proc, 2004; Patterson et al. JAMIA, 2004; Kawamoto et al., BMJ, 2005; Saleem et al., JAMIA, 2005; Kuperman et al., JAMIA, 2007; Weir et al., JAMIA, 2007)

The implementation of health IT and its integration into workflow has been slow to reach its potential.

(e.g., Garg et al., JAMA, 2005; Doebbeling et al., GJIM, 2005; Osheroff et al., JAMIA 2007; Linder et al., AIM, 2007; Sittig et al., JBI, 2007)

Multiple recent studies and reviews have specifically identified integration of CDS into clinical workflow as a key failing of current CDS efforts.

(e.g., Bates et al., JAMIA, 2003; Militello et al., HFES Proc, 2004; Patterson et al. JAMIA, 2004; Kawamoto et al., BMJ, 2005; Saleem et al., JAMIA, 2005; Kuperman et al., JAMIA, 2007; Weir et al., JAMIA, 2007)

Study Aims Specific Aim 1: Identify key approaches to CDS development for colorectal cancer screening at two VAMC sites and two nationally recognized non-VA sites, for effective CDS integration into clinical workflow. Specific Aim 2: Develop and test CDS design alternatives for improved integration into clinical workflow through a controlled simulation study and subsequent implementation.

Specific Aim 1: Identify key approaches to CDS development for colorectal cancer screening at two VAMC sites and two nationally recognized non-VA sites, for effective CDS integration into clinical workflow.

Specific Aim 2: Develop and test CDS design alternatives for improved integration into clinical workflow through a controlled simulation study and subsequent implementation.

National Organizational Survey of VHA Chiefs of Staff (Yano, PI) N = 111 Chiefs of Staff Mechanisms of Clinical Decision Support (CDS) Development

Key Informant Interviews of site-specific best-practices for integration of colorectal cancer screening CDS into workflow Direct Observation of colorectal cancer screening CDS for barriers and facilitators to workflow integration Implementation in primary care clinic after simulation study Rapid Prototyping of CDS design alternatives based on Phase 1 findings Simulation Study to test impact of CDS design alternatives on efficiency, usability, and workload Evaluation in primary care clinic after simulation study Figure. Project Overview Phase 1 Phase 2 Phase 3

Phase 1 - Observational Sites VAMC – West Haven, CT CRC screening computerized clinical reminder VAMC – Columbia, SC (originally SLC VAMC) OncWatch CDS (clinical reminder and management tool) Divides patients (based on the data) into four different cohorts, defined by their risk/needs Creates a “fail safe” system to identify patients and ensure follow-up recommendations are being fulfilled Regenstrief – Wishard Encounter form reminders for CRC screening Partners – Brigham & Women’s (??) Previous unsuccessful attempts to implement CRC screening CDS: “no easy way to feed back that an adequate colonoscopy was done and was normal” Other screening clinical reminders

VAMC – West Haven, CT

CRC screening computerized clinical reminder

VAMC – Columbia, SC (originally SLC VAMC)

OncWatch CDS (clinical reminder and management tool)

Divides patients (based on the data) into four different cohorts, defined by their risk/needs

Creates a “fail safe” system to identify patients and ensure follow-up recommendations are being fulfilled

Regenstrief – Wishard

Encounter form reminders for CRC screening

Partners – Brigham & Women’s (??)

Previous unsuccessful attempts to implement CRC screening CDS: “no easy way to feed back that an adequate colonoscopy was done and was normal”

Other screening clinical reminders

*Fictitious patient record*



Direct Observation Ethnographic, “naturalistic” observation Non-intrusive; shadowing of nurses and physicians 2 observers, 4 sites (2 VA, 2 non-VA) 1 full day at each site, in at least 2 outpatient clinics Capture observable activities and verbalizations Self-report data about how artifacts (tools) support or hinder performance (opportunistic interviews) “ Maximum sampling strategy” (1 provider through 2 encounters) Qualitative field data Key question : How to focus the observations? See handout for list of key aspects for prioritization…

Ethnographic, “naturalistic” observation

Non-intrusive; shadowing of nurses and physicians

2 observers, 4 sites (2 VA, 2 non-VA)

1 full day at each site, in at least 2 outpatient clinics

Capture observable activities and verbalizations

Self-report data about how artifacts (tools) support or hinder performance (opportunistic interviews)

“ Maximum sampling strategy” (1 provider through 2 encounters)

Qualitative field data

Key question : How to focus the observations? See handout for list of key aspects for prioritization…

Key Informant Interviews In-depth interview of at least 3 key personnel from each site. E.g., 1 high-level administrator; 1 clinical champion Semi-structured Sample questions What is the ideal workflow in your outpatient clinics? What difficulties have you experienced fitting use of CDS into your ideal workflow? Specifically use of clinical reminders for CRC screening? Have you altered your workflow to accommodate (or better utilize) clinical reminders or other CDS for CRC screening? Are there aspects of clinical reminders or other CDS for CRC screening that hinder or facilitate workflow? See handout for full list of sample questions for prioritization…

In-depth interview of at least 3 key personnel from each site.

E.g., 1 high-level administrator; 1 clinical champion

Semi-structured

Sample questions

What is the ideal workflow in your outpatient clinics?

What difficulties have you experienced fitting use of CDS into your ideal workflow?

Specifically use of clinical reminders for CRC screening?

Have you altered your workflow to accommodate (or better utilize) clinical reminders or other CDS for CRC screening?

Are there aspects of clinical reminders or other CDS for CRC screening that hinder or facilitate workflow?

See handout for full list of sample questions for prioritization…

Upward Abstraction of Qualitative Field Data Based on Hollnagel et al. (1981); Xiao and Vicente (2000); Patterson et al. (2002); Roth and Patterson (2005) Raw data (domain and context specific) Coding of data into based on events and timeline Sorting of coded data into emerging categories Integrate findings across observations/cases; patterns and replications across cases Collapse similar categories and split others into logical sub-categories Abstraction of data into emerging themes (recurrent strategies, mental models, - more generalizable constructs) Remove context to produce generic strategies / generalizable results

Findings Results from Phase 1 to inform design (Phase 2) Understand and incorporate key approaches to CDS development Translate key findings / strategies for workflow integration into improved CDS design alternatives for CRC screening

Results from Phase 1 to inform design (Phase 2)

Understand and incorporate key approaches to CDS development

Translate key findings / strategies for workflow integration into improved CDS design alternatives for CRC screening

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