Project Overview: “Improving the Integration of Decision Support into Outpatient Clinical Workflow”

January 8th, 2008

LEADERS SYMPOSIUM“Strategic Planning to Inform a Funded Project onhow to Achieve Workflow Integration in Developing and Implementing CDS for CRC Screening”

Goals for Today

Bring together thought leaders to advise and foster potential collaboration

Strategize about improving the quality of our research & implementation plans

Discuss uptake, dissemination and next steps

Who We Are

IU Center for Health Services & Outcomes Research (IU CHSOR), Regenstrief Institute, Inc.

VA HSR&D Center of Excellence in Implementing Evidence- based Practice (CIEBP)

Websites:- http://www.indyhsr.org

- http://www.ciebp.research.va.gov/

Mission, Vision and Focus

Mission: Advance the science of transforming healthcare delivery.

Vision: Become the leading national resource for promoting and studying health system transformation.

Focus: Implementation of health informatics, system redesign.

VISN 11

RoudebushVAMC

Regenstrief Institute, Inc.Medical Informatics

Aging ResearchHealth Services Research

Regenstrief Centerfor Healthcare Engineering

Indiana UniversitySchool of MedicineSchool of Nursing

Cancer Center

IUPUISchool of Engineering & Tech.

School of ScienceSchool of Informatics

PurdueCollege of Liberal ArtsCollege of EngineeringCollege of Pharmacy

College of TechnologyCancer Center

SystemRedesign

Office ofQuality & Performance

Patient Care Services

Academic & Research Partners

Other VISN’S & VAMC’S

VA Partners

RESEARCH PARTNERSRESEARCH PARTNERS

Community PartnersIndiana Health Information Exchange

Indiana Patient Safety CenterIndiana Hospital & Health Assoc.

Indianapolis Health Systems(Clarian, Community, St. Francis, St. Vincent’s, & Wishard Hospitals)

Rehab Hospital of Indiana

Office ofResearch & Development

HSR&DHSR&D & QuERI Programs

OtherCenters of Excellence

Office ofInformation

Research

Indiana UniversityCenter for Health Services

& Outcomes Research

ACTCenter ofIndiana

IUCAMMP

VACenter of Excellence

for ImplementingEvidence-based Practice

VA StrokeQuERI

Informatics

System Redesign

Core Investigators Doebbeling, Brad - Implementation, Informatics, Pt Safety, System Change Bair, Matt - Chronic Pain, Implementation Bravata, Dawn - Stroke, Implementation, Sleep Apnea Carney-Doebbeling, Caroline - Cancer Care, Mental Illness, Implementation Cook, Cynthia - Nursing, Implementation Damush, Teresa - Stroke, Implementation Frankel, Richard - Safety, Comm, Education, Qualitative Haggstrom, David - Cancer Care, Implementation Imperiale, Tom - Cancer Care, Implementation Inui, Tom - Communication, Education, System Change Krebs, Erin - Chronic Pain and Implementation Kroenke, Kurt - Chronic Pain, Depression, Cancer Care, Implementation Saleem, Jason - Safety, Informatics, HCI Salyers, Michelle - SMI, Implementation, Community Treatment Williams, Linda - Stroke, QI, Implementation, Post-Stroke Depression Woodward-Hagg, Heather - Systems Engineering, QI, Implementation Zillich, Alan - Implementation, Pharmacy

AHRQ ACTION Collaborative

TASK ORDER #8: Improving Quality Through Health IT: Testing the feasibility and assessing the impact of using existing health IT infrastructure for better care delivery

Title: “Improving the Integration of Decision Support into Outpatient Clinical Workflow”

Dates: 10/07 – 09/09

7

8

AHRQ Grant – Improving Integration of CDS into Workflow Research Team:

Brad Doebbeling, MD, MSc (PI) David Haggstrom, MD, MAS Jason Saleem, PhD Laura Militello, MA Heather Hagg, MS And representatives from West Haven VA,

Columbia, South Carolina VA, Partners Healthcare, & Regenstrief

Project managers: Shawn Hoke and Lori Losee

9

Motivation More effective use of IT is recommended in integrating point of care access

to (e.g., Committee on Quality Health Care in America): Health literature and evidence-based guidelines; Computerized clinical data; Computerized decision support (CDS) systems; Automation of decisions to reduce errors; Electronic communication among providers and patients into practice.

Computerized CDS can improve clinician decision making and support adherence to evidence-based guidelines. (e.g., Reid et al., 2005; Doebbeling et al., JGIM, 2006; Bates et al. JAMIA 1999 & 2001)

Colorectal cancer screening focus: high disease burden, relatively low screening rates, strong evidence for screening effectiveness

Failure to optimally integrate CDS into workflow has resulted in inconsistent and incomplete implementation strategies. (e.g., Doebbeling et al., JGIM 2006; Garg et al., JAMA, 2005)

Conceptual Framework: Sociotechnical Systems Theory to guide identification of factors important in better understanding how to best develop and implement CDS

10

Social Subsystem

Technological Subsystem

External Environment

Organizational Structure / Work System Design

Joint Optimization

Social Subsystem

Technological Subsystem

External Environment

Organizational Structure / Work System Design

Joint Optimization

Sociotechnical Framework

11

Study AimsSpecific 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.

H1: Effective colorectal cancer screening CDS integration into workflow requires system redesign, human factors assessment, pilot testing, use at the bedside or patient room, and provider training and support.

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

H2: Providers will experience improved efficiency and usability, and decreased workload when using design alternatives for colorectal cancer screening CDS compared to current CDS.

12

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

Implementationin 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

13

Multi-Organizational Approach Proposal includes 3 of the top 4 leaders in demonstrating improved quality and efficiency using health IT: VA, Regenstrief, Partners Healthcare (Chaudhry et al., Annals of Internal Medicine, 2006)

Each of these 3 organizations use very different designs and approaches for CDS with the electronic medical record

These differences all impact workflow integration Unique context of each organization vs. generalizable

design principles

TimelineProject Activity

YEAR 1 Data collection: West Haven VA Medical Center (target between months 2 and 5) Data collection: *Columbia VA Medical Center (target between months 3 and 6) Data collection: The Regenstrief Institute (target between months 4 and 7) Data collection: Partners Healthcare System (target between months 5 and 10) Continuous data reduction of observational and interview data through months 2-10 Data analysis of observational and interview data between months 10-12

YEAR 2 Rapid prototyping of clinical decision support (CDS) design alternatives, months 13-14 Initial pilot test of redesigned CDS, month 15 Simulation study of CDS to demonstrate improved integration into workflow, months 15-16 Evaluate impact / analyze measures: efficiency, usability, and workload, month 17 Implementation of refined CDS in local VA primary care clinics, months 18-20 Evaluate impact / analyze measures: efficiency, usability, and workload, months 20-21 Create and disseminate implementation handbook, tools, manuscripts, months 22-24

14

*Columbia VA is initial test site for new OncWatch CRC Screening CDS