Incorporating Guideline Adherence and Practice Implementation Issues into the Design of Decision Support for Beta-Blocker Titration for Heart Failure

Michael W. Smith; Charnetta Brown; Salim S. Virani; Charlene R. Weir; Laura A. Petersen; Natalie Kelly; Julia Akeroyd; Jennifer H. Garvin

doi:10.1055/s-0038-1660849

Applied Clinical Informatics, Table of Contents

Appl Clin Inform 2018; 09(02): 478-489
DOI: 10.1055/s-0038-1660849

Research Article

Schattauer GmbH Stuttgart

Incorporating Guideline Adherence and Practice Implementation Issues into the Design of Decision Support for Beta-Blocker Titration for Heart Failure

Michael W. Smith

¹Department of Industrial & Mechanical Engineering, Universidad de las Americas Puebla, Cholula, PUE, Mexico

,

Charnetta Brown

²Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States

,

Salim S. Virani

²Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States

³Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States

,

Charlene R. Weir

⁴Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States

⁵Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States

,

Laura A. Petersen

²Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States

⁶Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States

,

Natalie Kelly

⁴Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States

,

Julia Akeroyd

²Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States

,

Jennifer H. Garvin

⁴Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States

⁵Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States

⁷Division of Health Information Management and Systems, The Ohio State University, Columbus, Ohio, United States

⁸Indianapolis VA Medical Center HSR&D Center for Health Information and Communication, Indianapolis, Indiana, United States

› Author Affiliations

Abstract

Background The recognition of and response to undertreatment of heart failure (HF) patients can be complicated. A clinical reminder can facilitate use of guideline-concordant β-blocker titration for HF patients with depressed ejection fraction. However, the design must consider the cognitive demands on the providers and the context of the work.

Objective This study's purpose is to develop requirements for a clinical decision support tool (a clinical reminder) by analyzing the cognitive demands of the task along with the factors in the Cabana framework of physician adherence to guidelines, the health information technology (HIT) sociotechnical framework, and the Promoting Action on Research Implementation in Health Services (PARIHS) framework of health services implementation. It utilizes a tool that extracts information from medical records (including ejection fraction in free text reports) to identify qualifying patients at risk of undertreatment.

Methods We conducted interviews with 17 primary care providers, 5 PharmDs, and 5 Registered Nurses across three Veterans Health Administration outpatient clinics. The interviews were based on cognitive task analysis (CTA) methods and enhanced through the inclusion of the Cabana, HIT sociotechnical, and PARIHS frameworks. The analysis of the interview data led to the development of requirements and a prototype design for a clinical reminder. We conducted a small pilot usability assessment of the clinical reminder using realistic clinical scenarios.

Results We identified organizational challenges (such as time pressures and underuse of pharmacists), knowledge issues regarding the guideline, and information needs regarding patient history and treatment status. We based the design of the clinical reminder on how to best address these challenges. The usability assessment indicated the tool could help the decision and titration processes.

Conclusion Through the use of CTA methods enhanced with adherence, sociotechnical, and implementation frameworks, we designed a decision support tool that considers important challenges in the decision and execution of β-blocker titration for qualifying HF patients at risk of undertreatment.

Keywords

clinical decision support - heart failure - computer systems development - primary health care - adrenergic β-antagonists

Full Text

References

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