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
1  Department of Industrial & Mechanical Engineering, Universidad de las Americas Puebla, Cholula, PUE, Mexico
,
Charnetta Brown
2  Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States
,
Salim S. Virani
2  Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States
3  Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
,
Charlene R. Weir
4  Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States
5  Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
,
Laura A. Petersen
2  Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States
6  Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
,
Natalie Kelly
4  Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States
,
Julia Akeroyd
2  Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States
,
Jennifer H. Garvin
4  Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States
5  Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
7  Division of Health Information Management and Systems, The Ohio State University, Columbus, Ohio, United States
8  Indianapolis VA Medical Center HSR&D Center for Health Information and Communication, Indianapolis, Indiana, United States
› Author Affiliations
Funding This study was supported by the U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (CRE 12–037). The views expressed are those of the authors and not those of the Department of Veterans Affairs or affiliated institutions.
Further Information

Publication History

18 December 2017

12 May 2018

Publication Date:
27 June 2018 (online)

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.

Protection of Human and Animal Subjects

This study was approved by the Baylor College of Medicine Institutional Review Board.