CC BY-NC-ND 4.0 · Appl Clin Inform 2022; 13(04): 820-827
DOI: 10.1055/s-0042-1756366
Research Article

A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions

Tiffany Brown
1   Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
,
Brittany Zelch
2   Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, United States
,
Ji Young Lee
1   Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
,
Jason N. Doctor
3   Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, United States
,
Jeffrey A. Linder
1   Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
,
Mark D. Sullivan
4   Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, United States
,
Noah J. Goldstein
5   Anderson School of Management, University of California at Los Angeles, Los Angeles, California, United States
,
Theresa A. Rowe
1   Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
,
Daniella Meeker
3   Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, United States
,
Tara Knight
3   Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, United States
,
Mark W. Friedberg
6   Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts, United States
7   Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
,
Stephen D. Persell
1   Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
8   Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
› Author Affiliations
Funding The study was funded by R21AG057395, R21AG057383, R21AG057396, R33AG057395, R33AG057383, and P30AG059988 from the National Institutes of Health (NIH). The NIH had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report, and in the decision to submit the article for publication.

Abstract

Background Requiring accountable justifications—visible, clinician-recorded explanations for not following a clinical decision support (CDS) alert—has been used to steer clinicians away from potentially guideline-discordant decisions. Understanding themes from justifications across clinical content areas may reveal how clinicians rationalize decisions and could help inform CDS alerts.

Methods We conducted a qualitative evaluation of the free-text justifications entered by primary care physicians from three pilot interventions designed to reduce opioid prescribing and, in older adults, high-risk polypharmacy and overtesting. Clinicians encountered alerts when triggering conditions were met within the chart. Clinicians were asked to change their course of action or enter a justification for the action that would be displayed in the chart. We extracted all justifications and grouped justifications with common themes. Two authors independently coded each justification and resolved differences via discussion. Three physicians used a modified Delphi technique to rate the clinical appropriateness of the justifications.

Results There were 560 justifications from 50 unique clinicians. We grouped these into three main themes used to justify an action: (1) report of a particular diagnosis or symptom (e.g., for “anxiety” or “acute pain”); (2) provision of further contextual details about the clinical case (e.g., tried and failed alternatives, short-term supply, or chronic medication); and (3) noting communication between clinician and patient (e.g., “risks and benefits discussed”). Most accountable justifications (65%) were of uncertain clinical appropriateness.

Conclusion Most justifications clinicians entered across three separate clinical content areas fit within a small number of themes, and these common rationales may aid in the design of effective accountable justification interventions. Justifications varied in terms of level of clinical detail. On their own, most justifications did not clearly represent appropriate clinical decision making.

Protection of Human and Animal Subjects

The Northwestern University Institutional Review Board and the University of Southern California Institutional Review Board reviewed and approved this study.




Publication History

Received: 30 March 2022

Accepted: 12 July 2022

Article published online:
07 September 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany