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RRP 09-144 – HSR&D Study

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RRP 09-144
Implementation of ATHENA-OT Decision Support: Facilitators and Barriers
Ruth C. Cronkite PhD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: October 2009 - September 2010

Pain management is a significant issue for patients with substance use disorders (SUDs). VA SUD patients with chronic pain problems are at higher risk of abuse or addiction to opioid medications. In response to SUD QUERI goals of improving services for patients with SUDs and co-occuring conditions, SUD QUERI funded the development of the ATHENA OT DSS to promote evidence-based best practices for opioid therapy for chronic pain as well as improve detection of prescription opioid medication misuse. The DSS was successfully developed, installed, and implemented at VA Palo Alto in real clinical practice settings.

The objective of our study to obtain valuable information from VA stakeholders on the ATHENA-OT DSS while it is going through the process of conversion to Class 1 software under the auspices of the OI&T Innovation Program.

The objective is to obtain input from VA stakeholders to enhance the acceptability and utility of the ATHENA-OT DSS for use in a wide range of VA clinical settings nationwide. The ATHENA-OT DSS is a computerized system that uses patient information to generate evidence-based recommendations for opioid therapy for chronic pain and screen for possible opioid medication misuse at the time of the patient-provider visit. When we originally developed the ATHENA-OT DSS, we successfully conducted interviews and usability evaluations at the VA Palo Alto Health Care System (HCS) in order to obtain valuable feedback on optimal features of such a decision support system for use in primary care settings specific to this facility. Based on our successful development and implementation of ATHENA-OT DSS at the VA Palo Alto HCS, the VHA National Pain Management Program Office in the Office of Patient Care Services has strongly supported the ATHENA-OT DSS as an important resource for assuring safe and effective use of opioid medications. Moreover, VHA has provided funding for implementation of a stepped care model of pain care as the single standard of care for veterans experiencing pain. The foundation of this model is the delivery of evidence-based assessment and management of pain in primary care settings. For this model to be successfully implemented, primary care providers need tools and other resources to support their practice. Adoption of the ATHENA-OT DSS has been specifically identified as a tool that would meet such needs. Obtaining input from a range of VA stakeholders nationwide will dovetail with the planned efforts of the ATHENA-OT DSS team who will be working on optimizing, enhancing and converting the ATHENA-OT DSS from Class III to Class I software via the OI&T Innovation Program with the ultimate goal of implementation of the system at the national level once it is optimized and certified as Class I software.

We will set up the ATHENA-OT DSS in a test environment with hypothetical test patients. We will identify approximately 40 VA stakeholders comprised of experts in a range of areas/roles (primary care clinics, pain clinics, polytrauma units, pharmacy services, facility/network management) and invite them to participate in the project. Experts will first be provided with information about the ATHENA-OT DSS, its purpose, what it does, what could be added, and a context for its potential usefulness for screening for opioid misuse and for safe prescribing of opioids. In a 60-90 minute individual session, experts will think out loud as they interact with the decision support system in a simulated visit with one or more hypothetical patients. Experts will be asked a set of survey questions about substantive and logistic aspects of the DSS, such as if the system helps with screening for opioid misuse, helps with making clinical decisions, ease of use and interactive features of the system, whether the system fits well into clinical workflow, ideas for improving existing features, and ideas for additional features that would enhance the DSS, such as tracking prior opioid prescriptions, cost algorithms, etc. The "think out loud" sessions will be audio taped so that the researchers can accurately record the expert's comments after the session. These recordings will be destroyed as soon as the research team has coded the comments. All of the information obtained from the experts will be about the features of the decision support system, not about the individuals themselves.

The ATHENA-OT DSS team has delivered presentations about the system to VA leadership at national meetings and national VA webinars. As a result, management and clinical staff at some sites have already expressed a strong interest in and support for the system. Consequently, we anticipate a positive response to our invitation to experts to participate in this project.

The revised research methodology differs from the original plan in that we will be obtaining information from experts about the usability and acceptability of the system and ideas for ways to enhance the system, instead of asking about obstacles encountered during the process of attempting to install the system under two conditions (minimal support versus intense support). Because the focus is now on acceptability/usability and optimization/enhancement of the system instead of how many steps in the installation process were achieved in one of two conditions, the design now involves just one group of VA experts who interact with the system and provide feedback on its usability and on optimizing and enhancing the system. Instead of the comparing the two original subgroups on the stage/level achieved in the installation process, the revised planned analyses will involve only qualitative and descriptive analyses, such as a list of ideas for enhancing existing features, a list of additional desired features, and frequency distributions on the ease of use and helpfulness of the system for screening for opioid misuse and for making decisions, etc.

No findings at this time.

The results of this study will help to (1) identify areas of the system that require optimization and enhancement, and (2) set priorities for future DSS research efforts.


Journal Articles

  1. Midboe AM, Lewis E, Cronkite R, Chambers D, Goldstein M, Kerns RD, Trafton J. Behavioral medicine perspectives on the design of health information technology to improve decision-making, guideline adherence, and care coordination in chronic pain management. Translational behavioral medicine. 2011 Mar 28; 1(1): 35-44.
Conference Presentations

  1. Midboe AM, Lewis ET, Cronkite RC, Goldstein MK, Trafton JA. Behavioral Medicine Perspectives on a Clinical Decision Support System for Chronic Pain. Paper presented at: National Library of Medicine Training Conference; 2011 Jun 28; Bethesda, MD.
  2. Cronkite RC, Trafton JA, Chambers DA, Lewis ET, Midboe AM, Kerns R, Martins SB, Wang D, Ghaus S, Goldstein MK. Veterans Health Administration Stakeholders’ Input on Implementation of ATHENA-Opioid Therapy (OT) Clinical Decision Support (CDS) System. Poster session presented at: American Medical Informatics Association on Translational Bioinformatics Research Annual Summit; 2011 Mar 10; San Francisco, CA.
  3. Huggins JL, Bonn-Miller MO, Oser ML, Medina JL, Trafton JA. Cognitive-behavioral therapy for pain among individuals with HIV: The relations between changes in pain acceptance and pain anxiety in terms of pain reduction. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2010 Nov 19; San Francisco, CA.

DRA: Substance Abuse and Addiction
DRE: none
Keywords: Addictive Disorders, Decision support
MeSH Terms: none