Doebbeling BN (COE-Indianapolis), Saleem JJ
(COE-Indianapolis), Flanagan ME
(COE-Indianapolis, University of Indiana Department of Medicine), Yano EM
(VA Greater Los Angeles Healthcare System; UCLA School of Public Health)
Computerized clinical decision support can improve clinician decision-making, support adherence with evidence-based guidelines, and ultimately improve quality of care. Overall, however, the implementation of computerized clinical reminders (CCR) has been slow and not reached its potential. Little data exists regarding the extent of implementation of CCR nationally, particularly within inpatient settings. Our objective was to assess the extent of implementation of CCR in VHA facilities nationally.
VA’s Office of Quality & Performance/VA HSR&D funded the VA Clinical Practice Organizational Survey Study. We surveyed 111 Chief of Staffs (86%) at each VAMC in late 2006 to measure the organizational and practice system features of care potentially associated with VA performance. Questions assessed organizational characteristics, resources, informatics support, and QI activities.
Respondents noted that clinical order sets or CCRs were fully implemented in their VAMC for the following inpatient conditions: community acquired pneumonia (CAP, 41%), congestive heart failure exacerbations (CHFE, 34%), gastrointestinal bleeds (GIB, 7%), diabetic ketoacidosis (DKA, 9%), gastrointestinal bleed prophylaxis (GIBP, 8%), deep venous thrombosis prophylaxis (DVTP, 22%), pain management (PMG, 26%), and heparin dosing (HD, 46%). 27% of facilities had not implemented clinical order sets or CCRs for any of these eight conditions; 39% had implemented order sets or CCRs for 1-2 conditions. CCR pilot testing (p = .04) and analysis of reminder impact on performance improvement (p = .04) were related to having more order sets or CCRs implemented. Among facilities implementing clinical order sets or CCRs, over half reported the tools for HD (69%), CAP (64%), DVTP (64%), CHFE (59%), and GIBP (59%) as very useful.
CCRs are widely implemented in VHA for a variety of inpatient and outpatient conditions and considered by providers as very useful. Further research is needed to assess the extent of their use in routine clinical practice and opportunities for improvement in design and implementation.
With VHA’s recent OI&T reorganization, it will be important to ensure that these tools can be readily adapted to the local environment, integrated into clinical workflow, updated and continually improved to ensure they support both clinical decision making and operational needs.