Stroke is the third leading cause of death and a leading cause of disability in the United States. Stroke creates a significant burden for veterans as well with over 15,000 being hospitalized annually. Among veterans that survive stroke, 40 percent are left with moderate functional impairments and 15 to 30 percent live the remainder of their lives with severe disability. Although important evidence-based guidelines for acute management of stroke exist and have been demonstrated to improve outcomes, the Veterans Health Administration (VHA) currently lacks systematic tools to promote interdisciplinary implementation of acute stroke guidelines, methods for monitoring quality care processes, and mechanisms for tracking patient outcomes for quality benchmarking between VHA and non-VHA stroke care systems.
The objective of this Service Directed Project (SDP) was to develop and pilot test the implementation of the Stroke Quality Improvement Decision Support System (SQUIDSS), a software application that electronically facilitates guideline concordant care and monitoring of Acute Ischemic Stroke (AIS) quality indicators via an Electronic Medical Record (EMR) interface.
A usability engineering framework guided development of SQUIDSS to incorporate end-user perspectives. A pre-experimental design using descriptive and qualitative methods was applied. Aim 1 focused on design, development, and Alpha testing. Workflow walkthroughs and semi-structured interviews were completed with Emergency Department (ED) providers to create flow maps for AIS care processes in 3 VHA EDs (Houston, Indianapolis and Portland). Clinical practice guidelines for AIS were integrated with flow maps to identify where in the process of care specific best practice actions occurred. A mock-up of SQUIDSS was developed and iterative testing/design cycles were completed with multidisciplinary stroke-care clinicians. A Think-Aloud protocol was employed to test the usability of the SQUIDSS mockup. A convenience sample of (N=19) stroke-care providers from two VAMC facilities (Houston and Indianapolis) completed the Think-Aloud protocol. Participants' responses were grouped and tabulated into content categories to identify perceived barriers/facilitators for implementation in clinical practice. Audio-tapes from the Think-Aloud protocol were transcribed and investigator field notes were incorporated. A directed approach for content analysis was used to code participants' dialogue into word and word phrases that were indicative of either barriers or facilitators to accessibility, usability or usefulness. Results were applied to create a working prototype of SQUIDSS in the EMR.
Aim 2 was focused on Beta testing the SQUIDSS prototype during pilot implementation at the Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston. The SQUIDSS prototype was programmed at the Roudebush VAMC in Indianapolis as a platform independent Delphi application. The application was designed to communicate with the Veterans Health Information System Architecture (VistA) and the Computerized Patient Record System (CPRS) to capture and communicate patient specific information, manage workflow, support clinical decision making and document care. The programming was completed and a largely functional prototype was generated at the Roudebush VAMC. Usability was iteratively tested remotely via LiveMeeting demonstration with the stroke expert community. However, because the VHA Office of Health Information (OHI) underwent reorganization during the time period of this project and requirements for loading field developed software on local facility servers changed dramatically, loading the SQUIDSS application on the local server at the MEDVAMC was not possible within the time frame of the project. The new certification and accreditation process would require an additional year to complete. During this time, an opportunity for nationwide implementation with Emergency Department Information Software (EDIS) arose (see Results) that we pursued.
AIM 1: We learned a great deal about the complexity of care processes for AIS and clinicians' interaction with computer systems in the emergency department. Flow mapping of AIS care showed a process that involved multiple clinicians and support staff with the transport of the patient between multiple settings (ED to CT Scan and back to ED). We found effective and efficient AIS care requires numerous simultaneous best practice actions to be completed by a multidisciplinary team of clinicians that engages in prompt communication on the status and outcome of best practice actions to direct appropriate care decisions.
End-user testing identified that the systematic format, comprehensive information display, and automated features of the SQUIDSS prototype were key functionality facilitators. The best practice checklist format was viewed as 'very helpful for reminder of best practices'. The dashboard display linking best practice checklist actions with patient information was noted to be helpful for . 'organizing care', 'keeping up with what needs to be done', 'improving communication with the care team', and preventing errors'. Automated order sets, consultations, and documentation in CPRS were identified as 'big time savers'. Barriers to use in practice revolved around mobility, time, interoperability with CPRS, and access. Participants noted . 'we are always moving in the ER and are not sitting at a computer.' 'If the system is not mobile it will be difficult to use'. 'Time to use the tool will be limited if it is not part of what we do'. 'Using two systems, (CPRS and SQUIDSS) will be difficult'. Participants noted communication between CPRS and SQUIDSS as being necessary for use in practice. Multiple logins were seen as a barrier to access that would prevent use in the ER. Finally, the need for training and the knowledge that SQUIDSS was prompting current guidelines were noted to be possible concerns for use in practice.
AIM 2: To address deployment barriers, we created SQUIDSS reminder dialog templates that were accessible to clinicians within the existing CPRS platform. This strategy allowed us to provide clinicians immediate access to the electronic AIS pathways created within SQUIDSS for use in the existing EMR structure. The SQUIDSS templates incorporate reminder dialog programming with coded health factors to track quality care processes. Having the SQUIDSS templates implemented in this way will facilitate future integration of the SQUIDSS beta product because the coded health factors will be used as data items that are pulled from ViSTA and communicated to clinicians using the SQUIDSS interface. Moreover, making the SQUIDSS templates available to all VA facilities was particularly timely and addresses an immediate need for clinicians in the field as all VHA facilities are working to implement the requirements of the VHA National Directive for the Treatment of Acute Ischemic Stroke. The directive required all VA facilities to systematize and standardize care provided to victims of AIS based on site capabilities.
Most importantly, we leveraged our partnership with Patient Care Services and the Department of Emergency Services, through our collaborations with Dr. Gary Tyndall, National VA ED Director and consultant on the SQUIDSS project. We devised a strategy to adapt SQUIDSS programming and flow to create AIS care pathways within the EDIS project - which was already certified and approved for national deployment. We created a visualization model for the SQUIDSS/EDIS integration via multiple LiveMeeting sessions and a face-to-face meeting with the EDIS development team. The visualization model has been evaluated by experts in the field and will guide EDIS developers in programming SQUIDSS as a 'plug-in' module for AIS care in the ED.
This project enhanced our knowledge on how to address challenges associated with implementation research involving Health Information Technology (HIT) for AIS within the VHA. A major factor that influences the impact for continued development and implementation of SQUIDSS and other HIT implementation projects is the establishment of partnerships that facilitate the VHA strategic agenda. Our partnership with Patient Care Services, Emergency Services Department and the EDIS project is in line with the VHA Directive for the treatment of AIS. This partnership provides a basis by which electronic decision support for AIS can be pioneered in the ED and makes national deployment part of an already approved Enterprise Systems Management project. This approach will streamline implementation efforts by eliminating the lengthy process required to authorize deployment of field developed software.
Not only has SQUIDSS been modified for development in parallel with EDIS, but much of our work in developing SQUIDSS has facilitated other important initiatives that have resulted from the AIS Directive. Specifically, SQUIDSS pathways have been used to guide an ED Telestroke Workgroup, a SimLearn project to develop simulations education modules for AIS, and a National Institute of Health Stroke Scale (NIHSS) mobile application is under develop with VHA Enterprise Developers.. Once fully developed and implemented, SQUIDSS has the potential to assist VA stroke facilities in providing guideline concordant care and monitoring of AIS quality indicators. We look forward to Phase II of SQUIDSS to build on lessons learned and incorporate decision support for TIA, hemorrhagic stroke and eventually the full continuum of stroke care - from ED through discharge.
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