Implementing and Improving the Integration of Decision Support into Outpatient Clinical Workflow

This project analyzed a clinical decision support (CDS) tool for colorectal cancer screening that was integrated into an ambulatory clinical workflow. In the first phase of the study the project team collected qualitative data via site visits, interviews, and direct observation in order to analyze the factors needed for effective integration into clinical workflow in different electronic medical records (EMRs).  Findings from the first phase informed the second phase of the project in which alternative designs were prototyped in a simulated setting in order to test their impact on workload, efficiency, and usability.  The participants in the study included the Regenstrief Institute, the Veteran’s Health Administration (VHA), and Partners Healthcare System. The main objectives of the project were to:

• Identify key approaches to CDS development for colorectal cancer screening at two VHA Medical Center sites and two nationally recognized non-VHA sites to obtain effective CDS integration into clinical workflow. 
• Develop and test CDS design alternatives for improved integration into clinical workflow through a controlled simulation study and subsequent implementation.

Based on findings from phase one, the project team developed prototyped design enhancements to the VHA’s colorectal cancer (CRC) screening clinical reminder. In the controlled simulation experiment, 12 primary care providers were given four simulated patient encounters using both current and redesigned CRC screening reminders. “Think aloud” techniques were used during the scenarios.  A usability survey, workload assessment, and workflow integration surveys were completed. 

Despite each site using different EMRs and CDS, the project team found that barriers encountered were similar. These barriers included: a lack of coordination among “outside” exam results, primary care, and specialty care; poor data organization and presentation; omission of provider and patient education in the decision support tool; lack of interface flexibility; the need for technological enhancements; unclear role assignments; organizational issues; and a disconnect between decision support and quality reporting.

The enhancements made to the VHA reminder showed positive impact on usability and workflow integration, but not on workload.  The qualitative portion of the study showed broad support for the enhancements.  Specific suggestions were collected for future improvements to the tool.  The project team concluded that new CDS prototypes are needed to improve data organization and presentation; integrate outside results; and provide just-in-time education and cognitive support.