Barriers and Facilitators to Computer
Use in VA for Implementing Guidelines
Brad Doebbeling, MD, MSc
VA Indianapolis HSR&D Center of Excellence,
Indy VAMC & Regenstrief Institute,
Indiana University School of Medicine Indianapolis, IN
Focus Groups
19 VAMCs: Theoretical Sampling
(Hi/Low)
„ 50 Focus Groups 3/ site
‹ Administrators
‹ Primary Care Providers
‹ Clinicians
„ Major Stakeholder Variation:
‹ Barriers/ Facilitators to CPG
implementation
„
Major Barriers for All
Stakeholders
Personal Concerns
7 Themes
Data Location
„ Essential Data
„ Computer Glitches
„ User Friendly
„ Computer Literacy
„ Attitudes
„ Workload
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National Provider Survey
Major Focus by Stakeholder Group
Issue
MD
RN
Adm
Major focus
Continuity of care
▲
CPG Compliance
Patient benefits
▲
▲
Time
Attitudes
Workload
Computer Literacy
Computer Complaints
Workflow
Intrusiveness
„
4227 physicians, nurses, PAs and RNPs
„
Primary & ambulatory care, medicine, nursing,
and geriatrics.
„
Provider and organizational factors influencing
guideline adoption and adherence
„
139 VAMCs nationally.
„
Provider attitudes, time, work organization,
guideline-specific data, implementation
approaches, adherence tools, impact of tools on
care, availability of IT, culture, support,
audit/feedback.
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Providers' Assessment Regarding the Extent Their
Hospitals Provide IT for Key Dimensions of Practice
Results
1.2
P e r c e n t o f H o sp ita ls w ith A v e r a g e R e sp o n se
o f G re a t o r V e ry G re a t (> 3 .5 )
1
0.99 0.98
0.97 0.95
0.98
0.95
„
46% indicated their hospital provided access to literature and
EBM while delivering care.
„
22% computer assisted decision support systems (DSS)
available.
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Attitudes regarding ACR use very positive.
--74% believed ACRs helpful in adhering to clinical
guidelines.
--Tools or templates to facilitate documentation nearly as
high.
„
Interdisciplinary teamwork important in facilitating
adherence.
0.9
0.8
0.86
0.84
0.79
0.73
0.6
0.4
0.47
0.46
Overall
Physician
0.62
0.59
PA/NP
0.5
Nurse
0.41
0.29
0.2
0.22
0.15
0
0
Access to
Literature/Evidence
Based Medicine While
Delivering Care
Computer Assisted
Decision Support
Systems
Computerized Patient
Clinical Data
Automation of
Decisions to Reduce
Errors
Electronic
Communication
between Providers
0.04 0.04
0.07
Electronic
Communication
between Providers and
Patients
Results
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ACRs were not widely implemented across facilities.
--44% had ACRs for diabetes mellitus.
-- ~1/4 to provide recommended services for COPD and
MDD.
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Institutional factors associated with using IT:
--Urban location
--Cooperative culture
Experiences with Clinical Reminders
(Open(Open-ended)
Has an automated clinical reminder ever
helped you deliver care more effectively?
63% Yes
Have you ever been surprised by the actions of
any computerized clinical reminders in
CPRS?
24% Yes
Types of Computerized Clinical Reminders Across Facilities (n=104)
Barriers
Enough workstations in each clinician exam
room?
Enough workstations for other staff in
interview rooms?
Are formats tailored to specific populations?
Does computer speed impede use?
Lack of staff computer skills impedes use?
82%
68%
45%
31%
25%
2
Computer Use to Implement Guidelines
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Wins:
‹ Widely implemented electronic patient record, order
entry
‹ Significant gains in performance measures
Losses:
‹ Widespread computer use impacts providerprovider-patient
communication, teamwork
Errors:
‹ Focus on documentation to exclusion of system change
‹ Lack of consensus on how to effectively use computers
Ties:
‹ Uncertainty regarding optimal use, benefits/tradeoffs
‹ Sustainability for chronic care management uncertain
Questions?
Comments: Brad Doebbeling
(317) 554554-0000, 4493
bdoebbel@iupui.edu
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