Barriers and Facilitators to Computer Use in VA for Implementing Guidelines

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Barriers and Facilitators to Computer Use in VA
for Implementing Guidelines
Brad Doebbeling, MD, MSc
VA Indianapolis HSRD Center of Excellence,
Indy VAMC Regenstrief Institute, Indiana
University School of Medicine Indianapolis, IN
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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

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Major Barriers for All Stakeholders

• Data Location
• Essential Data
• Computer Glitches
• User Friendly
• Computer Literacy
• Attitudes
• Workload

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Personal Concerns

• 7 Themes
• Time
• Attitudes
• Workload
• Computer Literacy
• Computer Complaints
• Workflow
• Intrusiveness

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Major Focus by Stakeholder Group
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National Provider Survey

• 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
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Results

• 46 indicated their hospital provided access to
  literature and EBM while delivering care.
• 22 computer assisted decision support systems
  (DSS) available.
• 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.

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Results

• ACRs were not widely implemented across
  facilities. --44 had ACRs for diabetes
  mellitus. -- 1/4 to provide recommended
  services for COPD and MDD.
• Institutional factors associated with using IT
  --Urban location--Cooperative culture

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Types of Computerized Clinical Reminders Across
Facilities (n104)
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Experiences with Clinical Reminders (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

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Barriers
Enough workstations in each clinician exam room? 82
Enough workstations for other staff in interview rooms? 68
Are formats tailored to specific populations? 45
Does computer speed impede use? 31
Lack of staff computer skills impedes use? 25
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Computer Use to Implement Guidelines

• Wins
• Widely implemented electronic patient record,
  order entry
• Significant gains in performance measures
• Losses
• Widespread computer use impacts provider-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

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Questions?

• Comments Brad Doebbeling
• [phone], 4493
• bdoebbel_at_iupui.edu