Descriptive Usability Study of CirrODS: Clinical Decision and Workflow Support Tool for Management of Patients With Cirrhosis.

BACKGROUND: There are gaps in delivering evidence-based care for patients with chronic liver disease and cirrhosis. OBJECTIVE: Our objective was to use interactive user-centered design methods to develop the Cirrhosis Order Set and Clinical Decision Support (CirrODS) tool in order to improve clinical decision-making and workflow. METHODS: Two work groups were convened with clinicians, user experience designers, human factors and health services researchers, and information technologists to create user interface designs. CirrODS prototypes underwent several rounds of formative design. Physicians (n=20) at three hospitals were provided with clinical scenarios of patients with cirrhosis, and the admission orders made with and without the CirrODS tool were compared. The physicians rated their experience using CirrODS and provided comments, which we coded into categories and themes. We assessed the safety, usability, and quality of CirrODS using qualitative and quantitative methods. RESULTS: We created an interactive CirrODS prototype that displays an alert when existing electronic data indicate a patient is at risk for cirrhosis. The tool consists of two primary frames, presenting relevant patient data and allowing recommended evidence-based tests and treatments to be ordered and categorized. Physicians viewed the tool positively and suggested that it would be most useful at the time of admission. When using the tool, the clinicians placed fewer orders than they placed when not using the tool, but more of the orders placed were considered to be high priority when the tool was used than when it was not used. The physicians' ratings of CirrODS indicated above average usability. CONCLUSIONS: We developed a novel Web-based combined clinical decision-making and workflow support tool to alert and assist clinicians caring for patients with cirrhosis. Further studies are underway to assess the impact on quality of care for patients with cirrhosis in actual practice.

Application of contextual design methods to inform targeted clinical decision support interventions in sub-specialty care environments.

BACKGROUND & OBJECTIVES: In healthcare, the routine use of evidence-based specialty care management plans is mixed. Targeted computerized clinical decision support (CCDS) interventions can improve physician adherence, but adoption depends on CCDS' 'fit' within clinical work. We analyzed clinical work in outpatient and inpatient settings as a basis for developing guidelines for optimizing CCDS design. METHODS: The contextual design approach guided data collection, collation and analysis. Forty (40) consenting physicians were observed and interviewed in general internal medicine inpatient units and gastroenterology (GI) outpatient clinics at two academic medical centers. Data were collated using interpretive debriefing, and consolidated using thematic analysis and three work modeling approaches (communication flow, sequence and artifact models). RESULTS: Twenty-six consenting physicians were observed at Site A and 14 at Site B. Observations included attending (33%) and resident physicians. During research team debriefings, 220 of 341 unique topics were categorized into 5 CCDS-relevant themes. Resident physicians relied on patient assessment & planning processes to support their roles as communication and coordination hubs within the medical team. Artifact analysis further elucidated the evolution of assessment and planning over work shifts. CONCLUSIONS: The usefulness of CCDS tools may be enhanced in clinical care if the design: 1) accounts for clinical work that is distributed across people, space, and time; 2) targets communication and coordination hubs (specific roles) that can amplify the usefulness of CCDS interventions; 3) integrates CCDS with early clinical assessment & planning processes; and 4) provides CCDS in both electronic & hardcopy formats. These requirements provide a research agenda for future research in clinician-CCDS integration.

Engagement in Care of High-Risk Hepatitis C Patients with Interferon-Free Direct-Acting Antiviral Therapies.

BACKGROUND AND AIMS: The extent to which hepatitis C (HCV) treatment uptake is improved following introduction of interferon-free direct-acting antiviral (DAA) treatments is unknown. The purpose of this study was to determine HCV patient engagement and barriers to care for accessing DAA treatments in a real-world setting. METHODS: Patients with HCV viremia at high risk for fibrosis were identified using the Veterans Affairs (VA) registry within San Diego's VA in October 2014. Patients not enrolled in HCV clinic were systematically contacted by letter and phone. Logistic regression was used to examine patient factors associated with subsequent engagement in care over 12-20 months. RESULTS: In the local registry of 2089 patients, 481 were identified with high-risk fibrosis scores. Of those, 380 (79%) were eligible for antiviral treatment, and 178/380 (47%) patients were actively followed in clinic. The remaining 202/380 (53%) patients were never seen by a HCV clinic provider or lost to follow-up. Of these, 114/380 (30%) of the treatment-eligible cohort remained non-engaged in care following outreach. Compared with patients engaged in care, non-engaged patients were significantly more likely to have homelessness, COPD comorbidity, or active alcohol or/and drug use. Overall 74.4% of patients engaged in HCV clinic received antiviral treatment. CONCLUSIONS: A significant portion of eligible HCV patients could not be engaged in treatment after a programmatic outreach effort. These data indicate that more sustained or innovative outreach efforts are needed in order to maximize treatment access, with specific interventions targeting those with unstable housing and active alcohol/substance use disorders.