Measures of user experience in a streptococcal pharyngitis and pneumonia clinical decision support tools.

OBJECTIVE: To understand clinician adoption of CDS tools as this may provide important insights for the implementation and dissemination of future CDS tools. MATERIALS AND METHODS: Clinicians (n=168) at a large academic center were randomized into intervention and control arms to assess the impact of strep and pneumonia CDS tools. Intervention arm data were analyzed to examine provider adoption and clinical workflow. Electronic health record data were collected on trigger location, the use of each component and whether an antibiotic, other medication or test was ordered. Frequencies were tabulated and regression analyses were used to determine the association of tool component use and physician orders. RESULTS: The CDS tool was triggered 586 times over the study period. Diagnosis was the most frequent workflow trigger of the CDS tool (57%) as compared to chief complaint (30%) and diagnosis/antibiotic combinations (13%). Conversely, chief complaint was associated with the highest rate (83%) of triggers leading to an initiation of the CDS tool (opening the risk prediction calculator). Similar patterns were noted for initiation of the CDS bundled ordered set and completion of the entire CDS tool pathway. Completion of risk prediction and bundled order set components were associated with lower rates of antibiotic prescribing (OR 0.5; CI 0.2-1.2 and OR 0.5; CI 0.3-0.9, respectively). DISCUSSION: Different CDS trigger points in the clinician user workflow lead to substantial variation in downstream use of the CDS tool components. These variations were important as they were associated with significant differences in antibiotic ordering. CONCLUSIONS: These results highlight the importance of workflow integration and flexibility for CDS success.

User centered clinical decision support tools: adoption across clinician training level.

BACKGROUND: Dissemination and adoption of clinical decision support (CDS) tools is a major initiative of the Affordable Care Act's Meaningful Use program. Adoption of CDS tools is multipronged with personal, organizational, and clinical settings factoring into the successful utilization rates. Specifically, the diffusion of innovation theory implies that 'early adopters' are more inclined to use CDS tools and younger physicians tend to be ranked in this category. OBJECTIVE: This study examined the differences in adoption of CDS tools across providers' training level. PARTICIPANTS: From November 2010 to 2011, 168 residents and attendings from an academic medical institution were enrolled into a randomized controlled trial. INTERVENTION: The intervention arm had access to the CDS tool through the electronic health record (EHR) system during strep and pneumonia patient visits. MAIN MEASURES: The EHR system recorded details on how intervention arm interacted with the CDS tool including acceptance of the initial CDS alert, completion of risk-score calculators and the signing of medication order sets. Using the EHR data, the study performed bivariate tests and general estimating equation (GEE) modeling to examine the differences in adoption of the CDS tool across residents and attendings. KEY RESULTS: The completion rates of the CDS calculator and medication order sets were higher amongst first year residents compared to all other training levels. Attendings were the less likely to accept the initial step of the CDS tool (29.3%) or complete the medication order sets (22.4%) that guided their prescription decisions, resulting in attendings ordering more antibiotics (37.1%) during an CDS encounter compared to residents. CONCLUSION: There is variation in adoption of CDS tools across training levels. Attendings tended to accept the tool less but ordered more medications. CDS tools should be tailored to clinicians' training levels.