将指南依从性和实践实施问题纳入心力衰竭β受体阻滞剂滴定决策支持的设计中。
Incorporating Guideline Adherence and Practice Implementation Issues into the Design of Decision Support for Beta-Blocker Titration for Heart Failure.
机构信息
Department of Industrial & Mechanical Engineering, Universidad de las Americas Puebla, Cholula, PUE, Mexico.
Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States.
出版信息
Appl Clin Inform. 2018 Apr;9(2):478-489. doi: 10.1055/s-0038-1660849. Epub 2018 Jun 27.
BACKGROUND
The recognition of and response to undertreatment of heart failure (HF) patients can be complicated. A clinical reminder can facilitate use of guideline-concordant β-blocker titration for HF patients with depressed ejection fraction. However, the design must consider the cognitive demands on the providers and the context of the work.
OBJECTIVE
This study's purpose is to develop requirements for a clinical decision support tool (a clinical reminder) by analyzing the cognitive demands of the task along with the factors in the Cabana framework of physician adherence to guidelines, the health information technology (HIT) sociotechnical framework, and the Promoting Action on Research Implementation in Health Services (PARIHS) framework of health services implementation. It utilizes a tool that extracts information from medical records (including ejection fraction in free text reports) to identify qualifying patients at risk of undertreatment.
METHODS
We conducted interviews with 17 primary care providers, 5 PharmDs, and 5 Registered Nurses across three Veterans Health Administration outpatient clinics. The interviews were based on cognitive task analysis (CTA) methods and enhanced through the inclusion of the Cabana, HIT sociotechnical, and PARIHS frameworks. The analysis of the interview data led to the development of requirements and a prototype design for a clinical reminder. We conducted a small pilot usability assessment of the clinical reminder using realistic clinical scenarios.
RESULTS
We identified organizational challenges (such as time pressures and underuse of pharmacists), knowledge issues regarding the guideline, and information needs regarding patient history and treatment status. We based the design of the clinical reminder on how to best address these challenges. The usability assessment indicated the tool could help the decision and titration processes.
CONCLUSION
Through the use of CTA methods enhanced with adherence, sociotechnical, and implementation frameworks, we designed a decision support tool that considers important challenges in the decision and execution of β-blocker titration for qualifying HF patients at risk of undertreatment.
背景
识别和应对心力衰竭（HF）患者的治疗不足可能很复杂。临床提醒可以促进使用指南一致的β受体阻滞剂滴定治疗射血分数降低的 HF 患者。然而，设计必须考虑到提供者的认知需求和工作环境。
目的
本研究旨在通过分析任务的认知需求以及 Cabana 医生遵循指南框架、健康信息技术（HIT）社会技术框架和促进健康服务实施研究行动（PARIHS）框架中的因素，来制定临床决策支持工具（临床提醒）的要求。它利用一种从病历中提取信息的工具（包括自由文本报告中的射血分数）来识别有治疗不足风险的合格患者。
方法
我们在三个退伍军人事务部门诊诊所采访了 17 名初级保健提供者、5 名药剂师和 5 名注册护士。这些访谈是基于认知任务分析（CTA）方法进行的，并通过纳入 Cabana、HIT 社会技术和 PARIHS 框架进行了增强。对访谈数据的分析导致了临床提醒的要求和原型设计的开发。我们使用现实的临床场景对临床提醒进行了小规模的可用性评估。
结果
我们确定了组织挑战（如时间压力和药剂师的使用不足）、关于指南的知识问题以及关于患者病史和治疗状况的信息需求。我们根据如何最好地解决这些挑战来设计临床提醒。可用性评估表明，该工具可以帮助决策和滴定过程。
结论
通过使用增强了依从性、社会技术和实施框架的 CTA 方法，我们设计了一种决策支持工具，考虑了在决策和执行有治疗不足风险的合格 HF 患者的β受体阻滞剂滴定方面的重要挑战。
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