1. 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

2. Focus Groups 19 VAMCs: Theoretical Sampling (Hi/Low) 19 VAMCs: Theoretical Sampling (Hi/Low) 50 Focus Groups 3/ site 50 Focus Groups 3/ site  Administrators  Primary Care Providers  Clinicians Major Stakeholder Variation: Major Stakeholder Variation:  Barriers/ Facilitators to CPG implementation

3. Major Barriers for All Stakeholders Data Location Essential Data Computer Glitches User Friendly Computer Literacy Attitudes Workload

4. Personal Concerns 7 Themes Time Attitudes Workload Computer Literacy Computer Complaints Workflow Intrusiveness

5. Issue MD RNAdm Major focus Continuity of care ▲ CPG Compliance ▲ Patient benefits ▲ Major Focus by Stakeholder Group

6. 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.

7. Providers' Assessment Regarding the Extent Their Hospitals Provide IT for Key Dimensions of Practice

8. 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.

9. 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

10. Types of Computerized Clinical Reminders Across Facilities (n=104)

11. Experiences with Clinical Reminders (Open-ended) Has an automated clinical reminder ever helped you deliver care more effectively? 63% Yes 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

12. 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%

13. Computer Use to Implement Guidelines Wins: Wins:  Widely implemented electronic patient record, order entry  Significant gains in performance measures Losses: Losses:  Widespread computer use impacts provider-patient communication, teamwork Errors: Errors:  Focus on documentation to exclusion of system change  Lack of consensus on how to effectively use computers Ties: Ties:  Uncertainty regarding optimal use, benefits/tradeoffs  Sustainability for chronic care management uncertain

14. Questions? Comments: Brad Doebbeling (317) 554-0000, 4493 bdoebbel@iupui.edu