Information Technology Implementation by Cognitive Engineering of Organizational Routines

Successful implementation of clinical quality management systems (CQMS) is challenging in primary care. At a minimum, it requires that practices adapt their clinical workflow and potentially their organizational routines. This project identified three rural Federally Qualified Health Centers (FQHCs) to implement Crimson Care Registry, a commercial CQMS that includes: 1) a disease registry, 2) point-of‐care clinical reminder system for both preventive and chronic disease management, 3) call lists and automatically generated letters for patient reminders, and 4) detailed reports for administrative and quality improvement purposes.

Following an iterative process, Crimson Care was tailored to the quality improvement priorities at each FQHC. Cognitive task analysis (CTA) was used to examine the change process needed for successful adoption of the CQMS. CTA is a set of highly structured and complementary qualitative methods to understand work patterns and decisionmaking in real world environments. The findings from CTA were then used to guide interventions to improve the implementation process.

The specific aims of this project were as follows:

• Identify the barriers and facilitators to implementing CQMSs in safety-net ambulatory care settings. 
• Measure the impact of using cognitive engineering tools during implementation of a CQMS. 

CTA identified key features of organizational routines that influenced the success of adopting the CQMS. The first FQHC had significant planning and coordination deficiencies. The recommendations for addressing them were not adopted, and the implementation ultimately failed. The practice administrators at the second FQHC were skilled with planning and they followed the recommendations in their CTA report; however, the FQHC closed for unrelated reasons and adoption of the system was not achieved. The third FQHC had good coordination, but limited planning and monitoring skills. This FQHC followed the CTA report recommendations to improve its planning and monitoring processes, and ultimately overcame technical barriers to successfully implement the system.

This project demonstrated that CTA was effective in a primary care setting for identifying deficits in the implementation of a CQMS and that a guided intervention can improve system adoption.