Veterans Administration (VA) Integrated Medication Manager (Utah)

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Veterans Administration (VA) Integrated Medication Manager - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017186
  • Project Period: 
    September 2007 - March 2011
  • AHRQ Funding Amount: 
    $594,582
  • PDF Version: 
    (PDF, 185.43 KB)

Summary: Computerized clinical decision support (CDS) research often focuses on improving technology, but more research is needed on how CDS can improve patient outcomes in the context of the process of clinical care. The Veterans Administration (VA) has implemented CDS to assist clinicians in reaching quality goals. However, in 2006, 25 percent of hypertensive patients did not reach the performance standards. To better support providers in reaching quality goals for more hypertensive patients, this project funded the development and evaluation of a new health information technology application called the Integrated Medication Manager (IMM). The IMM facilitates clinicians' decisionmaking by helping them consider relevant data when planning patient care. In a departure from the traditional medical record, a major feature of this system is the explicit linking of patient problems, therapies, and goals. This project compared IMM to a standard electronic health record (EHR), thereby generating new knowledge about medication management.

Design guidelines for the IMM were determined by analyzing providers' cognitive processing of information and how and what information is shared among a clinical team. In the first phase of the project, physicians, mid-level providers, and pharmacists were followed during clinical visits. Between patients, they were asked to "think aloud" and describe their thought processes as they worked through decisionmaking for a patient using the EHR. The findings of the observations were shared with the development team to guide them as they refined the IMM software.

The second phase of the project evaluated the IMM software using test cases in simulation studies. The simulation studies provide insight into how providers integrate information and further support evaluation of the IMM.

Specific Aims:

  • Identify cognitive components of providers' therapeutic decisionmaking in the field. (Achieved)
  • Refine and evaluate the IMM using simulation studies. (Achieved)

2011 Activities: Fifty-eight providers were recruited to test the IMM through simulations. The IMM organizes information around the core concepts of interventions, observations, and conditions. IMM presents this information in a manner that reduces the cognitive effort to consider data across time, relationships among concepts, and decisionmaking strategies. Standard and VA-specific terminologies and knowledge bases are used to relate concepts and provide the basis for cognitive support and documentation. Participants were asked to review 10 patient cases and write assessments and plans for each patient. The patient's information was presented in either the new IMM EHR or the generic EHR patterned after the VA's EHR. Participants were randomly assigned to use only one of the programs for the task. Throughout the test cases, the complexity, time horizon, and saliency of the available information differed. The focus disease was more evident or less evident, important information was located further back in time in the patient's medical history or was more recent, and patients' problems were highly complex or less so. Finally, in certain test cases, the provider was interrupted while the complexity of the case was manipulated to see how quickly the provider could recover and return to what s/he was doing.

As last self-reported in the AHRQ Research Reporting System, project progress and activities were mostly on track and project budget spending was roughly on target. During the 6-month no-cost extension period that extended the project-end date to March 2011, the research team continued analysis and developed manuscripts.

Impact and Findings: The translation of the theory "Hollnagel's Contextual Control Model" to analyze clinicians' cognitive processing of information is promising. In this project, it was applied to targeting characteristics that predict higher levels of performance on tasks related to chronic disease management. Close attention to the design of electronic records can improve quality of care by presenting data that supports clinician decisionmaking. With only a few minutes of instruction, providers were significantly faster using the completely unfamiliar medical record. The largest improvement in time was the case of interruptions in considering complex patients. The data is presented such that relationships between data elements are explicit and the provider is not required to link the data as part of his/her analytical process.

Target Population: Adults, Veterans

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

Veterans Administration (VA) Integrated Medication Manager - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017186
  • Project Period: 
    September 2007 – March 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $594,582
  • PDF Version: 
    (PDF, 384.09 KB)


Target Population: Adults, Veterans

Summary: Computerized clinical decision support (CDS) research is often focused on improving technology, but more research is needed on how the use of CDS in the context of the process of clinical care can improve patient outcomes. The Veterans Administration (VA) has implemented CDS to assist clinicians in reaching quality goals. However, in 2006, 25 percent of hypertensive patients did not reach the performance standards. To better support providers in reaching quality goals for more hypertensive patients, this project funds the development and evaluation of a new health information technology application called the Integrated Medication Manager (IMM). The IMM facilitates clinicians’ decisionmaking by helping them consider relevant data when planning patient care. In a departure from the traditional medical record, a major feature of this system is the explicit linking of patient problems, therapies, and goals. This project will compare IMM to a standard electronic health record (EHR), thereby generating new knowledge about medication management.

Design guidelines for the IMM were determined by analyzing providers’ cognitive processing of information and how and what information is shared among a clinical team. In the first phase of the project, physicians, mid-level providers, and pharmacists were followed during clinical visits. Between patients, they were asked to “think aloud” and describe their thought processes as they worked through decisionmaking for a patient using the EHR. The findings of the observations were shared with the development team to guide them as they refined the IMM software.

The second phase of the project evaluates the IMM software using test cases in simulation studies. The simulation studies provide insight into how providers integrate information and further support evaluation of the IMM.

Specific Aims:
  • Identify cognitive components of providers’ therapeutic decisionmaking in the field. (Achieved)
  • Refine and evaluate the IMM using simulation studies. (Ongoing)

2010 Activities: The software design was completed for the IMM and the focus of the work was the development of test cases for the simulation studies. The research team completed creating, pilot testing, and revising all test cases. The team’s approach to creating test cases changed based on lessons learned in building the first case. The team initially thought creating test cases would be more difficult than using real patient cases but found that the reverse is true. Real patient cases are, in fact, too complex to be used for the tests.

Materials to support the simulation experiment, including followup interview questions, were also finalized. Pilot testing for the simulation experiment concluded in fall 2010. Pilot testing served three purposes: 1) testing the simulation design and materials; 2) evaluating the quality and accuracy of the test cases; and 3) refining interfaces and logic of the IMM software.

The pilot compared the new IMM software to the standard VA software. The goal is for the new software to allow faster decisionmaking by providing higher-quality data to the provider, especially when the patient’s problems are complex. Throughout the test cases, the complexity, time horizon, and saliency of the available information differ. The focus disease is more evident or less evident, important information is located further back in time in the patient’s medical history or is more recent, and patients’ problems are highly complex or less complex. And finally, in certain test cases, the provider is interrupted while the complexity of the case is manipulated to see if the provider can quickly recover and return to what they were doing. In all cases, the hypothesis is that faster and higher-quality decisionmaking will occur when providers use the new software instead of the standard EHR.

The first study participant completed the simulation experiment in December 2010, and experimentation has continued with other participants. The participants include VA and non-VA physicians and mid-level providers. Ten test cases are presented to each participant and the participants are randomly assigned to the new software or to the standard control software. The evaluation will measure the speed and quality of software use.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Progress is mostly on track. The team is meeting about 80 to 99 percent of their milestones and is generally on time. Project spending is roughly on target.

Preliminary Impact and Findings: The project team has completed the cognitive components analysis and is eager to share the results of this analysis and its implications on human factors analysis.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

Project Details - Ended

Project Categories

Summary:

A traditional medical record does not sufficiently facilitate nor capture the thought process of clinicians, including the conceptualization of conditions and the reasoning used for the choice of treatment. In addition, it does not express the relationships between conditions, treatments and goals effectively, with those relationships generally implied and thus difficult to access. This means that for each new encounter clinicians must re-familiarize themselves with a patient’s record in order to develop and reestablish a mental model of the current status of the patient and a plan of treatment. In addition, providers must review multiple progress notes in order to understand the relationship between established therapy and goals, a time consuming task. As such, conditions are treated in isolation, rather than in the context of a patient’s other conditions or in the context of overall goals.

This project developed a new application called the Integrated Medication Manager (IMM). IMM presents to clinicians an integrated representation of a patient’s status and care process over time. By relating conditions, therapies, and goals in the area of pharmacotherapy, the application allows providers to place orders and plan care directly in the context of these relationships. Data presented in this manner reduces clinicians’ cognitive effort and time needed to absorb data across time, understand relationships among concepts, and undergo decisionmaking strategies. This project specifically focused on the management of hypertension in the setting of the Veterans Healthcare Administration.

The specific aims of this project were to:

  • Identify cognitive components of providers’ therapeutic decisionmaking in the field.
  • Refine and evaluate the IMM using simulation studies.

For the first aim, qualitative methods including observation, task analysis, and semi-structural interviews were employed. The findings of the observations were shared with the development team to guide them in refining the IMM software. For the second aim, simulation studies with clinicians completing patient assessments were conducted comparing a traditional electronic health record (EHR) to IMM. These studies were used to gain insight into how providers integrate clinical information, including during times of interruptions. The study results indicated that despite minimal training on IMM the time to complete assessments was significantly less than with the traditional EHR. The greatest improvements in time were noted in those simulations in which clinicians writing assessments and plans on complex patients were interrupted. The team hypothesized that IMM presents relationships explicitly and thus the provider does not need to recreate a mental model of the patient after being interrupted.

Veterans Affairs Integrated Medication Manager - Final Report

Citation:
Nebeker J. Veterans Affairs Integrated Medication Manager - Final Report. (Prepared by VA Salt Lake City Health Care System under Grant No. R18 HS017186). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 701.81 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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