STAKEHOLDER INPUT TO CLINICAL DECISION SUPPORT (CDS) FOR COMPLEX CHRONIC DISEASE

Purpose: Patients with complex chronic disease are often managed with a team approach; yet, clinical decision support (CDS) for teams is limited.  We are developing a CDS system for primary care patient panel management with detailed patient-specific recommendations based on clinical practice guidelines.  The CDS system will be delivered through an existing Clinical Dashboard used by staff working in Patient Aligned Care Teams (PACT), which is a patient-centered medical home (PCMH) model of care used in VHA Primary Care sites.  We aim to design a system that meets both management and end-user requirements for functionality by including stakeholder input early in the design.

Method: We conducted detailed semi-structured interviews with 5 stakeholders representing clinical managers, front line staff, and implementation experts; these included physicians, nurses, and pharmacists from 2 different medical centers.  We ask about current practices of patient care, including team member roles; use of the Clinical Dashboard; types of CDS that would be useful for the PACTs; and how the system can best integrate into workflow.

Result: All of the stakeholders in these preliminary interviews agreed that multimorbidity creating complexity in care of chronic disease is common among their patients.  Front-line stakeholders reported that many PACT members use the Clinical Dashboard for panel management, with pharmacists and nurses using it more often than physicians.  They enumerated examples of specific challenges, such as the prioritization of treatment goals.  There was a high degree of variability in PACT team organizational structure (e.g. some with pharmacist integrated into PACT); in use of the Clinical Dashboard; and team workflow.  There was also a lack of consensus on appropriate methods of prioritization among the many management choices for patients with multimorbidity.

Conclusion: These interviews have emphasized the need to develop a CDS system that is capable of accommodating different staff roles found in PACT teams operating within varying workflows. The CDS system needs a task-assignment feature that assigns appropriate tasks to PACT members based on their roles and availability, with flexibility to customize to the organizational structure at that site.  A CDS system providing prioritization of management choices would likely need to include options of different approaches to prioritization.     Views expressed are those of the authors and not necessarily of the Department of Veterans Affairs.