CDS in a Learning Health Care System: Identifying Physicians' Reasons for Rejection of Best-Practice Recommendations in Pneumonia through Computerized Clinical Decision Support.
Journal
Applied clinical informatics
ISSN: 1869-0327
Titre abrégé: Appl Clin Inform
Pays: Germany
ID NLM: 101537732
Informations de publication
Date de publication:
01 2019
01 2019
Historique:
entrez:
3
1
2019
pubmed:
3
1
2019
medline:
31
3
2020
Statut:
ppublish
Résumé
Local implementation of guidelines for pneumonia care is strongly recommended, but the context of care that affects implementation is poorly understood. In a learning health care system, computerized clinical decision support (CDS) provides an opportunity to both improve and track practice, providing insights into the implementation process. This article examines physician interactions with a CDS to identify reasons for rejection of guideline recommendations. We implemented a multicenter bedside CDS for the emergency department management of pneumonia that integrated patient data with guideline-based recommendations. We examined the frequency of adoption versus rejection of recommendations for site-of-care and antibiotic selection. We analyzed free-text responses provided by physicians explaining their clinical reasoning for rejection, using concept mapping and thematic analysis. Among 1,722 patient episodes, physicians rejected recommendations to send a patient home in 24%, leaving text in 53%; reasons for rejection of the recommendations included additional or alternative diagnoses beyond pneumonia, and comorbidities or signs of physiologic derangement contributing to risk of outpatient failure that were not processed by the CDS. Physicians rejected broad-spectrum antibiotic recommendations in 10%, leaving text in 76%; differences in pathogen risk assessment, additional patient information, concern about antibiotic properties, and admitting physician preferences were given as reasons for rejection. While adoption of CDS recommendations for pneumonia was high, physicians rejecting recommendations frequently provided feedback, reporting alternative diagnoses, additional individual patient characteristics, and provider preferences as major reasons for rejection. CDS that collects user feedback is feasible and can contribute to a learning health system.
Sections du résumé
BACKGROUND
Local implementation of guidelines for pneumonia care is strongly recommended, but the context of care that affects implementation is poorly understood. In a learning health care system, computerized clinical decision support (CDS) provides an opportunity to both improve and track practice, providing insights into the implementation process.
OBJECTIVES
This article examines physician interactions with a CDS to identify reasons for rejection of guideline recommendations.
METHODS
We implemented a multicenter bedside CDS for the emergency department management of pneumonia that integrated patient data with guideline-based recommendations. We examined the frequency of adoption versus rejection of recommendations for site-of-care and antibiotic selection. We analyzed free-text responses provided by physicians explaining their clinical reasoning for rejection, using concept mapping and thematic analysis.
RESULTS
Among 1,722 patient episodes, physicians rejected recommendations to send a patient home in 24%, leaving text in 53%; reasons for rejection of the recommendations included additional or alternative diagnoses beyond pneumonia, and comorbidities or signs of physiologic derangement contributing to risk of outpatient failure that were not processed by the CDS. Physicians rejected broad-spectrum antibiotic recommendations in 10%, leaving text in 76%; differences in pathogen risk assessment, additional patient information, concern about antibiotic properties, and admitting physician preferences were given as reasons for rejection.
CONCLUSION
While adoption of CDS recommendations for pneumonia was high, physicians rejecting recommendations frequently provided feedback, reporting alternative diagnoses, additional individual patient characteristics, and provider preferences as major reasons for rejection. CDS that collects user feedback is feasible and can contribute to a learning health system.
Identifiants
pubmed: 30602195
doi: 10.1055/s-0038-1676587
pmc: PMC6327742
doi:
Substances chimiques
Anti-Bacterial Agents
0
Types de publication
Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, Non-P.H.S.
Langues
eng
Sous-ensembles de citation
IM
Pagination
1-9Subventions
Organisme : HSRD VA
ID : IK2 HX001908
Pays : United States
Organisme : NCRR NIH HHS
ID : UL1 RR025764
Pays : United States
Informations de copyright
Georg Thieme Verlag KG Stuttgart · New York.
Déclaration de conflit d'intérêts
None declared.
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