Pre-Implementation to Guide the Development of the MedSafe Clinical Decision Support System

ANJU SAHAY, PhD
Veterans Affairs Palo Alto Health Care System

The US Department of Veterans Affairs (VA) VISN 21 Pharmacy Benefits Program Service has developed the Clinical Dashboard for Patient Aligned Care Team (PACT) performance measures, which includes patient data showing whether the clinical care meets performance measures tracked by the VA. Embedded within the Clinical Dashboard is a decision support tool being developed by the Medication Safety (MedSafe) QUERI Program, the MedSafe Clinical Decision Support (CDS) system. It provides recommendations for the care of select patients who are not meeting VA performance measures.
 
We conducted a pre-implementation assessment of potential interest among PACT members in use of the MedSafe CDS system. We also examined barriers and facilitators to guide its implementation.

Participants (N=21) consisted of health professionals from PACT core teams at two sites: Primary Care Providers (PCPs) (n=7), PACT-nurses (n=8), and pharmacists (n=6).

A team of two interviewers conducted semi-structured phone interviews individually with each participant. All interviews were recorded, transcribed, and coded. We used an open iterative process to create the codebook; two coders adjudicated discrepancies.

Six participants (28.6%) expressed varied interest in using the CDS system to inform other PACT members about issues like medication adherence and goal attainment. PACT member role was important as a PACT-nurse said: “We really rely on the pharmacists to do more of the medication management and so nurses don’t typically focus on medication…” According to a pharmacist, the CDS system: “…keeps you up to date with the different formulary issues, with different drugs that doctors may not all be familiar with…all of those things are constantly changing so it can be overwhelming keeping up with it.”
 
Barriers to use included doubts about CDS recommendation alignment with their own/provider recommendations, time constraints, understaffing and potential technical difficulties. To implement the CDS system, significance of support from the members of the PACT was reflected as: “…just not having a proper PACT team set up and getting buy-in for everybody to still use it.” However, one PACT-nurse said: “I don’t really see any barriers to using it.”
 
Participants expected the recommendations from the CDS system would improve efficiency during patient visits. It could be used for panel management as a PCP stated: “…usually I would like to have a pre-visit planning done for my patients before my patient’s appointment…this is an ideal tool to figure out what can be done as a PACT team.” For population management purposes: “I think this really makes population management much more manageable being able to go in and have this information at your fingertips.”