NAT TRUSZCZYNSKI, PhD
University of Colorado Department of Emergency Medicine

Opioid analgesic administration and prescribing in Emergency Departments (EDs) has been identified as a contributor to the opioid epidemic. Evidence-based practices using alternatives to opioids (ALTs) exist, however utilization of ALTs remains low, and opioids remain the primary analgesic choice by ED providers. CDS order swaps are a tool to influence provider behavior. CDS cane be a non-intrusive way to change practice within providers’ workflow. Our objective is to increase the use of alternatives to opioids by iteratively developing and implement two electronic health record (EHR) embedded CDS that encourage the use of ALT clinical care pathways and suggest providers select alternatives to opioids.

This is a program implementation project implemented at a large healthcare system with 12 EDs and 450,000 visits per year.

Two separate CDS tools were created with the goal of decreasing opioid use and increasing use of ALTs. The first (pathway) is a non-interruptive reminder for providers to access existing condition-specific clinical care pathways which prioritize ALTs. These pathways had already been created but existed outside the usual workflow and suffered from low utilization despite the high prevalence of their applicable clinical conditions (back pain, headache, vomiting/abdominal pain, dental pain, musculoskeletal pain, and nephrolithiasis). Users are prompted within their usual workflow to “Consider XXX pathway” based on chief complaint and discrete patient factors. The second CDS (order swap) is an interruptive alert that is triggered by the provider searching for any opioid to order. The CDS alert allows the original order but suggests multiple alternatives within the same order.

Both CDS tools were developed and disseminated iteratively to allow for provider feedback and ensure high functionality. The pathway CDS was altered after its first iteration received overwhelming feedback that it was cumbersome and confusing. Due to the multiple screens of the initial design, using the pathway CDS caused providers to take more “clicks” to get to the corresponding pathway. The second iteration became a banner that prompted providers to “Consider the XXX pathway”. The order swap CDS was released after being redesigned based on pre-release focus group feedback from providers. After implementation other feedback about order labels was received and the CDS changed. Data collected on the program outcomes to help assess the impact of CDS is ongoing. Initial analysis from data collection is being used to troubleshoot CDS.

EHR CDS offer a promising way of creating behavior change among providers. Successful implementation of workflow CDS with real-time monitoring of changes in process (CDS utilization) and patient centered outcomes (medication use) will quantify the impact of CDS on behavior change regarding choice of analgesics in the ED.

HEATHER TOLLE, PhD
University of Colorado

Interruptive alerts within an electronic health record (EHR) provider workflow are a form of clinical decision support (CDS) that can be implemented to support delivery of evidence-based practices. When implementing CDS, it can be challenging and time-consuming to collect sufficient user feedback to iteratively improve CDS in real-world situations. Inclusion of a free-text box for user-response to bypass the alert was examined to determine the feasibility of this source of feedback in maintaining CDS.

EHR embedded CDS alerts fired when providers selected an opioid or benzodiazepine prescription to order on discharge in outpatient and inpatient settings. Alerts reminded the provider to check the patient’s prescription drug monitoring program (PDMP) prescription history and identify patient risk for adverse events. Data was pulled for providers in the UCHealth system exposed to CDS during normal clinical care. Comments entered by providers in the CDS free-text box were examined. Oncology, hospice/palliative care, and pediatric practices were excluded.

User entered responses to a CDS alert during the process of controlled medication prescribing were thematically analyzed looking for common trends and patterns in responses. Percentages of responses falling into identified themes are examined for their implications on CDS.

A total of 54,516 CDS alerts fired for 1,894 unique providers providing 15,492 comments in the CDS alert textbox. Valid responses (not single characters or random strings of text) were categorized into three main groups. The majority of responses (60%) indicated they checked the patient’s PDMP as prompted by the CDS. Thirty-four percent of responses gave a justification for the prescription, and 6% gave a complaint about the CDS. Among those complaints, 68% indicated they wanted to review the PDMP at a later time, 24% expressed frustration with having checked the PDMP and still receiving the alert, and 8% reported a technical error with checking the PDMP such as PDMP data not loading.

The utilization of a textbox during rollout of interruptive CDS can provide additional opportunities to improve use within the EHR to promote evidence-based practices. Alert responses can be used to identify providers who are struggling to understand the purpose or navigation of the CDS, as well as identify changes that may be needed in the CDS to better support providers in their workflow.

DENNIS GURFINKEL, MPH
University of Colorado

The Invested in Diabetes study is a comparative-effectiveness pragmatic trial comparing two diabetes shared medical appointment (SMA) delivery models (standardized [STD] vs patient-driven [PTD]). PTD SMAs use the same skills-building curriculum as the STD SMAs but include peer mentors and behavioral health providers (BHPs) as part of a multidisciplinary team, and allow patients to select topic order and emphasis. We hypothesized these features would yield increased patient engagement, evidenced by better attendance, and psychological needs support (autonomy, competence, and relatedness) as defined by self-determination theory (SDT) in the PTD arm. We also explored if greater demands of the PTD practices would result in lower fidelity to protocol.

21 primary care practices in CO and MO.

Trained observers observed approximately 8% of randomly selected SMAs using a structured template. SMA facilitators’ overall skill and style (didactic vs discussion) and fidelity to SDT core constructs (autonomy, competence, relatedness support) were graded on 5-point bipolar scales (low to high on skill, discussion, and support). Observers also reported on elements of protocol fidelity (time spent, personnel included, and use of curriculum). Practice attendance sheets were reviewed for patient attendance and personnel scheduled. We report results of 67 observed SMAs (37 STD, 30 PTD) and 147 cohorts (72 STD, 75 PTD). Descriptive statistics and t-tests assessed differences overall and between conditions.

Facilitators across both conditions demonstrated high support for autonomy (M=4.34), competence (M=4.55), and relatedness (M=4.60) overall. Facilitation skills were generally very good (M=3.86) and style was a balance of didactic and discussion (M=2.73). Results were not significantly different between study conditions. Both PTD and STD spent less time than expected on sessions (94min PTD vs. 88min STD out of 120min, p=.274), and covered a similar amount of the curriculum (86.7% PTD vs. 83.3% STD, p=.712). Attendance did not differ between PTD and STD (4.90 PTD vs. 4.96 STD of 6 sessions attended, p=.589). PTD classes had a BHP assigned in 81% of cohorts and a peer mentor assigned at 93% of cohorts (vs. 0 for both for STD). However, peer mentors were present at 53.3% of PTD sessions and 2% of STD sessions observed. BHPs were not required to be at each session so similar comparison could not be made.

Existing primary care personnel trained to deliver diabetes SMAs using a skills-building curriculum demonstrated excellent support for SDT-related psychological needs – with little observed difference in facilitation style or needs support between SMA delivery models and personnel types involved. Increased patient-focused features in the PTD protocol did not increase psychological needs support observed or patient attendance, but some issues with fidelity to protocol regarding personnel was show