PURPOSE We wanted to assess the impact of an electronic health record-based diabetes clinical decision support system on control of hemoglobin A 1c (glycated hemoglobin), blood pressure, and low-density lipoprotein (LDL) cholesterol levels in adults with diabetes. METHODSWe conducted a clinic-randomized trial conducted from October 2006 to May 2007 in Minnesota. Included were 11 clinics with 41 consenting primary care physicians and the physicians' 2,556 patients with diabetes. Patients were randomized either to receive or not to receive an electronic health record (EHR)-based clinical decision support system designed to improve care for those patients whose hemoglobin A 1c , blood pressure, or LDL cholesterol levels were higher than goal at any offi ce visit. Analysis used general and generalized linear mixed models with repeated time measurements to accommodate the nested data structure. RESULTSThe intervention group physicians used the EHR-based decision support system at 62.6% of all offi ce visits made by adults with diabetes. The intervention group diabetes patients had signifi cantly better hemoglobin A 1c (intervention effect -0.26%; 95% confi dence interval, -0.06% to -0.47%; P = .01), and better maintenance of systolic blood pressure control (80.2% vs 75.1%, P = .03) and borderline better maintenance of diastolic blood pressure control (85.6% vs 81.7%, P = .07), but not improved low-density lipoprotein cholesterol levels (P = .62) than patients of physicians randomized to the control arm of the study. Among intervention group physicians, 94% were satisfi ed or very satisfi ed with the intervention, and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued.CONCLUSIONS EHR-based diabetes clinical decision support signifi cantly improved glucose control and some aspects of blood pressure control in adults with type 2 diabetes. INTRODUCTIOND espite recent improvement trends in the United States, in 2008 less than 20% of patients with diabetes concurrently reach evidence-based goals for hemoglobin A 1c (glycated hemoglobin), systolic and diastolic blood pressure, and low-density lipoprotein (LDL) cholesterol levels.1,2 Care is unsatisfactory in both subspecialty and primary care settings, but because more than 80% of diabetes care is delivered by primary care physicians, effective strategies to improve diabetes care in primary care settings are urgently needed.Among the major barriers to better diabetes care is lack of timely intensifi cation of pharmacotherapy in patients who have not achieved recommended clinical goals. Many factors contribute to this problem, including competing demands at the time of the visit 3 and medication In theory, treatment intensifi cation and control of hemoglobin A 1c , blood pressure, and lipid levels in patients with diabetes mellitus could be improved by providing patient-specifi c and drug-specifi c clinical decision support at the time of a clinical encounter. Electronic health recor...
This EHR-integrated, web-based outpatient CDS system significantly improved 10-year CV risk trajectory in targeted adults.
Background In the United States, primary care providers (PCPs) routinely balance acute, chronic, and preventive patient care delivery, including cancer prevention and screening, in time-limited visits. Clinical decision support (CDS) may help PCPs prioritize cancer prevention and screening with other patient needs. In a three-arm, pragmatic, clinic-randomized control trial, we are studying cancer prevention CDS in a large, upper Midwestern healthcare system. The web-based, electronic health record (EHR)-linked CDS integrates evidence-based primary and secondary cancer prevention and screening recommendations into an existing cardiovascular risk management CDS system. Our objective with this study was to identify adoption barriers and facilitators before implementation in primary care. Methods We conducted semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) with 28 key informants employed by the healthcare organization in either leadership roles or the direct provision of clinical care. Transcribed interviews were analyzed using qualitative content analysis. Results EHR, CDS workflow, CDS users (providers and patients), training, and organizational barriers and facilitators were identified related to Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals CFIR domains. Conclusion Identifying and addressing key informant-identified barriers and facilitators before implementing cancer prevention CDS in primary care may support a successful implementation and sustained use. The CFIR is a useful framework for understanding pre-implementation barriers and facilitators. Based on our findings, the research team developed and instituted specialized training, pilot testing, implementation plans, and post-implementation efforts to maximize identified facilitators and address barriers. Trial registration clinicaltrials.gov , NCT02986230 , December 6, 2016. Electronic supplementary material The online version of this article (10.1186/s12913-019-4326-4) contains supplementary material, which is available to authorized users.
The CDS had a significant, beneficial effect on the recognition of hypertension, with a moderate increase in guideline-adherent management.
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