Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use

Abstract

Quality problem or issue: Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers.

Initial assessment: Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns.

Choice of solution: Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed.

Implementation: Geriatric order sets were implemented at two sites as part of the multicomponent 'Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department' quality improvement initiative.

Evaluation: Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups (n = 20), those 'EQUiPPED' with the interventions (n = 10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record (n = 10, 5 at each site). All providers were asked about order set 'use' and 'usefulness'. Users (n = 11) were asked about 'usability'.

Lessons learned: Order set adopters described 'usefulness' in terms of 'safety' and 'efficiency', whereas order set consultants and order set non-users described 'usefulness' in terms of 'information' or 'training'. Provider 'autonomy', 'comfort' level with existing tools, and 'learning curve' were stated as barriers to use.

Conclusions: Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care.

Keywords: appropriateness; elderly < specific populations; emergency care < setting of care; qualitative methods < general methodology; quality improvement < quality management; under-use and over-use < appropriate healthcare.