Credentials of Corresponding Author
MSN MS BSN RN-BC FAMIA
Name of Faculty Advisor
Nature and scope of the project
Diabetes is a chronic, complex disease that is increasing at an alarming rate nationwide. This chronic disease is becoming more challenging to manage for patients, families, and providers. As healthcare focuses on shared-decision making, patients need the necessary information to make informed decisions. It is known that individuals who are at risk for type 2 Diabetes Mellitus (T2DM) can postpone it by participating in an empowering behavior modification program known as diabetes self-management education (DSME). However, only a small percentage of those patients at Captain James A. Lovell Federal Health Care Center (FHCC) with T2DM have completed the program, mainly due to a lack of referrals. Clinical decision support systems can help translate evidence into practice by incorporating clinical decision tools into the clinician’s workflow. This quality improvement project aims to create an evidence-based clinical decision support bundle to assist primary care providers in diabetes management by ensuring the latest evidence is provided to both clinicians and patients at the point of care.
Synthesis and analysis of supporting literature
There is a need for computerized evidence-based guidelines implemented into primary care using CDS tools. Primary care providers can be faced with more challenging decisions as the number of patients presenting with chronic diseases continues to rise. Primary care providers need quick and user-friendly recommendations that are guided by evidence-based research. The importance of involving the providers in the beginning of the development of the CDS tool is crucial to the sustainability and usability of the CDS tool. From the review of evidence, it is apparent that if the provider does not find the CDS useful, the likelihood of them bypassing the CDS is high. Therefore, after meeting with providers to determine the workflow process and needs, a bundled order set will be created to translate the evidence into practice for this quality improvement project.
The purpose of this project is to implement a clinical decision support tool to increase the compliance of clinical practice guidelines by the VA/DoD for T2DM and to help translate the evidence into practice. The clinical decision support (CDS) type used for this project will be a disease management system containing one bundled order set that includes all the orders and labs recommended by the guidelines. The purpose of creating one order set bundle is in the interest of human factors by making the ordering process more efficient. Currently, there are four separate clinical reminders a provider must clear for diabetes, none of which include a consult to DSME. The evidence-based order set will automatically clear all the clinical reminders relating to T2DM. The goal is to work toward a shared decision-making process that is informed by the best possible current evidence. The rationale for selecting a bundled order set is to save the provider time while providing an evidence-based treatment plan focused on current practice guidelines. The five rights of clinical decision support are the right information, people, channel, intervention, and point. The right information is evidence-based guidance. The right people are ordering providers. The right channel is via the EHR. The right intervention is an evidence-based bundled order set. Finally, the right point is during workflow when the provider takes action and makes decisions.
To determine the direct impact of the order set bundle, evaluation measures will need to align with the original aim of the project. The timeline for the evaluation process will start prior to the implementation of the CDS and will be ongoing. The evaluation is a continuous process that will involve reviewing interventions, tracking outcomes, and addressing the usability of the order set. Without consistent monitoring and evaluation of the order set, workarounds could start to develop and become customary practice. Incorporating usability testing into the design of the order set is an effective way to increase provider use and compliance. Therefore, involving primary care providers from the beginning of the project will be imperative. In addition, maintenance of the knowledge will be important to manage as treatments and clinical practice guidelines change over time. The indicators used to measure the success of the project are an increase in DSME consults. A bar graph chart will be used to show the change in number of DSME consults biweekly over the 12-week period, compared to previous rate.
Data will be collected from the electronic health record (EHR) quantifying the number of consults placed to the DSME program biweekly over a 12-week period. A report will be produced from the EHR to determine the amount of DSME consults placed prior to implementation as a baseline and again biweekly until the project ends. Gathering the biweekly data will help determine if the order set has technical issues. In addition, after implementation providers will be requested to take an online survey (using the Likert 5-point scale) on the usability of the new CDS tool.
The timeline for the evaluation measures will start prior to implementation of the CDS tool and will be ongoing (reviewing interventions, tracking outcomes, and addressing the usage and usability of the bundled order set). The outcome indicators include the number of consults placed over a 12-week period.
According to the ADA (2017), everyone with T2DM, should be offered DSME. By creating a bundled order set, the provider can save time and lives. The CDS plan will not replace critical thinking, nor will it cause alert fatigue. In fact, the bundle will save time and improve the workflow by offering patient centric and evidence-based treatment following the best practice guidelines for diabetic patients. When new knowledge is generated, we must create ways to translate the new evidence into meaningful use of technology to care for the needs of the nation.
Implementing a Clinical Decision Support (CDS) Bundle for Diabetes Management: An Evidence-Based Quality Improvement Initiative