Iterative Design and Testing of a Tobacco Use Counseling Decision Support System

1. Iterative Design and Testing of a Tobacco Use Counseling Decision Support System Theodore W. Marcy, MD MPH University of Vermont

2. Vermont Cessation Services • Counseling Services • Free Quit Line • Free in person counseling at all hospitals in VT • Free website • Free or highly Subsidized Nicotine Replacement Therapy Ready, Set...STOP To be Tobacco Free

3. Patient Report of MD Interventions Vermont Adult Tobacco Survey VT Dept Health

4. Reasons Given by Vermont Physicians for Not Addressing Tobacco Use and Dependence • Inadequate time 48% • Patients are unreceptive 38% • No reimbursement for services 12% • Lack of resources for patients 10% Important or Very Important Marcy et al Prev Med 2005; 41(2) 479

5. Med recommendations • Info on med subsidies • Info on counseling • Tailored pt handout • Referral forms • Chart documentation Current Study: Clinical Decision Support Systems (CDSS) Software designed as an aid in determining appropriate actions to take for specific patient problems or situations General knowledge about the problem Information about the patient

6. Definition Usability Testing Clinical Testing Iterative Build-Test-Redesign Refined Prototype Surveys of Physicians Initial Patient Testing in clinic setting Design / re-design CDSS with information Usability testing with physicians. Validity testing with expert panel Surveys of Clinic Managers Pilot test in primary care clinics CDSS Development Plan Wyatt and Spiegelhalter Medical Informatics 1990

7. Contributors to the Process • MDs and clinic office managers through surveys • Yale Center for Medical Informatics for design and programming • Advisory board with varied areas of expertise • Hospital Information Services • MDs doing Usability testing in “lab setting” • Consenting patients in Pulmonary clinic • Pilot clinics staff and MDs

8. Priorities Identified by Surveys • CDSS best on a handheld computer (PDA) • Provide the four most valued information management services † : • Recommendations (patient specific) • Presentation to patients (a tailored handout) • Documentation of services (chart note) • Administrative data that guides recommendations (e.g., residence, health plan) • Prompt MD to use the CDSS * †Shiffman JAMIA 1999; 6:99 * Garg JAMA 2005; 293:1223

9. First Prototype CDSS System Nurse: Records vital signs, smoking status and smoking behavior in computer, transmits to MD’s PDA via server Physician: Alerted of smoking status by PDA; chooses if intervention appropriate. If yes, guided on discussion of meds, counseling Patient: Receives printed tailored handout based on choices entered by MD. Document printed for patient’s chart

10. Vital Sign Sheet with Smoking Status ID Server Physician PDA Printouts Tailored handout for patient Chart Note Fax form to counseling service Final Prototype Physician: Notes smoking status on chart; chooses if intervention appropriate. If yes, guided on discussion of meds, counseling Nurse: Records vital signs, and smoking status on chart record Patient: Receives printed tailored handout based on choices entered by MD. Document printed for patient’s chart

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13. Live Demonstration

14. Clinic Pilot Test Experience • Physicians used CDSS as often as six times a day • Systems in clinic worked to print out handouts and fax referrals • Concerns: • Time to use: varied with MD • Too many screens to work through • Not always possible to use

15. Clinic Pilot Test Experience • Positives • Shared decision making with patient • Patients “rallied around” the PDA • Made questions easier to understand • Facilitated decision making • Something new to offer than just lecturing • Medication information and printed instructions • Documentation for RVUs and insurance

16. Lessons Learned • Iterative design process added improvements, and avoided a fatal error in workflow integration • Increasing the value of CDSS comes with cost of additional equipment and time required • Unexpected benefit: viewing screens together enhances shared decision making with patient

17. Potential Impact on Identified Barriers to Performing Guideline • Inadequate Time • Eliminates need to write instructions and document • Rapid retrieval of information on meds, counseling • Patients are unreceptive • Patients responded positively to use of PDA with MD • No reimbursements for services • Facilitates Medicare reimbursement by documenting • Lack of resources for patients • Identifies patient specific resources for MD

18. Acknowledgements • University of Vermont • Brian Flynn ScD – Charles MacLean MD • John Hughes, MD – Berta Geller Ed D • Laura Solomon, PhD – Anne Dorwaldt • Scott Connolly, Ed D – Kathy Howe • Greg Dana, MPA – Joan Skelly, MS • Fletcher Allen Health Care IS • Sharon Weber • Yale University Center for Medical Informatics • Richard Shiffman, MD • George Michel MS, MBA • Bonnie Kaplan, PhD • Physicians, clinic staff, and patient volunteers