This practice improvement project tested the impact of a newly acquired electronic clinical decision support system on diagnostic accuracy among nurse practitioners (NPs) functioning in a community based setting. Nurse practitioners delivering primary care in a home visiting practice are especially vulnerable to lack of knowledge support as they are mobile in the community and often feel isolated from peers and experts who can support clinical decision making. A CDS accessed via wireless broadband was viewed as a means to assist these clinicians to deliver care based on best practice recommendations obtainable via laptop or smartphones at the time of the patient encounter. To ensure adoption of electronic decision support systems, the approach to integration is best accomplished by involving end-users throughout the process. In addition to a pilot group of NPs who were representatives of the workforce, other organizational stakeholders were engaged to provide tangible support and necessary resources for successful adoption of this innovation in practice. A structured conceptual model of Evidence Based Practice Improvement (EBPI) enhanced with elements of the Promoting Action on Research Implementation in Health Sciences (PARIHS) framework was used to guide the development, implementation and evaluation of the improvement initiative and ultimately informed decision making about CDS dissemination strategies for the entire practice. Using an implementation science approach helped illuminate the internal and external evidence that informed parameters of the work and elicited both patient and clinician input in the process. Attention to the culture of the practice setting including leadership attributes and availability of project evaluation support defined the local context of the improvement effort. The nature of the facilitation required to ensure adoption of the CDS system was designed to be flexible based on the nature of the evidence, the expectations of stakeholders and the purpose of this evidence based practice change.
Data collection was comprised of small tests of change (Plan, Do, Study, Act cycles) at the local practice level. Results informed refinement of CDS implementation processes that facilitated improvement in the correctness of medical diagnosis and appropriateness of substantiating clinical documentation over time. Clinician volunteers participated in vendor demonstrations and selection of the CDS system for the practice. A baseline chart audit was conducted using an audit tool that sought to identify that the primary diagnosis accurately reflects the current, most significant reason for the clinical encounter and that the secondary diagnoses are identified and substantiated in documentation found in the review of systems, history of present illness, diagnostic tests and physical examination. Clinical documentation elements must be linked to the chosen ICD-9 code which was expected to be of the highest diagnostic specificity. After training on the CDS system, charts of each participant were audited for the next three months to assess the impact of the CDS system availability on diagnostic accuracy. After several improvement cycles produced acceptable diagnostic accuracy results on chart audit, a focus group with the pilot NPs was conducted to determine the level of satisfaction with the CDS system and input on CDS system dissemination strategies to promote integration of decision support systems across the practice. In this practice setting, use of a CDS system by nurse practitioners was effective in impacting the outcome of diagnostic accuracy. Qualitative and quantitative data informed multiple strategies to guide ongoing improvement efforts aimed at sustaining long term results.
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