Barriers and facilitators to the use of computer-based intensive insulin therapy.
OBJECTIVE
Computerized clinical decision support systems (CDSSs) for intensive insulin therapy (IIT) are increasingly common. However, recent studies question IIT's safety and mortality benefit. Researchers have identified factors influencing IIT performance, but little is known about how workflow affects computer-based IIT. We used ethnographic methods to evaluate IIT CDSS with respect to other clinical information systems and care processes.


METHODS
We conducted direct observation of and unstructured interviews with nurses using IIT CDSS in the surgical and trauma intensive care units at an academic medical center. We observed 49h of intensive care unit workflow including 49 instances of nurses using IIT CDSS embedded in a provider order entry system. Observations focused on the interaction of people, process, and technology. By analyzing qualitative field note data through an inductive approach, we identified barriers and facilitators to IIT CDSS use.


RESULTS
Barriers included (1) workload tradeoffs between computer system use and direct patient care, especially related to electronic nursing documentation, (2) lack of IIT CDSS protocol reminders, (3) inaccurate user interface design assumptions, and (4) potential for error in operating medical devices. Facilitators included (1) nurse trust in IIT CDSS combined with clinical judgment, (2) nurse resilience, and (3) paper serving as an intermediary between patient bedside and IIT CDSS.


CONCLUSIONS
This analysis revealed sociotechnical interactions affecting IIT CDSS that previous studies have not addressed. These issues may influence protocol performance at other institutions. Findings have implications for IIT CDSS user interface design and alerts, and may contribute to nascent general CDSS theory.
Department of Biomedical Informatics, Vanderbilt University School of Medicine, United States. thc2015@med.cornell.edu
Thomas R
TR
Campion
Lemuel R
LR
Waitman
Nancy M
NM
Lorenzi
Addison K
AK
May
Cynthia S
CS
Gadd
D003195:Computer Communication Networks / Q000706:statistics & numerical data*; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data*; D004360:Drug Therapy, Computer-Assisted; D057286:Electronic Health Records; D006801:Humans; D007328:Insulin / Q000627:therapeutic use*; D007362:Intensive Care Units; D009726:Nurses; D036301:Qualitative Research; D012189:Retrospective Studies; D014193:Trauma Centers; D057188:Workflow
D007328:Insulin