Barriers and facilitators to the use of computer-based intensive insulin therapy

Abstract

Purpose: 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.

Conclusion: 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.

Figure 1

Architecture of clinical information systems developed and implemented in SICU and TICU at Vanderbilt University Hospital. All systems were in use at the time of study. Arrows indicate bidirectional data transfer. Users accessed clinical applications and specific application modules embedded within them from workstations connected to the hospital network located on mobile carts, at nursing stations, and in patient rooms at the bedside. The clinical data repository stored data generated by clinical applications and their modules. For implementation details, see [8] for IIT CDSS and [24] for dashboard. MARS was originally developed at the University of Pittsburgh in the mid-1980s.

Figure 2

IIT CDSS interface used by nurses. Similar to interfaces of other decision support modules in the provider order entry system, IIT CDSS displayed colorful numbers to guide users through a sequence of operations.

Figure 3

Current and future IIT CDSS documentation workflow. Nurses recorded data for each protocol iteration in IIT CDSS and HED, an electronic nursing documentation system. In the future, nurses could record these data in IIT CDSS, which could then transfer the data to HED to eliminate double documentation and save nurses time. Automatic transfer of infusion pump data to HED could also save time and help nurses double check that administered insulin rates match orders to improve safety.