Table 3 Determinants of implementation success and associated implementation strategies
Determinants of implementation success | Additional details | Illustrative quote – experienced sites (VA) | Illustrative quote – anticipating sites (MAQI2) |
|---|---|---|---|
Clinician authority and autonomy | Desire for staff and clinics to control/personalize their own workflow and integration of the DOAC Dashboard | “Like managing their workflow and work day so that they can incorporate it into that instead of things being maybe ‘dumped’ into their queue. So right now we’re working on, my clinical tech, our clinical tech and I are actually working on a process that we think is going to help with that.” Site H4, Study ID 173 | “My concern is how would we put this in our daily workflow? Of course. That’s the biggest question I think probably everybody has.” Site 2, Study ID 4 |
Concern that some centers will not allow pharmacists or nurses to make evidence-based medication changes | “I would like to see a greater change in you know, I wish that our interventions that we recommend, that more of those recommendations were taken.” Site G1, Study ID 112 | “The biggest thing I can think of is physician buy-in. So, what if Doctor Smith doesn’t want somebody else touching his patient? Like, how do we protect ourselves there so we are not putting a pharmacist in a situation?” Site 3, Study ID 9 | |
Clinician self-identity and job satisfaction | Fear that a computer program will be replacing the work of anticoagulation clinic staff and contribute to low job satisfaction | “I have heard from other facilities that their anticoagulation teams have been very reluctant to fully rely on the dashboard. I think there is a concern of losing workload credit... I think there’s also a concern or a lack of trust in the tool” Site I2, Study ID 4 | n/a |
Documentation, communication, and administrative needs | Concerns about how best to communicate with prescribing clinicians (e.g., physicians) and documentation burdens for a large number of patients | “So, sometimes the dosing adjustment, sometimes the indication, that's a barrier that now we have to communicate with outside provider because our providers simply likes to rewrite whatever is written outside, they're going to continue.” Site C1, Study ID 123 | “Unless we get this standing protocol with a group of physicians, we can’t just act on their patients without reaching out to them first. How is reaching out to them going to be taken – how is that going to be taken? Are we going to be stepping on their toes, or they're wondering why we're reaching out to them?” Site 2, Study ID 4 |
Current staff performance measures often do not include DOAC Dashboard related activities. Working with this tool might limit the ability to achieve other performance measures and revenue | “Our immediate supervisor probably knows that it’s out there and you know she may encourage us to use that for identifying our patients who are, you know how many months out or whatever, but use, no, it’s not, they don’t use it like as a performance measure or something that like” Site E2, Study ID 136 | “But, where I met the biggest resistance is, why can't we charge even a small fee? Why is there no charge associated with this? Why is this something we can’t bill? They really want something billable, and something that – and really, even if we did bill them based on pharmacist charge codes, and we brought them in to see us, we would not make what it costs to have my salary.” Site 2, Study ID 4 “Right now, the anticoag clinic in its own silo is a money loser. If cardiology absorbs it, it makes their budget look bad. And for some reason, people are not seeing the bigger picture where it’s the same money coming out of the same system and it doesn’t matter whose budget it belongs to. So, that’s another barrier.” Site 1, Study ID 3 | |
Staffing and work scheduling | Many anticoagulation clinics are busy managing warfarin-treated patients and have concerns about the extra workload of managing the DOAC Dashboard | “Well, I think a couple of barriers, one is just like being a little bit overwhelmed by the amount of alerts that we saw and thinking to ourselves, like how are we going to get this down, how are we going to keep this up on a regular basis, and then also too, I mean there were many patients that we had just never seen before.” Site I2, Study ID 4 | “ … we already kind of feel like we're busting at the seams a little bit, like we’re busy 100% of the time – and that is true. But again, I can't see not pursuing something that has the potential to allow us to do a better job at what we’re currently supposed to be doing and are failing at. ‘Failing’ is maybe a harsh word, but it's true. We're not following up with every patient the way our program is designed to do. We've lost the ability to do that, and if this has the ability to bring us back to that, it increases maybe the amount of patients we need to look at in a given day, but it also increases the rate with which we discover errors that are there. We know they're there; it's just how we find them. We're not finding them now.” Site 3, Study ID 6 |
Integration with existing information systems | Concerns about sufficient IT resources and priority to implement | n/a | “The biggest [system barrier] is the priorities of our IT department with rolling out Epic without looking at what’s clinically more useful to us and so, right now, this tool is amazing.” Site 1 Study ID 3 [Responding to perceived organizational hurdles] “Probably the time it will take for our Epic team to figure out a way to implement in our system. Things tend to take a long time. And I believe we have already gotten approval so that approval has already been done. Yeah, so, it’s probably just a matter of how long it will take for them to get this completed.” Site 4, Study ID 11 |
Uncertainty around accuracy of the DOAC Dashboard | “You kind of had to learn to trust the dashboard versus to scheduling a phone call or scheduling labs and then making sure that they’re going to go to labs or scheduling, make sure we follow up on them, whereas with this, we have to trust that the dashboard will let us know when there’s another problem that comes up.” Site D1, Study ID 5 “They certainly appreciated some of the same things, that they would be alerted to immediate abnormalities and other things but they were also concerned that they wouldn’t find bleeding events or hospitalizations or upcoming procedures or other things that we’re able to jump in and manage if they weren’t following up with patients as frequently.” Site I1, study ID 176 | “I could see someone who is very critical of this type of scoring tool because you want to make sure that all of the boxes are completely accurate for the time that you're looking at the patient … And make sure to go back and double check and confirm that these patients are actively on these medications and their weights are appropriate and their creatinine are appropriate. So, source of information is going to be critical in terms of legitimizing this. They can get very credible. We want to make sure that all of these extracted pieces of information are 100% sound before facilitating a transition.” Site 3, Study ID 7 | |
Challenge using the DOAC Dashboard if it takes too long to load or does not integrate into existing computer system and workflow | “It is so slow, I mean that is number one. I know that’s probably not the answer you're looking for, but it is so slow.” Site E1, Study ID 53 “My anticipation is that no, we don’t intend to probably use it at any point in the near future unless there’s some other pressure to do so. With upcoming changes in pharmacy software, changes how we’re moving to Cerner, having great concerns at that juncture about tracking patients and keeping our follow-up with patients intact. I don’t suspect any further changes are probably going to be adopted.” Site 1 Study ID 176 | “I can give you the example of seven years ago when [the EMR] went live and the users here had been working in a different electronic medical record before and a different software program that supported them specifically within the anticoagulation realm, and then those two things got rolled together into Epic, totally new system, and the day that Epic went live is the day that they found out that their patient records did not transfer from one to the other. So, I mean, it was a complete true disaster of knowing how to use this.” Site 3, Study ID 6 |