Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use.

Abstract

Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers. Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns. Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed. Geriatric order sets were implemented at two sites as part of the multicomponent 'Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department' quality improvement initiative. Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups (n=20), those 'EQUiPPED' with the interventions (n=10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record (n=10, 5 at each site). All providers were asked about order set 'use' and 'usefulness'. Users (n=11) were asked about 'usability'. Order set adopters described 'usefulness' in terms of 'safety' and 'efficiency', whereas order set consultants and order set non-users described 'usefulness' in terms of 'information' or 'training'. Provider 'autonomy', 'comfort' level with existing tools, and 'learning curve' were stated as barriers to use. Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care.