Provider Survey on Automated Clinical Decision Support System for Cardiovascular Risk Assessment

Abstract

Despite progress made in establishing primary and secondary preventive strategies for cardiovascular diseases, there are significant gaps between guideline recommended strategies and implementation of recommendations in practice. A clinical decision support (CDS) system entitled CV Risk Profile was developed at Mayo Clinic Rochester as a targeted solution for this gap in preventive cardiovascular care. The system remained in use for 10 years until it became non-functional in 2018 during transition to a new electronic health record (EHR). This study investigated provider opinions regarding the cardiovascular disease CDS system while it was still in operation, to determine if there exists a provider reported need for a similar system to be developed for use within the new EHR.

Introduction

Cardiovascular diseases are related to diverse risk factors including smoking, hypertension, high blood cholesterol levels, diabetes, and obesity. In the United States cardiovascular diseases account for 1 of every 3 deaths and remain a leading cause of death for both men and women [1 2]. While progress has been made in establishing strategies for primary and secondary prevention of cardiovascular diseases, many studies have identified gaps in implementation and adherence to guideline recommended strategies [3–6]. Another study demonstrated it takes an average of 17 years for 14% of guidelines to be integrated into practice [7]. Thus, there is need to find solutions to address these gaps in prevention to reduce both mortality and morbidity of cardiovascular disease via increased implementation of proven preventive strategies.

Prior studies used clinical decision support (CDS) systems and point-of-care technology to promote individualized cardiovascular prevention [8–11]. Our institution implemented a CDS system in 2008 in an effort to standardize and support guideline-based preventive cardiovascular care. The CDS system entitled CV risk profile displayed individualized patient information in the following categories: risk factors, body composition, vascular health, metabolic syndrome, heart disease risk analysis, lifestyle factors, recommendations and follow-up. Pertinent data elements were included in each category, including high-density lipoprotein (HDL) and blood glucose levels within the risk factor category and patient reported diet and exercise within the lifestyle factor category (Figure 1). In addition, the system also provided an overall mortality risk score calculated by the Framingham, Reynolds or pooled cohort equations. Results were categorized as low-risk, intermediate-risk, and high-risk for cardiovascular disease [12 13]. Each data element retrieved was also classified as “low”, “intermediate” or “high” risk using cut-points defined by published medical literature. These data elements are displayed in a color-coded categorization as follows: low-risk results displayed in green; intermediate-risk in yellow and high-risk in red (Figure 1). This system was linked to the Mayo Clinic Rochester electronic health record (EHR) for 10 years until transition of the EHR to a new system, at which time the CDS system became non-functional. The aim of this study was to investigate provider opinions regarding the CV risk profile system and on creation of a new CDS system compatible with the new EHR.

Figure 1:

Risk Profile CDS screen shot of a test subject

Methods

A provider survey with 9 questions was developed in conjunction with the Mayo Survey Research Center. The first question determined whether providers would continue with completion of the survey or not. If their answer was no, then they were not prompted to answer any other questions. However, if their answer was yes, then they were prompted to continue with survey completion. The survey questions are displayed in Table 1.

Table 1.

Survey Questions

1) In your clinical practice, have you used the CV risk profile? ( ) Yes ( ) No

2) How often have you used the current version of the CV risk profile? ( ) Every day ( ) Several times a week ( ) Several times a month ( ) About once a month ( ) Less than once a month

3) How important or unimportant is it for you to be able to continue to use the CV risk profile? ( ) Very Unimportant ( ) Unimportant ( ) Important ( ) Very Important

4) How easy or difficult is the use of the CV risk profile? ( ) Very Easy ( ) Easy ( ) Difficult ( ) Very Difficult

5) Does the CV risk profile support your thought process during patient encounters? ( ) Yes ( ) No

6) Should similar functionalities be added in the new electronic health record system? ( ) Yes ( ) No

7) Should new functionalities be added in the new electronic health record system? ( ) Yes ( ) No

8) What is your role as a healthcare provider? ( ) Staff Physician ( ) Nurse Practitioner/Physician Assistant ( ) Nurse ( ) Fellow or Resident ( ) Other care provider

9) How many years have you been in practice (post training)? ( ) 0-5 years ( ) 6-10 years ( ) 11-15 years ( ) 16-20 years ( ) More than 20 years

The Survey Research Center sent an invitation letter by e-mail with a link to a self-administered web-based survey for 279 providers including all staff physicians, fellows, nurse practitioners, physician assistants and nurses who provide cardiovascular assessment in the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN. Of this group, 100 providers responded to the survey resulting in a response rate of 35.8%. The email was sent to providers on 3/08/2018 and the survey closed on 4/16/2018 after 5 reminder emails. This study was approved by the Institutional Review Board.

Results

Among the 100 providers that responded to the survey, 52 (52%) indicated they had used the CV risk profile system and were prompted to continue the survey, while the remaining 48% indicated they had not used this system and were not asked to continue to complete the survey. Among the 52 providers who indicated they had used CV risk profile, 15.4% reported they used the system daily.

The majority reported using the CV risk profile system less than once per month (34.6%). 11 (21.2%) providers indicated they used the system several times a week and 6 (11.5%) indicated they used the system about once per month (Figure 2).

Figure 2:

Reported Usage of CV Risk Profile

When asked how important providers considered use of the system for their clinical practice, 42 (80.8%) indicated it was either important (25, 48.1%) or very important (17, 32.7%). Only 8 (15.4%) providers reported the system as very unimportant (Figure 3).

Figure 3:

Importance of Continued Use of CV Risk Profile

45 (86.5%) of respondents also reported that the system was either easy (28, 53.8%) or very easy (17, 32.7%) to use in their clinical practice (Figure 4). In addition, 48 (96.0%) of respondents reported that the CV risk profile supported their thought process at the time of patient encounters (Figure 4).

Figure 4:

Provider Opinions on CV Risk Profile

When asked if similar functionalities to the CV risk profile system should be added into the new EHR system, 47 (97.9%) of respondents indicated these functionalities should be implemented and 1 (2.1%) responded no need (Figure 5).

Figure 5:

Self-Reported Need for Similar CDS Functionalities in the New EHR

41 (85.4%) of respondents reported new functionalities should be implemented into the new EHR and 7 (14.6%) responded that there was no need for new functionalities (Figure 6).

Figure 6:

Self-Reported Want of New CDS Functionalities in the New EHR

The majority of respondents were staff physicians 29 (58.0%) (Figure 7). The next largest group of respondents was fellows/residents (13, 26%) followed by nurse practioners and physician assistants (6, 12%). Among the respondents, there were also 2 (4.0%) PhD exercise physiologists.

Figure 7:

Provider Roles

The responses for years in practice had a U shaped distribution (Figure 8). The majority of respondents were in practice 0-5 years (36.0%). The next largest group was providers who had completed more than 20 years in practice

Figure 8:

Respondents Years in Practice

Discussion

The major findings of this study were the high support for both similar and new CDS functions to be implemented into the new Mayo Clinic EHR. With 97.9% of providers surveyed indicating that similar functionalities present in the CV risk profile system should be implemented into the new EHR, there is a clear indication that their cardiovascular practice was supported and should continue to be supported by CDS systems providing point of care and individualized patient information. Importantly, 96% of providers reported that the CV risk profile supported their clinical thought processes at the point of care and 86.5% of providers thought the CDS system was easy to use.

In comparison to other survey studies, the provider response rate of 35.8% in the present study was greater than the response rate of 27% in a survey by Chaudhry et al investigating providers opinions about a CDS system to assist them in providing evidence-based care to peripheral artery disease patients at the point of care. Additionally, the response rate of the study herein was greater than the 10% to 15% range of responses from physicians across specialties (primary care, obstetrics/gynecology and cardiology) in a national survey of guideline-recommended strategies for cardiovascular disease prevention [10 14].

Our results showed provider need for a similar CDS system to be implemented and a need to add new functionalities. 85.4% of providers surveyed indicated new functionalities should be included in the new CDS system. The new functionalities could further prioritize and filter the information provided, thus further refining the system to fit provider needs. Our observations suggest creators of the next CDS system for cardiovascular risk assessment involve a multidisciplinary team composed of clinicians, informaticians, and information technologists for development of the replacement CDS incorporating established functionalities and adding new functionalities, to continue supporting their clinical needs.

In the present study, most providers reported that the CV risk profile supported their clinical thought processes at the point of care. The new CDS system will be designed in collaboration with clinicians to continue to achieve this purpose. Previously, physicians decreased usage rate of CDS systems if information was not provided at the point of care [15] underscoring the importance for design of a system that supports the clinician thought process. Additionally, physicians are more likely to use CDS systems when data entry is not required and when the information provided by the CDS system is accurate [15]. The new system will extract the necessary data elements from the EHR and manual data entry will not be necessary. The majority of providers found the system easy to use, however, 13.5% of providers still indicated they found the current CV risk profile system difficult indicating there is an opportunity to further improve system usability.

Challenges in CDS systems have been previously identified including improvement of the human-computer interface and summarization of patient-level information [16]. The new CV risk profile system will meet these challenges while supporting the meaningful use of EHRs.

Conclusions

In a continued attempt to reduce cardiovascular disease related morbidity and mortality, a CDS system similar to the previous CV risk profile system should be developed and refined to support providers needs for clinical practice. The new CDS system will display risk factors, results of risk calculations with individualized recommendations for guideline-based patient care, addressing both CDS challenges as well as factors that have prevented clinical practice guidelines for cardiovascular disease risk prevention to be successfully implemented into practice. Based on the results of the survey conducted in this study, the CV risk profile system was easy for most providers use and supported their thought process in assessment of risk factors of cardiovascular diseases. This study also identified the ability to continue to refine the CV risk profile when implementing it into the new EHR, thus allowing for future system improvement.