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Int J Qual Health Care. 2017 Feb 1;29(1):117-123. doi: 10.1093/intqhc/mzw129.

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

Vandenberg AE1,2,3, Vaughan CP1,2,3, Stevens M1,2,3, Hastings SN4,5, Powers J6,7, Markland A1,2,8, Hwang U9,10, Hung W9,11, Echt KV1,2,3.

Author information

Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.
Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.
Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA.
Durham VA GRECC and HSR&D Center, Durham VA Medical Centre, 508 Fulton St, Durham, NC 27705, USA.
Center for the Study of Aging and Department of Medicine, Duke University Medical Center 3710, Durham, NC 27710, USA.
Tennessee Valley VA GRECC, Tennessee Valley Healthcare System, 1310 24th Avenue S, Nashville, TN 37212-2637, USA.
Division of Geriatrics, Department of Medicine, Vanderbilt University School of Medicine, 7159 Vanderbilt Medical Center East, Nashville, TN 37232, USA.
Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294, USA.
James J Peters VA Medical Center GRECC, 130 West Kingsbridge Road, GRECC, 4A-17, Bronx, NY 10468, USA.
Departments of Emergency Medicine and Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, New York, NY 10029, USA.
Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, New York, NY 10029, USA.


Quality problem or issue:

Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers.

Initial assessment:

Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns.

Choice of solution:

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'.

Lessons learned:

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.


appropriateness; elderly < specific populations; emergency care < setting of care; qualitative methods < general methodology; quality improvement < quality management; under-use and over-use < appropriate healthcare

[Indexed for MEDLINE]

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