Coronary artery disease (CAD) is the leading cause of death in the United States, and guidelines for the prevention of CAD are well established and of proven benefit. Nevertheless, there remains a wide gap between these guidelines and actual clinical practice. The long-term objective of Dr. Schnipper, an Instructor at Harvard Medical School, is to improve the provision of cardiac preventive services. Dr. Schnipper spent most of his fellowship in general internal medicine studying the patient, physician, and system factors that lead to sub-optimal cardiac preventive care. He joined the faculty of the General Medicine Division at Brigham and Women's Hospital because of their experience developing and testing information systems to improve quality of clinical care and to work with his mentor, Dr. David Bates. This research project has four specific aims: 1) To develop a decision support tool, integrated into an electronic medical record (EMR), designed to improve the primary and secondary prevention of coronary artery disease. 2) To develop an EMR-based case management system to improve the secondary prevention of CAD. 3) To determine the effectiveness and cost-effectiveness of EMR-based clinical decision support and case management on the implementation of cardiac preventive services. 4) To identify and address patient, clinician, and system barriers to the effective use of computer-based quality improvement strategies in a variety of outpatient practice settings. The early phases of this project will consist of physician focus groups, questionnaires, and iterative development and testing of these interventions. Later, a series of three controlled trials, randomized by practice site, will compare usual care to decision support and decision support plus case management. Dr. Schnipper will be aided in this endeavor by an advisory committee of senior faculty with varied expertise. This research will lead to better ways to implement cardiac prevention. The experience gained by conducting this research, coupled with additional course work and mentoring in informatics, process improvement, and trial design, will ensure Dr. Schnipper's development as an independent researcher in improving the quality of care of patients with CAD.
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