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Tai-Seale M, Rosen R, Ruo B, Hogarth M, Longhurst CA, Lander L, Walker AL, Stults CD, Chan A, Mazor K, Garber L, Millen M. Implementation of Patient Engagement Tools in Electronic Health Records to Enhance Patient-Centered Communication: Protocol for Feasibility Evaluation and Preliminary Results. JMIR Res Protoc 2021; 10:e30431. [PMID: 34435960 PMCID: PMC8430844 DOI: 10.2196/30431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 01/16/2023] Open
Abstract
Background Patient–physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient–physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters. Objective In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient–physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters. Methods We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit “patient important issue” questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient–staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes. Results The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient–clinician communication, particularly during the COVID-19 pandemic. Conclusions EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians’ work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians. Trial Registration ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512 International Registered Report Identifier (IRRID) DERR1-10.2196/30431
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Affiliation(s)
- Ming Tai-Seale
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Rebecca Rosen
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Bernice Ruo
- Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Michael Hogarth
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Christopher A Longhurst
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, United States.,School of Medicine, Department of Pediatrics, University of California San Diego, La Jolla, CA, United States
| | - Lina Lander
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Amanda L Walker
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, United States.,Sutter Health Center for Health Systems Research, Palo Alto, CA, United States
| | - Albert Chan
- Sutter Health Center for Health Systems Research, Palo Alto, CA, United States.,Sutter Health Clinical Leadership Team, Sacramento, CA, United States.,Stanford Center for Biomedical Informatics Research, Stanford, CA, United States
| | - Kathleen Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States.,Meyers Primary Care Institute, University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, United States
| | - Lawrence Garber
- Meyers Primary Care Institute, University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, United States.,Reliant Medical Group, Worcester, MA, United States
| | - Marlene Millen
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, United States
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Barriers and facilitators influencing medication-related CDSS acceptance according to clinicians: A systematic review. Int J Med Inform 2021; 152:104506. [PMID: 34091146 DOI: 10.1016/j.ijmedinf.2021.104506] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/20/2021] [Accepted: 05/18/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND A medication-related Clinical Decision Support System (CDSS) is an application that analyzes patient data to provide assistance in medication-related care processes. Despite its potential to improve the clinical decision-making process, evidence shows that clinicians do not always use CDSSs in such a way that their potential can be fully realized. This systematic literature review provides an overview of frequently-reported barriers and facilitators for acceptance of medication-related CDSS. MATERIALS AND METHODS Search terms and MeSH headings were developed in collaboration with a librarian, and database searches were conducted in Medline, Scopus, Embase and Web of Science Conference Proceedings. After screening 5404 records and 140 full papers, 63 articles were included in this review. Quality assessment was performed for all 63 included articles. The identified barriers and facilitators are categorized within the Human, Organization, Technology fit (HOT-fit) model. RESULTS A total of 327 barriers and 291 facilitators were identified. Results show that factors most often reported were related to (a lack of) usefulness and relevance of information, and ease of use and efficiency of the system. DISCUSSION This review provides a valuable insight into a broad range of barriers and facilitators for using a medication-related CDSS as perceived by clinicians. The results can be used as a stepping stone in future studies developing medication-related CDSSs.
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Mogharbel A, Dowding D, Ainsworth J. Physicians' Use of the Computerized Physician Order Entry System for Medication Prescribing: Systematic Review. JMIR Med Inform 2021; 9:e22923. [PMID: 33661126 PMCID: PMC7974763 DOI: 10.2196/22923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/17/2020] [Accepted: 12/07/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Computerized physician order entry (CPOE) systems in health care settings have many benefits for prescribing medication, such as improved quality of patient care and patient safety. However, to achieve their full potential, the factors influencing the usage of CPOE systems by physicians must be identified and understood. OBJECTIVE The aim of this study is to identify the factors influencing the usage of CPOE systems by physicians for medication prescribing in their clinical practice. METHODS We conducted a systematic search of the literature on this topic using four databases: PubMed, CINAHL, Ovid MEDLINE, and Embase. Searches were performed from September 2019 to December 2019. The retrieved papers were screened by examining the titles and abstracts of relevant studies; two reviewers screened the full text of potentially relevant papers for inclusion in the review. Qualitative, quantitative, and mixed methods studies with the aim of conducting assessments or investigations of factors influencing the use of CPOE for medication prescribing among physicians were included. The identified factors were grouped based on constructs from two models: the unified theory of acceptance and use of technology model and the Delone and McLean Information System Success Model. We used the Mixed Method Appraisal Tool to assess the quality of the included studies and narrative synthesis to report the results. RESULTS A total of 11 articles were included in the review, and 37 factors related to the usage of CPOE systems were identified as the factors influencing how physicians used CPOE for medication prescribing. These factors represented three main themes: individual, technological, and organizational. CONCLUSIONS This study identified the common factors that influenced the usage of CPOE systems by physicians for medication prescribing regardless of the type of setting or the duration of the use of a system by participants. Our findings can be used to inform implementation and support the usage of the CPOE system by physicians.
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Affiliation(s)
- Asra Mogharbel
- Division of Informatics Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, Centre for Health Informatics, The University of Manchester, Manchester, United Kingdom
| | - Dawn Dowding
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - John Ainsworth
- Division of Informatics Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, Centre for Health Informatics, The University of Manchester, Manchester, United Kingdom
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Pilar MR, Proctor EK, Pineda JA. Development, implementation, and evaluation of a novel guideline engine for pediatric patients with severe traumatic brain injury: a study protocol. Implement Sci Commun 2020; 1:31. [PMID: 32885190 PMCID: PMC7427929 DOI: 10.1186/s43058-020-00012-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/13/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Severe traumatic brain injury (TBI) is a leading cause of death and disability for children. The Brain Trauma Foundation released evidence-based guidelines, a series of recommendations regarding care for pediatric patients with severe TBI. Clinical evidence suggests that adoption of guideline-based care improves outcomes in patients with severe TBI. However, guideline implementation has not been systematic or consistent in clinical practice. There is also a lack of information about implementation strategies that are effective given the nature of severe TBI care and the complex environment in the intensive care unit (ICU). Novel technology-based strategies may be uniquely suited to the fast-paced, transdisciplinary care delivered in the ICU, but such strategies must be carefully developed and evaluated to prevent unintended consequences within the system of care. This challenge presents a unique opportunity for intervention to more appropriately implement guideline-based care for pediatric patients with severe TBI. METHODS This mixed-method study will develop a novel technology-based bedside guideline engine (the implementation strategy) to facilitate uptake of evidence-based guidelines (the intervention) for management of severe TBI. Group model building and systems dynamics will inform the guideline engine design, and bedside functionality will be initially assessed through patient simulation. Using the Promoting Action on Research Implementation in Health Services (PARIHS) framework, we will determine the feasibility of incorporating the guideline engine in the ICU. Study participants will include pediatric patients with severe TBI and providers at three trauma centers. Quantitative data will include measures of guideline engine acceptance and organizational readiness for change. Qualitative data will include semi-structured interviews from clinicians. We will test the feasibility of incorporating the guideline engine in "real life practice" in preparation for a future clinical trial that will assess clinical and implementation outcomes, including feasibility, acceptability, and adoption of the guideline engine. DISCUSSION This study will lead to the development and feasibility testing of an adaptable strategy for implementing guideline-based care for severe TBI, a strategy that meets the needs of individual critical care environments and patients. A future study will test the adaptability and impact of the bedside guideline engine in a randomized clinical trial.
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Affiliation(s)
- Meagan R. Pilar
- Washington University in St. Louis, Brown School, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130 USA
| | - Enola K. Proctor
- Washington University in St. Louis, Brown School, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130 USA
| | - Jose A. Pineda
- Children’s Hospital Los Angeles/University of Southern California, Keck School of Medicine, 4650 Sunset Blvd, Los Angeles, CA 90027 USA
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Hardenbol AX, Knols B, Louws M, Meulendijk M, Askari M. Usability aspects of medication-related decision support systems in the outpatient setting: A systematic literature review. Health Informatics J 2018; 26:72-87. [DOI: 10.1177/1460458218813732] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this study, we evaluated the usability aspects of medication-related clinical decision support systems in the outpatient setting. Articles published between 2000 and 2016 in Scopus, PubMed and EMBASE were searched and classified into three usability aspects: Effectiveness, Efficiency and Satisfaction. Using Van Welie et al.’s usability model, we categorized usability aspects in terms of usage indicators and means. Out of the 1999 articles, 24 articles met the selection criteria of which the main focus was on reducing inappropriate medication, prescription rate and prescription errors. Evidence could mainly be found for Effectiveness and showed high rates of positive results in reducing medication errors. To date, the effects of Efficiency and Satisfaction of clinical decision support systems regarding medication prescription remain understudied. Usability aspects such as memorability, learnability, adaptability, shortcuts and consistency require more attention. Studies are needed for better insight into the user model and to design a knowledge/task model for clinical decision support systems regarding medication prescription.
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Winthereik AK, Neergaard MA, Jensen AB, Vedsted P. Development, modelling, and pilot testing of a complex intervention to support end-of-life care provided by Danish general practitioners. BMC FAMILY PRACTICE 2018; 19:91. [PMID: 29925332 PMCID: PMC6011239 DOI: 10.1186/s12875-018-0774-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 05/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most patients in end-of-life with life-threatening diseases prefer to be cared for and die at home. Nevertheless, the majority die in hospitals. GPs have a pivotal role in providing end-of-life care at patients' home, and their involvement in the palliative trajectory enhances the patient's possibility to stay at home. The aim of this study was to develop and pilot-test an intervention consisting of continuing medical education (CME) and electronic decision support (EDS) to support end-of-life care in general practice. METHODS We developed an intervention in line with the first phases of the guidelines for complex interventions drawn up by the Medical Research Council. Phase 1 involved the development of the intervention including identification of key barriers to provision of end-of-life care for GPs and of facilitators of change. Furthermore the actual modelling of two components: CME meeting and EDS. Phase 2 focused on pilot-testing and intervention assessment by process evaluation. RESULTS In phase 1 lack of identification of patients at the end of life and limited palliative knowledge among GPs were identified as barriers. The CME meeting and the EDS were developed. The CME meeting was a four-hour educational meeting performed by GPs and specialists in palliative care. The EDS consisted of two parts: a pop-up window for each patient with palliative needs and a list of all patients with palliative needs in the practice. The pilot testing in phase 2 showed that the CME meeting was performed as intended and 120 (14%) of the GPs in the region attended. The EDS was integrated in existing electronic records but was shut down early for external reasons; 50 (5%) GPs signed up. The pilot-testing demonstrated a need to strengthen the implementation as attending rate was low in the current set-up. CONCLUSION We developed a complex intervention to support GPs in providing end-of-life care. The pilot-test showed general acceptance of the CME meetings. The EDS was shut down early and needs further evaluation before examining the whole intervention in a larger study, where evaluation could be based on patient-related outcomes and impact on end-of-life care. TRIAL REGISTRATION Clinicaltrials.gov ( NCT02050256 ) January 30, 2014.
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Affiliation(s)
- Anna Kirstine Winthereik
- Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus C, Denmark.
- Department of Clinical Medicine, Aarhus University, Noerrebrogade 44, 8000, Aarhus C, Denmark.
| | - Mette Asbjoern Neergaard
- Palliative Care Team, Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus, Denmark
| | - Anders Bonde Jensen
- Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus C, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus, Denmark
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Handayani PW, Hidayanto AN, Budi I. User acceptance factors of hospital information systems and related technologies: Systematic review. Inform Health Soc Care 2017; 43:401-426. [PMID: 28829650 DOI: 10.1080/17538157.2017.1353999] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This study reviews the literature on the most important acceptance factors associated with Hospital Information Systems (HIS) and related technologies based on user groups' perspectives (medical staff, hospital management, administrative personnel, patient, medical student, and IT staff), which can assist researchers and hospital management to develop suitable acceptance models to improve the quality of HIS. We conducted searches in online databases with large repositories of academic studies, written in English and fully accessible by the authors. The articles being reviewed are related to health information technology (HIT), clinical information systems (CIS), HIS, electronic medical records (EMR), telemedicine or telehealth, picture archiving and communication systems (PACS), radio frequency identification (RFID), and computerized physician order entry (CPOE), where the use of most of those applications and technologies is highly integrated. A predefined string was used to extract 1,005 articles, and the results were reviewed and checked. The results of this study found 15 user acceptance factors related to HIS and related technologies that were frequently identified by a minimum of five previous studies. These factors were related to individual, technological, and organizational factors. In addition, HIS and related technologies' user acceptance factors in each user group describe different results.
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Affiliation(s)
- Putu Wuri Handayani
- a Faculty of Computer Science , Universitas Indonesia , West Java , Indonesia
| | | | - Indra Budi
- a Faculty of Computer Science , Universitas Indonesia , West Java , Indonesia
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Aziz MT, Ur-Rehman T, Qureshi S, Bukhari NI. Reduction in chemotherapy order errors with computerised physician order entry and clinical decision support systems. Health Inf Manag 2017; 44:13-22. [PMID: 26464298 DOI: 10.1177/183335831504400303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medication errors in chemotherapy are frequent and lead to patient morbidity and mortality, as well as increased rates of re-admission and length of stay, and considerable extra costs. Objective: This study investigated the proposition that computerised chemotherapy ordering reduces the incidence and severity of chemotherapy protocol errors. METHOD A computerised physician order entry of chemotherapy order (C-CO) with clinical decision support system was developed in-house, including standardised chemotherapy protocol definitions, automation of pharmacy distribution, clinical checks, labeling and invoicing. A prospective study was then conducted in a C-CO versus paper based chemotherapy order (P-CO) in a 30-bed chemotherapy bay of a tertiary hospital. Both C-CO and P-CO orders, including pharmacoeconomic analysis and the severity of medication errors, were checked and validated by a clinical pharmacist. A group analysis and field trial were also conducted to assess clarity, feasibility and decision making. RESULTS AND CONCLUSION The C-CO was very usable in terms of its clarity and feasibility. The incidence of medication errors was significantly lower in the C-CO compared with the P-CO (10/3765 [0.26%] versus 134/5514 [2.4%]). There was also a reduction in dispensing time of chemotherapy protocols in the C-CO. The chemotherapy computerisation with clinical decision support system resulted in a significant decrease in the occurrence and severity of medication errors, improvements in chemotherapy dispensing and administration times, and reduction of chemotherapy cost.
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Affiliation(s)
| | - Tofeeq Ur-Rehman
- Department of Pharmacy Quaid-i-Azam University, Islamabad, Pakistan
| | - Sadia Qureshi
- Department of Biochemistry FMH College of Medicine and Dentistry, Lahore, Pakistan
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Egan BM, Li J, Fleming DO, White K, Connell K, Davis RA, Sinopoli A. Impact of Implementing the 2013 ACC/AHA Cholesterol Guidelines on Vascular Events in a Statewide Community-Based Practice Registry. J Clin Hypertens (Greenwich) 2015; 18:663-71. [PMID: 26606899 DOI: 10.1111/jch.12727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 07/24/2015] [Accepted: 07/26/2015] [Indexed: 11/28/2022]
Abstract
Electronic health record data were analyzed to estimate the number of statin-eligible adults with the 2013 American College of Cardiology/American Heart Association cholesterol guidelines not taking statin therapy and the impact of recommended statin therapy on 10-year atherosclerotic cardiovascular disease (ASCVD10 ) events. Adults aged 21 to 80 years in an outpatient network with ≥1 clinic visit(s) from January 2011 to June 2014 with data to calculate ASCVD10 were eligible. Moderate-intensity statin therapy was assumed to lower low-density lipoprotein cholesterol by 30% and high-intensity therapy was assumed to reduce low-density lipoprotein cholesterol by 50%. ASCVD events were assumed to decline 22% for each 39 mg/dL decline in low-density lipoprotein cholesterol. Among 411,768 adults, 260,434 (63.2%) were not taking statins and 103,478 (39.7%) were eligible for a statin, including 79,069 (76.4%) patients with hypertension. Estimated ASCVD10 events were 18,781 without and 13,328 with statin therapy, a 29.0% relative and 5.3% absolute risk reduction with a number needed to treat of 19. The 2013 cholesterol guidelines are a relatively efficient approach to reducing ASCVD in untreated, statin-eligible adults who often have concomitant hypertension.
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Affiliation(s)
- Brent M Egan
- Greenville Health System, Care Coordination Institute, University of South Carolina School of Medicine-Greenville, Greenville, SC.,Department of Medicine, University of South Carolina School of Medicine-Greenville, Greenville, SC
| | - Jiexiang Li
- Department of Mathematics, College of Charleston, Charleston, SC
| | - Douglas O Fleming
- Greenville Health System, Care Coordination Institute, University of South Carolina School of Medicine-Greenville, Greenville, SC
| | - Kellee White
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Kenneth Connell
- Faculty of Medical Sciences, The University of the West Indies Cave Hill Campus, St. Michael, Barbados
| | - Robert A Davis
- Greenville Health System, Care Coordination Institute, University of South Carolina School of Medicine-Greenville, Greenville, SC
| | - Angelo Sinopoli
- Greenville Health System, Care Coordination Institute, University of South Carolina School of Medicine-Greenville, Greenville, SC.,Department of Medicine, University of South Carolina School of Medicine-Greenville, Greenville, SC
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Lugtenberg M, Pasveer D, van der Weijden T, Westert GP, Kool RB. Exposure to and experiences with a computerized decision support intervention in primary care: results from a process evaluation. BMC FAMILY PRACTICE 2015; 16:141. [PMID: 26474603 PMCID: PMC4608282 DOI: 10.1186/s12875-015-0364-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 10/08/2015] [Indexed: 01/22/2023]
Abstract
Background Trials evaluating the effects of interventions usually provide little insight into the factors responsible for (lack of) changes in desired outcomes. A process evaluation alongside a trial can shed light on the mechanisms responsible for the outcomes of a trial. The aim of this study was to investigate exposure to and experiences with a computerized decision support system (CDSS) intervention, in order to gain insight into the intervention’s impact and to provide suggestions for improvement. Methods A process evaluation was conducted as part of a large-scale cluster-randomized controlled trial investigating the effects of the CDSS NHGDoc on quality of care. Data on exposure to and experiences with the intervention were collected during the trial period among participants in both the intervention and control group - whenever applicable - by means of the NHGDoc server and an electronic questionnaire. Multiple data were analyzed using descriptive statistics. Results Ninety-nine percent (n = 229) of the included practices generated data for the NHGDoc server and 50 % (n = 116) responded to the questionnaire: both general practitioners (GPs; n = 112; 49 %) and practice nurses (PNs; n = 52; 37 %) participated. The actual exposure to the NHGDoc system and specific heart failure module was limited with 52 % of the GPs and 42 % of the PNs reporting to either never or rarely use the system. Overall, users had a positive attitude towards CDSSs. The most perceived barriers to using NHGDoc were a lack of learning capacity of the system, the additional time and work it requires to use the CDSS, irrelevant alerts, too high intensity of alerts and insufficient knowledge regarding the system. Conclusions Several types of barriers may have negatively affected the impact of the intervention. Although users are generally positive about CDSSs, a large share of them is insufficiently aware of the functions of NHGDoc and, finds the decision support not always useful or relevant and difficult to integrate into daily practice. In designing CDSS interventions we suggest to more intensely involve the end-users and increase the system’s flexibility and learning capacity. To improve implementation a proper introduction of a CDSS among its target group including adequate training is advocated. Trial registration Clinical trials NCT01773057. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0364-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marjolein Lugtenberg
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. .,Scientific Center for Care and Welfare (Tranzo), Tilburg School of Social and Behavioral Sciences, Tilburg University, P.O. Box 90153, 5000 LE, Tilburg, The Netherlands.
| | - Dennis Pasveer
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Trudy van der Weijden
- School for Public Health and Primary Care (CAPHRI), Department of General Practice, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Gert P Westert
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Rudolf B Kool
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Lugtenberg M, Weenink JW, van der Weijden T, Westert GP, Kool RB. Implementation of multiple-domain covering computerized decision support systems in primary care: a focus group study on perceived barriers. BMC Med Inform Decis Mak 2015; 15:82. [PMID: 26459233 PMCID: PMC4603732 DOI: 10.1186/s12911-015-0205-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 09/29/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the widespread availability of computerized decision support systems (CDSSs) in various healthcare settings, evidence on their uptake and effectiveness is still limited. Most barrier studies focus on CDSSs that are aimed at a limited number of decision points within selected small-scale academic settings. The aim of this study was to identify the perceived barriers to using large-scale implemented CDSSs covering multiple disease areas in primary care. METHODS Three focus group sessions were conducted in which 24 primary care practitioners (PCPs) participated (general practitioners, general practitioners in training and practice nurses), varying from 7 to 9 per session. In each focus group, barriers to using CDSSs were discussed using a semi-structured literature-based topic list. Focus group discussions were audio-taped and transcribed verbatim. Two researchers independently performed thematic content analysis using the software program Atlas.ti 7.0. RESULTS Three groups of barriers emerged, related to 1) the users' knowledge of the system, 2) the users' evaluation of features of the system (source and content, format/lay out, and functionality), and 3) the interaction of the system with external factors (patient-related and environmental factors). Commonly perceived barriers were insufficient knowledge of the CDSS, irrelevant alerts, too high intensity of alerts, a lack of flexibility and learning capacity of the CDSS, a negative effect on patient communication, and the additional time and work it requires to use the CDSS. CONCLUSIONS Multiple types of barriers may hinder the use of large-scale implemented CDSSs covering multiple disease areas in primary care. Lack of knowledge of the system is an important barrier, emphasizing the importance of a proper introduction of the system to the target group. Furthermore, barriers related to a lack of integration into daily practice seem to be of primary concern, suggesting that increasing the system's flexibility and learning capacity in order to be able to adapt the decision support to meet the varying needs of different users should be the main target of CDSS interventions.
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Affiliation(s)
- Marjolein Lugtenberg
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. .,Scientific center for care and welfare (Tranzo), Tilburg School of Social and Behavioral Sciences, Tilburg University, P.O. Box 90153, 5000 LE, Tilburg, The Netherlands.
| | - Jan-Willem Weenink
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Trudy van der Weijden
- School for Public Health and Primary Care (CAPHRI), Department of General Practice, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Gert P Westert
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Rudolf B Kool
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Fathima M, Peiris D, Naik-Panvelkar P, Saini B, Armour CL. Effectiveness of computerized clinical decision support systems for asthma and chronic obstructive pulmonary disease in primary care: a systematic review. BMC Pulm Med 2014; 14:189. [PMID: 25439006 PMCID: PMC4265443 DOI: 10.1186/1471-2466-14-189] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 11/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of computerized clinical decision support systems may improve the diagnosis and ongoing management of chronic diseases, which requires recurrent visits to multiple health professionals, disease and medication monitoring and modification of patient behavior. The aim of this review was to systematically review randomized controlled trials evaluating the effectiveness of computerized clinical decision systems (CCDSS) in the care of people with asthma and COPD. METHODS Randomized controlled trials published between 2003 and 2013 were searched using multiple electronic databases Medline, EMBASE, CINAHL, IPA, Informit, PsychINFO, Compendex, and Cochrane Clinical Controlled Trials Register databases. To be included, RCTs had to evaluate the role of the CCDSSs for asthma and/or COPD in primary care. RESULTS Nineteen studies representing 16 RCTs met our inclusion criteria. The majority of the trials were conducted in patients with asthma. Study quality was generally high. Meta-analysis was not conducted because of methodological and clinical heterogeneity. The use of CCDSS improved asthma and COPD care in 14 of the 19 studies reviewed (74%). Nine of the nineteen studies showed statistically significant (p < 0.05) improvement in the primary outcomes measured. The majority of the studies evaluated health care process measures as their primary outcomes (10/19). CONCLUSION Evidence supports the effectiveness of CCDSS in the care of people with asthma. However there is very little information of its use in COPD care. Although there is considerable improvement in the health care process measures and clinical outcomes through the use of CCDSSs, its effects on user workload and efficiency, safety, costs of care, provider and patient satisfaction remain understudied.
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Affiliation(s)
- Mariam Fathima
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
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13
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Ahmed S, Tamblyn R, Winslade N. Using decision support for population tracking of adherence to recommended asthma guidelines. BMJ Open 2014; 4:e003759. [PMID: 24595132 PMCID: PMC3948455 DOI: 10.1136/bmjopen-2013-003759] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 12/23/2013] [Accepted: 01/10/2014] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Decision support systems linked to administrative databases provide a unique opportunity to monitor adherence to guidelines and target disease management strategies towards patients not receiving guideline-based therapy. The objective of this study was to evaluate the discrepancy between actual asthma treatments prescribed by primary care physicians compared to those recommended by evidence-based guidelines using a decision support tool linked to a provincial health administrative database. DESIGN The drug and medical services information of individuals with asthma was identified from the provincial health database and was pushed through an asthma decision support system (ADSS). Recommendations aimed at optimising asthma treatment were generated on two index dates, 15 September 2007 (index date 1) and 15 March 2008 (index date 2). SETTING Primary care settings in a large Canadian metropolitan area. PARTICIPANTS Individuals with asthma and provincial health insurance primary and secondary outcome measures: well controlled asthma. RESULTS 16 803 eligible individuals were identified on index date 1, and 18 103 on index date 2. The distribution of recommendation categories was similar on both index dates. 94% were classified as well controlled and 7% as not well controlled. Among well-controlled individuals, the largest proportion was in the maintain treatment category (63.8%), followed by the maintain/decrease treatment category (28.2%) and the decrease treatment category (2.7%). Almost all individuals who were not well controlled had the recommendation to increase treatment (88%) with a small proportion in the refer category (1%). CONCLUSIONS The ADSS was able to identify subgroups of patients from an administrative database that could benefit from a medication review and possible change. Decision support systems linked to an administrative database can be used to identify individuals with uncontrolled asthma or prescriptions that deviate from recommended treatment. When connected to the point of care, this can provide an opportunity for physicians to intervene early.
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Affiliation(s)
- Sara Ahmed
- Faculty of Medicine, School of Physical and Occupational Therapy, McGill University 3654 Prom. Sir William Osler, Montreal, Quebec, Canada
- McGill University Health Center, Clinical Epidemiology, Montreal, Quebec, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain, Montreal, Quebec, Canada
- Faculty of Medicine, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Robyn Tamblyn
- McGill University Health Center, Clinical Epidemiology, Montreal, Quebec, Canada
- Faculty of Medicine, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
- Faculty of Medicine, Clinical and Health Informatics, McGill University, Montreal, Quebec, Canada
| | - Nancy Winslade
- McGill University Health Center, Clinical Epidemiology, Montreal, Quebec, Canada
- Faculty of Medicine, Clinical and Health Informatics, McGill University, Montreal, Quebec, Canada
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14
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Kortteisto T, Raitanen J, Komulainen J, Kunnamo I, Mäkelä M, Rissanen P, Kaila M. Patient-specific computer-based decision support in primary healthcare--a randomized trial. Implement Sci 2014; 9:15. [PMID: 24444113 PMCID: PMC3901002 DOI: 10.1186/1748-5908-9-15] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 01/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Computer-based decision support systems are a promising method for incorporating research evidence into clinical practice. However, evidence is still scant on how such information technology solutions work in primary healthcare when support is provided across many health problems. In Finland, we designed a trial where a set of evidence-based, patient-specific reminders was introduced into the local Electronic Patient Record (EPR) system. The aim was to measure the effects of such reminders on patient care. The hypothesis was that the total number of triggered reminders would decrease in the intervention group compared with the control group, indicating an improvement in patient care. METHODS From July 2009 to October 2010 all the patients of one health center were randomized to an intervention or a control group. The intervention consisted of patient-specific reminders concerning 59 different health conditions triggered when the healthcare professional (HCP) opened and used the EPR. In the intervention group, the triggered reminders were shown to the HCP; in the control group, the triggered reminders were not shown. The primary outcome measure was the change in the number of reminders triggered over 12 months. We developed a unique data gathering method, the Repeated Study Virtual Health Check (RSVHC), and used Generalized Estimation Equations (GEE) for analysing the incidence rate ratio, which is a measure of the relative difference in percentage change in the numbers of reminders triggered in the intervention group and the control group. RESULTS In total, 13,588 participants were randomized and included. Contrary to our expectation, the total number of reminders triggered increased in both the intervention and the control groups. The primary outcome measure did not show a significant difference between the groups. However, with the inclusion of patients followed up over only six months, the total number of reminders increased significantly less in the intervention group than in the control group when the confounding factors (age, gender, number of diagnoses and medications) were controlled for. CONCLUSIONS Computerized, tailored reminders in primary care did not decrease during the 12 months of follow-up time after the introduction of a patient-specific decision support system. TRIAL REGISTRATION ClinicalTrial.gov NCT00915304.
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Affiliation(s)
- Tiina Kortteisto
- School of Health Sciences, University of Tampere, Tampere, Finland.
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15
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Devine EB, Williams EC, Martin DP, Sittig DF, Tarczy-Hornoch P, Payne TH, Sullivan SD. Prescriber and staff perceptions of an electronic prescribing system in primary care: a qualitative assessment. BMC Med Inform Decis Mak 2010; 10:72. [PMID: 21087524 PMCID: PMC2996338 DOI: 10.1186/1472-6947-10-72] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 11/19/2010] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The United States (US) Health Information Technology for Economic and Clinical Health Act of 2009 has spurred adoption of electronic health records. The corresponding meaningful use criteria proposed by the Centers for Medicare and Medicaid Services mandates use of computerized provider order entry (CPOE) systems. Yet, adoption in the US and other Western countries is low and descriptions of successful implementations are primarily from the inpatient setting; less frequently the ambulatory setting. We describe prescriber and staff perceptions of implementation of a CPOE system for medications (electronic- or e-prescribing system) in the ambulatory setting. METHODS Using a cross-sectional study design, we conducted eight focus groups at three primary care sites in an independent medical group. Each site represented a unique stage of e-prescribing implementation - pre/transition/post. We used a theoretically based, semi-structured questionnaire to elicit physician (n = 17) and staff (n = 53) perceptions of implementation of the e-prescribing system. We conducted a thematic analysis of focus group discussions using formal qualitative analytic techniques (i.e. deductive framework and grounded theory). Two coders independently coded to theoretical saturation and resolved discrepancies through discussions. RESULTS Ten themes emerged that describe perceptions of e-prescribing implementation: 1) improved availability of clinical information resulted in prescribing efficiencies and more coordinated care; 2) improved documentation resulted in safer care; 3) efficiencies were gained by using fewer paper charts; 4) organizational support facilitated adoption; 5) transition required time; resulted in workload shift to staff; 6) hardware configurations and network stability were important in facilitating workflow; 7) e-prescribing was time-neutral or time-saving; 8) changes in patient interactions enhanced patient care but required education; 9) pharmacy communications were enhanced but required education; 10) positive attitudes facilitated adoption. CONCLUSIONS Prescribers and staff worked through the transition to successfully adopt e-prescribing, and noted the benefits. Overall impressions were favorable. No one wished to return to paper-based prescribing.
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Affiliation(s)
- Emily Beth Devine
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Box 357630, Seattle, WA 98195-7630, USA
- Department of Medical Education and Biomedical Informatics, University of Washington, Box 357240, Seattle, WA 98195-7240, USA
| | - Emily C Williams
- Health Services Research & Development, Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA
- Department of Health Services, University of Washington, Box 357660, Seattle, WA 98195-7660, USA
| | - Diane P Martin
- Department of Health Services, University of Washington, Box 357660, Seattle, WA 98195-7660, USA
| | - Dean F Sittig
- School of Health Information Sciences, University of Texas, Houston, UT-Memorial Hermann Center for Healthcare Quality & Safety, 6410 Fannin Street, Houston, TX 77030, USA
| | - Peter Tarczy-Hornoch
- Department of Medical Education and Biomedical Informatics, University of Washington, Box 357240, Seattle, WA 98195-7240, USA
| | - Thomas H Payne
- Department of Medicine, University of Washington, Box 359968, Seattle, WA 98195-9968, USA
| | - Sean D Sullivan
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Box 357630, Seattle, WA 98195-7630, USA
- Department of Health Services, University of Washington, Box 357660, Seattle, WA 98195-7660, USA
- Department of Medicine, University of Washington, Box 359968, Seattle, WA 98195-9968, USA
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Moxey A, Robertson J, Newby D, Hains I, Williamson M, Pearson SA. Computerized clinical decision support for prescribing: provision does not guarantee uptake. J Am Med Inform Assoc 2010; 17:25-33. [PMID: 20064798 PMCID: PMC2995634 DOI: 10.1197/jamia.m3170] [Citation(s) in RCA: 177] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 09/23/2009] [Indexed: 11/10/2022] Open
Abstract
There is wide variability in the use and adoption of recommendations generated by computerized clinical decision support systems (CDSSs) despite the benefits they may bring to clinical practice. We conducted a systematic review to explore the barriers to, and facilitators of, CDSS uptake by physicians to guide prescribing decisions. We identified 58 studies by searching electronic databases (1990-2007). Factors impacting on CDSS use included: the availability of hardware, technical support and training; integration of the system into workflows; and the relevance and timeliness of the clinical messages. Further, systems that were endorsed by colleagues, minimized perceived threats to professional autonomy, and did not compromise doctor-patient interactions were accepted by users. Despite advances in technology and CDSS sophistication, most factors were consistently reported over time and across ambulatory and institutional settings. Such factors must be addressed when deploying CDSSs so that improvements in uptake, practice and patient outcomes may be achieved.
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Affiliation(s)
- Annette Moxey
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Australia
| | - Jane Robertson
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Australia
| | - David Newby
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Australia
| | - Isla Hains
- UNSW Cancer Research Centre, University of New South Wales, Sydney, Australia
| | | | - Sallie-Anne Pearson
- UNSW Cancer Research Centre, University of New South Wales, Sydney, Australia
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Heselmans A, Van de Velde S, Donceel P, Aertgeerts B, Ramaekers D. Effectiveness of electronic guideline-based implementation systems in ambulatory care settings - a systematic review. Implement Sci 2009; 4:82. [PMID: 20042070 PMCID: PMC2806389 DOI: 10.1186/1748-5908-4-82] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 12/30/2009] [Indexed: 11/21/2022] Open
Abstract
Background Electronic guideline-based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines. A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services. Methods A systematic literature search (1990 to December 2008) of the English literature indexed in the Medline database, Embase, the Cochrane Central Register of Controlled Trials, and CRD (DARE, HTA and NHS EED databases) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care settings. Important inclusion criterions were the multidimensionality of the guideline (the guideline needed to consist of several aspects or steps) and real-time interaction with the system during consultation. Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier reviews were excluded. Two comparisons were considered: electronic multidimensional guidelines versus usual care (comparison one) and electronic multidimensional guidelines versus other guideline implementation methods (comparison two). Results Twenty-seven publications were selected for analysis in this systematic review. Most designs were cluster randomized controlled trials investigating process outcomes more than patient outcomes. With success defined as at least 50% of the outcome variables being significant, none of the studies were successful in improving patient outcomes. Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group (comparison one). No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found, neither for the patient outcomes nor for the process outcomes (comparison two). Conclusions There is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines. After more than a decade of development of numerous electronic systems, research on the most effective implementation strategy for this kind of guideline-based decision support systems is still lacking. This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care.
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Affiliation(s)
- Annemie Heselmans
- School of Public Health, Katholieke Universiteit Leuven, Kapucijnenvoer 35 blok d, 3000 Leuven, Belgium.
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