Brownbridge G et al. 1986 "An interactive computerized protocol for the management of hypertension: effects on the general-practitioner's clinical behavior."

Reference
Brownbridge G, Evans A, Fitter M, et al. An interactive computerized protocol for the management of hypertension: effects on the general-practitioner's clinical behavior. J R Coll Gen Pract 1986;36(286):198-202.
Abstract
"This paper reports an experimental study of general practitioners' use of an interactive computerized protocol for the management of hypertension, focusing particularly on the protocol's effects on doctors' clinical behavior. Prior to its computerization a paper-based version of the protocol was used enabling a comparison of the alternative forms. Doctors' delivery of care was assessed from video recordings of 89 consultations and from the records made during these consultations. Comparisons were made of consultations conducted under control and experimental conditions. Use of paper and computer protocols resulted in significant improvements in the doctors' delivery of care, in terms of the range of verbal and physical examinations conducted and recorded. The protocol's effects were most marked when the computerized version was used. However, use of the computer protocol resulted in the recording of information on the non-occurrence of certain events which had not been explicitly elicited during the verbal examination; features of the design which were intended to encourage adherence to the protocol resulted in the recording of unsubstantiated information. It is concluded that the detail of the verbal examination suggested by the protocol may have been inappropriate to the realities of a general practice consultation. The findings provide some useful insights for the design of future computerized protocols for the management of chronic conditions."
Objective

To report "an experimental study of general practitioners' use of an interactive computerized protocol for the management of hypertension, focussing particularly on the protocol's effects on doctors' clinical behaviour."

Tools Used
Type Clinic
Primary care
Size
Small and/or medium
Geography
Urban
Other Information
The control practice had four doctors and approximately 8,000 registered patients. The experimental practice had seven doctors and approximately 20,000 patients.
Type of Health IT
Decision support system
Type of Health IT Functions
In the course of the consultation, the computer protocol presented four screens to the physician. The first screen showed details of when the patient was asked to come in, whether the patient came in on time, and if there was a reason for bringing the patient in (high blood pressure readings, recommended tests). The doctor was prompted to ask the patient whether any new events had occurred since the last appointment (myocardial infarction, angina, intermittent claudication, cerebral ischaemia, vertigo, gout, other). The second screen listed up to nine physical examinations that should be performed. The third screen graphically displayed the last six recorded blood pressures and the doctor was asked if the blood pressures were outside the target. The fourth screen provided recommendations for tests, review of therapy, referrals, and scheduling new appointments.
Workflow-Related Findings
"The mean number of specific questions on events included in the protocol clearly increased with protocol use."
When the physician was using the protocol, the patients also provided more information about protocol events.
Physicians in the experimental condition asked significantly fewer questions that were not on the protocol.
When using the computer protocol, physicians recorded the non-occurrence of protocol events in the patient chart even when they did not ask about those events in the consultation. For example, the physician may have recorded that the patient did not have a stroke without asking the patient whether he had one.
"The percentage of consultations in which the doctors asked a general health question was not affected by use of the protocol."
More information on protocol-related examinations was recorded in the patient chart at the experimental site after implementation.
Using the paper or computer protocols increased consultation length by 35 percent.
Study Design
Pre-postintervention (no control group)
Study Participants
Study participants were from two practices in Sheffield, England. Three of the participating physicians worked in both practices.