Litzelman DK et al. 1993 "Requiring physicians to respond to computerized reminders improves their compliance with preventative care protocols."

Litzelman DK, Dittus RS, Miller ME, et al. Requiring physicians to respond to computerized reminders improves their compliance with preventative care protocols. J Gen Intern Med 1993;8(6):311-317.
"Objective: To improve compliance with computer-generated reminders to perform fecal occult blood testing (FOBT), mammography, and cervical Papanicolaou (Pap) testing.
Design: Six-month prospective, randomized, controlled trial.
Setting: Academic primary care general internal medicine practice.
Subjects: Thirty-one general internal medicine faculty, 145 residents, and 5,407 patients with scheduled visits who were eligible for any of the three cancer screening protocols.
Intervention: Primary care teams of internal medicine residents and faculty received either routine computer reminders (control) or the same reminders to which they were required to circle one of four responses: 1) "done/order today," 2) "not applicable to this patient," 3) "patient refused," or 4) "next visit."
Results: Intervention physicians complied more frequently than control physicians with all reminders combined (46% vs 38%, respectively, p = 0.002) and separately with reminders for FOBT (61% vs 49%, p = 0.0007) and mammography (54% vs 47%, p = 0.036) but not cervical Pap testing (21% vs 18%, p = 0.2). Intervention residents responded significantly more often than control residents to all reminders together and separately to reminders for FOBT and mammography but not Pap testing. There was no significant difference between intervention and control faculty, but the compliance rate for control faculty was significantly higher than the rate for control residents for all reminders together and separately for FOBT but not mammography or Pap testing. The intervention's effect was greatest for patients >= 70 years old, with significant results for all tests, together and singly, for residents but not faculty. Intervention physicians felt that the reminders were not applicable 21% of the time (due to inadequate data in patients' electronic medical records) and stated that their patients refused 10% of the time.
Conclusions: Requiring physicians to respond to computer-generated reminders improved their compliance with preventive care protocols, especially for elderly patients for whom control physicians' compliance was the lowest. However, 100% compliance with cancer screening reminders will be unattainable due to incomplete data and patient refusal."
"To improve compliance with computer-generated reminders to perform fecal occult blood testing (FOBT), mammography, and cervical Papanicolaou (Pap) testing."
Type Clinic
Primary care
Type Specific
Internal medicine
Other Information
The study site was the general medicine practice of the Regenstrief Health Center in Indianapolis, Indiana.
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
The intervention was a "computerized reminder system containing more than 1400 physician-authorized rules to review information stored in patients' electronic records" and "[print] indicated tests in the orders section of each patient's outpatient encounter form...A separate reminder report gave more patient-specific information for each reminder and explained the rule that generated it." The system presents preventative care test results to physicians, provides a set of responses for the physicians to select as an explanation for "why targeted procedures were not done or ordered, requir[es] that physicians select one of these explanations when they do not comply with a reminder and provid[es] discrete areas where physicians could update patient data to increase the accuracy of the processed information."
Context or other IT in place
An electronic medical record (EMR) system was already in place.
Workflow-Related Findings
"Intervention physicians recorded corrections or deletions to their patients' electronic database in the specified area of the preventive care sheet in 14% of cases compared with the control physicians, who recorded corrections/additions in the orders section in fewer than 1% of the encounter forms."
Some incomplete patient electronic medical records led to inappropriate screening reminders. "Review of information provided on completed prevention-care sheets showed that 96% of the time where the physician stated that the test was inappropriate, the test was indeed not indicated."
The authors "were able to significantly improve [their] resident physicians' compliance with computer-generated preventive care reminders by requiring them to acknowledge the reminder by circling one of four clinically meaningful responses. This simple intervention requires little additional work by residents but encourages physicians to think about the standard of care for the practice and commit to an action unless there is some justifiable contraindication."
One of the primary reasons given for provider noncompliance with appropriate reminders was physicians' lack of time.
"Overall, intervention physicians complied with target reminders 19% more often than did control physicians (46 vs 38%, p=0.002). Significant differences favoring intervention physicians were found separately for FOBT and mammography," but not for Pap tests.
"When residents were analyzed separately, intervention residents were significantly more compliant than control residents with all reminders combined and separately for FOBT and mammography but not Pap testing."
"Intervention-control differences were greater for [patients who were aged 70 or older] than for patients <70 years old ... These effects were almost entirely due to differences between intervention and control residents."
"The finding that the intervention had no effect on Pap testing is consistent with studies that demonstrate more power to improve physician compliance with protocols that involve ordering a test rather than performing a maneuver ... Obtaining a Pap smear requires many minutes by the physician and consent and cooperation by the patient."
Study Design
Randomized controlled trial (RCT)
Study Participants
The study participants included 31 general internal medicine faculty, 145 residents, and 5,047 patients.