McDonald CJ et al. 1984 "Reminders to physicians from an introspective computer medical record."

McDonald CJ, Hui SL, Smith DM, et al. Reminders to physicians from an introspective computer medical record. Ann Intern Med 1984;100(1):130-138.
"We developed a computer-stored medical record system containing a limited set of the total clinical database - primarily diagnostic studies and treatments. This system responds to its own content according to physician-authored reminder rules. To determine the effect of the reminder messages generated by 1490 rules on physician behavior, we randomly assigned practitioners in a general medicine clinic to study or control groups. The computer found indications for six different actions per patient in 12,467 patients during a 2-year study: 61 study group residents who received computer reminders responded to 49% of these indications; 54 control group residents, to only 29% (p < 0.0001). Preventive care (occult blood testing, mammographic screening, weight reduction diets, influenza and pneumococcal vaccines) was affected. The intentions of the study group to use a given action for an indications predicted their response to the indications (p < 0.03, r-squared = 0.33). The intentions of the control residents did not."
"To determine the effect of [a] reminder system on physician's use of individual clinical actions, to identify and explain the variability in the response rate of physicians to indications for these actions, and to find improvements in patient outcomes that may result from the computer reminders."
Type Clinic
Primary care
Other Information
The study took place at the general medicine clinic of Wishard Memorial Hospital located in Indianapolis, Indiana.
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
The system consists of rule-based computerized clinical reminders. The day before a patient's visit, the computer system would review the patient's electronic medical record (EMR) using the clinical reminder rules. The system would store any matching conditions it found on a disk and then print out a report that would be attached to the patient's paper chart. A total of 751 different reminder messages could be generated on topics related to preventive care (e.g., mammography), "obtaining tests needed to complete the initial data base or identify the cause of existing abnormalities," prophylactic treatment (e.g., using beta blockers after myocardial infarction), and treatment of active problems (e.g., congestive heart failure).
Context or other IT in place
An electronic health record system (EHR), which "include[d] most of the patient's diagnostic studies, treatments, discharge and visit diagnoses and clinic vital signs and test orders," was already in place.
Workflow-Related Findings
Gaps in the patient's electronic records, due to insufficient information about patient's history and/or lab results that were unavailable or delayed, could account for 29 percent of nonresponse to computer reminders.
In response to a group of less-common reminders, physicians were significantly more likely to order certain tests (such as "urine cultures for pyurea") and order certain medications (such as "metronidazole to treat trichomonas").
"Half of the physicians' nonresponse to [cervical smear] reminders were appropriate responses to a false-positive reminder message."
"Residents in study groups were two to four times more likely to apply preventive care to their eligible patients than were control group physicians."
Study Design
Randomized controlled trial (RCT)
Study Participants
The study participants included 115 residents, 11 faculty members, and four nurse-clinicians.