Mitchell E et al. 2001 "A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97."

Reference
Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97. Br Med J 2001;322(7281):279-282E.
Abstract
"Objectives: To appraise findings from studies examining the impact of computers on primary care consultations.
Design: Systematic review of world literature from 1980 to 1997.
Data sources: 5475 references were identified from electronic databases (Medline, Science Citation Index, Social Sciences Citation Index, Index of Scientific and Technical Proceedings, Embase, OCLC FirstSearch Proceedings), bibliographies, books, indentified articles, and by authors active in the field. 1892 eligible abstracts were independently rated, and 89 studies met the inclusion criteria.
Main outcome measures: Effect on doctors' performance and patient outcomes; attitudes towards computerisation.
Results: 61 studies examined effects of computers on practitioners' performance, 17 evaluated their impact on patient outcome, and 20 studied practitioners' or patients' attitudes. Computer use during consultations lengthened the consultation. Reminder systems for preventive tasks and disease management improved process rates, although some returned to pre-intervention levels when reminders were stopped. Use of computers for issuing prescriptions increased prescribing of generic drugs, and use of computers for test ordering led to cost savings and fewer unnecessary tests. There were no negative effects on those patient outcomes evaluated. Doctors and patients were generally positive about use of computers, but issues of concern included their impact on privacy, the doctor-patient relationship, cost, time, and training needs.
Conclusions: Primary care computing systems can improve practitioner performance, particularly for health promotion interventions. This may be at the expense of patient initiated activities, making many practitioners suspicious of the negative impact on relationships with patients. There remains a dearth of evidence evaluating effects on patient outcomes."
Objective
"To appraise findings from studies examining the impact of computers on primary care consultations."
Type Clinic
Primary care
Size
not applicable
Type of Health IT
Decision support system
Electronic medical records (EMR)
Type of Health IT Functions
The authors searched for articles that "described any computing system designed for use by a doctor" in a primary care setting. Functions listed in the review included immunization and prevention, disease management, and prescribing.
Workflow-Related Findings
"Studies evaluating hypertension management found improvements of 18-53% in examinations. Again the largest increase occurred with an electronic protocol, and consultation length increased by 35%."
"Computer use for ordering tests led to reductions of 6-75% in the number of tests."
"Most practitioners willingly accepted computers as part of their working environment and were positive about their use."
"Many [physicians] thought that computerized records were more accurate than conventional records or that they improved patient care."
"Patients said that computers gave their doctors better access to records and that consultations were unaffected."
"Both practitioners and patients were concerned about the possible negative impact of computers on the doctor-patient relationship. This concern was partly due to the logistics of incorporating a computer in the consultation and partly to the perception that computers would take over the doctor's role."
"Many doctors said that the time commitment involved in learning and using computers was too great and was more than they had expected, resulting in additional stress."
"Immunisation rates improved by 8-34% in the nine studies of this issue. In eight studies reminder systems were used, and the greatest improvements in immunisation rates were seen with patient-only reminders and reminders to both doctor and patient."
"Performance of preventative tasks, such as blood pressure screening and cervical smears, improved by up to 47%. The greatest increases occurred when physicians were prompted as part of the consultation."
Consultation length increased in five studies by 48-130 seconds. The increase tended to decline after "variable time periods."
"Two studies found that the doctors spent 11%-100% more time on computerised records than they had on conventional records. This was mainly because of increased administrative tasks and preventive issues prompted by computer use."
"Computer use led to increases in doctor-centered speech and the number of medical topics raised, often at the expense of patient-centered activity."
"Practitioners were also less likely to continue interacting with patients when using computerised records than when using paper records, and this did not diminish with increased familiarity."
The greatest improvement in disease management "occurred when physicians used an electronic protocol, although this increased the length of consultations by 10 minutes."
"Computerised alerts and reminders to doctors for management of HIV infection produced faster response times."
"The introduction of a computer algorithm for pediatrics increased recording and compliance with management plans, but doctors found it 'too tedious to use during routine care' and the study was abandoned after five weeks."
"One study found significant reductions in doctors' and receptionists' time when computerised prescriptions were issued."
Study Design
Systematic literature review
Study Participants
The authors conducted a review of worldwide (English and non-English) literature and searched the following databases: Medline, Science Citation Index, Social Sciences Citation Index, Index of Scientific and Technical Proceedings, Embase, and OCLC FirstSearch Proceedings. Books, bibliographies, conference proceedings of related topics and citations in them, as well as references provided by the authors' colleagues were also reviewed. Selection criteria required studies to examine the following: effects of computers on the consultation process, general practitioners' task performance, and patient outcomes. The search yielded a total of 5,475 references, of which 89 were included in the review.