Saleem JJ et al. 2005 "Exploring barriers and facilitators to the use of computerized clinical reminders."

Saleem JJ, Patterson ES, Militello L, et al. Exploring barriers and facilitators to the use of computerized clinical reminders. J Am Med Inform Assoc 2005;12(4):438-447.
"OBJECTIVE: Evidence-based practices in preventive care and chronic disease management are inconsistently implemented. Computerized clinical reminders (CRs) can improve compliance with these practices in outpatient settings. However, since clinician adherence to CR recommendations is quite variable and declines over time, we conducted observations to determine barriers and facilitators to the effective use of CRs. DESIGN: We conducted an observational study of nurses and providers interacting with CRs in outpatient primary care clinics for two days in each of four geographically distributed Veterans Administration (VA) medical centers. MEASUREMENTS: Three observers recorded interactions of 35 nurses and 55 physicians and mid-level practitioners with the CRs, which function as part of an electronic medical record. Field notes were typed, coded in a spreadsheet, and then sorted into logical categories. We then integrated findings across observations into meaningful patterns and abstracted the data into themes, such as recurrent strategies. Several of these themes translated directly to barriers and facilitators to effective CR use. RESULTS: Optimally using the CR system for its intended purpose was impeded by (1) lack of coordination between nurses and providers; (2) using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions; (3) workload; (4) lack of CR flexibility; and (5) poor interface usability. Facilitators included (1) limiting the number of reminders at a site; (2) strategic location of the computer workstations; (3) integration of reminders into workflow; and (4) the ability to document system problems and receive prompt administrator feedback. CONCLUSION: We identified barriers that might explain some of the variability in the use of CRs. Although these barriers may be difficult to overcome, some strategies may increase user acceptance and therefore the effectiveness of the CRs. These include explicitly assigning responsibility for each CR to nurses or providers, improving visibility of positive results from CRs in the electronic medical record, creating a feedback mechanism about CR use, and limiting the overall number of CRs."
To conduct observations in order to "determine barriers and facilitators to the effective use of" clinical reminders.
Tools Used
Type Clinic
Primary care
Other Information
The study was conducted in four Veterans Administration medical centers.
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
"The [reminder (CR)] system evaluates available patient data according to a defined logic, based on the clinical topic addressed. If the data indicate that an intervention is potentially appropriate for the patient, the reminder is deemed "applicable"; if the data indicate the intervention has been provided, the reminder is deemed "satisfied" and if not provided, "due." In the [electronic medical record (EMR)], each patient's chart opens to a cover sheet where due CRs are listed...The CR system is intended to be used by both nurses and providers at different points in the clinic workflow. During patient intake, nurses complete many of the routine preventive care and screening reminders that appear in the patients' electronic record such as depression screening. Reminders aimed at providers may require more clinical judgment...To satisfy the CRs, the clinician must first create a new progress note, then click on an icon to call up a list of reminders that are due, and then click on individual reminders to invoke a dialog box to address each one. Once the dialog is open, the clinician satisfies a reminder by selecting the appropriate dialog options...After each CR is processed, text is automatically inserted in the progress note. The reminders are passive in that clinicians have uninterrupted access to the [EMR] software regardless of whether they address any reminders."
Context or other IT in place
An electronic medical record (EMR) was already in place.
Workflow-Related Findings
"At each site except Site 3, nurses and providers displayed substantial confusion regarding delegation of responsibility for satisfying CRs (removing them from the due list)...Even when roles were clarified, the assigned responsibility of individual reminders sometimes changed over time, producing confusion."
"Six of 55 observed providers did not use the CRs at all."
"Several clinicians did not perceive the CRs as being a core work activity. Six providers and three intake nurses reported CRs as being least important or not a priority."
"Five providers and one LPN reported the CRs as being "time-consuming," and a second LPN was directly observed to be frustrated with how long
it took to use the depression, tobacco, and alcohol screening reminders. One provider and four LPNs reported that they would not satisfy a patient’s CRs until later in the day because of being busy. Four providers and seven LPNs reported not completing the CRs for a patient at all as a result of being busy."
To complete the CRs, clinicians must sometimes enter data twice, as the information is generally also reported in another place in the patient's chart.
"At [one] hospital, a list of the patient's CRs was automatically generated
and printed at check-in with the clerk. The nurses then used this printout to address the CRs during intake and recorded the responses on the printout itself. This printout traveled with the patient to the provider and eventually was returned to the nurse so that she could record the information in the [EMR] later in the day and "satisfy" the computerized CRs.... Additional time for patient intake would be needed if the nurses at this hospital were to use the CR system as it was designed (additional time to enter patient response and data into the interface for the computerized CRs and computer processing time)."
"We observed instances in which none of the available options to satisfy the CR applied to the patient or situation. In addition, clinicians reported that they faced situations in which CRs could not be removed and therefore continued to appear."
"There were cases in which clinicians reached a dead end within the CR system, with no reasonable option to proceed. When using a "Next" feature to satisfy a sequence of CRs, two nurses and one provider were observed to reach the dialogue box for a CR that they did not wish to satisfy. However, there was no means to cancel the CR without losing the data already inputted for the previous CRs."
"Options within the dialogue box of the CRs do not always match the patient's response or there is not an appropriate option for indicating why the provider has decided not to order a test, for example. This is a barrier to resolving the reminder. Seven nurses and seven providers reported that there was "no option" or "not enough options" in the CRs for specific reminders."
"CRs appear on [the EMR] cover sheet but are delayed in loading and displaying [for approximately 8 seconds]. During this delay, we observed providers and nurses use strategies such as clicking on the progress notes tab before the reminders have displayed..., thereby lessening the visibility of the reminders. Further, when defaulting past the cover sheet, feedback for the presence of due CRs is signified by a question mark icon in the upper right corner of the display. We observed three providers misinterpret this question mark to indicate that the patient had no CRs due, when in actuality it meant the system was still evaluating data to determine which CRs were due."
"We recorded computer system delays in approximately 10% of the encounters ... and computer crashes in approximately 1% of the encounters."
At site 3, physicians could use a "Feedback Tool" to let the Information Management Office know about an inappropriate reminder. In the experience of one provider, the feedback tool worked well and the inappropriate reminder would be removed without further work by the provider.
"Communication of positive screening findings by intake nurses using CRs to providers was problematic through the CPRS as providers generally did not open nursing progress notes before seeing patients. At all four sites, paper-based workarounds were employed to alert providers to positive findings from the screening."
"At Site 1, which has 65 CRs [in their system], we observed an average of eight reminders appear per patient. Assuming, for the sake of argument, that each reminder requires approximately 30 seconds to satisfy (open reminder, obtain necessary information information from patient, order any necessary consults or tests, and document), then the clinician would spend 4 minutes per a 15- to 30-minute encounter completing the reminders in an already time-pressured appointment."
Study Design
Only postintervention (no control group)
Study Participants
Thirty-five nurses, and 55 physicians and midlevel providers participated.