Toth-Pal E et al. 2008 "Implementing a clinical decision-support system in practice: a qualitative analysis of influencing attitudes and characteristics among general practitioners."
Reference
Toth-Pal E, Wardh I, Strender L-E, et al. Implementing a clinical decision-support system in practice: a qualitative analysis of influencing attitudes and characteristics among general practitioners. Inform Health Soc Care 2008;33(1):39-54.
Abstract
"In order to obtain a better understanding of barriers to the implementation of clinical decision-support systems (CDSSs) in primary health care, we explored general practitioners' (GPs) handling of a CDSS during the implementation process. An Internet-based application for the management of chronic heart failure was used that was an adaptation of established clinical guidelines for computer use. The whole implementation process was followed closely, using a combination of different methods for data collection: repeated interviews with the five participating GPs, observations of patient visits, patient interviews, and detection of usage. We analyzed the data using qualitative content analysis. The results showed that GPs' attitudes and characteristics constituted different profiles that seemed to be associated with the degree of acceptance of the CDSS. Those profiles were related to conceptions about the GPs' professional role and their attitudes towards the computer's function in disease management and in decision-making. Some additional barriers were insufficient level of computer skills and time constraints in everyday work. These findings can help us identify groups of GPs with definable needs during the implementation of a CDSS and make it easier to meet those needs with individually tailored interventions."
Objective
"To obtain a better understanding of barriers to the implementation of clinical decision-support systems (CDSSs) in primary health care by exploring general practitioners' (GPs) handling of a CDSS during the implementation process."
Tools Used
Type Clinic
Primary care
Type Specific
Family practice
Size
Small and/or medium
Geography
Suburban
Other Information
The study was conducted in Stockholm.
Type of Health IT
Decision support system
Type of Health IT Functions
"The CDSS ... is a freely available Internet-based application written in Swedish... [It has] four modules, two of them for support in the management of [congestive heart failure] CHF, [which] are based on three clinical guidelines... There is no connection between [CDSS] and the EPR, which means that the program does not collect any patient data automatically. The user fills in a form with patient data and thereafter clicks a button that triggers the program. The result is a recommendation sheet, immediately presented on screen and printable on demand. The most important outcome on the recommendation sheet from the diagnosing module is a calculation of the probability for the diagnosis of CHF in four levels, and recommendations for further investigations if needed to make the diagnosis more certain. The recommendation sheet from the treatment module gives suggestions for suitable medication group(s) to add to those already used, and lists the advantages and disadvantages of using each group... [The CDSS] program fills two functions: it gives recommendation(s) adapted to the present patient, and general educational information for the GP."
Context or other IT in place
"All the GPs had been using electronic patient records (EPRs) in their everyday practice for more than 5 years, and their desktop computers had fast Internet connections. The PHC [primary health care] centre had been using EPRs as the sole medical record
Workflow-Related Findings
The physicians who were most comfortable with computers used the CDSS slightly more often than those who were moderately comfortable. Physicians who were least comfortable with computers did not use the CDSS at all in the study period.
The CDSS is "concise and fairly easy to use after the initial training."
The CDSS "rarely failed to run properly, but some of the recommendations were not in agreement with local guidelines."
"All the GPs also reported experiencing the requirement to retrieve all patient data manually from the EPR and enter it into the CDSS as an annoying burden. This is a known disadvantage with Internet-based programs ... In our study, shortage of time seemed to be an accentuating factor."
"Computer usage [in the exam room] has to be minimized while the patient is telling their story."
It is "easier to run the [CDSS] program after clinic hours when there is less stress."
"All [patients] reported being very satisfied with their visits and not experiencing any disturbance because their GP was using the computer or the CDSS."
Physicians varied in their acceptance of the CDSS. The level of acceptance was related to comfort with and liking of computers. "When receiving the program's recommendations, [only the physicians most comfortable with computers] read the recommendations and the comments, and took them into account when deciding on further actions, but [they] did not always follow the recommendations."
"With respect to directing their focus of attention during the visit between the patient and the computer, the GPs chose a strict sequential division of time between the two, or changed their focus from one to the other either for short periods or almost simultaneously. This was part of each GP's individual way of working and was not related to the [level of comfort with computers]."
"In all visits, ...the GP tried to get a few minutes alone with the [CDSS] program while the patient was occupied with something else."
Study Design
Only postintervention (no control group)
Study Participants
Five of six GPs participated in the study. Four specialized in family medicine. They worked as GPs for 5 to 27 years and in this clinic for 2 to 25 years.