Zheng K et al. 2005 "Understanding technology adoption in clinical care: clinician adoption behavior of a point-of-care reminder system."

Zheng K, Padman R, Johnson MP, et al. Understanding technology adoption in clinical care: clinician adoption behavior of a point-of-care reminder system. Int J Med Inf 2005;74(7-8):535-543.
"Background: Evaluation studies of clinical decision support systems (CDSS) have tended to focus on assessments of system quality and clinical performance in a laboratory setting. Relatively few studies have used field trials to determine if CDSS are likely to be used in routine clinical settings and whether reminders generated are likely to be acted upon by end-users. Moreover, such studies when performed tend not to identify distinct user groups, nor to classify user feedback. Aim: To assess medical residents' acceptance and adoption of a clinical reminder system for chronic disease and preventive care management and to use expressed preferences for system attributes and functionality as a basis for system re-engineering. Design of study: Longitudinal, correlational study using a novel developmental trajectory analysis (DTA) statistical method, followed by a qualitative analysis based on user satisfaction surveys and field interviews. Setting: An ambulatory primary care clinic of an urban teaching hospital offering comprehensive healthcare services. 41 medical residents used a CDSS over 10 months in their daily practice. Use of this system was strongly recommended but not mandatory. Methods: A group-based, semi-parametric statistical modeling method to identify distinct groups, with distinct usage trajectories, followed by qualitative instruments of usability and satisfaction surveys and structured interviews to validate insights derived from usage trajectories. Results: Quantitative analysis delineates three types of user adoption behavior: "light", "moderate" and "heavy" usage. Qualitative analysis reveals that clinicians of distinct types tend to exhibit views of the system consistent with their demonstrated adoption behavior. Drawbacks in the design of the CDSS identified by users of all types (in different ways) motivate a redesign based on current physician workflows. Conclusion: We conclude that this mixed methodology has considerable promise to provide new insights into system usability and adoption issues that may benefit clinical decision support systems as well as information systems more generally."
"To assess medical residents' acceptance and adoption of a clinical reminder system for chronic disease and preventive care management and to use expressed preferences for system attributes and functionality as a basis for system re-engineering."
Type Clinic
Primary care
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
The system "uses patients' medical status data to provide 'just-in-time' reminders to clinicians at the point of care consistent with the latest evidence-based medicine guidelines for chronic disease and preventive care management." This point of care data is provided through the computers located in every exam room. It draws data from the hospital's administrative, lab, and clinical records system. The rest of the data required to produce guidelines are entered by the clinician at the time of the encounter. Reminders are in the form of on-screen recommendations "to have tests scheduled or performed, review abnormal test results, receive vaccinations, or follow-up on patients with medical conditions that require unscheduled interventions." At the time of the study, the system was designed to improve the quality of care for two chronic diseases and five preventive care categories.
Context or other IT in place
In place was an electronic medical record (EMR) which provided lab and medication data, as well as notes.
Workflow-Related Findings
"Residents classified as 'light' (41.46%) initially used the system for about 35% of all patient encounters, and this rate remained steady over the 10-month evaluation period. 'Moderate' users (36.59%) had the highest initial usage rate, about 70%, but this rate consistently decreased over the study period to a level comparable with that of the 'light' users. 'Heavy' users (21.95%) had an initial usage rate of about 50%, which increased consistently to almost 100%."
"Residents complained that the reminder system lacks guidance in the application of workflow. In contrast to the history and physical examination forms that residents typically use, the interface of [the EMR] appeared to provide little guidance as to a preferred order of data entry.... The user interface is composed of several tabs that lead to different functionality areas. These tabs, labeled 'current reminders', 'visit details', 'lab test', 'diagnosis' and so on, did not provide physicians with the specific guidance as to the order of data management; data to be reviewed prior to the encounter, data to enter during the encounter before generating reminders, data to be entered in response to reminders generated, and encounter summary forms to be printed for the patient chart and for patient check-out."
The theme of "heavy and hard data entry duty" relates to the considerable amount of time and effort required to enter patient data. Comments included "''it is very tedious to put in all of the work,' and 'takes too much time to enter patient'."
One user commented: 'I think nurses should enter [the patient information]. I don't have time in an appointment of 20 min to fill all reports.'"
Residents' would rather have a single system perform all encounter-related tasks, including labs, medications, and notes.
Some residents complained that it took too much time to review reminders and this cut into time with patients. "This theme originated primarily from residents classified as "light" or "moderate" users...this theme did not emerge from feedback of the "heavy" user group."
"A quantitative analysis based on recorded usage logs indicate that light and moderate user groups spent, approximately, 18.5 s on average on reviewing and responding to the reminders, whereas the heavy user group spent 37.1 s."
"Some physicians also believed that [using the EMR] disrupted physician-patient communication. Typical comments in this vein include: 'using the system is disruptive during patient encounters'."
"Observational descriptions reveal that use of the system during encounter did, in fact, impede physician-patient communication to some extent. For instance, residents repeatedly turned back and forth between the computer and their patient."
"Perspectives found to be distinct across groups include the themes of 'time-consuming and detrimental to efficiency' and 'disruptive to physician-patient communication.' The fact that 'heavy' users did not comment negatively on these two themes is noteworthy; we find that these users had adapted their behavior to use the system and act upon reminders at the end of encounters, or even after patients left. We do not favor such a modification to the intended system use because it is contrary to the rationale of reminding clinicians at the point-of-care to improve compliance with evidence-based guidelines. However, we view this behavior as an indication of these users' strong desire to use the system."
"Typical [physician] comments such as 'Easy to use, time efficient' suggest that use of the system required very minimal training and skills. Difficulty of use or lack of computer proficiency appears not to be a significant barrier for incorporating the system into their routine practice."
"One explanation for the low usage of the reminder system is that the clinicians primarily viewed the use of reminders as an 'add-on' to their work instead of an intrinsic part of the patient encounter. Use of the system and the effort they need to commit to activities such as data entry were viewed as a cumbersome addition to their traditional patterns of care delivery."
"Most of negative feedback is grouped under the theme of 'iterative advisories', criticizing the relevance of reminders issued for follow-up visits. Typical comments include: 'it does not take feedback from us' and 'it generates the same reminders every time'. The textual notes that accompanied reminder responses also provide evidence regarding the potential lack of relevance of the reminders: nearly 30% of such notes asserted 'the suggested action has already been taken but not yet recorded."
"Based on actual usage data, we found that 'light' users tended to limit their interaction with the system to accessing patient records, entering minimal new patient care data and rarely reviewing and responding to system-generated reminders. 'Medium' users tended to enter more patient care data and generated a higher volume of more relevant reminders, but not to act on them consistently. 'Heavy' users generally used all the system functionality, as intended for nearly all patient encounters.... They also often added comments that assisted in follow-up care."
"These comments suggested that [the EMR] had positive implications for the medical practice. Typical comments include: 'it does move me to think about some preventive measurements' and 'hard to miss things we usually tend to.' These comments are indicative of a general consensus among residents that use of this reminder system has the potential to improve clinician performance, leading to better quality of care."
Study Design
Only postintervention (no control group)
Study Participants
Forty-one internal medical residents used the system to treat approximately 4,500 patients. Structured interviews were completed with 16 residents.