The effects of on-screen, point of care computer reminders on processes and outcomes of care

New tools for an old trade: a socio-technical appraisal of how electronic decision support is used by primary care practitioners

This article explores Australian general practitioners' (GPs) views on a novel electronic decision support (EDS) tool being developed for cardiovascular disease management. We use Timmermans and Berg's technology-in-practice approach to examine how technologies influence and are influenced by the social networks in which they are placed. In all, 21 general practitioners who piloted the tool were interviewed. The tool occupied an ill-defined middle ground in a dialectical relationship between GPs' routine care and factors promoting best practice. Drawing on Lipsky's concept of 'street-level bureaucrats', the tool's ability to process workloads expeditiously was of greatest appeal to GPs. This feature of the tool gave it the potential to alter the structure, process and content of healthcare encounters. The credibility of EDS tools appears to be mediated by fluid notions of best practice, based on an expert scrutiny of the evidence, synthesis via authoritative guidelines and dissemination through trusted and often informal networks. Balanced against this is the importance of 'soft' forms of knowledge such as intuition and timing in everyday decision-making. This resonates with Aristotle's theory of phronesis (practical wisdom) and may render EDS tools inconsequential if they merely process biomedical data. While EDS tools show promise in improving health practitioner performance, the socio-technical dimensions of their implementation warrant careful consideration.

A clinical decision support needs assessment of community-based physicians

OBJECTIVE

To conduct a grounded needs assessment to elicit community-based physicians' current views on clinical decision support (CDS) and its desired capabilities that may assist future CDS design and development for community-based practices.

MATERIALS AND METHODS

To gain insight into community-based physicians' goals, environments, tasks, and desired support tools, we used a human-computer interaction model that was based in grounded theory. We conducted 30 recorded interviews with, and 25 observations of, primary care providers within 15 urban and rural community-based clinics across Oregon. Participants were members of three healthcare organizations with different commercial electronic health record systems. We used a grounded theory approach to analyze data and develop a user-centered definition of CDS and themes related to desired CDS functionalities.

RESULTS

Physicians viewed CDS as a set of software tools that provide alerts, prompts, and reference tools, but not tools to support patient management, clinical operations, or workflow, which they would like. They want CDS to enhance physician-patient relationships, redirect work among staff, and provide time-saving tools. Participants were generally dissatisfied with current CDS capabilities and overall electronic health record usability.

DISCUSSION

Physicians identified different aspects of decision-making in need of support: clinical decision-making such as medication administration and treatment, and cognitive decision-making that enhances relationships and interactions with patients and staff.

CONCLUSION

Physicians expressed a need for decision support that extended beyond their own current definitions. To meet this requirement, decision support tools must integrate functions that align time and resources in ways that assist providers in a broad range of decisions.

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors

OBJECTIVE

Expert authorities recommend clinical decision support systems to reduce prescribing error rates, yet large numbers of insignificant on-screen alerts presented in modal dialog boxes persistently interrupt clinicians, limiting the effectiveness of these systems. This study compared the impact of modal and non-modal electronic (e-) prescribing alerts on prescribing error rates, to help inform the design of clinical decision support systems.

DESIGN

A randomized study of 24 junior doctors each performing 30 simulated prescribing tasks in random order with a prototype e-prescribing system. Using a within-participant design, doctors were randomized to be shown one of three types of e-prescribing alert (modal, non-modal, no alert) during each prescribing task.

MEASUREMENTS

The main outcome measure was prescribing error rate. Structured interviews were performed to elicit participants' preferences for the prescribing alerts and their views on clinical decision support systems.

RESULTS

Participants exposed to modal alerts were 11.6 times less likely to make a prescribing error than those not shown an alert (OR 11.56, 95% CI 6.00 to 22.26). Those shown a non-modal alert were 3.2 times less likely to make a prescribing error (OR 3.18, 95% CI 1.91 to 5.30) than those not shown an alert. The error rate with non-modal alerts was 3.6 times higher than with modal alerts (95% CI 1.88 to 7.04).

CONCLUSIONS

Both kinds of e-prescribing alerts significantly reduced prescribing error rates, but modal alerts were over three times more effective than non-modal alerts. This study provides new evidence about the relative effects of modal and non-modal alerts on prescribing outcomes.

Efficacy of interventions to increase the uptake of chlamydia screening in primary care: a systematic review

Background

As most genital chlamydia infections are asymptomatic, screening is the main way to detect and cases for treatment. We undertook a systematic review of studies assessing the efficacy of interventions for increasing the uptake of chlamydia screening in primary care.

Methods

We reviewed studies which compared chlamydia screening in the presence and the absence of an intervention. The primary endpoints were screening rate or total tests.

Results

We identified 16 intervention strategies; 11 were randomised controlled trials and five observational studies, 10 targeted females only, five both males and females, and one males only. Of the 15 interventions among females, six were associated with significant increases in screening rates at the 0.05 level including a multifaceted quality improvement program that involved provision of a urine jar to patients at registration (44% in intervention clinics vs. 16% in the control clinic); linking screening to routine Pap smears (6.9% vs. 4.5%), computer alerts for doctors (12.2% vs. 10.6%); education workshops for clinic staff; internet-based continuing medical education (15.5% vs. 12.4%); and free sexual health consultations (16.8% vs. 13.2%). Of the six interventions targeting males, two found significant increases including the multifaceted quality improvement program in which urine jars were provided to patients at registration (45% vs. 15%); and the offering by doctors of a test to all presenting young male clients, prior to consultation (29 vs. 4%).

Conclusions

Interventions that promoted the universal offer of a chlamydia test in young people had the greatest impact on increasing screening in primary care.

The efficacy of computer reminders on external quality assessment for point-of-care testing in Danish general practice: rationale and methodology for two randomized trials

BACKGROUND

Point-of-care testing (POCT) is increasingly being used in general practice to assist general practitioners (GPs) in their management of patients with diseases. However, low adherence to quality guidelines in terms of split test procedures has been observed among GPs in parts of the Capital Region in Denmark. Computer reminders embedded in GPs electronic medical records (ComRem) may facilitate improved quality control behaviour, but more research is needed to identify what types of reminders work and when. The overall aim of this study is to evaluate the efficacy of ComRem to improve GPs adherence to quality guidelines. This article describes the rationale and methods of the study that constitute this research project.

METHODS/DESIGN

The study is conducted as two randomised controlled trials (RCTs) among general practices in two districts of the Capital Region in Denmark. These districts contain a total of 739 GPs in 567 practices with a total of 1.1 million patients allocated to practice lists. In the first RCT (RCT A), ComRem is compared to postal reminder letters. In the second RCT (RCT B), ComRem is compared to usual activities (no reminders) with a crossover approach. In both of these studies, outcomes are measured by the number of split tests received by the laboratory.

CONCLUSIONS

This study will contribute to knowledge on the efficacy of ComRem in primary care. Because the study does not explore GPs' perceptions and experiences with regard to ComRem, we will subsequently conduct a qualitative survey focusing on these aspects.

TRIAL REGISTRATIONS

Study A: ClinicalTrials.gov identifier: NCT01152151Study B: ClinicalTrials.gov identifier: NCT01152177.

Resident-initiated interventions to improve inpatient heart-failure management

BACKGROUND

Third-year internal medicine residents participating in a quality improvement rotation identified gaps between the Joint Commission's ORYX quality guidelines and clinical practices for the inpatient management of heart failure (HF) at the William S. Middleton Memorial Veterans Hospital. Residents focused on the performance metrics associated with tobacco-cessation counselling documentation, ejection fraction assessment and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescriptions.

METHODS

After analysing data collected by the External Peer Review Program, residents reviewed the institution's admissions and discharge processes with the aim of improving quality and compliance. In redesigning these processes, residents created an admissions template and a discharge face sheet, and compared specific ORYX measure compliance rates before and after institution-wide implementation.

RESULTS

Following implementation of the tobacco-cessation admissions template, 100% of HF patients who used tobacco received documented cessation counselling, compared with 59% prior to intervention (p<0.01, n=32). Following implementation of the mandatory discharge face sheet, 97% of HF patients (compared with 92% preintervention, p>0.05) received comprehensive discharge instruction; LV function assessment went from 98% to 100% (p>0.05); and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription for left ventricular systolic dysfunction at discharge (or documentation of a contra-indication) went from 82% to 100% (p<0.01, n=48).

DISCUSSION

By implementing a standardised admissions template and a mandatory discharge face sheet, the hospital improved its processes of documentation and increased adherence to quality-performance measures. By strengthening residents' learning and commitment to quality improvement, the hospital created a foundation for future changes in the systems that affect patient care.

Electronic medical record prompts for lab orders in patients initiating statins

BACKGROUND

The Institute of Medicine (IOM) reports that at least a fourth of all medication related injuries are preventable. Therefore, the IOM recommends healthcare organizations and providers implement electronic prescribing and clinical decision support systems in practices to aid in medication error prevention.

OBJECTIVE

To assess the impact of noninstrusive-intrusive prompts from an electronic medical record on recommended baseline and follow up laboratory monitoring, CK and liver transaminase levels (AST and ALT), in patients initiated on statin therapy.

METHODS

Hybrid nonintrusive-intrusive prompts for laboratory monitoring specific for statin initiation were implemented in the electronic medical record system in a community based, university affiliated family medicine residency program. A retrospective chart review was conducted to compare and assess laboratory monitoring in patients initiated on statin therapy from two specific time periods: a six month period prior to initiation of the prompts and a six month period after initiation of the prompts.

RESULTS

One hundred seventy three patients met inclusion criteria. There were no significant differences in assessment of baseline liver transaminases and CK levels from the initial study period to the follow up study period. There were significant differences in follow up liver transaminase levels (18% vs 33%, p = 0.035) and CK levels (none vs 7%, p = 0.03) from the initial study period to the activated prompt interval.

CONCLUSION

A hybrid nonintrusive-intrusive specific prompts for laboratory monitoring triggered by statin initiation within an electronic medical record improved follow up lab assessments for liver transaminases and CK but did not improve baseline assessments of CK or liver transaminases.

Designing computerized decision support that works for clinicians and families

Evidence-based decision-making is central to the practice of pediatrics. Clinical trials and other biomedical research provide a foundation for this process, and practice guidelines, drawing from their results, inform the optimal management of an increasing number of childhood health problems. However, many clinicians fail to adhere to guidelines. Clinical decision support delivered using health information technology, often in the form of electronic health records, provides a tool to deliver evidence-based information to the point of care and has the potential to overcome barriers to evidence-based practice. An increasing literature now informs how these systems should be designed and implemented to most effectively improve outcomes in pediatrics. Through the examples of computerized physician order entry, as well as the impact of alerts at the point of care on immunization rates, the delivery of evidence-based asthma care, and the follow-up of children with attention deficit hyperactivity disorder, the following review addresses strategies for success in using these tools. The following review argues that, as decision support evolves, the clinician should no longer be the sole target of information and alerts. Through the Internet and other technologies, families are increasingly seeking health information and gathering input to guide health decisions. By enlisting clinical decision support systems to deliver evidence-based information to both clinicians and families, help families express their preferences and goals, and connect families to the medical home, clinical decision support may ultimately be most effective in improving outcomes.

A qualitative study of Canada's experience with the implementation of electronic health information technology

BACKGROUND

In 2001, Canada Health Infoway unveiled a plan to implement a national system of interoperable electronic health records. This government-funded corporation introduced a novel model for interprovincial/territorial collaboration to establish core aspects of a national framework. Despite this $1.6 billion initiative, Canada continues to lag behind other Western countries in adopting electronic health records. We conducted a study to identify the success of different aspects of the Canadian plan and ways to improve the adoption of electronic health records.

METHODS

We used a case study approach to assess the 10-year history of Canada's e-health plan. National reports and documents were reviewed, and structured interviews were conducted with 29 key stakeholders representing national and provincial organizations responsible for establishing policy and strategic direction for health information technology. Using grounded theory, we analyzed transcripts of the interviews to identify themes and their relationships.

RESULTS

Key stakeholders identified funding, national standards, patient registries and digital imaging as important achievements of the e-health plan. Lack of an e-health policy, inadequate involvement of clinicians, failure to establish a business case for using electronic health records, a focus on national rather than regional interoperability, and inflexibility in approach were seen as barriers to adoption of the plan.

INTERPRETATION

To accelerate adoption of electronic health records and timely return on investment, an e-health policy needs to be tightly aligned with the major strategic directions of health care reform. Adoption needs to be actively fostered through a bottom-up, clinical-needs-first approach, a national policy for investment in electronic health records, and financial incentives based on patient outcomes that can be achieved with electronic health records.

The impact of eHealth on the quality and safety of health care: a systematic overview

BACKGROUND

There is considerable international interest in exploiting the potential of digital solutions to enhance the quality and safety of health care. Implementations of transformative eHealth technologies are underway globally, often at very considerable cost. In order to assess the impact of eHealth solutions on the quality and safety of health care, and to inform policy decisions on eHealth deployments, we undertook a systematic review of systematic reviews assessing the effectiveness and consequences of various eHealth technologies on the quality and safety of care.

METHODS AND FINDINGS

We developed novel search strategies, conceptual maps of health care quality, safety, and eHealth interventions, and then systematically identified, scrutinised, and synthesised the systematic review literature. Major biomedical databases were searched to identify systematic reviews published between 1997 and 2010. Related theoretical, methodological, and technical material was also reviewed. We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. This systematic review literature was found to be generally of substandard quality with regards to methodology, reporting, and utility. We thematically categorised eHealth technologies into three main areas: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies. Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.

CONCLUSIONS

There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and "techno-enthusiasts" as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption.

Process evaluation of appreciative inquiry to translate pain management evidence into pediatric nursing practice

BACKGROUND

Appreciative inquiry (AI) is an innovative knowledge translation (KT) intervention that is compatible with the Promoting Action on Research in Health Services (PARiHS) framework. This study explored the innovative use of AI as a theoretically based KT intervention applied to a clinical issue in an inpatient pediatric care setting. The implementation of AI was explored in terms of its acceptability, fidelity, and feasibility as a KT intervention in pain management.

METHODS

A mixed-methods case study design was used. The case was a surgical unit in a pediatric academic-affiliated hospital. The sample consisted of nurses in leadership positions and staff nurses interested in the study. Data on the AI intervention implementation were collected by digitally recording the AI sessions, maintaining logs, and conducting individual semistructured interviews. Data were analysed using qualitative and quantitative content analyses and descriptive statistics. Findings were triangulated in the discussion.

RESULTS

Three nurse leaders and nine staff members participated in the study. Participants were generally satisfied with the intervention, which consisted of four 3-hour, interactive AI sessions delivered over two weeks to promote change based on positive examples of pain management in the unit and staff implementation of an action plan. The AI sessions were delivered with high fidelity and 11 of 12 participants attended all four sessions, where they developed an action plan to enhance evidence-based pain assessment documentation. Participants labeled AI a 'refreshing approach to change' because it was positive, democratic, and built on existing practices. Several barriers affected their implementation of the action plan, including a context of change overload, logistics, busyness, and a lack of organised follow-up.

CONCLUSIONS

Results of this case study supported the acceptability, fidelity, and feasibility of AI as a KT intervention in pain management. The AI intervention requires minor refinements (e.g., incorporating continued follow-up meetings) to enhance its clinical utility and sustainability. The implementation process and effectiveness of the modified AI intervention require evaluation in a larger multisite study.

Role of physicians' reactance in e-iatrogenesis: a case study with ASTI guiding mode on the management of hypertension

Clinical decision support systems (CDSSs) have the potential to increase guideline adherence, but factors of success are not yet understood. ASTI guiding mode (ASTI-GM) is an on-demand guideline-based CDSS where the user navigates in a knowledge base to get the best treatment for a given patient. We conducted a web-based evaluation of ASTI-GM, carried out as a before-after study, where general practitioners (GPs) were asked to solve 5 clinical cases, first without ASTI-GM, then using the system. Of the 136 GPs that resolved the case on the management of hypertension, compliance with best practices increased from 69.1% to 80.9% with ASTI-GM. When the navigation matched the set of patient parameters described in the clinical case, the increase was even higher and reached 92.9%. E-iatrogenesis has been measured at 19.1%, with 5.1% of commission errors, 8.1% of negative reactance, and 5.9% of neutral reactance. Role of physicians' reactance in noncompliance with guideline-based CDSSs should be further investigated.

A pragmatic study exploring the prevention of delirium among hospitalized older hip fracture patients: Applying evidence to routine clinical practice using clinical decision support

Delirium occurs in up to 65% of older hip fracture patients. Developing delirium in hospital has been associated with a variety of adverse outcomes. Trials have shown that multi-component preventive interventions can lower delirium rates. The objective of this study was to implement and evaluate the effectiveness of an evidence-based electronic care pathway, which incorporates multi-component delirium strategies, among older hip fracture patients. We conducted a pragmatic study using an interrupted time series design in order to evaluate the use and impact of the intervention. The target population was all consenting patients aged 65 years or older admitted with an acute hip fracture to the orthopedic units at two Calgary, Alberta hospitals. The primary outcome was delirium rates. Secondary outcomes included length of hospital stay, in-hospital falls, in-hospital mortality, new discharges to long-term care, and readmissions. A Durbin Watson test was conducted to test for serial correlation and, because no correlation was found, Chi-square statistics, Wilcoxon test and logistic regression analyses were conducted as appropriate. At study completion, focus groups were conducted at each hospital to explore issues around the use of the order set. During the 40-week study period, 134 patients were enrolled. The intervention had no effect on the overall delirium rate (33% pre versus 31% post; p = 0.84). However, there was a significant interaction between study phase and hospital (p = 0.03). Although one hospital did not experience a decline in delirium rate, the delirium rate at the other hospital declined from 42% to 19% (p = 0.08). This difference by hospital was mirrored in focus group feedback. The hospital that experienced a decline in delirium rates was more supportive of the intervention. Overall, post-intervention there were no significant differences in mean length of stay (12 days post versus 14 days pre; p = 0.74), falls (6% post versus 10% pre; p = 0.43) or discharges to long-term care (6% post versus 13% pre; p = 0.20). Translation of evidence-based multi-component delirium prevention strategies into everyday clinical care, using the electronic medical record, was not found to be effective at decreasing delirium rates among hip facture patients.

Harnessing health IT for improved cardiovascular risk management

Robyn Whittaker and colleagues argue that IT-based programs can improve cardiovascular disease management and patient empowerment, but must be accompanied by supportive social and political environments and active patient and clinician engagement.

Automated electronic reminders to facilitate primary cardiovascular disease prevention: randomised controlled trial

BACKGROUND

Primary care databases contain cardiovascular disease risk factor data, but practical tools are required to improve identification of at-risk patients.

AIM

To test the effects of a system of electronic reminders (the 'e-Nudge') on cardiovascular events and the adequacy of data for cardiovascular risk estimation.

DESIGN OF STUDY

Randomised controlled trial.

SETTING

Nineteen general practices in the West Midlands, UK.

METHOD

The e-Nudge identifies four groups of patients aged over 50 years on the basis of estimated cardiovascular risk and adequacy of risk factor data in general practice computers. Screen messages highlight individuals at raised risk and prompt users to complete risk profiles where necessary. The proportion of the study population in the four groups was measured, as well as the rate of cardiovascular events in each arm after 2 years.

RESULTS

Over 38 000 patients' electronic records were randomised. The intervention led to an increase in the proportion of patients with sufficient data who were identifiably at risk, with a difference of 1.94% compared to the control group (95% confidence interval [CI] = 1.38 to 2.50, P<0.001). A corresponding reduction occurred in the proportion potentially at risk but requiring further data for a risk estimation (difference = -3.68%, 95% CI = -4.53 to -2.84, P<0.001). No significant difference was observed in the incidence of cardiovascular events (rate ratio = 0.96, 95% CI = 0.85 to 1.10, P = 0.59).

CONCLUSION

Automated electronic reminders using routinely collected primary care data can improve the adequacy of cardiovascular risk factor information during everyday practice and increase the visibility of the at-risk population.

Effects of automated alerts on unnecessarily repeated serology tests in a cardiovascular surgery department: a time series analysis

Background

Laboratory testing is frequently unnecessary, particularly repetitive testing. Among the interventions proposed to reduce unnecessary testing, Computerized Decision Support Systems (CDSS) have been shown to be effective, but their impact depends on their technical characteristics. The objective of the study was to evaluate the impact of a Serology-CDSS providing point of care reminders of previous existing serology results, embedded in a Computerized Physician Order Entry at a university teaching hospital in Paris, France.

Methods

A CDSS was implemented in the Cardiovascular Surgery department of the hospital in order to decrease inappropriate repetitions of viral serology tests (HBV).

A time series analysis was performed to assess the impact of the alert on physicians' practices. The study took place between January 2004 and December 2007. The primary outcome was the proportion of unnecessarily repeated HBs antigen tests over the periods of the study. A test was considered unnecessary when it was ordered within 90 days after a previous test for the same patient. A secondary outcome was the proportion of potentially unnecessary HBs antigen test orders cancelled after an alert display.

Results

In the pre-intervention period, 3,480 viral serology tests were ordered, of which 538 (15.5%) were unnecessarily repeated. During the intervention period, of the 2,095 HBs antigen tests performed, 330 unnecessary repetitions (15.8%) were observed. Before the intervention, the mean proportion of unnecessarily repeated HBs antigen tests increased by 0.4% per month (absolute increase, 95% CI 0.2% to 0.6%, p < 0.001). After the intervention, a significant trend change occurred, with a monthly difference estimated at -0.4% (95% CI -0.7% to -0.1%, p = 0.02) resulting in a stable proportion of unnecessarily repeated HBs antigen tests. A total of 380 unnecessary tests were ordered among 500 alerts displayed (compliance rate 24%).

Conclusions

The proportion of unnecessarily repeated tests immediately dropped after CDSS implementation and remained stable, contrasting with the significant continuous increase observed before. The compliance rate confirmed the effect of the alerts. It is necessary to continue experimentation with dedicated systems in order to improve understanding of the diversity of CDSS and their impact on clinical practice.

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people

BACKGROUND

The prevalence of obesity is increasing globally and will, if left unchecked, have major implications for both population health and costs to health services.

OBJECTIVES

To assess the effectiveness of strategies to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people.

SEARCH STRATEGY

We updated the search for primary studies in the following databases, which were all interrogated from the previous (version 2) search date to May 2009: The Cochrane Central Register of Controlled Trials (which at this time incorporated all EPOC Specialised Register material) (The Cochrane Library 2009, Issue 1), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and PsycINFO (Ovid). We identified further potentially relevant studies from the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in overweight or obese adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

We included six RCTs, involving more than 246 health professionals and 1324 overweight or obese patients. Four of the trials targeted professionals and two targeted the organisation of care. Most of the studies had methodological or reporting weaknesses indicating a risk of bias.Meta-analysis of three trials that evaluated educational interventions aimed at GPs suggested that, compared to standard care, such interventions could reduce the average weight of patients after a year (by 1.2 kg, 95% CI -0.4 to 2.8 kg); however, there was moderate unexplained heterogeneity between their results (I(2) = 41%). One trial found that reminders could change doctors' practice, resulting in a significant reduction in weight among men (by 11.2 kg, 95% CI 1.7 to 20.7 kg) but not among women (who reduced weight by 1.3 kg, 95% CI -4.1 to 6.7 kg). One trial found that patients may lose more weight after a year if the care was provided by a dietitian (by 5.6 kg, 95% CI 4.8 to 6.4 kg) or by a doctor-dietitian team (by 6 kg, 95% CI 5 to 7 kg), as compared with standard care. One trial found no significant difference between standard care and either mail or phone interventions in reducing patients' weight.

AUTHORS' CONCLUSIONS

Most of the included trials had methodological or reporting weaknesses and were heterogeneous in terms of participants, interventions, outcomes, and settings, so we cannot draw any firm conclusions about the effectiveness of the interventions. All of the evaluated interventions would need further investigation before it was possible to recommend them as effective strategies.

Effect of point-of-care computer reminders on physician behaviour: a systematic review

BACKGROUND

The opportunity to improve care using computer reminders is one of the main incentives for implementing sophisticated clinical information systems. We conducted a systematic review to quantify the expected magnitude of improvements in processes of care from computer reminders delivered to clinicians during their routine activities.

METHODS

We searched the MEDLINE, Embase and CINAHL databases (to July 2008) and scanned the bibliographies of retrieved articles. We included studies in our review if they used a randomized or quasi-randomized design to evaluate improvements in processes or outcomes of care from computer reminders delivered to physicians during routine electronic ordering or charting activities.

RESULTS

Among the 28 trials (reporting 32 comparisons) included in our study, we found that computer reminders improved adherence to processes of care by a median of 4.2% (interquartile range [IQR] 0.8%-18.8%). Using the best outcome from each study, we found that the median improvement was 5.6% (IQR 2.0%-19.2%). A minority of studies reported larger effects; however, no study characteristic or reminder feature significantly predicted the magnitude of effect except in one institution, where a well-developed, "homegrown" clinical information system achieved larger improvements than in all other studies (median 16.8% [IQR 8.7%-26.0%] v. 3.0% [IQR 0.5%-11.5%]; p = 0.04). A trend toward larger improvements was seen for reminders that required users to enter a response (median 12.9% [IQR 2.7%-22.8%] v. 2.7% [IQR 0.6%-5.6%]; p = 0.09).

INTERPRETATION

Computer reminders produced much smaller improvements than those generally expected from the implementation of computerized order entry and electronic medical record systems. Further research is required to identify features of reminder systems consistently associated with clinically worthwhile improvements.