Abstract
BackgroundReal-time clinical decision support (CDS) integrated into clinicians' workflow has the potential to profoundly affect the cost, quality, and safety of health care delivery. Recent reports have identified a surprisingly low acceptance rate for different types of CDS. We hypothesized that factors affecting CDS system acceptance could be categorized as relating to differences in patients, physicians, CDS-type, or environmental characteristics.MethodsWe conducted a survey of all adult primary care physicians (PCPs, n = 225) within our group model Health Maintenance Organization (HMO) to identify factors that affect their acceptance of CDS. We defined clinical decision support broadly as "clinical information" that is either provided to you or accessible by you, from the clinical workstation (e.g., enhanced flow sheet displays, health maintenance reminders, alternative medication suggestions, order sets, alerts, and access to any internet-based information resources).Results110 surveys were returned (49%). There were no differences in the age, gender, or years of service between those who returned the survey and the entire adult PCP population. Overall, clinicians stated that the CDS provided "helps them take better care of their patients" (3.6 on scale of 1:Never – 5:Always), "is worth the time it takes" (3.5), and "reminds them of something they've forgotten" (3.2). There was no difference in the perceived acceptance rate of alerts based on their type (i.e., cost, safety, health maintenance). When asked about specific patient characteristics that would make the clinicians "more", "equally" or "less" likely to accept alerts: 41% stated that they were more (8% stated "less") likely to accept alerts on elderly patients (> 65 yrs); 38% were more (14% stated less) likely to accept alerts on patients with more than 5 current medications; and 38% were more (20% stated less) likely to accept alerts on patients with more than 5 chronic clinical conditions. Interestingly, 80% said they were less likely to accept alerts when they were behind schedule and 84% of clinicians admitted to being at least 20 minutes behind schedule "some", "most", or "all of the time".ConclusionEven though a majority of our clinical decision support suggestions are not explicitly followed, clinicians feel they are of benefit and would be even more beneficial if they had more time available to address them.
Highlights
Real-time clinical decision support (CDS) integrated into clinicians' workflow has the potential to profoundly affect the cost, quality, and safety of health care delivery
Based on our knowledge of the literature and extensive clinical informatics experience, we recognize that there are a myriad of factors associated with clinicians' refusal to accept, or follow, computer-generated, care suggestions based on clinical guidelines including lack of: awareness that the guideline even exists, familiarity with the recommendation, agreement with the suggestion, belief that they could even perform the expected behavior, belief that the expected improvement in outcome will occur, ability to overcome the inertia of previous practice, and the existence of external barriers to the performance of the recommendations [9]
Perhaps the most interesting finding was that specific patient characteristics were associated with the decision to accept or ignore various clinical decision support features
Summary
Real-time clinical decision support (CDS) integrated into clinicians' workflow has the potential to profoundly affect the cost, quality, and safety of health care delivery. Based on our knowledge of the literature and extensive clinical informatics experience, we recognize that there are a myriad of factors associated with clinicians' refusal to accept, or follow, computer-generated, care suggestions based on clinical guidelines including lack of: awareness that the guideline even exists, familiarity with the recommendation, agreement with the suggestion, belief that they could even perform the expected behavior (often referred to as: self-efficacy), belief that the expected improvement in outcome will occur, ability to overcome the inertia of previous practice, and the existence of external barriers to the performance of the recommendations (e.g., no time or no reminder system) [9] In addition to these mostly internal, providerrelated factors, there are many computer-related hypotheses for why clinicians refuse to follow these suggestions including: failure to provide patient-specific information (which was not shown to be a factor in this study) [10], specific aspects of the human-computer interaction surrounding the presentation of the reminders, for example, presenting fully-completed orders that follow the guideline on the same screen as the reminder, rather than placing them "one click away", using a distinctive color scheme to "highlight" the recommendation, disabling the escape key which made it more difficult to override the suggestion, setting the default value of the suggestion to "order" rather than "not to order", and presenting the same reminder over and over to all clinicians who viewed a particular patient's data (i.e., until the suggestion was accepted) [11]. While we were not able to follow all of these "best practices" for the design of interactive clinical decision support features due to inherent limitations of our commercially available EMR and some institutional resistance on the part of clinical and information system administrators, we are doing our best to remove as many potential barriers as possible
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