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This study explored implementation and use of automatic, guideline-based reminders and related factors among primary care nurses. After one year, nurses reported only minor use of the new clinical decision support service as well as many practical
  1  AUTOMATIC GUIDELINE-BASED REMINDERS – WHAT DO PRIMARY CARENURSES SAY AFTER 1 YEAR?T. Kortteisto 1 , J. Komulainen 2 , M. Kaila 11 University of Tampere, Tampere, Finland 2 National Institute for Health and Welfare and the Finnish Medical Society Duodecim,Helsinki, Finland Summary This study explored implementation and use of automatic, guideline-based remindersand related factors among primary care nurses. After one year, nurses reported onlyminor use of the new clinical decision support service as well as many practical barriersfor the implementation of automatic reminders. Active implementation efforts should becontinued for facilitate uptake in the future, and first of all, to develop CDS reminders tobetter fulfill nurses’ information needs in primary care. Key words : automatic reminder, clinical decision support, guideline, implementation,primary care nurse Introduction Computer-based clinical decision support (CDS), e.g. automatic guideline-basedreminders, combines medical evidence with individual patient data and producesrecommendations for aiding professionals’ decision making in patient care (1). Fromreviewing of the literature it appears that CDS can improve healthcare professionals’performance and, in some cases, patient outcomes (2-4). However, these evaluatedsystems varied greatly in design, the majority of targeting only a single and specificdisease or a clinical circumstance, e.g. management of asthma or anti-coagulant therapy(5). There is a lack of evidence as to how well a more general computer-based CDSworks, particularly in primary care, where there is a wide variety of clinical areas (6, 7),and in nurse practice (8). There is also a need for qualitative evaluation, e.g. howprofessionals feel about CDS and its impact on their work (9, 10).Evidence-Based Medicine electronic Decision Support, EBMeDS, is a new Finnishinformation technology service (11). There are around 300 guideline-based reminder descriptions in the EBMeDS database (12). Many more reminders are generated using  2 available drug databases, e.g. those on interactions, contraindications and indications.The EBMeDS service was integrated within the Mediatri patient record system (13) andintroduced into clinical practice in Sipoo primary care in June 2009. Patient-specificautomatic reminders (see table 1) and diagnosis-based guideline links are shown oncomputer screen for nurses, physicians, and physiotherapists (altogether 46), when theyuse the Mediatri while seeing their patients.Table1. Patient-specific reminder with additional guidance for nurses in brackets; threeexamples that were hypothesized beneficial for nurse practice Message to intensifydyslipidaemia therapy inpatients with establishedcardiovascular disease(script 437) This patient has cardiovascular disease and an LDL-cholesterol concentration above the target value – thetarget value is below 2.5 mmol/l, and the optimalvalue is below 2.0 mmol/l. [Intensify dietaryintervention. Consult a doctor if it is not successfulwithin 3 months.] Reminder of elevatedfasting blood glucose(script 110) This patient‘s fasting glucose is significantly increasedsuggesting diabetes. Consider repeating the test or carrying out an oral glucose tolerance test. Encourageweight reduction and exercise. [Consult a doctor if theresult is repeatedly abnormal.] Diabetes risk test for patients with BMI above30 (script 86) This patient is overweight and his/her blood glucosehas not been measured during the last two years.Consider having the patient fill in the diabetes risk testquestionnaire. Consider preventive lifestyle changes if the risk of diabetes is increased (score 12 or higher). Objectives The study aims were to assess the use of automatic reminders and guideline linksamong nurses and to clarify their opinions about factors helping or hindering the uptakeof the CDS in primary care. Methods  3 The data were gathered using multiple methods (14); the Mediatri-based feedbacksystem, questionnaires, and focus group interviews. By using the Mediatri-basedfeedback channel professionals were able to send their spontaneous feedbackmessages immediately to researchers without any extra work. The feedback data wereplanned to analyze with descriptive method, but in the study period, there were nofeedback messages from the nurses. A before-after design survey with a questionnaire was performed in April 2009 and inSeptember 2010. The first round questionnaire was designed by the EBMeDS studygroup based on previous study (15). It was composed of 26 questions with specific items;use of the Mediatri, care of patient with increased blood glucose, job content andbackground. In the second round questionnaire, ten questions concerning of theEBMeDS service were added. Comparative analysis had been planned, but because of respondents’ drop out and turnover between the rounds only descriptive statistic wasperformed.In January 2010, after six months of introducing the EBMeDS, focus group interviewswere convened in the health centre. Altogether five nurses (at least one representativefrom preventive care, general nurse practice, and two wards) participated with twogroups. A broad discussion theme was used, and the group discussion was audio tapedand transcribed (16). The data were content analyzed with NVivo 8 software. Results The survey participants were 24 out of 26 nurses in the first round (response rate 92%)and 14 out of 24 nurses in the second round (response rate 58%).The nurserepresentatives in focus groups as well as the survey respondents reported onlyoccasional use of the EBMeDS service, and 29% of nurses reported that they did not usereminders at all (table 2). Table2. The EBMeDS service use among nurses (n = 14)OftenOccasionalNot at allReminders7%64%29%Guideline links14%43%43%  4  A majority of the nurses chose “I can not say” option for the questions concerning theEBMeDS service’s capacity, quality and usability (table 3).Table3. The EBMeDS service’s capacity, quality and usability: percentage valueYesNoCan not sayEasy to use (n = 13)31861Rapid enough (n = 13)46-54Reliable (n = 12)58-42Quality (n = 12)25-75Helps my work (n = 12)252550Effects on my decisions (n = 12 )83359Barriers for implementation and use of automatic CDS were identified: 1) existingreminders and guideline links were not essential for preventive care work, 2) reminderswere impractical for call centre work of nurses, 3) limited time per patient for generalpractice nurses, 4) old habits for seeking and using information in general, and 5) extrawork load with swine flu epidemic and vaccination between October 2009 and January2010. Also facilitators for implementation and use were reported: 1) positive attitudes towardsuse and usefulness of computer-based CDS, 2) more training and time for learning touse a new service, 3) dedicated nurse practice in future e.g. asthma nurse practice, and4) personal experience with the use of CDS. Discussion Nurses reported minimal use of the automatic guideline-based reminders as well asmany practical barriers for uptake these in nurse practice. From the identified barriers,only work load and limited time per patient features were absolutely comparable with theprevious studies (17-19). The swine flu epidemic was an external factor, which had aunique influence on the nurse practice for many months.Most of the participated nurses could not say where automatic reminders were or couldbe beneficial for their work. In addition, there was zero spontaneous feedback from thenurses. These indicate a failure of the EBMeDS service’s implementation for nurse  5 practice. However, the nurses, who responded to use automatic reminders often or sometimes, also reported that these were of good quality and reliable, and the EBMeDSservice worked rapidly enough. These features have been previously demonstratedsuccessful factors of the CDS systems (4).In conclusion, the developers’ hypothesis of easy to use and self-direct reminders wasnot fulfilled. On the contrary, more attention should be paid to instruct nurses on utilizingthe CDS service in practice, and first of all, to develop CDS reminders to better fulfillnurses’ information needs in primary care. References 1.Greenes RA. Definition, scope, and challenges. Boston: Elsevier; 2007.2.Bates DW, Gawande AA. Improving safety with information technology. N Engl JMed. 2003 Jun 19;348(25):2526-34.3.Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, BeyeneJ, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Jama. 2005 Mar 9;293(10):1223-38.4.Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practiceusing clinical decision support systems: a systematic review of trials to identify featurescritical to success. Bmj. 2005 Apr 2;330(7494):765.5.Berlin A, Sorani M, Sim I. A taxonomic description of computer-based clinicaldecision support systems. J Biomed Inform. 2006 Dec;39(6):656-67.6.Bryan C, Boren SA. The use and effectiveness of electronic clinical decisionsupport tools in the ambulatory/primary care setting: a systematic review of the literature.Inform Prim Care. 2008;16(2):79-91.7.Varonen H, Kaila M, Kunnamo I, Komulainen J, Mantyranta T. [With computer-based decision support toward resourceful patient record]. Duodecim.2006;122(10):1174-81.8.Weber S. Critical care nurse practitioners and clinical nurse specialists interfacepatterns with computer-based decision support systems. J Am Acad Nurse Pract. 2007Nov;19(11):580-90.
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