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

 

Abstract

Background

The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering ‘computer reminders’.

Objectives

To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care.

Search methods

We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles.

Selection criteria

Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care.

Data collection and analysis

Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome.

Main results

Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. 

In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

Authors' conclusions

Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.

 

Plain language summary

On screen point of care computer reminders to improve care and health

It is known that doctors do not always provide the care that is recommended or according to the latest research. Many strategies have been tried in an attempt to reduce this gap between what is recommended and what is done. A potentially low cost way to do this could be to use computer systems that remind physicians about important information while they make decisions. For example, a doctor could be ordering antibiotics for a child with an ear infection. At that point, the computer the doctor is working on displays a pop up window with a reminder about the evidence for the best dose and length of time the antibiotics should be prescribed. 

This review found 28 studies that evaluated the effects of different on-screen computer reminders. The studies tested reminders to prescribe specific medications, to warn about drug interactions, to provide vaccinations, or to order tests.  The review found small to moderate benefits. The reminders improved physician practices by a median of 4%. In eight of the studies, patients' health improved by a median of 3%.   

Although some studies showed larger benefits than these median effects, no specific reminders or features of how they worked were consistently associated with these larger benefits. More research is needed to identify what types of reminders work and when.

 

摘要

背景

使用電腦營幕進行重點照護提示,對於照護過程與預後的影響

當臨床醫師在進行的重點照護時，透過傳送決策支持來增進品質，是實施先進的臨床信息系統的主要誘因之一。以前關於電腦提示和決策支持系統的回顧研究顯示不一致的結果，可能是因為他們沒有將電腦營幕重點照護提示與下列方式做區分：如電子郵件警報，電腦產生的文件提醒，和其他方式傳送的電腦提示。

目標

評估由電腦營幕直接提示對臨床醫師在照護過程與預後之影響。

搜尋策略

我們檢索了Cochrane EPOC 登記試驗， MEDLINE，EMBASE，CINAHL，及CENTRAL(至2008年7月)等資料庫，並檢索關鍵文章的參考書目。

選擇標準

研究對象為經常使用電腦提示的臨床醫師，研究設計為隨機或半隨機設計，且結果參數至少一項涉及臨床性終點或對提示所建議照護事項的遵從性。

資料收集與分析

兩位作者獨立篩選研究和提取數據。對於每一個研究中，我們計算了醫囑遵從性的平均值與最大改善值。接著，我們使用每一個研究裡的平均結果與最佳結果來計算最後的醫囑遵從性之絕對改善平均值。

主要結論

28個研究(共32比較性的報告)被納入。統計所有研究報告，電腦提示的醫囑遵從改善度為4.2％(IQR：0.8％至18.8％)，開藥醫囑改善度3.3％(IQR：0.5％至10.6％)，注射疫苗改善度為3.8％(IQR：0.5％至6.6％)，檢查醫囑改善度為3.8％(IQR：0.4％至16.3％)。若使用每篇報告最好結果來進行敏感度分析，，則流程遵從性的改善度為 5.6％(IQR：2.0％至19.2％)，開藥醫囑改善度為6.2％(IQR：3.0％至28.0％)。在8個報告裡使用二分臨床終點，實驗組受試者絕對平均改善度為2.5％(IQR：1.3％至4.2％)。血壓是最常見的臨床終點，實驗組受試者平均減少其收縮壓 1.0毫米汞柱(IQR：下降2.3毫米汞柱到增加2.0毫米汞柱)。

作者結論

床邊電腦提示對於改善醫療服務提供者的行為平均而言，只達到小到中等的程度。少數的介入措施會有較大的影響，但沒有特別的提示工具或相關因子與影響的程度有顯著相關。如果電腦提示要獲得認定，必須進一步研究探討設計特點和情境關聯的因素是否能對醫療服務提供者的行為產生持續且較大的改善。而且必須多個研究報告均支持它的效果。

翻譯人

本摘要由高雄榮民總醫院王立峰翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

據了解，醫生並不總是根據最新的研究結果來提供照護。很多策略試圖來減少這種被建議執行與實際執行間的醫療差距。為了達到此目標，使用電腦系統是一個花費成本較低的方式，提醒醫師有關的重要資料，而使他們作出決定。例如，醫生可以為耳部感染孩子開立抗生素。在這時候，醫生的電腦上會顯示一個彈出窗口，提醒最佳劑量和時間的長短，及應使用抗生素的最佳證據。本回顧研究發現，有28個研究，評估不同的電腦營幕提醒效果(這些研究測試的內容包括：提醒某些特殊藥品的給予，警示藥物相互作用，疫苗接種規定，或開立檢查醫囑)，結論為小到中等等程度的好處，即提示系統對醫生的醫療行為改善度為4％。在其中8個研究裡，病人的健康改善度為3％。儘管有些研究顯示有較大的好處，但是並未具體的顯示這些提示功能是如何運作以持續造成這些更大的好處。因此，我們需要更多的研究來確定哪些類型的提醒有用與何時使用。