Saleem Jason J, Patterson Emily S, Militello Laura, Render Marta L, Orshansky Greg, Asch Steven M
VA GAPS Center, Cincinnati VAMC, 3200 Vine Street, MDP 111, Cincinnati, OH 45220, USA.
J Am Med Inform Assoc. 2005 Jul-Aug;12(4):438-47. doi: 10.1197/jamia.M1777. Epub 2005 Mar 31.
Evidence-based practices in preventive care and chronic disease management are inconsistently implemented. Computerized clinical reminders (CRs) can improve compliance with these practices in outpatient settings. However, since clinician adherence to CR recommendations is quite variable and declines over time, we conducted observations to determine barriers and facilitators to the effective use of CRs.
We conducted an observational study of nurses and providers interacting with CRs in outpatient primary care clinics for two days in each of four geographically distributed Veterans Administration (VA) medical centers.
Three observers recorded interactions of 35 nurses and 55 physicians and mid-level practitioners with the CRs, which function as part of an electronic medical record. Field notes were typed, coded in a spreadsheet, and then sorted into logical categories. We then integrated findings across observations into meaningful patterns and abstracted the data into themes, such as recurrent strategies. Several of these themes translated directly to barriers and facilitators to effective CR use.
Optimally using the CR system for its intended purpose was impeded by (1) lack of coordination between nurses and providers; (2) using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions; (3) workload; (4) lack of CR flexibility; and (5) poor interface usability. Facilitators included (1) limiting the number of reminders at a site; (2) strategic location of the computer workstations; (3) integration of reminders into workflow; and (4) the ability to document system problems and receive prompt administrator feedback.
We identified barriers that might explain some of the variability in the use of CRs. Although these barriers may be difficult to overcome, some strategies may increase user acceptance and therefore the effectiveness of the CRs. These include explicitly assigning responsibility for each CR to nurses or providers, improving visibility of positive results from CRs in the electronic medical record, creating a feedback mechanism about CR use, and limiting the overall number of CRs.
预防性护理和慢性病管理中的循证实践实施情况并不一致。计算机化临床提醒（CRs）可提高门诊环境中对这些实践的依从性。然而，由于临床医生对CR建议的遵守情况差异很大且会随时间下降，我们进行了观察以确定有效使用CRs的障碍和促进因素。
我们在四个地理位置分布的退伍军人事务部（VA）医疗中心的门诊初级保健诊所，对护士和医疗服务提供者与CRs的交互情况进行了为期两天的观察研究。
三名观察者记录了35名护士、55名医生和中级从业者与作为电子病历一部分的CRs的交互情况。现场记录被打字整理、在电子表格中编码，然后分类到逻辑类别中。然后，我们将观察结果整合为有意义的模式，并将数据提炼为主题，如反复出现的策略。其中几个主题直接转化为有效使用CRs的障碍和促进因素。
（1）护士和医疗服务提供者之间缺乏协调；（2）在未与患者在一起时使用提醒，损害了数据采集和/或推荐行动的实施；（3）工作量；（4）CR缺乏灵活性；（5）界面可用性差，这些因素阻碍了CR系统按其预期目的得到最佳使用。促进因素包括：（1）限制某一地点的提醒数量；（2）计算机工作站的战略位置；（3）将提醒整合到工作流程中；（4）记录系统问题并获得管理员及时反馈的能力。
我们确定了一些可能解释CRs使用中部分差异的障碍。尽管这些障碍可能难以克服，但一些策略可能会提高用户接受度，从而提高CRs的有效性。这些策略包括明确为每个CR指定护士或医疗服务提供者的责任，提高电子病历中CR阳性结果的可见性，建立关于CR使用的反馈机制，以及限制CR的总数。
