Evaluation of computer support for prescribing (CAPSULE) using simulated cases

Abstract Objective: To evaluate the potential effect of computer support on general practitioners' prescribing, and to compare the effectiveness of three different support levels. Design: Crossover experiment with balanced block design. Subjects: Random sample of 50 general practitioners (42 agreed to participate) from 165 in a geographically defined area of Oxfordshire. Interventions: Doctors prescribed for 36 simulated cases constructed from real consultations. Levels of computer support were control (alphabetical list of drugs), limited support (list of preferred drugs), and full support (the same list with explanations available for suggestions). Main outcome measures: Percentage of cases where doctors ignored a cheaper, equally effective drug; prescribing score (a measure of how closely prescriptions matched expert recommendations); interview to elicit doctors' views of support system. Results: Computer support significantly improved the quality of prescribing. Doctors ignored a cheaper, equally effective drug in a median 50% (range 25%-75%) of control cases, compared with 36% (8%-67%) with limited support and 35% (0-67%) with full support (P<0.001). The median prescribing score rose from 6.0 units (4.2-7.0) with control support to 6.8 (5.8 to 7.7) and 6.7 (5.6 to 7.8) with limited and full support (P<0.001). Of 41 doctors, 36 (88%) found the system easy to use and 24 (59%) said they would be likely to use it in practice. Conclusions: Computer support improved compliance with prescribing guidelines, reducing the occasions when doctors ignored a cheaper, equally effective drug. The system was easy to operate, and most participating doctors would be likely to use it in practice.

[1]  F. Mosteller,et al.  A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts. Treatments for myocardial infarction. , 1992, JAMA.

[2]  C. McDonald,et al.  Reminders to physicians from an introspective computer medical record. A two-year randomized trial. , 1984, Annals of internal medicine.

[3]  J. Grimshaw,et al.  Achieving health gain through clinical guidelines. I: Developing scientifically valid guidelines. , 1993, Quality in health care : QHC.

[4]  C J McDonald,et al.  Standard formats for electronic transfer of clinical data. , 1989, Annals of internal medicine.

[5]  Norton Pg,et al.  Self-audit: its effect on quality of care. , 1985 .

[6]  J. Wise.  Computer prescribing scheme gets green light , 1996 .

[7]  C J McDonald,et al.  Physician response to computer reminders. , 1980, JAMA.

[8]  John Fox,et al.  Logic engineering for knowledge engineering: design and implementation of the Oxford System of Medicine , 1990, Artif. Intell. Medicine.

[9]  C. Mc Donald,et al.  Use of a computer to detect and respond to clinical events: its effect on clinician behavior. , 1976, Annals of internal medicine.

[10]  C. McDonald.  Protocol-based computer reminders, the quality of care and the non-perfectability of man. , 1976, The New England journal of medicine.

[11]  C J McDonald,et al.  The Regenstrief medical record: 1991 a campus-wide system. , 1991, Proceedings. Symposium on Computer Applications in Medical Care.

[12]  D. Altman,et al.  STATISTICAL METHODS FOR ASSESSING AGREEMENT BETWEEN TWO METHODS OF CLINICAL MEASUREMENT , 1986, The Lancet.

[13]  D. Spiegelhalter,et al.  Evaluating medical expert systems: what to test and how? , 1990, Medical informatics = Medecine et informatique.

[14]  M. Daschbach,et al.  Initiation of warfarin therapy: comparison of physician dosing with computer-assisted dosing. , 1987, Journal of general internal medicine.

[15]  J P Ornato,et al.  Computer-assisted optimization of aminophylline therapy in the emergency department. , 1989, The American journal of emergency medicine.

[16]  K. N. Williams,et al.  Effect of medical care review on the use of injections: a study of the New Mexico Experimental Medical Care Review Organization. , 1976, Annals of internal medicine.

[17]  T A Pryor,et al.  Application of a computerized medical decision-making process to the problem of digoxin intoxication. , 1984, Journal of the American College of Cardiology.

[18]  J G Sotos.  MYCIN and NEOMYCIN: two approaches to generating explanations in rule-based expert systems. , 1990, Aviation, space, and environmental medicine.