The effect of computerized decision support on barriers to guideline implementation: A qualitative study in outpatient cardiac rehabilitation

CONTEXT Computerized decision support systems (CDSSs) can be used to improve the implementation of clinical practice guidelines by changing the behaviour of care professionals. While the influence of system characteristics on the effectiveness of CDSSs is studied, little is known about the relation between cognitive, organizational and environmental factors, and CDSSs' effectiveness. OBJECTIVE To assess the effect of CDSSs on cognitive, organizational, and environmental factors that hamper guideline implementation. DESIGN In-depth, semi-structured interviews with care professionals, on reasons for improved adherence or persistent non-adherence to the prevailing guideline after successful adoption of a CDSS. All remarks regarding guideline implementation were extracted and classified using the conceptual framework from Cabana et al. SETTING Outpatient cardiac rehabilitation clinics. PARTICIPANTS Care professionals that used the CARDSS decision support system for therapeutic decision making in cardiac rehabilitation. RESULTS Twenty-nine rehabilitation nurses and physiotherapists from 21 Dutch clinics were interviewed. CARDSS improved guideline adherence by increasing its users' familiarity with the guidelines' recommendations and decision logic, by overcoming users' inertia to previous practice, and by reducing guideline complexity for example by facilitating calculation and interpretation of data. If the system's recommendations were shared with patients, refusal to participate in therapies reduced. CARDSS never incited users to target barriers related to organizational or environmental constraints. CONCLUSION Our results suggest that computerized decision support can improve guideline implementation by increasing the knowledge of preferred practice, by reducing inertia to previous practice, and by reducing guideline complexity. However, computerized decision support is not effective when organizational or procedural changes are required that users consider to be beyond their tasks and responsibilities.

[1]  E. Balas,et al.  Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success , 2005, BMJ : British Medical Journal.

[2]  J M Grimshaw,et al.  Effectiveness and efficiency of guideline dissemination and implementation strategies , 2004, International Journal of Technology Assessment in Health Care.

[3]  J. Grimshaw,et al.  From best evidence to best practice: effective implementation of change in patients' care , 2003, The Lancet.

[4]  Trisha Greenhalgh,et al.  How to read a paper: Papers that go beyond numbers (qualitative research) , 1997 .

[5]  Martin Eccles,et al.  Implementing clinical guidelines: current evidence and future implications. , 2004, The Journal of continuing education in the health professions.

[6]  M H Trivedi,et al.  Development and Implementation of Computerized Clinical Guidelines: Barriers and Solutions , 2002, Methods of Information in Medicine.

[7]  J. Grimshaw,et al.  Potential benefits, limitations, and harms of clinical guidelines , 1999, BMJ.

[8]  Jeremy M. Grimshaw,et al.  Changing Provider Behavior: An Overview of Systematic Reviews of Interventions , 2001, Medical care.

[9]  Robert Short.  Access to cardiac rehabilitation varies widely across Europe , 2008, BMJ : British Medical Journal.

[10]  H. Mcdonald,et al.  Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. , 2005, JAMA.

[11]  Joan S Ash,et al.  Performing Subjectivist Studies in the Qualitative Traditions Responsive to Users , 2006 .

[12]  D. Littler,et al.  Where are we and where are we going , 2005 .

[13]  N. Oldridge,et al.  Quality of Life After Myocardial Infarction: Translation and Validation of the MacNew Questionnaire for a Dutch Population , 2004, Quality of Life Research.

[14]  Arie Hasman,et al.  Development of a guideline-based decision support system with explanation facilities for outpatient therapy , 2008, Comput. Methods Programs Biomed..

[15]  Sociedade Brasileira de Cardiologia.  Guidelines for cardiac rehabilitation , 2005 .

[16]  Monique W. M. Jaspers,et al.  Subjective usability of the CARDSS guideline-based decision support system , 2008, MIE.

[17]  K Khunti,et al.  Cost-effectiveness of a disease management programme for secondary prevention of coronary heart disease and heart failure in primary care , 2008, Heart.

[18]  A. Hasman,et al.  Effect of guideline based computerised decision support on decision making of multidisciplinary teams: cluster randomised trial in cardiac rehabilitation , 2009, BMJ : British Medical Journal.

[19]  M. Cabana,et al.  Why don't physicians follow clinical practice guidelines? A framework for improvement. , 1999, JAMA.

[20]  Marc Berg,et al.  Implementing information systems in health care organizations: myths and challenges , 2001, Int. J. Medical Informatics.

[21]  Brit Ross Winthereik,et al.  EPRs in the consultation room: A discussion of the literature on effects on doctor-patient relationships , 2006, Ethics and Information Technology.

[22]  Bonnie Kaplan,et al.  Evaluating informatics applications - clinical decision support systems literature review , 2001, Int. J. Medical Informatics.

[23]  Charles P. Friedman,et al.  Evaluation Methods in Medical Informatics , 1997, Computers and Medicine.

[24]  Arie Hasman,et al.  A parallel guideline development and formalization strategy to improve the quality of clinical practice guidelines , 2009, Int. J. Medical Informatics.

[25]  F A Sonnenberg,et al.  Computer-Interpretable Clinical Practice Guidelines , 2006, Yearbook of Medical Informatics.

[26]  Richard N. Shiffman,et al.  Review: Computer-based Guideline Implementation Systems: A Systematic Review of Functionality and Effectiveness , 1999, J. Am. Medical Informatics Assoc..

[27]  J. Grimshaw,et al.  Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations , 1993, The Lancet.

[28]  Anita L. Tucker,et al.  Why Hospitals Don't Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change , 2003 .

[29]  Al Ozonoff,et al.  Effect of an American Heart Association Get With the Guidelines program-based clinical pathway on referral and enrollment into cardiac rehabilitation after acute myocardial infarction. , 2008, The American journal of cardiology.

[30]  H. Dalal,et al.  Cardiac rehabilitation in the United Kingdom , 2008, Heart.