A guideline-based computerised decision support system (CDSS) to influence general practitioners management of chronic heart failure.

OBJECTIVES To explore the influence of a guideline-based computerised decision support system (CDSS) on general practitioners' (GPs') management of patient cases of chronic heart failure in a pragmatic clinical situation. We assessed changes in the GPs' confidence in the diagnosis, their considerations about investigations and medications and the support they perceived from using the CDSS. STUDY DESIGN Five GPs assessed the medical records of 48 of their own authentic patient cases using a guideline-based CDSS accessible on the internet for the diagnosis and treatment of chronic heart failure, and completed a questionnaire for each case. OUTCOME MEASURES Number of cases where the GP reported a change in confidence in the diagnosis, where the GP considered further investigations or changes in medication and the perceived support marked on a visual analogue scale. RESULTS The GPs' confidence in the diagnosis changed in 25% of the cases, with equal numbers of increases and decreases in confidence. The GPs considered further investigations in 31% of the cases and medication changes in 19%. Fourteen of the 31 considered investigations and four of the ten considered changes in medications which were in agreement with the CDSS's suggestions. The GPs tended to consider further investigations more often in cases when the CDSS found the diagnosis uncertain. There was a wide range in the values for perceived support, but it could be described as substantial in 35% of the cases. CONCLUSION Using a guideline-based CDSS for the GPs' own patient cases had an impact on the GPs' confidence in the diagnosis of chronic heart failure and their considerations about investigations and medications: they also perceived substantial support in every third case. Applying a CDSS developed using evidence-based guidelines for chronic heart failure in primary care could have a significant influence on GPs' disease management.

[1]  J. Berglund,et al.  Diagnosis and treatment of heart failure in primary health care among elderly patients with non-insulin-dependent diabetes mellitus, with special reference to use of echocardiography , 2003, Scandinavian journal of primary health care.

[2]  Dean F. Sittig,et al.  A survey of factors affecting clinician acceptance of clinical decision support , 2006, BMC Medical Informatics Decis. Mak..

[3]  N. Freemantle,et al.  Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey , 2002, The Lancet.

[4]  W. Remme.  The treatment of heart failure. Task Force of the Working Group on Heart Failure of the European Society of Cardiology. , 1997, European heart journal.

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

[6]  A Hasman,et al.  User satisfaction of general practitioners with HIOS+, a medical decision support system. , 1995, Computer methods and programs in biomedicine.

[7]  Stephan Dreiseitl,et al.  Do physicians value decision support? A look at the effect of decision support systems on physician opinion , 2005, Artif. Intell. Medicine.

[8]  C. McDonald,et al.  Effects of computerized guidelines for managing heart disease in primary care , 2003, Journal of General Internal Medicine.

[9]  R. Haynes,et al.  Effects of Computer-based Clinical Decision Support Systems on Clinician Performance and Patient Outcome: A Critical Appraisal of Research , 1994, Annals of Internal Medicine.

[10]  W. Hammond,et al.  Computerized decision support based on a clinical practice guideline improves compliance with care standards. , 1997, The American journal of medicine.

[11]  L M Irwig,et al.  Evidence‐based medicine: useful tools for decision making , 2001, The Medical journal of Australia.

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

[13]  Johanna I Westbrook,et al.  The Impact of an Online Evidence System on Confidence in Decision Making in a Controlled Setting , 2005, Medical decision making : an international journal of the Society for Medical Decision Making.

[14]  W. Tierney,et al.  A controlled trial of including symptom data in computer-based care suggestions for managing patients with chronic heart failure. , 2004, The American journal of medicine.

[15]  Joyce A. Mitchell,et al.  The clinical value of computerized information services. A review of 98 randomized clinical trials. , 1996, Archives of family medicine.

[16]  Elson Rb,et al.  Computerized decision support systems in primary care. , 1995 .

[17]  R. Haynes,et al.  Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. , 1998, JAMA.

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

[19]  J. Holmen,et al.  Implementing clinical guidelines in the treatment of hypertension in general practice. , 1998, Blood pressure.

[20]  O Bouhaddou,et al.  Implementation of practice guidelines in a clinical setting using a computerized knowledge base (Iliad). , 1993, Proceedings. Symposium on Computer Applications in Medical Care.

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

[22]  Lars-Erik Strender,et al.  Management of heart failure in primary health care. A retrospective study on electronic patient records in a registered population , 2002, Scandinavian journal of primary health care.

[23]  David Parkin,et al.  Effect of computerised evidence based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial , 2002, BMJ : British Medical Journal.

[24]  Julie M. Fiskio,et al.  Technology Evaluation: A Randomized Trial of Electronic Clinical Reminders to Improve Quality of Care for Diabetes and Coronary Artery Disease , 2005, J. Am. Medical Informatics Assoc..

[25]  J. Marc Overhage,et al.  Case Report: Computerizing Guidelines to Improve Care and Patient Outcomes: The Example of Heart Failure , 1995, J. Am. Medical Informatics Assoc..

[26]  E. Shortliffe,et al.  An analysis of physician attitudes regarding computer-based clinical consultation systems. , 1981, Computers and biomedical research, an international journal.

[27]  J. Grimshaw,et al.  Practice based, longitudinal, qualitative interview study of computerised evidence based guidelines in primary care , 2003, BMJ : British Medical Journal.

[28]  Patrik Eklund,et al.  Development and maintenance of guideline-based decision support for pharmacological treatment of hypertension , 2000, Comput. Methods Programs Biomed..

[29]  Blackford Middleton,et al.  A first step towards translating evidence into practice: heart failure in a community practice-based research network. , 2004, Informatics in primary care.

[30]  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.

[31]  T. Payne.  Computer decision support systems. , 2000, Chest.

[32]  J M Grimshaw,et al.  Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. , 1994, Lancet.