Barriers to the adoption of computerised decision support systems in general practice consultations: a qualitative study of GPs’ perspectives

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Abstract

Introduction: Computerised decision support systems are increasingly important in primary care for the practice of evidence-based medicine and the development of shared GP-patient decision making. However, despite their emergence, such systems have not been entirely embraced by GPs. There is little qualitative research exploring practical barriers to the adoption of decision support systems in this setting. Method: Qualitative interviews with 15 GPs in the West Midlands. Results: Several practical barriers were identified to the use of computerised support systems in primary care consultations. These included limitations of practitioners’ IT skills, problems for GPs in understanding the risk output of systems and GP concerns about communicating risk sufficiently well to patients. Concerns over the time implications of using a system in a consultation was also identified as a barrier. Conclusion: Designers of decision support systems for use in primary care consultations must account for the practical needs of users when developing computerised support systems. Systems must be acceptable to the format of a consultation, include definitions of what output means, and help facilitate dialogue between the GP and the patient.

Introduction

In outlining doctors’ duties and responsibilities, the General Medical Council highlight good communication with patients as an essential component of effective care [1]. One element of this is the need to present information to patients in a way that they can understand and where appropriate to use of “up-to-date written material, visual and other aids to explain complex aspects of the investigation” [2].

Of increasing importance to consultations therefore is the role of computerised decision support systems, which can help facilitate informed doctor–patient dialogue. Examples include structured presentations of the pros and cons of available treatment options and risk presentation tools.

The benefits of support systems for patients have been highlighted in several studies. The authors of a 1999 systematic review of randomised trials of patient decision aids concluded that trials had consistently shown beneficial effects [3]. “Decision aids do a better job than usual care in improving patients’ knowledge about options, reducing their decisional conflict and stimulating patients to take a more active role in decision making without increasing their anxiety.” A more recent literature review of both non-controlled and controlled studies also reported decision aids to be feasible, acceptable to patients and able to increase patients’ knowledge [4]. Subsequent randomised controlled trials of the effects of decision aids have yielded further positive results [5], [6], [7].

The potential benefits to doctors of computerised support systems in consultations are also significant. In addition to aids designed to facilitate improved doctor–patient communication, systems can also offer information intended for the clinician alone. Examples include automated prescribing advice and drug interaction alerts that are displayed when a doctor enters data onto a clinical system. Among the benefits demonstrated by studies are improvements in practitioner performance, reductions in doctors’ uncertainty and increases in levels of satisfaction with consultations [8], [9], [10].

Despite the advantages for both patients and doctors and the fact that the vast majority of general practitioners (GPs) now have access to computers and are increasingly proficient in their use, computerised support systems have not been adopted in primary care as may have been expected [11], [12], [13]. Concerns have been also raised about the role of IT in supporting evidence-based practice by GPs [14].

Integrating computerised decision aids into routine care has been shown to be difficult [15]. Suggested contributing factors include “a lack of agreed national standards, a failure of systems to examine the needs of users adequately, and the profusion of different systems that do not communicate with each other” [12]. Research specifically into the adoption of prognostic models in practice has proposed a lack of clinical credibility and uncertainty concerning the evidence as potential reasons [16].

There has, however, been little qualitative research exploring in depth why support systems are not more readily embraced in primary care. Previous explorations of barriers have tended to be quantitative or focussed upon specific applications and it is argued that such studies do not gain a depth of understanding of the practicalities required of decision aids [17], [18], [19], [20]. Measuring quantifiable benefits of systems are useful but it does not necessarily follow that those with good results will then be used in practice. Qualitative techniques have been used to examine user needs in relation to specific systems and these have highlighted how assumptions made in the design can present practical difficulties for their use in practice [21], [22].

In this paper we report a qualitative study among GPs of the practical barriers to using computerised support systems in general practice consultations. We adopted a broad scope and examined the perceived barriers to using both integrated and non-integrated systems in primary care.

Section snippets

Method

Following approval by the local research ethics committee, interviews were conducted with fifteen GPs from nine practices in the West Midlands. The practices comprise a research network established by the Department of Medicines Management, Keele University. Practices vary in size, type of location and catchment area. All 45 GPs from the network were invited to participate in the study and all of those agreeing to take part were interviewed. Respondents varied in age, sex and length of time

Results

Respondents were largely enthusiastic about the benefits of computerised decision support systems for general practice consultations but several potential barriers to use were identified.

Discussion

Computerised decision support systems can provide valuable information to practitioners and patients during a consultation and they are increasingly an important part of clinical care. They have not, however, been entirely embraced by GPs.

This study has provided fresh insights into generic barriers to their adoption in general practice consultations. A range of reasons have been identified. These include a reluctance by GPs to use systems because of limitations in their IT skills and,

Conclusion

Computerised decision support systems have an important role in promoting evidence-based practice and shared decision making. However, for these to be more readily embraced and become more a part of routine care, designers must consider more the practical circumstances and the knowledge base of potential users.

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