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PubMed2004

An adoption study of a clinical reminder system in ambulatory care using a developmental trajectory approach.

In this study, we assess 41 medical residents' acceptance and adoption of a clinical reminder system for chronic disease and preventive care management in the ambulatory care environment using a novel developmental trajectory approach. This group-based, semi-parametric statistical modeling method identifies distinct groups, following distinct usage trajectories, among those who recorded use of the reminder system within an evaluation period of 10 months. We trace system use within these groups over time using computer-generated logs and user satisfaction surveys. Our preliminary analysis of this small sample of users delineates three categories of users. Feedback from these categories of users is being used to re-engineer the application and adapt it better to their workflow and functionality requirements. Despite the small sample size in this particular study, we conclude that this methodology has considerable promise to provide new insights into system usability and adoption issues that may benefit clinical decision support systems as well as information systems more generally.

Ambulatory Care↗

PubMed2005

Understanding technology adoption in clinical care: clinician adoption behavior of a point-of-care reminder system.

BACKGROUND: Evaluation studies of clinical decision support systems (CDSS) have tended to focus on assessments of system quality and clinical performance in a laboratory setting. Relatively few studies have used field trials to determine if CDSS are likely to be used in routine clinical settings and whether reminders generated are likely to be acted upon by end-users. Moreover, such studies when performed tend not to identify distinct user groups, nor to classify user feedback. AIM: To assess medical residents' acceptance and adoption of a clinical reminder system for chronic disease and preventive care management and to use expressed preferences for system attributes and functionality as a basis for system re-engineering. DESIGN OF STUDY: Longitudinal, correlational study using a novel developmental trajectory analysis (DTA) statistical method, followed by a qualitative analysis based on user satisfaction surveys and field interviews. SETTING: An ambulatory primary care clinic of an urban teaching hospital offering comprehensive healthcare services. 41 medical residents used a CDSS over 10 months in their daily practice. Use of this system was strongly recommended but not mandatory. METHODS: A group-based, semi-parametric statistical modeling method to identify distinct groups, with distinct usage trajectories, followed by qualitative instruments of usability and satisfaction surveys and structured interviews to validate insights derived from usage trajectories. RESULTS: Quantitative analysis delineates three types of user adoption behavior: "light", "moderate" and "heavy" usage. Qualitative analysis reveals that clinicians of distinct types tend to exhibit views of the system consistent with their demonstrated adoption behavior. Drawbacks in the design of the CDSS identified by users of all types (in different ways) motivate a redesign based on current physician workflows. CONCLUSION: We conclude that this mixed methodology has considerable promise to provide new insights into system usability and adoption issues that may benefit clinical decision support systems as well as information systems more generally.

Attitude of Health Personnel↗

PubMed2006

Diagnostic omission errors in acute paediatric practice: impact of a reminder system on decision-making.

BACKGROUND: Diagnostic error is a significant problem in specialities characterised by diagnostic uncertainty such as primary care, emergency medicine and paediatrics. Despite wide-spread availability, computerised aids have not been shown to significantly improve diagnostic decision-making in a real world environment, mainly due to the need for prolonged system consultation. In this study performed in the clinical environment, we used a Web-based diagnostic reminder system that provided rapid advice with free text data entry to examine its impact on clinicians' decisions in an acute paediatric setting during assessments characterised by diagnostic uncertainty. METHODS: Junior doctors working over a 5-month period at four paediatric ambulatory units consulted the Web-based diagnostic aid when they felt the need for diagnostic assistance. Subjects recorded their clinical decisions for patients (differential diagnosis, test-ordering and treatment) before and after system consultation. An expert panel of four paediatric consultants independently suggested clinically significant decisions indicating an appropriate and 'safe' assessment. The primary outcome measure was change in the proportion of 'unsafe' workups by subjects during patient assessment. A more sensitive evaluation of impact was performed using specific validated quality scores. Adverse effects of consultation on decision-making, as well as the additional time spent on system use were examined. RESULTS: Subjects attempted to access the diagnostic aid on 595 occasions during the study period (8.6% of all medical assessments); subjects examined diagnostic advice only in 177 episodes (30%). Senior House Officers at hospitals with greater number of available computer workstations in the clinical area were most likely to consult the system, especially out of working hours. Diagnostic workups construed as 'unsafe' occurred in 47/104 cases (45.2%); this reduced to 32.7% following system consultation (McNemar test, p < 0.001). Subjects' mean 'unsafe' workups per case decreased from 0.49 to 0.32 (p < 0.001). System advice prompted the clinician to consider the 'correct' diagnosis (established at discharge) during initial assessment in 3/104 patients. Median usage time was 1 min 38 sec (IQR 50 sec-3 min 21 sec). Despite a modest increase in the number of diagnostic possibilities entertained by the clinician, no adverse effects were demonstrable on patient management following system use. Numerous technical barriers prevented subjects from accessing the diagnostic aid in the majority of eligible patients in whom they sought diagnostic assistance. CONCLUSION: We have shown that junior doctors used a Web-based diagnostic reminder system during acute paediatric assessments to significantly improve the quality of their diagnostic workup and reduce diagnostic omission errors. These benefits were achieved without any adverse effects on patient management following a quick consultation.

Adolescent↗

PubMed1996

An office system for organizing preventive services: a report by the American Cancer Society Advisory Group on Preventive Health Care Reminder Systems.

Despite increasing recognition of the importance of preventive services, such services are not provided in primary care practice as often as recommended. One of the most important reasons is the lack of a systematic, organized approach within practices. The American Cancer Society Ad Hoc Advisory Group on Preventive Health Care Reminder Systems reviewed evidence-based reports and expert opinion to summarize current knowledge about office systems for clinical preventive services. This article describes the process of developing an office system for preventive care, beginning with writing a practice policy, auditing charts for baseline performance, developing and implementing a plan for efficient delivery of preventive care, involving office staff, and monitoring progress. Strategies for dissemination of this approach to a wide range of primary care practices may involve professional medical organizations and managed care companies.

Ambulatory Care Information Systems↗

PubMedDate not supplied

Developing an educational reminder system for a handheld encounter log.

BACKGROUND AND OBJECTIVES: Medical students increasingly log patient encounters on handheld computers. Detailed patient records captured at the bedside would allow these log programs to complement medical education with automated reminders. We evaluated progress toward this goal. METHODS: A series of electronic student encounter logs (ESEL) were designed to quickly record common diagnoses in a family medicine clerkship. Common diagnoses were organized in a shallow, broad-tree structure that locates many concepts with one to four taps. Third-year clerks' ESEL records of patient problems were evaluated longitudinally and across two similar clerkships. Grading criteria were introduced to encourage attention to target problems, especially infrequently reported psychosocial issues. A pilot reminder system in ESEL-4, the latest version of the computer application program, included 17 high-specificity reminders. Students' viewing of reminders was monitored. RESULTS: Students recorded complex patients in ESEL-4 and entered 80% of patients during office hours. ESEL grading generated anxiety but was associated with significantly increased and plausible documentation of tobacco abuse, depression, and alcohol abuse. Students viewed titles of about 25% of generated reminders but reviewed less than 1% of reminders in detail. CONCLUSIONS: Students using ESEL-4 document plausibly complex patients, usually during office hours. Grading probably improves completeness and accuracy. Diagnosis-driven educational reminder systems are possible but do not yet capture students' attention.

Adult↗

PubMed1999

Development of a reminder system for general practitioners.

In this contribution we describe a prototype reminder system that has been developed to influence General Practitioners' (GP) test request behaviour. It is intended to substitute conventional written feedback by human experts. The system generates critical comments about the rationality of the test request at the moment the GP requests a test that is not in line with national or regional guidelines.

Artificial Intelligence↗

PubMedDate not supplied

Can computerized reminder systems have an impact on preventive services in practice?

This report reviews computerized reminder systems for tracking health maintenance in clinical practice and discusses the features of a useful, cost-effective system. Systems presently available are predominantly designed for large groups. The primary product of these systems is a health maintenance status report for the provider that is generated at each patient visit. Systems for smaller groups that will generate reminders for providers and patients at specified appropriate intervals and will easily send reminders to patients who do not have appointments or are inactive are not available. Necessary features of such "ideal" computerized tracking systems include: 1) Demographic data must be obtainable from the practice's billing system and not require separate data entry. 2) Data entry must be quick, preferably single-screen. 3) Multiple-entry options must be available for each procedure. 4) The system must generate reminders regardless of whether a patient has an appointment. 5) Providers must be able to specify or cancel patient reminders. 6) A status report must be created for the chart at specified intervals. 7) The frequency and description of indicated procedures must be modifiable without programmer assistance.

Ambulatory Care Information Systems↗

PubMed2003

Benefits of seat belt reminder systems.

This study sought to determine whether fitting a more aggressive seat belt reminder system to new vehicles would be cost-beneficial for Australia. While seat belt wearing rates have been observed around 95% in the front seat, non-wearing rates in casualty crashes are as high as 33% among persons killed and 19% among seriously injured occupants. Benefits were computed for three device options (simple, simple-2 and complex) and three introduction scenarios (driver-only, front seat occupants and all occupants). Four levels of effectiveness were assumed, from 10% to 40%, depending on the type of device fitted. Unit benefits were computed assuming a 5% discount rate and a 15yr fleet life. Various industry experts provided the costs. The findings showed that Benefit-Cost-Ratios ranged from 4.0:1 at best (simple device for the driver only) to 0.9:1 for all seating positions. These figures are conservative, given the assumptions made and the discounted human capital methods used.

Accidents, Traffic↗

PubMed2001

Effectiveness of reminder systems on appointment adherence rates.

The aim of this study was to determine the impact of reminder systems on appointment nonadherence rates in an low-income inner-city clinic population. A total of 2,304 consenting patients were randomly assigned to one of three groups: (1) automated telephone reminder, (2) postcard reminder, or (3) no reminder. In contrast with research on other populations, the results of this study demonstrated no significant difference in appointment adherence rates among the three groups. To aid in the development of more effective interventions in the future, individuals not attending their scheduled appointments were interviewed by telephone to determine reason for nonadherence.

Appointments and Schedules↗

PubMed1986

Evaluation of a computerized reminder system in the enhancement of patient medication refill compliance.

This study evaluated the use of a computerized patient profile combined with a reminder system to increase refill compliance of patients on cardiovascular medications. There were 311 patients randomly assigned into one of three groups. Patients in group 1 were monitored for refill compliance only. Group 2 patients received a postcard reminder; group 3 patients received a telephone call reminder. Refill compliance was monitored via the computerized patient profile system for a period of three months. Data collection included refill compliance, reasons for noncompliance, and the number of prescription medications for each patient. There was a significant difference between the overall mean rate of compliance between the control and intervention groups. An increase in refill compliance for all groups occurred over three months. There was no significant difference in compliance between the treatment groups. Overall, the medication reminder system appeared to be effective; however, modifications in the system should be pursued.

Ambulatory Care↗

PubMed2001

Use of seat belts in cars with different seat belt reminder systems. A study of injured car drivers.

The use of seat belts in cars with different seat belt reminder systems was analyzed in a population of 477 injured car drivers, transported by ambulance to Umeå University Hospital after car crashes. The ambulance personnel acted as independent observers regarding the use of seat belts. In this population the non-users were significantly (multivariate logistic regression) fewer (12%) in cars with a combined light and sound reminder, compared to cars without reminder (23%). In cars with only a light signal the proportion of non-users was the same as in cars without any reminder at all. An introduction of more effective reminders, at least in new cars, might be an effective way to increase seat belt usage rates in the long-term.

Accidents, Traffic↗

PubMedDate not supplied

A randomised, clinical trial comparing the effectiveness of hospital and community-based reminder systems for increasing uptake of influenza and pneumococcal vaccine in hospitalised patients aged 65 years and over.

Hospitalisation represents an opportunity to identify unimmunised people at risk for the complications of influenza and pneumococcal disease. We conducted a randomised controlled trial of two strategies to increase uptake of influenza and pneumococcal vaccines in eligible, hospitalised subjects aged 65 years or more, admitted between May and September 1998 to a Melbourne hospital. Unvaccinated participants were allocated randomly to alert systems for hospital staff or community general practitioners (GPs). Follow-up occurred at 1 and 3 months. The baseline vaccination rates were 70% for influenza (426/606) and 41% (248/606) for pneumococcal disease. For unvaccinated subjects, the hospital alert resulted in 67% uptake compared to 55% following a GP alert for pneumococcal vaccine; and 63% in hospital compared to 53% following a GP alert for influenza vaccine. Although there was a trend toward a higher uptake in hospital, neither of these differences was statistically significant. The majority (75%) of vaccinations following a GP alert occurred within 1 month of discharge. Despite hospital and community-based reminder systems, there are still significant missed opportunities for vaccination. We did not demonstrate significant differences between hospital and GP reminder systems, but there was a trend towards higher uptake with opportunistic vaccination in hospital.

Aged↗

PubMed1995

The effects of a computer-assisted reminder system on patient compliance with recommended health maintenance procedures.

In June of 1993 we implemented a computer-assisted reminder system in the outpatient clinic of an 18 resident family practice training program. The system notifies both patients and physicians of recommended health maintenance procedures. In the 22 months following implementation we documented a rapid increase in physician and patient compliance with several disease screening and prevention services. Despite high physician compliance, we were unable to increase patient compliance rates above 70% for any procedure. At the end of the study period patient compliance varied from a low of 26.7% for sigmoidoscopy to a high of 61.7% for pneumococcal pneumonia vaccination. We feel this study has important implications for the US Public Health Service's preventive services screening goals for the year 2000.

Ambulatory Care Facilities↗

PubMed2003

Electronic human immunodeficiency virus (HIV) clinical reminder system improves adherence to practice guidelines among the University of Washington HIV Study Cohort.

We conducted a prospective study of an electronic clinical reminder system in an academic medical center-based human immunodeficiency virus (HIV) specialty clinic. Published performance indicators were used to examine adherence to HIV practice guidelines before and after its implementation for 1204 patients. More than 90% of patients received CD4 cell count and HIV type 1 (HIV-1) RNA level monitoring every 3-6 months during both time periods, and approximately 80% of patients with a CD4 cell count nadir of <350 cells/mm(3) received highly active antiretroviral therapy. Patients were significantly more likely to receive prophylaxis against Mycobacterium avium complex (hazard ratio, 3.84; 95% confidence interval [CI], 1.58-9.31; P=.003), to undergo annual cervical carcinoma screening (OR, 2.09; 95% CI, 1.04-4.16; P=.04), and to undergo serological screening for Toxoplasma gondii (odds ratio [OR], 1.86; 95% CI, 1.05-3.27; P=.03) and syphilis infection (OR, 3.71; 95% CI, 2.37-5.81; P<.0001). HIV clinical reminders delivered at the time that HIV care is provided were associated with more timely initiation of recommended practices.

Anti-HIV Agents↗

PubMed2004

[Developing a computerized reminder system and evaluating the effects on the improvemtent of cancer screening].

PURPOSE: This study was aimed to develop a computerized reminder system and evaluate it's effect in terms of percent age change of screening, and satisfaction. METHOD: It was conducted through 6 phases : Analyzing the job and defining the basic input data, developing the information system, collecting and inputing data, testing the system, working with the system, and evaluating it's effect. Participants were 787 people (female 30-69 years, and males 40-49 years) in 2 dong of Suyoung gu, Busan, who haven't had cancer screening for the stomach, breast, or cervix since Dec. 2000. There were three experimental groups: a letter; calling and calling after the letter reminder, and a non-equivalent control group. To determine whether services were obtained, a telephone survey was done after two months of follow-up. RESULT: A cancer screening information system with five DB modules was developed. Overall compliance with screening was not statistically significantly changed before and after applying computerized reminders for all three screening sites. Only 16% were satisfied with the reminder. CONCLUSION: This data didn't show that a reminder effort was effective of screening. However, because the evaluation interval was too short to find a difference in screening rate, we recommend additional longer prospective follow up studies.

Adult↗

PubMed2006

Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study.

BACKGROUND: Computerized decision support systems (DSS) have mainly focused on improving clinicians' diagnostic accuracy in unusual and challenging cases. However, since diagnostic omission errors may predominantly result from incomplete workup in routine clinical practice, the provision of appropriate patient- and context-specific reminders may result in greater impact on patient safety. In this experimental study, a mix of easy and difficult simulated cases were used to assess the impact of a novel diagnostic reminder system (ISABEL) on the quality of clinical decisions made by various grades of clinicians during acute assessment. METHODS: Subjects of different grades (consultants, registrars, senior house officers and medical students), assessed a balanced set of 24 simulated cases on a trial website. Subjects recorded their clinical decisions for the cases (differential diagnosis, test-ordering and treatment), before and after system consultation. A panel of two pediatric consultants independently provided gold standard responses for each case, against which subjects' quality of decisions was measured. The primary outcome measure was change in the count of diagnostic errors of omission (DEO). A more sensitive assessment of the system's impact was achieved using specific quality scores; additional consultation time resulting from DSS use was also calculated. RESULTS: 76 subjects (18 consultants, 24 registrars, 19 senior house officers and 15 students) completed a total of 751 case episodes. The mean count of DEO fell from 5.5 to 5.0 across all subjects (repeated measures ANOVA, p < 0.001); no significant interaction was seen with subject grade. Mean diagnostic quality score increased after system consultation (0.044; 95% confidence interval 0.032, 0.054). ISABEL reminded subjects to consider at least one clinically important diagnosis in 1 in 8 case episodes, and prompted them to order an important test in 1 in 10 case episodes. Median extra time taken for DSS consultation was 1 min (IQR: 30 sec to 2 min). CONCLUSION: The provision of patient- and context-specific reminders has the potential to reduce diagnostic omissions across all subject grades for a range of cases. This study suggests a promising role for the use of future reminder-based DSS in the reduction of diagnostic error.

Analysis of Variance↗

PubMed2001

Evaluation of Baby Advocate, a childhood immunization reminder system.

Childhood immunizations, based on CDC recommendations, are recognized as a cost effective and health promoting practice. However, ensuring full immunization requires a long-term commitment on the part of parents and providers. This article describes a program at Advocate Health care to increase the percentage of children fully immunized at two years to 90%. Termed Baby Advocate, the program uses a mailed reminder system that includes vaccine and growth and development information along with gifts and incentives. Volume, satisfaction and immunization status data are presented.

Chicago↗

PubMed2003

Preventive medical care in remote Aboriginal communities in the Northern Territory: a follow-up study of the impact of clinical guidelines, computerised recall and reminder systems, and audit and feedback.

BACKGROUND: Interventions to improve delivery of preventive medical services have been shown to be effective in North America and the UK. However, there are few studies of the extent to which the impact of such interventions has been sustained, or of the impact of such interventions in disadvantaged populations or remote settings. This paper describes the trends in delivery of preventive medical services following a multifaceted intervention in remote community health centres in the Northern Territory of Australia. METHODS: The intervention comprised the development and dissemination of best practice guidelines supported by an electronic client register, recall and reminder systems and associated staff training, and audit and feedback. Clinical records in seven community health centres were audited at regular intervals against best practice guidelines over a period of three years, with feedback of audit findings to health centre staff and management. RESULTS: Levels of service delivery varied between services and between communities. There was an initial improvement in service levels for most services following the intervention, but improvements were in general not fully sustained over the three year period. CONCLUSIONS: Improvements in service delivery are consistent with the international experience, although baseline and follow-up levels are in many cases higher than reported for comparable studies in North America and the UK. Sustainability of improvements may be achieved by institutionalisation of relevant work practices and enhanced health centre capacity.

Adolescent↗