Computer decision support systems for opportunistic health screening and for chronic heart failure management in primary health care

Abstract

There are growing demands for effective management of chronic diseases and preventive services in primary health care (PHC). Computer decision support systems (CDSS) have been shown to improve the quality of care, but they are still underused. Further knowledge is needed about the obstacles and facilitators related both to the CDSSs and to the process of implementing them in order to benefit from their full potential.

A computer generated on-screen physician reminder program for opportunistic health screening was designed and implemented at a PHC centre (study I). The program was completely integrated with the electronic patient record system (EPR) and the battery of screening tests was adjusted to the individual patient on the basis of previous diagnoses, treatments and test results for seven screening areas. Of 914 patients over 70 years of age, 602 (66%) participated in the screening. The rates for pathological findings ranged from 2- 23% and new diagnoses were found in 1-4%.

In a controlled study (study II) the results from the health screening in study I were compared with corresponding data from 1989 patients at three neighbouring PHC centres. There was a significant increase (13 75%) in tests performed on the participants and in pathological test results for systolic blood pressure and serum cobalamin, and an increase in new diagnoses was found for cobalamin deficiency.

The influence of a guideline-based CDSS on five general practitioners' (GPs) management of 48 of their own patient cases of chronic heart failure was explored in a descriptive questionnaire study (study III). The CDSS was accessible on the Internet without connection to the EPR. The results showed that the GPs' confidence in the diagnosis changed in 25% of the cases, and they considered further investigations in 31% of the cases and medication changes in 19%. The support from the CDSS perceived by the GPs seemed to be substantial in 35% of the cases.

The implementation process of the CDSS used in study III was followed in a qualitative study (study IV). Different methods for data collection were used; repeated interviews with the GPs, observations of patient visits, patient interviews, and detection of usage. The results of a qualitative content analysis showed that GPs' attitudes and characteristics constituted different profiles that seemed to be associated with the degree of acceptance of the CDSS. Those profiles were related to conceptions about the GPs' professional role and their attitudes towards the computer's function in disease management and in decision making. Additional barriers were insufficient level of computer skills and time constraints in everyday work.

In conclusion, a computer-reminder program, completely integrated with an electronic patient record system, seems to be an effective method for increasing the delivery of preventive services in PHC. The system may be particularly clinically useful in screening areas that have thus far not been satisfactorily implemented, and when introducing new screening services. Applying a guideline-based CDSS for chronic heart failure may have a significant influence on GPs' disease management. It is possible to identify groups of GPs with definable needs during the implementation of a CDSS, thereby making it easier to meet those needs with individually tailored interventions.