Practice based, longitudinal, qualitative interview study of computerised evidence based guidelines in primary care

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Abstract
Objective: To understand the factors influencing the adoption of a computerised clinical decision support system for two chronic diseases in general practice. Design: Practice based, longitudinal, qualitative interview study. Setting: Five general practices in north east England. Participants: 13 respondents (two practice managers, three nurses, and eight general practitioners) gave a total of 19 semistructured interviews. 40 people in practices included in the randomised controlled trial (34 doctors, three nurses) and interview study (three doctors, one previously interviewed) gave feedback. Results: Negative comments about the decision support system significantly outweighed the positive or neutral comments. Three main areas of concern among clinicians emerged: timing of the guideline trigger, ease of use of the system, and helpfulness of the content. Respondents did not feel that the system fitted well within the general practice context. Experience of “on-demand” information sources, which were generally more positively viewed, informed the comments about the system. Some general practitioners suggested that nurses might find the guideline content more clinically useful and might be more prepared to use a computerised decision support system, but lack of feedback from nurses who had experienced the system limited the ability to assess this. Conclusions: Significant barriers exist to the use of complex clinical decision support systems for chronic disease by general practitioners. Key issues include the relevance and accuracy of messages and the flexibility to respond to other factors influencing decision making in primary care. What is already known on this topic Randomised controlled trials of complex computerised decision support systems have found low rates of use and no effects on process and outcomes of care What this study adds Clinicians found a computerised decision support system for chronic disease in general practice to be difficult to use and unhelpful clinically It did not fit well into a general practice consultation and compared unfavourably with “on-demand” information “Active” decision support can make clinicians aware of gaps between their own practice and “best” practice, but computer prompts need to be relevant and accurate