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Exploring Barriers and Facilitators to the Use of Computerized Clinical Reminders

Affiliations of the authors: VA Getting at Patient Safety (GAPS) Center, VAMC-Cincinnati, Cincinnati, OH (JJS, ESP, MLR); Department of Internal Medicine, University of Cincinnati, Cincinnati, OH (JJS); Institute for Ergonomics, The Ohio State University, Columbus, OH (ESP); University of Dayton Research Institute, Dayton, OH (LM); Division of Pulmonary Critical Care, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH (MLR); VA Greater Los Angeles Healthcare System and the David Geffen School of Medicine at UCLA, Los Angeles, CA (GO, SMA).

Correspondence and reprints: Jason J. Saleem, PhD, VA GAPS Center, Cincinnati VAMC, 3200 Vine Street, MDP 111, Cincinnati, OH 45220; e-mail: <Jason.Saleem{at}med.va.gov>.

Received for publication: 12/17/04; accepted for publication: 03/23/05.

Objective: Evidence-based practices in preventive care and chronic disease management are inconsistently implemented. Computerized clinical reminders (CRs) can improve compliance with these practices in outpatient settings. However, since clinician adherence to CR recommendations is quite variable and declines over time, we conducted observations to determine barriers and facilitators to the effective use of CRs.

Design: We conducted an observational study of nurses and providers interacting with CRs in outpatient primary care clinics for two days in each of four geographically distributed Veterans Administration (VA) medical centers.

Measurements: Three observers recorded interactions of 35 nurses and 55 physicians and mid-level practitioners with the CRs, which function as part of an electronic medical record. Field notes were typed, coded in a spreadsheet, and then sorted into logical categories. We then integrated findings across observations into meaningful patterns and abstracted the data into themes, such as recurrent strategies. Several of these themes translated directly to barriers and facilitators to effective CR use.

Results: Optimally using the CR system for its intended purpose was impeded by (1) lack of coordination between nurses and providers; (2) using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions; (3) workload; (4) lack of CR flexibility; and (5) poor interface usability. Facilitators included (1) limiting the number of reminders at a site; (2) strategic location of the computer workstations; (3) integration of reminders into workflow; and (4) the ability to document system problems and receive prompt administrator feedback.

Conclusion: We identified barriers that might explain some of the variability in the use of CRs. Although these barriers may be difficult to overcome, some strategies may increase user acceptance and therefore the effectiveness of the CRs. These include explicitly assigning responsibility for each CR to nurses or providers, improving visibility of positive results from CRs in the electronic medical record, creating a feedback mechanism about CR use, and limiting the overall number of CRs.

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