Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

Computerized medical records with health care maintenance reminders increased recommendations for some preventive health care protocols

ACP J Club. 1993 Sept-Oct;119:62. doi:10.7326/ACPJC-1993-119-2-062


Source Citation

Tape TG, Campbell JR. Computerized medical records and preventive health care: success depends on many factors. Am J Med. 1993 Jun;94:619-25.


Abstract

Objective

To evaluate the effectiveness of a computerized medical record in improving the delivery of preventive health care.

Design

Randomized controlled trial with 1 year follow-up.

Setting

University-affiliated, general internal medicine, teaching clinic.

Participants

45 internal medicine residents, 4 supervising attending physicians, and 1809 patients who were eligible for ≥ 1 of 8 preventive health care protocols: fecal occult blood testing (FOBT); sigmoidoscopy; mammography; Papanicolaou (Pap) smear; thyroxine screening; and tetanus, influenza, and pneumococcal vaccines.

Intervention

The intervention group used a computerized, ambulatory medical record system that included health care maintenance reminders. The control group used a conventional paper hospital record with a health care maintenance flow sheet.

Main outcome measure

Physician compliance with health care maintenance recommendations.

Main results

4088 visits from the 1809 patients occurred during the 1-year study period. Intervention physicians had higher compliance for proctosigmoidoscopy (7% vs 4%, P < 0.05), tetanus vaccination (6% vs 3%, P = 0.001), pneumococcal vaccination (11% vs 5%, P = 0.003), and influenza vaccination (29% vs 22%, P = 0.05). Computer reminders did not increase compliance for serum thyroxine screening (14% vs 17%), FOBT (28% vs 25%), mammography (33% vs 30%), and Pap smears (25% vs 24%). The level of resident training, time of year, and the supervising attending physician each affected health care maintenance success for some protocols. Senior residents were less compliant with the health care protocols than first-year residents for all but Pap smear and influenza vaccination. A seasonal effect was seen for FOBT and tetanus vaccine, with the highest compliance rates during July to September. The attending physician affected the success for FOBT, mammography, and all 3 types of vaccination (compliance varied 3 to 6 times). Factor analysis identified 3 predictors of combined health care maintenance success: group assignment (intervention or control group), level of training, and supervising attending physician.

Conclusions

Compared with physicians using a conventional paper hospital record, those using a computerized medical record that included health care maintenance reminders were more likely to recommend proctosigmoidoscopy and influenza, tetanus, and pneumococcal vaccines to their patients. Specific attending physicians and senior residents were less likely to comply.

Source of funding: National Center for Health Services Research.

For article reprint: Dr. T.G. Tape, Department of Internal Medicine, University of Nebraska Medical Center, 600 South 42nd Street, Omaha, NE 68198-3331, USA. FAX 402-559-6114.


Commentary

Requiring physicians to respond to computerized reminders increased physician compliance with preventive care protocols

Physicians readily agree that health promotion and early disease detection play a vital role in patient management. Increasing public awareness and declining costs of preventive services have encouraged physicians to increase the use of preventive procedures. Since 1972, the age-adjusted mortality caused by strokes has declined by more than 50% because of the early detection and treatment of hypertension, and since 1950, cervical cancer mortality has declined more than 73% because of the increasing use of the Pap smear (1). Yet, physicians still underuse preventive procedures that have proven benefit and widespread support from the medical community.

Previous research has shown the potential role of computer-prompting systems in improving physician compliance with preventive protocols. Advocates for computer prompting cite cost-effectiveness, efficiency in reminding physicians about multiple events, and acceptability to physicians and office staff as reasons for considering computers (2). The articles by Litzelman and colleagues and Tape and their colleagues address the role of computer prompting to enhance patient receipt of preventive procedures. Both studies were done in university hospitals. The study by Litzelman and colleagues was done to enhance physician compliance with computer-generated reminders that had been available to physicians for 14 years before the start of the study. Despite long-term access to a computer-prompting system, physician compliance with the reminders was less than 50%. In the study by Tape and colleagues, computer-generated reminders were introduced for the study. Unlike the former study, however, physicians were not required to respond to the reminders.

One reason for Tape and colleagues' negative findings was the inability of the study to detect less than a 30% change in the performance of any preventive procedure. The authors suggested that smaller changes may not be clinically significant. Many studies, however, have reported smaller changes in compliance. Tape and colleagues, however, did discuss several important caveats to the evaluation of studies of physician office structure: 1) the correlation between faculty attitudes about preventive procedures and compliance rates of the residents they precept; and 2) the avoidance of computers by some physicians in order to not appear "incompetent." Computer literacy may also partially explain why the intervention with a computer printout had better results than the intervention with a monitor display only.

Litzelman and colleagues showed an 8% absolute improvement when requiring physicians to act on prompts. It may not be practical, however, for busy clinicians to respond to every computer prompt on every patient. For example, the authors also reported the most common reason for physician noncompliance was lack of time. Neither study could improve physician compliance with Pap smears, where time usage may also be an important deterrent.

Other options have been effective in improving physician compliance. Harris and colleagues (3) found that a nurse-initiated prompting system increased the overall delivery of 7 preventive services and that this compared favorably with a computer-prompting system after adjustment for the number of patients enrolled. Gann and colleagues (4) described the positive influence of flow sheets, of patient-initiated mammography scheduling, and of characteristics of the mammography center itself on mammography use. These findings all suggest that physicians have a number of options to improve their use of preventive procedures, including paper systems, nurse-initiated prompting, and even computers. Computers may have a valuable role in physician office structure, but other effective alternatives exist to remind physicians about preventive health care.

James E. Shaw, MD
University of North CarolinaChapel Hill, North Carolina, USA


References

1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Baltimore, MD: Williams and Wilkins, 1989. Page xix.

2. McPhee SJ, Bird JA, Fordham D, Rodnick JE, Osborn EH. Promoting cancer prevention activities by primary care physicians. Results of a randomized, controlled trial. JAMA. 1991;266:538-44.

3. Harris RP, O'Malley MS, Fletcher SW, Knight BP. Prompting physicians for preventive procedures: a five-year study of manual and computer reminders. Am J Prev Med. 1990;6:145-52.

4. Gann P, Melville SK, Luckmann R. Characteristics of primary care office systems as predictors of mammography utilization. Ann Intern Med. 1993;118:893-8.