On screen point of care computer reminders to improve care and health

Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J

Published Online:

January 19, 2011

It is known that doctors do not always provide the care that is recommended or according to the latest research. Many strategies have been tried in an attempt to reduce this gap between what is recommended and what is done. A potentially low cost way to do this could be to use computer systems that remind physicians about important information while they make decisions. For example, a doctor could be ordering antibiotics for a child with an ear infection. At that point, the computer the doctor is working on displays a pop up window with a reminder about the evidence for the best dose and length of time the antibiotics should be prescribed.

This review found 28 studies that evaluated the effects of different on-screen computer reminders. The studies tested reminders to prescribe specific medications, to warn about drug interactions, to provide vaccinations, or to order tests. The review found small to moderate benefits. The reminders improved physician practices by a median of 4%. In eight of the studies, patients' health improved by a median of 3%.

Although some studies showed larger benefits than these median effects, no specific reminders or features of how they worked were consistently associated with these larger benefits. More research is needed to identify what types of reminders work and when.

Abstract (click to read)

Background:

The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering ‘computer reminders’.

Objectives:

To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care.

Search strategy:

We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles.

Selection criteria:

Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care.

Data collection and analysis:

Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome.

Main results:

Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering.

In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

Authors' conclusions:

Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.

This record should be cited as:

Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD001096. DOI: 10.1002/14651858.CD001096.pub2

Assessed as up to date:

January 11, 2009

Find the research

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Primary Review Group:

Effective Practice and Organisation of Care Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are on-screen, point of care computer reminders on processes and outcomes of care?

Bottom line:

The review found small to moderate benefits. The reminders improved physician practices (process adherence, medication ordering, vaccinations and test ordering) by a median of 4%. In 8 of the studies, patients' health (reduction in blood pressure or serum cholesterol) improved by a median of 3%.

Caveat:

Context:

The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from email alerts, computer-generated paper reminders, and other modes of delivering "computer reminders".

Cochrane Systematic Review:

Shojania KG et al. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Reviews 2009, Issue 3. Article No. CD001096. DOI: 10.1002/14651858. CD001096.pub2. This review contains 28 studies involving 126,099 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Effective practice/health systems > Reviews of specific types of interventions > Continuing education & quality assurance

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

On screen point of care computer reminders to improve care and health

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