The effect of computerized decision support on barriers to guideline implementation: A qualitative study in outpatient cardiac rehabilitation

Goud, Rick; van Engen-Verheul, Mariette; de Keizer, Nicolette F.; Bal, Roland; Hasman, Arie; Hellemans, Irene M.; Peek, Niels

doi:10.1016/j.ijmedinf.2010.03.001

« Previous Next »International Journal of Medical Informatics
Volume 79, Issue 6 , Pages 430-437, June 2010

The effect of computerized decision support on barriers to guideline implementation: A qualitative study in outpatient cardiac rehabilitation

Rick Goud
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Gupta Strategists, Ophemert, The Netherlands
Mariette van Engen-Verheul
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Nicolette F. de Keizer
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Roland Bal
- Department of Health Policy and Management, Erasmus University Medical Center, Rotterdam, The Netherlands
Arie Hasman
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Irene M. Hellemans
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Niels Peek
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Corresponding author at: Academic Medical Center, Department of Medical Informatics, Room J1b-110, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands. Tel.: +31 205667872; fax: +31 206919840.

Received 30 May 2009; received in revised form 21 February 2010; accepted 2 March 2010. published online 08 April 2010.

Abstract

Context

Computerized decision support systems (CDSSs) can be used to improve the implementation of clinical practice guidelines by changing the behaviour of care professionals. While the influence of system characteristics on the effectiveness of CDSSs is studied, little is known about the relation between cognitive, organizational and environmental factors, and CDSSs’ effectiveness.

Objective

To assess the effect of CDSSs on cognitive, organizational, and environmental factors that hamper guideline implementation.

Design

In-depth, semi-structured interviews with care professionals, on reasons for improved adherence or persistent non-adherence to the prevailing guideline after successful adoption of a CDSS. All remarks regarding guideline implementation were extracted and classified using the conceptual framework from Cabana et al. [5].

Setting

Outpatient cardiac rehabilitation clinics.

Participants

Care professionals that used the CARDSS decision support system for therapeutic decision making in cardiac rehabilitation.

Results

Twenty-nine rehabilitation nurses and physiotherapists from 21 Dutch clinics were interviewed. CARDSS improved guideline adherence by increasing its users’ familiarity with the guidelines’ recommendations and decision logic, by overcoming users’ inertia to previous practice, and by reducing guideline complexity for example by facilitating calculation and interpretation of data. If the system's recommendations were shared with patients, refusal to participate in therapies reduced. CARDSS never incited users to target barriers related to organizational or environmental constraints.

Conclusion

Our results suggest that computerized decision support can improve guideline implementation by increasing the knowledge of preferred practice, by reducing inertia to previous practice, and by reducing guideline complexity. However, computerized decision support is not effective when organizational or procedural changes are required that users consider to be beyond their tasks and responsibilities.

Keywords: Clinical decision support systems, Qualitative evaluation, Guideline adherence, Cardiac rehabilitation