title: Exploring barriers and facilitators to the use of computerized clinical reminders.
abstract: 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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: VA GAPS Center, Cincinnati VAMC, 3200 Vine Street, MDP 111, Cincinnati, OH 45220, USA. Jason.Saleem@med.va.gov
authors.forename: Jason J
authors.initials: JJ
authors.lastname: Saleem
authors.forename: Emily S
authors.initials: ES
authors.lastname: Patterson
authors.forename: Laura
authors.initials: L
authors.lastname: Militello
authors.forename: Marta L
authors.initials: ML
authors.lastname: Render
authors.forename: Greg
authors.initials: G
authors.lastname: Orshansky
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
mesh_terms: D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D009726:Nurses / Q000523:psychology; D010044:Outpatient Clinics, Hospital; D019555:Physician-Nurse Relations; D010820:Physicians / Q000523:psychology; D017010:Reminder Systems / Q000706:statistics & numerical data*; D014481:United States; D014493:United States Department of Veterans Affairs