The effects of on-screen, point of care computer reminders on processes and outcomes of care.
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'.


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


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


METHODS
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.


METHODS
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.


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).


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.
Shojania
Kaveh G
KG
Director, University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Room D474, 2075 Bayview Avenue, Toronto, Ontario, Canada, M4N 3M5.
Jennings
Alison
A
Mayhew
Alain
A
Ramsay
Craig R
CR
Eccles
Martin P
MP
Grimshaw
Jeremy
J
D003658:Decision Making, Computer-Assisted; D020000:Decision Support Systems, Clinical; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D019095:Point-of-Care Systems; D017010:Reminder Systems