title: Why do clinicians not refer patients to online decision support tools? Interviews with front line clinics in the NHS.
abstract: OBJECTIVE
  To assess whether clinical teams would direct patients to use web-based patient decision support interventions (DESIs) and whether patients would use them.
  
  
  METHODS
  Retrospective semistructured interviews and web server log analysis.
  
  
  METHODS
  57 NHS professionals (nurses, doctors and others) in orthopaedic, antenatal, breast, urology clinics and in primary care practices across 22 NHS sites given access to DESIs hosted on the NHS Direct website.
  
  
  RESULTS
  Fewer than expected patients were directed to use the web tools. The most significant obstacles to referral to the tools were the attitudes of clinicians and clinical teams. Technical problems contributed to the problems but the low uptake was mainly explained by clinicians' limited understanding of how patient DESIs could be helpful in clinical pathways, their perception that 'shared decision-making' was already commonplace and that, in their view, some patients are resistant to being involved in treatment decisions. External factors, such as efficiency targets and 'best practice' recommendations were also cited being significant barriers. Clinicians did not feel the need to refer patients to use decision support tools, web-based or not, and, as a result, felt no requirement to change existing practice routines. Uptake is highest when clinicians set expectations that these tools are integral to practice and embed their use into clinical pathways.
  
  
  CONCLUSIONS
  Existing evidence of patient benefit and the free availability of patient DESIs via the web are not sufficient drivers to achieve routine use. Health professionals were not motivated to refer patients to these interventions. Clinicians will not use these interventions simply because they are made available, despite good evidence of benefit to patients. These attitudes are deep seated and will not be modified by solely developing web-based interventions: a broader strategy will be required to embed DESIs into routine practice.
authors.affiliation: Cochrane Institute of Primary Care and Public Health,  Cardiff University, Cardiff,  UK.
authors.forename: Glyn
authors.initials: G
authors.lastname: Elwyn
authors.forename: Andrew
authors.initials: A
authors.lastname: Rix
authors.forename: Tom
authors.initials: T
authors.lastname: Holt
authors.forename: Deborah
authors.initials: D
authors.lastname: Jones