title: Feasibility and impact of a computerised clinical decision support system on investigation and initial management of new onset chest pain: a mixed methods study.
abstract: BACKGROUND
  Clinical decision support systems (CDSS) can modify clinician behaviour, yet the factors influencing their effect remain poorly understood. This study assesses the feasibility and acceptability of a CDSS supporting diagnostic and treatment decisions for patients with suspected stable angina.
  
  
  METHODS
  Intervention The Optimising Management of Angina (OMA) programme includes a CDSS guiding investigation and medication decisions for clinicians managing patients with new onset stable angina, based on English national guidelines, introduced through an educational intervention. Design and participants A mixed methods study i. A study of outcomes among patients presenting with suspected angina in three chest pain clinics in England before and after introduction of the OMA programme. ii. Observations of clinic processes, interviews and a focus group with health professionals at two chest pain clinics after delivery of the OMA programme.
  
  
  RESULTS
  Medication and cardiovascular imaging investigations undertaken within six months of presentation, and concordance of these with the recommendations of the CDSS. Thematic analysis of qualitative data to understand how the CDSS was used.
  
  
  RESULTS
  Data were analysed for 285 patients attending chest pain clinics: 106 before and 179 after delivery of the OMA programme. 40 consultations were observed, 5 clinicians interviewed, and a focus group held after the intervention. The proportion of patients appropriate for diagnostic investigation who received one was 50 % (95 CI 34-66 %) of those before OMA and 59 % (95 CI 48-70 %) of those after OMA. Despite high use of the CDSS (84 % of consultations), observations and interviews revealed difficulty with data entry into the CDSS, and structural and practical barriers to its use. In the majority of cases the CDSS was not used to guide real-time decision making, only being consulted after the patient had left the room.
  
  
  CONCLUSIONS
  The OMA CDSS for the management of chest pain is not feasible in its current form. The CDSS was not used to support decisions about the care of individual patients. A range of barriers to the use of the CDSS were identified, some are easily removed, such as insufficient capture of cardiovascular risk, while others are more deeply embedded in current practice, such as unavailability of some investigations or no prescribing privileges for nurses.
authors: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK. epraj@bris.ac.uk.
authors: Rachel
authors: R
authors: Johnson
authors: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors: Maggie
authors: M
authors: Evans
authors: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors: Helen
authors: H
authors: Cramer
authors: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors: Kristina
authors: K
authors: Bennert
authors: School of Social and Community Medicine, University of Bristol, Bristol, UK.|Department of Primary Care & Population Health, University College London, London, UK.
authors: Richard
authors: R
authors: Morris
authors: Centre for Primary Care and Public Health Queen Mary, University of London, London, UK.
authors: Sandra
authors: S
authors: Eldridge
authors: Bedminster Family Practice, Bristol, UK.
authors: Katy
authors: K
authors: Juttner
authors: James Paget University Hospital, Norfolk, UK.
authors: Mohammed J
authors: MJ
authors: Zaman
authors: Farr Institute of Health Informatics Research London, Institute of Health Informatics, University College London, London, UK.
authors: Harry
authors: H
authors: Hemingway
authors: Farr Institute of Health Informatics Research London, Institute of Health Informatics, University College London, London, UK.
authors: Spiros
authors: S
authors: Denaxas
authors: NIHR Cardiovascular Biomedical Research Unit, Barts Health NHS Trust, London, UK.
authors: Adam
authors: A
authors: Timmis
authors: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors: Gene
authors: G
authors: Feder
mesh_terms: D000368:Aged; D060050:Angina, Stable / Q000175:diagnosis* / Q000628:therapy*; D002637:Chest Pain / Q000175:diagnosis / Q000628:therapy*; D020000:Decision Support Systems, Clinical / Q000592:standards*; D005240:Feasibility Studies; D005260:Female; D006302:Health Services Research; D006801:Humans; D008297:Male; D008875:Middle Aged