The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients | BMC Medical Informatics and Decision Making | Full Text

David Meyers dm0015 at ICLOUD.COM
Wed Jun 28 02:02:12 UTC 2017


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> https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-017-0477-6 <https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-017-0477-6>
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> The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients
> Background
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> Clinical decision support systems (DSS) aimed at supporting diagnosis are not widely used. This is mainly due to usability issues and lack of integration into clinical work and the electronic health record (EHR). In this study we examined the usability and acceptability of a diagnostic DSS prototype integrated with the EHR and in comparison with the EHR alone.
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> Methods
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> Thirty-four General Practitioners (GPs) consulted with 6 standardised patients (SPs) using only their EHR system (baseline session); on another day, they consulted with 6 different but matched for difficulty SPs, using the EHR with the integrated DSS prototype (DSS session). GPs were interviewed twice (at the end of each session), and completed the Post-Study System Usability Questionnaire at the end of the DSS session. The SPs completed the Consultation Satisfaction Questionnaire after each consultation.
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> Results
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> The majority of GPs (74%) found the DSS useful: it helped them consider more diagnoses and ask more targeted questions. They considered three user interface features to be the most useful: (1) integration with the EHR; (2) suggested diagnoses to consider at the start of the consultation and; (3) the checklist of symptoms and signs in relation to each suggested diagnosis. There were also criticisms: half of the GPs felt that the DSS changed their consultation style, by requiring them to code symptoms and signs while interacting with the patient. SPs sometimes commented that GPs were looking at their computer more than at them; this comment was made more often in the DSS session (15%) than in the baseline session (3%). Nevertheless, SP ratings on the satisfaction questionnaire did not differ between the two sessions.
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> Conclusions
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> To use the DSS effectively, GPs would need to adapt their consultation style, so that they code more information during rather than at the end of the consultation. This presents a potential barrier to adoption. Training GPs to use the system in a patient-centred way, as well as improvement of the DSS interface itself, could facilitate coding. To enhance patient acceptability, patients should be informed about the potential of the DSS to improve diagnostic accuracy.
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> Keywords
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> Decision support systems Diagnosis Diagnostic error Usability Usefulness Acceptability Patient satisfaction Electronic health record Cognitive engineering
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> Computerised clinical decision support systems (DSS) are increasingly important in primary care for providing patient-specific, evidence-based advice for General Practitioners (GPs) [, , ]. GPs in the UK are family physicians with a gatekeeping role, controlling access to specialist services. They deal with a wide range of disease areas and have the difficult task of detecting uncommon but potentially serious diseases among common non-serious complaints.
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> Despite evidence that DSS improve GPs performance [, , ], their adoption in clinical practice is very limited [, ] and includes mainly alerts and reminders designed to support prescribing, treatment and disease management decisions [, ]. Measuring performance and quantifiable benefits of a DSS is necessary but having good results on these measures does not necessarily predict adoption in practice [].
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> There are several reasons GPs may be reluctant to adopt a DSS [, , ]. Usability issues including lack of integration into the clinical work is cited as a main barrier to broad adoption [, , , ]. This includes lack of integration with the EHR, which is important in order to trigger relevant patient information at appropriate points in the cognitive workflow and to prevent double entry of data, to both the DSS and EHR [, ].
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> Other concerns that specifically relate to diagnostic DSS are perceived need, and perceived challenge to one’s authority as a knowledgeable professional. It may be easier for GPs to acknowledge the need for support of memory-based tasks (e.g., prescribing, screening), rather than judgment-based tasks, such as diagnosis. They may, for example, not believe that their expert judgment can be reduced to a few rules, despite substantial evidence that the “actuarial” method (using a clinical prediction rule or formula that is based on and combines the evidence) performs better than unaided clinical judgment [].
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> GPs may also be concerned that their patients and/or colleagues would think less of them, if they used a diagnostic DSS. They may finally think that it will be time-consuming, and detract from the doctor-patient relationship []. There is indeed evidence that, in hypothetical clinical scenarios, GPs who do not use decision aids are thought as having higher diagnostic ability than those who do [, ] though this difference may be attenuated if the decision aid has been “developed at a prestigious institution” []. However, evidence that patients may derogate GPs who use decision aids comes from studies where participants were students reading hypothetical medical scenarios. We reviewed the literature, and to our knowledge, this is the first study that examined patients’ perceptions of GPs using a DSS in a naturalistic environment with standardised patients.
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> As part of the Translational Medicine and Patient Safety in Europe (TRANSFoRm) project (www.transformproject.eu <http://www.transformproject.eu/>) we designed, developed and evaluated a diagnostic DSS prototype for use in primary care [, , , ].
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> The DSS prototype was designed to support GPs cognitive requirements in the diagnostic process with the aim of designing a usable system that will integrate with the GPs’ clinical work []. We employed cognitive engineering methods [, ] to identify key decisions and uncover decision requirements in the diagnostic process. The decision requirements then guided the design of the system, specifically aiming to help GPs generate more diagnostic hypotheses to reduce narrow focus on one diagnosis developing early in the clinical encounter, and remind GPs of the key questions that they need to ask. Key features of the tool are described in Table . The evaluation of the prototype in a high-fidelity simulation found it to improve diagnostic accuracy and management without increasing consultation time and investigations ordered []. In this paper we report findings about the users’ perceived usability and acceptability of the DSS, and the patients’ satisfaction from the consultation, as measured during the evaluation study using interviews and standardised questionnaires. We aimed to identify facilitators and barriers to future DSS adoption.
> Table 1
> Key features of the diagnostic DSS prototype
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> • The DSS is integrated with Vision EHR system (www.inps4.co.uk/vision <http://www.inps4.co.uk/vision>) and is triggered by the GP entering the reason for encounter (RfE).
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> • Upon being triggered, the DSS presents a list of possible diagnoses, based on the RfE and information in the patient’s record (age, sex and risk factors). The intention is for the list to appear as early as possible, before GPs start gathering any further information.
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> • The interface allows the GP to easily code the patient’s signs, symptoms and examinations using a context-sensitive search box, while the order of diagnoses on the list is updated according to user input.
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> • For each suggested diagnosis, the GP can view a checklist of associated symptoms and signs, and indicate their presence or absence.
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> • At the end of the consultation, all the information is transferred automatically to the patient’s electronic health record, with the correct codes and structure.






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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