General practice
Has general practitioner computing made a difference to patient care? A systematic review of published reports
Frank Sullivan, senior lecturer,a Elizabeth Mitchell, research assistant aa Department of General Practice, University of Glasgow, Woodside Health Centre, Glasgow G20 7LR
Correspondence to: Dr Sullivan.
Abstract
Objective: To review findings from studies of the influence of desktop computers on primary care consultations.
Design: Systematic review of world reports from 1984 to 1994.
Setting: The computerised catalogues of Medline, BIDS, and GPlit were searched, as well as conference proceedings, books, bibliographies, and references in books and journal articles.
Subjects: 30 papers met the inclusion criteria and were included for detailed review.
Interventions: A validated scheme for assessing methodological adequacy was used to score each paper.
Main outcome measures: Papers were rated on sample formation, baseline differences, unit of allocation, outcome measures, and follow up. Differences in outcomes were also recorded.
Results: Four of the six papers dealing with the consultation process showed that consultations took longer. Doctor initiated and "medical" content of consultations increased at the expense of a reduction in patient initiated and "social" content. Each of the 21 studies which looked at clinician performance showed an improvement when a computer was used (from 8% to 50%, with better results for single preventive measures). Only one of the three studies looking at patient outcomes showed an improvement (diastolic blood pressure control 5 mm Hg better after one year, with fewer doctor-patient consultations).
Conclusions: Using a computer in the consultation may help improve clinician performance but may increase the length of the consultation. More studies are needed to assess the effects on patient outcomes of using a computer in consultations.
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Key messages
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Introduction
Almost 90% of general practices in Britain are now computerised, many using computers to carry out clerical tasks and repeat prescribing. In addition, 55% of general practitioners use desktop computers to access clinical data during consultations.1 Indeed, as general practitioner computing is "an integral part of the NHS IT [information technology] strategy,"2 the government currently spends around £47m on primary care computing each year (NHS Management Executives, personal communications). In the United States computing is seen as "an essential technology for health care."3
Computers can help with the care of individual patients through clinical decision support and with the care of groups of patients through strategic decision support. This help can operate at several levels--via access to scientific publications,4 provision of guidelines and protocols,5 prompting for missing information,6 and structured knowledge based systems.7
It is often considered axiomatic that the more structured the information system the better the care. However, computers are less likely to be of value in the loosely ordered world of general practice, where people present with a wide variety of undifferentiated problems. This makes evaluating the impact of computers in consultations even more important for primary care, in which intuitive responses may be as valid as more structured management.8
Another issue is that in order to improve outcome, possibly computer systems should develop a specifically clinical orientation allowing them to store and generate primarily medical data. However, "the design of many existing electronic medical records derives, implicitly or explicitly, from support for the use of aggregated data for research, audit, finance or planning,"9 producing a tool possibly structured more for information management than for clinical management.
This review concentrates on the use of computers by clinicians in terms of the effects on consultations, and on patient care in particular, rather than any advantages for administration or research, though both may influence patient care indirectly. The concern that "expensive computing systems are developed and installed in health care institutions without sufficient informed clinical improvement"10 exists in all aspects of medicine. This review, however, is concerned exclusively with primary care.
Methods
A SYSTEMATIC REVIEW OF PUBLISHED WORK 1984-94
A worldwide review of published work was conducted and prospective studies selected if (a) they concerned doctors or nurses in a primary care setting and (b) they described any computing system designed for use by a doctor, either in routine clinical practice or for a specific research project. The aspects examined effects on the consultation process, on doctors' task performance, and on patient outcomes.
We searched the computerised databases of Medline, BIDS (which accesses the science, social science, and arts and humanities citation indexes), and GPlit (the primary care subset of the biomedical databases) by using "computers in medicine," "primary care," "family practice," and "medical informatics" as the search terms. We also reviewed books,11 12 13 bibliographies,14 15 16 17 18 19 and conference proceedings of related topics20 as well as citations in these books and articles and references provided by colleagues. We excluded studies on aspects such as attitudes, accuracy, and completeness of data; comparisons with consultant letters; and epidemiological studies.
CRITERIA FOR EVALUATING STUDIES
Johnson et al reviewed the impact of clinical decision support systems on clinician performance and patient outcomes and proposed a scheme for assessing the methodological adequacy of studies on the impact of computers.15 In their system random allocation to study groups is rated more highly, as it reduces bias. Baseline differences between groups should be eliminated or adjusted for, and the unit of allocation to groups should be the practice in order to minimise the Hawthorne effect (the beneficial effect of participation in research). Measures of outcome should be objective and follow up should be as complete as possible (table I).
TABLE I--Criteria for methodological adequacy ------------------------------------------------------------------------------------------------------------------------------------------- Sample formation Baseline differences Unit of allocation Outcome measures Follow up ------------------------------------------------------------------------------------------------------------------------------------------- 2 Random 2 None or adjusted 2 Practice 2 Objective or blind 2 >90% of patients 1 Quasi-random 1 Differences unadjusted 1 Doctor 2 Subjective or not blinded 1 80-90% of patients 0 Selected, concurrent, or historical 0 No statement 1 Patient 0 Not explicit 0 <80% of patients |
Results
Thirty evaluations of computers in primary care met the criteria for review. Six examined the effects on the consultation process21 22 23 24 25 26 (see table II), 21 evaluated effects on clinicians' performance of tasks21 22 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 (see table III), and only three measured the impact on patient outcome47 48 49 50 (see table IV). Two studies examined more than one topic (consultation process and doctors' performance)21 22 and are included in both relevant tables (II and III). By means of the system described, each paper was reviewed and scored by each of us separately. Twenty two of the studies were scored identically. Differences in scores for the others were discussed and an agreed score reached. All 30 studies, including those with low scores, were incorporated to emphasise how little rigorous evaluation of computers in primary care has actually been carried out.
TABLE II--Effects on consultation process
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Sample Baseline Unit of Interaction Overall Difference in
Study formation differences allocation measures Follow up score (10) Process topic consultation behaviour Setting
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Herzmark et al (1984)21 0 1 1 2 0 4 Consultation length Consultation 54 seconds longer 5 Doctors, 374 consultations
Information handling Doctors found computer stressful 137 Computer consultations
237 Non-computer consultations
Pringle et al (1985)22 2 0 0 2 0 4 Patient stress and arousal No difference in stress; higher 3 Doctors, 120 patients
Consultation length arousal with computer 60 Computer consultations
Consultation 48 seconds longer 60 Non-computer consultations
Pringle et al (1985)24 2 0 0 2 0 4 Consultation topics 29% Increase in medical topics 3 Doctors, 120 patients
initiated by doctor or raised by doctors 39 Computer consultations
patient 81 Non-computer consultations
Brownbridge et al (1985)26 0 0 1 1 2 4 Standards of care No difference 6 Doctors, 60 patients
30 Computer consultations
30 Non-computer consultations
Pringle et al (1986)23 2 0 0 2 0 4 Consultation length Consultation 48 seconds longer 3 Doctors, 142 patients
Doctor and patient 4.5% Increase in doctors' speech; 93 Non-computer consultations
activities 12% less patients' speech; 49 Computer consultations
12% increase in tasks
Weingarten et al (1989)25 1 1 1 2 1 6 Consultation length Consultation 90 seconds longer 1 Doctor, 205 patients
112 Computer consultations
93 Non-computer consultations |
TABLE III--Details of clinician task performance studies
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Clinician
Sample Baseline Unit of perform- Overall Difference in
Study formation differences allocation ance Follow up score (10) Clinical aspect clinician performance Setting
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Gehlbach et al (1984)43 2 2 1 2 0 7 Drug prescribing 8% Increase in generic prescribing 32 Doctors, 3702 scripts
McDonald et al (1984)30 2 2 2 2 0 8 15 Preventive care study 14-20% Increase in response to 115 Doctors, 12 467 patients
actions study actions
Pringle et al (1985)22 2 0 0 2 0 4 Preventive care, smears, 16.7% Increase in smears, 55% 3 Doctors, 120 patients
blood pressure, tetanus increase in tetanus vaccinations,
vaccination 30% increase in blood pressure
measurements
Roland et al (1985)40 2 2 0 2 1 7 Repeat prescribing 6 min 37 s Receptionist time saved 5 Doctors, 590 patients
per 2 h period, 11 min 38 s
doctor time saved per 10 scripts
written, 4.9% fewer pharmacy
queries, 38% fewer telephone
script requests
Donald (1986)41 0 0 1 2 2 5 Repeat prescribing 13% Reduction in costs 1 Doctor, 1400 patients
Brownbridge et al (1986)44 0 0 1 1 2 4 Hypertension 33% More pulse examinations, 3 Doctors, 89 consultations
53% more fundal examinations
Tierney et al (1986)31 2 2 2 2 2 10 13 Preventive care protocols 133% Increase in faecal occult 135 Doctors, 6045 patients
blood tests, 300% increase in
mammograms
McDowell et al (1986)28 2 2 1 2 0 6 Influenza vaccinations-- 25.9% Increase by letter, 26.4% 6 Practices
patient reminders increase by phone, 13.3% 1420 patients aged >65
increase in person
McDowell et al (1989)35 2 2 0 2 0 6 Blood pressure screening-- 9.6% Increase by computer, 3% 6 Practices
patient reminders increase by phone, 14.6% 8298 patients aged >18 in past
increase by letter year
Donald (1989)42 0 0 1 2 2 5 Repeat prescribing 21.5-29.5% Reduction in costs: 1 Doctor, 1400 patients
greater when all scripts done
on computer
Chambers et al (1989)38 2 2 0 2 0 6 Mammography screening 6.7% More mammograms 30 Doctors, 1262 patients aged
>40
McPhee et al (1989)36 2 2 1 2 2 9 Cancer screening-- 16-31% Increase, 12-25% increase 62 Doctors, 1969 patients
physician reminders by audit
McDowell et al (1989)34 2 2 0 2 0 6 Cervical screening-- 2.4% Increase by doctor, 6.3% 1587 Patients, 6 practices
patient reminders increase by phone, 12.2%
increase by letter
Herzmark et al (1984)21 1 1 1 2 1 6 Preventive care Increase in tasks done 3-36% 1 Doctor, 205 patients, 112
more than control, computer consultations, 93
consultation 90 s longer non-computer consultations
Mazucca et al (1990)45 2 2 2 2 0 8 Diabetes 5-15% Increase in blood glucose 114 Doctors, 2791 patients
examinations
McPhee et al (1991)37 2 2 1 2 2 9 Cancer screening-- 10.5-17.3% Increase in faecal 40 Doctors, 2400 patients
physician reminders occult blood tests, rectal/pelvic
examination, breast examination,
Papanicolaou smears, diet/
smoking assessment, diet/
smoking counselling
Ornstein et al (1991)32 2 2 2 2 0 8 5 Preventive services Greater increase with doctor 49 Doctors, 7397 patients
and patient reminders,
12.0-18.6% in cholesterol
estimations, faecal occult blood
tests, tetanus vaccinations,
mammograms
Rosser et al (1992)27 2 2 0 2 0 6 Tetanus vaccination 7.8% Increase in vaccinations 6 Practices, 8069 patients
McDonald et al (1992)29 2 2 1 2 0 7 Influenza vaccinations Around 15% increase in 4555 Patients
vaccinations
Gilliland et al (1992)46 2 1 1 2 2 8 Presenting symptoms, 17-24% Increase in symptoms 9 Doctors, 4318 study
problems+diagnoses, recorded, threefold increase in consultations, 3575 control
investigations problems recorded, no increase consultations
in investigations recorded
Garr et al (1993)33 0 2 0 2 0 4 5 Preventive services 0.1-9.5% Increase in tetanus 44 Doctors, 7321-8067 patients
vaccinations, faecal occult blood
tests, smears, mammograms |
TABLE IV--Details of patient outcome studies
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Sample Baseline Unit of Outcome Overall
Study formation differences allocation measures Follow up score (10) Clinical aspect Difference in outcome Setting
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
McAlister et al (1986)47 2 1 1 2 2 8 Hypertension Patients with moderate hypertension 60 Doctors, 2231 patients
had 4.1 fewer visits to doctor per
year, 3.8 mm Hg larger decrease in
diastolic blood pressure, 4.6% less
drop out rate
Rethans et al (1988)50 0 1 0 2 0 3 Patient satisfaction No change. 66% Of patients worried 3 Doctors, 263 patients
about privacy returned questionnaires
Sullivan et al (1992)49 1 2 0 2 1 6 Patient satisfaction No overall difference, nor in subscales 4 Doctors; 110 patients
of general satisfaction, professional before, 6 weeks, and 6
care, depth of relationship, and months after computerisation
perceived time |
EFFECTS ON CONSULTATION PROCESS
Studies of the effects of computers on the consultation process were concerned mainly with the length of the consultations and the activities included (table II). The studies contained only few doctors (range one to six), indicating the difficulty of assessing the content of consultations. Three studies showed that consultations were 48-54 seconds longer when a computer was used.21 22 23 This difference was mainly due to tasks involving the computer. Doctor initiated and "medical" content of the consultations increased at the expense of a reduction in patient initiated and "social" content. Only one study tried to observe the longer term impact of introducing a computer to consultations.25 After 30 months it found that consultations were on average 90 seconds longer--10 minutes as compared with 8 1/2 minutes for controls. Only one study found no change in the content of the consultations and used a subjective measure to detect differences in the "standard of care attained."26
CLINICIAN PERFORMANCE STUDIES
Studies of the effects of computers on clinician performance were the most numerous and were concerned with preventive care, clinical tasks, screening, and repeat prescribing. Many used a more robust methodology, including patient follow up. The emphasis was on immunisation and other preventive tasks (14 studies) and on prescribing (four), fewer studies being concerned with the management of disease (diabetes, one study; hypertension, one study). Only one study examined the performance of doctors in recording presenting symptoms and in generating problem lists.46 Most of the improvements were in the positive direction (table III). Immunisation rates improved by 8-18%27 28 29 and other preventive tasks performed improved by up to 50%.21 25 30 31 32 33 34 35 36 37 38 The biggest improvements were noted when single rather than repeated measurements were performed.
Results were better when studies concerned more deprived patient populations,35 emphasising the potential for opportunistic case finding to reverse the "inverse care law"39 when supported by an adequate information infrastructure. Consultation based prompting could work only for attenders. Letters or telephone contacts, usually by a nurse,28 34 35 were more effective strategies for those who rarely visited. Tierney et al used a randomised block design and showed that clinical decision support was marginally better than strategic decision support.31 They also showed that there was no additive effect when both were employed.
Early studies of prescribing confirmed the anticipated time savings for doctors and receptionists, which probably persuaded most practices to buy computers in the first place.40 Further studies showed that more generic prescribing is encouraged as electronic formularies are adopted, which partly explains the 13-30% reduction in prescribing costs reported.41 42 43 However, the few practices concerned in prescribing studies makes their generalisability less certain.
Both studies examining process measures of chronic disease management suggested that improvements are encouraged.44 45 The study by Brownbridge et al on hypertension44 also examined a paper protocol, so that the effects of computerisation by itself were difficult to disentangle. The remaining study46 indicated that a computer can encourage more complete data capture of aspects of consultations which doctors consider important. However, doctors are more resistant to recording data which they consider less essential.46
PATIENT OUTCOME STUDIES
Only three studies could be classified as examining patient outcome (table IV). The first concerned doctors completing an encounter form for each patient seen. The data were entered in a remote clinical program and feedback was returned to the study doctors. Though the critique provided was remote from the consultation which produced the data, the doctors nevertheless changed their management of patients in the light of suggestions made (one in three consultations). An average reduction of 5 mm Hg in diastolic blood pressure was recorded for moderately hypertensive patients despite four visits a year fewer than controls.47 It is reasonable to expect that "patient specific reminders at the time of consultation" would be even more successful.48 The remaining two studies, which used patient satisfaction as an outcome measure, failed to detect any appreciable change.49 50
Discussion
Despite the major cost of computers to the health service, systematic review of published work yielded only 30 papers evaluating their effects on the consultation process, clinician performance, and patient outcomes. Most of these studies indicated a neutral or positive effect when a computer was used. However, every study of the introduction of computing evaluates more than simply a new information system. The reason for any observed effect can be hard to disentangle from the effects of other changes that may occur at the same time--for example, greater teamwork, redefining working relations, and consultation with outside resources and training.
Many of the papers highlighted the clinical aspects of decision support in a research setting. However, in many cases it is the more strategic approach which is measured by outcome studies. Their emphasis on the more easily quantified aspects of performance reflects the current reality of available technology. Current systems are poorly placed to support the provision of feedback for strategy planning. Only 24% can audit the clinical content of a patient review and only 52% can audit prescribing activity.51 Seventy nine per cent of systems cannot perform any statistical analysis and 76% have no graphical ability. The capacity to export data to third party software is also often limited.52
The studies reviewed provide evidence that using a computer in a consultation may lengthen that consultation by as much as 90 seconds. Patient initiated and social content may be reduced, though this may be offset by increased clinical performance on the part of the physician. The focus has been on the usefulness of computers in highly structured tasks. These may be laid open to computerisation, but surely the rich interaction of the consultation cannot be replaced by a computer. As Bleich et al noted, "Any doctor who could be replaced by a computer deserves to be."53
Most of the studies reviewed assessed the effects of computers on the clinician, but future research should centre on outcomes of care for patients. This is problematical because of the wide ranging tasks in primary care consultations, including prevention, current health problems, and public health issues. It is also difficult to determine the link between the process of care and outcomes for patients when clinical problems are diffuse.
The way forward would be randomised controlled trials to evaluate the benefits and drawbacks of existing computer use in consultations for clinicians, support staff, and patients. However, over half of the general practitioners in Britain already have desktop computers and the remainder could be described as laggards who may be reluctant to follow suit. Therefore, we need to look at new methods of evaluating these major changes in "the essential unit of medical practice"54 such as quasiexperimental and pragmatic trials. The introduction of new aspects of information technology (such as Medline access, Cochrane databases,55 and decision support systems) should also be examined.
It is five years since Mike Pringle challenged the suppliers of general practitioner computing systems to work with clinicians to improve the quality of patient care.56 Only by clearly documenting the successes, failures, and lessons learnt will computers enable general practitioners "cum technologica caritas."
We thank Sue Ross and Professor John Howie for their comments, Bill Dodd (NHS Management Executive, Leeds) for his cooperation, and Michele Beaumont for secretarial work.
Funding: EM is funded by the Clinical Resource and Audit Group of the Scottish Office Home and Health Department.
Conflict of interest: None.
- Department of Health. Computerisation in GP practices, 1993 survey. Leeds: NHS Management Executive, 1993.
- Leaning M. The new information management and technology strategy of the NHS. BMJ 1993;307:217.
- Dick RS, Steen EB, eds. The computer-based patient record: an essential technology for health care. Washington, DC: National Academy Press, 1991.
- Bradley P. Computers in primary health care. Computing Bulletin 1993;49: 151-60.
- Johnson P. Flexible protocols at the touch of a keyboard. Practice Computing 1991;6:47-9.
- Barnett GO. The application of computer-based medical record systems in ambulatory practice. N Engl J Med 1984;310:1643-50. [Medline]
- Shortliffe EH, Perrault L, Wiederhold G, Fagan L, eds. Medical informatics. Wokingham: Addison Wesley, 1990.
- Feinstein AR. The need for humanised science in evaluating medication. Lancet 1972;ii:421-3.
- Rector AL, Nowlan WA, Kay S. Foundations for an electronic medical record. Methods Inf Med 1991;30:179-86. [Medline]
- Wyatt JC. Clinical data systems, part 1: data and medical records. Lancet 1994;344:1543-7. [Medline]
- Llewelyn H, Hopkins H. Analysing how we reach clinical decisions. London: Royal College of Physicians Publications, 1993.
- Essex B. Doctors, dilemmas, decisions. London: BMJ Publishing Group, 1994.
- Sheldon M, Brooke J, Rector A, eds. Decision making in general practice. London: MacMillan, 1994.
- Wyatt JC. Clinical data systems, part 3: development and evaluation. Lancet 1994;344:1682-8. [Medline]
- Johnson ME, Langton KB, Haynes B, Mathieu A. Effects of computer-based clinical decision support systems on clinician performance and patient outcome. Ann Intern Med 1994;120:135-42.
[Abstract/Free Full Text] - Mugford M, Banfield P, O'Hanlon M. Effects of feedback of information on clinical practice: a review. BMJ 1991;303:398-402.
- Effective Health Care. Implementing clinical practice guidelines. Bulletin 8. Leeds: University of Leeds, 1994.
- Haynes RB, Walker CJ. Computer aided quality assurance. A critical appraisal. Arch Intern Med 1987;147:1297-301.
[Abstract/Free Full Text] - Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317-21. [Medline]
- Wyatt J, Spiegelhalter D. Field trials of medical decision aids. In: Clayton PD, ed. Proceedings of the 15th annual symposium on computer applications in medical care. Washington, DC: American Medical Informatics Association, 1991:3-7.
- Herzmark G, Brownbridge G, Fitter M, Evans A. Consultation use of a computer by general practitioners. Journal of the Royal College of General Practitioners 1984;34:649-54.
- Pringle M, Robins S, Brown G. Computer assisted screening: effect on the patient and his consultation. BMJ 1985;290:1709-12.
- Pringle M, Robins S, Brown G. Timer: a new objective measure of consultation content and its application to computer assisted consultations. BMJ 1986;293:20-2.
- Pringle M, Robins S, Brown G. Topic analysis: an objective measure of the consultation and its application to computer assisted consultations. BMJ 1985;290:1789-91.
- Weingarten MA, Bazel D, Shannon HS. Computerised protocol for preventive medicine: a controlled self-audit in family practice. Fam Pract 1989;6:120-4.
[Abstract/Free Full Text] - Brownbridge G, Evans A, Wall T. Effect of computer use in the consultation on the delivery of care. BMJ 1985;291:639-42.
- Rosser W, Hutchison BG, McDowell I, Newell C. Use of reminders to increase compliance with tetanus booster vaccination. Can Med Assoc J 1992;146: 911-7.
- McDowell I, Newell C, Rosser W. Comparison of three methods of recalling patients for influenza immunisation. Can Med Assoc J 1986;135:991-7. [Abstract]
- McDonald CJ, Hui SL, Tierney WM. Effects of computer reminders for influenza vaccination on morbidity during influenza epidemics. MD Comput 1992;7:532-4.
- McDonald CJ, Hui SL, Smith DM, Tierney WM, Cohen SJ, Weinberger M, et al. Reminders to physicians from an introspective computer medical record. A two-year randomized trial. Ann Intern Med 1984;100:130-8.
- Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Med Care 1986;24:659-66. [Medline]
- Ornstein SM, Garr DR, Jenkins RG, Rust PF, Arnon A. Computer-generated patient reminders. Tools to improve population adherence to selected preventive services. J Fam Pract 1991;32:82-90. [Medline]
- Garr DR, Ornstein SM, Jenkins RG, Zemp LD. The effect of routine use of computer-generated patient reminders in a clinical practice. Am J Prev Med 1993;9:55-61. [Medline]
- McDowell I, Newell C, Rosser W. Computerized reminders to encourage cervical screening in family practice. J Fam Pract 1989;28:420-4. [Medline]
- McDowell I, Newell C, Rosser W. A randomized trial of computerized reminders for blood pressure screening in primary care. Med Care 1989;27:297-305. [Medline]
- McPhee SJ, Bird JA, Jenkins CNH, Fordham D. Promoting cancer screening. A randomized, controlled trial of three interventions. Arch Intern Med 1989;149:1866-72.
[Abstract/Free Full Text] - McPhee SJ, Bird JA, Fordham D, Rodnick JE, Osborn EH. Promoting cancer prevention activities by primary care physicians. Results of a randomized controlled trial. JAMA 1991;266:538-44.
[Abstract/Free Full Text] - Chambers CV, Balaban DJ, Carlson BL, Ungemack JA, Grasberger DM. Microcomputer-generated reminders. Improving the compliance of primary care physicians with mammography screening guidelines. J Fam Pract 1989;29:273-80. [Medline]
- Hart JT, Thomas C, Gibbons B, Edwards C, Hart M, Jones J, et al. Twenty five years of case finding and audit in a socially deprived community. BMJ 1991;302:1509-13.
- Roland MO, Zander LI, Evans M, Morris R, Savage RA. Evaluation of a computer assisted repeat prescribing programme in a general practice. BMJ 1985;291:456-8.
- Donald JB. On line prescribing by computer. BMJ 1986;292:937-9.
- Donald JB. Prescribing costs when computers are used to issue all prescriptions. BMJ 1989;299:28-30.
- Gehlbach SH, Wilkinson WE, Hammond WE, Clapp NE, Finn AL, Taylor WJ, et al. Improving drug prescribing in a primary care practice. Med Care 1984;22:193-201. [Medline]
- Brownbridge G, Evans A, Fitter M, Platts M. An interactive computerised protocol for the management of hypertension: effects on the general practitioner's clinical behaviour. Journal of the Royal College of General Practitioners 1986;36:198-202.
- Mazucca SA, Vinicor E, Einterz RM, Tierney WM, Norton JA, Kalasinski LA. Effects of the clinical environment on physicians' response to postgraduate medical education. American Education Research Journal 1990;27:473-88.
- Gilliland AEW, Mills KA, Steele K. General practitioner records on computer--handle with care. Fam Pract 1992;9:441-50.
[Abstract/Free Full Text] - McAlister NH, Covvey HD, Tong C, Lee A, Wigle ED. Randomised controlled trial of computer assisted management of hypertension in primary care. BMJ 1986;293:670-4.
- Grimshaw JM, Russell IT. Achieving health gain through clinical guidelines II: ensuring guidelines change medical practice. Quality in Health Care 1994;3:45-52.
[Free Full Text] - Sullivan FM, Manchip A, Hussain S. Does the arrival of a desk-top computer reduce patients' satisfaction with consultations in general practice? Theoretical Surgery 1992;7:454.
- Rethans JJ, Hoppener P, Wolfs G, Diederiks J. Do personal computers make doctors less personal? BMJ 1988;296:1446-8.
- Harriss C, Pringle M. Do general practice computer systems assist in medical audit? Fam Pract 1994;11:51-6.
- Kinn S, Sullivan FM. Good relations. British Journal of Healthcare Computing 1994;11:21-4.
- Bleich HL, Beckley RF, Horowitz GL, Jackson JD, Moody ES, Franklin C, et al. Clinical computing in a teaching hospital. N Engl J Med 1985;312: 756-64.
- Spence J. Function of the hospital outpatient department. Lancet 1953;i:275.
- Chalmers I, Altman DG. Systematic reviews. London: BMJ Publishing Group, 1995.
- Pringle M. The new agenda for general practice computing. BMJ 1990;301: 827-8.
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Makoul, G., Curry, R. H., Tang, P. C.
(2001). The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters. J. Am. Med. Inform. Assoc.
8: 610-615
[Abstract] [Full text] -
Overhage, J. M., Perkins, S., Tierney, W. M., McDonald, C. J.
(2001). Controlled Trial of Direct Physician Order Entry: Effects on Physicians' Time Utilization in Ambulatory Primary Care Internal Medicine Practices. J. Am. Med. Inform. Assoc.
8: 361-371
[Abstract] [Full text] -
Thornett, A.
(2001). Computer use must not affect doctor-patient relationship. BMJ
322: 1369-1369
[Full text] -
Heathfield, H. A.
(2001). Evaluating clinical systems: the social programme perspective. Health Informatics Journal
7: 8-12
[Abstract] -
Mitchell, E., Sullivan, F.
(2001). A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97. BMJ
322: 279-282
[Abstract] [Full text] -
Treweek, S., Flottorp, S., Oxman, A.
(2000). Improving the quality of primary care through tailored interventions and customizable software linked to electronic medical records. Health Informatics Journal
6: 212-218
[Abstract] -
Emery, J., Walton, R., Murphy, M., Austoker, J., Yudkin, P., Chapman, C., Coulson, A., Glasspool, D., Fox, J.
(2000). Computer support for interpreting family histories of breast and ovarian cancer in primary care: comparative study with simulated cases. BMJ
321: 28-32
[Abstract] [Full text] -
Coiera, E.
(2000). When Conversation Is Better Than Computation. J. Am. Med. Inform. Assoc.
7: 277-286
[Abstract] [Full text] -
Tai, S. S., Donegan, C., Nazareth, I.
(2000). Computers in general practice and the consultation: the health professionals' view. Health Informatics Journal
6: 27-31
[Abstract] -
Thiru, K., de Lusignan, S., Hague, N.
(1999). Have the completeness and accuracy of computer medical records in general practice improved in the last five years? The report of a two-practice pilot study. Health Informatics Journal
5: 224-232
[Abstract] -
Delaney, B. C, Fitzmaurice, D. A, Riaz, A., Hobbs, F D R.
(1999). Can computerised decision support systems deliver improved quality in primary care?. BMJ
319: 1281-1281
[Full text] -
AYLWARD, G W, PARMAR, D N
(1999). Information technology in ophthalmology---experience with an electronic patient record. Br J Ophthalmol
83: 1264-1267
[Full text] -
Ellis, N. T., May, C. R.
(1999). Computers and the general practice consultation. Health Informatics Journal
5: 124-127
[Abstract] -
Emery, J., Walton, R., Coulson, A., Glasspool, D., Ziebland, S., Fox, J.
(1999). Computer support for recording and interpreting family histories of breast and ovarian cancer in primary care (RAGs): qualitative evaluation with simulated patients. BMJ
319: 32-36
[Abstract] [Full text] -
Tang, P. C., LaRosa, M. P., Gorden, S. M.
(1999). Use of Computer-based Records, Completeness of Documentation, and Appropriateness of Documented Clinical Decisions. J. Am. Med. Inform. Assoc.
6: 245-251
[Abstract] [Full text] -
Tang, P. C., LaRosa, M. P., Newcomb, C., Gorden, S. M.
(1999). Measuring the Effects of Reminders for Outpatient Influenza Immunizations at the Point of Clinical Opportunity. J. Am. Med. Inform. Assoc.
6: 115-121
[Abstract] [Full text] -
Heathfield, H., Pitty, D., Hanka, R.
(1998). Evaluating information technology in health care: barriers and challenges. BMJ
316: 1959-1961
[Full text] -
Roberts, C.
(1998). Quality assurance in primary care with information management and technology. Health Informatics Journal
4: 101-105
[Abstract] -
Keen, J.
(1998). Rethinking NHS networking. BMJ
316: 1291-1293
[Full text] -
Fraser, G. L., Stogsdill, P., Dickens, J. D. Jr, Wennberg, D. E., Smith, R. P. Jr, Prato, B. S.
(1997). Antibiotic Optimization: An Evaluation of Patient Safety and Economic Outcomes. Arch Intern Med
157: 1689-1694
[Abstract] -
Miller, A., Jeffcote, R.
(1997). Practice nurses and computing: some evidence on utilization, training, and attitudes to computer use. Health Informatics Journal
3: 10-16
[Abstract] -
Sturdy, P., Livingstone, A.E.
(1997). Can general practice computer data be of use in assessing asthma service delivery and needs?. Health Informatics Journal
3: 93-99
[Abstract] -
Donaldson, L. J
(1996). From black bag to black box: will computers improve the NHS?. BMJ
312: 1371-1372
[Full text] -
Lock, C.
(1996). What value do computers provide to NHS hospitals?. BMJ
312: 1407-1410
[Full text] -
Donaldson, L. J
(1996). From black bag to black box: will computers improve the NHS?. BMJ
312: 1371a-1372
[Full text] -
Lock, C.
(1996). What value do computers provide to NHS hospitals?. BMJ
312: 1407a-1410
[Full text] -
Purves, I. N
(1996). The paperless general practice. BMJ
312: 1112-1113
[Full text] -
Sullivan, R.
(1996). Cascade system for getting urgent information to doctors. BMJ
312: 578-578
[Full text] -
Wyatt, J., Walton, R.
(1995). Computer based prescribing. BMJ
311: 1181-1182
[Full text]
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