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A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7281.279 (Published 03 February 2001) Cite this as: BMJ 2001;322:279

Data supplement

  • Box 1

    Box 2

    Web References

    Table 1

    Table 2

    Table 3
     

    Box 1

       

      Scoring system for methodological adequacy of randomised controlled trials, controlled trials, and controlled before and after studies

      Sample formation

      2=Random allocation

      1=Quasi-random allocation

      0=Selected, concurrent, historical

      Baseline differences

      2=None or adjusted

      1=Differences unadjusted

      0=No statement

      Unit of allocation

      2=Practice or clinic

      1=Doctor or nurse

      0=Patient or family

      Outcome measures

      2=Objective or blind

      1=Subjective or not blind

      0=No explicit criteria

      Follow up rate

      2=>90% of subjects

      1=80-90% of subjects

      0=<80% of subjects
       

      Box 2
         

        Criteria for methodological adequacy of non-experimental studies

        Case report

        Source of case (1=identified; 0=not identified)

        Description of system (1=information; 0=no information)

        Validity of measures* (1=statement; 0=no statement)

        Quality control (1=statement; 0=no statement)

        Subject compliance rate (1=information; 0=no information)

        Post-intervention data (1=given; 0=not given)

        Case series

        Source of cases (1=identified; 0=not identified)

        Inclusion/exclusion (1=statement; 0=no statement)

        Sampling method (1=given; 0=not given)

        Description of system (1=information; 0=no information)

        Validity of measures (1=statement; 0=no statement)

        Lost to follow-up (1=information; 0=no information)

        Cross sectional study

        Research question† (1=statement; 0=no statement)

        Source of cases (1=identified; 0=not identified)

        Inclusion/exclusion (1=statement; 0=no statement)

        Sample size (1=statement; 0=no statement)

        Dealing with bias (1=information; 0=no information)

        Analytic methods (1=description; 0=no description)

        Cohort study

        Research question (1=statement; 0=no statement)

        Source of cases (1=identified; 0=not identified)

        Inclusion/exclusion (1=statement; 0=no statement)

        Non-response rate (1=statement; 0=no statement)

        Starting point‡ (1=definition; 0=no definition)

        Description of system (1=information; 0=no information)

        Case-control study

        Research question (1=statement; 0=no statement)

        Source of cases (1=identified; 0=not identified)

        Source of controls (1=identified; 0=not identified)

        Inclusion/exclusion (1=statement; 0=no statement)

        Sampling method (1=given; 0=not given)

        Comparability with controls (1=statement; 0=no statement)

        Before and after study/time series

        Research question (1=statement; 0=no statement)

        Source of cases (1=identified; 0=not identified)

        Inclusion/exclusion (1=statement; 0=no statement)

        Sample size (1=statement; 0=no statement)

        Starting point (1=definition; 0=no definition)

        Validity of measures (1=statement; 0=no statement)

        *If there was an explicit statement of validity or measures had face validity, they were given 1. HIf "to evaluate" or "report the impact" was stated but no details were provided, this was given 1. ICondition for patients; clear statement of study background, or origins of evaluation for practitioners.
         


         

        Web references

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        3. 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.
        4. Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance. Med Care 1986;24:659-66.
        5. McDowell I, Newell C, Rosser W. Comparison of three methods of recalling patients for influenza vaccination. Can Med Assoc J 1986;135:991-7.
        6. 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.
        7. 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.
        8. 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.
        9. McDowell I, Newell C, Rosser W. Computerized reminders to encourage cervical screening in family practice. J Fam Pract 1989;28:420-4.
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        31. Barton MB, Schoenbaum SC. Improving influenza vaccination performance in an HMO setting: the use of computer-generated reminders and peer comparison feedback. Am J Public Health 1990;80:534-6.
        32. Christensen-Szalanski JJJ, Diehr PH, Wood RW, Tompkins RK. Phased trial of a proven algorithm at a new primary care clinic. Am J Public Health 1982;72:16-21.
        33. Hutchison BG. Effect of computer-generated nurse/physician reminders on influenza immunization among seniors. Fam Med 1989;21:433-7.
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        36. Harris RP, O’Malley MS, Fletcher SW, Knight BP. Prompting physicians for preventive procedures: a five-year study of manual and computer reminders. Am J Prev Med 1990;6:145-52.
        37. Lobach DF. Electronically distributed, computer-generated, individualised feedback enhances the use of a computerized practice guideline. Proc Am Med Inform Assoc Annu Fall Symp 1996:493-7.
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        39. Jones DL, Kroenke K, Landry FJ, Tomich DJ, Ferrel RJ. Cost savings using a stepped-care prescribing protocol for nonsteroidal anti-inflammatory drugs. JAMA 1996;275:926-30.
        40. Rosser WW, McDowell I, Newell C. Use of reminders for preventive procedures in family medicine. Can Med Assoc J 1991;145:807-12.
        41. Frame PS, Zimmer JG, Werth PL, Hall WJ, Eberly SW. Computer-based vs manual health maintenance tracking. A controlled trial. Arch Fam Med 1994;3:581-8.
        42. Chambers CV, Balaban DJ, Carlson BL, Grasberger DM. The effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. J Am Board Fam Pract 1991;4:19-26.
        43. Hobbs FDR, Delaney BC, Carson A, Kenkre JE. A prospective controlled trial of computerized decision support for lipid management in primary care. Fam Pract 1996;13:133-7.
        44. Turner BJ, Day SC, Borenstein B. A controlled trial to improve delivery of preventive care: physician or patient reminders? J Gen Intern Med 1989;4:403-9.
        45. Davidson KW, Kahn A, Price RD. Reduction of adverse drug reactions by computerized drug interaction screening. J Fam Pract 1987;25:371-5.
        46. Barnett GO, Winickoff RN, Morgan MM, Zielstorff RD. A computer-based monitoring system for follow-up of elevated blood pressure. Med Care 1983;21:400-9.
        47. Burack RC, Gimotty PA, George J, Simon MS, Dews P, Moncrease A. The effect of patient and physician reminders on use of screening mammography in a health maintenance organization. Results of a randomized controlled trial. Cancer 1996:78:1708-21.
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        52. Herzmark G, Brownbridge G, Fitter M, Evans A. Consultation use of a computer by general practitioners. J R Coll Gen Pract 1984;34:649-54.
        53. Pringle M, Robins S, Brown G. Computer assisted screening: effect on the patient and his consultation. BMJ 1985;290:1709-12.
        54. 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.
        55. 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.
        56. Weingarten MA, Bazel D, Shannon HS. Computerized protocol for preventive medicine: a controlled self-audit in family practice. Fam Pract 1989;6:120-4.
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          Table 1 Details of studies of effect of computers in primary care on practitioner performance
         
        Study and designResearch topic(s)ParticipantsEffect on performanceMethodology scoreOverall score (out of 10)
        Gehlbach et al (1984)w1 Randomised controlled trialComputerised feedback, generic prescribing32 doctors; 3702 scriptsMedian generic prescribing increased by 41-48% more for study groupSample-2; Differences-2; Allocation-1; Outcomes-2; Follow up-07
        McDonald et al (1984)w2 Randomised controlled trialPhysician reminder, preventive care126 doctors; 4 nurses; 12467 patients14-20% increase in response to study actions; study group 2-4 times more likely to apply preventive careSample-2; Differences-2; Allocation-2; Outcomes-2; Follow up-08
        Roland et al (1985)w3 Randomised controlled trialComputerised prescribing5 doctors; 658 patientsAverage of 6 min 37 sec receptionist time saved per 2 hr period, 11 min 38 sec doctor time per 10 scripts; 4.9% fewer queries from pharmacy; 38% fewer telephone requestsSample-2; Differences-0; Allocation-0; Outcomes-2; Follow up-15
        Tierney et al (1986)w4 Randomised controlled trialComputerised feedback, physician reminder, preventive care135 doctors; 6045 patients33% greater increase in compliance for faecal occult blood testing, 30% for pneumococcal vaccination, 16% for mammography, 4% for cervical cytologySample-2; Differences-0; Allocation-2; Outcomes-2; Follow up-28
        McDowell et al (1986)w5 Randomised controlled trialPatient reminder, flu immunisation6 practices (4-6 doctors, 1 nurse); 1420 patients aged 6513.3% increase with computerised physician reminder, 25.9% with computerised letter, 26.4% with phone reminder; phone most cost effectiveSample-2; Differences-2; Allocation-0; Outcomes-1; Follow up-27
        McDowell et al (1989)w6 Randomised controlled trialPatient reminder, blood pressure screening6 practices (4-6 doctors, 1 nurse); 8298 patients aged 183.0% increase with phone reminder, 9.6% with computerised physician reminder, 14.6% with computerised letter; physician most cost effectiveSample-2; Differences-2; Allocation-0; Outcomes-1; Follow up-27
        Chambers et al (1989)w7 Randomised controlled trialPhysician reminder, mammography screening30 doctors; 1262 women aged 406.6% increase in screening; numbers fell to pre-intervention levels when reminders stoppedSample-2; Differences-2; Allocation-0; Outcomes-2; Follow up-unknown7.5
        McPhee et al (1989)w8 Randomised controlled trialPhysician reminder, cancer screening62 doctors; 1969 patients16-31% increase in tests performed with computer generated reminders; 12-25% with audit and feedbackSample-2; Differences-2; Allocation-1; Outcomes-2; Follow up-29
        McDowell et al (1989)w9 Randomised controlled trialPatient reminder, cervical screening6 practices (4-6 doctors, 1 nurse); 2034 women aged 18-352.4% increase with computerised physician reminder, 6.3% with phone reminder, 12.2% with computerised letter; physician most cost effectiveSample-2; Differences-2; Allocation-0; Outcomes-1; Follow up-27
        Mazzuca et al (1990)w10 Randomised controlled trialPhysician reminder, diabetes management114 doctors; 2791 patients; 8132 visits5-14% increase in compliance with five diabetes care standardsSample-2; Differences-2; Allocation-2; Outcomes-2; Follow up-210
        McPhee et al (1991)w11 Randomised controlled trialPhysician reminder, cancer screening40 doctors; 2420 patients10.5-30.7 point increase in physician performance score for stool occult bloods; rectal, pelvic, or breast exams; pap smears; diet or smoking assessment; counsellingSample-2; Differences-2; Allocation-1; Outcomes-2; Follow up-29
        Ornstein et al (1991)w12 Randomised controlled trialPhysician reminder, patient reminder, preventive care49 doctors; 7397 patientsGreatest increase with reminders to both; 12-18.6% increase in blood cholesterol tests, faecal occult blood tests, mammograms, tetanus vaccination; decrease in pap smears for all groupsSample-2; Differences-1; Allocation-2; Outcomes-2; Follow up-29
        Rosser et al (1992)w13 Randomised controlled trialPhysician reminder, patient reminder, tetanus vaccination6 practices (4-6 doctors, 1 nurse); 8069 patients aged 2019.6% increase with computerised physician reminder, 20.8% with phone reminder, 27.4% with computerised patient letter; physician most cost effectiveSample-2; Differences-2; Allocation-0; Outcomes-0; Follow up-26
        McDonald et al (1992)w14 Randomised controlled trialPhysician reminder, flu immunisation126 doctors; 4 nurses; 4555 patientsAverage increase of 14.5% in vaccinations over 3 years; study group received vaccinations at almost twice rate of controlsSample-2; Differences-2; Allocation-2; Outcomes-2; Follow up-08
        Rubenstein et al (1995)w15 Randomised controlled trialComputerised feedback, functional status, quality of life73 doctors; 557 patientsStudy group physicians diagnosed 9% more patients with depression or anxiety, 12% more with physical, psychological, or social functioning problems; functional status interventions 0.8% higher per patient; 0.8% more clinical problems recorded per patientSample-1; Differences-2; Allocation-2; Outcomes-1; Follow up-06
        Burack et al (1994)w16 Randomised controlled trialPhysician reminder, patient reminder, mammography screening25 doctors (5 sites); 4401 women aged 4013-29% increase in appointment rates at 6 months; 2-25% at 12 months; no significant increase in mammograms with patient reminderSample-2; Differences-2; Allocation-0; Outcomes-2; Follow up-28
        Litzelman et al (1993)w17 Randomised controlled trialPhysician reminder, preventive care176 doctors; 5407 patients3-12% greater compliance for faecal occult blood tests, mammography, pap smearsSample-2; Differences-2; Allocation-2; Outcomes-2; Follow up-210
        Moran et al (1992)w18 Randomised controlled trialPatient reminder, flu immunisation8 doctors; 1 physician assistant; 409 patientsNo significant difference in immunisation rates (29.7% v 40% v 38.2%); patients with appointments more likely to be immunisedSample-2; Differences-2; Allocation-0; Outcomes-2; Follow up-28
        Lobach et al (1994)w19 Randomised controlled trialComputerised protocol, diabetes management54 doctors; 2 physician assistants; 2 nurses; 497 patients14.4% greater compliance for diabetes care standards; significant difference for physical exam (26.6%), urine protein determination (69.4%), blood cholesterol checks (30.3%); 10 min increase in length if diabetes assessedSample-2; Differences-2; Allocation-1; Outcomes-2; Follow up-29
        Tierney et al (1987)w20 Randomised controlled trialComputer display, test results111 doctors13% reduction in charges per visit; 5.9% fewer tests ordered; 4.7 secs longer to order tests in study groupSample-1; Differences-2; Allocation-0; Outcomes-2; Follow up-05
        McDowell et al (1990)w21 Randomised controlled trialPatient reminder, flu immunisation6 practices; 1175 patients aged 6529.6% increase in immunisations; rate fell to similar as control group when reminders stoppedSample-2; Differences-2; Allocation-0; Outcomes-1; Follow up-27
        Robson et al (1989)w22 Randomised controlled trialComputer assisted follow up, preventive care5 doctors; 1 nurse; 3206 patients aged 30-6412-28% increase in recording of blood pressure, smoking, blood cholesterol, cervical smears, family history of MISample-2; Differences-2; Allocation-0; Outcomes-2; Follow up-unknown7.5
        Brownbridge et al (1986)w23 Controlled before and after studyComputerised protocol, hypertension management3 doctors; 89 consultations33% more peripheral pulse exams; 53% more fundal exams; protocol use increased consultation length by 35%Sample-0; Differences-0; Allocation-2; Outcomes-1; Follow up-not applicable4
        Safran et al (1996)w24 Controlled trialComputer based record, guidelines, HIV infection126 doctors; 349 patientsMedian response time with alerts 41 days faster, 385 days faster with remindersSample-1; Differences-2; Allocation-2; Outcomes-2; Follow up-29
        Warshawsky et al (1994)w25 Before and after studyComputer based record, consultation length, consultation content4 physicians; 132 consultationsNo significant difference in average length for 3/4 doctors; computer used for 1-11% more of consultation than conventional records, 2-13% less on record review, 5-20% more on documentation; 7-28% increase in non-interaction timeResearch question-1; Source of cases-1; Inclusion or exclusion-0; Sample size-0; Starting point-0; Validity of measure-13
        Margolis et al (1992)w26 Before and after studyComputer algorithm, paediatrics6 doctorsSignificant increase in data items collected for otitis media (61%), pharyngitis (55%), URI (58%); significant increase in compliance with management plans recommended for otitis media (41%), pharyngitis (28%); significant decrease in incorrect antibiotic use; no significant increase in lengthResearch question-1; Source of cases-1; Inclusion or exclusion-0; Sample size-0; Starting point-1; Validity of measure-14
        Greatbatch et al (1995)w27 Before and after studyDoctor-patient relationship, communication7 doctors; 250 consultationsIncreasing familiarity with system did not reduce adverse effect on social interaction; patients attempted to synchronise speech with potential pauses in keyboard useResearch question-0; Source of cases-1; Inclusion or exclusion-0; Sample size-0; Starting point-0; Validity of measure-12
        DeVore (1991)w28 Case seriesComputerised feedback, geriatric assessment, preventive care1 doctor; 22 patientsNew medical problem diagnosed for 19/22 patients; new medication prescribed or existing medication altered for 8 patientsSource of cases-1; Inclusion or exclusion-0; Sampling method-0; Exposure-0; Validity of measure-1; Follow up-02
        Singh et al (1992)w29 Before and after studyInformation management, immunisation, family planning5 health centres (2 doctors; 1 pharmacist; 2 community health workers; 1 auxiliary nurse/midwife); only 1 centre studied in this paperImmunisation rates increased by 34%Research question-0; Source of cases-0; Inclusion or exclusion-0; Sample size-0; Starting point-0; Validity of measure-11
        Tierney et al (1990)w30 Randomised controlled trialComputer display, test ordering121 doctors, 6873 patients (pre-intervention); 121 doctors, 8392 patients (intervention); 74 doctors, 5590 patients (post-intervention)8-14% fewer tests ordered during intervention; 11-14% reduction in charges; test ordering was 1.5 seconds longer in study groupSample-2; Differences-2; Allocation-1; Outcomes-2; Follow up-07
        Barton et al (1990)w31 Time seriesPhysician reminder, patient reminder, flu immunisation100 physicians; 845 patients aged 65 or high riskNo change in immunisations rates for patients 65 years 1-2, increased by 18% years 2-3; rates for patients <65 increased by 3% years 1-2 and by 14% years 2-3; greatest increase with physician feedbackResearch question-0; Source of cases-1; Inclusion or exclusion-1; Sample size-0; Starting point-1; Validity of measure-14
        Christensen-Szalanski et al (1982)w32 Time seriesComputer algorithm, physician feedback, respiratory illness15 nurses; 1 physician assistant; 2 medex; 881 patientsImproved completeness of medical records; 20-75% reduction in tests ordered; 36% reduction in non-provider costs per visitResearch question-0; Source of cases-1; Inclusion or exclusion-0; Sample size-0; Starting point-1; Validity of measure-13
        Hutchison (1989)w33 Case-control studyPhysician reminder, nurse reminder, flu immunisation2 practices; 1211 patients aged 6515.6% greater increase in overall immunisation rate in study group during intervention; 22.3% more attenders immunised in study groupResearch question-0; Source of cases-1; Source of controls 1; Inclusion or exclusion-1; Sampling method-0; Comparability-14
        Turner et al (1994)w34 Randomised controlled trialPhysician prompt, preventive care44 doctorsIncrease of 1-11% in study group for all five measures, none significant; controls increased for flu immunisations (7%), mammography (3%), decreased for stool occult blood tests (5%), pap smear (11%), breast exams (2%)Sample-2; Differences-1; Allocation-1; Outcomes-2; Follow up-17
        Tape et al (1993)w35 Randomised controlled trialPhysician reminder, preventive care49 doctors; 1809 patients; 4088 encounters2.7% more recommendations for sigmoidoscopy, 3% for tetanus, 7.8% for flu vaccination, 6.6% for pneumococcal vaccination; no difference for faecal occult blood tests, mammography, pap smears, serum thyroxine screening in the elderlySample-0; Differences-2; Allocation-2; Outcomes-2; Follow up-unknown7.5
        Harris et al (1990)w36 Time seriesPhysician prompt, preventive care1 medical practice (177 doctors); 450 women aged 50Overall performance increased by 15%; 5% increase from no prompt to nurse prompt, 10% from nurse prompt to physician prompt; 47% increase in flu vaccination, 29% in mammography; non-significant increase of 7-8% in tonometry, breast exam, pneumococcal vaccinationResearch question-1; Source of cases-0; Inclusion or exclusion-1; Sample size-0; Starting point-1; Validity of measure-14
        Lobach (1996)w37 Randomised controlled trialComputerised feedback, guidelines, diabetes45 doctorsMedian compliance was 29.2% greater for physicians in study group; 62% felt feedback increased guideline use; 52% liked getting feedbackSample-2; Differences-2; Allocation-1; Outcomes-2; Follow up-29
        Krall (1995)w38 Time seriesComputer based record, physician attitudes, consultation length2 practices (30 doctors; 16 physician assistants or nurse practitioners)After 2 months, doctors spent 2 min 10 sec longer per patient; 1 min 56 sec on >orders and diagnosis=; worked average of 30 days before reaching baseline rates; average of 25-38 hrs per clinician >lost= to decreased productivity learning the systemResearch question-0; Source of cases-1; Inclusion or exclusion-0; Sample size-0; Starting point-1; Validity of measure-13
        Jones et al (1996)w39 Controlled before and after studyComputer prompting, prescribing, costs2 military medical centres; 2 primary care clinicsReduction in NSAID costs per 100 visits for protocol group, none for computer ordering plus costs group, and increase in computer ordering only group; significant reduction of 13.2% in prescribing expensive NSAIDS for protocol group, 3.6% for computer plus costs group, 1.7% in computer only groupSample-0; Differences-1; Allocation-2; Outcomes-2; Follow up-unknown6
        Rosser et al (1991)w40 Randomised controlled trialPatient reminder, preventive care6 practices (4-6 doctors, 1 nurse) 8502 patients aged 1529.5% increase in procedures with computerised letter, 28.8% with phone reminder, 19.2% with computerised physician reminder; physician most cost effectiveSample-2; Differences-2; Allocation-0; Outcomes-2; Follow up-28
        Frame et al (1994)w41 Randomised controlled trialPhysician reminder, patient reminder, preventive care1 practice (7 physicians, 5 physician assistants); 1665 patients aged 1811% increase in overall compliance with health maintenance protocol; 2% for mammography or weight, 3% for blood pressure, 6% for blood cholesterol checks, 9% for pap smears, 11% for breast exams,15% for faecal occult blood tests, 21% for tetanus; no change for smokingSample-2; Differences-1; Allocation-0; Outcomes-2; Follow up-unknown6
        Chambers et al (1991)w42 Randomised controlled trialPhysician reminder, flu immunisation32 doctors; 686 patientsImmunisation rate increased by 21% for those receiving reminders for all patients, 8% for those receiving for half; fell by 10% for those receiving no remindersSample-2; Differences-0; Allocation-1; Outcomes-2; Follow up-unknown6
        Hobbs et al (1996)w43 Controlled before and after studyDecision support system, computer prompting, lipid management25 practicesNo difference in prescribing or gross rate of requests for lipid tests; small increase in patients receiving full lipid profiles, reduction in those receiving partial profilesSample-1; Differences-0; Allocation-2; Outcomes-1 ; Follow up-04
        Turner et al (1989)w44 Controlled trialPhysician reminder, preventive care39 doctors; 253 patients aged 20Significant improvements for mammography (0.7-32%), breast exam (9-16%), stool guaiac test (10-16%), rectal exam (12-18%), pap smears (13-19%); after 1 year completed tests ranged from 33% to 52%, compared with 9-39% before interventionSample-0; Differences-0; Allocation-1; Outcomes-2; Follow up-25
        Davidson et al (1987)w45 Case seriesDecision support system, prescribing, drug interactions13 physicians; 103 patients152 drug interactions detected for 71 patients; prescription plans changed as a result for 15.5% of patients; physicians gained new information in 46% of casesSource of cases-1; Inclusion or exclusion-1; Sampling method-0; Exposure-1; Validity of measure-1; Follow up-15
        Barnett et al (1983)w46 Randomised controlled trialPhysician reminder, blood pressure management1 practice; 115 adult patientsAfter 24 months, follow up had been attempted for 52% more patients in study group, blood pressure recorded for 18% moreSample-2; Differences-0; Allocation-0; Outcomes-1; Follow up-14
        Burack et al (1996)w47 Randomised controlled trialPhysician reminder, patient reminder, mammography screening1 HMO (2 practices); 20 physiciansNo significant increase in mammography or visitation rates with patient reminder only; physician reminder increased mammograms by 14% at one site; mammography rate for visitors increased by 2-16%Sample-2; Differences-2; Allocation-0; Outcomes-2; Follow up-28
        Landis et al (1992)w48 Randomised controlled trialPhysician prompt, patient reminder, mammography screening1 practice (24 doctors); 122 women aged 50-7020% more patients received a mammography in doctor prompt plus patient reminder groupSample-2; Differences-1; Allocation-1; Outcomes-2; Follow up-28
        Tierney et al (1988)w49 Randomised controlled trialComputer display, test ordering112 doctors; 9496 patients; 23830 visits8.8% less charges per visit in study group, from 3.8% for electrocardiogram to 26.8% urine culture; during intervention fell by 10.8% for study group, 3.7% for controlsSample-2; Differences-0; Allocation-0; Outcomes-2; Follow up-unknown5
        McDonald et al (1980)w50 Randomised controlled trialPhysician reminder, prescribing1 practice (26 doctors; 5 nurses)16.1% increase in average physician response with reminder alone, 21.1% with reminder plus supporting citationsSample-1; Differences-2; Allocation-1; Outcomes-1; Follow up-27
        Lobach et al (1997)w51 Randomised controlled trialComputer protocol, guidelines, diabetes care54 doctors; 2 physician assistants; 2 nursesSee Lobach et al (1994)w19Sample-2; Differences-2; Allocation-1; Outcomes-2; Follow up-29
        Herzmark et al (1984)w52 Controlled before and after studyConsultation length, information handling, preventive care5 doctors; 374 consultationsConsultation 54 seconds longer; doctors spent twice as much time using computer; discontinued interaction with patient on 24% more occasionsSample-0; Differences-2; Allocation-1; Outcomes-2; Follow up-27
        Pringle et al (1985)w53 Randomised controlled trialPatient stress and arousal, consultation length, preventive care3 doctors; 120 patientsConsultation 48 seconds longer; 16% increase in mention of smears, 55% tetanus, 30% blood pressure; no difference in stress levels; more patients from computer group had higher arousal levels after consultationSample-2; Differences-0; Allocation-0; Outcomes-1; Follow up-25
        Pringle et al (1986)w54 Randomised controlled trialConsultation length, doctor activities, patient activities3 doctors; 142 patientsConsultation 48 seconds longer; 4.5% increase in doctor speech, 12% less patient speech; 15% increase in physical exams; 12% increase in secondary tasks; 4.5% increase in administrationSample-2; Differences-0; Allocation-0; Outcomes-2; Follow up-not applicable5
        Pringle et al (1985)w55 Randomised controlled trialDoctor initiated topics, patient initiated topics3 doctors; 120 patients29% increase in medical topics raised by doctorSample-2; Differences-0; Allocation-0; Outcomes-2; Follow up-not applicable5
        Weingarten et al (1989)w56 Randomised controlled trialComputer protocol, consultation length, preventive care1 doctor; 205 patientsConsultation an average of 90 seconds longer; 3-36% increase in recording of 11 preventive care items over controlsSample-1; Differences-1; Allocation-0; Outcomes-2; Follow up-15
        Brownbridge et al (1985)w57 Case-control studyStandards of care6 doctors; 60 patientsNo difference in identifying complaints, physical exams, interpreting evidence, reaching medical decisionsResearch question-1; Source of cases-1; Source of controls 1; Inclusion or exclusion-0; Sampling method-0; Comparability-14
        Garr et al (1993)w58 Before and after studyPhysician reminder, patient reminder, preventive care44 doctors; 15388 patients9.3% increase for cholesterol checks, 9.5% for tetanus immunisations, 3.4% for pap smears; non-significant increase for faecal occult blood tests and mammograms (0.1%)Research question-0; Source of cases-1; Source of controls-1; Inclusion or exclusion-0; Sampling method-1; Comparability-14
        Donald (1986)w59 Before and after studyPrescribing1 doctor; 1400 patients13% reduction in total cost of prescriptionsResearch question-0; Source of cases-1; Inclusion or exclusion-0; Sample size-not applicable; Starting point-1; Validity of measure-13.5
        Donald (1989)w60 Before and after studyPrescribing1 doctor; 1400 patients22%-30% reduction in costs; greater when all prescriptions done on computerResearch question-1; Source of cases-1; Inclusion or exclusion-0; Sample size-not applicable; Starting point-1; Validity of measure-15
        Mitchell et al (1997)w61 Controlled before and after studyChronic disease management, patient outcomes, service use12 practices; 1272 patients2-20% increase in recording for 11/15 items in the study group, compared with 1-11% for 7/15 items in the control groupSample-0; Differences-2; Allocation-2; Outcomes-1; Follow up-16

        MI=myocardial infarction. URI=upper respiratory infection. HMO=health maintenance organisation.


         

        Table 2 Details of studies of effect of computers in primary care on patient outcomes
         

        Author(s)

        Study design

        		Research topicParticipantsMain outcomesMethodology scoresOverall score (out of 10)
        McAlister et al (1986)w62 Randomised controlled trialComputerised feedback, hypertension management60 doctors; 2231 patientsModerate hypertensives had 4.8 mm Hg larger decrease in diastolic pressure; 4.1 visits less to GP per year; drop out rate was 4.6% lowerSample formation-2; Baseline differences-2; Unit of allocation-1; Outcome measures-1; Follow up-17
        Fitzmaurice et al (1996)w63 Randomised controlled trialDecision support system, anticoagulation2 practices; 49 patients32-66% improvement in INR control; mean recall for study patients extended by 8-12 days; satisfaction in study group was highSample formation-1; Baseline differences-0; Unit of allocation-0; Outcome measures-2; Follow up-25
        Lewis et al (1996)w64 Randomised controlled trialComputerised feedback, mental health1 practice (6 doctors, 1 trainee); 681 patientsGHQ score improved by 2.5 points at 6 weeks; no difference at 6 months; no significant differences in consultations, prescriptions, referrals to mental health for any groupSample formation-2; Baseline differences-2; Unit of allocation-0; Outcome measures-1; Follow up-05
        Rubenstein et al (1995)w15 Randomised controlled trialComputerised feedback, functional status, quality of life73 doctors; 557 patients4.5 point increase in emotional wellbeing scores; limitations on social activities score decreased by 19.6 for patients aged 70Sample formation-1; Baseline differences-2; Unit of allocation-2; Outcome measures-1; Follow up-06
        Liaw et al (1996)w65 Randomised controlled trial Computer health record (CHR), health promotion5 practices; 551 patients aged 25-6518-27% more patients in CHR only group attended for health check; 13-22% more in the CHR plus patient health record used the recordSample formation-2; Baseline differences-0; Unit of allocation-0; Outcome measures-0; Follow up-02
        Safran et al (1996)w24 Controlled trialComputer based record, guidelines, HIV infection126 residents; 349 patientsPrimary care visits, admission rates, emergency visits, survival were unaffectedSample formation-1; Baseline differences-2; Unit of allocation-2; Outcome measures-2; Follow up-29
        Campbell et al (1996)w66 Before and after studyAppointment system1 practice (6-8 doctors)Median time to make appointment reduced by 4 seconds by phone, 12 seconds in person; patients waiting 90 seconds to make appointment reduced by 11% by phone, 6% in person; number of doctor movements to check appointment board or computer list reduced by 129Research question-0; Source of cases-1; Inclusion or exclusion-0; Sample size-0; Starting point-0; Validity of measure-12
        Tierney et al (1990)w30 Randomised controlled trialComputer display, test ordering121 doctors, 6873 patients (pre-intervention); 121 doctors, 8392 patients (intervention); 74 doctors, 5590 patients (post-intervention)No significant difference in admissions, emergency visits, outpatient visitsSample formation-2; Baseline differences-2; Unit of allocation-1; Outcome measures-2; Follow up-07
        Solomon et al (1995)w67 Randomised controlled trialComputer based record, patient satisfaction2 doctors; 60 patientsNo significant differences for familiarity, computer experience, satisfaction with record taking, interaction, physician attentiveness, eye contactSample formation-1; Baseline differences-2; Unit of allocation-0; Outcome measures-1; Follow up-26
        Strecher et al (1994)w68 Randomised controlled trialComputer tailoring, smoking cessationStudy 1: 72 patients aged 40-65; Study 2: 296 patients aged 18-7511.8-23.6% greater increase in smoking cessation rates for moderate or light smokersSample formation-2; Baseline differences-2; Unit of allocation-0; Outcome measures-0; Follow up-04
        Quattlebaum et al (1991)w69 Randomised controlled trialPatient reminder, appointment dates1 practice (27 doctors; 2 behavioural scientists; 1 nurse); 901 appointmentsNo difference in cancellation rates; 9% greater reduction in no show rates, 8-10% for appointments made before scheduled visitsSample formation-2; Baseline differences-2; Unit of allocation-0; Outcome measures-2; Follow up-28
        Hobbs et al (1996)w43 Controlled before and after studyDecision support system, computer prompting, lipid management25 practices55% decrease in expected referrals, not significantSample formation-1; Baseline differences-0; Unit of allocation-2; Outcome measures-1 ; Follow up-04
        Van den Hoogen et al (1990)w70 Case-control studyComputerised feedback, hypertension management15 practices95 mm Hg target blood pressure achieved for 14% more patients in study group; 31% more hypertensives under permanent surveillanceResearch question-1; Source of cases-0; Source of controls-0; Inclusion or exclusion-0; Sampling method-0; Comparability-12
        Barnett et al (1983)w46 Randomised controlled trialPhysician reminder, blood pressure management1 practice; 115 adult patients18% more patients with diastolic pressure <100 mm Hg or on treatment in study group after 12 months, 18% more after 24 monthsSample formation-2; Baseline differences-0; Unit of allocation-0; Outcome measures-1; Follow up-14
        Fihn et al (1994)w71 Randomised controlled trialComputer scheduling of appointment, anticoagulation5 practices, 620 patientsScheduled follow up 0.9 weeks longer in study group, actual follow up still 0.3 weeks longer; no significant differences in anticoagulation controlSample formation-2; Baseline differences-2; Unit of allocation-0; Outcome measures-2; Follow up-28
        Sullivan et al (1992)w72 Before and after studyPatient satisfaction1 practice (4 doctors); 900 patientsNo difference in overall patient satisfaction, or in individual subscales of general satisfaction, professional care, depth of relationship or perceived timeResearch question-0; Source of cases-1; Inclusion or exclusion-0; Sample size-0; Starting point-1; Validity of measure-13
        Mitchell et al (1997)w61 Controlled before and after studyChronic disease management, patient outcomes, service use12 practices; 1272 patientsNo effects on GP attendance, hospital admission, disease related referrals; no significant difference in satisfaction or health statusSample formation-0; Baseline differences-2; Unit of allocation-2; Outcome measures-1; Follow up-16

        INR=international normalised ratio. GHQ=general health questionnaire.


         

        Table 3 Details of studies of attitudes towards computerisation in primary care
         

        Author(s)

        Survey method

        		ParticipantsPositive aspects mentionedNegative aspects mentioned
        Liaw (1994)w73 Questionnaire315 doctors54% planned to computerise records in next 5 years; partially computerised systems more likely to be used by doctors who believed in an empowered doctor-patient relationshipLack of funds (61%); expensive packages (52%); uncooperative partners (30%)
        Moidu et al (1992)w74 Questionnaire43 doctorsWilling to accept computers as part of working environment (98%); main reasons for acquisition were health management (58%) and patient care (53%)Reservations about use (31%); interference with doctor-patient relationship (26%); dehumanisation of medicine (26%)
        Thakurdas et al (1996)w75 Questionnaire268 doctorsComputerisation becoming a necessity (85%); computerisation was a good thing (73%); felt comfortable using computer (50%)Interference with doctor-patient relationship (43%); privacy (33%); time commitment (28%); cost prohibitive (24%)
        Ridsdale et al (1994)w76 Interview1 practice; 30 patientsEfficient tool for access, current medication, or saving time (87%); enjoy discussing what to record (33%); not intrusive if doctor spoke or maintained eye contact (87%); prefer to see screen (97%)Loss of confidentiality (70%); computers >unfriendly=, eventually take over doctor=s role (17%); unauthorised access (66%)
        Carman et al (1995)w77 Interview1 practice; 39 patients Concerned about who would have access; threat to privacy or confidentiality; should be restricted to non-sensitive information (56%); eager to negotiate with doctor over content
        Brownbridge et al (1985)w78 Questionnaire2 practices; 353 patientsNo significant effect on perceptions of doctor attentiveness or rapport, information provision, satisfaction with treatment or post-consultation stress; 87% felt consultation had not been affectedPost-consultation stress linked to patient attitudes about computer use
        Rethans et al (1988)w79 Questionnaire1 practice; 263 patientsContact with doctor was no less personal (92.7%); disagreed that consultation was longer (87.7%); doctor got picture of medical history more quickly (86.6%)Easier for others to gain information about patients (30.8%); disagreed privacy was more secure (66.5%); does not mean that doctor delivers better care (84.4%)
        Baldwin (1985)w80 Questionnaire41 doctorsPatient care improved either a little or a great deal (76%)More time required than expected (52%); hardware problems (82%); software problems (85%)
        Rowe et al (1995)w81 Questionnaire433 1st year family medicine residentsComputers should be a component of training (71%)Training was a major concern (48%); barriers to this were lack of time (56%), cost (49%), lack of computers (37%), lack of courses (30%); extra training would make use more efficient (56%) and increase skills and comfort with using computer (27%)
        Krall (1995)w38 Questionnaire2 practices (9 physicians; 12 internists; 9 paediatricians; 16 physician assistants or nurse practitioners)Only 15% had reservations about computers pre-intervention; after 4 months, system was worth time and effort to use it (85%); system was easy to use (79%)After 4 months 15% agreed they would return to the old system if given a choice
        Bolton et al (1995)w82 Questionnaire398 RACGP members49.2% computerised; 41.6% believed patients= were positive; highest ranked priorities for choosing system were market presence (7.8), upgrade of existing system (6.8), networking (6.7)Computer records less secure; highest ranked barriers to use were no advantage to practice management (8.9), fear (6.5), poor training (6.4), poor support (6.3), cost (6.2)
        Valenta et al (1996)w83 Group / questionnaire46 doctors categorised as 4 typesUseful for obtaining data and access to literature; did not believe computers were hard to learn, depersonalised consultation or made medical care too standardisedConcern over confidentiality and security; consultation use was depersonalising, medical care too standardised; negative view of computers for research, literature retrieval, data sharing
        Ornstein et al (1994)w84 Interview1 practice; 16 patientsNo worries over confidentiality if security measures taken (69%); doctor-patient relationship unchanged (88%); better access; time saved, better legibility and durability, less paperwork, improved prescribing3 patients saw other patient=s record, had missing information, or saw doctor getting frustrated at malfunction; concern over confidentiality (31%); system downtime, data back up, training
        Cruickshank (1984)w85 Questionnaire645 patients (229 outpatients, 416 primary care)Patients with experience were more positive; time saving (81% of outpatients, 70% of primary care patients); check against mistakes (84%, 80%); save money (43%, 40%); lead to better treatment or diagnosis (42%, 33%)See even less of doctor (48% of outpatients, 35% of primary care patients); loss of personal touch (56%, 52%); doctor would spend more time checking computer than patient (39%, 30%)
        Potter (1981)w86 Questionnaire2 practices; 462 patientsMajority had positive attitude towards computerisationAnxiety over doctor using computer (19%); items they would not like recorded on computer (14.5%); unwilling to speak frankly (26.5%); change doctor if computer used (6.7%)
        Pringle et al (1984)w87 Questionnaire2 practice; 304 patientsIn general patients had positive attitude towards computerisationDid not favour computer use (17%); loss of confidentiality (31%); consultations would become less personal (15%); negative views of the cost of computerisation (13%)
        Als (1997)w88 Interview5 practices; 5 doctors; 12 patientsThe more patients knew about computers the more positive their attitudesDoctors unaware of using computer to guide conversation or provide >time out=; saw possible intrusion on doctor-patient relationship; only 5/12 patients aware of computerised records; 11/12 thought information was accessible to others; concern over confidentiality; some had lack of confidence in doctor
        Bright (1991)w89 Questionnaire1 practice; 144 patientsDid not mind or were glad computer was there (97% in near group, 96% in far group); patients preferred having computer near to themselves and doctor during consultationsComputer interfered with consultation (1.5% in near group, 5.6% in far group)
        Herzmark et al (1984)w52 Interview5 doctors; 374 consultations Doctors found computer use stressful; felt communication with patient was impaired
        Sullivan et al (1992)w72 Questionnaire1 practice (4 doctors); 900 patientsBefore computer was introduced, 77% patients thought it was a good idea; increased to 85% six weeks after introduction; increased to 88% 6 months after 

        RACGP=Royal Australian College of General Practitioners
         

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