Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms. A randomized, controlled trial. Reminders to physicians from an introspective computer medical record. A two-year randomized trial. A controlled trial to improve delivery of preventive care: physician or patient reminders? Physician response to computer reminders. Clinical reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction increase use of beta-blockers: a randomized trial. ACE inhibitor reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction. Application of a computerized medical decision-making process to the problem of digoxin intoxication. Promoting cancer screening. A randomized, controlled trial of three interventions. The effect of computer-generated reminders on charting deficiencies in the ICU. Use of a computer to detect and respond to clinical events: its effect on clinician behavior. Protocol-based computer reminders, the quality of care and the non-perfectability of man. Microcomputer-generated reminders. Improving the compliance of primary care physicians with mammography screening guidelines. An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: Improving Primary Care of African Americans with Diabetes (IPCAAD) 8. The Enhancing Secondary Prevention in Coronary Artery Disease trial. Improving completion of advance directives in the primary care setting: a randomized controlled trial. Using a claims data-based sentinel system to improve compliance with clinical guidelines: results of a randomized prospective study. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance. The effect on cost of medical care for patients treated with an automated clinical audit system. A computer-generated reminder system improves physician compliance with diabetes preventive care guidelines. A computerized intervention to decrease the use of calcium channel blockers in hypertension. A computer-based monitoring system for follow-up of elevated blood pressure. Pap smear outreach: a randomized controlled trial in an HMO. The effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. Computerized decision support based on a clinical practice guideline improves compliance with care standards. Improving preventive care at a medical clinic: how can the patient help? Use of reminders for preventive procedures in family medicine. How reminders given to patients and physicians affected pap smear use in a health maintenance organization: results of a randomized controlled trial. Computer-generated physician and patient reminders. Tools to improve population adherence to selected preventive services. The effect of patient and physician reminders on use of screening mammography in a health maintenance organization. Results of a randomized controlled trial. Computerized concurrent review of prenatal care.
Physicians can increase the rate of completion of advance directive forms by discussing directives with their patients, but the means by which physicians can be induced to initiate these discussions are unclear. Computer-generated reminders have been shown to increase physician compliance with practice guidelines.
                To determine the effects of computer-generated reminders to physicians on the frequency of advance directive discussions between patients and their primary caregivers and the frequency of consequent establishment of advance directives.
                Randomized, controlled trial with a 2 x 2 factorial design.
                An outpatient general medicine practice associated with an urban public hospital.
                Participants were 1) 1009 patients who were at least 75 years of age or were at least 50 years of age with serious underlying disease and 2) 147 primary care physicians (108 housestaff and 39 faculty).
                Computer-generated reminders that recommended discussion of one or both of two types of advance directives compared with no reminders.
                Discussions about advance directives, determined by patient interviews after all scheduled patient-physician outpatient encounters, and completed advance directive forms. The study period was approximately 1 year.
                Physicians who did not receive reminders (controls) discussed advance directives with 4% of the study patients compared with 24% for physicians who received both types of reminders (adjusted odds ratio, 7.7 [95% CI, 3.4 to 18]; P < 0.001). Physicians who did not receive reminders completed advance directive forms with only 4% of their study patients compared with 15% for physicians who received both types of reminders (adjusted odds ratio, 7.0 [CI, 2.9 to 17]; P < 0.001). Overall, 45% of patients with whom advance directives were discussed completed at least one type of advance directive.
                Simple computer-generated reminders aimed at primary caregivers can increase the rates of discussion of advance directives and completion of advance directive forms among elderly outpatients with serious illnesses. We developed a computer-stored medical record system containing a limited set of the total clinical data base--primarily diagnostic studies and treatments. This system responds to its own content according to physician-authored reminder rules. To determine the effect of the reminder messages generated by 1490 rules on physician behavior, we randomly assigned practitioners in a general medicine clinic to study or control groups. The computer found indications for six different actions per patient in 12 467 patients during a 2-year study: 61 study group residents who received computer reminders responded to 49% of these indications; 54 control group residents, to only 29% (p less than 0.0001). Preventive care (occult blood testing, mammographic screening, weight reduction diets, influenza and pneumococcal vaccines) was affected. The intentions of the study group to use a given action for an indication predicted their response to the indications (p less than 0.03, r2 = 0.33). The intentions of the control residents did not. To improve the delivery of preventive care in a medical clinic, a controlled trial was conducted of two interventions that were expected to influence delivery of preventive services differently, depending on level of initiative required of the physician or patient to complete a service.
                A prospective, controlled trial of five-months' duration.
                A university hospital-based, general medical clinic.
                Thirty-nine junior and senior medical residents who saw patients in stable clinic teams throughout the study.
                A computerized reminder system for physicians and a patient questionnaire and educational hand-out on preventive care.
                Delivery of five of six audited preventive services improved significantly after the interventions were introduced. The computerized reminder alone increased completion rates of services that relied primarily on physician initiative; the questionnaire alone increased completion rate of the service that depended more on patient compliance as well as on some physician-dependent services. Both interventions used together were slightly less effective in improving performance of physician-dependent services than the computerized reminder used alone.
                These interventions can improve the delivery of preventive care but they differ in their impacts on physician and patient behaviors. Overall, the computer reminder was the more effective intervention. A computerized medical record system was designed to detect and remind the responsible clinician about clinical events that might need corrective action. These reminders significantly increased the clinician response rate (in terms of test orders and treatment changes) to the events in question. The addition of relevant medical literature citations to the reminders did not significantly change the clinician response rate as compared with that with reminders alone, nor did it stimulate the physicians to read any of the cited articles kept in an immediately available "library" of reprints. Although beta-blockers are known to prolong survival for patients with reduced left ventricular ejection fraction, they are often underused. We hypothesized that a reminder attached to the echocardiography report would increase the use of beta-blockers for patients with reduced left ventricular ejection fraction.
                We randomized 1546 consecutive patients with a left ventricular ejection fraction <45% found on echocardiography at 1 of 3 laboratories to a reminder for use of beta-blockers or no reminder. Patients were excluded from analysis if they died within 30 days of randomization (n=89), did not receive medications through the Veterans Affairs system after 30 days (n=180), or underwent echocardiography at >1 laboratory (n=6). The primary outcome was a prescription for an oral beta-blocker between 1 and 9 months after randomization. The mean age of the 1271 included patients was 69 years; 60% had a history of heart failure, and 51% were receiving treatment with beta-blockers at the time of echocardiography. More patients randomized to the reminder had a subsequent beta-blocker prescription (74%, 458 of 621) compared with those randomized to no reminder (66%, 428 of 650; P=0.002). The effect of the reminder was not significantly different for subgroups based on patient location (inpatient versus outpatient) or prior use of beta-blockers.
                A reminder attached to the echocardiography report increased the use of beta-blockers in patients with depressed left ventricular systolic function. nan A computerized medical decision-making system was used to monitor signs and predisposing factors of digoxin intoxication in patients receiving digoxin. This process automatically reviewed the patient's data base nightly for drug interactions, laboratory data and electrocardiographic findings with known association with digoxin intoxication. These decisions were formated into a "digoxin alert report" and sent to line printers in the nursing division to be placed on the individual patients' charts. To assess the effect of these reports on patient management, a randomized double-blind study was undertaken. Patients were assigned to an alert or nonalert group. Alert reports were withheld from charts of patients in the nonalert group. A medical record review was subsequently carried out, wherein the physician's orders were searched to identify actions taken with possible relation to the digoxin alerts. The computer monitored 396 patients over a 3 month period. Of these, 211 (53%) were randomized to the alert group and 185 (47%) to the nonalert group. Seventy-two percent of patients received at least one alert. The most frequently occurring alerts included: hypoxemia, hypokalemia, concurrent use of a beta-adrenergic blocking agent, renal insufficiency and ventricular arrhythmia. Results from the record review demonstrated a 22% increase in physician actions for the alert group. Specifically, patients in the alert group were 2.7 times more likely to have a serum digoxin determination ordered and 2.8 times more likely to have digoxin withheld on the day of a digoxin alert than were patients in the nonalert group. To determine effective methods of promoting routine cancer screening, we randomly assigned 62 internal medicine residents to receive cancer screening reminders (computer-generated lists of overdue tests at patients' visits), audit with feedback (monthly seminars about screening, with feedback about their performance rates), or no intervention (controls). Half of the residents in each group also were randomized to receive patient education (patients received literature and notices of overdue tests). We reviewed a sample of each physician's medical records to assess performance of seven tests during 9-month periods before and after initiating the interventions. Cancer screening reminders increased performance of six of seven tests; audit with feedback, four of seven tests; and patient education, one of two targeted breast cancer screening tests. The results indicate that the cancer screening reminders strategy was the most effective in promoting the performance of routine cancer screening tests. To examine the effect of computer-generated reminders on nurse charting deficiencies in two intensive care units.
                Nurses caring for a group of 60 study patients received patient-specific paper reminder reports when charting deficiencies were found at mid-day. Nurses caring for a group of 60 control patients received no reminders. A group of 60 retrospective patients was also formed.
                The average numbers of charting deficiencies at the end of the shift in each of the three groups were compared using two planned orthogonal contrasts.
                The average in the study group patients was 1.02 deficiencies per day per patient, whereas the control group the average was 1.40 deficiencies per day per patient (p = 0.001). The average number of end-of-shift deficiencies in the pooled prospective (study/control) population was 1.21 deficiencies per day per patient, compared with the average in the retrospective group of 1.56 deficiencies per day per patient (p < 0.001).
                The decrease was likely due both to the appropriate response of the nurses to the reminders and to a learned attentiveness to the tasks on the part of the nurses who cared for study patients. Greater gains were hindered by incomplete "coupling" of the reminders to the end-of-shift deficiencies and by inaccuracies in the reminders. A computer was used to prospectively detect and suggest responses to simple, medication-related events as reflected in a computerized record in a prospective, randomized study of a diabetes clinic with primary-care responsibility. There were two categories of event/suggestions: when the last observation of a test required for medication control was too old, the computer suggested a repeat; and when an abnormality with therapeutic implications was detected, the computer suggested a specific change in therapeutics. Clinicians responded to 36% of events in the first category with computer reminders and 11% without (P less than 0.0001); they responded to 28% of events in the second category with computer assistance and 13% without (P less than 0.026). For the most clinically significant of these second category events, the difference was even greater: 47% with and 4% without computer assistance (P less than 0.0004). I believe that computer detection and response (in the form of reminders) to simple clinical events will change clinician behavior. To determine whether clinical errors can be reduced by prospective computer suggestions about the management of simple clinical events, I studied the responses of nine physicians to computer suggestions generated by 390 protocols in a controlled crossover design. These protocols dealt primarily with conditions managed (e.g., elevated blood pressure) or caused (e.g., liver toxicity) by drugs. Physicians responded to 51 per cent of 327 events when given, and 22 per cent of 385 events when not given computer suggestions. Neither level of postgraduate training (first-year postgraduate or third-year post-graduate) nor the order in which physicians served as study and control subjects had statistically significant overall effect on the results. It appears that the prospective reminders do reduce errors, and that many of these errors are probably due to man's limitations as a data processor rather than to correctable human deficiencies. Recent studies have documented that physician compliance with recommended periodic health screening improves with reminders to physicians. These reminders, however, are often costly to maintain and modify. This study investigates the influence of a microcomputer tickler system on the ordering of mammograms. All women (N = 1262) aged 40 years and older who made visits to an outpatient office during a 6-month period were randomly assigned to one of two groups. For the experimental group, the date of the last mammogram ordered and recorded in the clinical database was printed on the encounter form generated for each patient visit. No information regarding previous mammograms was printed for patients in the control group. Women in the experimental group were more likely to have a mammogram ordered during the study period (19% compared with 12%, P = .001) and, as a result, were more likely to be in compliance with mammography guidelines at the study's completion (27% compared with 21%, P = .011). Microcomputerized data storage and retrieval systems may help increase physicians' attention to preventive health screening recommendations. Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated--clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control.
                In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 150 mg/dL (8.33 mmol/L) during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations).
                At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy were indicated, and there were no differences among intervention groups. During the trial, intensification increased most during the first year and then declined. However, intensification increased more in the feedback alone and feedback plus reminders groups than for reminders alone and control groups (P<.001). After 3 years, health care provider behavior in the reminders alone and control groups returned to baseline, whereas improvement with feedback alone and feedback plus reminders groups was sustained: 52% did anything, and 30% did enough (P<.001 for both vs the reminders alone and control groups). Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c (P<.001 for both).
                Feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels. Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care settings. Proven efficacious therapies are sometimes underused in patients with chronic cardiac conditions, resulting in suboptimal outcomes. We evaluated whether evidence summaries, which were either unsigned or signed by local opinion leaders, improved the quality of secondary prevention care delivered by primary care physicians of patients with coronary artery disease.
                We performed a randomized trial, clustered at the level of the primary care physician, with 3 study arms: control, unsigned statements or opinion leader statements. The statements were faxed to primary care physicians of adults with coronary artery disease at the time of elective cardiac catheterization. The primary outcome was improvement in statin management (initiation or dose increase) 6 months after catheterization.
                We enrolled 480 adults from 252 practices. Although statin use was high at baseline (n=316 [66%]), most patients were taking a low dose (mean 32% of the guideline-recommended dose), and their low-density lipoprotein (LDL) cholesterol levels were elevated (mean 3.09 mmol/L). Six months after catheterization, statin management had improved in 79 of 157 patients (50%) in the control arm, 85 of 158 (54%) patients in the unsigned statement group (adjusted odds ratio [OR] 1.18, 95% CI 0.71-1.94, p=0.52) and 99 of 165 (60%) patients in the opinion leader statement group (adjusted OR 1.51, 95% CI 0.94-2.42, p=0.09). The mean fasting LDL cholesterol levels after 6 months were similar in all 3 study arms: 2.35 (standard deviation [SD] 0.86) mmol/L in the control arm compared with 2.24 (SD 0.73) among those in the opinion leader group (p=0.48) and 2.19 (SD 0.68) in the unsigned statement group (p=0.32).
                Faxed evidence reminders for primary care physicians, even when endorsed by local opinion leaders, were insufficient to optimize the quality of care for adults with coronary artery disease. ClinicalTrials.gov trial register no. NCT00175240. Since 1991, hospitals have asked patients whether they have advance directives, but few patients complete these documents. We assessed two simple interventions to improve completion of advance directives among elderly or chronically ill outpatients.
                We conducted a cluster randomized controlled trial involving 1079 patients from five general medicine clinics that were affiliated with an academic medical center. Patients were either > or =70 years of age or > or =50 years old with a chronic illness. The study comprised three arms: physician reminders recommending documentation of advance directives, physician reminders plus mailing advance directives to patients together with educational literature, or neither intervention (control). The main outcome measure was completion of an advance directive.
                After 28 weeks, 1.5% (5/332) of patients in the physician reminder group, 14% (38/277) in the physician reminder plus patient mailing group, and 1.8% (5/286) in the control group had completed advance directives. In multivariate analyses, patients in the physician reminder plus patient mailing group were much more likely than controls to have completed advance directives (odds ratio [OR] = 5.9; 95% confidence interval [CI]: 1.5 to 22), whereas patients in the physician reminder-only group were no more likely than controls to have completed advance directives (OR = 0.88; 95% CI: 0.21 to 3.7).
                Mailing health care proxy and living will forms and literature to patients before an appointment at which their physicians received a reminder about advance directives yielded a small but significant improvement in completion of these documents. A physician reminder alone did not have an effect. To demonstrate the potential effect of deploying a sentinel system that scans administrative claims information and clinical data to detect and mitigate errors in care and deviations from best medical practices.
                Members (n = 39 462; age range, 12-64 years) of a midwestern managed care plan were randomly assigned to an intervention or a control group. The sentinel system was programmed with more than 1000 decision rules that were capable of generating clinical recommendations. Clinical recommendations triggered for subjects in the intervention group were relayed to treating physicians, and those for the control group were deferred to study end.
                Nine hundred eight clinical recommendations were issued to the intervention group. Among those in both groups who triggered recommendations, there were 19% fewer hospital admissions in the intervention group compared with the control group (P < .001). Charges among those whose recommendations were communicated were dollar 77.91 per member per month (pmpm) lower and paid claims were dollar 68.08 pmpm lower than among controls compared with the baseline values (P = .003 for both). Paid claims for the entire intervention group (with or without recommendations) were dollar 8.07 pmpm lower than those for the entire control group. In contrast, the intervention cost dollar 1.00 pmpm, suggesting an 8-fold return on investment.
                Ongoing use of a sentinel system to prompt clinically actionable, patient-specific alerts generated from administratively derived clinical data was associated with a reduction in hospitalization, medical costs, and morbidity. In an academic general medicine clinic, we performed a randomized, controlled trial to compare (1) the effects of supplying monthly feedback reports of compliance with preventive care protocols by 135 internal medicine house staff with (2) the effects of specific reminders given to them at the time of patient visits. The protocols were randomly divided into two groups, A and B, and half the house staff were given feedback for Group A and half for Group B. Thus, each group served as a control for the other. Each feedback group was also randomly assigned to receive reminders for either Group A or B protocols. House staff receiving feedback more often complied with fecal occult blood testing, mammography, pneumococcal vaccination, use of metronidazole, and combined Group A and B protocols than did controls (P less than 0.01). There was also significantly more compliance with the same protocols by house staff receiving reminders, but the increase for fecal occult blood testing, pneumococcal vaccination, and combined Group A protocols was twice that seen in physicians given feedback alone. In addition, reminders alone increased compliance with oral calcium supplementation. Overall compliance with the preventive care protocols was low: 10-15% in physicians receiving neither feedback nor reminders, increasing to 15-30% in those receiving reminders. Physician compliance with suggested preventive care protocols can be increased by both delayed feedback and immediate reminders, but reminders have a greater effect. An automated clinical medical record and audit system was developed to evaluate the effect of modifying physician behavior at the control points in the ambulatory care process and to determine if this change was reflected in patient care cost outcomes. This study compared clinical and cost results of patients in an experimental group, who had the automated record and audit system, to a control group, who had a traditional clinic record without chart audit. Physicians responded to the automated audit suggestions at a rate of 50.25 in the experimental group and 37.3 in the control group. No major differences were observed in clinical outcomes, with the exception of the number of days of hospitalizations and, consequently, the cost of hospitalizations. The experimental group cost for hospitalizations was one-third of the control group and accounted for a majority of the differences in the total annual cost for the two groups. Computerized reminder systems have been shown to be effective in improving physician compliance with preventive services guidelines. Very little has been published about the use of computerized reminders for preventive care in diabetes. We implemented a computer-generated reminder system for diabetes care guidelines in a randomized controlled study in the outpatient clinics of 35 internal medicine residents at the University of Utah and Salt Lake Veterans Affairs Hospitals. After a six month study period, compliance with the recommended care significantly improved in both the intervention group that received patient-specific reminders about the guidelines (38.0% at baseline, 54.9% at follow-up) and the control group that received a nonspecific report (34.6% at baseline, 51.0% at follow-up). There was no significant difference between the two groups. Both clinic sites showed similar improvement over baseline levels of compliance. Residents who completed encounter forms used by the system showed a significantly greater improvement in compliance than those who did not complete encounter forms (19.7% vs. 7.6%, p = 0.006). The improvements in guideline compliance were seen in all areas of diabetes preventive care studied, and significant improvements were seen with recommended items from the medical history, physical exam, laboratory testing, referrals, and patient education. The use of encounter forms by the providers significantly improved documented compliance with the guidelines in almost all categories of preventive care. These results suggest that computerized reminder systems improve compliance with recommended care more by facilitating the documentation of clinical findings and the ordering of recommended procedures than by providing the clinician with patient-specific information about guideline compliance status. Further study is needed to understand the implications of these findings to the development of future computerized reminder systems for chronic diseases such as diabetes. To determine whether a computer-assisted reminder would alter prescribing habits for the treatment of hypertension in accordance with current clinical guidelines in a general internal medicine clinic.
                A randomized trial.
                The General Internal Medicine Clinic of the Veterans Affairs Puget Sound Health Care System, Seattle Division.
                Clinic providers were randomized to a control group (n = 35) or intervention group (n = 36). We targeted the providers of patients being treated for hypertension with calcium channel blockers, a class of drug not recommended for initial therapy.
                An automated computer query identified eligible patients and their providers. A guideline reminder was placed in the charts of patients of intervention providers; the charts of patients of control providers received no reminder.
                During the 5-month study period, 346 patients were seen by the 36 primary care providers (staff physicians, nurse practitioners, residents, and fellows) in the intervention group, and 373 patients were seen by the 35 providers in the control group. Intervention providers changed 39 patients (11.3%) to other medications during the study period, compared with 1 patient (<1.0%) of control providers (p < .0001). For patients whose therapy was unchanged, providers noted angina in 23.1%, indications other than those for hypertension in 9.5%, intolerable adverse effects with first-line therapy in 13.9%, and inadequate control with first-line therapy in 13.9%. Of those patients without provider-indicated contraindications, 23.6% were switched from calcium channel blockers to first-line agents during the intervention period.
                The use of a computerized, clinic-based intervention increased compliance with guidelines in the treatment of primary hypertension in general, and decreased the use of calcium channel blockers for the treatment of hypertension in particular. An automated surveillance system utilizing a computer-based medical record system (COSTAR) was designed to improve the follow-up of patients with newly identified elevated diastolic blood pressure. A population of patients was selected where, in the 6-month period following the initial measurement of an elevated diastolic blood pressure, there were fewer than two visits during which blood pressure was recorded. In a randomized controlled clinical trial, this poor follow-up population was divided into two groups, with computer-generated reminders being automatically generated for only patients in the experimental group. Follow-up was significantly improved in the group receiving the reminders, both in terms of rate of follow-up attempted or achieved by the responsible physician and in the repeated recording of blood pressure. We conclude that a computer-based reminder system improves follow-up of newly discovered elevation in diastolic blood pressure. nan Less than 20 percent of elderly and other high-risk persons targeted for annual influenza vaccination are immunized each year. In most busy practice settings, it is difficult for primary care physicians to identify every patient in need of preventive health interventions. The purpose of this study was to assess the effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. The practice uses an interactive encounter form system from which updated clinical information is routinely entered into a cumulative database. During a 2-month period, 686 patients were identified in the database as eligible to receive influenza vaccine according to accepted criteria. Practice physicians (n = 32) were stratified by level of training and randomized to one of three groups, thereby receiving printed reminders on the encounter forms of all, none, or half of their eligible patients. Patients of physicians who always received reminders were more likely to receive influenza vaccine during the study period than patients of the never-reminded physicians (51 percent versus 30 percent, P less than 0.001). Patients whose physicians received reminders for only half their patients had an intermediate likelihood of receiving a vaccination if a reminder was printed (38 percent) but were less likely than the patients of never-reminded physicians to receive the vaccine if no reminder was printed (20 percent, P less than 0.001). This study suggests that physicians learn to depend on reminders for preventive health activities and that reminders are most effective when they are provided at every patient encounter. Clinical guidelines are designed to assist in the management of specific diseases; however, these guidelines are often neglected in the delivery of care. The purpose of this study was to determine whether clinician use of an clinical practice guideline would increase in response to having, at the patient visit, a decision support system based on a practice guideline that generates a customized management protocol for the individual patient using data from the patient's electronic medical record.
                In a 6-month controlled trial at a primary care clinic, 58 primary care clinicians were randomized to receive either a special encounter form with the computer-generated guideline recommendations or a standard encounter form. The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations. Data from 30 clinicians were analyzed; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care.
                Availability of patient management recommendations generated by the decision support system resulted in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus (P = 0.01). Median compliance for the group receiving the recommendations was 32.0% versus 15.6% for the control group.
                Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients. This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care standards. Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care. We developed a comprehensive individualized preventive care reminder system and then tested the hypothesis that directly involving patients in the reminder process would lead to greater use of preventive services than involving physicians only. There were three experimental groups of 350 patients each: in group 1 physicians and patients received the reminder; in group 2 physicians only received the reminder; in group 3 neither physicians nor patients received the reminder. Nine preventive care services were studied: blood pressure measurement; dental exam; ocular pressure measurement; stool exam for occult blood; influenza, pneumococcal, and tetanus vaccinations; mammography; and Papanicolaou smears. Need for these services was determined by telephone interview and chart review. To determine whether services were obtained, charts were reviewed after four to eight months of follow-up. For overall compliance with preventive recommendations and for several individual services (stool exam for occult blood, tetanus vaccination, mammography), group 1 patients received significantly more preventive care than group 2. Likewise, group 2 patients received more preventive care than group 3. These data show that involving patients in reminder efforts is an effective means of raising the level of preventive services. To compare the effectiveness of three computerized reminder systems in the delivery of five preventive procedures in family practice.
                Prospective, randomized, controlled study.
                Ottawa Civic Hospital Family Medicine Centre.
                Of 8502 patients 15 years of age or more who were not in a hospital or institution 5883 were randomly assigned, by family, to a control group, a physician reminder group (passive) or a telephone or letter reminder group (active). The remaining 2619 patients were not included in the randomized portion of the study but were monitored.
                During 1 year the patients in the active reminder groups received a telephone call or letter reminding them of any overdue preventive procedures; for those in the passive reminder group the physician was reminded at an office visit to provide any overdue service.
                Rates of completion of the preventive procedures required.
                All three reminder systems significantly improved the delivery of preventive services (p less than 0.001). The procedure completion rates were 42.0% in the letter reminder group, 42.0% in the telephone reminder group, 33.7% in the physician reminder group and 14.1% in the randomized control group. The use of a letter was more cost-effective than the telephone system, but the physician reminder system was the most cost-effective.
                Computerized reminder systems do improve the delivery of preventive services in family practice. Despite its effectiveness as a method of controlling cervical carcinoma, the use of Pap smear testing remains incomplete, and its promotion in the primary care setting provides an important opportunity for intervention.
                The authors conducted a randomized controlled trial that involved three sites of a health maintenance organization (HMO) serving an urban minority population. Their aim was to evaluate the impact of reminders given to patients and physicians on site visitation by patients and Pap smear use. Eligible women (n=5801) were randomly assigned to 1 of 4 intervention combinations (in which reminders were given to either the patient or the physician, to both, or to neither). If they were ineligible for patient reminder intervention, patients were randomized only to physician reminder intervention (the presence or absence of it). The letter of reminder mailed to the patient invited women due for Pap smears to visit the HMO site, and the reminder for physicians was a medical record notice that a Pap smear was due. Logistic and survival analyses were used to investigate the correlation of intervention status with visitation, interval of time to a visit, and Pap smear use.
                In the primary intent-to-treat analysis, there was no significant effect of either patient or physician reminder interventions on rates of visitation or Pap smear completion. The secondary efficacy analyses demonstrated no overall effect of either patient or physician reminders, but effects among subgroups of women at individual HMO sites were noted. At Site 3, there was an apparent increase in time to the next visit among the subgroup of women with a chronic illness (16 weeks with intervention vs. 9 weeks without). With the physician reminder, the odds that a Pap smear would be given during the study year were increased among women without a previous Pap smear at Site 1 (adjusted odds ratio=1.39) and those with a chronic illness at Site 2 (adjusted odds ratio=3.38).
                Reminders given to patients and physicians had a limited impact on visitation by patients to the HMO sites or Pap smear completion. Although some subgroups of women may benefit, the authors also observed a possibly unfavorable impact among other subgroups. These results emphasize the importance of identifying more effective interventions, targeting them to women most likely to benefit, and not overlooking the possibility that preventive intervention will have an unanticipated adverse effect. Despite an emerging consensus on appropriate preventive services, a minority of patients receive them. A study was undertaken to assess the impact of computer-generated reminders to adult patients, their physicians, or both patients and physicians on adherence to five recommended preventive services: cholesterol measurements, fecal occult blood testing, mammography, Papanicolaou smears, and tetanus immunization. During the academic year 1988-1989, all 7397 adult patients and their 49 physicians in a university family medicine clinical practice were randomized by practice group into one of four study groups: control, physician reminders, patient reminders, and both physician and patient reminders. Adherence was defined in community-oriented terms: the percentage of patients within each group who had received the preventive service in the recommended interval. During the study period, adherence to four of the five preventive services increased significantly, with the largest increases in the physician and patient reminder group: cholesterol measurements increased from 19.5% to 38.1%, fecal occult blood testing 9.3% to 27.0%, mammography 11.4% to 27.1%, and tetanus immunization 23.4% to 35.4% (for each increase, P less than .0001, McNemar's chi-square test). In general, increases were greater in blacks and in patients with any form of insurance coverage. Computer-based physician and patient reminder systems have great promise of improving adherence to preventive services in primary care settings. Despite its demonstrated efficacy in reducing breast carcinoma mortality, screening mammography remains underutilized and its promotion in the primary care setting provides an important opportunity for intervention.
                A randomized controlled trial was conducted in two sites of a health maintenance organization (HMO) serving an urban, minority population to evaluate the impact of patient and physician reminders on site visitation and mammography use. Eligible women (n = 2368) were randomly assigned to 1 of 4 intervention combinations (patient and physician reminders individually, together, or neither). The patient reminder letter invited mammography-due women to visit. The physician reminder was a notice placed in the medical record of mammography-due women. Logistic analysis and survival analysis were used to investigate the relationship of intervention status to visitation, time to a visit, and mammography use.
                The patient reminder intervention had no effect upon rates of study year visitation or mammography at either site. However, among HMO Site 2 enrollees with entitlement insurance, the median time to the next visit was reduced from 12 to 9 weeks in association with assignment to patient reminder intervention. The physician reminder intervention was also effective in increasing the rate of completed mammography at Site 2 among all assignees (36% vs. 22% for those with vs. those without physician reminders) and among assignees who visited (59% vs. 43%).
                Patient reminder letters had limited impact on visitation in this setting. Physician reminders are more effective but sites vary in their responsiveness. Further improvement in mammography utilization will require a better understanding of the determinants of patient and physician behavior. nan
There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder’s content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions