OBJECTIVE:To evaluate the influence of computer-based reminders about influenza vaccination on the behavior of individual clinicians at each clinical opportunity.DESIGN:The authors conducted a prospective study of clinicians' influenza vaccination behavior over four years. Approximately one half of the clinicians in an internal medicine clinic used a computer-based patient record system (CPR users) that generated computer-based reminders. The other clinicians used traditional paper records (PR users).MEASUREMENTS:Each nonacute visit by a patient eligible for an influenza vaccination was considered an opportunity for intervention. Patients who had contraindications for vaccination were excluded. Compliance with the guideline was defined as documentation that a clinician ordered the vaccine, counseled the patient about the vaccine, offered the vaccine to a patient who declined it, or verified that the patient had received the vaccine elsewhere. The authors calculated the proportion of opportunities on which each clinician documented action in the CPR and PR user groups.RESULTS:The CPR and PR user groups had different baseline compliance rates (40.1 and 27.9 per cent, respectively; P<0.05). Both rates remained stable during a two-year baseline period (P = 0.34 and P = 0.47, respectively). The compliance rates in the CPR user group increased 78 per cent from baseline (P<0.001), whereas the rates for the PR user group did not change significantly (P = 0.18).CONCLUSIONS:Clinicians who used a CPR with reminders had higher rates of documentation of compliance with influenza-vaccination guidelines than did those who used a paper record. Measurements of individual clinician behavior at the point of each clinical opportunity can provide precise evaluation of interventions that are designed to improve compliance with guidelines.

OBJECTIVETo investigate whether using a computer-based patient record (CPR) affects the completeness of documentation and appropriateness of documented clinical decisions.DESIGNA blinded expert panel of four experienced internists evaluated 50 progress notes of patients who had chronic diseases and whose physicians used either a CPR or a traditional paper record.MEASUREMENTSCompleteness of problem and medication lists in progress notes, allergies noted in the entire record, consideration of relevant patient factors in the progress note's diagnostic and treatment plans, and appropriateness of documented clinical decisions.RESULTSThe expert reviewers rated the problem lists and medication lists in the CPR progress notes as more complete (1.79/2.00 vs 0.93/2.00, P < 0.001, and 1.75/2.00 vs. 0.91/2.00, P < 0.001, respectively) than those in the paper record. The allergy lists in both records were similar. Providers using a CPR documented consideration of more relevant patient factors when making their decisions (1.53/2.00 vs. 1.07/2.00, P < 0.001), and documented more appropriate clinical decisions (3.63/5.00 vs. 2.50/5.00, P < 0.001), compared with providers who used traditional paper records.CONCLUSIONSPhysicians in our study who used a CPR produced more complete documentation and documented more appropriate clinical decisions, as judged by an expert review panel. Because the physicians who used the CPR in our study volunteered to do so, further study is warranted to test whether the same conclusions would apply to all CPR users and whether the improvement in documentation leads to better clinical outcomes.

Ambulatory care is assuming an increasing role in health-care delivery. Yet, most health-care information systems were developed for the acute-care setting. To address the needs of ambulatory care, developers need a comprehensive understanding of the information-related activities of clinicians in heterogeneous outpatient practices. We studied the information activities of clinicians in seven diverse (primary-care, specialty-care, faculty, and independent private practices) ambulatory care sites. The results of our study allow us to characterize clinicians' information-related activities, their perceived information needs, and their satisfaction with computer resources. Developers of health-care information systems can use the results to design applications for clinicians in ambulatory care.

Clinical information systems that provide physicians with relevant information at the time and place where decisions are being made can positively affect the quality and cost of health care. We have developed an assessment methodology to study clinicians' information needs in the context of the work flow and operational constraints of the ambulatory care practice environment. We employed a combination of methods, including observational studies, process flowcharting, semi-structured interviews, and surveys to comprehensively define clinicians' needs. Results from our study point to functional requirements not commonly found in hospital-based systems, such as access to problem lists and medications, computer-based support for health-care team communications, and patient-specific instructions and education.