Design of a Decision Support System for Test Ordering in General Practice: Choices and Decisions to Make

M. van Wijk; M. Mosseveld; J. van der Lei

doi:10.1055/s-0038-1634405

Methods of Information in Medicine, Table of Contents

Methods Inf Med 1999; 38(04/05): 355-361
DOI: 10.1055/s-0038-1634405

Original Article

Schattauer GmbH

Design of a Decision Support System for Test Ordering in General Practice: Choices and Decisions to Make

Authors

M. van Wijk

¹Institute of Medical Informatics, Erasmus University Rotterdam, The Netherlands
M. Mosseveld

¹Institute of Medical Informatics, Erasmus University Rotterdam, The Netherlands
J. van der Lei

¹Institute of Medical Informatics, Erasmus University Rotterdam, The Netherlands

Abstract

The increased availability of tests in the past years has been accompanied by an increased number of blood tests ordered by general practitioners. Dutch investigators report a lack of general practitioners’ knowledge concerning the indications for blood tests leading to inappropriate and inadequate use of diagnostic tests. Taking advantage of the use of electronic patient records by Dutch general practitioners, the authors replaced the traditional paper forms for test ordering by a decision-support system. The objective of the decision-support system is to change test-ordering behavior. Designing a system to change test-ordering behavior, however, required the selection of a method to provide support. To study different methods for changing test-ordering behavior, the authors developed two versions of the decision-support system BloodLink. The first version, Blood-Link-Restricted, is based on the notion of restricting the number of choices presented to the general practitioners. The second version, BloodLink-Guideline, is based on the guidelines provided by the Dutch college of general practitioners.

Keywords

Decision Support - Guidelines - Test-ordering Behavior - General Practice

Full Text

References

REFERENCES
1 Kluijt I, Zaat JOM, Van der Velden J, van Eijk JTM, Schellevis FG. Voor een prikje: Huisarts en bloedonderzoek. Huisarts en Wetenschap 1991; 34: 67-71.
2 Summerton N. Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. Br Med J 1995; 310: 27-9.
3 Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JEJ. Characteristics of physicians with participatory decisions-making styles. Ann Intern Med 1996; 124: 497-504.
4 Hewson MG, Kindy PJ, Van Kirk J, Gennis VA, Day RP. Strategies for managing uncertainty and complexity. J Gen Intern Med 1996; 11: 481-5.
5 McKinlay JB, Potter DA, Feldman HA. Non-medical influences on medical decision-making. Soc Sci Med 1996; 42: 769-76.
6 Hamm RM, Smith SL. The accuracy of patients’ judgements of disease probability and test sensitivity and specificity. J Fam Pract 1998; 47: 44-52.
7 Veldhuis M. Defensive behavior of Dutch family physicians. Widening the concept. Fam Med 1994; 26: 27-9.
8 Van Boven K, Dijksterhuis P, Lamberts H. Defensive testing in Dutch family practice. Is the grass greener on the other side of the ocean?. J Fam Pract 1997; 44: 468-72.
9 Epstein AM, Begg CB, McNeil BJ. The effect of physicians’ training and personality on test ordering for ambulatory patients. Am J Public Health 1984; 74: 1271-3.
10 Rosser WW. Approach to diagnosis by primary care clinicians and specialists: is there a difference?. J Fam Pract 1996; 42: 139-44.
11 Sox HC. Decision-making: a comparison of referral practice and primary care. J Fam Pract 1996; 42: 155-60.
12 Kristiansen IS, Hjortdahl P. The general practitioner and laboratory utilization: why does it vary?. Fam Pract 1992; 9: 22-7.
13 Zaat JO, Van Eijk JT, Bonte HA. Laboratory test form design influences test ordering by general practitioners in the Netherlands. Med Care 1992; 30: 189-98.
14 Zaat JOM. General practitioners’ uncertainty, risk preference, and use of laboratory tests. Med Care 1992; 30: 846-54.
15 Grol R, Whitfield M, De Maeseneer J, Mok-kink H. Attitudes to risk taking in medical decision making among British, Dutch and Belgian general practitioners. Brit J Gen Pract 1990; 40: 134-6.
16 Holtgrave DR, Lawler F, Spann SJ. Physicians’ risk attitudes, laboratory usage, and referral decisions: the case of an academic family practice center. Med Dec Making 1991; 11: 125-30.
17 Ornstein SM, Markert GP, Johnson AH, Rust PF, Afrin LB. The effect of physician personality on laboratory test ordering for hypertensive patients. Med Care 1988; 26: 536-43.
18 Kassirer JP. Our stubborn quest for diagnostic certainty. New Engl J Med 1989; 320: 1489-91.
19 Boohaker EA, Ward RE, Uman JE, McCarthy BD. Patient notification and follow-up of abnormal test results. A physician survey. Archives of Internal Medicine 1996; 12: 327-31.
20 DeKay ML, Asch DA. Is the defensive use of diagnostic tests good for patients, or bad?. Medical Decision Making 1998; 18: 19-28.
21 Kassirer JP. Diagnostic reasoning. Ann Intern Med 1989; 110: 893-900.
22 Axt-Adam P, Van der Wouden JC, Van der Does E. Influencing behavior of physicians ordering laboratory tests: A literature study. Med Care 1993; 31: 784-94.
23 Eisenberg JM, Nicklin D. Use of diagnostic services by physicians in community practice. Med Care 1981; 19: 297-309.
24 Wong ET, Lincoln TL. Ready! Fire!... Aim. J Am Med Assoc 1983; 250: 2510-3.
25 Zaat JOM. De macht der gewoonten: Over de huisarts en zijn laboratorium onderzoek. [Thesis]. Amsterdam: Free University Amsterdam; 1991. (On the General Practitioner and his laboratory test ordering. In Dutch, English Summary).
26 Van Walraven C, Naylor CD. Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits. J Am Med Assoc 1998; 280: 550-8.
27 Van Walraven C, Goel V, Chan B. Effect of population-based interventions on laboratory utilization: a time-series analysis. J Am Med Assoc 1998; 280: 2028-33.
28 Solomon DH, Hashimoto H, Daltroy L, Liang MH. Techniques to improve physicians’ use of diagnostic tests. J Am Med Assoc 1998; 280: 2020-7.
29 Winkens RAG, Pop P, Grol RPTM. Effect of feedback on test ordering behavior of general practitioners. Br Med J 1992; 304: 1093-7.
30 Pop P, Winkens RAG. A diagnostic centre for general practitioners: results of individual feedback on diagnostic actions. Journal of the Royal College of General Practitioners 1989; 39: 507-8.
31 Winkens RAG, Pop P, Grol RP. et al. Effects of routine individual feedback over nine years on general practitioners’ requests for tests. Br Med J 1996; 24: 490.
32 Winkens RA, Pop P, Bugter-Maessen AM. et al. Randomised controlled trial of routine individual feedback to improve rationality and reduce numbers of test requests. Lancet 1995; 25: 498-502.
33 Bugter-Maessen AM, Winkens RA, Grol RP. et al. Factors predicting differences among general practitioners in test ordering behaviour and in the response to feedback on test requests. Family Practice 1996; 13: 254-8.
34 Smithuis LOMJ, Van Geldrop WJ, Lucassen PLBJ. Beperking van het laboratoriumonderzoek door een probleemgeorienteerd aanvraagformulier. Een partiele implementatie van NHG-standaarden. Huisarts Wet 1994; 37: 464-6 (Reducing test ordering by introducing a problem-oriented order form. Partial implementation of the guidelines of the Dutch Colleges of General Practitioners. In Dutch, English abstract).
35 Van Gend JMWA, Van Pelt J, Cleef THM, Mangnus TM, Muris JWM. Kwaliteitsverbeteringsproject “laboratoriumdiagnostiek door huisartsen” leidt tot aanzienlijke reductie van het aantal laboratoriumanalysen. Ned Tijdschr Geneeskd 1996; 140: 495-500 (The quality improvement project “laboratory test ordering by general practitioners”, reduces the number of test ordered. In Dutch, English abstract).
36 Van Geldrop WJ, Lucassen PLBJ, Smithuis LOMJ. Een probleemgeorienteerd aanvraagformulier voor laboratoriumonderzoek. Effecten op het aanvraaggedrag van huisartsen. Huisarts Wet 1992; 35: 192-6 (A problem-oriented test order form. Impact on test ordering behavior of general practitioners).
37 Van der Lei J, Duisterhout JS, Westerhof HP. et al. The introduction of computer-based patient records in the Netherlands. Ann Intern Med 1993; 119: 1036-41.
38 Tierney WM, Overhage JM, Takesue BY. et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc 1995; 2: 316-22.
39 Elson RB, Connelly DP. Computerized patient records in primary care. Their role in mediating guideline-driven behavior change. Arch of Fam Med 1995; 4: 698-705.
40 Henry SB, Douglas K, Galzagorry G, Lahey A, Holzemer WL. A template-based approach to support utilization of clinical practice guidelines within an electronic record. J Am Med Inform Assoc 1998; 5: 237-44.
41 Van Wijk MA, Bohnen AM, Van der Lei J. Analysis of the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests. J Am Med Inform Assoc 1999; 6: 322-31.
42 Schriger DL, Baraff LJ, Rogers WH, Cretin S. Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health workers exposed to body fluids. J Am Med Assoc 1997; 278: 1585-90.
43 Margolis A, Bray BE, Gilbert EM, Warner HR. Computerized practice guidelines for heart failure management: the HeartMan system. Proceedings of the Annual Symposium of Computer Applications in Medical Care 1995 1995: 228-32.
44 Hollingworth GR, Bernstein RM, Viner GS, Remington JS, Wood WE. Prompting for cost-effective test ordering: a randomized controlled trial. Proceedings of the Annual Symposium of Computer Applications in Medical Care 1995 1995: 635-9.
45 Zielstorff RD. Online practice guidelines: issues, obstacles, and future prospects. J Am Med Inform Assoc 1998; 5: 227-36.
46 Johnston ME, Langton KB, Haynes RB, Mathieu A. Effects of computer-based clinical decision support systems on clinicians’ performance and patient outcome. Ann Intern Med 1994; 11: 497-9.
47 Ohno-Machado L, Gennari JH, Murphy SN. et al. The guideline interchange format: a model for representing guidelines. J Am Med Inform Assoc 1998; 5: 357-72.
48 Jenders RA, Hripcsak G, Sideli RV. et al. Medical decision support: experience with implementing the Arden Syntax at the Columbia-Presbyterian Medical Center. Proceedings of the Annual Symposium of Computer Applications in Medical Care 1995 1995: 169-73.
49 Durand-Zaleski I, Rymer JC, Roudot-Thor-aval F. Reducing unnecessary laboratory use with new request form: example of tumour markers. Lancet 1993; 342: 150-3.
50 McColl A, Smith H, White P, Field J. General practitioners’ perceptions of the route to evidence based medicine: a questionnaire survey. Br Med J 1998; 316: 361-5.
51 Lomas J. Words without action? The production, dissemination and impact of consensus recommendations. Annu Rev Public Health 1991; 12: 41-65.
52 Feder G, Eccles M, Grol R, Griffiths C, Grimshaw J. Using clinical guidelines. Br Med J 1999; 318: 728-30.
53 Hogan WR, Wagner MM. Accuracy of data in computer-based patient records. J Am Med Inform Assoc 1997; 4: 342-55.
54 Litzelman DK, Tierney WM. Physicians’ reasons for failing to comply with computerized preventive care guidelines. J Gen Intern Med 1996; 11: 497-9.
55 Elson RB, Connelly DP. Computerized decision support systems in primary care. Prim Care 1995; 22: 365-84.
56 Miller PL, Frawley SJ. Trade-offs in producing patient-specific recommendations from a computer-based clinical guideline: a case-study. J Am Med Inform Assoc 1995; 2: 238-42.
57 Miller RA, Masarie FE. The demise of the Greek oracle model for medical diagnosis systems. Method Inform Med 1990; 29: 1-2.
58 Taylor TR. The computer and clinical decision-support systems in primary care. J Fam Pract 1990; 30: 137-40.