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Table 4 Representative quotes from the fieldwork

From: Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study

Theme 1: Workflow

Theme 6: Governance

"People practice in very different ways. Some physicians look at the screen once before they see the patients, and then they don't really touch the computer [again] until they have to write prescriptions. So, the opportunities to interact with the computer and receive decision support can be limited for those practitioners."

"Now they need to turn the alerts back on, condition by condition. They plan on customizing the alerts before they turn them back on."

"She uses the point and click charting templates to complete her review of systems [and] history and physical very quickly."

"We moved to the EMR because we felt it would standardize or help quality."

"I think the underlying drive, perhaps not surprisingly, it's the recognition that we need to distinguish ourselves as an organization from amongst the competitors."

"We sort of have a very tight knit connection with [our vendor]. So, I think everyone sort of collaborates with them and cross-communicates with them on practically everything."

Theme 2: Knowledge management

"We assess new drugs as they are introduced as possible candidates for CDS."

Theme 7: Translation for collaboration

"She is a 'development analyst' and the team leader for similar analysts. They write specs, test, and modify and they serve as liaisons between the users and IT. There are other analysts who are implementation and support analysts."

"A lot of her job and a lot of my job is working with [the vendor] to make sure things are running correctly."

Theme 3: Data as a foundation for CDS

"The patient we were looking at had an LDL reminder but the patient had actually had the LDL done. The reminder didn't work correctly since he didn't have lab results in the EMR (so it thought the test hadn't been done when it had been)."

Theme 8: The meaning of CDS

"Sometimes the best decision support is not to give them [physicians] the decision [and to design a nursing protocol instead]."

Theme 4: User computer interaction

"We have to build custom-like orders, we have to build for the practice, medications, problems, custom lists for each practice and when they log into the system, it automatically defaults to their custom list."

"It flags it in red, so it's a visual cue to the physicians that it's a little bit outside of the range and if you're ordering something with a narrow therapeutic index, you need to be aware."

Theme 9: Roles of special essential people

"We do have people who are practicing clinicians who are helping create the rules. You definitely need someone who knows the technical side of the equation."

"I know how challenging it is for clinicians to take time to address these important issues. That has been compensated."

Theme 5: Measurement and metrics

"Most physicians will use the reminders because they get report cards on their completion rates. . . if you go down into the clinics you'll see graphs that compare clinics to one another as a form of competition."

"We are now better able to track the timeliness and the labor required to meet those maintenance obligations."

Theme 10: Communication, training, support

"There are always new features that come up and I think we still completely suck at letting people know about these new features."

"We actually make it very easy [for clinicians] to write patients a letter describing their test results in a patient-friendly format."

"We have to understand what the physician is going to be doing. Are they going to be dictating, typing their notes? So, really trying to gear the training around workflow."