Setting
In the Netherlands, there are approximately 5,000 general practices. Within these practices nearly 11,000 GPs are delivering care [24]. More than 1,700 medical doctors are in training to become GPs [24]. These GP trainees all have completed a 6-year master program in general medicine and work 4 days a week during an average period of three years in a group practice under supervision of an experienced GP. One day per week is focused on educational activities and group meetings in which daily problems are discussed and videotapes are sometimes presented [25]. Aside from GPs and GP trainees, between 3.700 and 4.700 practice nurses (PNs) work within 75 % of these general practices [26]. They are mainly responsible for providing basic care such as regular check-ups for patients with a chronic illness and completing their patient files. Together, these PCPs (GPs, GP trainees and PNs) are responsible for providing primary care in Dutch general practices. Currently, a total of seven major different electronic health record systems (EHRS) are used.
CDSS initiative in Dutch general practice: NHGDoc
Within the Dutch primary care setting there is one main CDSS initiative, which is called NHGDoc. NHGDoc is a CDSS initiated and developed in 2006 by ExpertDoc BV and currently owned by the Dutch College of General Practitioners (DCGP, NHG in Dutch). NHGDoc is integrated by web services within the electronic health record system (EHRS) and is based on the NHG guidelines, the prevailing guidelines for general practice in the Netherlands [27]. It provides GPs, GP trainees and PNs evidence-based and, on the basis of structured data in the EHRS, patient-specific advices during consultation in terms of patient data registration, drug prescription and management [28].
At the time of conducting the focus group study NHGDoc covered the following disease areas: Cardiovascular risk management, Asthma/COPD, Diabetes mellitus type II, Thyroid disorders, Viral hepatitis and other liver diseases, Atrial fibrillation and Subfertility, Gastro protection and Chronic renal failure. For each NHG guideline key recommendations have been selected based on relevance of disease burden, revision status of the guideline, and opportunity to translate or normalise the recommendation into if-then rules. This selection of key recommendations is approved by representative experts of the guideline committees. Subsequently, the selected key recommendations are digitized, thoroughly tested and deployed into the NHGDoc system. The total number of key recommendations/advices that could be shown per domain varies from 50–250 key recommendations/advices. However, the average number of key recommendations/ advices that is shown per patient encounter is 7.2, based on an average number of 2.3 domains/disease areas.
At the time of conducting this study, NHGDoc was integrated in 6 out of 7 major EHRSs being used in Dutch general practice, covering approximately two-third of all Dutch general practices. NHGDoc had been available for approx. 2.5 years for MicroHIS X users, 2 years for Promedico-ASP users and less than half a year for users of the other included EHRSs.
NHGDoc - Basic functions: alerts and feedback
When a PCP opens a patient file in the EHRS, anonymous patient data and medical performance data are sent to the NHGDoc server. The data are then compared to the digitized guideline recommendations and in case of a discrepancy between current and advised care, an alert will be sent back to the PCP. By default, the NHGDoc alert button is displayed in green, but turns into yellow when a discrepancy is detected (see Fig. 1). It is up to the PCP to open the NHGDoc alert or not. In the Promedico EHRS, the alert button could also be gray, in which case the user would need to manually request the alert.
When the GP (trainee) or PN clicks on the yellow NHGDoc alert button, an alert window appears (see Fig. 2). For each relevant domain, the NHGDoc alert includes up to three types of patient-specific advices: on patient data registration, on management and on drug prescription. The alert is sensitive to the specific patient case (based on patient-specific ICPC (International Classification of Primary Care) codes, NHG Lab codes (codes used by the Dutch College of General Practitioners for laboratory and other diagnostic tests and results) and ATC (Anatomical Therapeutic Chemical Classification System) codes), and generates feedback by showing the recommendation(s) for which discrepancies were found as compared to the guideline recommendations. At the bottom of the alert, the patient profile (characteristics of patient file) consisting of the data on which the advices are based, is shown.
By clicking on the Feedback link at the top right corner, users have the option to ask or provide feedback to/from ExpertDoc (the organization that has developed and maintains NHGDoc) about the received alert. ExpertDoc also informs the NHG about the received user feedback.
NHGDoc - Personalization functions: Tailoring My NHGDoc to PCPs’ specific needs
Aside from the basic functions, NHGDoc allows the user to adapt the decision support to meet their personal preferences in two different ways.
Alert settings
Users can adjust the preferences of the alerts to match their personal needs. They can choose to switch alerts on and off on demand at several levels: the system (NHGDoc as a whole – only in the EHRS MicroHIS X), the modules (NHGDoc domains), the types of alerts (patient data registration, management, drug prescription), and the patients. NHGDoc can also be used as an educational tool for specific domains, for example, a practice can choose a temporary switch-on of a module to generate input for small-group peer review and quality improvement activities.
Reporting settings
Users also have the option to request specific reports with respect to the number and types of alerts they have received per domain within a specific period of time (per year, per month, per week or per day).
Study design
We used a qualitative study design including three 1.5-h focus groups. Focus groups have proven to be useful as a method of providing in-depth information and for exploring cognitions and motivations underlying behavior [29–32]. The focus group sessions therefore enabled us to identify the perceived barriers to using CDSSs in primary care among the target groups of users.
The focus group study, of which the results are presented in this paper, is part of a larger evaluation study on the effectiveness of NHGDoc in improving quality of primary care [33]. The need for ethical approval for the NHGDoc evaluation study was waived by the research ethics committee of the Radboud university medical center.
This focus group study has been designed and reported (whenever applicable) in accordance with the RATS guidelines [34].
Selection of participants
To select participants we sent a direct email to all 233 practices that participated in the NHGDoc evaluation study [33]. All PCPs working within these practices (GPs, GP trainees and PNs) were invited to participate in the focus group study. After two weeks a first reminder was sent and after four weeks we sent a second reminder. Also, an invitation was sent by email to all medical doctors receiving training as a GP at the University Medical Centre in Utrecht, the medical centre located in the area in which the focus groups were to be conducted. Additional announcements were placed on relevant websites, in newsletters and through social media (i.e. Facebook, Twitter and LinkedIn). PCPs could register for one of the three focus groups organized. All participants received a gift voucher of €100, − and were offered reimbursement of their travel expenses.
Focus group sessions
The focus group sessions were conducted at the NHG, which is located in the center of the Netherlands. In each focus group session, the PCPs had a semi-structured discussion about their perceived barriers to using CDSSs such as NHGDoc in primary care. The sessions were moderated by ML and RBK (principal investigators of the NHGDoc evaluation study and experienced moderators of focus groups) and by a representative of the NHG.
Prior to the formal start of the discussion, one of the moderators gave instructions about the focus group session and explained that the responses of the participants will remain anonymous and that their names will not be mentioned in publications. In addition, the moderators’ independence towards NHGDoc, the main CDSS in Dutch general practice, was emphasized. Representatives of ExpertDoc, the organization that has commercial interests in NHGDoc, were deliberately not invited to the focus group sessions. Participants were asked for their approval to participate and gave permission to audio-tape the session.
A predefined topic list was used to structure the discussion. This list consisted of the following broad themes: the value of CDSSs in a primary care setting, CDSSs in an ideal world, experiences with using CDSSs with the example of NHGDoc, perceived advantages and disadvantages, and barriers to using them in practice. The three focus group sessions were audio-taped.
Data analysis and synthesis
The focus group sessions were transcribed verbatim. Two researchers (ML and JWW) independently studied the transcripts in Atlas.ti 7.0. They first independently created a code list consisting of the main barriers to using CDSSs. After studying the first half of the first transcript, the two code lists were compared and discrepancies were discussed until consensus was reached. This process was repeated after studying the second half of the first transcript. The remaining transcripts were categorized using the mutually agreed on code list.
Next, the code list was discussed and emerging themes were grouped by theory-based categories. As a basis we used the framework of Cabana [35], which presents barriers to using clinical practice guidelines, complemented with literature focusing on barriers to using CDSSs [4, 17, 18]. The information in each category of barriers was reflected on and interpreted jointly. This process resulted in the framework of barriers to using CDSSs presented in Table 2.