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• W3145234639 abstract "Objective: To investigate factors that determine the feasibility and effectiveness of a critiquing system for asthma/COPD that will be integrated with a general practitioner's (GP’s) information system. Design: A simulation study. Four reviewers, playing the role of the computer, generated critiquing comments and requests for additional information on six electronic medical records of patients with asthma/COPD. Three GPs who treated the patients, playing users, assessed the comments and provided missing information when requested. The GPs were asked why requested missing information was unavailable and why requested missing information that was available had not been recorded. The reviewers reevaluated their comments after receiving requested missing information. Measurements: Descriptions of the number and nature of critiquing comments and requests for missing information. Assessment by the GPs of the critiquing comments in terms of agreement with each comment and judgment of its relevance, both on a five-point scale. Analysis of causes for the (un)availability of requested missing information. Assessment of the impact of missing information on the generation of critiquing comments. Results: Four reviewers provided 74 different critiquing comments on 87 visits in six electronic medical records. Most were about prescriptions (N=28) and the GPs’ workplans (N=27). The GPs valued comments about diagnostics the most. The correlation between the GP’s agreement and relevance scores was 0.65. However, the GPs’ agreements with prescription comments (complete disagreement, 31.3%; disagreement, 20.0%; neutral, 13.8%; agreement, 17.5%; complete agreement, 17.5%) differed from their judgments of these comments' relevance (completely irrelevant, 9.0%; irrelevant, 24.4%; neutral, 24.4%; relevant, 32.1%; completely relevant, 10.3%). The GPs were able to provide answers to 64% of the 90 requests for missing information. Reasons available information had not been recorded were: the GPs had not recorded the information explicitly; they had assumed it to be common knowledge; it was available elsewhere in the record. Reasons information was unavailable were: the decision had been made by another; the GP had not recorded the information at the time of the encounter. The reviewers left 74% of the comments unchanged after receiving requested missing information. Conclusion: Human reviewers can generate comments based on information currently available in electronic medical records of patients with asthma/COPD. The GPs valued comments regarding the diagnostic process the most. Although they judged prescription comments relevant, they often strongly disagreed with them, a discrepancy that poses a challenge for the presentation of critiquing comments for the future critiquing system. Requested additional information that was provided by the GPs, led to few changes. Therefore, as system developers, faced with the decision to build an integrated, non-inquisitive or an inquisitive critiquing system, the authors choose the former. INTRODUCTION Decision-support systems have shown to be able to provide users with support. Most of these systems, however, have failed to get incorporated into daily clinical practice . The main reason for this failure is the failure to meet the specific requirements of the future users, resulting in a mismatch between problem and solution. For example, the system requires special data entry which interferes with normal practice, it is too time consuming for daily use, the system’s timing does not fit the clinical routine, or it ignores the physician’s intelligence. Researchers have argued that decision-support systems need to be integrated with electronic medical records to improve these systems' chances to be incorporated into the physician's daily routine . Such an integration with the electronic medical record allows a decision-support system to review or critique the physician's treatment using the data already available in the electronic medical record. In The Netherlands, over 50% of the general practitioners have been using an electronic medical record for several years, making the time ripe for the development of integrated decisionsupport systems. We are developing a particular kind of integrated decision-support systems, critiquing systems, that generate critiquing comments based on the user’s actions as recorded in these medical records. Integrated critiquing systems aim to support physicians based on facts already entered in the electronic medical record, thus avoiding the problem of double data entry. We are building integrated systems that will not ask the physician for additional data: non-inquisitive critiquing systems. The downside of this approach is the limited availability of data . That is, the ability of such a system to critique diagnosis and treatment is limited by the data available in the electronic medical record. If the electronic medical records do not contain sufficient data, the concept of an integrated, non-inquisitive critiquing system is unfeasible. To determine the feasibility of such a system, we need insight into the number and the nature of comments that can be made based upon the information in the electronic medical record. If the lack of patient data in the record prohibits the development of a non-inquisitive critiquing system, we can consider a separate module that requests additional information. To determine the viability of a separate data collection module, we need insight into the availability of information missed from the record for the critiquing task. Such a module would be useful only when physicians are able to provide the required information. In addition, we have to gain insight into the relevance of this information. When the impact of additional information on the generation of comments is small, obtaining the additional data may require too much effort on the part of the general practitioner. Whether a critiquing system will be rejected or accepted is also determined by the users' judgment of its critiquing comments. To determine which critiquing comments might be perceived as inappropriate, builders of a critiquing program need insight into general practitioners' responses to these critiques. Before building an integrated non-inquisitive critiquing system, a system builder thus has to face a number of questions, that center around two issues: • Will it be possible to generate critiquing comments based on the information available in the electronic medical record, and how will general practitioners judge them? • How much information is missing? Can general practitioners provide the missing information? Why and why not? Does provided information make a difference for the generation of critiquing comments? In the past, we addressed these issues by building and evaluating prototypes. This process, however, is very time-consuming. An alternative to building prototypes is to perform a simulation study in which humans play the role of the system. To our surprise, we have not found examples of studies using such an approach. The closest comparable technique is used in the field of human-computer interface (HCI). It is called the “Wizard-of-Oz” technique; to reveal important aspects of an interface design, humans play the role of a computer. The user's commands are interpreted by humans, who, invisible to the users, generate the expected responses. The difference of our approach from the Wizard-of-Oz technique is that we do not blind our users for the fact that humans play the role of the computer system. In this article, we report the results of a small-scale simulation study that attempted to answer the system builders' questions with regard to a critiquing system that supports general practitioners in the diagnosis and treatment of patients with asthma/chronic obstructive pulmonary disease (COPD). METHODS In this simulation study, we reviewed six medical records of patients who had been diagnosed as having chronic respiratory disease (asthma/COPD) by their general practitioners. The records were randomly selected from the electronic medical record systems of three general practitioners. In The Netherlands, most general practitioners make use of electronic medical records that adhere to the national standard prescribing the data elements that an electronic medical record should contain (WCIA). For our study, we worked with physicians who were using the general practitioners’ information system ELIAS, one of the most commonly used information systems for general practitioners in The Netherlands. The role of the computer system was played by four reviewers with special interest in asthma/COPD: two specialists (one pulmonologist and one pediatric pulmonologist) and two general practitioners. The role of “users” was played by the same three general practitioners who provided the medical records. The simulation was conducted in three phases as illustrated in Figure 1." @default.
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• W3145234639 title "Assessment of the feasibility and effect of computer-based critiquing on asthma and COPD management in daily practice" @default.
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