General practitioner and nurse practitioner attitudes towards electronic reminders in primary care: a qualitative analysis

Objectives Reminders in primary care administrative systems aim to help clinicians provide evidence-based care, prescribe safely and save money. However, increased use of reminders can lead to alert fatigue. Our study aimed to assess general practitioners’ (GPs) and nurse practitioners’ (NPs) views on electronic reminders in primary care. Design A qualitative analysis using semistructured interviews. Setting and participants Fifteen GPs and NP based in general practices located in North-West London and Yorkshire, England. Methods We collected data on participants’ views on: (1) perceptions of the value of information provided; (2) reminder-related behaviours and (3) how to improve reminders. We carried out a thematic analysis. Results Participants were familiar with reminders in their clinical systems and felt many were important to support their clinical work. However, participants reported, on average, 70% of reminders were ignored. Four major themes emerged: (1) reaction to a reminder, which was mixed and varied by situation. (2) Factors influencing the decision to act on reminders, often related to experience, consultation styles and interests of participants. Time constraints, alert design, inappropriate presentation and litigation were also factors. (3) Negative consequences of using reminders were increased workload or costs and compromising GP and NPs behaviour. (4) Factors relating to improving users’ engagement with reminders were prevention of unnecessary reminders through data linkage across healthcare administrative systems or the development of more intelligent algorithms. Participants felt training was vital to effectively manage reminders. Conclusions GPs and NPs believe reminders are useful in supporting the provision of good quality patient care. Improving GPs and NPs’ engagement with reminders centres on further developing their relevance to their clinical practice, which is personalised, considers cognitive workflow and suppresses inappropriate presentation.

I agree with the patients' concern, that level of EHR competency as well as level of primary care experience (eg trainee, vs PN vs years of practice experience) might effect responses given. I appreciate that this was addressed in the demographics table.
However, only one (apparently PN) trainee was enrolled. I'm not sure that this furthers your research question, as trainee attitudes may not be representative of practicing clinicians. Was there consideration to exclusion of trainees? Perhaps more of the trainee comments could be added to the Training section.
You describe the modality of typical alerts in Table 1. I suggest using terminology of alerts (modal) vs reminders (non-modal). You mention that distinction in the table and do begin to address under implications. It seems to my reading that most of themes relate to modal alerts but perhaps I'm not correct about that. This would be an interesting observation and helpful to discuss.
Finally, from a US perspective, what about the fact that only two EHRs are represented in your sample, even though they are the top UK EHRs? It may be helpful to explain how the use of CDS varies between these systems for an international reader, or to say which system each participant represents.
It would be helpful to comment more on which parts of the map you think are missing.
Overall, I appreciate the qualitative approach to this topic. This is an important addition to the literature in trying to document the barriers that primary care clinicians face in CDS workflow and in reducing burnout.

REVIEWER
Jan Frich University of Oslo

27-Dec-2020
GENERAL COMMENTS This is a focused and well-written paper. Some minor comments: It is a bit confusing that participant numbers in table 2 differs from N = 15 in this study. Fig. 1 is difficult to read. Could you consider making it simpler or splitting it up or making a table?
Page 21: Comparison with previous [rather than "past"] research?
References: You need to consult the author hub and format references in accordance with the style (titles of journals need to be abbreviated etc).

VERSION 1 -AUTHOR RESPONSE
Reviewer: 1 Prof. Jeffrey Weinfeld, Georgetown University Comments to the Author: The researchers sought to understand how UK GPs and PNs interact with alerts and reminders. They used semi-structured interviews and then coded the interviews with thematic analysis.
I agree with the patients' concern, that level of EHR competency as well as level of primary care experience (eg trainee, vs PN vs years of practice experience) might effect responses given. I appreciate that this was addressed in the demographics Finally, from a US perspective, what about the fact that only two EHRs are represented in your sample, even though they are the top UK EHRs? It may be helpful to explain how the use of CDS varies between these systems for an international reader, or to say which system each participant represents.

1) We have highlighted differences in
administrative systems in the discussion as follows: 'All participants were from practices using either EMIS Web or SystmOne administrative systems. Although, Tthese are the market leaders , however, 10% of practices in England do not use these systems.23 However, all primary care administrative systems use same clinical coding system, prescribing classification, appointment system and consultation classification. and core alerts and pop-ups.
The systems may slightly differ in the way the reminder is presented and how the clinician interacts with the reminder. For example, some systems may allow the user to 'switch off' the reminder.' 2) We have highlighted the participant EHR system for quotes -EC It would be helpful to comment more on which parts of the map you think are missing.
We have added to the strengths and limitations section 'However, we do acknowledge that parts of the knowledge 'map' may be missing. Primary care clinicians who engaged with the study may have different views than those who did not.'P4 Also updated in discussion Overall, I appreciate the qualitative approach to this topic. This is an important addition to the literature in trying to document the barriers that primary care clinicians face in CDS workflow and in reducing burnout.
Reviewer: 2 Dr. Jan C Frich, Universitetet i Oslo Avdeling for samfunnsmedisin Comments to the Author: This is a focused and well-written paper. Some minor comments: It is a bit confusing that participant numbers in table 2 differs from N = 15 in this study. Section heading updated References: You need to consult the author hub and format references in accordance with the style (titles of journals need to be abbreviated etc).