Year : 2020 | Volume
: 3 | Issue : 1 | Page : 36--38
Clinical decision support for primary care system strengthening: Report of an educational workshop
Kieran Walsh1, Jens Ruhbach2,
1 BMJ Best Practice and BMJ Learning, London, England, UK
2 Jubilee Street Practice, London, England, UK
Dr. Kieran Walsh
BMJ Best Practice and BMJ Learning, BMA House, Tavistock Square, London WC1H 9JR, England
Health system strengthening will only be possible if there is a comprehensive system of primary care. This, in turn, will only be possible with adequate numbers of high-quality general practitioner (GP) trainees. These trainees need medical education and clinical decision support. This paper reports on an educational workshop conducted with GP trainees that describes their needs and views on decision support. The workshop focused on the use of the clinical decision support resource BMJ Best Practice. GP trainees see clinical decision support as a feasible means of helping them to learn and improve their practice. They value content that is continually updated and evidence based and that will help them put what they have learned into practice. Clinical decision support needs to be easily navigable and to give users answers in seconds (rather than minutes). GP trainees most appreciate resources that are low cost or funded by their training institution.
|How to cite this article:|
Walsh K, Ruhbach J. Clinical decision support for primary care system strengthening: Report of an educational workshop.Educ Health Prof 2020;3:36-38
|How to cite this URL:|
Walsh K, Ruhbach J. Clinical decision support for primary care system strengthening: Report of an educational workshop. Educ Health Prof [serial online] 2020 [cited 2021 Oct 20 ];3:36-38
Available from: https://www.ehpjournal.com/text.asp?2020/3/1/36/280537
Health systems strengthening has been defined as “any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency.” It is increasingly being realized that health system strengthening will only be possible if there is a comprehensive system of primary care. This, in turn, will only be possible with adequate human resources for health who are competent to work in primary care. Thus, it is vital that all health systems have sufficient numbers of high-quality general practitioner (GP) trainees. These trainees require educational resources, but the amount of medical knowledge that is currently available means that it is impossible for GP trainees to learn by heart what they need to know to practice medicine. For this reason, GP trainees need clinical decision support. Clinical decision support should offer knowledge that is continually updated, evidence-based, and practical., It should also be centered on the needs of users. However, this is not always the case. The provision of evidence-based clinical decision support knowledge resources has been criticized as being lacking in evidence, marginal to clinical practice, “management driven rather than patient centered,” and not based on the needs of health-care professionals. This paper seeks to redress these shortcomings by reporting on the results of an educational workshop conducted with GP trainees that describes their needs and views on clinical decision support in primary care. The workshop focused on the use of the clinical decision support resource BMJ Best Practice.
BMJ Best Practice is the online clinical decision support tool of the BMJ. BMJ Best Practice supports medical professionals with their clinical decisions at the point of care. It provides content that is evidence based, continually updated, and at the same time, practical and actionable. It gives answers that are structured around the patient consultation and fit with the clinical workflow. It is available online and offline (via an app) and can be accessed on a wide range of different electronic devices. GP trainees in Tower Hamlets in London were invited to access BMJ Best Practice and to use the tool to help them solve a hypothetical clinical problem involving a patient who had clinical findings that were suggestive of influenza. The GP trainees subsequently attended an educational workshop to discuss their use of clinical decision support generally and BMJ Best Practice specifically. The workshop took place at the GP training day in Tower Hamlets on June 11, 2019. There were 24 attendees at the workshop, they were all GP trainees at various stages of their training program. The author (JR) introduced the workshop and then the corresponding author (KW) gave an outline of the BMJ's tool in clinical decision support, BMJ Best Practice. Both authors facilitated a discussion among the trainees on the utility of the clinical decision support tool. The themes that emerged from the discussions are outlined below.
The first theme that emerged from the discussion related to navigating the tool. The GP trainees largely used the search box functionality on the site and found that it worked well. Some felt that an autocorrect function, where any misspellings are corrected, would be useful. The trainees felt that what is needed from the search function is initially a broad overview and then more details. However, they felt that headlines at the start are most useful. All the trainees stated that they were short of time and so needed to be able to find an answer within 30 s or less. If it took any longer, they would simply give up. The trainees had similar expectations of any multimedia content within the tool. They felt that the ideal video would be only 2 min long and would enable them to find out what they needed easily. They expected any multimedia to be relevant to general practice (for example, how to perform Hallpike's maneuver) and some said that they would look at such a video in real time in the clinic, immediately before carrying out the procedure. Many of the trainees said that they would appreciate more infographics. They described themselves as “visual learners” and requested flowcharts or algorithms to support their learning. However, they did not want infographics that were too complex. The ideal infographic would be one that they could look at with their patients and therefore facilitate shared decision-making. The attendees expected these graphics to be a supplement to the text, they did not think that they could completely replace the text.
The second theme was about the currency of the content within clinical decision support. They wanted content that was continually updated, but there was no consensus on exactly what they meant by “updated.” One trainee said that The National Institute for Health and Care Excellence (NICE) guidelines might be 3 or more years old, but they can still be current. Attendees also said that some treatments might be very recently discovered but not yet tried and trusted, and hence, it is sometimes a good idea to steer clear of these in primary care. However, another trainee stated that certain other recommendations change very quickly, for example, guidelines on the management of flu during an outbreak. Many attendees felt that it would be helpful if the clinical decision support tool highlighted important updates on the home page, but once again, there was no agreement on what constituted an important update. The following were thought to be an important update: a compelling piece of new evidence, something that would change your practice, or an important drug safety alert. Some of the attendees said that they would like to be messaged when a piece of content which they had looked at in the past had changed. However, they were also wary of message fatigue and considered being informed about important updates once per week to be about appropriate.
The third theme related to evidence-based medicine. Most attendees expected the content to be evidence-based, yet they would not actively look at the evidence-based foundations of the clinical decision support tool (in the case of BMJ Best Practice, the underlying evidence base comes from Cochrane Clinical Answers, which are based on Cochrane reviews). Most attendees said that they did not have time to look at the underlying evidence, especially when they were in the clinic. Most users were reassured that the author of the content had looked at the evidence base. One user said that it can be helpful to look at the evidence when a patient has detailed questions or asks for a treatment that they have found on the internet, for which there is weak evidence. Attendees also said that they appreciate reference sections that provide further information if needed. Finally, there was some discussion about the tension between practicing medicine based on evidence and that based on guidelines. The case of NICE guidelines was discussed as not all of these guidelines are based on evidence, and sometimes, they are based on expert opinion. The attendees felt that, where there is insufficient evidence available, the recommendations can be based on expert opinion.
The fourth theme related to using the tool to improve care. The attendees found that the clinical scenario helped to prime them to use the tool. Fifteen of the attendees used the tool to solve the scenario, 14 of these correctly thought that influenza or another serious infection disease was the most likely diagnosis. However, some of the attendees identified barriers to using the tool in their actual practice. Some felt that the content was not always appropriate for primary care. It suggested too many tests which sometimes were not available or suitable for use in primary care. However, the attendees knew that they were not going to order all these tests and would not blindly follow the suggestions of this or any other clinical decision support tool. Some felt that the content could be more comprehensive. Others suggested that it would be of more value if the tool enabled them to access local protocols and local guidelines, because ultimately, it is these local guidelines that they are going to have to follow (this functionality is now being developed). However, there were some national resources that they would always use, for example, drug formularies such as the British National Formulary or British National Formulary for Children.
The fifth theme was about the degree to which clinical decision support tools were a provider of knowledge or resources to support decision-making or whether in some cases, they might make decisions on behalf of the health-care professionals. There was considerable debate on this issue. Currently, BMJ Best Practice and other similar tools provide support, and health-care professionals take ultimate responsibility for their actions. However, in the future, artificial intelligence might mean that clinical decision support tools would take certain actions without human input. Attendees felt that this might work for certain problems (e.g., simple prescriptions) but that it would not work for many problems in primary care which are complex and for which there is no simple answer. There was consensus that complicated problems constituted the mainstay of work in primary care. There was also agreement that artificial intelligence will need to be based on good data and that data at present are not always reliable. Attendees valued certain tasks that current clinical decision support tools enabled, such as online medical calculators that were integrated with the tool. However, they needed reassurance that such calculators were the most updated versions available.
The sixth and final theme that was discussed was the financial and environmental sustainability of clinical decision support tools. The cost of these tools is important to trainees. Some might be willing to pay for resources that are of high quality. Some attendees suggested the “Massive Open Online Course” model, where the users are able to access the content for free but pay for a certificate of usage. Many felt that a fee for a decision support tool in addition to their considerable professional fees would deter many health-care professionals from using this, in particular, those in training. There was support for a model whereby institutions pay for group access. The environmental sustainability of clinical decision support was of interest to the trainees. It was felt that using online clinical decision support could be an environmentally friendly form of education, because it avoids having to travel to educational meetings. However, attendees thought that primary care practitioners do not travel as much as secondary care practitioners anyways, so the reduction in their carbon footprint might not be as significant. Online clinical decision support also saves users from having to print paper, which was valued as well.
GP trainees see clinical decision support as a feasible means of helping them to learn and improve their practice. They value content that is continually updated and evidence based and that will help them put what they have learned into practice. To enable this to happen, clinical decision support needs to be easily navigable and to give users answers in seconds (rather than minutes). GP trainees most appreciate resources that are low cost or paid for by their training institution.
There are limitations to this paper. This paper is a report of an educational workshop with GP trainees. The views are likely to be representative of this group but should not be cited as being representative of doctors or other health-care professionals as a whole. Furthermore, the workshop focused on the use of a single clinical decision support tool, BMJ Best Practice. The perceptions of users are likely to be valid in the context of this and other similar tools but should not necessarily be applied to other tools that are different to BMJ Best Practice.
Much of the discourse in evidence-based medicine and clinical decision support is dominated by the views of those who create the evidence, rather than those who use it. This report is an attempt to rebalance this by giving voice to the perceptions of GP trainees. These trainees represent the immediate future of the health-care workforce and it would be wise for all stakeholders to listen to their views and attempt to ensure that clinical decision support meets their immediate and long-term needs.
This was not sought as this was not a trial.
We are grateful to all those who attended and contributed to the workshop.
Financial support and sponsorship
Conflicts of interest
KW works for BMJ Best Practice which produces a range of resources in infectious and noninfectious diseases.
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