Electronic clinical decision support tool for assessing stomach symptoms in primary care (ECASS): a feasibility study

Abstract

ObjectiveTo determine the feasibility of a definitive trial in primary care of electronic clinical decision support (eCDS) for possible oesophago-gastric (O-G) cancer.Design and settingFeasibility study in 42 general practices in two regions of England, cluster randomised controlled trial design without blinding, nested qualitative and health economic evaluation.ParticipantsPatients aged 55 years or older, presenting to their general practitioner (GP) with symptoms associated with O-G cancer. 530 patients (mean age 68 years, 58% female) participated.InterventionPractices randomised 1:1 to usual care (control) or to receive a previously piloted eCDS tool for suspected cancer (intervention), for use at the discretion of the GPs, supported by a theory-based implementation package and ongoing support. We conducted semistructured interviews with GPs in intervention practices. Recruitment lasted 22 months.OutcomesPatient participation rate, use of eCDS, referrals and route to diagnosis, O-G cancer diagnoses; acceptability to GPs; cost-effectiveness. Participants followed up 6 months after index encounter.ResultsFrom control and intervention practices, we screened 3841 and 1303 patients, respectively; 1189 and 434 were eligible, 392 and 138 consented to participate. Ten patients (1.9%) had O-G cancer. eCDS was used eight times in total by five unique users. GPs experienced interoperability problems between the eCDS tool and their clinical system and also found it did not fit with their workflow. Unexpected restrictions on software installation caused major problems with implementation.ConclusionsThe conduct of this study was hampered by technical limitations not evident during an earlier pilot of the eCDS tool, and by regulatory controls on software installation introduced by primary care trusts early in the study. This eCDS tool needed to integrate better with clinical workflow; even then, its use for suspected cancer may be infrequent. Any definitive trial of eCDS for cancer diagnosis should only proceed after addressing these constraints.Trial registration numberISRCTN125595588.

Optimization of a Quality Improvement Tool for Cancer Diagnosis in Primary Care: Qualitative Study

“…While QI tools for cancer diagnosis in primary care are posited to improve the quality of care for patients, reduce practitioner errors, and allow for efficiency in everyday practice, previous studies have reported a range of barriers to implementation and low acceptance in practice. Issues with CDSSs for cancer include tools that are underused [39], too complex [40], incompatible with the workflow [41], incompatible with GP software [42], or do not align with practitioner practice [43]. The results of this study align with the findings of a previous systematic review [28].…”

“…The ability to verify the recommendations by understanding the research underpinning the recommendation was not being met as part of FHT [28]. For the diagnosis of cancer, embedding tools in the workflow is often a key barrier [39]; however, the limited disruption caused by the tool and the timing of the prompt meant that FHT aligned with most participants workflow.…”

Workload And Workflow Implications Associated With The Use Of Electronic Clinical Decision Support Tools Used By Health Professionals In General Practice: A Scoping Review

“…Among the 36 studies that indicated a perceived increase in consultation duration, the most commonly highlighted concerns related to existing time pressures and lack of time during a consultation for clinicians to interact with eCDS tools and/or to carry out resultant recommended actions. 16,[26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] A prevalent view was that workload was 'already heavy' and that using eCDS tools would inevitably add burden. 36,38,39,[41][42][43][44][45][46][47][48] In the case of one tool to support delivery of preventive care through review of patients' lifestyle factors, the sense of lack of time for preventive care in general drove the view towards the tool increasing consultation duration.…”

“…49 The usual ow of tasks to complete during a consultation (often referred to as 'work ow' 31,[50][51][52][53][54][55][56][57][58][59][60][61][62][63][64] ) was commonly expected to be disrupted by eCDS tools, causing an increase in consultation duration. 28,31,33,36,50,[65][66][67] Speci c time-consuming functions of tools, such as reading text, additional data-entry and using tools which were stand-alone from the EMR 16,36,41,46,65,[68][69][70] , as well as perceptions of poor-or slow-functioning software 45,50,67,71 were also highlighted. A potential for negative impact of eCDS tools on the trajectory of the conversation with patients was expressed by some health professionals.…”

“…[10][11][12][13][14] Many CDS tools exist for use in primary care and more recently are being embedded in electronic form (eCDS) within practice IT systems, drawing directly on data within patients' electronic medical records (EMR) for their operation. 11,15,16 Many Clinical Commissioning Groups and Primary Care Networks have supported the introduction of eCDS tools that facilitate diagnosis and expedite referral for certain conditions, such as cancer, particularly since the COVID-19 pandemic. 17 For the purpose of this article, an eCDS tool is de ned as any electronic or computerised tool which provides an output pertaining to a possible diagnosis and/or management of a health condition, using patient-speci c information.…”