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This article reviews the usefulness and importance of written information, specifically leaflets, being given to patients. Evidence suggesting how both patient and doctor may benefit from the giving of written information is reviewed. Identification of good practice relating to the content and readability of leaflets is discussed. An argument is put forward that the giving of written information is an under-utilized resource in contributing to improving patient outcomes but that this may be changing with the increasing use of patient leaflet databases. The advantages and disadvantages of computer-generated patient leaflets are discussed and desirable further areas of research on computer-generated leaflets are proposed. [ABSTRACT FROM AUTHOR]

This paper proposes a clinical method for general practice which is patient-centred and which ensures that the doctor's agenda is supported to secure ‘best practice’. It encompasses self-learning for GPs which is patient-focused and describes the encouragement and support of patient self-care. The method attempts to be pragmatic and usable within GPs' available time. The method, however, is not solely focused on the GP; it encompasses the primary health care team and the patient. It uses clinical information systems to assist in the management of the patient care plan, to supply information to the GP and patient, in order to aid shared decision making and to quality assure clinical activity. It goes further by extending the care process to handle ‘virtual’ encounters in which the clinical information systems play a central role. [ABSTRACT FROM PUBLISHER]

This paper looks at aspects of doctor-patient communication and focuses on how prescribing decisions fit into the consultation within the context of the use (and non-use) of a technological clinical decision support system (CDSS) in the UK. Analysis of 6 simulated consultations filmed as part of the evaluation of a CDSS system indicated that the general practitioners (GPs) used their computers for a short time during consultations. The data showed that doctors' utterances, occurring at an early stage of the consultations, signalled the prescribing decision and eventual outcome of the consultation. The concept of 'verbal prescriptions' is used to describe these utterances of the GPs, and facilitates an understanding of how prescribing decisions are routinely achieved. Prescribing decisions can occur in the relatively early stages of the consultation, and both prior to and independently of the CDSS. Consequently, we suggest that the pattern of GP decision-making needs to be taken into account in CDSS design. However, this is not just an issue for CDSS design and implementation, as the verbal prescription phenomenon may impact upon patient involvement in decision-making, and even the appropriate use of evidence based medicine.

This paper is a vision paper presenting a framework that describes a set of integrated "tools" for supporting "knowledge management". These "tools" span technical, organizational and human story telling. The framework is based on the authors' involvement in many research projects, the literature and conversations sounding the issues.

Background: Advances in information technology mean that it is now possible to provide contextually relevant, evidence-based information during the course of the consultation. As a consequence, the practitioner has to consider the new information (from the computer) in the situation of the present consultation and in the light of his or her own experience. This task has to be carried out in a short time, in the presence of the patient., Method: Drawing on experience of the development of one decision support system, this paper places that task for the practitioner in an educational framework. We begin by reviewing theories of professional experience and knowledge and go on to look at schema theory and the role of cognitive dissonance and reflection in learning., Conclusion: This paper considers the provision of real time decision support in the light of learning and the experienced practitioner. We conclude that framing the implementation of decision support in this way provides useful insights. The key process is learning by the practitioner, in the course of the consultation. This process should be supported by decision support and information support software. There are implications here for the design of such software, and also for the way in which practitioners are trained to use it.

Objective: To evaluate the use of a computerised support system for decision making for implementing evidence based clinical guidelines for the management of asthma and angina in adults in primary care., Design: A before and after pragmatic cluster randomised controlled trial utilising a two by two incomplete block design., Setting: 60 general practices in north east England., Participants: General practitioners and practice nurses in the study practices and their patients aged 18 or over with angina or asthma., Main Outcome Measures: Adherence to the guidelines, based on review of case notes and patient reported generic and condition specific outcome measures., Results: The computerised decision support system had no significant effect on consultation rates, process of care measures (including prescribing), or any patient reported outcomes for either condition. Levels of use of the software were low., Conclusions: No effect was found of computerised evidence based guidelines on the management of asthma or angina in adults in primary care. This was probably due to low levels of use of the software, despite the system being optimised as far as was technically possible. Even if the technical problems of producing a system that fully supports the management of chronic disease were solved, there remains the challenge of integrating the systems into clinical encounters where busy practitioners manage patients with complex, multiple conditions.

A major obstacle in deploying computer-based clinical guidelines at the point of care is the variability of electronic medical records and the consequent need to adapt guideline modeling languages, guideline knowledge bases, and execution engines to idiosyncratic data models in the deployment environment. This paper reports an approach, developed jointly by researchers at Newcastle and Stanford, where guideline models are encoded assuming a uniform virtual electronic medical record and guideline-specific concept ontologies. For implementing a guideline-based decision-support system in multiple deployment environments, we created mapping knowledge bases to link terms in the concept ontology with the terminology used in the deployment systems. Mediation components use these mapping knowledge bases to map data in locally deployed medical record architectures to the virtual medical record. We discuss the possibility of using the HL7 Reference Information Model (RIM) as the basis for a standardized virtual medical record, showing how this approach also complies with the European pre-standard ENV13606 for electronic healthcare record communication.

Research carried out on repeat prescribing indicates the low quality of repeat medication management. This paper reports on the project methodology, some initial results and ongoing work on the UK NHS Repeat Prescribing Project currently under way in the North East of England aimed at developing an intervention to improve the quality of repeat prescribing.

This paper reports on the results of a series of focus groups held during the Phase 1 pilot intervention period of a NHS decision-support system (Prodigy), which aims to offer contextual clinical guidance in general practice consultations. The aim of the focus groups was to collect qualitative data about users' interaction with the pilot system as part of a wider evaluation.

The Prodigy system is a guideline-based decision-support system designed to assist general practitioners in England choose the appropriate therapeutic action for their patients. As part of the system, we developed a novel model for encoding clinical guidelines for managing patients with chronic diseases such as asthma and hypertension. The model structures a guideline as a set of choices to be made by the clinician. It models patient scenarios which drive decision making and are used to synchronize the management of a patient with guideline recommendations. The model is robust with respect to available input data and leaves the control of decision-making to the clinician. We have built execution engines to verify the computability of the model. We intend to test the model integrated in up to 200 live systems from at least four system vendors in English General practice.

We summarise the findings of the first two research phases of the PRODIGY project and describe the guidance model for Release One of the ensuing nationally available system. This model was a result of the iterative design process of the PRODIGY research project, which took place between 1995 and 1998 in up to 183 general practices in the England. Release One of PRODIGY is now being rolled out to all (27,000) General Practitioners in England during 1999-2000.

This paper aims to describe why we need to change the health care record paradigm that is currently accepted. The paper goes on to describe the new paradigm of a goal oriented health record (GOHR) and the relevance of computerization.

This chapter introduces the role of clinical guidelines in improving the quality of care in Primary Health Care. It goes on to describe the literature with respect to the development, dissemination and implementation of clinical guidelines while attempting to highlight factors liable to impede their use. It concludes with a discussion of the role of informatics in ensuring the difficulties described are avoided.