Vol. 9, No. 3 Printed in Great Britain
Family Practice © Oxford University Press 1992
J SZECSENYI, A BUSCHHORN AND M M KOCHEN Szecsenyi J, Buschhorn A and Kochen MM. General practitioners'attitudes towards future developments in practice computing—a representative survey in the north of Germany. Famify Practice 1992; 9: 357-361. A postal questionnaire was sent to a random sample of general practitioners in Lower Saxony, Germany to assess how general practitioners regard newly developed but not yet implemented options of practice computers and future applications such as expert systems and information retrieval systems. Replies were received from 276 (response rate 73.6%) general practitioners. Replying doctors were younger {P < 0.05) but they did not differ by sex, practice location, type of vocational training and grade of computerization from non-responding GPs. Twenty-eight per cent of the practices wefe computerized. Doctors who currently used a computer and those who intended to do so within the next 5 years were significantly younger than those doctors who did not intend to computerize their practice (P < 0.001). Female doctors were less willing to buy a computer than their male colleagues (P < 0.05). A computerized drug database and a medical library ranked best from 8 options given. Overall attitudes to all features were positive, except for an expert system giving criteria for referrals to specialist care. Doctors already working with a computer and those intending to buy one were signrficantty more positive about future options for computers than those doctors who do not intend to use a computer ( P < 0.01). GPs' attitudes about new features of practice computers in general were positive but even more so about those options which are already available. Referral to a specialist seems to be a crucial point for GPs—they apparently do not want to be guided by a computer here. The influence of new technologies on process of care and the role of GPs have to be considered before further implementation.
INTRODUCTION In general practice computers are typically used for patient registration, drug prescribing and clinical records. In countries such as Germany with a fee for service system, computers are also widely used for remuneration purposes. There are now many hardware and software developments on the market which might be implemented into practice computers in the near future. These include large databases on compact discs (CD-ROM) which can give physicians rapid and easy access to up-to-date medical literature;1'2 special software which can enhance medical audit, research, screening and prevention activities in general practice;^5 and systems which support drug prescribing
options and which allow analysis of repeat prescriptions. These might be of great help for general practitioners faced with increasing malpractice liability and government restrictions on prescribing.6 A further step will be the introduction of expert systems into general practice. An expert system tries to mimic the abilities of medical experts on their area of expertise. It can give qualified support when it is consulted on a point of decision, for example in the diagnostic process. Such systems are normally restricted to a narrow special area of knowledge but are now also being constructed for the special needs of the general practice setting. This might lead to the implementation of all of the above mentioned features, linking decision support options with information retrieval, treatment proposals and patient management procedures.78
Department of General Practice, University of Gottingen, RobertKoch-Str. 40, D-3400 Gottingen, FRG.
357
Downloaded from http://fampra.oxfordjournals.org/ at Florida Atlantic University on August 31, 2015
General Practitioners' Attitudes Towards Future Developments in Practice Computing— a Representative Survey in the North of Germany
358
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
If 'traditional' practice computing is carefully adopted to the consultation, no negative influences on the consulting process have been reported.9-10 The implementation of new practice computing features and the involvement of expert systems in the decision process might change the situation and negative effects have to be considered. It is yet unclear which of these new facilities will have a substantial impact on the daily work of a general practitioner. This paper reports a study on general practitioners' attitudes towards future features of practice computing systems.
RESULTS Of the 400 GPs we contacted, 16 were no longer practising, eight were wrongly addressed as GPs but were specialists and one had moved overseas. These 25 doctors were excluded from the study. From the remaining 375 GPs we received 276 questionnaires, giving a response rate of 73.6%. The mean age of participants was 46.4 years, 20% were female and 80% were male. Non-participants were on average 3 years older than participants (P < 0.05). We found no significant differences between participants and nonparticipants in the study regarding sex, type of vocational training, and grade of computerization (Table 1). There was no sex difference between participants of the study and all GPs working in Lower Saxony (20% male versus 21% female). Of the responding practices, 78 (28%) already used a computer, 96 (35%) intended to buy one within the next 5 years and 102 (37%) did not plan to computerize their practice (Tables 2 and 3). Doctors who already had a computer and those who planned to buy one were significantly younger than the ones who did not want to do so (P < 0.001). Sex of the doctor also influenced the computerization of general practices: significantly more women than men did not plan to buy a computer (P < 0.05). The type of vocational training of general practitioners did not correlate with the actual or intended computerization of their practices. Those GPs who did not intend to use a computer had also been much longer in practice and had a longer time since medical school than other doctors. The results of GPs' judgements of future developments and of expert systems are shown in Table 4. A computerized drug database was favoured by almost all doctors and ranged first. The availability of a medical library within the framework of a practice computing system was another feature which was favoured by all groups of doctors. Automatic monitoring of patients achieved the third best rating of all features mentioned. Features of expert systems were rated much lower than drug database, medical library and automatic monitoring opportunities. An expert
Downloaded from http://fampra.oxfordjournals.org/ at Florida Atlantic University on August 31, 2015
SUBJECTS AND METHODS The study was conducted in April and May 1991 in Lower Saxony, one of the large 'lands' in the north of Germany. We sent a postal questionnaire with an accompanying letter and a return envelope to a random sample of 400 (11.2%) of 3557 general practitioners from the actual health care scheme list." There was only one questionnaire per practice and in the case of a group practice (n = 11) only one of the partners was randomly drawn for the sample. Sex distribution in the random sample was the same as in the whole group of GPs (21% female and 79% male). As a response to postal surveys is most likely during weekends,12 the questionnaires were mailed on a Wednesday in order to arrive on a Friday. After 3 weeks a reminder was mailed to all doctors that had not replied. Two weeks after sending out the reminding letter, the physicians who did not yet answer were called by telephone to obtain some basic information (e.g. age of doctor, practice already computerized or not). During this telephone call no further attempt was made to persuade the doctors to fill out the questionnaires. We administered a revised version of the questionnaire originally used by Ginzler and Pritchard in an international survey.8 It was proven to be feasible in a pilot study with 49 GPs conducted by us in November 1990. There were 57 questions concerning actual computer applications in general practice, information seeking behaviour of general practitioners, attitudes towards computers and towards future developments such as knowledge based information systems. The latter mentioned part will be presented in this paper. There was an introductory text which explained that new uses for practice computers may emerge in the next 5 years. Doctors were asked to judge the usefulness of these developments for their practice. The list of items contained: a comprehensive and updatable drug-database, including dosages, contra-indications, interactions and cost; an expert system which supports GPs to make decisions about managing their patients' problems including diagnosis, investigations, prescribing, treatment planning and criteria for referrals to specialists; a computerized medical library of textbooks, relevant to general practice, so that information could be searched and displayed instantly; and
automatic monitoring of patients' records for treatment options or screening. Each item was rated on a 4-point Likert scale (1 = very useful, 2 = quite useful, 3 = of little use and 4 = useless). Data were entered into a d-BASE 3 + databank and processed with the Statistical Package for the Social Sciences (SPSS-PC+ ). Univariate analysis of variance (SPSS-oneway) was carried out for mean age, years since graduation and years in practice of doctors. A Scheffe's procedure with alpha = 0.05 then was applied to determine differences between groups of doctors, x2 testing was applied for nominal data. Ordinal rated data was analysed by the Kruskal-Wallis test, followed by a Mann-Whitney U-Test with alpha = 0.05 for group differences.
GP ATTITUDES TOWARDS PRACTICE COMPUTING
3 59
TABLE 1 Comparison of participants and non-participants (total n = 375 randomly selected general practitioners) Participants (/i = 276; 73.6%)
Non-participants (p = 99; 26.4%)
Significance
Age Mean
46.4 32-80, SD = 9.5
49.3* 31-82, SD = 11.3
Family Practice © Oxford University Press 1992
J SZECSENYI, A BUSCHHORN AND M M KOCHEN Szecsenyi J, Buschhorn A and Kochen MM. General practitioners'attitudes towards future developments in practice computing—a representative survey in the north of Germany. Famify Practice 1992; 9: 357-361. A postal questionnaire was sent to a random sample of general practitioners in Lower Saxony, Germany to assess how general practitioners regard newly developed but not yet implemented options of practice computers and future applications such as expert systems and information retrieval systems. Replies were received from 276 (response rate 73.6%) general practitioners. Replying doctors were younger {P < 0.05) but they did not differ by sex, practice location, type of vocational training and grade of computerization from non-responding GPs. Twenty-eight per cent of the practices wefe computerized. Doctors who currently used a computer and those who intended to do so within the next 5 years were significantly younger than those doctors who did not intend to computerize their practice (P < 0.001). Female doctors were less willing to buy a computer than their male colleagues (P < 0.05). A computerized drug database and a medical library ranked best from 8 options given. Overall attitudes to all features were positive, except for an expert system giving criteria for referrals to specialist care. Doctors already working with a computer and those intending to buy one were signrficantty more positive about future options for computers than those doctors who do not intend to use a computer ( P < 0.01). GPs' attitudes about new features of practice computers in general were positive but even more so about those options which are already available. Referral to a specialist seems to be a crucial point for GPs—they apparently do not want to be guided by a computer here. The influence of new technologies on process of care and the role of GPs have to be considered before further implementation.
INTRODUCTION In general practice computers are typically used for patient registration, drug prescribing and clinical records. In countries such as Germany with a fee for service system, computers are also widely used for remuneration purposes. There are now many hardware and software developments on the market which might be implemented into practice computers in the near future. These include large databases on compact discs (CD-ROM) which can give physicians rapid and easy access to up-to-date medical literature;1'2 special software which can enhance medical audit, research, screening and prevention activities in general practice;^5 and systems which support drug prescribing
options and which allow analysis of repeat prescriptions. These might be of great help for general practitioners faced with increasing malpractice liability and government restrictions on prescribing.6 A further step will be the introduction of expert systems into general practice. An expert system tries to mimic the abilities of medical experts on their area of expertise. It can give qualified support when it is consulted on a point of decision, for example in the diagnostic process. Such systems are normally restricted to a narrow special area of knowledge but are now also being constructed for the special needs of the general practice setting. This might lead to the implementation of all of the above mentioned features, linking decision support options with information retrieval, treatment proposals and patient management procedures.78
Department of General Practice, University of Gottingen, RobertKoch-Str. 40, D-3400 Gottingen, FRG.
357
Downloaded from http://fampra.oxfordjournals.org/ at Florida Atlantic University on August 31, 2015
General Practitioners' Attitudes Towards Future Developments in Practice Computing— a Representative Survey in the North of Germany
358
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
If 'traditional' practice computing is carefully adopted to the consultation, no negative influences on the consulting process have been reported.9-10 The implementation of new practice computing features and the involvement of expert systems in the decision process might change the situation and negative effects have to be considered. It is yet unclear which of these new facilities will have a substantial impact on the daily work of a general practitioner. This paper reports a study on general practitioners' attitudes towards future features of practice computing systems.
RESULTS Of the 400 GPs we contacted, 16 were no longer practising, eight were wrongly addressed as GPs but were specialists and one had moved overseas. These 25 doctors were excluded from the study. From the remaining 375 GPs we received 276 questionnaires, giving a response rate of 73.6%. The mean age of participants was 46.4 years, 20% were female and 80% were male. Non-participants were on average 3 years older than participants (P < 0.05). We found no significant differences between participants and nonparticipants in the study regarding sex, type of vocational training, and grade of computerization (Table 1). There was no sex difference between participants of the study and all GPs working in Lower Saxony (20% male versus 21% female). Of the responding practices, 78 (28%) already used a computer, 96 (35%) intended to buy one within the next 5 years and 102 (37%) did not plan to computerize their practice (Tables 2 and 3). Doctors who already had a computer and those who planned to buy one were significantly younger than the ones who did not want to do so (P < 0.001). Sex of the doctor also influenced the computerization of general practices: significantly more women than men did not plan to buy a computer (P < 0.05). The type of vocational training of general practitioners did not correlate with the actual or intended computerization of their practices. Those GPs who did not intend to use a computer had also been much longer in practice and had a longer time since medical school than other doctors. The results of GPs' judgements of future developments and of expert systems are shown in Table 4. A computerized drug database was favoured by almost all doctors and ranged first. The availability of a medical library within the framework of a practice computing system was another feature which was favoured by all groups of doctors. Automatic monitoring of patients achieved the third best rating of all features mentioned. Features of expert systems were rated much lower than drug database, medical library and automatic monitoring opportunities. An expert
Downloaded from http://fampra.oxfordjournals.org/ at Florida Atlantic University on August 31, 2015
SUBJECTS AND METHODS The study was conducted in April and May 1991 in Lower Saxony, one of the large 'lands' in the north of Germany. We sent a postal questionnaire with an accompanying letter and a return envelope to a random sample of 400 (11.2%) of 3557 general practitioners from the actual health care scheme list." There was only one questionnaire per practice and in the case of a group practice (n = 11) only one of the partners was randomly drawn for the sample. Sex distribution in the random sample was the same as in the whole group of GPs (21% female and 79% male). As a response to postal surveys is most likely during weekends,12 the questionnaires were mailed on a Wednesday in order to arrive on a Friday. After 3 weeks a reminder was mailed to all doctors that had not replied. Two weeks after sending out the reminding letter, the physicians who did not yet answer were called by telephone to obtain some basic information (e.g. age of doctor, practice already computerized or not). During this telephone call no further attempt was made to persuade the doctors to fill out the questionnaires. We administered a revised version of the questionnaire originally used by Ginzler and Pritchard in an international survey.8 It was proven to be feasible in a pilot study with 49 GPs conducted by us in November 1990. There were 57 questions concerning actual computer applications in general practice, information seeking behaviour of general practitioners, attitudes towards computers and towards future developments such as knowledge based information systems. The latter mentioned part will be presented in this paper. There was an introductory text which explained that new uses for practice computers may emerge in the next 5 years. Doctors were asked to judge the usefulness of these developments for their practice. The list of items contained: a comprehensive and updatable drug-database, including dosages, contra-indications, interactions and cost; an expert system which supports GPs to make decisions about managing their patients' problems including diagnosis, investigations, prescribing, treatment planning and criteria for referrals to specialists; a computerized medical library of textbooks, relevant to general practice, so that information could be searched and displayed instantly; and
automatic monitoring of patients' records for treatment options or screening. Each item was rated on a 4-point Likert scale (1 = very useful, 2 = quite useful, 3 = of little use and 4 = useless). Data were entered into a d-BASE 3 + databank and processed with the Statistical Package for the Social Sciences (SPSS-PC+ ). Univariate analysis of variance (SPSS-oneway) was carried out for mean age, years since graduation and years in practice of doctors. A Scheffe's procedure with alpha = 0.05 then was applied to determine differences between groups of doctors, x2 testing was applied for nominal data. Ordinal rated data was analysed by the Kruskal-Wallis test, followed by a Mann-Whitney U-Test with alpha = 0.05 for group differences.
GP ATTITUDES TOWARDS PRACTICE COMPUTING
3 59
TABLE 1 Comparison of participants and non-participants (total n = 375 randomly selected general practitioners) Participants (/i = 276; 73.6%)
Non-participants (p = 99; 26.4%)
Significance
Age Mean
46.4 32-80, SD = 9.5
49.3* 31-82, SD = 11.3
