Surveys^3–5 and focus groups^6,7 are typical methods used to investigate barriers to guideline adherence. However, these approaches often engage clinicians when they are temporally remote from the specific clinical scenarios in which medical decisions are made, increasing the likelihood that physicians will have a biased recall of specific management decisions.

Collecting feedback at the point of care during clinical practice offers several distinct advantages to data collection methods such as surveys. First, when integrated with the presentation of decision support, a point-of-care feedback interface facilitates real-time submission of clinician feedback in the context of decision-making and can reduce recall biases present in clinician surveys. Second, clinician feedback is automatically linked to the specific patient scenario and/or specific displayed drug recommendation about which the clinician is commenting. Finally, submitted comments are automatically logged by the DSS, eliminating the need for respondents to return surveys as required with paper-based data collection methods.

Overall, “other patient factors” was the most frequently reported barrier to intensifying therapy (49%), followed by clinician perceptions that hypertension was not a clinical priority for that visit (23%), and patient non-adherence (19%) (Figure 2). The need to continue monitoring and/or to provide lifestyle counseling was less frequently reported, but was described in nearly 1 in 10 visits.

When assessed by the specific pattern of barriers reported at a given visit, two or more types of barriers were reported in 14.4% of visits (Figure 3). Among visits for which only one type of barrier was reported, the relative frequencies of the different barrier types remained unchanged.

Our findings shed light on several specific areas where automated decision support systems for hypertension management may be improved. Compared with human review of medical records, computer-aided review can produce different judgments about whether a clinician behavior is guideline nonadherent. This is due in part to the presence of clinically relevant information in the EMR that is entered in non-standardized formats (e.g., free-text comments).¹⁴ In a randomized trial comparing office-BP-driven hypertension treatment decisions with home-BP-driven decisions, reliance on home BPs (i.e., information often captured only in free-text in medical records) led to less intensive drug treatment.¹⁵ Our finding that clinicians frequently did not consider the recorded office BP to be representative of the patient’s typical BP is consistent with that of Ferrari et al., who found that satisfactory patient self-measured BPs were a main reason clinicians reported for not intensifying therapy.⁵ Standardized collection and coding of data on home BPs may improve the usefulness and applicability of displayed recommendations in facilitating optimal hypertension management. Analysis of point-of-care feedback also identified instances where the primary care clinician was not responsible for managing the patient’s hypertension. Approaches to identify the correct clinician decision-maker are needed to ensure effective guideline implementation and to appropriately target decision support.

Other factors identified in our study, such as clinician reports that hypertension was not a clinical priority or that more monitoring was needed, have been reported in previous studies.^3–5 These factors may describe appropriate clinician guideline non-adherence in certain patient scenarios. However, Oliveria et al. found that clinicians often deferred intensification even when uncontrolled hypertension had been documented for at least six months preceding the patient’s most recent visit.⁴

Our study has several limitations. Given the extra work required to offer optional comments, it may be expected that busy clinicians would do so infrequently. Clinicians voluntarily provided feedback at 7% of visits. Many barriers may be under-reported. While provision of feedback was not associated with patient demographic characteristics or the number of active antihypertensive medications, clinicians in our study were more likely to provide feedback at visits where the patient had a significantly elevated BP and/or an elevated BP at their previous visit (data not shown). It is possible that clinicians selectively offered comments for scenarios they encountered repeatedly or for scenarios they believed required justification. We are not able to confirm this using our data. For these reasons, our findings may not be generalizable beyond our study sample. Nevertheless, these spontaneously offered comments, provided during actual patient encounters, offer additional insight into the various factors and challenges clinicians consider at the time of the medical decision.