Recruitment and GP background findings
Out of 68 GPs invited: 22 consented to participate in the study; 14 refused and 32 did not respond to the invitation. The practices of the 46 GPs who either refused or did not respond were contacted to try to ascertain why they were not interested. The reasons given were: the GP did not use the EDS tool; were too busy; had no interest, moved to other practices or unknown. Out of nine PNs invited, all responded with two consenting to participate in the study and seven nurses declining to take part. The reasons for not participating were: not using the EDS tool or unknown reason.
In total, 22 GPs and two 2 PNs (who were involved in diabetes care and education) consented to participate in this study. All 22 GPs completed the background information questionnaire (Table
) and 15 of them plus 2 PNs took part in the semi-structured interviews. Semi-structured interviews were also completed with two practice nurses.
GPs’ demographic and background information
Thematic analysis resulted in 3 major themes which were described as below.
Use of the tool and impact on diabetes care
When GPs and PNs were asked about their reasons for using the EDS tool, many reported that it was useful in giving them a quick summary of their patients’ type 2 diabetes care; the tool also provided a good reminder of their patients’ risk factor information and any related care that was outstanding. This was the most common reason for their use of the tool.
"It gives us a … very quick summary and … very good reminder of what needs to be done. GP1009"
"Highlighted whether it’s been done recently, more to the point whether it hasn’t been done recently. PN 0201"
The design of the EDS tool offers multiple screens which involve different functions supporting the care of patients with diabetes. These multiple functions were tailored by participating GPs and PNs and used to a greater or lesser degree in managing different individual patients. Many GPs reported that the most useful function was the side bar screen which provided an overview at a glance of all the important factors in diabetes management and a reminder of the outstanding items in the patient’s type 2 diabetes care. Overall, those two functions were viewed as the tool’s key role in diabetes care and we the most commonly used features.
"If you don’t have a prompting tool you may forget something and so on. Here it’s quite hard to forget something because it’s flashing in red there so it almost makes you want to do those things in a way. -GP0101"
"Acts as a reminder to check certain things like weight, blood pressure, smoking and so on regularly and it also reminds me to do blood sort of on a regular basis. It’s more like a reminder system for me to be honest but I know anyway but it just keeps me, reminds me to do again. -GP1303"
The extent of use of some of the more detailed aspects of the tool in practice is variable, partly because of the tool’s shortcoming such as the speed of the software causing some delays in the consultation when users attempt to access these sections, and partly because of a lack of users’ understanding of the full set of features contained within the tool.
"The more you use it the more your realise it is useful - GP1303"
Both GPs and PNs reported using the tool as a resource to assist in the process of education of patients about diabetes and the targets for control of glycaemia and macrovascular risk factors. The fact that information was presented in a graphical format and presented on the screen was considered a visual aide to patient understanding.
"More understanding on the basis of the patient. If you just talk and you don’t illustrate, very little of it gets retained, whereas illustrations help the patient to link the information to something else in their brain and they’re more likely to remember it. –GP1701"
One of the PNs not only used the tool as a visual aide but also used it to provide print out patient educational material relevant to the discussion.
"It’s nice to give a visual thing for the actual patient themselves. It makes them feel included when you share that information with them and because it comes from their file also they think that it makes it seem a little bit more personal. Print it out into, onto the particular specified screen that you like. So say for example they’re not to increase their activity then you can expand and go into that and then you can print out information so you can take it step by step –PN 0201"
Most GPs and both PNs felt that the use of the tool positively affected their management of patient lifestyle risk factors with the focus determined by individual need. This is because they were reminded or prompted by the tool to do so.
"I discuss it more often because I’m reminded about it because of the software. –GP1702"
The tool reminded GP to reinforce to their patients the nature of diabetes lifestyle management which needed to be addressed.
"We’re always reminded about things like their weight and their exercise and things like that and whether they smoke or drink or all those other things that go on that screen so it’s probably just reinforcing it again. –GP1706"
The GPs and PNs saw less value and reported less use of the tools of functions such decision support on use medicines, making referrals or providing follow-up reminders. This was often as the clinicians did not see a need for decision support in this aspect of care. For example in the area of medicines for diabetes one GP commented:
"I think it doesn’t affect someone if your knowledge of diabetes is substantial but if your diabetes knowledge is not that good it offers a lot of advice of what might be the best thing to do with –it does depend on the doctor’s level of knowledge. –GP0201"
The EDS tool provides diabetes guideline information for clinicians to access during the consultation. Many GPs and both PNs reported that they were already familiar with the guidelines for diabetes management, but that the tool did reinforce application of the guidelines in daily work.
"I think the guidelines are essentially buried into the tool so it’s what tells me whether or not the targets are reached so it’s, it’s almost like a, a reminder in the background about the guidelines so the tool applies to guidelines and informs me how I’m going with each particular patient. –GP0201"
There was a range of views on the value of the EDS tool in completing an annual diabetes cycle of care. A diabetes cycle of care is a defined list of care processes to be conducted each year and the completion of the cycle attracts an incentive payment to the GP from Medicare Australia. While only a small number of GPs perceived any value of the tool in this regard both PNs thought the tool helped in getting the cycle of care completed.
"A prompt for the GPs to remind them the patient is a diabetic, to send them to me for their annual cycle of care if it’s due. PN0401"
Impact on the consultation process
The perceptions of GPs varied on the impact of the tool on consultation times. Many GPs felt that they tended to spend longer with their patients when using the tool compared their usual consultations, however this was because they were using the tool to provide better quality of care for their patients. One of the PNs interviewed felt that the consultation was lengthened, and the other reported no change.
Problems with the functionality of the tool software were perceived by some GPs as costing time. Some GPs thought the EDS tool software itself slowed down their IT systems and did not always import information appropriately which resulted in the need of adding information manually. Additionally, some felt the tool was distracting them at times from the purpose of their consultation, in particular when the patient was not attending for a problem related to their diabetes care.
"I mean even to load it up and stuff just takes too much time and it slows down the consultation quite a lot you know. –GP1009"
"I think it takes a bit longer because it’s you know a lot of ticking and putting things in – it doesn’t always automatically do it for some reason. GP1303"
The use of the tool as a visual aide to patient education has been previously discussed. The majority of GPs said they shared the information displayed by the tool to discuss issues such as pathology results, cardiovascular risk factors, guideline recommendations and metabolic targets. It also made it easier to illustrate to patients what they were talking about. The majority of the GPs and one of the PNs thought their communication with patients improved by using the EDS tool. This was because that the tool provided detailed information to them when needed and removed the need to spend time searching different fields of their desktop software.
By sharing the screen with the patients, many GP believed that their patients’ understanding of their diabetes care improved.
"If you just talk and you don’t illustrate, very little of it gets retained, whereas illustrations help the patient to link the information to something else in their brain and they’re more likely to remember it. –GP1701"
Related to improved communication more than half of the GPs thought use of the tool was of benefit to the doctor-patient relationship.
"I think doing it correctly would reinforce the doctor/patient relationship and also create more rapport. –GP1401"
One of the PNs thought the tool also helped her communicate with the GPs in the practice about the care provided.
"Because when you’re printing out it will document that down so you can – instead of writing everything down you, you can communicate more effectively to the GP. –PN0201"
However a few GPs thought the tool interfered with communication with the patient.
"It [the tool] sort of diverts my attention…… It makes me focus more on the computer. -GP1705"
Some GPs expressed a perception of increased patient satisfaction and engagement with their diabetes care in the consultation as a result of seeing their doctor’s interest in using the EDS software.
"If I’m focussing on the screen often it will make the patient focus on thescreen as well and then I’d, I would point a few things out and then show, show a few things on the screen. –GP0101"
"The patient gets happy about it because the thing is they know the doctor is taking a particular interest in them, so I think that’s useful, yes. -GP 1007"
Most importantly, no GPs or PNs reported that their patients had any negative experience associated with the use of the tool during consultations.
Problems/barriers to use and suggestions for improvement
There were a range of problems identified with the tool and barriers to use. These included problems with the functionality of the tool itself and barriers related to the skills of the users. These problems and barriers are summarised in Table
There was a range of suggestions for improvements. These included addressing problems with functionality such as the software running slowly, improving the printing function and also improving integration of the tool with the practice clinical software program. There were also suggestions for new functionality such as providing automatically updated diabetes guidelines via a pop-up or link and being able to modify the goals of treatment for individual patients.
A common suggestion for improvement was a request for a summary information report for the diabetes annual cycle of care. Some GPs were keen to see if the tool could technically be configured to better assist them in determining when they had completed a diabetes annual cycle of care and somehow trigger them to automatically bill this item.
"You would want to know when the last cycle was completed and whether you have been able to satisfy all the criteria for a cycle of care for example, and if the tool could produce a summary of the cycle of care for example. –GP0101"
There was variability into the extent of training and support that the GPs and PNs had received. Nearly all participants thought that introductory training was necessary and there were a range of suggestions on this and ongoing support
"I think it does require a fairly good introduction, introductory session to show where the effectiveness of the tool can, can come in, where you can benefit from this and how to fit it into a consultation. –GP0101"
Suggestion on the content for the introductory training included demonstrating the range of capabilities of the tool, practising on dummy patients and testing on the practice’s own software system.
In contrast to the introductory training, only some participants supported the need for providing continuous support as they felt that the tool was pretty straight forward.
"I think because I mean it works actually quite well on its own. I don’t think there’s much training necessary really. Maybe you know initial training and that’s it. I don’t think ongoing support is necessary really. –GP1303"
Among those who thought ongoing support was needed, suggestions for providing this included having regular follow-ups by practice visits or telephone calls and/or a telephone helpline.