General practitioners' perceptions of the pharmaceutical decision-support tools in their prescribing software

Michael D Ahearn and Stephen J Kerr
Med J Aust 2003; 179 (1): 34-37. || doi: 10.5694/j.1326-5377.2003.tb05415.x
Published online: 7 July 2003


Objectives: To explore how Australian general practitioners use pharmaceutical decision-support (PDS) systems; to determine GPs' perceptions of the deficiencies and strengths of these systems; and how they believe they can be improved.

Design and setting: Qualitative analysis of discussion from three focus groups of GPs (from one rural and two urban Divisions of General Practice) between April and May 2002.

Participants: 22 GPs selected to include users of the five most popular prescribing/clinical practice software products available in Australia.

Main outcome measures: Advantages and disadvantages of using PDS software; ideas for improving PDS systems; attitudes to electronic evidence-based guidelines.

Results: GPs believed that important interactions may be missed because of desensitisation resulting from too many alerts (which also intrude on workflow); that interaction alerts need to be severity graded and only significant ones should appear; and that improved computer–user interface design could enhance the usefulness of PDS systems.

Conclusions: Our results will provide useful feedback to government, software vendors and software developers on the needs and expectations of end users and on the development of agreed software standards.

Adoption of information technology (IT) in general practice has accelerated in recent years, as practices take advantage of federal government Practice Incentives Program (PIP) payments that were specifically targeted to improve IT uptake. The Health Insurance Commission estimates that, as at August 2002, 89% of practices were collecting PIP payments for electronic prescribing.1

The Federal Government's National Electronic Decision Support Task Force has defined "electronic decision support" as "access to knowledge stored electronically to aid patients, carers, and service providers in making decisions on health care".2 Computerised prescribing, combined with decision-support features, has in some cases demonstrated benefits for general practitioners and patients, including enhanced safety of prescribing.3 However, the development and subsequent integration of decision-support tools has happened in an ad-hoc and uncoordinated fashion, with different products evolving in different ways. In particular, there is no established framework of standards for quality and safety within which software developers are required to work. Similarly, there are no uniform requirements in areas such as drug and disease terminology and coding; messaging and communication; and clinical knowledge databases.2,4

Different prescribing programs feature various tools to support GPs in making prescribing decisions. These are often in the form of prompts, warnings, or links to additional information to assist in the decision-making process and streamline work practices. A recent study in the United Kingdom5 assessed GPs' views of the relevance of drug-interaction alerts in their prescribing software and the frequency with which they admitted to overriding these alerts. Thirty-six per cent of respondents admitted to sometimes dismissing alerts without properly checking them (eg, because the interaction was not serious, or was irrelevant to the patient), 55% thought the alerts would be more useful if they were severity graded, and 52% said they had more faith in other information they could obtain.

There is little information available, however, about the attitudes of Australian GPs in these areas. The objectives of our study were to explore how GPs use pharmaceutical decision-support (PDS) systems currently available (within prescribing software or as stand-alone systems), GPs' perceptions of the strengths and deficiencies of these systems, and how GPs believe they can be improved.


Three GP focus groups were conducted between April and May 2002. We approached several IT officers of Divisions of General Practice to help us select GPs who used software for all prescribing, and who ideally had some knowledge of the decision-support tools within their software. The GPs were chosen from one rural and two urban Divisions, and included users of five of the most popular prescribing software packages available in Australia. These software products were identified through discussion with Divisional IT officers and National Prescribing Service facilitators within Divisions.


Some characteristics of participating GPs are summarised in the Box. The greater number of GPs using Medical Director software in our focus groups reflects the dominance of this product in the marketplace. (As group participants were using a variety of software products incorporating different decision-support features, some responses are not relevant to every product in the marketplace.)

The main themes identified, and a selection of GPs' comments, are set out below.

Theme 6: Suggested improvements

GPs had a number of suggestions for improving the functionality or "user-friendliness" of the software they were using, in order to streamline their work processes and improve their ability to care for patients. Some of the issues identified and sample responses are given below.


The issues raised by participants in our focus groups echoed the concerns of GPs in the UK study.5

All software programs used by GPs in our focus groups featured warnings about drugs contraindicated for patients with certain allergies. While GPs considered that PDS tools were an important resource, they found prompts and alerts annoying when they were very repetitious, time-consuming, or not relevant to the prescribing decision. When the prompts are of little clinical significance, or inappropriate for a particular patient, GPs may become desensitised to warnings. This is particularly a problem when alerts are presented in "modal dialog boxes". (A modal dialog box [or window] is one that requires the user to click one of two buttons [typically "OK" and "Cancel"] in order to resume the previous task. In other words, it becomes the "active window" in the application, and no other tasks can be performed until the user intervenes to close it.) However, modal alerts were seen as necessary in cases where GPs ought to be prevented from prescribing a certain drug (eg, a drug contraindicated for patients with a particular allergy). Procedural constraints of this kind are a reliable form of error proofing6 and a means of reducing preventable morbidity and mortality.7

One reason for the number and frequency of alerts is the inclusion of many theoretical and minor drug interactions. To reduce this problem, GPs proposed that programs should incorporate a more sophisticated system of grading interaction alerts (based on their clinical significance), or the facility to customise alerts. So, for example, a clinician experienced in prescribing antidepressants could elect to suppress all but the most critical warnings with this class of drugs. On the other hand, GPs recognised that, while it might be preferable to be alerted only to important interactions, what is not important for one patient may be critically important for another.

GPs were very clear that PDS systems, to be acceptable, must improve consultation workflow and not hamper interactions with patients.8 They felt that many electronic resources had poor search engines, or were cumbersome and time-consuming to navigate. Moreover, the GPs did not always have confidence in the comprehensiveness of PDS alerts or the evidence base behind them. In some cases, they felt more comfortable consulting a book, especially when electronic guidelines were not integrated with the prescribing software.

A major barrier to developing more sophisticated decision-support tools is the lack of agreed standards in areas such as drug and disease terminology. The Medicines Coding Council of Australia has been working to develop and implement unique numbering codes for all pharmaceutical products available in Australia, but agreement by all stakeholders has not been reached and a final product is likely to be many months away. Similarly, there are no agreed standards for message content and format, accuracy of information and representation of clinical knowledge, although many individuals are lobbying for some standards to be mandated in these areas.4

The GPs in our focus groups were predominantly computer literate and at similar stages of learning in the use of their software packages. However, they believed that many of their colleagues were not particularly computer literate and would require support and training to make full use of their prescribing software to enhance patient care. It is possible that our selection process resulted in fairly homogeneous groups that introduced a systematic bias into our results, and that some important issues may have been missed. Nevertheless, the responses of GPs in our study will provide useful input for policymakers, government, the National Prescribing Service, and developers of medical software and decision-support resources in designing systems that better meet the needs and expectations of end users. They may also stimulate discussion between the software industry and relevant stakeholders to seek consensus on priority areas for PDS systems, and on an agreed set of requirements for accreditation of software, which will ultimately benefit GPs, other health professionals and patients.

  • Michael D Ahearn1
  • Stephen J Kerr2

  • National Prescribing Service, Surry Hills, NSW.



We thank Dr Sonia Wutzke from the National Prescribing Service for helpful discussions in planning the focus groups. This work was supported by National Prescribing Service core funding provided by the Commonwealth Department of Health and Ageing.

Competing interests:

None identified.

  • 1. Health Insurance Commission. PIP participation figures for August 2002. Available at: (accessed May 2003).
  • 2. National Electronic Decision Support Task Force. Electronic decision support for Australia's health sector (November 2002). Canberra: Commonwealth Department of Health and Ageing, 2003.
  • 3. Richards B. Information technology in general practice. Canberra: Commonwealth Department of Health and Aged Care, 1999.
  • 4. Liaw ST. General practice and computing standards. Aust Fam Physician 2002; 31: 509-514.
  • 5. Magnus D, Rodgers S, Avery AJ. GPs' views on computerized drug interaction alerts: questionnaire survey. J Clin Pharm Ther 2002; 27: 377-382.
  • 6. Nolan TW. System changes to improve patient safety. BMJ 2000; 320: 771-773.
  • 7. Bates D, Leape L, Cullen D, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280: 1311-1316.
  • 8. Hersh WR. Medical informatics: improving health care through information. JAMA 2002; 288: 1955-1958.


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