A descriptive feast but an evaluative famine: Systematic review of published articles on primary care computing during 1980-97

Objectives: To appraise findings from studies examining the impact of computers on primary care consultations. Design: Systematic review of world literature from 1980 to 1997. Data sources: 5475 references were identified from electronic databases (Medline, Science Citation Index, Social Sciences Citation Index, Index of Scientific and Technical Proceedings, Embase, OCLC FirstSearch Proceedings), bibliographies, books, identified articles, and by authors active in the field. 1892 eligible abstracts were independently rated, and 89 studies met the inclusion criteria. Main outcome measures: Effect on doctors performance and patient outcomes; attitudes towards computerisation. Results: 61 studies examined effects of computers on practitioners' performance, 17 evaluated their impact on patient outcome, and 20 studied practitioners' or patients' attitudes. Computer use during consultations lengthened the consultation. Reminder systems for preventive tasks and disease management improved process rates, although some returned to pre-intervention levels when reminders were stopped. Use of computers for issuing prescriptions increased prescribing of generic drugs, and use of computers for test ordering led to cost savings and fewer unnecessary tests. There were no negative effects on those patient outcomes evaluated. Doctors and patients were generally positive about use of computers, but issues of concern included their impact on privacy, the doctor-patient relationship, cost, time, and training needs. Conclusions: Primary care computing systems can improve practitioner performance, particularly for health promotion interventions. This may be at the expense of patient initiated activities, making many practitioners suspicious of the negative impact on relationships with patients. There remains a dearth of evidence evaluating effects on patient outcomes.