Barriers and facilitators to use of a clinical evidence technology in the management of skin problems in primary care: insights from mixed methods

Marianne D. Burke, Liliane B. Savard, Alan S. Rubin, Benjamin Littenberg


Objective: Few studies have examined the impact of a single clinical evidence technology (CET) on provider practice or patient outcomes from the provider’s perspective. A previous cluster-randomized controlled trial with patient-reported data tested the effectiveness of a CET (i.e., VisualDx) in improving skin problem outcomes but found no significant effect. The objectives of this follow-up study were to identify barriers and facilitators to the use of the CET from the perspective of primary care providers (PCPs) and to identify reasons why the CET did not affect outcomes in the trial.

Methods: Using a convergent mixed methods design, the authors had PCPs complete a post-trial survey and participate in interviews about using the CET for managing patients’ skin problems. Data from both methods were integrated.

Results: PCPs found the CET somewhat easy to use but only occasionally useful. Less experienced PCPs used the CET more frequently. Data from interviews revealed barriers and facilitators at four steps of evidence-based practice: clinical question recognition, information acquisition, appraisal of relevance, and application with patients. Facilitators included uncertainty in dermatology, intention for use, convenience of access, diagnosis and treatment support, and patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulties, presence of irrelevant information, and lack of decision impact.

Conclusion: PCPs found the CET useful for diagnosis, treatment support, and patient communication. However, the barriers of interface difficulties, irrelevant search results, and preferred use of other sources limited its positive impact on patient skin problem management.


Evidence-Based Medicine; Evidence-Based Practice; Decision-Support Systems; Medical Informatics Applications; Libraries, Hospital; Information Storage and Retrieval; Databases, Factual; Information-Seeking Behavior; Skin Diseases; Primary Health Care; Tec

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Sackett DL. Evidence-based medicine: how to practice and teach EBM. London, UK: Churchill Livingstone; 2000.

Marshall JG, Sollenberger J, Easterby-Gannett S, Morgan LK, Klem ML, Cavanaugh SK, Oliver KB, Thompson CA, Romanosky N, Hunter S. The value of library and information services in patient care: results of a multisite study. J Med Libr Assoc. 2013 Jan;101(1):38–46. DOI:

Sievert M, Burhans D, Ward D, Jones BB, Bandy M, Carlson J, Decker S, Henderson H. Value of health sciences library resources and services to health care providers in medium and large communities across two Mid-Continental states. J Hosp Librariansh. 2011;11(2):140–57. DOI:

Alper BS, White DS, Ge B. Physicians answer more clinical questions and change clinical decisions more often with synthesized evidence. Ann Fam Med. 2005 Nov;3(6):507–13. DOI:

Ely JW, Osheroff JA, Chambliss ML, Ebell MH, Rosenbaum ME. Answering physicians’ clinical questions: obstacles and potential solutions. J Am Med Inform Assoc. 2005 Mar–Apr;12(2):217–24. DOI: 10.1197/jamia.M1608.

Andrews JE, Pearce KA, Ireson C, Love MM. Information-seeking behaviors of practitioners in a primary care practice-based research network (PBRN). J Med Libr Assoc. 2005 Apr;93(2):206–12.

Green ML, Ruff TR. Why do residents fail to answer their clinical questions? a qualitative study of barriers to practicing evidence-based medicine. Acad Med. 2005 Feb;80(2):176–82.

Federman DG, Reid M, Feldman SR, Greenhoe J, Kirsner RS. The primary care provider and the care of skin disease: the patient’s perspective. Arch Dermatol. 2001 Jan;137(1):25–9.

Fleischer AB Jr., Herbert CR, Feldman SR, O’Brien F. Diagnosis of skin disease by nondermatologists. Am J Manag Care. 2000 Oct;6(10):1149–56.

Verhoeven EW, Kraaimaat FW, van Weel C, van de Kerkhof PC, Duller P, van der Valk PG, van den Hoogen HJ, Bor JH, Schers HJ, Evers AW. Skin diseases in family medicine: prevalence and health care use. Ann Fam Med. 2008 Jul–Aug;6(4):349–54. DOI:

Ojeda RM, Graells J. [Effectiveness of primary care physicians and dermatologists in the diagnosis of skin cancer: a comparative study in the same geographic area]. Actas Dermosifiliogr. 2011 Jan;102(1):48–52. DOI:

Kownacki S. Skin diseases in primary care: what should GPs be doing? Br J Gen Pract. 2014 Aug;64(625):380–1. DOI:

Gulati A, Harwood CA, Rolph J, Pottinger E, McGregor JM, Goad N, Proby CM. Is an online skin cancer toolkit an effective way to educate primary care physicians about skin cancer diagnosis and referral? J Eur Acad Dermatol Venereol. 2015 Nov;29(11):2152–9. DOI:

David CV, Chira S, Eells SJ, Ladrigan M, Papier A, Miller LG, Craft N. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011 Mar 15;17(3):1.

Burke M, Littenberg B. Effect of a clinical evidence technology on patient skin disease outcomes in primary care: a cluster-randomized controlled trial. J Med Libr Assoc. 2019 Apr;107(2):151–62. DOI:

Logical Images. VisualDx [Internet]. Logical Images [cited 22 Oct 2018]. .

Creswell JW. Chapter 10: Mixed methods procedures. In: Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. 4th ed. Thousand Oaks, CA: SAGE Publications; 2014. pp. 215–40.

O’Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. J Health Serv Res Policy. 2008 Apr;13(2):92–8. DOI:

Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009 Apr;42(2):377–81. DOI:

Davis FD. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Q. 1989 Sep;13(3):319–40. DOI:

StataCorp. Stata statistical software: release 14. College Station, TX: StataCorp; 2015.

Straus SE. Evidence-based medicine: how to practice and teach it. 4th ed. Edinburgh, UK: Elsevier Churchill Livingstone; 2011. 293 p.

Albarqouni L, Hoffmann T, Straus S, Olsen NR, Young T, Ilic D, Shaneyfelt T, Haynes RB, Guyatt G, Glasziou P. Core competencies in evidence-based practice for health professionals: consensus statement based on a systematic review and delphi survey. JAMA Network Open. 2018 Jun 1;1(2):e180281. DOI:

QSR International. NVivo qualitative data analysis software version. 12th ed. QSR International; 2018.

O’Cathain A, Murphy E, Nicholl J. Three techniques for integrating data in mixed methods studies. BMJ. 2010 Sep 17;341:c4587. DOI:

Ely JW, Osheroff JA, Ebell MH, Chambliss ML, Vinson DC, Stevermer JJ, Pifer EA. Obstacles to answering doctors’ questions about patient care with evidence: qualitative study. BMJ. 2002 Mar 23;324(7339):710.

Cook DA, Sorensen KJ, Wilkinson JM, Berger RA. Barriers and decisions when answering clinical questions at the point of care: a grounded theory study. JAMA Intern Med. 2013 Nov 25;173(21):1962–9. DOI:

Zwolsman S, te Pas E, Hooft L, Wieringa-de Waard M, van Dijk N. Barriers to GPs’ use of evidence-based medicine: a systematic review. Br J Gen Pract. 2012 Jul;62(600):e511–21. DOI:

Cook DA, Sorensen KJ, Hersh W, Berger RA, Wilkinson JM. Features of effective medical knowledge resources to support point of care learning: a focus group study. PLoS One. 2013;8(11):e80318. DOI:

Dunn K, Marshall JG, Wells AL, Backus JEB. Examining the role of MEDLINE as a patient care information resource: an analysis of data from the Value of Libraries study. J Med Libr Assoc. 2017 Oct;105(4):336–46. DOI:

Rübsam ML, Esch M, Baum E, Bösner S. Diagnosing skin disease in primary care: a qualitative study of GPs’ approaches. Fam Pract. 2015 Oct;32(5):591–5. DOI:

Swetter SM, Chang J, Shaub AR, Weinstock MA, Lewis ET, Asch SM. Primary care-based skin cancer screening in a Veterans Affairs health care system. JAMA Dermatol. 2017 Aug 1;153(8):797–801. DOI:

Barbieri JS, French B, Umscheid CA. Uptake and impact of a clinical diagnostic decision support tool at an academic medical center. Diagnosis (Berlin, Germany). 2015 Jun 1;2(2):123–7. DOI:



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