Information system support as a critical success factor for chronic disease management: Necessary but not sufficient

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This is a review for Green C, Fortin P, Maclure M, Macgregor A, Robinson S. for the article entitled Information system support as a critical success factor for chronic disease management: Necessary but not sufficient. [1]

Research question

What are the critical success factors enabling the translation of clinical and operational knowledge about effective and efficient chronic care management into primary care practice?


A chronic disease management [1] (CDM) collaborative of primary care physicians with documented improvement in adherence to clinical practice guidelines using a web-based patient registry system with CDM guideline-based flow sheet. Participants in this study were thirty community-based physician using predominantly paper records, plus a project management team including the physician lead, project manager, and support team. A critical success factor analysis was then performed to analyze necessary and sufficient pathways which could then be used to translate the knowledge into clinical practice.


Two separate qualitative studies that attempted to identify user task flows with an existing EMR, to better understand the environment in which these tasks are performed, and to determine how overall usability can be improved.


This project was created as a prospective case study which noted aberrations. Positive deviants were identified using the following key feature sets:

  • Key informant interviews
  • Process observation
  • Document review


Each of the qualitative studies focused on users of the Longitudinal Medical Record, a web-based application that facilitates the management of patient information, provides clinical messaging, and standardizes methods of data entry and retrieval.


Findings from both studies raised issues with the amount and organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues and feedback. These findings were then used to recommend user interface design changes.

Main results

A web-based clinical decision management 'toolkit' was found to be a direct critical success factor that allowed this group of physicians to improve their practice by tracking patient care processes using evidence-based clinical practice guideline-based flow sheets. The information and communication technology 'factor' was sufficient for success only as part of a set of six direct critical success factor components:

  • Health delivery system enhancements
  • Organizational partnerships
  • Funding mechanisms
  • Project management
  • Practice models
  • Formal knowledge translation practices


There is a complexity associated in dealing with chronic conditions in the primary care setting. In complex primary care settings environment where physicians have low adoption rates of electronic tools to support the care of patients with chronic conditions, successful implementation may require a set of interrelated system and technology factors.


Improvement of chronic disease management in primary care entails monitoring indicators of quality over time and across patients and practices. Informatics tools are needed, yet implementing them remains challenging. Electronic Health Record EHR have utilized Clinical Decision Support Systems CDS to facilitate the management of chronic diseases, however there is a complexity in applying the CDS. First, there has always been gaps to clinical care--Known gaps in the care of patients with the chronic conditions of diabetes, congestive heart failure and depression highlight the need for improved practice and knowledge translation among primary care physicians. In addition, clinical leadership and adequate resources are critical to successful knowledge translation in clinical settings. However the Institute for Healthcare Improvement breakthrough has shown that chronic care has improved by the following indirect aspects that indirectly contributed to knowledge translation through the success of the information system: (1) listing and tracking patients, (2) allowing data sharing, (3) demonstrating performance improvement, and (4) integration with workflow.

Related articles

Describing and Modeling Workflow and Information Flow in Chronic Disease Care


  1. . International Journal of Medical Informatics 2006 December; 75(12): 818-828.