Reminders consist of prompts either before or during a patient encounter that suggest a specific behavior should or should not be performed. The reminder may consist of a note in a patient’s chart; a computer print-out; a message appearing on a computer screen; a verbal cue from an assistant; or a checklist, wall poster, flowchart, or other paper- or computer-based job aid that guides the health provider through the appropriate steps in a process. The major assumption underlying reminder interventions is that provider forgetfulness or lack of awareness are major barriers to performance in accordance with standards, as opposed to deficiency in knowledge or skill.
Systematic reviews have coincided in concluding that reminders have been proven effective in increasing provider adherence to preventive care standards and prescribing guidelines (Davis, Thomson, Oxman, & Haynes, 1995; Hulscher, Wensing, Grol, van der Weijden, & van Weel, 1999; Wensing & Grol, 1994). Grimshaw and Russell (1994) reported improvements in performance according to standards in both hospital and general practice settings in several studies where guidelines were imbedded in medical record cards and other forms. However, Solomon, Hashimoto, Daltroy, and Liang (1998) cautioned that not all trials of reminders have demonstrated effects. The effects of reminders often disappeared after the reminders were stopped, suggesting that to be effective, reminders must be applied continuously and incorporated into daily routines.
Asking health providers to respond to the reminder appears to boost effectiveness. In their review of interventions to influence physician test ordering, Axt-Adam, van der Wouden, and van der Does (1993) noted that requiring physicians to acknowledge the reminder (i.e., by noting some response as to whether the reminder was followed and why) enhanced its effect. Both manual and computerized reminders have been found to be similarly effective in inducing doctors in primary care settings to perform various preventive services, including immunization and breast cancer screening. Computer-based reminders known as clinical decision support systems go beyond generic reminders about practice guidelines to integrate patient-specific information from a computer database in order to generate patient-specific assessments or recommendations. A review of controlled trials of clinical decision support systems found positive effects on physician performance for preventive services and positive results with computer-based drug-dosing systems (Hunt, Haynes, Hanna, & Smith, 1998).
Job aids are a type of reminder and have been widely used in developing country settings, especially with non-physician health workers. Job aids are visual tools used by the provider during a health care activity that give direction on what actions to take and how. The purpose of the job aid is to reduce the amount of recall necessary to correctly perform the task. Job aids are thought to be most appropriate when provider forgetfulness or lack of recall is an important barrier to performance, such as when the task to be performed is complex or infrequent.
Several Quality Assurance Project studies found that job aids could be feasible and effective in hospital, primary care and community settings to prompt health workers to perform key tasks or communicate specific messages during patient counseling. A study by HCI in Benin found that the use of a pictorial set of counseling cards by nurses resulted in significantly improved maternal knowledge in birth preparedness, maternal and newborn danger signs, newborn care, and healthy home practices. The study also found that unskilled providers (matrons) were able to achieve similarly high performance levels using the job aids, even though counseling was not previously part of their role. This finding highlights the important contribution that job aids can make as part of interventions to shift tasks from higher skilled to lower skilled health workers.