Electronic audit and feedback

Audit and feedback (A&F) defined as the provision of clinical performance summaries to healthcare providers and organisations [1] is a well-used approach to support clinical behaviour change [2]. The increasing availability of health data in an electronic format (e.g. in Electronic Health Records), significantly increases potential for use of these data to provide electronic A&F (e-A&F). e-A&F can be defined as the utilisation of interactive computer interfaces to provide clinical performance summaries to healthcare professionals [1, 3–۷]. It aims to support the decision-making process or guide team management [3–۷]. Although A&F is generally used when the patient is not present (e.g. like in bedside consultations, thereby making it distinctly different from computerized clinical decision support tools), e-A&F interventions specifically target clinicians or their managers and can aid improvement of patient care by providing timely or even real-time information for decision-making as part of operational management [8]. Furthermore, the interactive computer interface may allow users to filter, drill down and further explore their performance summaries. Mechanisms of how A&F leads to behaviour change are variable and largely ignored in both individual and team-based contexts [9, 10]. While individual-based feedback is desirable [11], feedback to providers organised in teams or organisational units (e.g. whole facilities or departments) may offer a more scalable implementation model appropriate for low- and middle-income contexts [12]. In team-based care, multiple healthcare professionals are responsible for the same patients, and complex coordination is required [13]. Given previous A&F research showing team processes to explain more variance in outcome than practice structure[14], e-A&F interventions might additionally better facilitate improvement in teambased settings by addressing the aforementioned features.

Use of theory

A&F is posited to increase accountability and quality of care through implicit behaviour regulation of healthcare professionals [9]—given it involves techniques of goal setting, monitoring and providing feedback [15]—and is postulated to be most effective when its design is guided by theory [9, 16, 17]. However, explicit use of theory in A&F interventions is scarce [18]. As a consequence, little is known on the more specific topic of how e-A&F interventions may enhance the quality of care. It is noteworthy that barriers to behaviour change can be influenced by A&F [19] and that these barriers differ across clinicians, originating from differences in clinicians’ training, knowledge, work experience, personality and other individual characteristics. These barriers are complex and dynamic (they are influenced by ongoing changes in the healthcare organization which in turn influence clinicians’ behaviours) [20]. Use of theory can help direct predictions on the effect size of audit and feedback used to help clinicians’ behaviour change. A&F interventions with graphical or written presentations, to our knowledge, provide feedback in the same format for all recipients. In this way, A&F is not sensitive to individual differences in barriers to behaviour change given the media platform. e-A&F could help address this individual-indifferent approach in applying theory to overcome this significant limitation for traditional A&F presentations [21].