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    Barriers and Facilitators to Use of a Clinical Evidence Technology for Management of Skin Problems in Primary Care: Insights from Mixed Methods

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    Background: A previous cluster-randomized controlled trial tested the effectiveness of a clinical evidence technology (CET), VisualDx, for skin problems seen by Primary Care Providers (PCPs). Based on patient report, there was no effect on time to problem resolution or return appointments. Objective: To explain, from the provider perspective, why the CET did not make a difference in the clinical trial and to identify barriers and facilitators to use. Methods: Mixed methods study design. Providers from both arms completed a survey about their use of VisualDx and information-seeking during and after the trial. Active arm providers participated in interviews to explore their opinions and experiences using VisualDx. Behavioral steps of the evidence-based medicine (EBM) paradigm informed the 6 step model. Results: PCPs found VisualDx easy to use (median 3 on a 1-4 scale), but found it only somewhat useful (median 2 on a 1-4 scale). PCPs with fewer years in practice used it more often and found it easier to use. Interviews identified facilitators and barriers to using VisualDx. Facilitators included diagnostic uncertainty, positive attitude, easy access, utility for diagnosis and therapy decisions, and utility for patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulty, and retrieval of irrelevant diagnoses and images. Some PCPs reported positive impacts on patient treatment and fewer referrals; others saw no difference. PCPs found VisualDx easy to access, but some found the interface difficult to use. They found it useful and relevant at times, but also frustrating and time-consuming. They used other sources in addition to, or instead of, VisualDx. Conclusion: PCPs did not perceive VisualDx as “useful” often enough for them to use it frequently or exclusively, thereby reducing the likelihood of its making a difference in patient-level outcomes such as problem resolution and return appointments