This pilot study describes the implementation of electronic HRQoL assessment in 14 general practices, comprising not only technical integration, but also an on-site practice training session and an evaluation of barriers to its routine use.
Participation and practice sample
As this was a pilot study, the sample size of practices was limited. Thus, on the practice level, it might be most adequate to interpret the results in a qualitative way. At least three types of responses can be distinguished with respect to the practices: (i) Some subscribers of the mailing list announcing the project may have read the invitation, but decided not to take part. Reasons for non-participation might be limited capacity due to workload or scepticism towards new technologies . (ii) Three practices withdrew informed consent after initially having indicated interest in participation. Reasons for withdrawal included lack of time, change in practice software and severe illness of the practice assistant. Other potential reasons could have been doubt regarding the benefits of electronic HRQoL assessment compared to the effort. (iii) Participating practices were heterogeneous with respect to the GPs' experience, age and gender as well as practice location. This may partly explain the variation in assessment frequencies, which are discussed below in more detail.
Practice assistants reported that virtually all patients who were invited agreed to participate. Hidden decision criteria of practice assistants regarding the selection of patients cannot be ruled out, but were not assessed in the interview. Most patients had little or no experience with computers, and the distribution of age and gender was typical for the general practice population, so we have no clear evidence for a selective invitation, e.g. of younger or more educated patients. Similarly, patients who participated vs. those who did not participate in the telephone interviews showed comparable characteristics.
By means of wirelessly integrated tablet computers, HRQoL data could be easily collected, transferred and automatically printed, making the results available during the same office visit. Thus, several technical and logistic problems such as the patients' inability to handle a mouse or incorrect allocation of patient numbers (IDs) have been successfully solved. Results could be automatically imported into a variety of electronic patient records as recommended by physicians in another study . Patients had no difficulty in completing the HRQoL questionnaires on the tablet computer, which confirms other findings .
The user perspective and utility of results
The majority of participating patients, practice assistants and GPs were satisfied with the electronic HRQoL measurement. GPs appreciated the additional information indicating marked HRQoL impairments in their patients. The assessments showed that most patients had specific limitations e.g. in their physical or role function. Among the QLQ-C30 symptom scales, those for pain, fatigue and sleep disturbance in particular showed clinically significant differences compared to reference values from the general population . These symptoms are often overlooked in daily routine . Asthma patients, too, showed an impaired quality of life in the SGRQ compared to the general population , with different patterns in symptoms, activity and the impact of the disease. Results for individual patients showed distinct impairments, rather than uniform patterns, which could help the GP to recognise those patients' individual difficulties.
GPs emphasised that the standardised and reproducible HRQoL results helped them to initiate a focused dialogue with the patient, e.g. regarding sensitive topics. As the questionnaires addressed multiple aspects, patients felt the assessment contributed to the physicians' understanding of their personal condition and circumstances. This is in line with other studies showing that patients perceive HRQoL assessments as a valuable support for their care [26, 27] and prefer electronic procedures to paper-pencil assessment [10, 28].
Barriers towards electronic HRQoL assessment
Technically, the HRQoL assessment was functional, well accepted and provided usable HRQoL information. Most participants, however, made less practical use of the new tool than expected. Obviously, there are still barriers to overcome. As indicated by other studies, there seems to be a discrepancy between physicians' appraisal of the importance of HRQoL assessment  and the intensity of its application in everyday practice [6, 11]. In our study, the HRQoL assessment was organised by the practice staff and took place within the normal routine, while most previous studies employed research assistants to manage the data collection .
A typical single-handed German GP may see 50 to 100 patients per day. There are no specialised practice managers, and the practice assistant must complete all administrative and medical tasks per patient within 3 – 15 minutes. In the year of our study, legislative changes increased the practice workload by bringing in new documentation requirements and billing system changes. Germany has the shortest consultation times of several European countries . While practice assistants considered the effort to simply explain the study aims, and the purpose and handling of the QL-recorder acceptable, additional activities – including obtaining formal informed consent – required more time than some practice assistants could afford during busy practice hours. The effort to carry out a HRQoL assessment may be judged positive with the expected benefit in mind, but still be prohibitive given the time pressures of practice reality.
Consistent with this, participating GPs pointed at two primary hindrances: The lack of time to inform patients and to discuss HRQoL data in a busy general practice, and the paucity of resources to alleviate HRQoL deficits. Though the electronic tool reduces workload compared to a paper-pencil measurement, HRQoL assessment still remains an additional task. Time constraints limit the effectiveness of HRQoL assessment if physicians have no capacity to act and appropriately use the information obtained [14, 32]. One practice however was able to perform a high number of electronic HRQoL assessments. This practice cared for the population of a larger island, and was run by a GP and practice team with special organisational skills, dedication and proven research interest .
Strengths and limitations
Our study tried to bring quite advanced tools (HRQoL measurement and up-to-date computer appliances) into multiple, real-life, general practices. Technical function and easy usability demonstrated under these conditions may be considered robust findings, and the transition from a laboratory setting into practice, or from a university clinic into a GP's office, has already taken place. Future clinical trials (e.g. regarding the impact of HRQoL measurement on patient management) can be planned based on the pilot reported here. While it was not the main focus of this study, results of the electronic HRQoL assessment could be further analysed as indicated below.
The "unprotected" setting of our study meant that our intervention competed with the time required by practice assistants and physicians to carry out established (and essential) procedures. In most practices, our instrument was used less than we had expected. While participants did express their appreciation of HRQoL results in the interviews, we could not examine the consequences of HRQoL measurements, and we have no data regarding objective improvements of care or patients' well-being resulting from the integration of HRQoL assessments into general practices. Due to the methodological approach of a pilot study, including a limited sample size, objective benefits of routine HRQoL assessment, as well as generalisability of the participants' statements, need to be confirmed within a larger controlled study. Ideally information regarding the proportion, motives and characteristics of non-participants should also be systematically collected within these controlled trials.