The importance of patients' health related quality of life (HRQoL) in medical practice is nowadays beyond dispute. Two decades ago a committee of the American College of Physicians specifically supported the view that maintenance of a patient's functional well-being is a fundamental goal of medical practice. They also noted that the assessment of the physical, psychological, and social functioning of the patient in terms of the impact of disease is "an essential part of clinical diagnosis, a major determinant of therapeutic choices, a measure of their efficacy, and a guide in planning long-term care..."1.

Since 2001, several impact high impact articles have been published on the effectiveness of HRQoL measurement in clinical practice, which have presented positive results such as more frequent discussion and identification of HRQoL related problems, improved emotional functioning, improved HRQoL, a decrease in depression, a decrease in debilitating symptoms, and expressed interest in continued use of the information by both physicians and patients 234567. Despite these positive results, standard measurement and feedback of HRQoL has as of yet not been widely implemented in clinical practice. This may be explained by the initial lack of convincing data regarding the effectiveness of standardized HRQoL measurement in actually improving HRQoL or psychosocial outcomes 3891011, and by practical and attitudinal barriers that have been associated with the implementation of HRQoL measurement in clinical practice. Practical barriers that have been reported include general lack of time, money and human resources, impracticality of instruments, disruption of clinical routine, lack of IT support and health professionals' lack of knowledge in this area. Attitudinal barriers may include health professionals' scepticism of the validity of HRQoL questionnaires, and ability to intervene should the questionnaires reveal any problems 11121314151617.

To the best of our knowledge, only two studies have actually implemented the procedure of HRQoL measurement in clinical practice and subsequently described the issues encountered in terms of feasibility. In one of the studies, the main finding was that higher compliance occurred when the computerized data collection was integrated into routine care. However, it should be noted that the follow-up time was very short (12 weeks), resulting in a large number of patients attending only once which makes it difficult to draw any firm conclusions on patient compliance in the long run 18. In the other study, only 18 patients participated and the questionnaires were not computerized 19. A previous study has shown that pen-and-paper versions of HRQoL questionnaires, which have to be scored by hand, take too much time and are costly in the long term 20. Providing clinicians with instant information about their patients' HRQoL at busy outpatient clinics can only be obtained if this HRQoL is assessed by means of computers that can generate an output which can instantly be accessed by clinicians.

The aim of the present study was to gain more insight in the practical and attitudinal feasibility problems encountered during the process of implementing computerized HRQoL measurement at a busy outpatient department of Hepatology (liver disease) (Erasmus MC, Rotterdam, the Netherlands). Chronic liver disease is one of the most prevalent diseases in the world, affecting over 560 million people (http://www.epidemic.org, 4-12-2006). It is a serious disease that is associated with impaired HRQoL 2122. Chronic liver disease is an appropriate example of a typical chronic disease, with patients experiencing substantial comorbidity and possibly mortality as is the case in many other chronic diseases.

This study was among the first to actually implement the complete procedure of routine computerized HRQoL measurement at an outpatient department, and to subsequently describe all feasibility issues encountered throughout the process. The focus was on technical as well as logistic feasibility issues such as optimization of patient compliance in the long run, rather than effects of the intervention on patient well-being which have been presented elsewhere 34567. Practical suggestions for researchers and health care workers interested in implementing assessment of HRQoL in clinical practice were given.

The present study is, to the best of our knowledge, the first to describe a variety of feasibility issues encountered during the implementation of computerized HRQoL measurement in clinical practice, in a population of patients with chronic liver disease. Feasibility problems concerning technical aspects of developing a user-friendly computer program with safe data transmission over the Internet, patients' computer skills, and patients' compliance were encountered. Physicians were generally positive about the instant computerized availability of HRQoL information.

Technical problems that we encountered during the developmental phase of the computer program were substantial, and cost substantial time and effort to correct. Assistance from an IT professional is advised if one intends to develop a computer program that includes the particular questionnaires of interest, is easy for patients to complete, and transmits the information to the physicians' computer in such a way that privacy is assured.

With regard to patients' lack of basic computer skills, the use of touch-screen computers, which have been shown to be easy to handle by various patient populations 202627282930, is recommended when implementing HRQoL measurement in clinical practice. This may optimise patient participation, and the quality of the answers, which will be less biased by the presence of family members or friends that help with completing the questionnaires such as found in the study of Velikova et al (2002) 31.

A limitation of the present study was the high number of non-participants. Part of the explanation may lie in the fact that patients themselves were responsible for contacting their physician if they were interested in participating in the study. In addition, the number of non-Dutch speaking patients visiting the department of Hepatology of the Erasmus MC is relatively large (Hepatitis B for example, is most common among people from North Africa). These patients were also invited to partcipate, but were not able to participate since the questionnaires in this study were only available in Dutch. Future studies should aim at including non-native speakers, whose data are of particular interest to the physicians in this study.

The low compliance of patients that did participate in our study, is in accordance with findings of a previous study showing deterioration of compliance with longer follow-up 17. Bad timing and other priorities were given as possible explanations. In our study, an explanation may lie in the small window of opportunity to complete the questionnaires before each consultation. Indeed, patients mentioned in the retrospective questionnaire that lack of time was one of the main reasons for not completing the questionnaires. Simply forgetting to complete the questionnaires was the most important reason, despite eye-catching posters that were put up in the waiting room. The fact that the retrospective question "have you completed the questionnaires with each visit" was answered with "no" in 57% of the cases supposes an honest attitude of the respondents, who were informed about the anonymity of their responses. Considering these results, it seems that patient participation cannot be left to patients themselves, who may be nervous about the upcoming consultation and/or used to going to the waiting room after announcing themselves at the reception desk. To optimise participation it is, in our opinion, of vital importance that all staff of the department concerned, especially the reception desk personnel but also the nurses and physicians, approves of the intervention, considers it as part of standard clinical routine, and acts accordingly by sending patients to the computer before each consultation.

The positive attitudes of the physicians in our study towards the availability of instant computerized HRQoL information during the consultation are in accordance with previous studies in oncology 1830, and advocate the continued use of such a procedure in patients with chronic liver disease. However, future studies should aim at including more liver specialists in order to substantiate these findings. Expressed concerns of an increase in workload as a result of the HRQoL data 30 were absent in our study. These positive findings in liver specialists, treating patients with a disease that is generally less acute and life threatening than cancer for instance, give incentive to further exploration of routine computerized HRQoL measurement in other specialisations within internal medicine such as nephrology or gastroenterology. When implementing such a procedure, it should be stressed to physicians that standardized HRQoL information should never replace the clinical dialogue between patient and physician, as important symptoms may then be overlooked, or exaggerated 30. Rather, the HRQoL information should be seen as an indication of possible problems worth discussing and exploring further during the consultation.

This study addressed practical feasibility issues associated with routine computerized measurement of HRQoL at a busy outpatient department of Hepatology. Feasibility is an important requirement for more widespread implementation of such an intervention. Another requirement is that the intervention is effective in improving patients' well-being and/or medical treatment. The current study has directly contributed to the first requirement by showing that the attitudes of physicians were generally positive, by identifying probable barriers towards successful implementation, and by providing solutions on how to overcome these barriers. These include hiring an IT expert, involving all personnel and using touch-screen computers. While the findings of the current study are encouraging they also emphasise that these implementation processes are complex and should not be underestimated. Further studying of the feasibility and effectiveness of routine computerized HRQoL measurements in clinical practice is needed before widespread implementation can be achieved.

The authors declare that they have no competing interests.

JG participated in the design of the study and conducted it. She also drafted the manuscript. RDM participated in the design of the study and helped to conduct it. JB and ASD participated in the design of the study and helped to draft the manuscript. All authors read and approved the final manuscript.