Review ArticleSystematic Review

Barriers and Facilitators to the Use of Clinical Decision Support Systems in Primary Care: A Mixed-Methods Systematic Review

Pierre-Yves Meunier, Camille Raynaud, Emmanuelle Guimaraes, François Gueyffier and Laurent Letrilliart
The Annals of Family Medicine January 2023, 21 (1) 57-69; DOI: https://doi.org/10.1370/afm.2908

Article Figures & Data

Figures

  • Figure 1:
    Figure 1:

    HOT-fit framework (derived from Yusof et al29).

    HOT-fit = human, organization, technology, net benefits.

    Note: The HOT-fit framework describes the interdependent human, organizational, and technological factors related to health information system adoption. A fit between the human, organizational, technological factors and the net benefit dimension is required for the adoption of these systems.

  • Figure 2.
    Figure 2.

    Mixed-methods synthesis design.

    CDSS = clinical decision support system; HOT-fit = human, organization, technology, net benefits.

  • Figure 3.
    Figure 3.

    PRISMA flow chart.

    CDSS = clinical decision support system; PRISMA = Preferred Reporting Items for Systematic Review and Meta-Analysis.

Tables

  • Table 1.

    Main Features of the 45 Identified CDSSs

    CDSS n = 45 in 48 StudiesNameCountry of UseCare ProceduresTargeted Health Issues
    North America
    Alagiakrishnan et al,36 2016SMART-CDSCanadaPrevention (iatrogenesis)Adaption of medication to renal function from the patient’s EHR
    Ash et al38 2011USADiagnosis, Therapeutics (prescribing, vaccination)Drug-drug, drug-condition, and drug-allergy interaction checking, patient care plan dashboard with reminders, nearly 3,000 condition specific point-and-click templates for documentation
    Curry et al42 2011Decision Support ServerCanadaPrevention (disease, test ordering)Prescription of diagnostic imaging
    Dixon et al43 2013USAPrevention (disease, test ordering), Management of chronic disease(s)Diabetes mellitus type II, hypertension, coronary artery disease
    Doerr et al44 2014My FamilyUSAPrevention (disease, test ordering)Cancer risk management
    Edelman et al45 2014The Pregnancy and Health Profile (PHP)USAPrevention (disease, test ordering)Prenatal genetic screening
    Feldstein et al46 2013Patient Panel-Support Tool (PST)USAPrevention (iatrogenesis, disease, test ordering), Management of chronic diseaseGraphically displays ‘‘care gaps’’ (eg, for screening, medication use, monitoring, risk-factor control, vaccination)
    Guenter et al47 2019McMaster Pain Assistant (MPA)CanadaDiagnosis, Therapeutics (prescribing, vaccination)Neuropathic pain
    Jenssen et al51 2016USAPrevention (disease, test ordering)
    Therapeutics (prescribing, vaccination)    		Smoking cessation
    Kempe et al52 2017Immunization information systemsUSAPrevention (disease, test ordering)Vaccination
    Lam Shin Cheung et al54 2020eAMSCanadaTherapeutics (prescribing, vaccination), Management of chronic disease(s)Asthma
    Lemke et al55 2020GWAUSAPrevention (disease, test ordering)Genetic risk assessment
    Litvin et al. (2012)ABX-TRIP CDSSUSAPrevention (disease, test ordering), Diagnosis, Therapeutics (prescribing)Acute respiratory infections
    Litvin et al56 2016USAPrevention (disease, test ordering)Identification and management of chronic kidney disease
    Minian et al62 2021CanadaPrevention (disease, test ordering)Alcohol cessation
    Montini et al63 2013USAPrevention (disease, test ordering)
    Therapeutics (prescribing, vaccination)    		Tobacco cessation
    Price et al67 2017CanadaPrevention (iatrogenesis)Potentially inappropriate prescriptions in the elderly
    Richardson et al68 2019USATherapeutics (prescribing, vaccination)Sore throat, upper respiratory tract infections
    Rubin et al72 2006USATherapeutics (prescrbiing, vaccination), DiagnosisAcute respiratory tract infections
    Trafton et al76 2010ATHENA-OTUSATherapeutics (prescribing, vaccination)Opioid therapy for chronic, noncancer pain
    Trinkley et al77 2021USATherapeutics (prescribing, vaccination)Heart failure
    Williams et al79 2016USAPrevention (disease, test ordering)Pediatric cardiovascular risk
    Zheng et al81 2005CRSUSAPrevention (iatrogenesis, disease, test ordering), Therapeutics (prescribing, vaccination), Management of chronic disease(s)Diabetes mellitus type II, hyperlipidemia, steroid-induced osteoporosis, influenza, pneumonia, breast cancer, cervical cancer
    Europe
    af Klercker et al35 1998SwedenDiagnosisEar, nose, throat diseases
    Arts et al37 2018The NetherlandsManagement of chronic disease(s)Diabetes mellitus type II, atrial fibrillation, hypertension, medication prescriptions relating to care of older adults
    Bindels et al41 2003GRIF Automated Feedback SystemThe NetherlandsPrevention (disease, test ordering)Comments on the appropriateness of diagnostic tests ordered by general practitioners
    Helldén et al48 2015The renal buttonSwedenPrevention (iatrogenesis)Adaption of medication to renal function from the patient’s EHR
    Heselmans et al49 2020 and Koskela et al53 2016EBMeDSBelgium, Estonia, Finland, ItalyPrevention (iatrogenesis, disease, test ordering), Therapeutics (prescribing, vaccination), Management of chronic disease> 1,000 NICE-accredited international guidelines
    Lugtenberg et al58,59 2015 (2 articles)NHGDocThe NetherlandsPrevention (disease, test ordering, iatrogenesis), Therapeutics (prescribing, vaccination), Management of chronic disease(s)Diabetes mellitus type II, cardiovascular risk management, asthma/COPD, thyroid disorders, viral hepatitis and other liver diseases, atrial fibrillation, subfertility
    Pannebakker et al64 2019EnglandPrevention (disease, test ordering)Pigmented skin lesions
    Rieckert et al68,69 2018, 2019PRIMA-EDSGermany, Austria, Italy, EnglandPrevention (iatrogenesis)Polypharmacy in older and chronically ill people
    Rousseau et al71 2003EnglandTherapeutics (prescribing, vaccination), Management of chronic disease(s)Asthma and angina in adults
    Toth-Pal et al75 2008EvibaseSwedenManagement of chronic disease(s)Congestive heart failure
    Australia
    Abimbola et al34 2019Health TrackerAustraliaPrevention (disease, test ordering)Cardiovascular risk management
    Bandong et al39 2019My Whiplash
    Navigator    		AustraliaTherapeutics (prescribing, vaccination)Whiplash-associated disorders
    Peiris et al65 2014AustraliaDiagnosis, Therapeutics (prescribing, vaccination)Back pain management
    Wan et al78 2012AustraliaManagement of chronic disease(s)Diabetes mellitus type 2
    Wilson et al80 2007EMPOWERAustraliaPrevention (disease, test ordering), Therapeutics (prescribing, vaccination)Cardiovascular risk management, hypertension
    South America
    Maia et al60 2016BrazilManagement of chronic disease(s)Diabetes mellitus type II
    Marcolino et al61 2021BrazilPrevention (disease, test ordering), Management of chronic diseasesDiabetes mellitus type II, hypertension, cardiovascular risk treatment
    Silveira et al73 2019TeleHASBrazilPrevention (disease, test ordering), TherapeuticsCardiovascular risk management, hypertension
    Africa
    Bessat et al40 2019RECBurkina FasoDiagnosis, Therapeutics (prescribing, vaccination)Follow-up and treatment of children under the age of 5 years in developing countries
    Jensen et al50 (2019)eIMCISouth AfricaPrevention (disease, test ordering), Therapeutics (prescribing, vaccination)Management of childhood illness
    Sukums et al74 2015QUALMATBurkina Faso, Ghana, TanzaniaTherapeutics (prescribing, vaccination)Antenatal and intrapartum care
    Asia
    Praveen et al66 2014India, Indonesia, ThailandManagement of chronic disease(s)Cardiovascular risk management

    • CDSS = clinical decision support system; COPD = chronic obstructive pulmonary disease; EHR = electronic health record; NICE = National Institute for Health and Care Excellence.

  • Table 2.

    Main Facilitators Reported in More Than 7 CDSSs, and Their Explanatory Elements, Classified According to the HOT-Fit Framework

    HOT-Fit FrameworkMain Facilitatorsa (No. CDSSs Concerned)Explanatory Elements
    Factors and Dimensions (No. CDSSs concerned)Evaluation Measures
    Human (n = 41)
        User satisfaction (n = 31)
    Perceived usefulness
    Training
    Software satisfaction
    Motivation to use
    Overall satisfaction
    Perceived usefulness of the CDSS (n = 23)
    Training before use is appreciated (n = 10)
    PCPs would continue to use the CDSS (n = 9)
    Patients’ perceived usefulness of the CDSS increases PCPs motivation to use it (n = 7)
    CDSSs increase PCPs satisfaction (n = 7)
    Organization (n = 41)
        Structure (n = 39)    		Clinical processNatural integration of the CDSS in the clinical workflow (n = 13)
    AutonomyProducing reports of quality measures through collected data increases the value from the CDSS’s use in clinical practice (n = 7)Expansion of skill set and roles in assisting physicians and patients in meeting care needs
    TeamworkOther professionals ease physician’s increased workload with the CDSS (n = 6)
    Technology (n = 45)
        System quality (n = 45)    		Ease of useThe CDSS is user-friendly (ergonomic) (n = 30)
    CDSS recommendations are easy to understand (n = 9)
    Usefulness of system features and functionsReminders (n = 8)
    Ease of learningEasy to use after a short learning period (n = 9)
        Information quality (n = 40)UsefulnessInformation provided is useful for the targeted process of care (n = 13)
    Educational materials for patients are valuable (n = 7)    		General agreement with the validity of recommendations
    FormatPleasing visual layout [n = 12]
    RelevanceRecommendations are relevant (n = 11)
    ReliabilityRecommendations are reliable (n = 9)
        Service quality (n = 11)Technical supportSatisfaction with the CDSS service support (n = 7)CDSS technical staff availability
    Net benefits (n = 42)EffectivenessPotential to improve the quality of care (n = 23)Brings preventive care to the forefront
    Helps to systematize assessment of every patient
    Facilitates patient care management
    CDSS helps PCPs to improve guideline adherence (n = 11)
    EfficiencyUsing CDSS saves time (n = 22)Shortening documentation time
    Giving a quick patient evaluation from relevant data in patients’ EHRs
    Decision-making qualityCDSS facilitates decision making (n = 22)CDSS is facilitating decision making about referral
    CommunicationCDSS helps focus on patient education (n = 18)
    CDSS eases patient-PCP communication (n = 13)    		CDSS helps increase patient engagement
    Clinical practiceCDSS is a way to update PCP’s knowledge (n = 17)
    CDSS leads to better teamwork in primary care (n = 7)
    CDSS increases PCPs’ self-confidence (n = 7)
    Error reductionCDSS helps PCPs to identify unrecognized information needs (n = 17)

    • CDSS = clinical decision support system; EHR = electronic health record; HOT-fit = human, organization, technology, net benefits; PCP = primary care professional.

    • ↵a Main facilitators are ranked by the number of CDSSs concerned.

  • Table 3.

    Main Barriers Reported in at Least 7 CDSSs, and Their Explanatory Elements, Classified According to the HOT-Fit Framework

    HOT-Fit FrameworkMain Barriersa (No. CDSSs Concerned)Explanatory Elements
    Factors and Dimensions (No. CDSSs Concerned)Evaluation Measures
    Human (n = 41)
        System use (n = 39)
    Resistance or reluctance
    Conflicts between CDSS recommendations and PCP expertise or beliefs (n = 18)
    CDSS recommendations do not reflect the complexity of the situation
    Report acceptanceAlert fatigue (n = 13)
    Information overload (n = 8)    		Lack of a concise synthesis of the CDSS recommendation
    TrainingTraining before use is needed (n = 11)The training session to the CDSS is inadequate or too short
    AttitudePCPs don’t need help with the targeted health issue (n = 8)
    Lack of engagement from PCPs (inertia of previous practice) (n = 8)
    Knowledge and expertiseLack of computer skills (n = 7)
    Motivation to useAsk for financial compensation to use the CDSS (n = 7)
    Organization (n = 41)Clinical processUsing CDSS disrupts usual workflow (n = 25)
        Structure (n = 39)TeamworkNeed of more teamwork with other PCPs to help physicians with CDSS’s increased workload (n = 13)Physicians fear more the CDSS workload than assistants or nurses
    HardwareLack or computers or tablets (n = 7)
    Environment (n = 18)Inter-organizational relationshipDifficulty to use CDSSs for patients comanaged by other specialists (n = 11)Information is sometimes missing or not integrated from external sources
    Technology (n = 45)
        System quality (n = 45)    		Ease of useThe CDSS is not user-friendly (n = 21)Need to switch windows in the EHR while using CDSSs
    Location of CDSS recommendations should be changed
    Need to switch windows between the EHR and the CDSS
    Turnaround timeCDSS slowness (n = 16)CDSS’s slowness impairs the interaction with the patient and increases the consultation time
    Usefulness of system features and functionsCDSS not fully integrated in the EHR (n = 14)A CDSS not fully integrated in the EHR is time consuming and disrupts workflow
    The most current information collected in the EHR is sometimes not updated in the CDSS
    Database contentsThe CDSS should target more health issues (n = 11)
    Questioning validity of CDSS’s knowledge database (n = 7)Concerns about the CDSS’s independence from pharmaceutical industry
    FlexibilityNeed of customization options (n = 8)
        Information quality (n = 40)FormatFormat of recommendations (length, structure, font colors) (n = 13)
    ReliabilityDoubtful reliability of the recommendations (n = 12)The reliability of the recommendations depends on the quality and completeness of the information collected
    RelevanceRecommendations are not relevant (n = 11)Conflicts between patient complaints and unrelated CDSS recommendations
    General recommendations are often irrelevant
    UsefulnessRecommendations are not helpful (n = 8)
    Net benefits (n = 42)EfficiencyIncreased workload during the consultation (n = 33)Lack of time to use the CDSS during the consultation
    Structured data collection takes too much time
    Duplication of data collection
    Coping strategies: increased consultation time, need of additional time to use the CDSS outside the consultation, scheduling follow-up consultations
    Negative effect on patient-PCP communication (n = 7)

    • CDSS = clinical decision support system; EHR = electronic health record; HOT-Fit = human, organization, technology, net benefits; PCP = primary care provider.

    • ↵a Main barriers are ranked by the number of CDSSs concerned.

  • Table 4.

    Mean Impacts of HOT-Fit Categories on CDSS Use by PCPs

    HumanOrganizationTechnologyNet Benefits
    Mean impact of HOT-fit categories on CDSS useSlightly negativeSlightly negativeNeutralPositive
    Mean difference between barriers and facilitators (95% CI)−1.5 (−2.2 to −0.8)−1.9 (−2.6 to −1.1)−0.5 (−1.5 to 0.5)+ 3.1 (2.2 to 3.9)

    • CDSS = clinical decision support system; HOT-fit = human, organization, technology, net benefits; PCP = primary care professional.

    • Note: In the human factor, there was 1.5 additional barriers per CDSS than there were facilitators. In the net benefits dimension, there was 3.1 additional facilitators per CDSS than there were barriers.

  • Table 5.

    Expected Features of a CDSS for Primary Care

    Intrinsic features
    Including preventive care
    Covering a large array of conditions
    Providing reminders personalized to the patient
    Minimizing information overload and alert fatigue
    Providing educational materials to patients
    Integrated in the EHR, with the fewest possible duplicate data entries
    Fast processing
    Contextual features
    Developed in close collaboration with PCPs
    Providing the rationale for the selection of sources of its knowledge base
    With teamwork for data collection and use of the CDSS
    With systematic training for its use

    • CDSS = clinical decision support system; EHR = electronic health record; PCPs = primary care professionals.

Additional Files

  • SUPPLEMENTAL MATERIALS IN PDF FILE BELOW
Back to top

In this issue

Print
Download PDF
Article Alerts
Email Article
Citation Tools
Get Permissions

Jump to section

Subjects

Keywords