Main Barriers Reported in at Least 7 CDSSs, and Their Explanatory Elements, Classified According to the HOT-Fit Framework
| HOT-Fit Framework | Main 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 acceptance | Alert fatigue (n = 13) Information overload (n = 8) | Lack of a concise synthesis of the CDSS recommendation | |
| Training | Training before use is needed (n = 11) | The training session to the CDSS is inadequate or too short | |
| Attitude | PCPs don’t need help with the targeted health issue (n = 8) | ||
| Lack of engagement from PCPs (inertia of previous practice) (n = 8) | |||
| Knowledge and expertise | Lack of computer skills (n = 7) | ||
| Motivation to use | Ask for financial compensation to use the CDSS (n = 7) | ||
| Organization (n = 41) | Clinical process | Using CDSS disrupts usual workflow (n = 25) | |
| Structure (n = 39) | Teamwork | Need 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 |
| Hardware | Lack or computers or tablets (n = 7) | ||
| Environment (n = 18) | Inter-organizational relationship | Difficulty 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 use | The 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 time | CDSS slowness (n = 16) | CDSS’s slowness impairs the interaction with the patient and increases the consultation time | |
| Usefulness of system features and functions | CDSS 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 contents | The 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 | ||
| Flexibility | Need of customization options (n = 8) | ||
| Information quality (n = 40) | Format | Format of recommendations (length, structure, font colors) (n = 13) | |
| Reliability | Doubtful reliability of the recommendations (n = 12) | The reliability of the recommendations depends on the quality and completeness of the information collected | |
| Relevance | Recommendations are not relevant (n = 11) | Conflicts between patient complaints and unrelated CDSS recommendations General recommendations are often irrelevant | |
| Usefulness | Recommendations are not helpful (n = 8) | ||
| Net benefits (n = 42) | Efficiency | Increased 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.