This review identified a range of factors influencing CDSS use and demonstrated that simply providing the clinical information in electronic format does not guarantee uptake. Our overall findings suggest that there is no “one size fits all approach” to influencing prescribing via CDSSs,75
and factors beyond software and content must be considered when developing CDSS systems for prescribing. Fundamental issues include the availability and accessibility of hardware, sufficient technical support and training in the use of the system, the level of system integration into clinical workflow and the relevance and timeliness of the clinical messages provided. Further, acceptance of the system by the various stakeholders (eg, management and end users), clear articulation and endorsement of the system's benefits in patient care, and minimizing the perceived threats to professional autonomy are important to the success of CDSSs.
Importantly, our review suggests that despite advances in technology and likely increased sophistication of CDSSs, issues influencing CDSSs use for prescribing have not changed substantially over time. Key concerns relate to the usability of the system and relevance of the content. The mention of these issues in more recent studies suggests there is still much to be done to make these systems work in routine clinical practice. There appeared to be some differences according to the practice setting; problems due to lack of integration of prescribing tools with existing software tended to be mentioned in studies conducted in ambulatory care. However, these issues may be equally important in institutional settings, just more easily addressed in hospitals where there are high levels of computerization for managing patient administration and a range of aspects of clinical care.
Not surprisingly, provider-related issues were reported consistently over time and irrespective of setting, which probably relates to the challenges of changing the knowledge, attitudes and behaviors of human beings. On the positive side, these issues are predictable and those armed with the responsibility of CDSS implementation should be well prepared to counter some of the fundamental barriers to use. However, it would be unrealistic to expect that even best practice system implementation will result in immediate and sustainable change across the entire target audience. Healthcare organizations need to have dedicated staff to champion and facilitate an appropriate environment for implementing CDSS so that it may be used to its full potential.4
Further, we established a notable consistency in CDSS-specific issues over time. Some CDSSs are highly sophisticated, well developed and evaluated extensively, however they tend to come from a small number of institutions recognized internationally for their work in medical informatics.19
The recurring themes related to CDSS specific issues most likely reflects the range of systems and platforms being tested and implemented, and the heterogeneity of prescribing software deployed across many healthcare settings.
We highlighted a notable absence of studies reporting the impact of system endorsement before 2000. While many interventions targeting physician behavior change use endorsement and promotion by respected peer group members as a fundamental component of their implementation strategy,76
this may not have been seen as a key driver for change in the early studies. Thus, study designs may have omitted addressing this factor and/or respondents did not acknowledge its importance as a facilitator of uptake. This could also be true for the absence of reporting patient factors in the earlier studies. With more widespread use of computers in clinical practice over time, the potential for interference in the doctor–patient interaction might be magnified. Interestingly, the earlier studies highlighted concerns about professional liability and patient privacy in relation to the use of CDSSs. However, greater acceptance of the technology on the part of end-users and the efforts of organizations such as the American Medical Informatics Association in overseeing and endorsing the introduction of guidelines and regulations75
is likely to have dispelled some of the early concerns.
Studies evaluating the impact of CDSSs for prescribing in ambulatory care highlighted a lack of technical support addressing day-to-day software and hardware issues and limited integration of CDSS with existing software as important barriers to uptake. In many ways this is not surprising given the greater diversity of clinic locations in community practice and the heterogeneity of systems used in this setting.77
In contrast, hospitals have their own information technology infrastructure and many CDSSs have been designed specifically to dovetail with their existing computerized physician order entry systems. Further, the influence of patient factors was a key feature of studies conducted in ambulatory care and effectively absent from studies conducted in institutional care. Again, this is likely to relate to the nature of ambulatory care and the conditions physicians treat in this setting. Previous systematic reviews have demonstrated the greater effectiveness of CDSSs in hospital compared with ambulatory care10
and for the management of acute rather than chronic conditions.13
It was postulated that these differences might be attributed to the stricter controls on healthcare professionals and a greater willingness to abide by externally imposed rules in institutional settings. However, this review suggests that patient factors may create an additional layer of complexity in healthcare professionals' decisions in community practice.
The strengths of this study lie in the systematic approach to identifying studies, the inclusion of a range of study designs, our attempts to capture CDSS features beyond content and functionality, and the stratification of our analysis by the time period in which the studies were conducted and the setting in which they were undertaken. Importantly, our key findings, generated from a diverse literature, support the opinions and recommendations of luminaries in the field who have written extensively about the key requirements for successful implementation of CDSS in clinical practice.3
The review however, has a number of limitations. Despite our intensive efforts we may not have identified all relevant studies as some may not be available in the public domain, and others may be published outside the peer-reviewed academic literature. Our review studies were heterogeneous in terms of design and data collection methods so we did not conduct comprehensive quality assessment of individual reports. Although time periods were defined somewhat arbitrarily, we believed that year of study conduct would more accurately capture any changes in the factors influencing CDSS uptake over time. However, we imputed year of study conduct when it was absent using publication year, and our “sensitivity” analysis however confirmed that our classification system did not change study findings. We used an organizational framework adapted from previous research20
that may not necessarily reflect the level of interplay between the various factors, and we did not attempt to map these interrelationships or infer their relative importance. We also noted the frequency with which studies reported specific domains, themes and subthemes (). Importantly, these data may not necessarily indicate the significance of a particular issue. Rather, the relative weight of these factors should be determined in planning and implementing specific CDSSs.
The limited information available in many of the published manuscripts precluded stratifying results by specific CDSS features. Clearly an important move for future research will be greater clarity and emphasis on reporting of specific design features; journal editors may have a role in setting minimum standards for this purpose. With the advent of supplementary online information for manuscript publication there is a mechanism for making these details available in the public domain.
A number of important questions also remain unanswered. What are practitioners' perceived needs for prescribing decision support? Do these needs vary according to their clinical experience? How can needs be best met within the time constraints of a patient consultation? The complexities relating to CDSSs for prescribing and the state of current technology means that most organizations will probably only realize moderate benefits from the implementation of such systems.4
However, substantial opportunities do exist for all stakeholders to collaborate and explore the potential of CDSSs to support medication use that is as safe and effective as possible.
Although there is widespread interest in CDSS development, worthwhile progress will come with attention to both computer system enhancements and the human factors influencing responsiveness to new systems and change. Further work with end-users is required to explore these issues before system implementation. Although widespread dissemination of appropriate CDSSs might be expected to improve clinical practice, simply providing the information in electronic format alone does not ensure uptake.