The facilitating and hindering factors of pre-implementation phase in establishment of clinical decision support systems: A systematic review and meta synthesis

Background

Clinical decision support systems (CDSS) are increasingly adopted in healthcare; however, their success and uptake among healthcare workers vary significantly across different contexts. This systematic review aims to identify and synthesise literature on the facilitating and hindering factors influencing the establishment of CDSS during the pre-implementation phase in hospital settings.

Methods

Five major databases were searched for relevant studies published from January 2010 to July 2024. All steps, including screening, data extraction, quality appraisal, and synthesis, were conducted independently by two authors. The quality appraisal used the JBI checklist for qualitative studies [1]. Data on study characteristics and determinant factors were extracted, and a deductive meta-synthesis categorised these determinants into five dimensions of the Consolidated Framework for Implementation Sciences (CFIR). The grey literature was also searched for prospective studies.

Results

A total of 12,010 papers were identified from the databases, of which 21 papers were systematically reviewed and synthesised. The data from the included studies were organised into five main themes based on the CFIR framework: Inner Setting, Intervention Process, Intervention Characteristics, Individual Characteristics, and Outer Setting.

Conclusion

Despite the longstanding existence of CDSS and extensive literature in this area, there is limited evidence on the determinants of CDSS from an implementation science perspective, particularly in less digitally developed healthcare systems. Moreover, existing literature lacks a focused analysis of the different phases of CDSS establishment (Adoption, Pre-implementation, Implementation, Maintenance, and Promotion). Future research should aim to develop a more granular understanding of the determinants influencing CDSS establishment across various contexts and phases.

Public summary

The healthcare sector is transitioning from paper-based medical records to the digitalisation of not only medical records but also all patient journey pathways. Clinical Decision Support Systems (CDSS) are one of the digital solutions designed to assist clinicians by reminding them of critical information essential for decision-making. However, many CDSS implementations have failed to achieve their intended purpose, resulting in minimal impact on expected outcomes.

In exploring the reasons for this, we found that the willingness and capacity of clinicians, managers, hospitals, and the healthcare sector as a whole are crucial determinants of CDSS success. The pre-implementation stage is particularly critical before rolling out any selected technology. During this phase, it is essential to customise the CDSS to align with internal processes, enhance IT capacities, engage clinicians in the decision-making process, and develop comprehensive plans to oversee these actions effectively.