"I worry we'll blow right by it:" Barriers to Uptake of the STRATIFY-CDS for Acute Heart Failure.

Clinical decision support (CDS) tools in electronic health records (EHRs) often face low uptake due to limited usability, workflow integration, and other implementation issues. We recently designed and implemented the STRATIFY-CDS tool, which calculates a validated risk-prediction model and recommends disposition for emergency department (ED) patients with acute heart failure. Despite applying human-centered design and implementation science strategies, initial utilization in the first 3 months of the STRATIFY-CDS tool was just 3%.To identify usability issues and contextual barriers to uptake of STRATIFY-CDS tool among ED clinicians.We performed an exploratory qualitative and simulation study with ED clinicians at Vanderbilt University Medical Center who had used the STRATIFY-CDS tool at least once. Semi-structured interviews with interactive simulation (summative usability) were conducted via videoconference. Two authors performed thematic analysis informed by the Technology Acceptance Model.Of 13 invited ED clinicians, 10 participated (7 attending and 3 resident physicians) with 1 to 11 prior tool uses. Although the main user interface had high perceived usability, participants struggled to find the launch button. The perceived utility was low-to-moderate and varied based on whether the recommendation matched the participant's clinical gestalt. When there was mismatch, perceived utility was lower, and participants needed more information about the risk model and supporting evidence, which were not readily available. Despite educational implementation strategies and ED leadership approval, there was not a strong social norm to use the tool.Although the main user interface had high usability, poor visibility of the launch button coupled with low familiarity with the underlying evidence and lack of a social norm impaired uptake of the STRATIFY-CDS tool. Future work on CDS design should test novel non-interruptive launch mechanisms and evaluate training with simulation as an implementation strategy to bolster initial confidence and excitement around the CDS.