“So, we need to optimise”: Applying the NASSS framework across implementation stages to identify key strategies to facilitate CDSS integration within a large metropolitan hospital system. (Preprint)

Abstract

Computerised Clinical Decision Support Systems (CDSSs) enhance patient care through real-time evidence-based guidance for healthcare professionals. Despite this, the effective implementation of these systems within health services presents multifaceted challenges leading to inappropriate use and abandonment over time. Using the NASSS framework, this study examined CDSS adoption in a digitally mature metropolitan hospital, identifying determinants across implementation stages to optimise CDSS integration into healthcare practice.

This study aimed to identify the theory-informed (NASSS) determinants that either facilitate or hinder the application of CDSSs within the context of large-scale hospital services. Additionally, this study aimed to map these determinants onto specific stages of the implementation process, thereby developing a systems-level understanding of CDSS application across implementation stages.

Participants involved in various stages of the implementation process were recruited (n=30). Participants took part in interviews and focus groups. Thematic analysis was used to categorize findings into barriers, enablers, or neutral determinants aligned to NASSS framework domains. These determinants were also mapped to implementation stages using the ‘Active Implementation Framework stages’ approach.

Participants comprised clinical adopters 47% (n=14), organizational champions 16% (n=5), and organizational clinical informatics 16% (n=5) roles. Most determinants mapped to organization level, technology and adopter sub-domains, consistent with the literature and our previous work. However, our findings also demonstrated a relative lack of long-term implementation planning. Consequently, determinants were distributed in a ‘U’ shape across implementation stages: 61% (n=77) linked to exploration, 31% (n=39) to full implementation, and just 5% (n=6) to installation stages. Stakeholders engaged in more pre-implementation and full-scale implementation activities, with fewer cycles of monitoring and iteration activities identified.

These findings addressed a significant knowledge gap in the literature by using systems thinking principles to identify the interdependent dynamics of CDSS implementation. A lack of sustained implementation strategies (i.e., training, and longer-term adopter level championing), weakened the socio-technical network between developers and adopters, leading to communication barriers. More rigorous implementation planning, encompassing all four implementation stages, may go some way in addressing the barriers identified and enhancing enablers.