BackgroundAdvanced Computerized Decision Support Systems (CDSSs) assist clinicians in their decision-making process, generating recommendations based on up-to-date scientific evidence. Although this technology has the potential to improve the quality of patient care, its mere provision does not guarantee uptake: even where CDSSs are available, clinicians often fail to adopt their recommendations. This study examines the barriers and facilitators to the uptake of an evidence-based CDSS as perceived by diverse health professionals in hospitals at different stages of CDSS adoption.MethodsQualitative study conducted as part of a series of randomized controlled trials of CDSSs. The sample includes two hospitals using a CDSS and two hospitals that aim to adopt a CDSS in the future. We interviewed physicians, nurses, information technology staff, and members of the boards of directors (n = 30). We used a constant comparative approach to develop a framework for guiding implementation.ResultsWe identified six clusters of experiences of, and attitudes towards CDSSs, which we label as “positions.” The six positions represent a gradient of acquisition of control over CDSSs (from low to high) and are characterized by different types of barriers to CDSS uptake. The most severe barriers (prevalent in the first positions) include clinicians’ perception that the CDSSs may reduce their professional autonomy or may be used against them in the event of medical-legal controversies. Moving towards the last positions, these barriers are substituted by technical and usability problems related to the technology interface. When all barriers are overcome, CDSSs are perceived as a working tool at the service of its users, integrating clinicians’ reasoning and fostering organizational learning.ConclusionsBarriers and facilitators to the use of CDSSs are dynamic and may exist prior to their introduction in clinical contexts; providing a static list of obstacles and facilitators, irrespective of the specific implementation phase and context, may not be sufficient or useful to facilitate uptake. Factors such as clinicians’ attitudes towards scientific evidences and guidelines, the quality of inter-disciplinary relationships, and an organizational ethos of transparency and accountability need to be considered when exploring the readiness of a hospital to adopt CDSSs.Electronic supplementary materialThe online version of this article (10.1186/s13012-017-0644-2) contains supplementary material, which is available to authorized users.

Abstract-It is debated whether white-coat (WCHT) and masked hypertension (MHT) are at greater risk of developing a sustained hypertensive state (SHT). In 1412 subjects of the Pressioni Arteriose Monitorate e Loro Associazioni Study, we measured office blood pressure (BP), 24-hour ambulatory BP, and home BP. Key Words: masked hypertension Ⅲ white-coat hypertension Ⅲ ambulatory blood pressure monitoring Ⅲ prognosis N o conclusive evidence exists as to whether isolated office or white-coat hypertension (HT; WCHT) and masked HT (MHT), ie, the conditions in which, respectively, only office or out-of-office blood pressure (BP) is elevated, are clinically innocent or rather associated with an increase in cardiovascular (CV) risk. [1][2][3] This is because in white-coat and masked hypertensive individuals, the prevalence of structural organ damage has not invariably been found to be greater than in "truly" normotensive individuals. [3][4][5][6][7] It is also because the longitudinal studies that have addressed this issue by assessing the incidence of morbidity and mortality have been based on a small number of CV events and/or a relatively short observation period. 8 -14 Information on the clinical significance of WCHT and MHT can also be obtained by investigating whether, compared with "true" normotension, these conditions are accompanied by a greater rate of development of a "sustained" hypertensive state, ie, HT both in and outside the clinical environment. We have addressed this issue in the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) population by identifying subjects with WCHT and MHT through in-office and out-of-office BP measurements and by detecting the development of sustained HT (SHT) over a 10-year time interval, ie, a long follow-up that allowed a large number of cases to occur. A peculiar aspect of the study was that out-of-office BP was measured both at home and over 24 hours, which allowed us to obtain 2 separate identifications of WCHT and MHT. MethodsThe methodology used in the PAMELA Study has been reported in detail elsewhere. 12,15 Briefly, 3200 individuals were randomly selected from the white residents of Monza (a town in the northeast outskirts of Milan), to be representative of its residents for sex, age (25 to 74 years), and socioeconomic characteristics, according to the criteria used by the World Health Organization Monitoring Diseases Project 16 conducted in the same geographic area. 6 Data were collected in 2051 subjects (64% of the original sample), and survivors were contacted 10 years later to be re-examined. All of the subjects agreed to participate in the study after explanation of its nature and purpose the study, and protocol was approved by the ethics committee of the institutions involved.Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.

Abstract-Alterations in blood glucose and cholesterol are more frequently detectable in hypertensive than in normotensive conditions. However, no information exists as to whether this phenomenon involves only office or also home and 24-hour ambulatory blood pressure (ie, when values are representative of daily life). In 2045 subjects enrolled in the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study, we measured home, 24-hour, and office blood pressure. Measurements also included fasting blood glucose and serum total and HDL cholesterol values. Prevalence of diabetes (Ն126 mg/dL or use of antidiabetic drugs), impaired fasting blood glucose (Ն110 to Ͻ126 mg/dL), and hypercholesterolemia (serum total cholesterol Ն240 mg/dL or 200 mg/dL) increased progressively from "optimal" to "normal," " high-normal," and "elevated" office systolic or diastolic blood pressure. Fasting blood glucose and total serum cholesterol also increased progressively from the first to the fourth group, with HDL cholesterol values showing a concomitant progressive decrease. This was also the case for quartiles of office, home, and 24-hour blood pressure.In the whole population, there was a positive correlation between serum cholesterol or blood glucose and all blood pressure values (P always Ͻ0.0001), with a much smaller and less consistent relationship with heart rate. 1,5,7,12 suggesting that the relationship between blood pressure and metabolic alterations may have a continuous rather than a threshold-related nature.We thought that the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study 13 could provide relevant information on this issue because: (1) blood pressure, total serum cholesterol, and blood glucose were assessed in a sample representative of the general population; and (2) blood pressure measurements were obtained not only in the office but at home and during the 24 hours (ie, under conditions devoid of biological artifacts such as the white coat effect and representative of daily life values). 14 -15 MethodsThe methodology used in the PAMELA study has been reported in detail previously. 13 Briefly, 3200 individuals were selected randomly from the residents of Monza (a town in the northeast part of the Milan province) to be representative of the town population for gender, age decades (25 to 74 years), and socioeconomic characteristics, according to the criteria used in the World Health Organization Monitoring Diseases (WHO-MONICA) project conducted in the same geographic area. 16 -17 The overall participation rate was 64% consistently in each age-gender stratum. The demographic characteristics of nonparticipants were similar to those of participants. This was also the case for cardiovascular risk factors on the basis of information collected via telephone interviews. Entry DataParticipants were invited to come to the outpatient clinic of the local hospital (San Gerardo) in the morning of a working day (Monday through Friday) where several data were collected. Relevant to the present study are: (1) ...