The implementation, use and sustainability of a clinical decision support system for medication optimisation in primary care: A qualitative evaluation

Abstract

Background The quality and safety of prescribing in general practice is important, Clinical decision support (CDS) systems can be used which present alerts to health professionals when prescribing in order to identify patients at risk of potentially hazardous prescribing. It is known that such computerised alerts may improve the safety of prescribing in hospitals but their implementation and sustainable use in general practice is less well understood. We aimed to understand the factors that influenced the successful implementation and sustained use in primary care of a CDS system. Methods Participants were purposively recruited from Clinical Commissioning Groups (CCGs) and general practices in the North West and East Midlands regions of England and from the CDS developers. We conducted face-to-face and telephone-based semi-structured qualitative interviews with staff stakeholders. A selection of participants was interviewed longitudinally to explore the further sustainability 1–2 years after implementation of the CDS system. The analysis, informed by Normalisation Process Theory (NPT), was thematic, iterative and conducted alongside data collection. Results Thirty-nine interviews were conducted either individually or in groups, with 33 stakeholders, including 11 follow-up interviews. Eight themes were interpreted in alignment with the four NPT constructs: Coherence (The purpose of the CDS: Enhancing medication safety and improving cost effectiveness; Relationship of users to the technology; Engagement and communication between different stakeholders); Cognitive Participation (Management of the profile of alerts); Collective Action (Prescribing in general practice, patient and population characteristics and engagement with patients; Knowledge);and Reflexive Monitoring (Sustaining the use of the CDS through maintenance and customisation; Learning and behaviour change. Participants saw that the CDS could have a role in enhancing medication safety and in the quality of care. Engagement through communication and support for local primary care providers and management leaders was considered important for successful implementation. Management of prescribing alert profiles for general practices was a dynamic process evolving over time. At regional management levels, work was required to adapt, and modify the system to optimise its use in practice and fulfil local priorities. Contextual factors, including patient and population characteristics, could impact upon the decision-making processes of prescribers influencing the response to alerts. The CDS could operate as a knowledge base allowing prescribers access to evidence-based information that they otherwise would not have. Conclusions This qualitative evaluation utilised NPT to understand the implementation, use and sustainability of a widely deployed CDS system offering prescribing alerts in general practice. The system was understood as having a role in medication safety in providing relevant patient specific information to prescribers in a timely manner. Engagement between stakeholders was considered important for the intervention in ensuring prescribers continued to utilise its functionality. Sustained implementation might be enhanced by careful profile management of the suite of alerts in the system. Our findings suggest that the use and sustainability of the CDS was related to prescribers’ perceptions of the relevance of alerts. Shared understanding of the purpose of the CDS between CCGS and general practices particularly in balancing cost saving and safety messages could be beneficial.

Do clinical decision support systems for prescribing improve patient safety? a systematic literature review

“…Information includes the year of publication, clinical domain or development focus, focus of discussion, impacts, performance indicators, and weaknesses. The summary of the results of the literature review is shown in Table 2 in Appendix [2], [5]- [8], [11], [14], [17]- [19], [24]- [55].…”

“…The discussion on electronic prescription alerts is only mapped to two impacts, namely reducing prescribing errors and improving compliance with protocols. [6], [7], [18], [24], [26], [29], [30], [35], [39], [43]- [46], [48], [49], [55] [31], [42] [2], [40], [41], [53] [5], [8], [19] CDSS and EHR (or other system) integration [34], [50], [52] [17], [47], [51] [33] [25] Electronic prescription alert [6], [11], [14], [18], [28], [32], [35], [36], [37], [38], [43], [46], [48], [49] [27], [54] --DDI [11], [14], [36], [37] ---…”

“…A total of eight articles reported the weaknesses in the implementation of CDSS. The eight weaknesses are: i) incomplete information about drug side effects, prescribing recommendations for specific patient profiles, and adaptation to local epidemiology [2]; ii) the increase in prescribing time using CDSS is overestimated by end users [19]; iii) different prescribers' perceptions of the relevance of alerts [24]; iv) great variation in response to inpatient and outpatient alerts, as well as multiple alerts fatigue [27]; v) time consuming to get data and workflow interruption [44]; vi) the "alert fatigue" caused by a large number of irrelevant alerts reduces the effectiveness of CDSS [49]; vii) has no impact on compliance with appropriate usage guidelines [50]; and viii) the effect on clinical impact remains unclear [53].…”

“…Patient safety can be improved with CDSS developed with user-centric design principles. Engagement between stakeholders is considered essential for interventions aimed at ensuring prescribers continue to utilize their functions [24]. Similarly, the involvement of end users in clinical decision support designs can facilitate Indonesian J Elec Eng & Comp Sci ISSN: 2502-4752  adoption [25].…”

Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: A qualitative exploration using the Theoretical Framework of Acceptability

“…In the developed world, novel computer technologies have been utilised to improve medication safety across the length of the medication pathway (i.e. from clinical decision-making and prescription through to dispensing and adherence) [9][10][11][12][13]. With a particular focus on the primary care setting, one prominent evidence-based prescribing safety and medication monitoring intervention is the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) [14,15].…”