Accepted for/Published in: JMIR Medical Informatics
Date Submitted: Sep 21, 2020
Date Accepted: Jan 16, 2021
Applying CDS design best practices with PRISM versus reliance on commercially available CDS tools: A randomized controlled trial
ABSTRACT
Background:
Limited consideration of clinical decision support (CDS) design best practices, such as a user-centered design, are often cited as a key barrier to CDS adoption and effectiveness. Application of CDS best practices is resource-intensive, thus institutions often rely on commercially available CDS tools which are created to meet the generalized needs of many institutions and not user-centered. Beyond resource availability, insufficient guidance on how to address key aspects of implementation such as contextual factors may also limit application of CDS best practices. An implementation science (IS) framework could provide needed guidance and increase reproducibility of CDS implementations.
Objective:
To compare the effectiveness of an ‘enhanced’ CDS tool informed by CDS best practices and an IS framework with a generic, commercially available CDS tool.
Methods:
We conducted an explanatory sequential mixed methods study. An ‘IS-enhanced’ and commercial CDS alert were compared in a cluster-randomized trial across 28 primary care clinics. Both alerts aimed to improve beta-blocker prescribing for heart failure. The enhanced alert was informed by CDS best practices and the PRISM (Practical, Robust, Implementation and Sustainability) IS framework, whereas the commercial alert followed the vendor-supplied specifications. Following PRISM, the enhanced alert was informed by iterative, multilevel stakeholder input and the dynamic interactions of the internal and external environment. Outcomes aligned with PRISM’s evaluation measures and included patient reach, clinician adoption, and change in prescribing behavior. Clinicians exposed to each alert were interviewed to identify design features that might influence adoption. Interviews were analyzed using a thematic approach.
Results:
Between March 15 and August 23, 2019, the enhanced alert fired for 61 patients (106 alerts, 87 clinicians) and the commercial alert fired for 26 patients (59 alerts, 31 clinicians). Adoption and effectiveness of the enhanced alert were significantly higher than the commercial (62% versus 29% alerts adopted, p<0.0001; 14% versus 0% changed prescribing, p=0.006). Of the 21 clinicians interviewed, most stated they preferred the enhanced alert.
Conclusions:
This study suggests applying CDS best practices with an IS framework to create CDS tools improves implementation success compared with a commercially available tool. Clinical Trial: https://clinicaltrials.gov/ (NCT04028557),
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