Why aren't they used? Systematic review of barriers to implementation of clinical decision support systems for early cancer detection in primary care.

Abstract

Early cancer detection is crucial for patient outcomes. Clinical decision support systems (CDSSs) have been developed to assist with decision making about screening or symptomatic assessment in primary care, but implementation remains challenging. To compare barriers to implementation of cancer-specific CDSSs for screening and symptomatic presentation in primary care. Systematic mixed-methods literature review. A subanalysis within a systematic review was conducted. Qualitative and quantitative data on barriers were coded into themes guided by the Theoretical Domains Framework. Frequencies of studies mentioning barriers were compared between CDSSs for cancer detection and other conditions, and between cancer-specific CDSSs for screening and symptomatic presentation. In total, 29 cancer-specific CDSSs were identified, addressing screening (<i>n</i> = 15) and symptomatic presentation (<i>n</i> = 14), with a further 70 addressing other conditions. There were minimal differences in barriers for cancer-specific CDSSs and other CDSSs. There were differences between cancer-specific CDSSs for screening and symptomatic presentation. Barriers more frequently reported for CDSSs for symptomatic presentation involved workflow integration (<i>n</i> = 9/14, 64% versus <i>n</i> = 4/15, 27%), medicolegal uncertainty (<i>n</i> = 4/14, 29% versus <i>n</i> = 0/15, 0%), requirements of skills (<i>n</i> = 7/14, 50% versus <i>n</i> = 2/15, 13%), interference with decision-making processes (<i>n</i> = 6/14, 43% versus <i>n</i> = 2/15, 13%), and negative emotions (<i>n</i> = 8/14, 57% versus <i>n</i> = 4/15, 27%). The function and healthcare context of CDSSs in the diagnostic process (symptomatic assessment or screening decision making) appears to be more relevant to implementation than the targeted condition. Involving stakeholders to clarify medicolegal issues and workflow integration is essential for the implementation of CDSSs for symptomatic presentation.