Unlocking the potential of clinical decision support in cardiovascular care: A mixed-methods systematic review of implementation barriers and enablers.

Abstract

Clinical decision support significantly enhances effective healthcare delivery by empowering healthcare providers with the necessary tools and resources to make evidence-based decisions. To date, only limited research studies have discussed the effective implementation of clinical decision support systems (CDSS) in managing cardiovascular care. To identify the barriers and facilitators of integrated CDSS implementation through electronic health records in cardiovascular care. A convergent integrated design aligned with Joanna Briggs Institute (JBI) methodology for mixed methods review was followed. Four databases were included from October 2023 to July 2025. Eligible peer-reviewed studies (quantitative, qualitative, or mixed-methods) reported on barriers or facilitators to implementing CDSS in cardiovascular care. A total of 718 articles were screened; 12 studies were included in this review (2008-2025). Studies spanned diverse settings across five countries and included qualitative (n = 4), quantitative (n = 2), and mixed-methods (n = 6) designs. All studies evaluated knowledge-based CDSS applied in cardiovascular care, in primary (n = 9) and tertiary care settings. Barriers and facilitators were synthesised into a three-level framework: macro (organisational and regulatory), meso (technical and clinical), and micro (patient and training). Common barriers included workflow disruption, alert fatigue, limited interoperability, regulatory burden, and lack of staff training. Key facilitators included leadership commitment, workflow integration, stakeholder engagement, iterative tool refinement, and targeted clinician training. Our review underscored the critical need for contextual, multi-level strategies to enable the effective adoption and sustainability of CDSS in cardiovascular care. The establishment of standardised guidelines to systematically address implementation barriers was also considered essential. A coordinated governance framework encompassing organisational commitment, technical integration, clinician involvement, patient engagement, and regulatory alignment must be supported by ongoing training and capacity building. Recognising and addressing these interdependent factors can equip healthcare systems to scale CDSS adoption, optimise clinical workflows, and improve patient outcomes through enhanced decision-making.