Lessons learned from implementing service-oriented clinical decision support at four sites: A qualitative study

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Clinical decision support (CDS) has been implemented within the electronic health record (EHR). Most health systems face barriers to successful implementation. There is no comprehensive library of knowledge, it is difficult to maintain and keep information up-to-date, it is difficult to share data among different locations, and retrieving data has limitations. This qualitative study looked at sharing CDS across diverse clinical settings among four healthcare systems with differing EHRs. The sharing of CDS among multiple sites is called service-oriented clinical decision support. [1]

The goal of the study

To assess, define, demonstrate, and evaluate best practices for knowledge management and clinical decision support across multiple ambulatory care settings and EHR technology platforms.


Use of ethnography investigation, site visits and interviews were conducted. In addition to baseline interviews, observations were also conducted. After site visits were conducted the implementation and go-live included detailed interviews with staff, including IT and informatics specialists. Two EHR vendors were also interviewed. A total of 91 interviews were conducted, 43 before and 48 after implementation. Debriefings and an in-depth analysis followed standard qualitative processes.


Eight broad challenges were identified in the adoption of service-oriented CDS:

  • Hardware and software computing infrastructure
  • Clinical Content
  • Human-Computer interface
  • Workflow and communication
  • System measurement and monitoring
  • Internal organizational policies, procedures and culture
  • External rules, regulations, and pressures
  • People


Several recommendations and best practices for implementation were identified. The biggest challenge was related to performance. Faster performance was essential. The liberal use of codes so as to accept multiple variations of clinical assessments would prevent loss of data capture and transparency of clinical data was identified as being crucial to success. Developing a legal framework and improvement of standards would reduce the risk of delays. And lastly, a dedicated technical and clinical staff with work site flexibility to develop workflow and coordination among sites would help to manage the complexity of implementation.

Area of interest

The CDS is critical to capturing the most correct and complete data and is critical to the patient quality and outcome. Sharing the data in support of the patient care is crucial.


  1. Wright, A., Sittig, DF, Ash, JS, Erickson, JL, et. al., Lessons learned from implementing service-oriented clinical decision support at four sites: A qualitative study http://www.ncbi.nlm.nih.gov/pubmed/26343972