Contributions to the literature
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We provide a comprehensive literature review and narrative synthesis of the role of professional identity in CDSS implementation among diverse health care professionals and identify human, technological, and organizational determinants that influence professional identity and implementation.
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The review shows that a perceived threat to professional identity plays a significant role in explaining failures of CDSS implementation. As such, our study highlights the need to recognize significant challenges related to professional identity in the implementation of CDSS and similar technologies. A better understanding and awareness of individual barriers to CDSS implementation among health professionals can promote the diffusion of such data-driven tools in health care.
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This narrative synthesis maps, interconnects, and reinterprets existing empirical research and provides a foundation for further research to explore the complex interrelationships and influences of perceived professional identity-related mechanisms among health care professionals in the context of CDSS implementations.
Background
Understanding professional identity
Method
Findings
Descriptive analysis
Journal title | No. of articles | 5-year journal impact factor (2022)a
|
---|---|---|
BMC Medical Informatics and Decision Making
| 25 | 3.5 |
International Journal of Medical Informatics
| 15 | 4.9 |
Journal of the American Medical Informatics Association
| 8 | 6.4 |
Applied Clinical Informatics
| 5 | 2.9 |
International Journal of Environmental Research and Public Health
| 3 | 4.8 |
Plos One
| 3 | 3.8 |
BMC Family Practice
| 3 | 3.3 |
BMJ Open
| 3 | 3.3 |
Implementation Science
| 2 | 9.7 |
Journal of Medical Systems
| 2 | 5.2 |
Applied Ergonomics
| 2 | 3.9 |
BMC Health Services Research
| 2 | 3.5 |
BMC Primary Care
| 2 | 3.3 |
Health Informatics Journal
| 2 | 3.0 |
Other journals
| 55 |
CDSS implementation dimension | CDSS implementation factor | Included study references |
---|---|---|
Technological (n = 532) | System fits into existing clinical workflow and organizational structures (n = 67) | |
Functionalities meeting users’ needs, incl. display of relevant information, customization (n = 58) | ||
Design of interface and workflow, intuitive navigation (n = 49) | ||
System’s technical quality and scientific evidence, incl. explainability and transparency of decision outcomes ( n = 43) | ||
Ease of use ( n = 39) | ||
Irrelevant, inaccurate, excessive alerts (n = 36) | ||
Usefulness of system features and functions, incl. practical guidance and functions meeting complexity of patients’ clinical picture (n = 32) | ||
Robust and reliable system (n = 30) | ||
System interoperability (n = 30) | ||
Technical, IT support (n = 30) | ||
Timely and fast access to relevant information, functions (n = 26) | ||
Data privacy and security issues (n = 22) | ||
Data quality, standards, and terminologies (n = 22) | ||
Rigidity of system (functional and interface) (n = 17) | ||
Value, benefit to end users (n = 16) | ||
Efficiency and time saving potential (n = 15) | ||
Organizational (n = 287) | Work, time pressure and tension (n = 52) | |
User training and supervision ( n = 48) | ||
Internal communication, feedback, collaboration, involvement of end users ( n = 45) | ||
Endorsement, support of management, leadership for change (n = 33) | ||
Readiness of internal IT infrastructure and hardware (n = 32) | ||
Internal (re)organization, change of routines, incl. standardization of processes (n = 21) | ||
Organizational culture, innovation climate and policies, incl. psychological safety (n = 20) | ||
Internal IT competencies and knowledge (n = 13) | ||
Financial and legal issues (n = 13) | ||
Hierarchical boundaries (n = 10) | ||
Human (n = 197) | Individual attitudes and emotional responses, incl. resistance to change (n = 41) | |
Experience and familiarity with system (n = 35) | ||
Trust in system and underlying rule or algorithm (n = 31) | ||
Computer illiteracy, IT skills (n = 23) | ||
Perceived usefulness (n = 22) | ||
Perceived potential of patient education and empowerment ( n = 13) | ||
Intrinsic motivation, passion, expected effort (n = 12)
| ||
Clinical knowledge and skills (n = 10) | ||
Perceived potential of training, education of clinicians by system (n = 10) | ||
Benefits (n = 93) | System improves effectiveness and efficiency of care (n = 34) | |
System is beneficial to patient safety (n = 25) | ||
System improves quality of care (n = 21) | ||
System prevents prescription and treatment errors (n = 13) | ||
Professional identity threat (n = 90) | Perceived threat to professional control, autonomy, responsibilities, role (n = 58) | |
Perceived loss of control over patient relationship (n = 17) | ||
Perceived threat to clinical skill and expertise, incl. risk of overdependence (n = 15) | ||
Professional identity enhancement (n = 44) | Perceived enhancement of control of patient relationship, incl. beneficial for patient-provider communication (n = 18) | |
Perceived enhancement of professional control and autonomy, responsibilities, role (n = 15) | ||
Perceived enhancement of clinical skill and expertise (n = 11) |
Technological factors
Author | Professional type | Examples |
---|---|---|
CDSS fit into clinical workflow
| ||
[12] | Physicians | Physicians note that CDSS fit into the clinical workflow is a condition for using CDSSs, otherwise the CDSS is perceived as workflow disruption. |
[34] | Nursing professionals | If a CDSS provides recommendation that is discrepant with what user thinks or does not appear to consider patient context, it prompts threat to thinking: “Don’t let a tool overtake critical thinking”. |
Intuitive navigation, customization flexibility, applicability
| ||
[102] | Physicians | A CDSS has to be intuitive and its information must be short and clear. |
[127] | Physicians | Physicians welcome possibility to customize CDSS recommendation and to adjust personal preferences: “I want to be able to set the threshold myself”. |
CDSS’s technical quality and scientific evidence
| ||
[77] | Junior and senior physicians | Senior physicians demand regularly updated evidence-based CDSS whereas junior physicians prefer quick answers, trust the CDSS and do not necessarily read the source. |
[127] | Physicians and nursing professionals | Irrelevant alerts for different user groups and for individual users, with varying needs over time: “It shouldn’t be necessary to override so many alerts; only the sections that apply to us [nurses] should be highlighted”; “… You don’t want to receive that alert over and over again”. |
Organizational factors
Author | Professional type | Examples |
---|---|---|
Collaboration and communication
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[145] | Physicians and managers | Successful CDSS adoption requires involvement of physicians and nursing professionals in CDSS customization: “… what they [managers] need to do is sit down with the people in each department and work out what are the processes that are critical for that department because the paper processes that have evolved in each individual section of the hospital have been … refined over years … and if you just provide a generic template (there is) no way of replicating any of that.” |
[178] | Pharmacist | Communication and collaboration were seen as important for the intervention and for embedding the intervention into routine practice. Pharmacists adopted different ways of communication with clinicians, in order to engage them with the intervention: “It’s difficult, … when’s the best time to approach doctors to discuss things, … when the surgery is not on, they’re on home visits or they’re in meetings, it’s quite a different way of working. So that’s probably one barrier …, so it’d be difficult probably to get everybody together unless you went to the practice meeting on another day.” |
(Top) management and leadership support
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[72] | Manager | High importance of communication and follow-up on nursing professionals’ roles and tasks; top management needs to reward users for their self-sufficiency and motivation to use CDSS: “… Some people take it and run with it—the medical assistant and doctor are working together, and some just don’t really see it as their job. Part of what physicians have to do is understand they need to make it known to their MA [medical assistant] that this is an expectation. Some doctors have gotten that and some say they can’t or don’t know how to make their MA [medical assistant] do anything.” |
[24] | Physicians | CDSSs should not be introduced like an imposition, as it has the potential to affect clinical autonomy and decision-making. If the use of CDSSs is perceived as a top-down order, clinicians will reject it. Strong endorsement from the top management is essential. |
[167] | Physicians | Physicians emphasized the role of leadership in overcoming negative perceptions, fear, and resistance to change by highlighting benefits of CDSSs for the patient. |
Innovation culture, climate for innovation, and psychological safety
| ||
[171] | Junior physicians | A cultural barrier exists where junior health care professionals believe “… that the use of [CDSS] in front of a patient is perceived as being unprofessional. They, therefore, chose not to use devices in plain view. This concern was also raised in relation to senior colleagues considering junior physicians’ use of their mobile device in front of patients or on the ward as being unprofessional.” |
[70] | Junior physician | “I think we hit all the 5 rights of CDS on this one. It’s coming at the right time, to the right person, with the right information, using the right channel, and in the right situation…. There is been no interest in turning it off …” |
Organizational silos and hierarchies
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[69] | Junior and senior physicians | Senior physicians influence the practices of junior physicians. Junior physicians need organizational support in order to adopt CDSSs due to clinical hierarchy. |
[77] | Junior and senior physicians | The implementation of CDSSs leads to changes in professional boundaries: “It’s more hierarchical whether or not we look at the recommendations. Often, I look at guidelines, but after my superiors told me to do something else.” (junior physicians) “The nurses put the residents in a somewhat inferior position because of their confidence and their experience….” (senior physician). |
[82] | Junior and senior physicians | Senior physicians emphasize that they should not surrender their autonomy to the CDSS whereas junior physicians perceive a sense of greater clinical autonomy when using the CDSS as it reduces their reliance on senior colleagues |
[24] | Physicians and nursing professionals | Disputes over power and control between physicians and nursing professionals arise as the CDSS allows widespread access to scientific evidence, which lead to nursing professionals’ control over medical decisions: “… If we want to implement it it’s key to discuss the rules of access for each profession” (surgeon). |
Social norms and endorsement
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[154] | Physicians and pharmacists | Uncertainty about the accuracy of the CDSS is mitigated by invoking expert: “… if I was recommended by the pharmacists and by ID [infectious disease] and micro [microbiology] then I am more than happy to use [the CDSS]”; “… I want someone from pharmacology or someone that we trust to tell us that the [CDSS recommendations] are accurate if not more accurate than doing it by hand.” |
[192] | Physicians | Physicians sought support from colleagues: “… probably more important have been colleagues sharing tips and kind of best practice or best use. Those are the most useful...” |
Human factors
Author | Professional type | Examples |
---|---|---|
Individual attitudes and emotional responses
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[81] | Physicians | Physicians express sentiment of apathy toward CDSSs and perception of not being able to “change the tide”. |
[154] | Physicians | Physicians express a degree of skepticism toward the use of CDSSs. |
[77] | Junior physicians | If CDSS “is not worked on upstream and if it is not ergonomic, it is a disaster and perceived as a real suffering.” |
Experience and familiarization with the CDSS
| ||
[127] | Physicians & nursing professionals | Perceived barriers related to knowledge regarding CDSSs functions: “I had no idea about all these options! Now, I’m a lot more enthusiastic. I’m going to use it right away!”; “I didn’t even know there was a feedback option, never heard of it before.” |
[3] | Physicians | Physicians are unfamiliar with sophisticated CDSSs features, “… such as procedures, reminders, and charting templates, and thus do not fully utilize them.” |
[82] | Junior and senior physicians | Junior physicians use CDSSs more than senior physicians because they are still learning the clinical area. Senior health care professionals are experienced and familiar with common practices that they do not need CDSSs. |
Trust in the CDSS and underlying rule or algorithm
| ||
[154] | Physicians | Physicians want to know the functionality of the CDSS’ underlying decision support rule and its limitations, especially in situations of high risk for patient safety: “There’s just a lot of guesswork and I don’t know what happens when someone’s kidneys are suddenly knocked off. I don’t know if it takes that into consideration.” |
[128] | Junior and senior health care professionals | Junior health care professionals trust the CDSS recommendations and use them as a “confidence booster” and to “cross-reference” for their decisions, while senior health care professionals rarely use the CDSS because they believe that the CDSS’ and their own knowledge are identical. |
[132] | Physicians | Physicians are comfortable following CDSS recommendations if the guideline is perceived as coming from a credible source. |
[151] | Nursing professionals | Nursing professionals perceive CDSSs as more trustworthy and precise compared to paper-based assessment. |
The role of professional identity threat and enhancement perceptions in CDSS implementation
Author | Professional group | Examples |
---|---|---|
Threat to professional control and autonomy
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[154] | Physicians | CDSSs’ potential to substitute physician knowledge is viewed as a threat: “…So, the fact that it [CDSS] can’t take in the whole clinical picture but manually we can.” |
[91] | Physicians | “… it [CDSS recommendation] makes me feel useless.” |
[128] | Senior and junior physicians | Senior physicians perceive CDSSs as threat to their authority over junior physicians: “Junior physicians were inclined to accept [the CDSS’] recommendations most of the time, but had to override its recommendations when senior colleagues decided on a different antibiotic.” |
Threat to professional skills and expertise
| ||
[74] | Nursing professionals and physicians | Physicians and nursing professionals become dependent on pharmacists’ knowledge and expertise when resolving complicated CDSS order checks. |
[24] | Physicians | CDSSs threaten physicians’ expertise and conscience: “… It’s humiliating to think that we can be substituted by a computer! … We need to have the courage to do what we think is right, not to merely comply with the guidelines dictated by a system. … The knowledge that I get from visiting 150 patients is more substantial than what [the CDSS] can give me.” |
[77] | Junior physicians | Even junior physicians acknowledge that if CDSSs are misused or used too much, they “forget to think” and “going to lose the ability to think by ourselves.” |
[154] | Physicians | This potential loss of skill was seen as particular problematic in situations in which decision support differs between institutions: “… when we use a lot more programs we don’t think as much, so if we do go to other hospitals where they don’t have these programs then you may not be as well versed in how to dose and adjust vancomycin.” |
[24] | Orthopedics | CDSSs are perceived as not being a useful tool for orthopedic specialties: “The actual evidences in [orthopedic surgery] are not very many, you know, I can’t really see how [the CDSS] would be useful for us. …. The actual tools of an orthopedic resemble those of a crafts worker. … We learn by reading books and articles, but also by … observing the experts at work, learning how they do things...” |
Loss of control over patient relationships
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[162] | Physicians | Physicians stated that they “… are responsible for the treatment of their patients and not a CDSS.” |
[81] | Physicians | Physicians stated that “the problem with all of this (digitization) is that it is so impersonal. It takes all the joy out of practicing medicine. I want to build a relationship with the patient. It isn’t all about the medication, they want to share their pain, anxiety, family issues. We can’t change the tide. We can’t do anything about this (the move to digital).” |
Enhancement of professional control and autonomy
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[34] | Nurse practitioners | Nurse practitioners perceived the CDSS as an empowerment: “… If a CDS tool is designed well, it could empower nurses to advocate for patients and contribute to treatment decision-making. As an objective assessment of a patient’s condition, the CDS tool has the potential to provide participants with a structured method by which nurses can garner support for their recommendations.” |
[8] | Nurse practitioners | The CDSS “empowered staff nurses to manage more complicated scenarios independently.” |
[155] | Physicians | The care professionals expressed that the CDSS could enhance their control and confidence in their work: “Off hand, I would say that I would get a better feeling of what I do – and an overview of the patients, especially when we take over each other’s patients.” |
Enhancement of professional skills and expertise
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[162] | Physicians, nurse practitioners | “… sixty-two percent of the respondents reported that advice of a CDSS on how to treat a (…) patient is a welcome supplement to their own expertise, …” |
[178] | Pharmacist | Pharmacists saw the CDSS as: “offering opportunities to demonstrate their skills and to further develop their role working within general practice settings.” |
[24] | Physicians | Physicians viewed the CDSS as a useful tool, but not to support their own work, but as a support tool for other specialists or residents with less clinical experience: “Maybe I could use it. I think it would be more useful for young physicians, those who have only just graduated, or those with little experience… You know, to avoid mistakes…” “It’s brilliant. Really, really useful. I think it’s more so for medics though, rather than [surgeons].” |
Enhancement of control over patient relationships
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[35] | Physicians | Physicians expressed the need for CDSS features which enhance patient communication, such as “informative yet brief patient summaries” as this would provide them with a “greater sense of control” over the digitalized information and knowledge exchange with patients, and engender greater trust between patients and physicians. |
Author | Professional group | Examples |
---|---|---|
Perceived professional identity threats
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Exploration phase
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[1] | Physicians | “… the more reliant we become on technology even with [the CDSSS] and things you de-skill a bit.”; “… the clinical judgement aspect of prescribing vancomycin will go down.” |
[2] | Physicians | “You want to be free to decide what you are prescribing, when you are prescribing it and you want to be free to decide if you are going to get the information or not.” |
[3] | Physicians | “The digital clinic that steal our patients, we experience that.” |
[4] | Physicians | “[Physicians] were concerned about the deskilling of future doctors through the use of [CDSSs].” |
[5] | Physicians | “Clinical decision making is still my primary role, like, so it’s up to me.“ |
[6] | Physicians and nurse practitioners | “I mean, I know it’s not mandatory to follow the recommendations, but it still feels that way. Sometimes, you’re just happy that somebody is using the medication you prescribe at all, and then you get the recommendation to switch the medication. [The CDSS] seems to always tell you that it’s not good enough. It’s never good enough.” |
[7] | Physicians | “I am opposed to [the CDSS], as I see it as another task being delegated to physicians that can better be done by those trained and experienced in it. I would prefer to concentrate on those things I do well rather than spending time doing secretarial work. Some of us do not round frequently in the hospital anymore, which will make staying competent in the system difficult…” |
[8] | Physicians | “The computer system should be allowed to block you. I have my reasons to do what I do and maybe I will think about its suggestions, but I do not want [the] IT [department] to block me at those moments. … I always want to do what I want.” |
[9] | Physicians | “CDSS technology enforces strict working according to guidelines and thus may deprive physicians from their sense of added value. This (…) makes physicians feel less valuated.” |
[10] | Nurse practitioners | The nurse practitioners complained that “…critical thinking [is lost] once the tool is embedded into [the] workflow.” |
Adoption decision, implementation preparation, active implementation phase
| ||
[11] | Physicians and other healthcare professionals | Physicians and nurse practitioners mentioned being threatened in their own clinical practice and autonomy and they were reluctant to use a CDSS when it interfered too much with clinical practice: “When the CDSS becomes leading and the clinical view of the practitioner is subordinated”, “When my role as a care provider is undermined or becomes more complicated.”, and “I would like to keep my own clinical reasoning without a CDSS.” |
[12] | Physicians, pharmacists, general practice staff | “Pharmacists saw the dashboard component as offering opportunities to demonstrate their skills and to further develop their role working within general practice settings.”; “I think it’ll give us a useful tool to be able to perhaps design our programmes of work, and also thinking about if we’re going to run any quality programmes in the future, it will hopefully help us to design what we’re working on because it will give us that information, give us that baseline that we need so often.” |
Sustainment phase
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[13] | Cardiologists, heart failure nurses | “Seventy-nine percent stated that they are responsible for the treatment of ‘their’ patients and not a CDSS.” |
[14] | Physicians | “The professionals who participated in this study’s in-depth interview were dissatisfied with this integrated management system and wanted the ability to customize and adjust the alerts they received.” |
[15] | Nurse practitioners | “… I should be able to order that if I think it’s indicated without needing further approval.” |
Perceived professional identity enhancements
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Exploration phase
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[16] | Physicians and nurse practitioners | The physicians expressed that the CDSS could enhance their control and confidence in their work: “Off hand, I would say that I would get a better feeling of what I do – and an overview of the patients, especially when we take over each other’s patients.” (physician); Nurses appreciated the CDSS recommendations, protocols and checklists to support monitoring activities: “I think it would be great to know what is recommended because we have tuberculosis patients” (nurse practitioner). |
[10] | Nurse practitioners | “If a [CDSS] is designed well, it could empower nurses to advocate for patients and contribute to treatment decision-making.” |
[6] | Physicians and nurse practitioners | “We think that the traditional treatment relationship between patient and clinician is fundamentally changing, it is becoming more horizontal, not in every aspect but in many. That is where it is supposed to go. I really think [the CDSS] can facilitate this because it increases commitment and a feeling of ownership.” |
Adoption decision, implementation preparation, active implementation phase
| ||
[20] | Physicians and nurse practitioners | “As a consequence of a reminder for drug dosing in renal malfunction, I reduced the methotrexate dose, which I had forgotten” (physician); “Once when my doctor was away, I used the warfarin assistant to define the dosing” (nurse practitioner). |
[21] | Physicians | “[The CDSS] is integrated in the workflow because after talking with the patient, the physician always returns to the computers and goes into the EHR. The [CDSS] fits in this workflow. If the physician is unsure on what to order, they will go to [the CDSS].” |
[22] | Pharmacists | “Despite the fact that these evaluations would represent an added responsibility, pharmacists felt that this was in line with why they chose the profession in the first place, and welcomed any [CDSS] that would increase their role in patient care.” |
Sustainment phase
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[13] | Cardiologists, heart failure nurses | “A total of […] 55% stated that a CDSS supplements their independency as a [heart failure] care expert.” |
[23] | Nurse practitioners | “Some nurses thought that [the CDSS] could supplement their clinical reasoning to facilitate decision-making; …” |
[24] | Nurse practitioners | “After the implementation of the CDSS, we are now more focused on the kind of food we order for the residents”, and “When screening a new resident, I can see from using the CDSS the new interventions that are necessary, what we can work on and what can wait.” |
CDSS implementation outcomes
Measurement approach and number of studies | Included study references |
---|---|
Self-reported interest in using or intention, willingness to use, adoption (n = 74) | |
Self-reported attitude toward using CDSS (n = 29) | |
Self-reported use (n = 7) | |
Self-reported satisfaction, performance (n = 5) | |
Both self-reported and objective measure of implementation success (n = 21) | |
Both self-reported and objective measure of usefulness, usability (n = 1) | [119] |
Objective actual use measurement (n = 10) |