{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,11]],"date-time":"2026-03-11T07:41:07Z","timestamp":1773214867149,"version":"3.50.1"},"reference-count":48,"publisher":"Oxford University Press (OUP)","issue":"8","license":[{"start":{"date-parts":[[2021,4,25]],"date-time":"2021-04-25T00:00:00Z","timestamp":1619308800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"funder":[{"name":"RAND Center of Excellence on Health System Performance","award":["1U19HS024067-01"],"award-info":[{"award-number":["1U19HS024067-01"]}]},{"name":"RAND Corporation and the Agency for Healthcare Research and Quality"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2021,7,30]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Objective<\/jats:title><jats:p>We quantify the use of clinical decision support (CDS) and the specific barriers reported by ambulatory clinics and examine whether CDS utilization and barriers differed based on clinics\u2019 affiliation with health systems, providing a benchmark for future empirical research and policies related to this topic.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and Methods<\/jats:title><jats:p>Despite much discussion at the theoretic level, the existing literature provides little empirical understanding of barriers to using CDS in ambulatory care. We analyze data from 821 clinics in 117 medical groups, based on in Minnesota Community Measurement\u2019s annual Health Information Technology Survey (2014-2016). We examine clinics\u2019 use of 7 CDS tools, along with 7 barriers in 3 areas (resource, user acceptance, and technology). Employing linear probability models, we examine factors associated with CDS barriers.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Clinics in health systems used more CDS tools than did clinics not in systems (24 percentage points higher in automated reminders), but they also reported more barriers related to resources and user acceptance (26 percentage points higher in barriers to implementation and 33 points higher in disruptive alarms). Barriers related to workflow redesign increased in clinics affiliated with health systems (33 points higher). Rural clinics were more likely to report barriers to training.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>CDS barriers related to resources and user acceptance remained substantial. Health systems, while being effective in promoting CDS tools, may need to provide further assistance to their affiliated ambulatory clinics to overcome barriers, especially the requirement to redesign workflow. Rural clinics may need more resources for training.<\/jats:p><\/jats:sec>","DOI":"10.1093\/jamia\/ocab064","type":"journal-article","created":{"date-parts":[[2021,3,25]],"date-time":"2021-03-25T04:13:46Z","timestamp":1616645626000},"page":"1667-1675","source":"Crossref","is-referenced-by-count":20,"title":["Barriers to using clinical decision support in ambulatory care: Do clinics in health systems fare better?"],"prefix":"10.1093","volume":"28","author":[{"given":"Yunfeng","family":"Shi","sequence":"first","affiliation":[{"name":"Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania, USA"}]},{"given":"Alejandro","family":"Amill-Rosario","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania, USA"}]},{"given":"Robert S","family":"Rudin","sequence":"additional","affiliation":[{"name":"RAND Corporation, Boston, Massachusetts, USA"}]},{"given":"Shira H","family":"Fischer","sequence":"additional","affiliation":[{"name":"RAND Corporation, Boston, Massachusetts, USA"}]},{"given":"Paul","family":"Shekelle","sequence":"additional","affiliation":[{"name":"RAND Corporation, Santa Monica, California, USA"}]},{"given":"Dennis P","family":"Scanlon","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania, USA"}]},{"given":"Cheryl L","family":"Damberg","sequence":"additional","affiliation":[{"name":"RAND Corporation, Santa Monica, California, USA"}]}],"member":"286","published-online":{"date-parts":[[2021,4,25]]},"reference":[{"key":"2021073020265815500_ocab064-B1","year":"2018"},{"issue":"10","key":"2021073020265815500_ocab064-B2","doi-asserted-by":"crossref","first-page":"1223","DOI":"10.1001\/jama.293.10.1223","article-title":"Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review","volume":"293","author":"Garg","year":"2005","journal-title":"JAMA"},{"key":"2021073020265815500_ocab064-B3","year":"2012"},{"key":"2021073020265815500_ocab064-B4","first-page":"S103","article-title":"Clinical decision support: a 25 year retrospective and a 25 year vision","volume":"Suppl 1","author":"Middleton","year":"2016","journal-title":"Yearb Med Inform"},{"issue":"1","key":"2021073020265815500_ocab064-B5","doi-asserted-by":"crossref","first-page":"48","DOI":"10.7326\/M13-1531","article-title":"Health information technology: an updated systematic review with a focus on meaningful use","volume":"160","author":"Jones","year":"2014","journal-title":"Ann Intern Med"},{"issue":"2","key":"2021073020265815500_ocab064-B6","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1016\/j.jbi.2007.09.003","article-title":"Grand challenges in clinical decision support","volume":"41","author":"Sittig","year":"2008","journal-title":"J Biomed Inform"},{"key":"2021073020265815500_ocab064-B7","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1186\/1472-6947-12-6","article-title":"Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study","volume":"12","author":"Ash","year":"2012","journal-title":"BMC Med Inform Decis Mak"},{"key":"2021073020265815500_ocab064-B8","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1186\/s13012-014-0105-0","article-title":"Barriers and facilitators to the uptake of computerized clinical decision support systems in specialty hospitals: protocol for a qualitative cross-sectional study","volume":"9","author":"Moja","year":"2014","journal-title":"Implement Sci"},{"issue":"2","key":"2021073020265815500_ocab064-B9","doi-asserted-by":"crossref","first-page":"e24","DOI":"10.2196\/medinform.8912","article-title":"Reasons for physicians not adopting clinical decision support systems: critical analysis","volume":"6","author":"Khairat","year":"2018","journal-title":"JMIR Med Inform"},{"issue":"4","key":"2021073020265815500_ocab064-B10","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1177\/1077558718823130","article-title":"Landscape of health systems in the United States","volume":"77","author":"Furukawa","year":"2020","journal-title":"Med Care Res Rev"},{"issue":"S 02","key":"2021073020265815500_ocab064-B11","first-page":"e115\u201323","article-title":"A pharmacogenomics clinical decision support service based on FHIR and CDS Hooks","volume":"57","author":"Dolin","year":"2018","journal-title":"Methods Inf Med"},{"issue":"1","key":"2021073020265815500_ocab064-B12","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1186\/s12911-017-0513-6","article-title":"A Fast Healthcare Interoperability Resources (FHIR) layer implemented over i2b2","volume":"17","author":"Boussadi","year":"2017","journal-title":"BMC Med Inform Decis Mak"},{"issue":"1","key":"2021073020265815500_ocab064-B13","doi-asserted-by":"crossref","first-page":"73","DOI":"10.3390\/ijerph17010073","article-title":"Experience in developing an FHIR medical data management platform to provide clinical decision support","volume":"17","author":"Semenov","year":"2019","journal-title":"Int J Environ Res Public Health"},{"issue":"9","key":"2021073020265815500_ocab064-B14","first-page":"450","article-title":"What defines a high-performing healthcare delivery system: a systematic review","volume":"43","author":"Ahluwalia","year":"2017","journal-title":"Jt Comm J Qual Patient Saf"},{"key":"2021073020265815500_ocab064-B15","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1016\/j.jbi.2017.12.005","article-title":"Clinical decision support models and frameworks: Seeking to address research issues underlying implementation successes and failures","volume":"78","author":"Greenes","year":"2018","journal-title":"J Biomed Inform"},{"issue":"10","key":"2021073020265815500_ocab064-B16","doi-asserted-by":"crossref","first-page":"1141","DOI":"10.1093\/jamia\/ocz095","article-title":"Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review","volume":"26","author":"Hussain","year":"2019","journal-title":"J Am Med Inform Assoc"},{"key":"2021073020265815500_ocab064-B17","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1038\/s41746-020-0221-y","article-title":"An overview of clinical decision support systems: benefits, risks, and strategies for success","volume":"3","author":"Sutton","year":"2020","journal-title":"NPJ Digit Med"},{"key":"2021073020265815500_ocab064-B18"},{"issue":"2","key":"2021073020265815500_ocab064-B19","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1089\/tmj.2018.0114","article-title":"Key factors affecting the adoption of telemedicine by ambulatory clinics: insights from a statewide survey","volume":"26","author":"Ranganathan","year":"2020","journal-title":"Telemed J E Health"},{"issue":"2","key":"2021073020265815500_ocab064-B20","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1093\/jamiaopen\/ooz004","article-title":"Level of agreement on health information technology adoption and use in survey data: a mixed-methods analysis of ambulatory clinics in 1 US state","volume":"2","author":"Rudin","year":"2019","journal-title":"JAMIA Open"},{"key":"2021073020265815500_ocab064-B21","year":"2019"},{"key":"2021073020265815500_ocab064-B22","year":"2017"},{"issue":"1","key":"2021073020265815500_ocab064-B23","first-page":"39","article-title":"Understanding U.S. Health Systems: using mixed methods to unpack organizational complexity","volume":"7","author":"Ridgely","year":"2019","journal-title":"EGEMS (Wash DC)"},{"key":"2021073020265815500_ocab064-B24","doi-asserted-by":"crossref","DOI":"10.1007\/978-3-319-17975-9","volume-title":"Healthcare Technology Innovation Adoption","author":"Daim","year":"2016"},{"issue":"2","key":"2021073020265815500_ocab064-B25","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1111\/j.1540-5915.2008.00192.x","article-title":"Technology Acceptance Model 3 and a research agenda on interventions","volume":"39","author":"Venkatesh","year":"2008","journal-title":"Decis Sci"},{"issue":"4","key":"2021073020265815500_ocab064-B26","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1002\/pa.303","article-title":"Resource-based theory: creating and sustaining competitive advantage edited by J.B. Barney and D.N Clark Oxford University Press, Oxford, Paperback, 2007; 316 pages, ISBN 978-019-927769-8","volume":"8","author":"Mitchell","year":"2008","journal-title":"J Publ Aff"},{"key":"2021073020265815500_ocab064-B27","doi-asserted-by":"crossref","first-page":"425","DOI":"10.2307\/30036540","article-title":"User acceptance of information technology: toward a unified view","volume":"27","author":"Venkatesh","year":"2003","journal-title":"MIS Quarterly"},{"issue":"6","key":"2021073020265815500_ocab064-B28","doi-asserted-by":"crossref","first-page":"654","DOI":"10.1093\/jamia\/ocx135","article-title":"Are all certified EHRs created equal? Assessing the relationship between EHR vendor and hospital meaningful use performance","volume":"25","author":"Holmgren","year":"2018","journal-title":"J Am Med Inform Assoc"},{"issue":"1","key":"2021073020265815500_ocab064-B29","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1056\/NEJMp1003173","article-title":"The uncritical use of high-tech medical imaging","volume":"363","author":"Hillman","year":"2010","journal-title":"N Engl J Med"},{"issue":"8","key":"2021073020265815500_ocab064-B30","doi-asserted-by":"crossref","first-page":"574","DOI":"10.7326\/0003-4819-157-8-201210160-00535","article-title":"The overuse of diagnostic imaging and the Choosing Wisely initiative","volume":"157","author":"Rao","year":"2012","journal-title":"Ann Intern Med"},{"issue":"6","key":"2021073020265815500_ocab064-B31","doi-asserted-by":"crossref","first-page":"953","DOI":"10.1016\/j.pec.2015.12.010","article-title":"Automated alerts and reminders targeting patients: a review of the literature","volume":"99","author":"Perri-Moore","year":"2016","journal-title":"Patient Educ Couns"},{"key":"2021073020265815500_ocab064-B32","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1186\/1748-5908-6-92","article-title":"Computerized clinical decision support systems for chronic disease management: a decision-maker-researcher partnership systematic review","volume":"6","author":"Roshanov","year":"2011","journal-title":"Implement Sci"},{"key":"2021073020265815500_ocab064-B33","first-page":"4","article-title":"Trends in the use of clinical decision support by health system\u2013affiliated ambulatory clinics in the United States, 2014-2016","volume":"7","author":"Rudin","year":"2019","journal-title":"Am J Account Care"},{"key":"2021073020265815500_ocab064-B34","author":"Doebbeling","year":"2011"},{"issue":"2","key":"2021073020265815500_ocab064-B35","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1093\/jamia\/ocy145","article-title":"Physician stress and burnout: the impact of health information technology","volume":"26","author":"Gardner","year":"2019","journal-title":"J Am Med Inform Assoc"},{"key":"2021073020265815500_ocab064-B36","volume-title":"Improving Outcomes with Clinical Decision Support: An Implementer\u2019s Guide","author":"Osheroff","edition":"2nd ed."},{"key":"2021073020265815500_ocab064-B37","author":"Boan","year":"2017"},{"key":"2021073020265815500_ocab064-B38","year":"2017"},{"key":"2021073020265815500_ocab064-B39","author":"Pearl","year":"2017"},{"key":"2021073020265815500_ocab064-B40","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1186\/1472-6947-13-111","article-title":"On the alert: future priorities for alerts in clinical decision support for computerized physician order entry identified from a European workshop","volume":"13","author":"Coleman","year":"2013","journal-title":"BMC Med Inform Decis Mak"},{"issue":"2","key":"2021073020265815500_ocab064-B41","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1197\/jamia.M1809","article-title":"Overriding of drug safety alerts in computerized physician order entry","volume":"13","author":"van der Sijs","year":"2006","journal-title":"J Am Med Inform Assoc"},{"issue":"1","key":"2021073020265815500_ocab064-B42","doi-asserted-by":"crossref","first-page":"32","DOI":"10.37765\/ajmc.2020.42143","article-title":"Health information technology for ambulatory care in health systems","volume":"26","author":"Shi","year":"2020","journal-title":"Am J Manag Care"},{"issue":"1","key":"2021073020265815500_ocab064-B43","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1055\/s-0039-1677903","article-title":"Artificial intelligence in clinical decision support: challenges for evaluating AI and practical implications","volume":"28","author":"Magrabi","year":"2019","journal-title":"Yearb Med Inform"},{"issue":"1","key":"2021073020265815500_ocab064-B44","doi-asserted-by":"crossref","first-page":"e100054","DOI":"10.1136\/bmjhci-2019-100054","article-title":"Extending an open-source tool to measure data quality: case report on Observational Health Data Science and Informatics (OHDSI)","volume":"27","author":"Dixon","year":"2020","journal-title":"BMJ Health Care Inform"},{"key":"2021073020265815500_ocab064-B45","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1016\/j.ebiom.2019.07.019","article-title":"Artificial intelligence to support clinical decision-making processes","volume":"46","author":"Garcia-Vidal","year":"2019","journal-title":"EBioMedicine"},{"key":"2021073020265815500_ocab064-B46","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1016\/j.jbi.2016.10.016","article-title":"Evaluating common data models for use with a longitudinal community registry","volume":"64","author":"Garza","year":"2016","journal-title":"J Biomed Inform"},{"key":"2021073020265815500_ocab064-B47","author":"Castro","year":"2017"},{"key":"2021073020265815500_ocab064-B48","doi-asserted-by":"crossref","DOI":"10.17226\/27122","volume-title":"Optimizing Strategies for Clinical Decision Support: Summary of a Meeting Series","author":"Tchen","year":"2017"}],"container-title":["Journal of the American Medical Informatics Association"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/28\/8\/1667\/39502276\/ocab064.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/28\/8\/1667\/39502276\/ocab064.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,10,23]],"date-time":"2023-10-23T22:56:45Z","timestamp":1698101805000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jamia\/article\/28\/8\/1667\/6250921"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,4,25]]},"references-count":48,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2021,4,25]]},"published-print":{"date-parts":[[2021,7,30]]}},"URL":"https:\/\/doi.org\/10.1093\/jamia\/ocab064","relation":{},"ISSN":["1527-974X"],"issn-type":[{"value":"1527-974X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2021,8,1]]},"published":{"date-parts":[[2021,4,25]]}}}