Promoting the implementation of clinical decision support systems in primary care: A qualitative exploration of implementing a Fractional exhaled Nitric Oxide (FeNO)-guided decision support system in asthma consultations

Background: Clinical decision support systems (CDSSs) can promote adherence to clinical guidelines and improve patient outcomes. Exploring implementation determinants during the development of CDSSs enables intervention optimisation to promote acceptability, perceived appropriateness and fidelity during subsequent implementation. This study sought to explore how clinicians perceive the use of a CDSS which makes recommendations for asthma management based on factors including Fractional exhaled Nitric Oxide testing, and how CDSSs can be designed to promote their implementation. Methods: Twenty-three interviews were conducted with clinicians to explore perceptions about the CDSS. Participants included asthma nurses, pharmacists, General Practitioners and respiratory nurse specialists involved in conducting asthma reviews in primary care. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. Results: Three themes were developed: Appreciating the recommendations of the CDSS, whilst wanting to retain control; Doubt about appropriateness of CDSS recommendations, especially when you can’t see how they were produced; and Potential for the CDSS to increase patients’ trust and adherence to their treatment. Clinicians perceived the CDSS could help them prioritise management options and consider broader factors relating to patients’ asthma symptoms, but it was important to be able to override the recommendation. Lack of transparency over how recommendations were generated and concern about appropriateness of recommendations for specific patients led to uncertainty about adhering to the CDSS. Clinically tailored recommendations were perceived to help reassure patients and/or to support their adherence to asthma management. Conclusions: Even small changes to the content of CDSS recommendations, such as explaining how recommendations were generated and showing they are consistent with guidance, may help to overcome barriers to acceptability and perceived appropriateness for clinicians. Focusing on implementation during the development of CDSS interventions is worthwhile to help reduce the evidence-practice gap.