Background: High and sustained clinical decision support (CDS) use rates are a necessary precondition for CDS success, because CDS systems that are not used are unlikely to improve care. In this comparative case report, we describe various strategies used for CDS training, financial incentives, feedback of CDS use rates, and other factors associated with both high and low CDS use rates in primary care clinics.
Methods: Comparative case report of 3 National Institutes of Health-funded CDS implementation projects that address cardiovascular risk factor control in primary care settings. These studies were conducted in 3 large multispecialty medical groups over a 10-year period of time.
Results: In Project A, CDS use rates rose to 60% at targeted primary care encounters over a 6-month period of time using in-clinic training and financial incentives to clinicians and office staff. In Project B, CDS use rates rose to 70% using in-clinic training, feedback of CDS use rates (at targeted encounters) to clinic leaders and individual clinicians, but with no financial incentives. In Project C, CDS use rates rose to 50%–60% after virtual CDS training, with feedback of CDS use rates and no financial incentives, subsequently fell when the proportion of targeted encounters was increased, but rose again after face-to-face in-clinic refresher training. For CDS aimed only at diabetes patients, clinicians could accurately identify target patients, but when targeting was based on less obvious measures of cardiovascular risk, algorithmic identification of targeted patients was required.
Conclusion: These case studies suggest that training delivered using existing local medical group training procedures or customs is less effective than face-to-face training in clinic settings. We found little to support the use of financial incentives to providers as an effective strategy to achieve or maintain high CDS use rates, although incentives to clinic “pools” was effective. We found strong evidence that monitoring and feedback of primary care provider-specific and clinic specific CDS use rates by name is an effective strategy to initiate and sustain desired levels of CDS use in primary care clinics.