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Appl Clin Inform 2025; 16(04): 1014-1023
DOI: 10.1055/a-2594-3770
Special Issue on CDS Failures

“I worry we'll blow right by it:” Barriers to Uptake of the STRATIFY-CDS for Acute Heart Failure

Matthew A. Christensen
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
2   Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Carrie Reale
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
3   Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
4   Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Shilo Anders
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
3   Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
4   Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Tim Coffman
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
5   Health Information Technology and Services, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Hala Alaw
5   Health Information Technology and Services, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Janos L. Mathe
5   Health Information Technology and Services, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Dan Albert
5   Health Information Technology and Services, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Anna Sachs
6   Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Allison B. McCoy
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Dandan Liu
7   Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Alan B. Storrow
8   Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Sunil Kripalani
9   Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
10   Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Laurie L. Novak
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
› Author Affiliations
Funding This work was supported by the National Heart Lung and Blood Institute (grant no.: R01 HL157596). Dr. Christensen was supported by an institutional training grant from the National Institute of General Medical Science (grant no.: T32 GM135094).
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Abstract

Background

Clinical decision support (CDS) tools in electronic health records (EHRs) often face low uptake due to limited usability, workflow integration, and other implementation issues. We recently designed and implemented the STRATIFY-CDS tool, which calculates a validated risk-prediction model and recommends disposition for emergency department (ED) patients with acute heart failure. Despite applying human-centered design and implementation science strategies, initial utilization in the first 3 months of the STRATIFY-CDS tool was just 3%.

Objective

To identify usability issues and contextual barriers to uptake of STRATIFY-CDS tool among ED clinicians.

Methods

We performed an exploratory qualitative and simulation study with ED clinicians at Vanderbilt University Medical Center who had used the STRATIFY-CDS tool at least once. Semi-structured interviews with interactive simulation (summative usability) were conducted via videoconference. Two authors performed thematic analysis informed by the Technology Acceptance Model.

Results

Of 13 invited ED clinicians, 10 participated (7 attending and 3 resident physicians) with 1 to 11 prior tool uses. Although the main user interface had high perceived usability, participants struggled to find the launch button. The perceived utility was low-to-moderate and varied based on whether the recommendation matched the participant's clinical gestalt. When there was mismatch, perceived utility was lower, and participants needed more information about the risk model and supporting evidence, which were not readily available. Despite educational implementation strategies and ED leadership approval, there was not a strong social norm to use the tool.

Conclusion

Although the main user interface had high usability, poor visibility of the launch button coupled with low familiarity with the underlying evidence and lack of a social norm impaired uptake of the STRATIFY-CDS tool. Future work on CDS design should test novel non-interruptive launch mechanisms and evaluate training with simulation as an implementation strategy to bolster initial confidence and excitement around the CDS.

Keywords

clinical decision support - user-centered design - electronic health record - heart failure - risk adjustment

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed and approved by the Vanderbilt University Medical Center Institutional Review Board. Informed consent was obtained from all participants.


Supplementary Material



Publication History

Received: 31 January 2025

Accepted: 24 April 2025

Article published online:
05 September 2025

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