Barriers and facilitators to use of a digital clinical decision support tool: a cohort study combining clickstream and survey data

BMJ Open. 2022 Nov 21;12(11):e064952. doi: 10.1136/bmjopen-2022-064952.


Objectives: This research aimed to understand the barriers and facilitators clinicians face in using a digital clinical decision support tool-UpToDate-around the globe.

Design: We used a mixed-methods cohort study design that enrolled 1681 clinicians (physicians, surgeons or physician assistants) who applied for free access to UpToDate through our established donation programme during a 9-week study enrolment period. Eligibility included working outside of the USA for a limited-resource public or non-profit health facility, serving vulnerable populations, having at least intermittent internet access, completing the application in English; and not being otherwise able to afford the subscription.

Intervention: After consenting to study participation, clinicians received a 1-year subscription to UpToDate. They completed a series of surveys over the year, and we collected clickstream data tracking their use of the tool.

Primary and secondary outcome measures: (1) The variation in use by demographic; (2) the prevalence of barriers and facilitators of use; and (3) the relationship between barriers, facilitators and use.

Results: Of 1681 study enrollees, 69% were men and 71% were between 25 and 35 years old, with the plurality practicing general medicine and the majority in sub-Saharan Africa or Southeast Asia. Of the 11 barriers we assessed, fitting the tool into the workflow was a statistically significant barrier, making clinicians 50% less likely to use it. Of the 10 facilitators we assessed, a supportive professional context and utility were significant drivers of use.

Conclusions: There are several clear barriers and facilitators to promoting the use of digital clinical decision support tools in practice. We recommend tools like UpToDate be implemented with complementary services. These include generating a supportive professional context, helping clinicians realise the tools' use and working with health systems to better integrate digital, clinical decision support tools into workflows.

Keywords: change management; health & safety; information technology; international health services; medical education & training; quality in health care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cohort Studies
  • Decision Support Systems, Clinical*
  • Female
  • General Practice*
  • Humans
  • Male
  • Surgeons*
  • Workflow