A thematic analysis to examine the feasibility of EHR-based clinical decision support for implementing Choosing Wisely ® guidelines

To identify important barriers and facilitators relating to the feasibility of implementing clinical practice guidelines (CPGs) as clinical decision support (CDS). We conducted a qualitative, thematic analysis of interviews from seven interviews with dyads (one clinical expert and one systems analyst) who discussed the feasibility of implementing 10 Choosing Wisely guidelines at their institutions. We conducted a content analysis to extract salient themes describing facilitators, challenges, and other feasibility considerations regarding implementing CPGs as CDS. We identified five themes: concern about data quality impacts implementation planning; the availability of data in a computable format is a primary factor for implementation feasibility; customized strategies are needed to mitigate uncertainty and ambiguity when translating CPGs to an electronic health record-based tool; misalignment of expected CDS with pre-existing clinical workflows impact implementation; and individual level factors of end-users must be considered when selecting and implementing CDS tools. The themes reveal several considerations for CPG as CDS implementations regarding data quality, knowledge representation, and sociotechnical issues. Guideline authors should be aware that using CDS to implement CPGs is becoming increasingly popular and should consider providing clear guidelines to aid implementation. The complex nature of CPG as CDS implementation necessitates a unified effort to overcome these challenges. Our analysis highlights the importance of cooperation and co-development of standards, strategies, and infrastructure to address the difficulties of implementing CPGs as CDS. The complex interactions between the concepts revealed in the interviews necessitates the need that such work should not be conducted in silos. We also implore that implementers disseminate their experiences.