Interorganizational Mechanisms for Developing and Implementing Clinical Decision Support Systems in Primary Care: Exploratory, Qualitative Case Study

Journal of Medical Internet Research, vol. 28, pp. e83084

Abstract

Background: Clinical decision support systems (CDSS) have the potential to improve patient safety and reduce costs in primary care. However, CDSS adoption remains limited due to development and implementation challenges. CDSSs are complex interventions involving multiple interacting components that require technological innovation and behavioral and organizational change. Additionally, the primary care context is considered a complex system with high care demand, fragmented structures, and many independent yet interdependent organizations. Established determinant frameworks for implementing and scaling up complex health care interventions support the identification of implementation determinants. However, they offer limited guidance on the underlying processes of these determinants, such as the implementation processes involved in complex interorganizational collaboration in primary care. Objective: This study examined how an interorganizational collaboration in Dutch primary care (Gezonde zorg, Gezonde regio [GzGr]) achieved an iterative CDSS development and implementation. We aimed to identify the mechanisms that supported the collaboration in overcoming challenges. Methods: We performed an exploratory process-level case study. Data were collected through 15 semistructured interviews. The nonadoption, abandonment, scale-up, spread, and sustainability framework was used to ensure comprehensive topic coverage during the interviews, but not as an analytical framework. We triangulated the interviews with internal and external documents and expert input. Using a thematic, inductive approach, we developed a chronological overview of the collaboration and identified mechanisms offering insights into how GzGr navigated complexity in the development and implementation of CDSS. Results: We identified two mechanisms: (1) enacting an interorganizational value model and (2) iterative, co-creative experimentation. First, GzGr was driven by a coalition of the willing (ie, individuals willing to take an extra step), with shared goals that prioritized collective benefit while respecting organizational values. They established shared principles that translated the broad GzGr mission into concrete CDSS development choices, while also guiding strategic expansion by involving mission-aligned, innovative organizations. Second, after initial prototypes, GzGr established an iterative learning and improvement experimentation for both the technology and the collaboration. This process allowed for rapid feedback, validation of added value, and ongoing refinement. Additionally, this experimentation approached the development and implementation phase as a continuous process involving multistakeholders, supporting both the technology and the collaboration. Conclusions: This study identified 2 mechanisms that sustained interorganizational collaboration and CDSS development. These mechanisms connected collaborative and technical changes across people, technology, and organizational levels, enabling technological viability, stakeholder value, and multilevel support. The mechanisms operated both within and between organizations through iterative cycles of development and implementation. Practical implications include involving multilevel, innovative, and influential stakeholders; maintaining alignment through an orchestrating actor; and adopting an iterative approach between development and implementation. Our findings extend existing determinant frameworks by offering process-level insights into how such mechanisms help overcome challenges in the development and implementation of CDSS within interorganizational collaborations.

Authors 6

1. Jesse J M M Santema

   Delft University of Technology

   Affiliation as printed

   Industrial Design Engineering, Delft University of Technology, Mekelweg 5, Delft, South Holland, 2628 CD, The Netherlands, 31 612815254

2. Jeroen D. H. van Wijngaarden

   Erasmus University Rotterdam

   Affiliation as printed

   Health Services Management & Organization, Erasmus School of Health Policy and Management, Rotterdam, South Holland, The Netherlands

3. Eric Hiddink Aachen National eHealth Living Lab Department of Public Health and Primary Care (PHEG)

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Health Base Foundation, Houten, Utrecht, The Netherlands

   National eHealth Living Lab, Department of Public Health & Primary Care, Leiden University Medical Center, Leiden, South Holland, The Netherlands

4. Fleur Deken

   Vrije Universiteit Amsterdam

   Affiliation as printed

   School of Business and Economics, Knowledge, Information and Innovation, Vrije Universiteit Amsterdam, Amsterdam, North Holland, The Netherlands

5. Maaike S. Kleinsmann Aachen Department of Cardiology, Leiden University Medical Center

   Leiden University Medical Center · Delft University of Technology

   Affiliation as printed

   Department of Cardiology, Leiden University Medical Center, Leiden, South Holland, The Netherlands

   Industrial Design Engineering, Delft University of Technology, Mekelweg 5, Delft, South Holland, 2628 CD, The Netherlands, 31 612815254

6. Hendrikus J. A. van Os Aachen National eHealth Living Lab Department of Public Health and Primary Care (PHEG)

   Leiden University · Leiden University Medical Center · University Medical Center Utrecht

   Affiliation as printed

   Department of Psychiatry, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands

   National eHealth Living Lab, Department of Public Health & Primary Care, Leiden University Medical Center, Leiden, South Holland, The Netherlands