Factors determining the adherence to antimicrobial guidelines and the adoption of computerised decision support systems by physicians: A

Article

Reference

Factors determining the adherence to antimicrobial guidelines and the adoption of computerised decision support systems by physicians: A

qualitative study in three European hospitals

CATHO, Gaud, et al . & Q-COMPASS study group

Abstract

Antimicrobial stewardship (AMS) programs aim to optimize antibiotic use and reduce inappropriate prescriptions through a panel of interventions. The implementation of clinical guidelines is a core strategy of AMS programs. Nevertheless, their dissemination and application remain low. Computerised decision support systems (CDSSs) offer new opportunities for semi-automated dissemination of guidelines. This qualitative study aimed at gaining an in-depth understanding of the determinants of adherence to antimicrobial prescribing guidelines and CDSSs adoption and is part of a larger project, the COMPASS trial, which aims to assess a CDSS for antimicrobial prescription. The final objective of this qualitative study is to 1) provide insights from end-users to assist in the design of the COMPASS CDSS, and to 2) help with the interpretation of the quantitative findings of the randomised controlled trial assessing the COMPASS CDSS, once data will be analysed.

CATHO, Gaud, et al . & Q-COMPASS study group. Factors determining the adherence to antimicrobial guidelines and the adoption of computerised decision support systems by

physicians: A qualitative study in three European hospitals. International Journal of Medical Informatics , 2020, vol. 141, p. 104233

DOI : 10.1016/j.ijmedinf.2020.104233 PMID : 32736330

Available at:

http://archive-ouverte.unige.ch/unige:149334

Disclaimer: layout of this document may differ from the published version.

1 / 1

Contents lists available atScienceDirect

International Journal of Medical Informatics

journal homepage:www.elsevier.com/locate/ijmedinf

Factors determining the adherence to antimicrobial guidelines and the adoption of computerised decision support systems by physicians: A qualitative study in three European hospitals

Gaud Catho

*, Nicolò Saverio Centemero

, Heloïse Catho

, Alice Ranzani

, Carlo Balmelli

, Caroline Landelle

, Veronica Zanichelli

, Benedikt David Huttner

, on the behalf of the Q- COMPASS study group

aDivision of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland

bClinical Informatics Unit, Ente Ospedaliero Cantonale, Bellinzona, Switzerland

cGrenoble Alpes University Hospital and Faculty of Medicine, Grenoble, France

dDivision of Infection Control and Hospital Epidemiology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland

eHospital Hygiene Unit, Grenoble Alpes University Hospital, University Grenoble Alpes/CNRS, ThEMAS TIM-C UMR 5525, Grenoble, France

fLady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada

A R T I C L E I N F O

Keywords:

Antimicrobial stewardship Antimicrobial guidelines

Computerised decision support system Medical informatics

Qualitative methodology Semi-structured interview

A B S T R A C T

Background and Objectives:Antimicrobial stewardship (AMS) programs aim to optimize antibiotic use and re- duce inappropriate prescriptions through a panel of interventions. The implementation of clinical guidelines is a core strategy of AMS programs. Nevertheless, their dissemination and application remain low. Computerised decision support systems (CDSSs) offer new opportunities for semi-automated dissemination of guidelines. This qualitative study aimed at gaining an in-depth understanding of the determinants of adherence to antimicrobial prescribing guidelines and CDSSs adoption and is part of a larger project, the COMPASS trial, which aims to assess a CDSS for antimicrobial prescription. Thefinal objective of this qualitative study is to 1) provide insights from end-users to assist in the design of the COMPASS CDSS, and to 2) help with the interpretation of the quantitativefindings of the randomised controlled trial assessing the COMPASS CDSS, once data will be ana- lysed.

Methods:We conducted semi-structured individual interviews among in-hospital physicians in two hospitals in Switzerland and one hospital in France. Physicians were recruited by convenience sampling and snowballing until data saturation was achieved.

Results:Twenty-nine physicians were interviewed. We identified three themes related to the potential barriers to guideline adherence: 1) insufficient clarity, accessibility and applicability of guidelines, 2) need of critical thinking skills to adhere to guidelines and 3) impact of the team prescribing process and peers on physicians in training. As to the perception of CDSSs, we identified four themes that could affect their adoption: 1) CDSSs are perceived as time-consuming, 2) CDSSs could reduce physicians’critical thinking and professional autonomy and raise new medico-legal issues, 3) effective CDSSs would require specific features, such as ease of use and speed, which affect usability and 4) CDSSs could improve physicians’adherence to guidelines and patient care.

Discussion: CDSSs have the potential to overcome several barriers for adherence to guidelines by improving accessibility and providing individualised recommendations backed by patient data. When designing CDSSs, mixed clinical and information technology teams should focus on user-friendliness, ergonomics, workflow in- tegration and transparency of the decision-making process.

https://doi.org/10.1016/j.ijmedinf.2020.104233

Received 30 January 2020; Received in revised form 7 May 2020; Accepted 8 July 2020

⁎Corresponding author at: Rue Gabrielle Perret-Gentil, 4 Geneva University Hospitals, 1205, Geneva, Switzerland.

E-mail address:gaud.catho@hcuge.ch(G. Catho).

1Q-COMPASS study group: Enos Bernasconi, Marlies Huschler, Patricia Pavese, Virginie Prendki, Jeroen Schouten.

1386-5056/ © 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

T

1. Introduction

Antimicrobial stewardship (AMS) programs aim at optimising an- tibiotic use and reducing inappropriate antibiotic prescriptions through a panel of interventions [1,2]. The development and implementation of facility-specific clinical practice guidelines are an AMS core element [3]. Interventions enhancing adherence to guidelines showed to im- prove quality of care [4] but they require important human resources.

Furthermore, the traditional“passive”method to disseminate clinical practice guidelines is probably not very effective to change behaviour [5,6]. Among limited and competing resources, computerised decision support systems (CDSSs) may offer innovative solutions to enhance guideline implementation [3], can provide point-of-care recommenda- tions for clinicians and generate case-specific guidance. Although CDSSs are recommended by international companies as part of AMS programs [3], physicians are often reluctant to accept new technologies [7]. Understanding the determinants of physicians’perception of the new intervention and its components [9] is a fundamental prerequisite for its implementation. In the COMPASS randomised multicentre con- trolled trial (clinicaltrials.gov: NCT03120975), we implemented a CDSS containing local antimicrobial guidelines [8], which was preceded by a qualitative study to understand barriers and facilitators perceived by in- hospital physicians for guideline adoption and use of CDSSs. This qualitative study aims to 1) provide insights from end-users to assist in the design of the COMPASS CDSS, and to 2) help with the interpretation of the quantitative findings of the randomised controlled trial (RCT) assessing the COMPASS CDSS once data will be analyzed.

2. Materials and methods

This qualitative study, using individual face-to-face interviews, be- longs to the COMPASS research project [8], a randomised trial testing the effectiveness of a CDSS providing decision support to physicians when prescribing antimicrobials for in-hospital patients (see additional material). Recommendations on antimicrobial treatment are proposed to physicians according to local guidelines and prescriber’s indications.

The COMPASS trial has been conducted in four hospitals, in two hos- pital systems in Switzerland (one French speaking academic tertiary care center, Geneva University Hospitals with two locations, and one Italian-speaking secondary-care center with two locations in Lugano and Bellinzona; start September 2018, end March 2020). The CDSS was created by local information technology (IT) teams in co-operation with infectious diseases clinicians and is embedded into the electronic health record (EHR) and the computerised physician order entry system. It covers approximately one hundred infectious conditions and provides support mostly for empiric antimicrobial therapy.

2.1. Setting and participants

This study was conducted in two Swiss hospital systems (Geneva University Hospitals, Ticino Regional Hospitals EOC - Bellinzona and Lugano hospitals) - also participating in the COMPASS trial - and an acute-care hospital in France (Grenoble Alpes University Hospitals) - not participating in the COMPASS trial. In hospitals participating in the COMPASS trial, the qualitative study has been conducted before the implementation of the CDSS, includingphysicians, that did not work in wards participating in the trial.

The Swiss hospitals had regularly updated antibiotic-prescribing guidelines distributed as a pocket booklet and available through the hospital-intranet platform. The French hospital had no formal AMS program and its local antibiotic-prescribing guidelines were available on the hospital-intranet platform. Inclusion criteria were both: a) being an in-hospital physician with direct patient interaction and b) being regularly involved in antimicrobial prescribing decisions.

2.2. Participants recruitment and data collection

Participants were recruited through convenience sampling and snowballing to enroll a heterogeneous group of individuals according to age, gender and seniority. The study was advertised at department meetings and information leaflets were distributed. Two pilot inter- views were conducted in Geneva and the interview guide was refined later. Following the theoretical saturation criteria [9], we progressively recruited participants until no new information was gained from the interviews in each center (data saturation). Three researchers (GC, NSC, HC) conducted interviews that were recorded using an audio recorder, transcribed verbatim, and de-identified. These researchers were all physicians trained in qualitative research without direct connection with participants. Before the interview, participants were asked to an- swer a short online questionnaire (demographics and previous use of e- tools).

2.3. Theoretical framework

We conducted semi-structured interviews, supported by an inter- view guide and flexible probes based on participants’ answers. The interview guide questions were informed by a review of the literature and the Flottorp framework for determinants of clinical practice [10]

including 57 potential practice determinants grouped in seven areas (additional materials).

Barriers and facilitators were examined according to the following two dimensions:

(a) participants’ views and previous experiences with guidelines and determinants for adoption of clinical recommendations in routine practice;

(b) participants’ experiences with information technology tools, apps and CDSSs integrated into EHRs for clinical practice and perceived determinants for adoption of CDSSs in clinical practice.

2.4. Data analysis-qualitative approach

Data were analyzed using Atlas.ti 8.4 software (ATLAS.ti Scientific Software Development, GmbH, Berlin, Germany). We used a mixed approach combining a deductive (“framework analysis”) and an in- ductive approach [9,11] (additional materials).

2.5. Ethical approval

According to Swiss law, this type of study does not require approval from the Ethical Committee (an official request was submitted to Geneva Ethical Committee, number 2018−0050). Approval was ob- tained from “Conseil Académique of Geneva University Hospitals”

(protocol number 2018−4) and the Ethical Committee of “Centres d’Investigation Clinique de l’inter-région Rhône-Alpes-Auvergne”

(number 5891). Participants in Geneva receivedfinancial compensation in the form of a gift voucher of 20 CHF. No compensation was offered in the other centers. All participants signed an informed consent form.

3. Results

3.1. Demographics of the participants

In total, 29 physicians (14 females/15 males) were interviewed (Geneva: 6 females/5 males, Grenoble: 4/4, Ticino: 4/6). The position was: 13 residents (45 %), 7 senior fellows (24 %) and 9 attending physicians (31 %) (Table 1). Audio-recorded interviews were conducted from 01/2018 to 03/2019 and lasted 30 min on average (range: 13−44 min).

The seven themes emerged from the interviews are shown inTables 2 and 3.

Three themes concernedbarriers to guideline adherence:

G. Catho, et al. International Journal of Medical Informatics 141 (2020) 104233

2

1) Insufficient clarity, accessibility and applicability of guidelines hinder adherence

2) Physicians’insufficient critical thinking skills hinder adherence 3) Team prescribing preference and other professionals may impact

guideline adherence of physicians-in-training

Four themes concerned the potential determinants for CDSS adoption:

1) CDSSs are considered time-consuming

2) CDSSs are perceived as tools that may reduce physicians’critical thinking and professional autonomy and raise new medico-legal issues

3) Specific CDSS features such as user-friendliness and speed (affecting usability) could impact adoption

4) CDSSs are perceived as tools that could improve physicians’ad- herence to guidelines and patient care

We did notfind major differences between participants of the three centers except for the theme“CDSSs are considered time-consuming”

who only emerged from participants from Geneva.

3.2. Determinants of physicians’adherence to guidelines when prescribing antimicrobials in a hospital setting

3.2.1. Insufficient clarity, accessibility, applicability of guidelines hinder adherence

Some participants, mainly junior physicians, complained about the lack of clarity of the guidelines as they believed guideline details were insufficient to allow their effective use in daily practice or guidelines did not clearly state what to do in specific situations. They claimed guidelines were not easily accessible, both because they were difficult tofind (with considerable differences between centers) and because of a perceived lack of time to consult them.

Many participants consider that the guidelines are not appropriate for complex cases as they do not include the patient’s overall situation (particularly in geriatric environments or with patients at the end of their life). Patient care was described as a complex process where multiple factors should be considered and guidelines were perceived as

“cookbooks”with no room for personalised medicine. Physicians per- ceived a rather contradictory desire to follow guidelines, and mean- while, to provide patients with personalised care.

FRANCE(FR)_04 (F, resident):“It can improve prescribing in common situations, but really it applies to common, classic conditions. As soon as you get offthe track, it can no longer be part of recommendations”

3.2.2. Physicians’insufficient critical thinking skills hinder adherence Some physicians expressed concerns about the skills needed to ad- here to guidelines, particularly the need to be able to evaluate their content critically. Some senior physicians believe that a prerequisite for the adoption of guidelines is previous experience in prescribing anti- microbials to understand the evidence and basic reasoning better. A senior physician mentioned inconsistency between guidelines as a po- tential obstacle to the adoption of guidelines by younger physicians.

GENEVA(GE)_06 (M, resident):“It can be even more destabilizing for the person who has not done the work beforehand to understand the ther- apeutic strategy, it makes no sense”

3.2.3. Team prescribing process and other professionals negatively impact guideline adherence by physicians-in-training

Antimicrobial prescribing behaviours within the team of healthcare workers responsible for the patient were described as factors affecting adherence to guidelines for physicians in training who reported that senior physicians took thefinal decision. They usually followed the instructions from their hierarchy, although this implied deviating from guidelines. A senior physician suggested that residents, specifically those following initial training, were influenced in their antimicrobial prescribing decisions also by nurses.

FR_01 (F, resident):“I think it’s because I was told‘prescribe this’that I prescribed it and then I didn’t have time to dig into the rational of what they told me to prescribe.”

3.3. Perception of CDSSs and determinants of their potential adoption 3.3.1. CDSSs are considered time-consuming

On the other hand, some participants, at all levels of seniority, de- scribed CDSSs as tools that can reduce time spent with patients.

Computer facilities, in particular, EHR, were described as tools re- quiring additional work to enter data,fill in boxes and understand how the system works. Digital tools were also perceived as increasingly numerous and overwhelming in the physician’s daily routine.

Some physicians were concerned about electronic skills required to use CDSSs. Familiarity with current tools and reluctance to change were also mentioned as potential barriers to their implementation.

3.3.2. CDSSs are perceived as tools that can reduce physician’s cognitive reflection, decision making and raise new medico-legal issues

Some senior physicians perceived risk for junior physicians: if CDSSs Table 1

Characteristics of the participants.

Characteristics Geneva

n = 11

Grenoble n = 8

Ticino n = 10

N (%) Overall 29 Yearsof clinical experience

< 5 years 8 5 4 17 (58)

5−10 years 1 2 3 6 (21)

> 10 years 2 1 3 6 (21)

Gender

Female 6 4 4 14 (48)

Male 5 4 6 15 (52)

Position

Attending or staffphysician 3 2 4 9 (31)

Senior fellow 3 1 3 7 (24)

Resident or physician-in-training 5 5 3 13 (45)

Use of electronic tools

Often 4* 5 10 19*(76)

Sometimes 4* 3 0 7*(24)

Use of computerised decision support systems

Often 3* 2 7 12*(46)

Sometimes 5* 3 3 11*(42)

Rarely 0* 3 0 3*(12)

* missing data for 3 participants.

Table 2

Themes identified through the semi-structured interviews.

Themes related to the barriers for adherence to guidelines

1) Insufficient clarity, accessibility and applicability of guidelines hinder adherence 2) Insufficient critical thinking skills of physicians hinder adherence

3) The team prescribing process and other professionals may impact guidelines adherence of physicians-in-training

Themes related to potential determinants of adoption of CDSS 1) CDSSs are perceived as time-consuming

2) CDSSs are perceived as tools that can reduce physicians’cognitive reflection, decision making and raise new medico-legal issues

3) Specific CDSS features such as user-friendliness and speed (affecting usability) could impact adoption

4) CDSSs are perceived as tools that improve physicians’adherence to guidelines and patient outcomes

Table 3

Quotes related to Flottorp domains and determinants.

Flottorp domains Flottorp determinants Quotes

Themes Related to the Barriers for Adherence to Guidelines

1) Insufficient clarity, accessibility and applicability of guidelines hinder adherence Guideline factors/

recommendation

Clarity Lack of clarity

•

•

Accessibility of the recommendation

Lack of accessibility and availability

•

Source of the recommendations Importance of providing the sources of the guidelines

•

•

•

Cultural appropriateness Lack of applicability

•

•

•

precisely tailored to the patient”

•

•

2) Insufficient critical thinking skills of physicians hinder adherence Individual health professional factors/

knowledge and skills

Skills needed to adhere

•

Guideline factors/

recommendations

Consistency with other guidelines

•

3) The team prescribing process and other professionals may impact guidelines adherence of physicians-in-training

Professional interactions Communication and influence

•

Often, I look at guidelines, but after my superiors told me to do something else”.

•

•

THEMES RELATED TO POTENTIAL DETERMINANTS OF ADOPTION OF CDSS 1) CDSSs are perceived as time-consuming

CDSS factors/

Recommended behaviour

Effort

Emotions

•

•

•

2) CDSS are perceived as tools that can reduce physician cognitive reflection, decision making and raise new medico-legal issues Individual health professional factors/

Cognition

Attitudes toward guidelines in general

Expected outcomes Learning style Emotions

•

•

•

•

•

•

•

(continued on next page)

G. Catho, et al. International Journal of Medical Informatics 141 (2020) 104233

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suggest them what to do, this may negatively impact their training, critical thinking and clinical judgment.

The fear of errors caused by blindly accepting suggested re- commendations was another issue raised by some participants who also stressed responsibility of physicians who should remain those who make thefinal decision. Moreover, the risk that CDSSs may reduce their professional autonomy (e.g. reluctance to be told what to do) was also noted. Some participants described defensive medicine as a factor that may limit the uptake of CDSSs (e.g. if the CDSS suggests a narrow- spectrum antibiotic but the patient is very ill). Conversely, others sug- gested they could be accused of negligence if CDSS recommendations were not followed (e.g. by making a decision not in accordance with local guidelines)

GE_06 (M, resident):“I support the local antibiotic therapy guidelines but if we misuse them or use them too much, we forget to think”.

TICINO(TI)_05 (M, senior physician):“They give you a false sense of security. The risk is that you accept the CDSS proposal without even knowing what you’ve accepted”.

3.3.3. Specific CDSS features such as user-friendliness and speed (affecting usability) could impact adoption

Motivation or intention to use CDSSs were frequently described as linked to the amount of effort required to use them. Participants would like a system to be user-friendly, fast and with limited need for data entry. The source of recommendations available directly in the system was described as an important factor for adherence, particularly by senior physicians who perceived the possibility to provide feedback on compliance with CDSS recommendations as a tool to increase younger physicians’motivation to adopt them.

Several participants described the importance of providing technical assistance to physicians among the incentives for adopting CDSSs.

3.3.4. CDSS are tools that can improve physicians’adherence to guidelines and care provided to patients

Several physicians perceived CDSSs as innovative solutions that can improve many aspects of their professional activities. The assumption

that CDSSs can reduce errors and facilitate access to up-to-date in- formation was indicated as a potential benefit of CDSSs. Some physi- cians also mentioned the potential time saved by the use of CDSSs, which could allow them to focus on other tasks. Several participants believe that the economic constraints of current healthcare budgets can promote the purchase of these tools that may help to save money in the long term. They perceived the CDSS implementation as a potential way to devote resources to other tasks that cannot be replaced by machines.

FR_03 (M, resident):“Computer tools are a good way to focus the work on things that computers can never replace, like the human [interaction], the time of consultation. We, doctors, are clearly all overwhelmed.”

4. Discussion

This multicenter qualitative study conducted in three European re- gions located in two countries identified several significantfindings on barriers and facilitators to physicians’ adherence to guidelines and CDSS adoption. Missing patient-focused instructions and complex pre- scribing team dynamics were perceived as important barriers to guideline adherence. Physicians had different views about CDSSs: while some perceived them as time-consuming tools limiting their cognitive reflection and autonomy, others mainly perceived their added value for patient safety.

Although junior physicians mostly execute the actual antibiotic prescribing process, it is their seniors who often make the decision whether and what to prescribe. This hierarchy culture belongs to the

“prescribing etiquette”, recently reported by Charani et al. [12], that often leads junior physicians to adopt prescribing behaviours that are inconsistent with guidelines [12].

Nurses were described in our study as influential elements in the junior physicians’prescribing decision-making process as they exert a pressure to prescribe, as previously reported [13].

Physicians had the perception that CDSSs would reduce their au- tonomy and freedom of choice and replace or degrade their clinical tasks. Research on resistance to information technology implementa- tion found that the most important drivers of resistance are threats Table 3(continued)

Flottorp domains Flottorp determinants Quotes

Social, political and legal factors Malpractice liability

•

•

•

•

3) Specific CDSS features such as user-friendliness and speed (affecting usability) could impact adoption Individual health professional factors/

Professional behaviour

Self-monitoring and feed-back

•

•

•

Knowledge about own practices

•

Capacity for organizational change Assistance for organizational

change

•

•

4) CDSS are perceived tools that improve physician adherence to guidelines and patient outcomes Individual health professional factors/

Cognition

Expected outcome

Intention and motivation

•

•

•

Social, political and legal factors Economical constraints on the

healthcare budget

•

perceived by individuals, such as a perceived loss of power [14].

Consideration of user needs and expectations when designing the CDSS may help reduce these barriers. Transparency about how the CDSS makes output decisions is a key factor in CDSS acceptance by physicians who can understand what the computer recommendation is based on, and be more willing to accept it [15]. Systems embedded into the workflow are also more likely to be accepted [16,17]. Vashitzet al.

described how unsolicited advice might lead to opposite behaviour as a means of preserving autonomy [18]. Reminders and alerts should be presented in such a way that the user does notfind them threatening or obtrusive. “Alert fatigue”, a consequence of too many alerts being presented, is an established and enduring problem for prescribers [19,20] which did, however, not emerge from our interviews. Repeated requests for data entry are another major source of physicians’ dis- satisfaction with EHRs since they contribute to the time burden asso- ciated with EHRs themselves [20]. However, thisfinding emergedonly in one center (Geneva). Usability testing should be performed early in the design process and throughout the development cycle. Inter- disciplinary teams, including clinicians and developers, should work together to design and implement CDSSs.

The complexity and lack of applicability of guidelines are well- known issues [21,22].“One size does notfit all”is a common saying physicians use to describe the rigidity they faced when trying to apply the guideline recommendations in the care of their patients with spe- cific comorbidities.“My patient is different”was a frequent answer in the interviews showing the perception of guidelines as a general clinical picture that is insufficiently tailored to the complexity of patients.

Despite this common perception, CDSSs are expected to evolve to- wards precision medicine, supported by more patient data, and to provide personalised treatments instead of a blanket approach. Digital tools can serve as a gateway to general practice guidelines for more tailored recommendations. With the integration of the latest evidence provided at the point-of-care through a digital interface, computerised systems enable physicians to make informed, accurate and precise de- cisions [23]. Moreover, CDSSs allow a more detailed analysis of the prescribing process and a better understanding of the reasons behind prescribers’choices; conversely, simple CDSSs are still helpful for most clinical cases. Preliminary data from the use of the COMPASS tool show that deviation from guidelines for the selection of antimicrobials occurs in only about 30 % of antimicrobial prescriptions with CDSS. This highlights that guidelines are still relevant in at least 70 % of situations, but physicians probably experience a recall bias in the most severe or complex cases. While saving time and cognitive load for common cases, CDSSs leave physicians more time and energy to use their clinical judgment to treat more complex cases.

This study has been conducted in the context of a larger study, the COMPASS trial. The intervention of the COMPASS trial contains several components targeting the behaviour of health professionals and there- fore is classified as a“complex intervention”. Qualitative methods are advocated in the pre-trial development phase of complex interventions but also alongside and after the trial to facilitate interpretations of trial results [24,25]. These recommendations form part of the guidance for the use of qualitative methods in RCTs in the Medical Research Council guidance, a framework for development and evaluation of RCTs of complex interventions to improve health [26]. The modeling or ob- servational phase that occurs before the launch of the trial aims at improving understanding components of an intervention and their in- terrelationships. In the context of the COMPASS trial, this qualitative work was conducted when the CDSS was still under development.

Therefore,findings of this study helped us to refine relevant compo- nents of our intervention and identified potential barriers to change.

For example, ourfindings on the lack of accessibility of guidelines and the lack of time or resources to consult them legitimate an intervention that focuses on providing guidelines directly through the electronic prescribing and not only trying to improve knowledge. Similarly, our findings on the request for transparency of the decision process and for

limiting data entry were taken into account in the development of COMPASS CDSSs.

Qualitative research is also increasingly used to explore reasons for thefindings after a trial has been completed [24], particularly for the evaluation of complex health interventions as these involve behavior processes that are difficult to explore or capture using quantitative methods alone. Thanks to thefindings of this qualitative study, we hope - once the COMPASS trial has been completed and analyzed - to un- derstand, for example, why components of the intervention were adopted to different degrees and to potentially identify reasons for unequal adoption among settings or variation in the effectiveness be- tween the study sites (Geneva and Ticino). Such analysis will help to decide which particular component of the intervention can be main- tained successfully and how to improve some other components. Based on our quantitativefindings, we may also consider performing a new qualitative study to explore participants’experience of the intervention and factors influencing the effects of the intervention or to explore why the intervention was introduced successfully in some settings but not in others. We are also in the process of adapting the COMPASS tool for the pediatric environment of Geneva University Hospitals. For this process, thefindings of this qualitative study are also particularly relevant.

To our knowledge, this study is one of thefirst to explore physicians’ attitudes towards antimicrobial guidelines and CDSSs. The diversity of care centers and cultural settings in our study make thefindings more generalisable. In particular, the level of uptake of IT tools and im- plementation of guidelines varied across the settings involved. Our study has, however, several limitations. All interviews were kept con- fidential, but participants may have been inclined to give socially de- sirable answers. Moreover, although thematic saturation was observed at the end of 29 interviews, we cannot exclude the possibility that minority perspectives were lost.

Antibiotic-prescription decision making is a complex process. To achieve sustainable improvements in antibiotic use, each new compo- nent of a stewardship program should address local cultural factors and social networks affecting prescribing practices and the potential adop- tion of new interventions. Through our interviews, we highlighted the key features that each CDSS should have to increase its adoption, such as user-friendliness, ergonomics, transparency of the decision-making process and workflow integration. The “number of clicks” is what counts for the end-user. Physicians’concerns, such as fear of losing autonomy or being overwhelmed by computer tasks should be taken seriously. Appropriate changes or adaptations in response to resistance behaviour should be considered in the early stages of the CDSS design and implementation process.

Before a technology is mainstream, resistance to change and nega- tive perception are common [14]. However, these negative perceptions reflect the physicians’real needs that should be considered and met to provide the most appropriate tools allowing for optimal patient care.

Providing physicians with competent and rewarding tools is also a way to care for those who care for others while leaving physicians more time for their patients. This is precisely what IT tools should be used for, not to take time away from patients.

Summary points

What was already known on the topic:

▪Clinical practices guidelines and computerized decision support systems are set to become increasingly prevalent in the future and more closely connected

▪Several local cultural factors and social networks can affect the potential adoption of new technological interventions

What this study added to our knowledge:

▪Consideration of user needs and expectations when designing the

G. Catho, et al. International Journal of Medical Informatics 141 (2020) 104233

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CDSS may help reduce resistance to changes

▪User-friendliness, ergonomics, transparency of decision-making process and workflow integration are key features that each CDSS should have to increase its adoption by physicians

▪Physicians’ concerns, such as fear of losing autonomy or being overwhelmed by computer tasks, should be taken seriously and appropriate solutions should be considered in the early stages of the CDSS design and implementation process

Funding

Gaud Catho is partially supported by the Swiss National Science Foundation in the context of the National Research Plan (NRP) 72

“Antimicrobial Resistance”(Project numbers 407240_167079 and 40AR40-180215 / 1). Gaud Catho also received funding from Geneva University Hospitals “Research and Development” Young researchers (PRD 15-2018-II).

Transparency declarations

All authors do not have anyfinancial conflicts of interest and the funder has not played any decision-making role in the research.

Declaration of interests

The authors declare that they have no known competingfinancial interests or personal relationships that could have appeared to influ- ence the work reported in this paper.

Acknowledgements

We thank all the participants in the interviews. We thank members of the teams involved in the COMPASS project, in particular Valentina Coray, Serge Da Silva, Emmanuel Durand, Francesco Pagnamenta, Marie-Françoise Piuz, Javier Portela, Roberta Valotti, Brigitte Waldispuehl Suter. We thank Simonetta Incerpi for English proof- reading.

Appendix A. Supplementary data

Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.ijmedinf.2020.

104233.

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