Advancing sustainable design and adoption of clinical decision support systems

By Manasha Fernando, AusHSI PhD Scholar

“Will my research make an impact?”

This was the question I carried with me when I began my PhD journey.

I never imagined my work would take me so deeply into the world of computerised clinical decision support systems (CDSSs)—digital tools that provide clinicians with patient-specific alerts, predictions and tailored guidance at the point of care. These technologies hold enormous promise: improving patient outcomes, reducing prescribing errors, and enabling more efficient healthcare delivery. Yet, when introduced into the complex realities of busy hospitals, CDSSs often struggle to deliver on that promise in practice.

Reflecting on this journey, when I began, I imagined my research would follow a straight path: map the use of frameworks, test them in practice, and draw lessons for improvement. In reality, the journey was less linear. Some plans shifted as new challenges emerged, such as witnessing first-hand how different stakeholders either did not use, or reinterpreted, frameworks. I realised early on that the challenge was twofold: many clinically effective CDSS interventions fail to be adopted into routine use in hospital settings, and the very tools of implementation science intended to support CDSS adoption—its theories, models, and frameworks—are frequently adapted, selectively applied, or even set aside. This creates a gap between ‘work as imagined’ and what actually happens in day-to-day care.

To explore this tension, I turned to two complementary frameworks. The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework explains why technologies thrive in some settings but not in others, while the Active Implementation Stages Framework highlights the step-by-step processes needed for lasting adoption. Guided by these, I carried out three interconnected studies.

A scoping review revealed that, although frameworks are frequently cited in CDSS research, they are rarely applied consistently across the full adoption cycle. A qualitative case study within a large Australian health service showed that most attention is devoted to planning and installation, with far less effort spent on long-term adaptation and sustainability. Finally, a qualitative study with research-to-practice professionals demonstrated that success is not driven by a lone champion, but by harnessing collective agency built on trust, collaboration, and shared purpose across multiple stakeholders.

So, what does this mean for the future of healthcare? My research findings inform several recommendations. The research-to-practice professionals emphasised widening the circle of voices in CDSS design and evaluation—engaging not only clinicians but also patients, vendors, and non-clinical staff. Likewise, the case study pointed to the need for practical supports to bridge the gap between theory and practice, such as simulation labs for near-real testing, structured checklists and targeted training in implementation. At a national level, broader lessons underscore the need for sustained investment, workforce development, and clear regulation to ensure CDSSs are integrated equitably and effectively into routine care. My research has the potential to influence not only implementation scientists and digital health researchers, but also patients, hospital decision-makers, vendors, and policymakers, who can carry these insights forward into practice.

I could not have done this work alone. It was shaped by the support of AusHSI, the scholarship and professional development opportunities from the Digital Health CRC, the partnership with Metro South Health, and the generosity of study participants who shared their time and expertise. What began as a question of impact has evolved into a contribution to applied research—one grounded in collaboration and shared learning. While there are no easy fixes, the insights from this work bring us a step closer to ensuring that CDSSs not only work in theory, but truly deliver in practice for patients, clinicians, and health systems alike.