Understanding keys to successful implementation of electronic decision support in rural hospitals: analysis of a pilot study for antimicrobial prescribing.

Electronic clinical decision support systems (CDSS) have been hailed for their potential to improve clinical outcomes. Using a pretest/posttest design, an Internet-based CDSS designed to optimize antimicrobial prescribing was pilot tested for community-acquired pneumonia in 5 rural hospitals in southwestern Idaho. An antimicrobial management team was created in each hospital to address clinicians' perception of excessive time required for direct use of the CDSS. In pooled hospital data, agreement with CDSS recommendations improved to a statistically significant level. However, inspection of data at the individual hospital level demonstrated that almost all improvement occurred in a single hospital. Failure in the other hospitals appeared to be primarily a consequence of organizational and cultural barriers. These barriers are discussed to understand keys for successful future implementation of CDSS in rural hospitals, drawing on experience with cultural barriers from other industries, specifically aviation.