This is a two-centre study (both large tertiary and teaching hospitals) from the middle and north area of Jordan in which 254 healthcare professionals provided their insights about their positive perceptions toward AMS, demonstrated by their agreement that its use would improve patient outcomes and curtail AMR. This study aimed to examine the potential barriers and facilitators that hinder or enable CDSS use in clinical practice and AMS based on the healthcare professionals' views. Therefore, understanding perceived barriers and facilitators to CDSSs is vital to maximise the technology's adoption and uptake and potentially impact patient outcomes.
The study survey adopted was refined to study CDSS considering various contexts, from two healthcare centres where the healthcare professionals would be unfamiliar with the technology to those in mature stages in its implementation. Consequently, the results from this study are expected to help guide the development of strategies and recommendations essential to introducing and integrating CDSS into wider national healthcare settings, including the two hospital centres.
This study showed that healthcare professionals had a positive awareness and perceptions toward the electronic prescribing and electronic health record systems explained by their understanding that AMS use would improve patient outcomes and limit AMR. Also, the healthcare professionals perceived that electronic prescribing is beneficial and would reduce the high cost of prescribing antibiotics (i.e., reduce the expenditure of antibiotics), improve the efficacy and the safety of antibiotic use, and may improve the ability to deliver AMS to optimise the rational use of antibiotics. In addition, many systematic reviews and studies demonstrated the impact of adopting the CDSS on antibiotics management and AMS (12, 13, 22–29).
The lack of appropriate training to use the electronic prescribing and electronic health record systems and the lack of access to reliable technical support were the most perceived barriers to CDSS adoption among healthcare professionals. Also, more than half of the healthcare professionals had a low level of awareness and were unfamiliar with using electronic prescribing and electronic health record systems. Furthermore, given that healthcare professionals have busy work schedules, they do not have enough time to learn how to use the system. Therefore, adequate training should be encouraged for novice and experienced healthcare professionals to use the CDSS system and improve workflow effectively. Also, technical support should be provided to the healthcare professionals in each ward of the hospital to avoid any difficulties in using the systems and to maximise the effective use of CDSS. Previous studies reported similar results (21, 29–33). For example, one recent cross-sectional study from Australia that evaluated the impact of CDSS adoption on antibiotics management reported that the lack of appropriate training and technical support was an essential barrier to CDSS adoption (29). In addition, the significance of training and technical support for CDSS adoption was evident in previous studies (21, 34–36).
Making the system in an easily portable format (i.e., like a mobile or a personal digital assistant) was the most perceived facilitator for adopting CDSS by healthcare professionals. This is expected to enable healthcare professionals to make a decision regarding the prescribing and monitoring of antibiotics from remote areas without the need to be in the ward or even in the hospital to prescribe and monitor antibiotics, thus, making work more flexible. Also, lab and radiology results linked to the CDSS are facilitators for adopting CDSS. As a result, healthcare professionals will not be required to check different databases to confirm the diagnosis and adjust treatment based on laboratory results. This will make the work schedule more flexible and efficient. Similar studies reported the same results (21, 31, 33). For example, one cross-sectional study conducted in a tertiary care university hospital in Melbourne, Australia, reported making the CDSS in an easily portable format, linking lab and radiology results as a facilitator to the adoption of CDSS (21). This was also evident in a recent systematic review (33) and a previous study (31).
The logistic regression results about the factors affecting participants' awareness about the use of electronic prescribing and electronic health record systems in antimicrobial stewardship showed that female healthcare providers had significantly lower awareness about using electronic prescribing and electronic health record systems. In contrast, the nurses showed significantly higher awareness about using those systems in stewardship programs. Gender as a factor affecting participants' awareness about the use of electronic prescribing and electronic health record systems was studied in the literature (37–40), with studies showing no difference (39), and others showed higher awareness among females (38, 40) contrasted to the results from our study. Considering that males and females are supposed to have equal technological exposure, knowledge, and awareness, the results from our study should be further explored.
The response rate was less than optimal similar to other response rates in the literature (29, 41); this may affect the representative of the data obtained and may be a limitation to this study. Nevertheless, it is vital to note that the study attracted healthcare professionals with various degrees of system usage. Therefore, the sample seems adequate to address the study's aims.
This study has several strengths. First, the sample size of 254 healthcare providers (despite a low response rate = 46%) from two large tertiary teaching hospitals is considered satisfactory and would add to the representativeness of the results drawn from this study. Second, the CDSS system was designed by developers independent of the end-user healthcare professionals. So, the healthcare professionals were not involved in designing and implementing the CDSS. This is expected to reduce the potential for investigator bias. Finally, it is noteworthy that the use of the CDSS was optional, which minimises the likelihood that healthcare professionals were influenced by hospital policy to use the CDSS system.
While the CDSS system is increasingly gaining popularity in implementing hospital guidelines for prescribing antibiotics, significant barriers to its adoption exist. To implement CDSS systems successfully, the developer needs to understand the barriers to their adoption. The present study measures healthcare professionals' perceptions of using the CDSS system in two tertiary care settings in Jordan's middle and north areas. Both the study setting and study participants represent a metropolitan area. Therefore, the findings from the study could apply to other healthcare settings interested in the launch and implementation of CDSS systems. While the study investigators are independent of the developer and implementer of the CDSS system at the study hospitals, the present study results have been available to them to improve the implementation and deployment strategies.