Why aren’t they used? Systematic review of barriers to implementation of clinical decision support systems for early cancer detection in primary care

Christina Derksen; Kate A Le Noury; Adriana B Akbar; Thomas Round; Fiona M Walter; Suzanne E Scott

doi:10.3399/BJGP.2025.0579

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What matters most may be workflow, not cancer type
Christina Derksen, Thomas Round, Fiona M Walter and Suzanne E Scott

Published on: 27 April 2026
What matters most may be workflow, not cancer type
Kinan Mokbel

Published on: 15 April 2026

Published on: (27 April 2026)
Page navigation anchor for What matters most may be workflow, not cancer type
What matters most may be workflow, not cancer type
Christina Derksen, Postdoctoral Researcher in Health Psychology (CanDetect), Wolfson Institute of Population Health, Queen Mary University of London
Other Contributors:
Thomas Round, Academic GP, King’s College London

Fiona M Walter, Director of the Wolfson Institute of Population Health and Professor of Primary Care Cancer Research

Suzanne E Scott, Professor of Health Psychology & Early Cancer Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London
We would like to thank Dr Mokbel for his thoughtful comments on our review on barriers to implementation of computerised clinical decision support systems (CDSS) designed to support early cancer detection in primary care. We are pleased there is agreement with our conclusion that CDSS introduced during the consultation are difficult to implement and potentially disruptive to clinical decision making.

Our analysis draws on an initial review¹ in which we suggested that researchers should explore more feasible alternatives that can support the diagnostic process outside of consultations (recommendations can also be found here: www.candetect.org/research/workstream-3/recommendations-for-the-implementation-of-clinical-decision-support-systems/. That review highlighted that few CDSS used during consultations provide follow up functions to support monitoring and usually cannot incorporate new information or additional tests conducted in primary care. This limits their usefulness for conditions such as cancer, where risk estimates often change in response to test results that return after the consultation.

We agree that systems should be prioritised that support monitoring, safety-netting, and decision-making over time. In the next phase of the CanDetect project (www.cand...
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We would like to thank Dr Mokbel for his thoughtful comments on our review on barriers to implementation of computerised clinical decision support systems (CDSS) designed to support early cancer detection in primary care. We are pleased there is agreement with our conclusion that CDSS introduced during the consultation are difficult to implement and potentially disruptive to clinical decision making.

Our analysis draws on an initial review¹ in which we suggested that researchers should explore more feasible alternatives that can support the diagnostic process outside of consultations (recommendations can also be found here: www.candetect.org/research/workstream-3/recommendations-for-the-implementation-of-clinical-decision-support-systems/. That review highlighted that few CDSS used during consultations provide follow up functions to support monitoring and usually cannot incorporate new information or additional tests conducted in primary care. This limits their usefulness for conditions such as cancer, where risk estimates often change in response to test results that return after the consultation.

We agree that systems should be prioritised that support monitoring, safety-netting, and decision-making over time. In the next phase of the CanDetect project (www.candetect.org/), we will be investigating how primary care systems could draw on new test results and intraindividual changes over time and how this could can be integrated into primary care workflows in ways that support decision making. Our aim is to understand how such tools can enhance processing of test results and understanding of changing risk.

Reference

1. Derksen, C., Walter, F.M., Akbar, A.B. et al. The implementation challenge of computerised clinical decision support systems for the detection of disease in primary care: systematic review and recommendations. Implementation Sci 2025; 20, 33. DOI: 10.1186/s13012-025-01445-4.

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Competing Interests: None declared.
Published on: (15 April 2026)
Page navigation anchor for What matters most may be workflow, not cancer type
What matters most may be workflow, not cancer type
Kinan Mokbel, Senior Lecturer (Clinical Pharmacy, Advanced Clinical Practice, Pharmacology), University of Exeter
I found Derksen et al’s review a useful and timely account of why cancer-related clinical decision support systems remain underused in primary care. What I particularly valued was its reminder that implementation problems are not simply technical. They are also about workflow, trust, training, medicolegal concern and the realities of services that are already under considerable strain.

My main reservation concerns the comparison between screening tools and tools for symptomatic presentation. The authors suggest that the function and healthcare context of the CDSS may matter more for implementation than the target condition itself. That seems entirely plausible to me, but I found the comparison difficult to interpret because the two groups are so closely tied to different health-system contexts. Most screening studies were US-based, whereas most symptomatic studies came from the UK and Australia, and the review appropriately acknowledges that these influences could not be disentangled. What struck me is that symptomatic tools are not just addressing a different point in the cancer pathway. In many of the settings included here, they are being introduced into live diagnostic work, in short consultations, within systems where uncertainty, referral thresholds, safety-netting and medicolegal anxiety are already significant. Read in that light, the review may suggest less that symptomatic cancer CDSSs are inherently harder to implement, and more that consultation-f...
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I found Derksen et al’s review a useful and timely account of why cancer-related clinical decision support systems remain underused in primary care. What I particularly valued was its reminder that implementation problems are not simply technical. They are also about workflow, trust, training, medicolegal concern and the realities of services that are already under considerable strain.

My main reservation concerns the comparison between screening tools and tools for symptomatic presentation. The authors suggest that the function and healthcare context of the CDSS may matter more for implementation than the target condition itself. That seems entirely plausible to me, but I found the comparison difficult to interpret because the two groups are so closely tied to different health-system contexts. Most screening studies were US-based, whereas most symptomatic studies came from the UK and Australia, and the review appropriately acknowledges that these influences could not be disentangled. What struck me is that symptomatic tools are not just addressing a different point in the cancer pathway. In many of the settings included here, they are being introduced into live diagnostic work, in short consultations, within systems where uncertainty, referral thresholds, safety-netting and medicolegal anxiety are already significant. Read in that light, the review may suggest less that symptomatic cancer CDSSs are inherently harder to implement, and more that consultation-facing tools are especially difficult to embed in routine primary care. Earlier evidence seems consistent with that interpretation; Cancer decision-support tools have been available but underused in UK primary care, while systematic review evidence suggests that tools used during consultation showed limited benefit on referral appropriateness, whereas some tools used outside the consultation produced more encouraging findings.^1,2

For that reason, I would have liked to see a more explicit distinction between consultation-interrupting diagnostic aids and post-consultation tools for case-finding, follow-up and safety-netting. To my mind, these are not operationally equivalent interventions, and grouping them together risks blurring where implementation effort should now be focused.

The practical question, then, is not only why these systems are not used, but which systems should be prioritised first. My understanding of the evidence discussed here, I think the better starting point may be tools that strengthen tracking and safety-netting around the consultation, rather than those that compete with the clinician’s diagnostic reasoning within it.

References

1. Price, S., Spencer, A., Medina-Lara, A., & Hamilton, W. Availability and use of cancer decision-support tools: a cross-sectional survey of UK primary care. Br J Gen Pract 2019; 69(684): e437–e443. https://doi.org/10.3399/bjgp19X703745.

2. Chima, S., Reece, J. C., Milley, K., Milton, S., McIntosh, J. G., & Emery, J. D. Decision support tools to improve cancer diagnostic decision making in primary care: a systematic review. Br J Gen Pract 2019; 69(689): e809–e818. https://doi.org/10.3399/bjgp19X706745.
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Competing Interests: None declared.

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