Graduation Date

Spring 5-8-2021

Document Type


Degree Name

Doctor of Philosophy (PhD)


Biomedical Informatics

First Advisor

Russell McCulloh MD

Second Advisor

Bethany Lowndes PhD

Third Advisor

James McClay MD

Fourth Advisor

Hongying Dai PhD


Electronic clinical decision support (ECDS) tools are often developed within quality improvement (QI) projects to increase adherence with the latest clinical practice guidelines. However, the potential reach and maintenance of ECDS use beyond the time and location of their associated project are very limited. Deploying ECDS using a mobile app (mECDS) has shown the potential to be a viable method of overcoming these limitations. However, it is unclear what pattern the reach and adoption of such a tool might follow and what effect this use has on clinical practice. Our team developed an app which contained two different mECDS tools released as part of two national quality improvement projects. By connecting the patient care collected by these projects to the usage of their corresponding mECDS tools, we aimed to investigate the effect of mECDS tool usage on clinical practice within both projects and determine long term mECDS use patterns within (reach and adoption) and beyond (maintenance) the projects. We quantified mECDS utilization using cumulative project metric-related screen views over the study period in the area in which each participating site was located. We determined associations between mECDS utilization and project metrics using mixed-effect generalized linear models, adjusted for time, site characteristics (project 1) and additionally for site-level QI project engagement, and patient characteristics (project 2). Weekly mECDS utilization was further examined for trends within and for 2 years after the first project’s intervention period. Despite limitations in directly linking usage and practice data, a clear association between area-level tool use and an increase in that site’s adherence to national practice standards was found. Additionally, project 1’s tool use was found to increase, both temporally and geographically, beyond the project period. Further research is needed to determine the factors driving use, whether this continued use has an impact on clinical practice and patient outcomes and linking clinicians’ mECDS usage more directly to their behavior.

Available for download on Saturday, April 29, 2023