Barriers and Facilitators to the Adoption of Clinical Decision Support Systems in Public Hospitals: A Public Management Perspective

Clinical decision support systems (CDSS)—including computerized alerts, order sets, and decision logic embedded in electronic health records—are widely promoted to improve safety, quality, and efficiency, yet organizational adoption in public hospitals remains uneven and frequently contested. Public hospitals face distinctive constraints and levers (statutory procurement, political oversight, civil-service staffing regimes, and formal accountability chains) that shape whether adoption decisions translate into implementable and sustainable CDSS capabilities. This targeted literature review synthesizes a retrieved corpus of 30 studies to identify barriers and facilitators to CDSS adoption in public hospitals from a public management perspective. Using qualitative thematic synthesis with stage (adoption vs implementation/optimization) and level (macro–meso–micro) mapping, we find that adoption trajectories are strongly conditioned by procurement and contracting quality, multi-level governance and decision-rights clarity, organizational capacity to configure and optimize CDSS over time, accountability/inspection and med-ico-legal framing, and public-sector financing structures that often underfund post–go-live optimization. We propose a multi-level conceptual model linking public management mechanisms to “adoption quality,” and we provide an evidence map highlighting where the corpus is most and least informative. The synthesis reframes CDSS adoption as an institutional capacity commitment rather than a discrete purchase, and it offers actionable implications for public hospital executives and policy-makers seeking to scale CDSS safely and legitimately.