Table 1 Key informant-identified barriers and facilitators to the implementation and adoption of the cancer prevention CDS by CFIR domain and construct (n = 28)

 B. Evidence Strength and Quality

Concern about inaccuracy or conflicting CDS recommendations compared to healthcare system recommendations^a

9

CDS follows USPSTF recommendations

 C. Relative Advantage

CDS improvement over current EHR alerts and tools

Potential for time savings

CDS similar to current EHR alerts and tools

 D. Adaptability

Optimize CDS integration into clinic workflow

 G. Design Quality and Packaging

CDS duplicates or complicates care

11

 A. Patient Needs and Resources

Financial costs to patients

11

Patient self-education^a

Patient socioeconomic disparities

5

Patients controlling own health^a

Patient transportation issues

4

Organization increasing PCP patient visits from 18 to 22 a day^a

Reminders to patients^a

Repeated exposure for patients^a

Focus on prevention over crisis or acute^a

Lung cancer screening^a

 D. External Policy and Incentives

Positive impact on quality metrics^a

 C. Culture

Alignment with institutional aims^a

  1. Tension for change

PCP time limitations^a

25

PCP time limitations are manageable

Alert fatigue (PCPs and/or patients)

25

  2. Compatibility

Not appropriate for acute visits – annual only

9

CDS appropriate for many visit types

Not everything in the EHR is accurate or easy to find

9

Others than PCPs using CDS:

RN CDS use issues (e.g., not appropriate for all RN visit types, RN roles can vary by clinic, RN shortage in healthcare system)^a

5

 RNs using CDS in general

 RNs using CDS during Medicare annual Wellness visits

 RNs using CDS alongside other PCPs

 Clinic rooming staff using CDS

Get CDS printouts to patients before provider (e.g., pre-visit use, before PCP enters room)

Alignment with institutional aims^a

Institution-wide streamlining of EHR alerts

Team model of care

  3. Relative Priority

Seen as just another initiative

10

Organization increasing PCP patient visits from 18 to 22 a day^a

8

Lack of institutional initiative prioritization

3

  4. Organizational Incentives and Rewards

Positive impact on quality metrics^a

  2. Available Resources

PCP time limitations^a

25

Not all clinics have color printers - looks better in color

6

RN CDS use issues (e.g., not appropriate for all RN visit types, RN roles can vary by clinic, RN shortage in healthcare system)^a

5

PCP shortage/burnout

4

Too few printers

3

Clinic rooming staff – already crunched for time

2

  3. Access to Knowledge and Information

Does not recall receiving cardiovascular CDS training

8

Providing in-person training on the CDS

E-learning not always effective

6

E-learning or webinars are acceptable

Provide PCPs with supporting CDS evidence

Focus on workflow in training

Provide multiple learning points

 A. Knowledge and Beliefs about the Intervention

Concern about inaccuracy or conflicting CDS recommendations compared to healthcare system recommendations^a

9

Patient self-education^a

PCP distrust of HPV vaccine or cancer risk calculators

3

Patients controlling own health^a

Reminders to patients^a

Repeated exposure for patients^a

Focus on prevention over crisis or acute^a

Lung cancer screening^a