Abstract
BackgroundIn the United States, primary care providers (PCPs) routinely balance acute, chronic, and preventive patient care delivery, including cancer prevention and screening, in time-limited visits. Clinical decision support (CDS) may help PCPs prioritize cancer prevention and screening with other patient needs. In a three-arm, pragmatic, clinic-randomized control trial, we are studying cancer prevention CDS in a large, upper Midwestern healthcare system. The web-based, electronic health record (EHR)-linked CDS integrates evidence-based primary and secondary cancer prevention and screening recommendations into an existing cardiovascular risk management CDS system. Our objective with this study was to identify adoption barriers and facilitators before implementation in primary care.MethodsWe conducted semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) with 28 key informants employed by the healthcare organization in either leadership roles or the direct provision of clinical care. Transcribed interviews were analyzed using qualitative content analysis.ResultsEHR, CDS workflow, CDS users (providers and patients), training, and organizational barriers and facilitators were identified related to Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals CFIR domains.ConclusionIdentifying and addressing key informant-identified barriers and facilitators before implementing cancer prevention CDS in primary care may support a successful implementation and sustained use. The CFIR is a useful framework for understanding pre-implementation barriers and facilitators. Based on our findings, the research team developed and instituted specialized training, pilot testing, implementation plans, and post-implementation efforts to maximize identified facilitators and address barriers.Trial registrationclinicaltrials.gov, NCT02986230, December 6, 2016.
Highlights
In the United States, primary care providers (PCPs) routinely balance acute, chronic, and preventive patient care delivery, including cancer prevention and screening, in time-limited visits
Some of which were adapted from the Consolidated Framework for Implementation Research (CFIR) [19], included understanding: (1) factors that facilitate or hinder key informant support for the intervention; (2) key informant knowledge and beliefs about the intervention and tension for change; (3) the relative advantage(s) of the intervention compared with other interventions currently available in the electronic health record (EHR); (4) relevant organizational culture norms and values related to cancer prevention and screening; (5) factors that may foster adoption from a key informant perspective; (6) related external policies and incentives; and (7) the implementation climate
Informants described barriers to and facilitators of Clinical decision support (CDS) implementation and adoption related to constructs in the Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals CFIR domains
Summary
In the United States, primary care providers (PCPs) routinely balance acute, chronic, and preventive patient care delivery, including cancer prevention and screening, in time-limited visits. Introducing clinical decision support (CDS) into the electronic health record (EHR) provides an avenue for triggering cancer screening and prevention reminders for PCPs and patients, supporting the Chronic Care Model [2]. Computerized CDS systems can perform multiple tasks These include identifying patients who could benefit from evidence-based interventions, presenting prioritized evidence-based prevention and treatment options to both patient and PCP at the point of care, and facilitating efficient ordering of recommended treatments, screening tests, medications, or referrals [3, 4]. Decision aids provide written information on the type of cancer, screening or treatment options, risks, benefits, and questions or statements designed to help patients decide how to proceed
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