Large Health Systems’ Prevention Guideline Implementation: A Qualitative Study

Abstract

Health systems now employ more than half of U.S. physicians. They have the potential to affect primary care through decision support and financial incentives around clinical prevention guidelines. The processes by which they respond to and implement clinical guidelines remain largely unexplored. In 2015, the research team conducted and analyzed interviews with quality leaders from eight hospital-based systems and one physician organization which together employ >33,000 physicians and serve >15 million patients. Executives explained organizational processes to adapt, adopt, disseminate, and incentivize adherence to preventive services guidelines. Nearly all have a formal process for reviewing and refining guidelines, developing clinician support, and disseminating the approved guidelines. Internal and external factors like organizational structure, patient demographics, and payer contracts affect the review processes and resulting guideline adaptations. Challenges to guideline uptake include competing demands on clinician time and the absence of accurate and timely patient data in accessible and user-friendly formats. Interviewees reported that engaging clinicians in guideline review is critical to successful implementation. Electronic health record reminders represent the primary tool for guideline dissemination and reinforcement. Interviewees reported widespread use of performance monitoring and feedback to clinicians, with varying levels of success. Most organizations use financial incentives tied to performance for some of their clinicians, although details vary widely depending on network structures and contractual arrangements. Health systems play a critical intermediary role between guideline-developing organizations and practicing clinicians. Strengthening the adoption of guidelines requires attention to many factors beyond care delivery.