Barriers and facilitators to implementing cancer prevention clinical decision support in primary care: a qualitative study

Abstract

Background 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. 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. Methods We 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. Results EHR, 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. Conclusion Identifying 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 registration clinicaltrials.gov , NCT02986230 , December 6, 2016. Electronic supplementary material The online version of this article (10.1186/s12913-019-4326-4) contains supplementary material, which is available to authorized users.

Understanding primary care providers’ perceptions of cancer prevention and screening in a predominantly rural healthcare system in the upper Midwest

“…Few studies have assessed PCPs’ attitudes about cancer screening and prevention in predominately rural areas. As noted elsewhere, engaging patients through cancer SDM with PCPs is challenging, particularly given current time constraints in primary care [23, 24]. Although 37% of PCPs were not very prepared to discuss cancer risk factors and screening with patients, less than half (49%) said that the EMR was well integrated to help assess and manage cancer risk.…”

“…Only 53% of respondents said that their patients give cancer screening a high priority in relation to other health services, and this percentage was even lower in advanced care practitioners. This finding could be due to several issues we identified in key informant interviews [24] and through continued engagement with our intervention clinics: lack of time for patients and/or providers to discuss cancer prevention; and patients visiting for acute reasons. Most PCPs also reported that they often do not have enough time to discuss screening or HPV vaccination with patients.…”

“…Strengths of the study included administering a confidential electronic survey, achieving a high survey response rate, and inviting all PCPs who provide ongoing primary care for 25 or more patients to take the survey. A post-intervention implementation PCP survey is planned for future study years to allow assessment of changes in PCP opinions over time following the use of a developed CDS targeted to improve cancer screening and prevention known as the Cancer Prevention Wizard study [24, 28].…”

Assessment of and Interventions for Women at High Risk for Breast or Ovarian Cancer: A Survey of Primary Care Physicians

“…Primary Care Physicians (PCPs) play an increasing role in cancer risk assessment and prescribing of preventive interventions (25). Patients rely on their PCPs to identify their cancer risk and provide recommendations for risk reduction (26)(27)(28).…”

The impact of personalized clinical decision support on primary care patients’ views of cancer prevention and screening: a cross-sectional survey

“…We also have an incomplete understanding of whether shared decision making between patients and PCPs leads to improved cancer preventive care. Shared decision making involves PCPs presenting patients with cancer prevention and screening options, risk, and benefits, including when using decision aids, then assisting patients with making a decision that fits patients’ personal preferences [ 19 , 20 ]. Research shows that shared decision making between patients and PCPs is effective in the decision making process [ 18 ].…”