Table 4.

Representative quotations of clinicians’ perceptions of dimensions of acceptability by specialty.

Dimension of acceptability	Primary care providers	Cardiologists	Surgeons
Affective attitude How an individual feels about the intervention	“I think it’s a really good patient safety initiative. I think the harms, potential harms of antiplatelet therapy are just now being recognized, even within medicine, much less than kind of the lay public, and so this is just kind of one more step away from the reason why we’re not putting aspirin in the water, right, because of the internal bleeding risk, especially for the older folks, many of whom have a. fib or whatever and are on DOACs or warfarin.” – PCP 4 "First of all, I love, you know, if there’s someone identified who would benefit from evidence-based change that I’m not perfectly aware of, it’s hard to find all these little things to manage. It’s really nice when it’s something that can be a high-risk thing, to give me awareness of that. So, I really appreciate that." – PCP 2 “I would be ticked if I got another portal message because you sent them [my patients] something in between appointments. Ugh…There ought to be an email to all of us saying, ‘this is a project over the next 6 months, or the next year, people who fall into this category of being high risk for GI bleed on anticoagulation and not on omeprazole will receive a letter to discuss with their doctor whether to start a PPI or stop one of their medications’. I mean, to hit me, to have no idea where this came from. And you don’t understand how many times people say, ‘oh, I saw this on the internet.’ So, I would have no idea what, and patients are frequently very inarticulate about where things came from.” – PCP 5	“I am [interested in receiving more messages like this]. I consider them my patients and if I make mistakes or it needs to be reviewed, I certainly want to know about it.” – Cardiologist 1 “I mean the inbox is the inbox, you know how that goes. But it’s like I said, this is important and it’s important enough that I certainly didn’t mind receiving messages about it.” – Cardiologist 2 “Yes, I think it makes sense [to continue sending clinician notification messages]. I mean, it’s a good checkup. Sometimes you don’t think about – how many people have those drugs on for years, and you just don’t think about or forget about it or whatever.” – Cardiologist 3	“I recommend that you continue sending them [clinician notification messages] because I think it’s important. The more redundancies we have to the system in this way, I think is better. I think too, I do like the idea of patient outreach because some patients are just super adamant against taking another medication, and I’ve had patients just refuse, because they just don’t want another medication and they don’t see it as necessary. So, getting some good education to the patients I think is important.” – Surgeon 3 “I don’t know if it’s just surgeons. We’re all so damn busy that, you know, this is not as much of a burning platform for me as it is for you, so I’m not going to read this [notification message].” – Surgeon 2
Burden The perceived amount of effort that is required to participate in the intervention	Interviewer: “Did it take much time to sort of like think through whether the patient should stop his aspirin or start the PPI?” Clinician: “A little bit, just because they weren’t on my radar, and I didn’t know them that well. But if it was someone that I knew a little bit better, probably wouldn’t have. And I think that the person that I don’t know very well, it’s even more important to send me that information.” – PCP 2 “It probably took me a half hour of time to take care of this one person. So, that would be the other thing is how do we streamline this because it wasn’t easy. You know, I had to page back years to find a neuro-ophthalmology consult and then they didn’t actually consult hematology, they did a verbal or written consult, it was written but it wasn’t a visit, so I had to figure out does this person actually need to see hematology or, you know how do we get there from here. So, it wasn’t, it’s not something that’s a good add-on into the end-of-your-day workbasket.” – PCP 3	“I just think, you know, if I get a lot of, a lot of those letters, it takes a lot of time and effort to respond to it, and that, I think, is the issue.” – Cardiologist 1 Interviewer: “Did this [responding to the clinician notifications] feel burdensome or that it was taking you away from other things that you needed to do?” Clinician: “Oh yeah. Every time I get an in basket thing I shudder. But, nevertheless, that’s just life. So [LAUGHS]. But, when it comes to patient safety, then that’s what it is. But, yes, I find it burdensome.” – Cardiologist 3	“I worry a little bit about the length of the message and whether or not it’s too onerous for a busy provider. You know [the name of a surgical APP] is juggling, you know, hundreds of patients and it might be laborious to do that sort of stuff.” – Surgeon 2 "There are lots of medications that cause risk and we do not send letters to providers to ask them whether they want to add other protective drugs to prevent adverse outcomes. Sorry, I am acutely hypersensitive to MyChart [EHR] traffic and workload and don’t want to see this become hundreds of patients I have to respond to about this." – Surgeon 1a
Ethicality The extent to which the intervention has good fit with an individual's value system	“So, who does the patient contact when they a have a bleed or who follows-up when they get hospitalized for the bleed? It’s the PCP, it’s not the specialist. And so I kind of feel like the holistic management of multiple medications kind of falls on the PCP in this situation.” – PCP 1 “I freely admit my immense bias toward prevention, that’s why I do what I do for a living. So, I’d much rather, like I said, I’d much rather that projects like this send more messages to PCPs or cardiologists than have even one patient end up with a preventable GI bleed.” – PCP 4 "So, the only people I have that are on antiplatelet [therapy] are people that cardiology, or occasionally neuro, has put on antiplatelet [therapy]. So, then it’s not my call, it’s their call…The bottom line is when it comes to antiplatelet, it’s neuro and cardiology that have to call that, because I’m never the one putting them on that.” – PCP 5	“I think it’s appropriate that it comes to me. I mean, they’re cardiology patients so we’re the ones usually giving the aspirin and the Coumadin. So, yeah, it would make sense we would make that decision. I wouldn’t send it to the PCP, because then we’re just going to get another message from the PCP, ‘Can I stop the aspirin?’ I would just send it directly to us [cardiology].” – Cardiologist 3 “I think if the question is do you want to stop the aspirin, that’s probably more the question for the general cardiologist than it would be for me. If the question is do you want to stop this anticoagulation, then that might be more for somebody like myself.” – Cardiologist 4, who specializes in cardiac procedures	“It [optimizing medical therapy] is an important thing to address, but I am not going to address it because I don’t have time and it’s not my primary objective.” – Surgeon 1b “We follow the patients until their postop visit and then usually we just release them back to somebody else. Because, you know, we’re their short-term doctor, not their long-term doctor…But we are not necessarily the long-term investment for the patient like a cardiologist is. So, there may be some gain from it, we may respond and make changes to it [medical therapy], but long term I think your bigger bang is going to be through cardiology.” – Surgeon 2
Perceived effectiveness The extent to which the intervention is perceived as likely to achieve its purpose	“I think it generally worked well. You know, I appreciate somebody looking out for those interactions, those things that, you know, I hadn’t really thought about. In his [the patient’s] case, he actually needed both, so it didn’t change anything, but it made me document it more clearly and pull it up to where somebody else can see it. Because one day I’m going to retire or he’s going to change doctors or something. And try to keep that into the problem list as much as we can and not buried back into some computer system that we used to use.” – PCP 3 “So particular to your intervention, I think it’s a great intervention, and in fact, I’ve had one patient that was caught by your QI project. And it turned out, just like can happen, his med [PPI] had just fell off of his medication list and it wasn’t something that I was very practically looking for. He’d been off of it for a year, but he actually had been on a PPI for dual antiplatelet therapy or dual anticoagulation, and it just dropped off his medication list and I didn’t catch it when I saw him that year.” – PCP 1	Interviewer: “So, overall, how effective do you think the messages were in helping you reduce bleeding risk in your patients?" Clinician: “At attempting to reduce bleeding risk? Very effective. If I actually have reduced the bleeding risk, I don’t know yet… No, I think it’s good. It’s a second set of eyes to review stuff.” – Cardiologist 1 “I found the notifications helpful, and I did change some of my patients’ regimens based on the recommendations. I think the format in which the recommendations were delivered also made sense.” – Cardiologist 2 “And I think the problem is maybe moreso the way that our practice works as a proceduralist clinic, too, you know. This may be a more effective means of communication for people that are more clinic-based. But for us, you know, if I’m at work for 10 hours, probably 6 to 8 of those hours I’m scrubbed in without access to a computer. And so, to sit down and try to do some of your Epic stuff and to have these complex ways of responding to communications is really difficult.” – Cardiologist 4, who specializes in cardiac procedures	Interviewer: “So, I don’t know if you recall seeing any of these [clinician notification] messages about this? Clinician: Are they in MyChart [the EHR]?” Interviewer: “They’re somewhere in MyChart [the EHR], yeah.” Clinician: “Yeah, I don’t read any of that shit [LAUGHS]. Way too many things in there to read. I can’t keep up.” – Surgeon 2 “I think it’s a great idea to highlight the risk [of GI bleeding]. I think it’s hard as a nonmedical provider whose clinical pathway is not to prescribe meds and our APPs and nursing support are instructed not to refill meds, they [these alert messages] should go back to the PCP or the specialist who ordered them.” – Surgeon 1b
Self-efficacy The participant's confidence that they can perform the behavior(s) required to participate in the intervention	“It was an opportunity to nip something in the bud before there was a problem. Which, as a primary care, preventive medicine doctor, is my absolute, 100% favorite thing to do. And he [the patient] was like, ‘Great, one less pill a day,’ and like thanked us for letting him know…But it was really nice to have that very clear-cut guidance so we could reach out to him and with a simple phone call from my nurse potentially prevent a disastrous situation.” – PCP 4 “So, in family medicine we think we own everything. But we’d like some time to do that… I think it’s right to send it to family medicine… I might not have the answer, but I can find who [does] and it [the answer] comes back to me, and I prescribe it. That works well. It’s just, do we really have the resources to do it, and to do it well? We’re kind of drowning in that stuff now, but it’s what patients need. So, I think it’s the right thing to do, but whether we can really keep up with it, I don’t know.” – PCP 3 "I think the difficulty with PPIs in general is just the extreme variety of opinions you hear about them and applying that individually sometimes gets lost in the shuffle when we have tried to de-escalate PPI use as a generality in the last 10 years, perhaps." – PCP 1	Interviewer: “One barrier we clearly identified is that people don’t want to stop a drug that someone else has started. It’s like this, you know, stepping on someone else’s toes.” Clinician: “I mean, it’s not even sort of like, am I going to offend that person? It’s more like, do they [the antiplatelet prescriber] know something I don’t know about this patient’s care that means this drug is important. And a lot of times it will seem to me like we could stop it [aspirin], but, you know, I don’t know, was there something else that came up that they [the antiplatelet prescriber] know. That’s sort of the main thing. You know, if the question is would I feel comfortable starting a PPI for somebody, yeah, I’d have no problem with that. It’s more about stopping a drug, I think, that there would be more worries.” – Cardiologist 4 “There are still a lot of folks where we can really safely reduce the aspirin, I think. I am seeing myself doing this. And then, like, we have some patients with really specialty needs, and I really have to think carefully or consult some other providers to see if they should stop the aspirin or not. And those are usually related to patients who recently had CT surgery, and I really want the surgeon to weigh in on stopping the aspirin." – Cardiologist 1	“This type of action was really clunky for me to figure out how to do since I don’t know hardly any of the PCPs in the health system, and I don’t know how to get a hold of them.” – Surgeon 1b “Communications are tough. Like, I’ll look through them… I know some people in my group who have not looked through their encounter communications at all, like because that’s where like all the pathology results and lab results and, you know, they fall into results section, and then the communications they get where they’re cc’d, they don’t even look at those things. And I have some of my partners who have, like, I’m not joking, 1,000 communications that are unread.” – Surgeon 3

APP, advanced practice provider; CT, cardiothoracic; DOAC, direct oral anticoagulant; EHR, electronic health record; GI, gastrointestinal; PCP, primary care provider; PPI, proton pump inhibitor; QI, quality improvement.

^aFrom email communication.

^bParaphrased from interview memo notes.