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)

CFIR Domains & Constructs	Barriers	Count	Facilitators	Count
I. Intervention Characteristics
B. Evidence Strength and Quality	Concern about inaccuracy or conflicting CDS recommendations compared to healthcare system recommendationsa	9	CDS follows USPSTF recommendations	3
C. Relative Advantage			CDS improvement over current EHR alerts and tools	18
			Potential for time savings	7
			CDS similar to current EHR alerts and tools	5
D. Adaptability			Optimize CDS integration into clinic workflow	22
G. Design Quality and Packaging	CDS duplicates or complicates care	11
II. Outer Setting
A. Patient Needs and Resources	Financial costs to patients	11	Patient self-educationa	10
	Patient socioeconomic disparities	5	Patients controlling own healtha	9
	Patient transportation issues	4	Organization increasing PCP patient visits from 18 to 22 a daya	8
			Reminders to patientsa	5
			Repeated exposure for patientsa	5
			Focus on prevention over crisis or acutea	5
			Lung cancer screeninga	3
D. External Policy and Incentives			Positive impact on quality metricsa	11
III. Inner Setting
C. Culture			Alignment with institutional aimsa	16
D. Implementation Climate
1. Tension for change	PCP time limitationsa	25	PCP time limitations are manageable	5
	Alert fatigue (PCPs and/or patients)	25
2. Compatibility	Not appropriate for acute visits – annual only	9	CDS appropriate for many visit types	5
	Not everything in the EHR is accurate or easy to find	9	Others than PCPs using CDS:	22
	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	22
			RNs using CDS during Medicare annual Wellness visits	14
			RNs using CDS alongside other PCPs	4
			Clinic rooming staff using CDS	4
			Get CDS printouts to patients before provider (e.g., pre-visit use, before PCP enters room)	18
			Alignment with institutional aimsa	16
			Institution-wide streamlining of EHR alerts	9
			Team model of care	8
3. Relative Priority	Seen as just another initiative	10
	Organization increasing PCP patient visits from 18 to 22 a daya	8
	Lack of institutional initiative prioritization	3
4. Organizational Incentives and Rewards			Positive impact on quality metricsa	11
E. Readiness for Implementation
2. Available Resources	PCP time limitationsa	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	16
	E-learning not always effective	6	E-learning or webinars are acceptable	6
			Provide PCPs with supporting CDS evidence	6
			Focus on workflow in training	5
			Provide multiple learning points	4
IV. Characteristics of Individuals
A. Knowledge and Beliefs about the Intervention	Concern about inaccuracy or conflicting CDS recommendations compared to healthcare system recommendationsa	9	Patient self-educationa	10
	PCP distrust of HPV vaccine or cancer risk calculators	3	Patients controlling own healtha	9
			Reminders to patientsa	5
			Repeated exposure for patientsa	5
			Focus on prevention over crisis or acutea	5
			Lung cancer screeninga	3

CFIR - Damschroder et al. [19]. Sample size (n) refers to number of informants interviewed. Count refers to the number of informants that mentioned a specific barrier or facilitator

^aCode fit with two CFIR constructs. Could also be a barrier for one construct and a facilitator for another