Table 3.

Select salient challenges and illustrative quotes

Current challenges	Key informant quotes
Prioritization   Absence of patient input in prioritizing topics for PC CDS	“We often don’t generate the evidence with the patient engaged in the conversation. Whatever you do downstream in terms of the interaction about the compliance or behavior change … or whatever, it pushes it more towards doing what the clinicians want, or believe, is correct…” (Federal Stakeholder)
Authoring   Variations in guideline translation	“Everyone uses a different methodology to create recommendations and then they write them up in ways that are not understandable to clinicians, let alone people who haven't read and reviewed the literature. So, it's really starting at the top and making all of the guidance clear to follow…I think once we get that done … the wobbliness of the interpretations of the differences in implementation will slowly phase out; there will be less wiggle room about what people should be doing and the specific situations.” (Implementing Partner)
	“…the more we can have centralized sources that keep [knowledge] up [to date] and translate clinical guidelines into structured logic that EHRs can look to, [the easier it will be for] the rest of us to do the implementation and work with people in clinical settings to use them.” (Healthcare Provider)
Implementation   Limited understanding of patient decision-making Need for translation of decision-making best practices into PC CDS development Lack of alignment of PC CDS modalities with patients’ daily lives	“Some people are early adopters and they'll take a new device or they'll try new things. But for a lot of people … if it's not really easy for them to incorporate what they already do, they're probably going to forget about it or not use it.”(Researcher)
	“You can’t expect someone to be sitting on a bus and thinking about cancer treatment. You expect them to be in a place that is somewhat comfortable, maybe looking at a computer screen and looking at a pamphlet and writing things down and doing a cost benefit structure. I think that envisioning the environments where people are going to use these tools will help. (Federal Stakeholder)”
Measuring   Limited research that measures or compares methods for increasing patient and provider engagement	“I think one of the areas [for future investment] clearly is in consumer engagement and what are the methods that work and don't work, and what are the key criteria that have to be met to actually successfully engage consumers in their care. That is … a huge remaining issue, because you can create all this cool technology, you can push all this stuff out, but if you don't really get people's attention, you've done nothing.” (Health IT Vendor)
External factor   Lack of patient and provider trust in app safety and efficacy	“We want to be providing them the ability to make decisions for themselves and to make sure that what goes out is safe. We need research on the effect of apps and safety of apps for patient care and patient-centered decision support.” (Implementing Partner)
	“There probably should be some industry-wide principles or style guides saying here is the safe and effective thing to do for a consumer facing app…on the consumer side of the apps today is that there is no downside to making a mistake. When we talk about managing diabetes or your sleep apnea or whatever at home the intended or unintended outcomes will become more important and these principles will need to be established.” (Health IT and App Vendor)