Cancer prevention, screening, and shared decision-making between patients and PCPs may be enhanced by EHR-linked CDS systems and SDMT. Tailored, patient-focused CDS interventions utilizing a team approach may also reduce PCP workload burden and burnout. In this paper, we describe incorporating cancer prevention and screening CDS into an existing cardiovascular CDS that was shown to be effective in previous research [39,40,41,42]. We then adapted the cancer prevention and screening CDS to the rural multi-state healthcare system’s goals and culture prior to implementation. We did so through engaging with and gaining feedback from leaders and providers, including by attending primary care medical group and other healthcare system meetings, interviewing key informants [15], and pilot testing the CDS and SDMT. Although we added a new SDMT study arm, medical assistants and other rooming staff still present patients with cancer prevention CDS materials for discussion with their PCP as supported in the literature [17,18,19,20,21,22,23]. The healthcare system encourages a team model of patient care, which our revised protocol supports.
CDS systems are often complex, requiring extensive algorithms and coding to correctly capture EHR cancer prevention and screening orders and patient medical history data. With over 50 years of development, CDS still face barriers to use [43]. CDS systems appear to require thoughtful integration into existing clinic workflows in order to be adopted by busy PCPs. In 2003, Bates and colleagues presented the “Ten commandments for Effective Clinical Decision Support” [44], which still hold true today. Speed really is still everything [44], especially in primary care settings. While the goal of the cancer prevention CDS is to anticipate patients’ cancer prevention and screening needs and deliver them to patients and providers in real time, interventions like the cancer prevention CDS will only be adopted and used if it fits into exiting workflows without hard stops and if it is user-friendly [44]. Our key informants emphasized the importance of each of these areas [15], as well as the need for continual monitoring and maintenance of CDS performance [44], which we attempted to address in the CDS design. However, although we conducted a 6-month silent pilot in one non-study healthcare system clinic and a 7-week live pilot in two additional non-study clinics, we discovered post-implementation that neither were long enough to capture or correct all potential issues. The site Principal Investigator, project manager, and research coordinators traveled to all 26 intervention arm clinics to provide in-person, on-site CDS training for clinic rooming staff, PCPs, and management. Additional adaptations were made based on clinic feedback received after going live with the intervention and included developing and implementing half page SDMT that automatically print with the patient and provider CDS handouts. This was primarily due to the length of the full length SDMT, which range from 2 to 4 pages, and the amount of paper that was being printed. Full length SDMT are still available for printing within the CDS interface in the EHR. We also uncovered and addressed multiple printer issues, some related to clinic computers not being correctly mapped to network printers, driver issues, and/or printer firmware. However, unidentified printing problems continue to be an issue for some clinics. Furthermore, to encourage usage, we instituted an incentive program for clinics that consistently have high CDS utilization. Since the cancer prevention CDS intervention went live in June 2018, we have also continued to engage with our primary care clinics and healthcare system leaders. The study is currently in a 12-month follow-up period, after which full study results will be available. We are continuing to monitor CDS use, troubleshoot technical issues as they arise, and collect data from patients, PCPs, rooming staff, and clinic leaders to further inform our ongoing D&I efforts.
Transportable lessons
Based on our experiences, we can share seven transportable lessons for other researchers modifying current CDS systems pre-implementation.
1. One size does not fit all
We recommend following models of CDS that have proven track records for success, while being prepared to adapt to unique site characteristics prior to implementation. A CDS system that works well in one healthcare system or setting may not translate into another. Although the cancer prevention CDS was integrated into an existing and successful cardiovascular CDS that was based in urban settings [39,40,41,42], we had to make adaptations for it to function most effectively with new clinical domains and in a new healthcare system setting with a more rural population and different clinic resources. Moreover, the team had to adapt the implementation strategy given each clinic’s unique culture around cancer prevention, the use of the EHR to address cancer prevention, as well as overall clinic interest in using the integrated CDS.
2. Use a guiding framework – or more than one
The research team selected the CFIR as one of our guiding D&I frameworks in the grant writing phrase and used it when conducting our key informant interviews [15]. However, since that time, Van de Velde and colleagues published the GUIDES checklist that is specifically focused on helping CDS developers create more successful CDS [45]. Medlock and colleagues also proposed a “two-stream model” that CDS developers can use as an additional checklist for identifying potentially influential barriers and facilitators to CDS effectiveness [46]. Greene and colleagues recently outlined a number of additional models and frameworks related to CDS, noting that more than one may be needed due to the complexity of CDS [44].
3. Gain front-line key informant input early – and sustain those relationships
Early feedback from front-line CDS users, such as clinic rooming staff and PCPs, may be most helpful in designing a CDS intervention that works best with or can adapt to clinic workflow. Plan on sustaining those relationships while continuing to identify and adapt to healthcare system concerns after implementation through routine solicitation of feedback. Doing so could not only continually improve the intervention, but also make it easier to undertake future pragmatic trials within the healthcare system.
4. CFIR domains and constructs may overlap or not be applicable pre-implementation
Although the CFIR was designed to eliminate redundancies between other implementation frameworks [26], we found that multiple CFIR domains and constructs could apply to a single change. We encourage others to interweave CFIR domains and constructs as needed to more completely describe changes made [26]. Also, not all CFIR domains or constructs may be appropriate pre-implementation. Other models, frameworks, or checklists more specific to CDS [44], like the GUIDES checklist or “two-stream model” [45, 46], could also be applied during CDS development in addition to the CFIR.
5. Do not underestimate the challenges of technology
Algorithms working between two organizations using different versions of the same EHR, including differing codes, made it difficult to programmatically search EHR reports and scanned documents. We engaged study healthcare system information support staff during CDS development and implementation to troubleshoot these issues as they arose. As we noted, we experience multiple issues with printers used by primary care clinics for printing patient materials. The research team has continued working on printing issues during the intervention and follow-up periods, troubleshooting problems as they arise.
6. Start small
Prior to implementation, we anticipated that the CDS would print at a higher frequency than the cardiovascular CDS and that doing so would drive utilization down – it did at first. Big changes within an existing intervention may be best accomplished with small stepwise changes over a longer period of time rather than all at once.
7. Prepare for continual adaptation
Do not be afraid to continue modifying your intervention if it is apparent that there are significant issues in the workflow across many intervention clinics. The nature of pragmatic CDS studies across multiple primary care clinics within multiple states requires adaptability. Clinic workflows will differ, CDS recommendations will change, technology will advance, and you must be prepared to take seriously the feedback you receive from PCPs, rooming staff, and leadership. Modifications will be required if the same feedback is received over an extended period of time.
Limitations
This study did have limitations. This paper only focuses on pre-implementation changes made based on barriers and facilitators identified from the perspective of healthcare system leaders, providers, PCPs, medical assistants, and other rooming staff. Additional post-implementation D&I efforts are planned with these individuals, as well as with patients. However, study team members carefully reviewed the intervention and protocol changes presented here for accuracy. We also reported separately the results from our key informant interviews, which led to some of the changes described here [15]. Another limitation is that we report no statistical results in this paper, as quantitative data were unavailable on the cancer prevention CDS prior to full implementation. However, the primary aims of the overarching randomized control trial include evaluating the effectiveness of the cancer prevention CDS, the results of which will be published at the end of the trial.