|CFIR Domain & Related Constructs||Change Number||Elements of the Initial Protocol||Barriers|
|New Protocol (Change Made)||Source of Barriers or Facilitators Encountered|
|I. INTERVENTION CHARACTERISTICS|
|D. Adaptability||The degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs.|
|1||Cancer prevention CDS providers to include PCP physicians, advanced practitioners, and medical assistants.||Intervention arm with medical assistants replaced by an arm where PCPs receive SDMT for eligible patients. Medical assistants no longer considered as study primary care providers.||The cardiovascular CDS system was being triggered for registered nurses conducting Medicare Annual Wellness Visits.||Cancer prevention CDS PCPs include registered nurses conducting Medicare Annual Wellness Visits in both intervention arms. Along with other rooming staff, medical assistants continue to receive the best practice alert that triggers printing of the cancer prevention CDS in both the integrated CDS and integrated CDS + SDMT intervention arms.||Pre-implementation engagement (Healthcare system cardiovascular CDS team members).|
Key informant interviews.
|2||Cancer prevention CDS used the phrase “smoking cessation” and state quit telephone lines.||Healthcare system refers to “tobacco cessation”.||The healthcare system had recently initiated a tobacco cessation counseling program.||Rephrased to use tobacco cessation wording and tobacco cessation counseling referrals used by the healthcare system.||Pre-implementation engagement (Healthcare system primary care leaders and technology learning and support staff).|
Key informant interviews.
|3||Risk calculators for breast [29, 30] and colorectal cancers .||Healthcare system offered lung cancer screening.|
Healthcare system leadership asked for a lung cancer risk calculator to be included.
|Added a lung cancer risk calculator .||Pre-implementation engagement (Healthcare system primary care and other leaders).|
|E. Trialability||The ability to test the intervention on a small scale in the organization, and to be able to reverse course (undo implementation) if warranted.|
|4||Cancer prevention CDS trigger for body mass index alone.||Pilot testing showed frequent triggering of the cancer prevention CDS based on body mass index alone.||Healthcare system-level goal to address body mass index. Body mass index also triggers the cardiovascular CDS.||The cancer prevention CDS only triggers for body mass index if at least one other primary or secondary cancer area is also triggered.||Pre-implementation engagement (Healthcare system primary care leaders).|
|F. Complexity||Perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement.|
|5||Separate cancer prevention and cardiovascular CDS systems.||Potential burden of two separate CDS systems on PCPs.||One institution is designing both CDS systems.|
Preference for a single system by healthcare system leadership.
Different implementation and intervention dates.
|Integrating cancer prevention with cardiovascular risk assessment in one CDS system.||Pre-implementation engagement (Healthcare system primary care and other leaders).|
|6||Cancer prevention CDS PCP goal-setting function and patient follow-up and monitoring plan.||Inconsistent patient follow-up and monitoring infrastructure across the healthcare system’s three markets.||Healthcare system has own system of best practice advisories and screening and prevention recommendations within the EHR.||Eliminated CDS goal-setting function and patient follow-up and monitoring plan.||Pre-implementation engagement (Healthcare system staff managing patient communication).|