Table 1.

Clinician and Practice Leader Perspectives on Factors Affecting Implementation of Changes in Evidence

Themes and Findings	Example Quotes
Patient Factors
Trust and fear strongly influence patient decisions Patients largely rely on clinician recommendations Patients appreciate clinicians explaining how a guideline applies to them Guideline changes can foster patient distrust Doing less sometimes makes patients feel less cared for Personal experiences influence decisions Patient education (mostly) helps guideline adoption Informed patients are typically more engaged and activated But being more engaged does not always mean ready to change Less engaged patients may do whatever their doctors recommend Misinformation can undermine evidence-based care But being accurately informed about the evidence does not necessarily mean a patient will want to follow the evidence	“I think most patients just want you to make a recommendation. Like prostate cancer, I support informed decision-making and they say, ‘just tell me what to do.” (Clinician) “I always knew that doing yearly paps was not a good idea…A lot of that stuff, especially when it’s less services, I’m only doing because patients are so used to it.” (Clinician) “Quite a few folks are leery about statins. The’ve seen ads on TV saying there are potential side effects. ‘I know my Aunt Suzi had problems and I’m not going to do that to myself.’” (Clinician) “I think our population is pretty well educated but, by the same token, they’re also creatures of habit. Nobody likes change; everyone resists change.” (Practice Leader) “Sometimes people educate themselves and are all for following guidelines, other folks have educated themselves and have determined they are pretty hesitant.” (Clinician)
Clinician Factors
Clinicians believe in tailoring guidelines to individual patients Clinicians pride themselves on knowing their patients Clinicians like to discuss guidelines and share decisions with patients Clinicians may prioritize other patient needs (co-morbidities, patient beliefs, cost) over guidelines Clinicians’ personal beliefs impact guideline adoption Clinicians are quicker to adopt guidelines that they agree with and make sense Clinicians’ personal healthcare experiences at times inform guideline recommendations given to patients De-escalating services can create fear of missing something Negative patient outcomes from prior misses can increase fear	“I’m a big believer in kind of the mutual decision; not just me telling them what to do, and realistically if they don’t believe what I’m saying they won’t do it anyway.” (Clinician) “We had a patient who died of cervical cancer and she had had a Pap smear six months before that was normal …you know if you’re counting on a test to give you a five year pass, that’s a long time.” (Clinician) “I always knew that doing yearly Paps was not a good idea. I was sort of waiting for that to happen.” (Clinician)“Mammography…I tell them that I personally am experimenting on myself with every other year but I let them decide.” (Clinician)
Practice Factors
Attention to workflow and staff roles support guideline implementation Integrating guidelines into clinic workflow decreases dependence on clinician memory Clinical support staff who work at the top of their licenses can enhance the promotion of guidelines Practices dedicated protected time to define workflow and roles Practice culture shapes the adoption and implementation of evidence-based guidelines Practices work to continually evolve and become better Having a teaching mission helps build a culture of evidence-based care and keeping up-to-date with guidelines. Practices have regular meetings to share knowledge about care Clinicians and staff who participate in committees to define health system policies carry knowledge back to their practices Practices view quality improvement as a continual process	“When we weren’t getting workflows going for new guidelines, some providers were doing it and some weren’t and it was sort of left up to memory…sometimes you leave too much up to the individual provider and there’s just too much to keep in your head.” (Clinician) “We’re trying to have the nurses [sic] be the frontline more and more…They are protecting the provider’s time…” (Clinician) “Once a month [we hold] a provider meeting where we do peer review…[and discuss] case studies or interesting fun facts.” (Practice Leader) “We participate in a couple of committees…then there are practice councils that our nurses attend…I would say updates regarding guidelines come through all those different avenues ” (Practice Leader)
Health System Factors
Maintaining EHR functionality is the main way health systems promote guideline adoption and implementation EHR alerts are useful for reinforcing and reminding clinicians about guidelines EHR templates and standing orders can further incorporate rooming staff into workflow when implementing a new guideline Patient portals can help communicate guidelines to patients There are noticeable gaps in EHR alerts and functionality Health systems standardize guideline adoption and implementation processes Health system committees often review and make recommendations about guideline implementation Practices typically cannot institute major changes in guidelines without approval by the health system’s quality committee. Financial interests and input from specialists can shape health system guideline recommendations	“The quality tab has been very helpful because of the prompts that it offers you for things that you might have otherwise forgotten.” (Clinician) “We are guided into following or keeping up-to-date on guidelines because it’s entered in the medical record…it flags us that somebody is due for something.” (Clinician) “If it’s something that is brand-new, like when Shingrix came out, we take it to the quality [committee] for approval, and then we send an email out to the clinical staff, the clerical staff, and the providers.” (Practice Leader) “Building the algorithm in the EHR is not just a guideline-based recommendation, it has to be a recommendation that the clinical organization agrees with from a financial or strategic perspective…does the screening have a negative financial impact on my organization? That’s where the PSOs and CMOs and COOs decide.” (Clinician)
Environmental Factors
Media and specialists can promote both evidence-based care and unnecessary care Patients increasingly hear about prevention through ads Specialists may promote services that do not follow guidelines For-profit organizations often promote unnecessary services Traditional barriers to care were reported, but resources and solutions existed to help patients Clinicians and staff generally reported good access to care Health systems and communities try to reduce barriers to care Insurance coverage for prevention improves access to care, but lag time in coverage can delay adoption of new guidelines	“It all depends on the marketing of different things…like for the new shingles vaccine, people are just coming to us like crazy.” (Practice Leader) “For colonoscopies, we got an arrangement with the local hospital medical group to take four to five uninsured patients per year to do colonoscopy” (Clinician) “At a talk we had one time from an oncologist…he said he’s been ordering [low dose chest CT for lung cancer screening] on all his patients now…he was completely unaware of the ages, the pack-year, nothing.” (Clinician) “They came out with the Prevnar recommendation, but Medicare didn’t cover it for about a year. What good does it do if everybody’s 65 and they don’t have coverage?” (Clinician)
Guideline Factors
Some guidelines are easier to adopt and implement If they can be incorporated into workflow If they can be programmed into the EHR as an alert If they can be appropriately measured for audit and feedback If patients who benefit from the services can be clearly identified Some guidelines are harder to adopt and implement If they frequently change or change more radically If there are differing guidelines from multiple groups If the topic is less familiar to patients If the results can be difficult to explain to patients If they involve services outside the clinic	“Now that we have that built into our workflow to offer lung cancer screening to patients who qualify, that’s been something we’ve gotten better about.” (Clinician) “I think having the risk calculators…having some numbers to discuss with people about what we think their risk is and how much the risk might be reduced if they took medicine, I think that’s helpful.” (Clinician) “AAA screens…It’s not one of our core quality measures…It’s not a meaningful-use measure…I haven’t ignored it…but I haven’t directly addressed it because I feel like we’re working on so many quality things.” (Clinician) “Mammography is a little harder…the guideline has changed so many times over the years.” (Clinician)

EHR, electronic health record; PSO, patient safety organization; CMO, Chief Medical Officer; COO, Chief Operating Officer; CT, Computed Tomography.