Implementing shared decision making in the everyday work of clinicians providing cardiovascular preventive care: evaluating the implementation of an electronic encounter tool in three U.S. healthcare systems

Shared decision making (SDM) is guideline-recommended for primary prevention of cardiovascular (CV) disease, but there are barriers to routine adoption of tools to promote SDM. This pragmatic trial evaluated the effect of tailored strategies on implementation of an SDM tool ( CV Prevention Choice ) used during clinical encounters. Fifteen primary care and preventive cardiology sites within three U.S. healthcare systems participated. Outcomes were organized using the RE-AIM evaluation framework and included reach (number, proportion and characteristics of patient encounters), adoption (clinician uptake), implementation (fidelity), and maintenance (sustained use). Effectiveness is not reported here. Data included electronic health record (EHR) encounter data, surveys and interviews with clinicians and administrators, periodic reflections with implementation facilitators, and site visits. Surveys and EHR data were analyzed descriptively. Qualitative data were analyzed using content analysis and the Consolidated Framework for Implementation Research. We explored fidelity by reviewing a sample of video-recorded encounters. Between May 2021 and January 2025, 136 surveys, 38 interviews, 65 periodic reflections, and 6 site visits were completed. CV Prevention Choice was used with 3031 patients. The 76 clinicians (43%) considered adopters used the tool a median of 22 times (IQR 5–61, range 2 to 330). The top quartile of adopters (≥ 61 encounters with tool use) used the tool in a median 20% (range 10 to 53%) of encounters. The tool was used with older patients, more likely to have prehypertension and borderline-high total cholesterol. Key determinants of implementation were clinician perceptions about the SDM tool, its advantage compared to extant EHR resources, and the perceived time it would take to use it. The most successful strategies were at-the-elbow demonstration, using patient cases and conducted during site visits, and site-level clinical champions. Tool use increased from 0.8% of encounters in usual care to 4.9% in active implementation and 8% in the maintenance phase. While exploratory, analysis of video-recorded encounters suggests moderate fidelity to implementation. Integration of an SDM tool in the EHR led to modest adoption, which increased with tailored strategies. Sustainability should focus on improved functionality of embedded tools, workflow adaptations to expand care team involvement, and potentially EHR alerts that identify eligible patients. SDM tools may support organizational initiatives connecting SDM to quality metrics. The protocol described herein was registered with ClinicalTrials.gov on 22 June 2020 (No. NCT04450914).