Improving the Implementation of Lung Cancer Screening Guidelines at an Academic Primary Care Practice Alison T. Brenner · Laura Cubillos · Katherine Birchard · Caleb Doyle-Burr · John Eick · Louise Henderson · Laura Jones · Michael Massaro · Bailey Minish · Paul Molina · Michael Pignone · Shana Ratner · Maria Patricia Rivera · Daniel S. Reuland ABSTRACT Expert groups recommend annual chest computed tomography for lung cancer screening (LCS) in high-risk patients. Lung cancer screening in primary care is a complex process that includes identification of the at-risk population, comorbidity assessment, and shared decision making. We identified three key processes required for high-quality screening implementation in our academic primary care practice: (1) systematic collection of lifetime cumulative smoking history to identify potentially eligible patients; (2) visit- based clinical reminders and order sets embedded in the electronic health record (EHR); and (3) tools to facilitate shared decision making and appropriate test ordering. We applied quality improvement techniques to address gaps in these processes. Over 12 months, we developed and implemented a nurse protocol for collecting complete smoking history and entering that data into discrete EHR fields. We obtained histories on over 50% of the clinic’s more than 2,300 known current and former smokers, aged 55–80 years. We then built and pilot tested an automated visit-based reminder (VBR) system, driven by the discrete smoking history data. The VBR included an order set and template for documentation of shared decision making. Physicians interacted with the VBR in approximately 30% of opportunities for use. Further work is needed to better understand how to systematically provide appropriate LCS in primary care environments. Keywords: lung cancer screening, electronic health record, shared decision making Introduction The US Preventive Services Task Force (USPSTF) now recommends lung cancer screening (LCS) with annual low-dose computed tomography (CT) for patients aged 55–80 years with at least 30 pack-years of smoking history who currently smoke or quit fewer than 15 years ago. 1 Lung cancer screening is a complex process requiring population identification based on cigarette smoking history, comorbidity assessment, shared decision making (SDM) including use of a decision aid, multidisciplinary care coordination, and systematic management of lung nodules. Identi- fying high-quality implementation approaches is critical particularly because screening can lead to both harms and benefits, even under the ideal conditions of the National Lung Screening Trial. 2,3 Expert groups have offered general guidance on implementation, but operationalizing such guidance is challenging. 4 Within the field of implementation science, quality improvement (QI) programs play an important role in translating high-quality evidence and guidelines into real-world settings, such as primary care practice. 5 Demonstration projects within large health systems may be useful for developing systems and protocols for a screening program. The Department of Veterans Affairs (VA), for example, conducted an LCS demonstration at eight VA medical centers over 2 years, allowing for the development of system-level tools and protocols for population identification, tracking, and follow-up. 6 However, although many U.S. health systems are becoming increasingly in- tegrated, most are substantially more fragmented than the VA system. Thus, other models for developing, testing, and implementing LCS are needed. In this article, we describe components of a 1-year, institutionally funded QI project. We report on interventions to address three key quality gaps identified Journal for Healthcare Quality, Vol. nnn, No. nnn, pp. 1–9 © 2017 National Association for Healthcare Quality M. Pignone is a member of the US Preventive Services Task Force. The views presented here are not necessarily those of the Task Force. The remaining authors declare no conflicts of interest. For more information on this article, contact Alison T. Brenner at alison.brenner@unc.edu. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and in the HTML and PDF versions of the article at www.jhqonline.com. DOI: 10.1097/JHQ.0000000000000089 Journal for Healthcare Quality Month 2017 · Volume 0 · Number 0 1 Original Article Copyright Ó 2017 by the National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.