How Implementation Context Shapes Clinician Acceptance and Engagement with Guideline-Based Clinical Decision Support Systems in Primary Care: A Qualitative Study.

Background: Guideline-based clinical decision support (CDS) tools have become central to promoting evidence-based, high-quality primary care. Despite widespread implementation, clinician adoption and sustained use remain inconsistent. Existing research has typically examined technological usability or organizational implementation factors separately, providing limited understanding of how these influences interact in real-world primary care settings. This study examined how organizational implementation context and clinician technology acceptance jointly shape adoption and sustained use of guideline-based CDS tools in US primary care using an integrated Consolidated Framework for Implementation Research (CFIR) and Technology Acceptance Model (TAM) perspective. Methods: A qualitative study using reflexive thematic analysis was conducted with 13 US primary care clinicians, including physicians, nurse practitioners, physician assistants, and pharmacists with prescribing authority. Participants were purposively recruited from diverse ambulatory settings. Semi-structured interviews explored experiences with CDS usability, workflow integration, organizational support, trust, cognitive burden, and implementation processes. Data were analyzed iteratively using Braun and Clarke's reflexive thematic analysis, informed by CFIR and TAM. Results: Six interrelated themes emerged. Clinician acceptance and sustained use of CDS were shaped by (1) workflow integration, (2) organizational legitimacy and leadership support, (3) preservation of clinical judgment, particularly with emerging AI-enabled CDS, (4) social reinforcement and team-based implementation, (5) cognitive and resource constraints, and (6) clinician role, experience, and digital comfort. Across themes, acceptance was driven less by technological capability than by the interaction of workflow design, organizational context, implementation climate, trust, and clinician perceptions. Conclusion: Guideline-based CDS implementation is fundamentally a sociotechnical process requiring alignment between technology, workflow, organizational context, and clinician acceptance. Integrating CFIR and TAM provides a comprehensive framework for understanding these interactions. The findings informed the TRUST framework, which offers practical implementation guidance emphasizing tailored workflow integration, reinforced organizational legitimacy, usability, social reinforcement, and transparent, trustworthy AI-supported CDS to support sustainable implementation in primary care.