Background  A growing body of literature documents the value of decision support interventions (DESIs) in facilitating patient participation in preference sensitive decision making, but little is known about their implementation in routine care. Objective  This study explored barriers and facilitators to prescribing DESIs in primary care. Setting and participants  Four community‐based primary care practices across Los Angeles County serving diverse low and middle income populations participated. Design  The first phase focused on implementing DESI prescribing into routine care. Weekly academic detailing visits served to identify barriers to DESI prescribing, generate ethnographic field notes and record DESI prescriptions. The second phase explored the impact of a financial incentive on DESI prescribing. At the project’s conclusion, each physician completed an in‐depth interview. Results  The four practices prescribed an average of 6.5 DESIs a month (range 3.6–9.2) during Phase I. The financial incentive increased DESI prescribing by 71% to 11.1 per month (range 3.5–21.4). The estimated percentages of patients who viewed the DESI were 37.9 and 43.9% during Phases I and II, respectively. Qualitative data suggest that physician buy‐in with the project goal was crucial to DESI distribution success. Competing demands and time pressures were persistent barriers. The effects of the financial incentive were mixed. Conclusions  This study confirmed the importance of physician engagement when implementing DESIs and found mixed effects for providing financial incentives. The relatively low rate of DESI viewing suggests further research on increasing patient uptake of these interventions in routine practice is necessary.