Facilitators and challenges of implementing a digital patient education programme for rheumatoid arthritis into clinical practice.

BACKGROUND: The integration of telehealth interventions into clinical practice is frequently delayed, hindering the full adoption. Previously, we developed a digital patient education (PE) programme for self-management in rheumatoid arthritis (RA). While the programme design considered crucial factors to ensure the likelihood of success in clinical practice, there is a need for a systematic evaluation of implementation perspectives. The purpose of this study was to explore perspectives crucial to implementation of a digital PE programme in clinical practice. METHODS: The non-adoption, abandonment, scale-up, spread and sustainability (NASSS) framework was used to evaluate the successes and challenges of implementing the digital PE programme. We included a data set consisting of qualitative focus group discussions involving study nurses, rheumatologists, and leaders from rheumatology departments. Data analysis was guided by a deductive content analysis approach. Further we included data from earlier studies pertaining to the programme's implementation, comprising the programme development process, a randomized controlled trial evaluating the programme's effectiveness, and a qualitative study exploring patients' perspectives of the programme. RESULTS: Facilitators and challenges of importance to implementation of digital PE were identified. While a wide range of patients could benefit from using digital PE, future implementation should aim for an even broader group than those studied. Both patients and healthcare providers embraced the technology, and the fact that it did not require specific technical skills enhances its potential for success. However, offering digital PE should be based on individual assessments, and expanding its use will require organizational adjustments. An adaptable structure is needed to accommodate unforeseen care needs that may arise following the use of digital PE at home. There was indication of some reluctance among healthcare providers toward the programme shown by concerns about changing roles, which could impact the adoption of the program. CONCLUSIONS: The design and ease of use of the technology, the program's effectiveness, its availability, and the potential to release healthcare resources may encourage the implementation of digital patient education. Challenges associated with implementing this mode of care pertains to the condition and the patient population, user adoption of the technology, and the organization of patient education. TRIAL REGISTRATION: The study is registered by the Central Denmark Region Scientific Committee (no. 1-16-02-52-19).

Adoption of C-reactive protein rapid tests for the management of acute childhood infections in hospitals in the Netherlands and England: a comparative health systems analysis.

BACKGROUND: The adoption of C-reactive protein point-of-care tests (CRP POCTs) in hospitals varies across Europe. We aimed to understand the factors that contribute to different levels of adoption of CRP POCTs for the management of acute childhood infections in two countries. METHODS: Comparative qualitative analysis of the implementation of CRP POCTs in the Netherlands and England. The study was informed by the non-adoption, abandonment, spread, scale-up, and sustainability (NASSS) framework. Data were collected through document analysis and qualitative interviews with stakeholders. Documents were identified by a scoping literature review, search of websites, and through the stakeholders. Stakeholders were sampled purposively initially, and then by snowballing. Data were analysed thematically. RESULTS: Forty-one documents resulted from the search and 46 interviews were conducted. Most hospital healthcare workers in the Netherlands were familiar with CRP POCTs as the tests were widely used and trusted in primary care. Moreover, although diagnostics were funded through similar Diagnosis Related Group reimbursement mechanisms in both countries, the actual funding for each hospital was more constrained in England. Compared to primary care, laboratory-based CRP tests were usually available in hospitals and their use was encouraged in both countries because they were cheaper. However, CRP POCTs were perceived as useful in some hospitals of the two countries in which the laboratory could not provide CRP measures 24/7 or within a short timeframe, and/or in emergency departments where expediting patient care was important. CONCLUSIONS: CRP POCTs are more available in hospitals in the Netherlands because of the greater familiarity of Dutch healthcare workers with the tests which are widely used in primary care in their country and because there are more funding constraints in England. However, most hospitals in the Netherlands and England have not adopted CRP POCTs because the alternative CRP measurements from the hospital laboratory are available in a few hours and at a lower cost.

Development and feasibility of a telemedicine tool for patients with recurrent urinary tract infection: myRUTIcoach.

INTRODUCTION AND HYPOTHESIS: Patients with recurrent urinary tract infection (rUTI) have limited knowledge of preventive strategies to lower the risk of UTI. We aimed to develop and test the feasibility of an eHealth system for women with rUTI, named myRUTIcoach, and explored the facilitators and barriers related to its adoption. METHODS: We developed myRUTIcoach in a structured iterative process and tested its feasibility among 25 women with rUTI over 2 months. Subsequent questionnaires covered satisfaction, accessibility, and experiences with myRUTIcoach. A random selection of participants and relevant stakeholders took part in semi-structured interviews to explore adoption. Data were analyzed and elaborated using inductive and deductive approaches using the Non-adoption, Abandonment, Spread, Scale-up, and Sustainability (NASSS) framework. RESULTS: MyRUTIcoach was not only widely accepted but also facilitated communication with health care professionals (HCPs) and contributed to greater knowledge of rUTI. Women graded the system a mean of 8.0 (±0.6) out of 10, with 89% stating that they would recommend it to others. Patients indicated that self-management skills were the major facilitators and barriers related to adoption, whereas HCPs stated that the disconnect between myRUTIcoach and electronic health care records (EHRs) was the major barrier. CONCLUSIONS: This research describes the development and testing of myRUTIcoach for women with rUTI. Patients and HCPs reported high satisfaction and compliance with myRUTIcoach. However, adoption by the intended users is complex and influenced by all examined domains of the NASSS framework. We have already improved linkage to EHRs, but further optimization to meet patient needs may improve the effectiveness of this self-management tool for rUTI.

Afterhours telehealth in Australian residential aged care facilities: a mixed methods evaluation.

BACKGROUND: The aged care system in Australia is under pressure. Residential aged care facilities (RACFs) and general practitioners (GPs) have difficulty providing the care needed by their residents, particularly after hours. Many residents are given ambulance support and transferred to hospital emergency departments (EDs) for care that could be provided at RACFs. The MyEmergencyDoctor (MED) service was commissioned in a 12-month program (February 2020-February 2021) using ED physicians to provide afterhours telehealth care in six RACFs. METHODS: Using the NASSS framework, we synthesised descriptive analyses of statistical data from the MED service, RACFs and the ambulance service and a thematic analysis of interview data collected from GPs, RACF and MED service staff, and family members of residents. RESULTS: Most calls to MED (179/209) were resolved with in-house treatment thereby reducing ambulance usage and hospital admissions. Interviews further revealed that MED enabled timely care for residents who were unwell but did not need hospital transfer. Technology, training, and rapid access to MED assisted RACF staff and complemented usual GP care. MED potentially reduced GP burnout. Refresher training was considered important especially in RACFs with high staff turnover, as was greater afterhours access to medications. CONCLUSIONS: The afterhours telehealth model provided in-house care and reduced ambulance transfers, and GPs and RACF staff generally felt supported. The service was easy to use and fostered good communications with GPs and RACF staff. Some GPs preferred to provide their own care, commenting on the need for a good understanding of patient and family needs and of the local context. Other stakeholders suggested this model could be extended to palliative care settings and to normal business hours when GPs were unavailable. The reduced ambulance and hospital use suggested benefits to wider health systems, however policies and funding that remunerate GPs, support community-based care and provide additional staffing in RACFs are needed to sustain afterhours telehealth in RACFs. Use of the NASSS (non-adoption, abandonment, scale-up, spread, and sustainability) Framework provided a valuable explanatory lens for our analyses.

Addressing complexity when developing an education program for the implementation of a stroke Electronic Medical Record (EMR) enhancement.

BACKGROUND: Digital interventions in health services often fail due to an underappreciation of the complexity of the implementation. This study develops an approach to address complexity through an evidenced-based, theory-driven education and implementation program for an Electronic Medical Record (EMR) digital enhancement for acute stroke care. METHODS: An action research approach was used to design, develop, and execute the education and implementation program over several phases, with iterative changes over time. The study involved collaboration with multiple statewide and local key stakeholders and was conducted across two tertiary teaching hospitals and a regional hospital in Australia. RESULTS: Insights were gained over five phases. Phase 1 involved a review of evidence that supported blended learning strategies for the education and training of staff end-users. In Phase 2, contextual assessment was conducted via observation of study sites, providing awareness of local context variability and insight into key implementation considerations. The Non-adoption, Abandonment, Scale-Up, Spread and Sustainability (NASSS) framework assisted in Phase 3 to identify and manage the key domains of complexity. Phase 4 involved the design of the program which included group-based training and an e-learning package, endorsed and evaluated by key leaders. Throughout implementation in Phase 5, further barriers were identified, and iterative changes were tailored to each context. CONCLUSIONS: The NASSS framework, combined with a multi-phased approach employing blended learning techniques, context evaluations, and iterative modifications, can serve as a model for generating theory-driven and evidence-based education strategies that adresss the complexity of the implementation process and context.

Adoption of C-reactive protein point-of-care tests for the management of acute childhood infections in primary care in the Netherlands and England: a comparative health systems analysis.

BACKGROUND: The use of point of care (POC) tests varies across Europe, but research into what drives this variability is lacking. Focusing on CRP POC tests, we aimed to understand what factors contribute to high versus low adoption of the tests, and also to explore whether they are used in children. METHODS: We used a comparative qualitative case study approach to explore the implementation of CRP POC tests in the Netherlands and England. These countries were selected because although they have similar primary healthcare systems, the availability of CRP POC tests in General Practices is very different, being very high in the former and rare in the latter. The study design and analysis were informed by the non-adoption, abandonment, spread, scale-up and sustainability (NASSS) framework. Data were collected through a review of documents and interviews with stakeholders. Documents were identified through a scoping literature review, search of websites, and stakeholder recommendation. Stakeholders were selected purposively initially, and then by snowballing. Data were analysed thematically. RESULTS: Sixty-five documents were reviewed and 21 interviews were conducted. The difference in the availability of CRP POC tests is mainly because of differences at the wider national context level. In the two countries, early adopters of the tests advocated for their implementation through the generation of robust evidence and by engaging with all relevant stakeholders. This led to the inclusion of CRP POC tests in clinical guidelines in both countries. In the Netherlands, this mandated their reimbursement in accordance with Dutch regulations. Moreover, the prevailing better integration of health services enabled operational support from laboratories to GP practices. In England, the funding constraints of the National Health Service and the prioritization of alternative and less expensive antimicrobial stewardship interventions prevented the development of a reimbursement scheme. In addition, the lack of integration between health services limits the operational support to GP practices. In both countries, the availability of CRP POC tests for the management of children is a by-product of the test being available for adults. The tests are less used in children mainly because of concerns regarding their accuracy in this age-group. CONCLUSIONS: The engagement of early adopters combined with a more favourable and receptive macro level environment, including the role of clinical guidelines and their developers in determining which interventions are reimbursed and the operational support from laboratories to GP practices, led to the greater adoption of the tests in the Netherlands. In both countries, CRP POC tests, when available, are less used less in children. Organisations considering introducing POC tests into primary care settings need to consider how their implementation fits into the wider health system context to ensure achievable plans.

Rapid implementation of remote digital primary care in Stockholm and implications for further system-wide implementation: practitioner's and manager's experience of the Always Open mobile application.

OBJECTIVE: To contribute actionable knowledge how to increase appropriate use of digital technologies in primary care by understanding clinical managers experiences with a digital connection system, Always Open, during the COVID-19 pandemic. DESIGN AND SUBJECTS: The overall design was a qualitative study with directed content analysis method. Data were collected from documents and focus group (n = 12) interviews with clinical managers (n = 99) of primary care. The seven domains of the Non-adoption, Abandonment, and challenges to the Scale-up, Spread and Sustainability (NASSS) framework was used to understand the implementation process, as described by the clinical managers. RESULTS: Focus group participants reported that their units made their own local decisions to make more use of the technology provided by the health system. Most participants considered that the technology was ready to use, despite some limitations, that included individual clinician's and patient preferences, and how ready their unit was for making changes to practice and organization. Some raised concerns about how standardizing some aspects possibly conflicted with the decentralized management model of the organization. The overall experience was reported to be positive, with an intention to sustain the achievements. CONCLUSION: Focus group interviews found that clinical unit managers reported that they and their staff were positive about the digital technology system for remote care. For the future, they wanted changes to be made at different levels of the health system to better combine digital and physical care. Possibilities to use digital technology to integrate primary and hospital health care were identified.

Rapid adoption of Always Open as a digital connection mHealth system for remote digital care was observed during the pandemic without a structured implementation program.Many factors could explain the rapid adoption and the intention to sustain the use of Always Open such as professional ethics, financial reimbursement, patient needs and support.Standardization needs to be balanced with flexibility to ensure that staff can decide what is appropriate for patients.The general experience was positive and a continual high use of Always Open was reported in units that adopted the system.The decentralized management model may have contributed to the capacity to provide flexible services suited to local needs.

Toward Inclusive Approaches in the Design, Development, and Implementation of eHealth in the Intellectual Disability Sector: Scoping Review.

BACKGROUND: The use of eHealth is more challenging for people with intellectual disabilities (IDs) than for the general population because the technologies often do not fit the complex needs and living circumstances of people with IDs. A translational gap exists between the developed technology and users' needs and capabilities. User involvement approaches have been developed to overcome this mismatch during the design, development, and implementation processes of the technology. The effectiveness and use of eHealth have received much scholarly attention, but little is known about user involvement approaches. OBJECTIVE: In this scoping review, we aimed to identify the inclusive approaches currently used for the design, development, and implementation of eHealth for people with IDs. We reviewed how and in what phases people with IDs and other stakeholders were included in these processes. We used 9 domains identified from the Centre for eHealth Research and Disease management road map and the Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability framework to gain insight into these processes. METHODS: We identified both scientific and gray literature through systematic searches in PubMed, Embase, PsycINFO, CINAHL, Cochrane, Web of Science, Google Scholar, and (websites of) relevant intermediate (health care) organizations. We included studies published since 1995 that showed the design, development, or implementation processes of eHealth for people with IDs. Data were analyzed along 9 domains: participatory development, iterative process, value specification, value proposition, technological development and design, organization, external context, implementation, and evaluation. RESULTS: The search strategy resulted in 10,639 studies, of which 17 (0.16%) met the inclusion criteria. Various approaches were used to guide user involvement (eg, human or user-centered design and participatory development), most of which applied an iterative process mainly during technological development. The involvement of stakeholders other than end users was described in less detail. The literature focused on the application of eHealth at an individual level and did not consider the organizational context. Inclusive approaches in the design and development phases were well described; however, the implementation phase remained underexposed. CONCLUSIONS: The participatory development, iterative process, and technological development and design domains showed inclusive approaches applied at the start of and during the development, whereas only a few approaches involved end users and iterative processes at the end of the process and during implementation. The literature focused primarily on the individual use of the technology, and the external, organizational, and financial contextual preconditions received less attention. However, members of this target group rely on their (social) environment for care and support. More attention is needed for these underrepresented domains, and key stakeholders should be included further on in the process to reduce the translational gap that exists between the developed technologies and user needs, capabilities, and context.

Using the Non-Adoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) Framework to Identify Barriers and Facilitators for the Implementation of Digital Twins in Cardiovascular Medicine.

A digital twin is a computer-based "virtual" representation of a complex system, updated using data from the "real" twin. Digital twins are established in product manufacturing, aviation, and infrastructure and are attracting significant attention in medicine. In medicine, digital twins hold great promise to improve prevention of cardiovascular diseases and enable personalised health care through a range of Internet of Things (IoT) devices which collect patient data in real-time. However, the promise of such new technology is often met with many technical, scientific, social, and ethical challenges that need to be overcome-if these challenges are not met, the technology is therefore less likely on balance to be adopted by stakeholders. The purpose of this work is to identify the facilitators and barriers to the implementation of digital twins in cardiovascular medicine. Using, the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, we conducted a document analysis of policy reports, industry websites, online magazines, and academic publications on digital twins in cardiovascular medicine, identifying potential facilitators and barriers to adoption. Our results show key facilitating factors for implementation: preventing cardiovascular disease, in silico simulation and experimentation, and personalised care. Key barriers to implementation included: establishing real-time data exchange, perceived specialist skills required, high demand for patient data, and ethical risks related to privacy and surveillance. Furthermore, the lack of empirical research on the attributes of digital twins by different research groups, the characteristics and behaviour of adopters, and the nature and extent of social, regulatory, economic, and political contexts in the planning and development process of these technologies is perceived as a major hindering factor to future implementation.

General Practice Nurses' experiences of changing care delivery during COVID-19. Implications for future practice: Qualitative study protocol.

AIM: To explore how General Practice Nurses experience implementing change at pace and scale in delivering care during consecutive waves of the COVID-19 pandemic. To evaluate the impact of changes to general practice nurses' working practices on professional wellbeing. BACKGROUND: In response to the COVID-19 pandemic, general practice rapidly and extensively changed care delivery. There has been little exploration of the experiences of General Practice Nurses and care delivery, job satisfaction, workload, stress and professional support. DESIGN: A qualitative case study design of three to five general practice case sites will explore General Practice Nurses' experiences during the Covid-19 pandemic. The study was funded and approved by the General Nursing Council Trust in June 2021. University ethics approval was gained in July 2021. Health Research Authority approval has been obtained [IRAS:30353. Protocol number: R23982. Ref 21/HRA/5132. CPMS: 51834]. METHODS: Data will consist of focus groups and/or semi-structured interviews with General Practice Nurses, primary healthcare team members and other key informants. Business/strategy and nurse team meetings relating to workforce planning/review will be observed. Documents will be analysed and routinely collected general practice data will provide descriptive contextualisation at each site. The study will be theoretically underpinned by the Non-adoption, Abandonment, Scale-up, Spread and Sustainability Framework and data analysed using framework analysis. DISCUSSION: General Practice Nurses have a unique sphere of knowledge and undertake specific work in primary care. This workforce is challenged by recruitment, retention and retirement issues, leading to the loss of highly experienced and knowledgeable professionals. It is important to explore how working practices brought about by Covid-19 affect General Practice Nurses. IMPACT: This study will explore working practices brought about by the Covid-19 pandemic to inform care delivery, patient care and support General Practice Nursing workforce wellbeing and will highlight and mitigate negative aspects of novel and changing care delivery. Key factors in implementing and supporting future practice and change implementation will be developed. TRIAL REGISTRATION: CPMS: 51834.

Adopt, adapt, or abandon technology-supported person-centred care initiatives: healthcare providers' beliefs matter.

BACKGROUND: Technology support and person-centred care are the new mantra for healthcare programmes in Western societies. While few argue with the overarching philosophy of person-centred care or the potential of information technologies, there is less agreement on how to make them a reality in everyday clinical practice. In this paper, we investigate how individual healthcare providers at four innovation arenas in Scandinavia experienced the implementation of technology-supported person-centred care for people with long-term care needs by using the new analytical framework nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability (NASSS) of health and care technologies. We also discuss the usability and sensitivity of the NASSS framework for those seeking to plan, implement, and evaluate technology-supported healthcare programmes. This study is part of an interdisciplinary research and development project called Patients and Professionals in Partnership (2016-2020). It originates at one of ten work packages in this project. METHOD: The main data consist of ethnographic field observations at the four innovation arenas and 29 interviews with involved healthcare providers. To ensure continuous updates and status on work in the four innovation arenas, we have also participated in a total of six annual network meetings arranged by the project. RESULTS: While the NASSS framework is very useful for identifying and communicating challenges with the adoption and spread of technology-supported person-centred care initiatives, we found it less sensitive towards capturing the dedication, enthusiasm, and passion for care transformation that we found among the healthcare providers in our study. When it comes to technology-supported person-centred care, the point of no return has passed for the involved healthcare providers. To them, it is already a definite part of the future of healthcare services. How to overcome barriers and obstacles is pragmatically approached. CONCLUSION: Increased knowledge about healthcare providers and their visions as potential assets for care transformation might be critical for those seeking to plan, implement, and evaluate technology-supported healthcare programmes.

Experiences from implementation of internet-delivered cognitive behaviour therapy for insomnia in psychiatric health care: a qualitative study applying the NASSS framework.

BACKGROUND: Insomnia is a common diagnosis among patients in psychiatric health care and effective treatments are highly demanded. Previous research suggests that internet-delivered cognitive behavioural therapy for insomnia (ICBT-i) is helpful for a variety of patients and may be effective for psychiatric health care patients. Little is known about implementation of ICBT-i in psychiatric health care. The aim of this study was to explore experiences among therapists and managers who participated in a pilot implementation of ICBT-i in outpatient psychiatric health care, and to identify determinants for the implementation. METHODS: Semi-structured interviews were conducted with 7 therapists and 5 managers working in outpatient psychiatric health care and directly involved with the pilot implementation. Data were analysed using qualitative content analysis guided by the NASSS framework, combining inductive and deductive approaches. RESULTS: The analysis revealed 32 facilitators, 21 barriers, and 2 determinants that were both a barrier and a facilitator, organised in 1-5 themes under each of the 7 NASSS domains. Key facilitators included: meeting a demand for treatment options with the ICBT-i programme, the experienced benefits of ICBT-i as a treatment option for insomnia, training and support, engagement and support from managers and the wider system, and a long-term organisation for maintenance of the technology. Key barriers included: low interest in ICBT-i among therapists, difficulty in recruiting patients, perceived low ability in therapists to deliver treatment online, technical problems, and therapists' competing demands leading to low priority of ICBT-i. Complexity analysis assessed two NASSS domains as simple, four as complicated, and one as complex. CONCLUSIONS: The study contributes new knowledge and insights into the implementation process of ICBT-i in psychiatric health care. Our findings highlight the importance of providing training, support, and guidance in online treatment for therapists when implementing a technological innovation. Technical problems should be minimised and the maintenance and demand-side value for the technology must be clear. Support from managers at all levels is crucial, particularly support to therapists in everyday prioritisation among competing demands. Besides taking the identified determinants into account, managing complexity is important for successful scale-up implementation.

The NASSS framework for ex post theorisation of technology-supported change in healthcare: worked example of the TORPEDO programme.

BACKGROUND: Evaluation of health technology programmes should be theoretically informed, interdisciplinary, and generate in-depth explanations. The NASSS (non-adoption, abandonment, scale-up, spread, sustainability) framework was developed to study unfolding technology programmes in real time-and in particular to identify and manage their emergent uncertainties and interdependencies. In this paper, we offer a worked example of how NASSS can also inform ex post (i.e. retrospective) evaluation. METHODS: We studied the TORPEDO (Treatment of Cardiovascular Risk in Primary Care using Electronic Decision Support) research programme, a multi-faceted computerised quality improvement intervention for cardiovascular disease prevention in Australian general practice. The technology (HealthTracker) had shown promise in a cluster randomised controlled trial (RCT), but its uptake and sustainability in a real-world implementation phase was patchy. To explain this variation, we used NASSS to undertake secondary analysis of the multi-modal TORPEDO dataset (results and process evaluation of the RCT, survey responses, in-depth professional interviews, videotaped consultations) as well as a sample of new, in-depth narrative interviews with TORPEDO researchers. RESULTS: Ex post analysis revealed multiple areas of complexity whose influence and interdependencies helped explain the wide variation in uptake and sustained use of the HealthTracker technology: the nature of cardiovascular risk in different populations, the material properties and functionality of the technology, how value (financial and non-financial) was distributed across stakeholders in the system, clinicians' experiences and concerns, organisational preconditions and challenges, extra-organisational influences (e.g. policy incentives), and how interactions between all these influences unfolded over time. CONCLUSION: The NASSS framework can be applied retrospectively to generate a rich, contextualised narrative of technology-supported change efforts and the numerous interacting influences that help explain its successes, failures, and unexpected events. A NASSS-informed ex post analysis can supplement earlier, contemporaneous evaluations to uncover factors that were not apparent or predictable at the time but dynamic and emergent.

Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies.

BACKGROUND: Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level. OBJECTIVE: Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program. METHODS: The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs-video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing-using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback. RESULTS: The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs. CONCLUSIONS: Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.

Applying the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework to evaluate automated evidence synthesis in health behaviour change.

Automated tools to speed up the process of evidence synthesis are increasingly apparent within health behaviour research. This brief review explores the potential of the Non-adoption, Abandonment, Scale-up, Spread and Sustainability framework for supporting automated evidence synthesis in health behaviour change by applying it to the ongoing Human Behaviour-Change Project, which aims to revolutionize evidence synthesis within behaviour change intervention research. To increase the relevance of NASSS for health behaviour change, we recommend i) terminology changes ('condition' to 'behaviour' and 'patient' to 'end user') and ii) that it is used prospectively address complexities iteratively. We draw conclusions about i) the need to specify the organizations that will use the technology, ii) identifying what to do if interdependencies fail and iii) even though we have focused on automated evidence synthesis, NASSS would arguably be beneficial for technology developments in health behaviour change more generally, particularly for invention development.

Exploring the Role of Complexity in Health Care Technology Bottom-Up Innovations: Multiple-Case Study Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability Complexity Assessment Tool.

BACKGROUND: New digital technology presents new challenges to health care on multiple levels. There are calls for further research that considers the complex factors related to digital innovations in complex health care settings to bridge the gap when moving from linear, logistic research to embracing and testing the concept of complexity. The nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to help study complexity in digital innovations. OBJECTIVE: This study aims to investigate the role of complexity in the development and deployment of innovations by retrospectively assessing challenges to 4 digital health care innovations initiated from the bottom up. METHODS: A multicase retrospective, deductive, and explorative analysis using the NASSS complexity assessment tool LONG was conducted. In total, 4 bottom-up innovations developed in Region Västra Götaland in Sweden were explored and compared to identify unique and shared complexity-related challenges. RESULTS: The analysis resulted in joint insights and individual learning. Overall, the complexity was mostly found outside the actual innovation; more specifically, it related to the organization's readiness to integrate new innovations, how to manage and maintain innovations, and how to finance them. The NASSS framework sheds light on various perspectives that can either facilitate or hinder the adoption, scale-up, and spread of technological innovations. In the domain of condition or diagnosis, a well-informed understanding of the complexity related to the condition or illness (diabetes, cancer, bipolar disorders, and schizophrenia disorders) is of great importance for the innovation. The value proposition needs to be clearly described early to enable an understanding of costs and outcomes. The questions in the NASSS complexity assessment tool LONG were sometimes difficult to comprehend, not only from a language perspective but also due to a lack of understanding of the surrounding organization's system and its setting. CONCLUSIONS: Even when bottom-up innovations arise within the same support organization, the complexity can vary based on the developmental phase and the unique characteristics of each project. Identifying, defining, and understanding complexity may not solve the issues but substantially improves the prospects for successful deployment. Successful innovation within complex organizations necessitates an adaptive leadership and structures to surmount cultural resistance and organizational impediments. A rigid, linear, and stepwise approach risks disregarding interconnected variables and dependencies, leading to suboptimal outcomes. Success lies in embracing the complexity with its uncertainty, nurturing creativity, and adopting a nonlinear methodology that accommodates the iterative nature of innovation processes within complex organizations.

Implementation of Video-Based Care in Interdisciplinary Primary Care Settings at the Veterans Health Administration: Qualitative Study.

BACKGROUND: With the rapid shift to telehealth, there remains a knowledge gap in how video-based care is implemented in interdisciplinary primary care (PC) settings. OBJECTIVE: The objective of this study was to gain an in-depth understanding of how video telehealth services were implemented in PC from the perspectives of patients and interdisciplinary PC team members at the Veterans Health Administration (VHA) 2 years after the onset of the COVID-19 pandemic. METHODS: We applied a positive and negative deviance approach and selected the 6% highest (n=8) and the 6% lowest (n=8) video-using PC sites in 2022 from a total of 130 VHA medical centers nationally. A total of 12 VHA sites were included in the study, where 43 PC interdisciplinary team members (August-October 2022) and 25 patients (February-May 2023) were interviewed. The 5 domains from the diffusion of innovation theory and the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework guided the development of the 2 study interview guides (provider and patient). We identified themes that emerged across all interviews that were associated with the implementation of video-based care in interdisciplinary PC settings, using directed-content rapid analysis of the interview transcripts. The analysis was guided by 5 a priori NASSS domains: (1) patient condition or characteristic, (2) technology, (3) adopter system, (4) health care organization, and (5) adaptation over time. RESULTS: The study findings include the following common themes and factors, organized by the 5 NASSS domains: (1) patient condition or characteristic-visit type or purpose (eg, follow-up visits that do not require physical examination), health condition (eg, homebound or semihomebound patients), and sociodemographic characteristic (eg, patients who have a long commute time); (2) technology-key features (eg, access to video-enabled devices), knowledge (eg, how to use videoconferencing software), and technical support for patients and providers; (3) adopter system-changes in staff roles and clinical practice (eg, coordination of video-based care), provider and patient preference or comfort to use video-based care, and caregiver's role (eg, participation of caregivers during video visits); (4) health care organization-leadership support and access to resources, scheduling for video visits (eg, schedule or block off digital half or full days), and training and telehealth champions (eg, hands-on or on-site training for staff, patients, or caregivers); (5) adaptation over time-capacity to improve all aspects of video-based care and provide continued access to resources (eg, effective communication about updates). CONCLUSIONS: This study identified key factors associated with the implementation of video-based services in interdisciplinary PC settings at the VHA from the perspectives of PC team members and patients. The identified multifaceted factors may inform recommendations on how to sustain and improve the provision of video-based care in VHA PC settings as well as non-VHA patient-centered medical homes.

Evaluation of the Newborn Screening Pilot for Sickle Cell Disease in Suriname Using the Non-Adoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) Framework.

The early detection of sickle cell disease (SCD) is vital to reduce mortality among affected children. Suriname currently lacks a newborn screening programme (NSP) for SCD. We performed a pilot programme to evaluate the scalability of such an initiative. Dried blood spots were collected from five birth centres and subjected to electrophoresis analysis. The programme scalability was evaluated using the non-adoption, abandonment, scale-up, spread, and sustainability framework. Challenges across six domains (illness, technology, value proposition, adopter system, organisation, and societal system), were categorised hierarchically as simple 😊, complicated 😐, or complex 😢. It has been proven that implementing programmes with mainly complicated challenges is difficult and those in mainly complex areas may be unachievable. SCD was detected in 33 of 5185 (0.64%) successfully screened newborns. Most of the domains were classified as simple or complicated. Disease detection and technology suitability for screening in Suriname were confirmed, with favourable parental acceptance. Only minor routine adjustment was required from the medical staff for programme implementation. Complex challenges included a reliance on external suppliers for technical maintenance, ensuring timely access to specialised paediatric care for affected newborns, and securing sustainable financial funding. Scaling up is challenging but feasible, particularly with a targeted focus on identified complex challenges.

Integrating Explainable Machine Learning in Clinical Decision Support Systems: Study Involving a Modified Design Thinking Approach.

BACKGROUND: Though there has been considerable effort to implement machine learning (ML) methods for health care, clinical implementation has lagged. Incorporating explainable machine learning (XML) methods through the development of a decision support tool using a design thinking approach is expected to lead to greater uptake of such tools. OBJECTIVE: This work aimed to explore how constant engagement of clinician end users can address the lack of adoption of ML tools in clinical contexts due to their lack of transparency and address challenges related to presenting explainability in a decision support interface. METHODS: We used a design thinking approach augmented with additional theoretical frameworks to provide more robust approaches to different phases of design. In particular, in the problem definition phase, we incorporated the nonadoption, abandonment, scale-up, spread, and sustainability of technology in health care (NASSS) framework to assess these aspects in a health care network. This process helped focus on the development of a prognostic tool that predicted the likelihood of admission to an intensive care ward based on disease severity in chest x-ray images. In the ideate, prototype, and test phases, we incorporated a metric framework to assess physician trust in artificial intelligence (AI) tools. This allowed us to compare physicians' assessments of the domain representation, action ability, and consistency of the tool. RESULTS: Physicians found the design of the prototype elegant, and domain appropriate representation of data was displayed in the tool. They appreciated the simplified explainability overlay, which only displayed the most predictive patches that cumulatively explained 90% of the final admission risk score. Finally, in terms of consistency, physicians unanimously appreciated the capacity to compare multiple x-ray images in the same view. They also appreciated the ability to toggle the explainability overlay so that both options made it easier for them to assess how consistently the tool was identifying elements of the x-ray image they felt would contribute to overall disease severity. CONCLUSIONS: The adopted approach is situated in an evolving space concerned with incorporating XML or AI technologies into health care software. We addressed the alignment of AI as it relates to clinician trust, describing an approach to wire framing and prototyping, which incorporates the use of a theoretical framework for trust in the design process itself. Moreover, we proposed that alignment of AI is dependent upon integration of end users throughout the larger design process. Our work shows the importance and value of engaging end users prior to tool development. We believe that the described approach is a unique and valuable contribution that outlines a direction for ML experts, user experience designers, and clinician end users on how to collaborate in the creation of trustworthy and usable XML-based clinical decision support tools.

Health Care Professionals' Experiences and Views of eHealth in Pediatric Care: Qualitative Interview Study Applying a Theoretical Framework for Implementation.

BACKGROUND: The development and evaluation of eHealth interventions in clinical care should be accompanied by a thorough assessment of their implementation. The NASSS (Non-adoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies) framework was designed to facilitate the implementation and scale-up of health technology programs, providing an option for analyzing the progression of these initiatives as they are implemented in real-time. Considering health care provider perspectives within the framework for implementation offers valuable insights into the early identification of barriers and facilitators in the implementation of potentially effective eHealth innovations. Nevertheless, there is a dearth of studies on eHealth interventions that encompass longer time frames and delve into the complexities of scaling up and sustaining such interventions within real-world health care environments. OBJECTIVE: This study aims to investigate the perspectives and insights of health care professionals (HCPs) regarding the implementation of an eHealth intervention in pediatric health care while applying the NASSS framework to theorize and evaluate the conditions influencing the implementation of eHealth solutions. METHODS: Semistructured interviews were performed with health care providers, including both staff and management personnel, within a university pediatric hospital (N=10). The data collection process occurred concurrently with a clinical trial focused on developing and assessing an eHealth app for self-management in pediatric care following hospital discharge. Using an abductive approach, the interviews were initially analyzed qualitatively and subsequently mapped onto the 7 domains of the NASSS framework to identify factors influencing implementation, encompassing facilitators, barriers, and varying levels of complexity. RESULTS: In the realm of pediatric care, the family was identified as the primary unit of care, and patient heterogeneity was a prominent feature. The implementation of eHealth tools, while deemed usable and flexible, was also seen as a delicate balance between safety and adaptability, highlighting challenges related to health care integration. Child participation and secrecy, especially for adolescents, contributed to the complexity of using eHealth. HCPs had high eHealth literacy, and thus challenges concerning adoption were related to work adaptations and the risk of "app overload." The readiness for implementation was experienced as induced through the research study and the pandemic situation. However, to move from research to implementation in clinical practice, organizational challenges identified a need to update the concept of care and ensure activity measurements. In a wider context, HCPs raised concerns related to regulatory requirements for documentation, public procurement, and data safety. Implementation became more complex due to a lack of overview in a large organization. CONCLUSIONS: Important perspectives for implementation were considerations of regulatory requirements, as well as the need for a shared vision of eHealth and the establishment of eHealth-related work as part of regular health care. Key contextual factors that support reach and impact are communication channels between different levels at the hospital and a need for paths and procedures compatible with legal, technological, and security concerns. Further research should focus on how eHealth interventions are perceived by children, adolescents, their parents, and other stakeholders. TRIAL REGISTRATION: ClinicalTrials.gov NCT04150120; https://clinicaltrials.gov/ct2/show/NCT04150120.