Table 3.
Staff interview results showing categories, codes and key findings mapped across the Exploration, Preparation, Implementation, Sustainment (EPIS) framework
| Phase | Construct | Category | Code | Key findings |
|---|---|---|---|---|
| Exploration | Inner context | Leadership | Involvement | Varying levels of involvement across sites from 2017 to 2020 |
| Needs assessment | Variable awareness of and involvement in needs assessment activities across sites, which were felt to focus on patient needs | |||
| Preparation | Innovation factors | Innovation characteristics | Development team | Digital product development team were supportive and engaged |
| Digital platform | Many felt the platform was well-designed and user-friendly, but one individual felt it was not ready for clinician engagement | |||
| Administrative support | The DPC has a central role in managing the remote monitoring service, which makes it easy to use. This ‘human factor’ also enables effective triaging of patient responses | |||
| Service design | The remote monitoring service was well-designed for both staff and patients. Existence of a previous database laid important groundwork | |||
| Fit to clinicians | Use alongside face-to-face appointments | Although the remote monitoring service should not replace face-to-face appointments, many felt it could be a useful complement and creates the potential to allocate and use face-to-face appointments more effectively. However, some questioned the necessity and value of the service | ||
| Potential to support clinical decision making | Potential to support clinical decision making, as regular capture of PROM scores can provide a more objective representation of a patient's disease activity over time, but limitations exist | |||
| Unmet expectations | Expectations of developing a ‘database’ for all patients not delivered | |||
| Fit to patients | Patient characteristics | Suitable for most patients but not all, including those with more active disease, a secondary pain diagnosis, those with poor communication skills and who are unable or unwilling to use the internet. Some sociodemographic barriers may be more prevalent in certain contexts | ||
| Fit into day-to-day routine | Remote monitoring service is quick, easy and non-intrusive for patients, vs burdensome, anxiety-inducing and an unwelcome reminder of disease | |||
| Connection and safety | An alternative and potentially more effective line of communication for patients, which can offer a feeling of connection, safety and improved access to care. But worry that this could replace face-to-face care | |||
| Promoting self-management or dependence | Offering patients more autonomy and empowerment, which can support self-management, vs encouraging overreliance on clinical services | |||
| Fit to system | Blending face-to-face and remote working is important for future service provision | |||
| Adaptations | Considerations made to adapt service to suit local needs | |||
| Inner context | Leadership | Leadership characteristics | Passionate and engaged multidisciplinary leadership team | |
| Teamwork and collaboration | Desire for shared understanding and collaboration, but concerns and feedback not always taken on board | |||
| Communication | Communications were varied, focused on the patient perspective, and served as reminders, to report progress and elicit feedback | |||
| Advocates | The varied success of appointed champions was bolstered by the emergence of unexpected advocates | |||
| Clinician factors | Clinician characteristics | Facilitators include clinical and digital acumen, familiarity with remote monitoring technology, but clinical experience may dictate levels of engagement | ||
| Teamwork and collaboration | Local teamworking efforts seen as a facilitator | |||
| Attitude towards innovation | Fear of increased workload, loss of ‘control’ over patients, and lack of ‘confidence’ in the remote monitoring service | |||
| Readiness for change | Potential lack of readiness for change | |||
| Outer context | Leadership ties | Clinical Lead liaised with commissioners and senior boards | ||
| Inter-organizational environment | Similar platforms may compete for clinicians’ attention | |||
| Climate | The coronavirus pandemic created favourable implementation conditions, as the remote monitoring service helped meet evolving needs. However, these advantages were offset by barriers introduced by the pandemic | |||
| Bridging factors | NHS Innovation Team provided support and funding | |||
| Implementation | Engagement | Staff engagement was variable over time and greatest at the pilot site. Recent increases attributed to innovation adaptations | ||
| Innovation factors | Innovation characteristics | Digital platform | Several limitations mentioned, including lack of automatic start-up and visual prompts, log-in difficulties and lack of interoperability with existing programmes | |
| Administrative support | Good admin support, for example with recruitment, monitoring and clinical escalation, makes the service straightforward for clinicians to use | |||
| Training | Staff spoke positively about training, with some informally adopting a ‘train-the-trainer’ approach. However, the requirement for training to permit log-in access also acted as a ‘limiting factor’ and discouraged engagement of the innovation | |||
| Fit to clinicians | Not being able to identify which patients are onboard the service acted as a barrier | |||
| Adaptations | Adaptations to address staff needs received mixed reviews. These included increasing the availability of training, making the platform more user-friendly, relaxing patient eligibility criteria and refining triaging processes. Shifting the responsibility of patient management towards clinicians was particularly controversial | |||
| Inner context | Leadership | Leadership characteristics | Clinician involvement brought new insights, but lack of clear leadership seen as a barrier | |
| Communication | Communications around service promotion and training facilitated clinician engagement, but others commented that the strategy was at times unrealistic and misguided | |||
| Evaluation | Lack of evaluation activities | |||
| Organizational support | Lack of tangible organizational support | |||
| Clinician factors | Attitude towards innovation | Remote monitoring service not seen as a priority in busy, time-pressured clinics | ||
| Barriers at roll-out sites | Leadership—communication and champions | Poor leadership engagement, for example lack of a regular ‘in-person’ presence and effective champions | ||
| Organizational characteristics | A central approach to patient management at roll-out sites was challenging. Plus, potential lack of appreciation of contextual differences | |||
| Clinician factors—attitude towards innovation | Distrust and feeling like unequal partners | |||
| Outer context | Inter-organizational environment | Difficulties surrounding patient management arising from a centralized approach based at the pilot site | ||
| Climate | The coronavirus pandemic reduced clinicians’ capacity to implement the remote monitoring service, through reduced manpower, disruption to clinical services and changing patient needs | |||
| Sustainment | Feasibility | Wider scale up could be feasible, especially in smaller trusts | ||
| Innovation factors | Innovation characteristics | Digital platform | Ensuring the system has inbuilt flexibility to respond to local and evolving needs, and addressing current unmet needs, in particular the lack of integration with other key platforms | |
| Administrative support | Administrative support should be increased in line with service expansion, feature at all relevant clinical sites, and include properly trained staff, information technology support and improved infrastructure | |||
| Service design | Improving patient guidance to promote self-management, to ensure patient safety and help manage workloads | |||
| Fit to clinicians | Important to prioritise clinician needs alongside patient needs | |||
| Inner context | Leadership | Leadership characteristics | Strong leadership with good listening skills needed | |
| Communication | Effective communications strategy that includes regular stakeholder engagement and face-to-face time | |||
| Evaluation | Requirement for comprehensive and transparent evaluation activities | |||
| Organizational support | Need for robust organizational support | |||
| Clinician factors | Readiness for change | Need for culture change and consideration of readiness for change | ||
DPC: Digital Pathway Coordinator; PROM: Patient Reported Outcome Measure.