Table 3.

Summary of the challenges of the IBD-live telemonitoring strategy based on the nonadoption, abandonment, scale-up, spread, and sustainability framework.

Domain and question		Ratinga	Explanation
Domain 1: The illness
	1A. How well does the Flarometer strategy predict out-of-range or all-is-well events?	+++	Ad hoc face-to-face follow-up consultations were fairly predictable and consistent in the group with out-of-range results; few unpredictable eventualities in the all-is-well results.
	1B. What are the sociocultural factors associated with good adherence to the technology?	+++	Majority of teenage patients were considered suitable for the technology, except for those with concurrent diseases such as arthritis and sclerosing cholangitis; Patients with delayed emotional maturity, prominent functional gastrointestinal disease, or with little knowledge of the Dutch language were considered less suitable for the technology.
Domain 2: The technology
	2A. Perceived usability	+++	Access to Web-based portal was easy via a link in the email notification. The tunnel design (Figure 1) guided the patients in a few steps in sequential order through the Flarometer. Successful stool-based monitoring system for teenagers heavily relies on active and coordinating role of the parent.
	2B. Appropriateness of the automated treatment advice	+++	Treatment advice was accepted and trusted by patients. Concurrent gastrointestinal infection was found to be the cause of the out-of-range result in a minority of cases.
	2C. Knowledge and/or support required to use the technology	+++	Use of the technology requires no previous knowledge from the patient, except for recognizing what conditions count as urgent.
	2D. Technology supply model	++	Technology relies on bespoke solution from a small-sized enterprise with risk of supplier withdrawal.
Domain 3: The value proposition
	3A. Developer’s business case for the technology (supply-side value)	++	Not sure that use of the technology reduces the demand on health services, but it certainly allows selecting and targeting the patients who are most likely to benefit from a face-to-face encounter with their specialist.
	3B. Efficacy, safety, and cost-effectiveness of the technology (demand-side value)	+++	Technology is desirable for patients, it is safe and cost effective, particularly in those who are adherent to the telemonitoring strategy.
Domain 4: The adopter system
	4A. Implications for staff roles, practices, and identities in case of adoption	+++	Difference between innovators and early adopters (who embraced the technology) on 1 side and a minority of other health providers (who were reluctant to adopt the technology). Technology was not seen as a threat to job security.
	4B. What is expected of the patient (and/or immediate caregiver)—and is this achievable by, and acceptable to, them?	+++	Patients were already familiar with the stool collection procedure. Logging on to the system was easy. The study presupposed that parents or carers were actively supporting their child during the study observation period.
Domain 5: The organization
	5A. Organization’s capacity to innovate	+	Technology follows the natural work flow but conflicts with established hospital electronic databases and therefore requires double data entry. This will put a strain on the already overstretched health service.
	5B. Readiness for this technology-supported change	++	No linked routine for booking face-to-face appointments in case of a red alert.
	5C. Easiness of adoption and funding	++	Anticipated reduction in costs were not realized as case management was not always successful in avoiding follow-up consultations and day care admissions. Neutral cost-benefit balance.
	5D. Changes required in team interactions and routines	++	Variation in clinician engagement was based on the vision of local teams of whether remote biomarker monitoring enhances rather than threatens the existing service. Expansion of rapid access possibilities is required.
	5E. Work and persons involved in implementation	+	Significant work needed to build shared vision, engage staff, enact new practices, and monitor impact.
Domain 6: The wider context
	6A. Political, economic, regulatory, professional, and sociocultural context for program rollout	+++	Effect of January 2018, the Dutch Health care Authority has agreed that screen-to-screen consultations will be reimbursed at a rate equivalent to face-to-face consultations, provided that a substantive report is added to the patient’s medical record.
Domain 7: The time dimension
	7A. Scope for adapting and coevolving the technology over time	++	The technology can easily be adapted over time.
	7B. Handling critical events and adaptation to unforeseen eventualities	+++	The research head quarter and the Web designer were able to detect critical events quickly and respond to these through coordinated action.

^aRating: Simple +++; Complicated ++; Complex +.