Evaluating Organizational Readiness for Change in the Implementation of Telehealth and mobile Health Interventions for Chronic Disease Management

Introduction

Advancements in digital technology innovations have resulted in an increasing ability for Telehealth and mobile health (mHealth) technologies to provide efficient and effective healthcare¹. This has resulted in a growing interest in the use of these technologies to develop solutions that can improve the management of chronic conditions^1,2. A high chronic disease burden within the US, an increasingly aging population, high costs of chronic disease care, challenges with timely and effective access to care, the need to obtain a holistic picture of a patient's health outside of the health care setting, and a fragmented health care system have led to an increase in interest toward the use of these technologies^1,3,4. Furthermore, given the disproportionate burden of chronic conditions among older adults and the projected increase in the number of Americans age 65 and older to 98 million by year 2060, there is an increased need for innovative approaches to improving the management of chronic diseases within the US^5-7.

Based on this, Telehealth and mHealth solutions that can facilitate increased self-care and self-management through the use of remote patient monitoring (RPM) technologies among the older adult US population are being developed. This is also projected to be able to potentially address the dis proportionate burden of care giving on family members and a projected decrease in care giver population given the increasingly aging population^6-8. Although chronic conditions are prevalent among older adults, they tend to begin in early adulthood, and this makes it important to begin to address these issues in early adulthood. These challenges have reiterated the need to proactively provide avenues for self-management and remote monitoring of these chronic conditions that affect adults and older adult US populations through the use of innovative digital health technologies^1,7.

Telehealth and mHealth interventions have been observed to enable patients' self-monitoring, self-management and provider enabled remote monitoring⁹. Prior to the COVID-19 pandemic a good number of Telehealth and mHealth interventions were focused on chronic conditions that involved the cardiovascular, respiratory, neurological and endocrine systems such as hypertension, Chronic Obstructive Pulmonary Disease (COPD), Alzheimer/dementia, and diabetes. Currently, due to the ongoing COVID-19 pandemic there has been an increased interest in the use of Telehealth and mHealth interventions for the management of acute conditions in a bid to maintain access to health care services while reducing the potential for the spread of the virus caused by SARS-CoV-2. Also, policy makers at the global and national level such as the WHO and the US Center for Medicaid Services (CMS) have reiterated the importance of Telehealth and mHealth services to reduce the spread of the virus and maintain access to care irrespective of a patient's location^10,11. Based on this, there has been a lessening of restrictions on Telehealth and mHealth services in the US and other parts of the globe with HCOs rising up speedily to meet the upsurge in demand for virtual visits, remote symptom tracking and evaluation and RPM. Based on these, Telehealth and mHealth interventions show promise for maintaining access to care during the pandemic as well as after the pandemic, hence, these seemingly temporary changes raise some pertinent questions, to clinicians, patients, hospital administrators and other stakeholders, one of which is how organizations can sustain this trend post COVID-19 pandemic by developing and implementing sustainable Telehealth and mHealth interventions that are best suited for their health organizations, staff populations, and their level of Telehealth or mHealth organizational readiness. It is important for HCOs to be aware of organizational factors that are key to enabling sustained adoption and implementation of Telehealth and mHealth interventions so as to be able to design or adopt Telehealth or mHealth interventions that their HCO is ready for and has the capacity to maintain and sustain its use over an appreciable period of time.

Studies have shown that Organizational Readiness for Change (ORC) is key to organizations' ability to successfully adopt, implement and sustain innovative technology solutions such as Telehealth and mHealth interventions^12-14. ORC has been defined as a multi-level and multi-faceted construct that involves organizational members' shared resolve and commitment to implement a specific change or a set of changes and their shared belief in their collective capability to do so¹⁵. ORC also refers to the degree to which members of an organization are prepared psychologically and behaviorally to implement organizational change¹⁴. ORC varies based on how much organizational members value the change and how they perceive determinants of implementation capability such as availability of resources, task demands, and situational factors¹⁴. A high level of ORC is more likely to result in organizational members initiating change, exerting greater effort, exhibiting greater persistence, and displaying more cooperative behavior, which results in a more effective and successful implementation^13,15,16.

One of the key Implementation Science (IS) frameworks that has been used to evaluate ORC is the Consolidated Framework for Implementation Research (CFIR). The CFIR was developed by unifying several IS theories, and provides a pragmatic and unifying framework for assessing organizational readiness factors that have been observed to be key to the successful adoption or implementation of new interventions^17,18. The CFIR offers a comprehensive, unifying taxonomy of constructs related to the intervention (e.g. Telehealth or mHealth intervention), the organization's inner and outer settings, the characteristics of involved individuals (such as members of staff or implementers), and the implementation process¹⁷. These CFIR domains interact in rich and complex ways to influence implementation effectiveness and are useful for planning or evaluating implementation processes.

Despite the importance of evaluating ORC prior to and during the implementation of Telehealth and mHealth interventions, prior studies have been largely focused on patients' or end users' acceptance of Telehealth or mHealth technology, the effectiveness or efficiency of the Telehealth or mHealth technologies in aiding remote or virtual diagnoses and treatment, and the ability of the technologies to enable RPM, and aid patients' self-management^19,20. Few studies have evaluated organizational factors in the implementation of Telehealth or mHealth interventions within US HCOs that can influence readiness for change in the implementation of these technologies.

Given the increasing burden of chronic diseases, particularly among the adult and older adult US population and the increasing need for enhanced and enabled self-management of chronic conditions in this population, this systematic review of literature was conducted to understand organizational factors that can enable ORC in the implementation of Telehealth and mHealth interventions for chronic disease management among US adults and older adults. Study findings were organized and analyzed using the CFIR this is with a view to enabling implementers to have an understanding of organizational factors that can increase ORC and thereby increase the potential for successful implementation and sustained adoption. Findings from this review can benefit HCOs as they decide on Telehealth and mHealth interventions to adopt or implement. It can also assist HCOs to know what organizational factors to look out for when evaluating their readiness for change by presenting them with an up to date and comprehensive review of key organizational factors that impact the adoption and implementation of Telehealth and mHealth interventions as reported in the academic literature. This can inform and guide HCOs in the development of strategies for promoting the adoption of these tools and enable them to realize their potential benefits.

Methods

This study conducted a systematic review of study articles focused on evaluating organizational factors that are important in evaluating ORC in the implementation of Telehealth and mHealth interventions for chronic disease management using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. This review focused on Telehealth or mHealth interventions designed for US adults and older adults for the management of their chronic conditions by HCOs such as hospitals or physician practices. The CFIR was used in this study to organize and analyze identified organizational factors. The CFIR given its robust set of constructs offered an avenue to clearly elicit organizational factors that influenced readiness for change in the implementation of Telehealth and mHealth interventions within HCOs. The CFIR's domain and constructs was used to evaluate identified internal and external organizational facilitators and barriers to implementation within the selected articles in order to elicit how these factors affected ORC¹⁷.

Eligible studies for this review included peer-reviewed articles that 1) were written in English language; 2) were focused on the implementation or deployment of community facing Telehealth or mHealth interventions by healthcare related organizations; and, 3) involved the description of organizational facilitators and barriers to implementation and change in the implementation of home or community facing Telehealth or mHealth interventions for chronic disease management. Study population included adults ages 18 years and older with one or more chronic conditions who lived in their homes or in communities. This study excluded articles that were 1) non-original studies or generic reports that were not focused on home or community facing Telehealth or mHealth interventions; 2) articles or reviews that were focused on patients' or providers' perspective of the effectiveness or efficiency of the Telehealth or mHealth intervention; and 3) studies that were conducted outside of the US.

Electronic databases and search engines such as PubMed, CINAHL, SCOPUS and Web of Science were searched for potentially eligible articles. Furthermore, experts in the use of electronic databases for conducting systematic review related searches were contacted and asked to assist in database searches as well as suggest additional relevant articles that had not been included. Duplicate articles were excluded at each stage of the search process. An initial search was conducted in November 2019, with follow up searches carried out in February 2020. Search strategy included keywords and terms such as "Telehealth, telemedicine, mHealth, ehealth, chronic disease, condition, or illness," which were searched in any combination. These search terms were identified during a preliminary search of the literature focused on discovering the various terms used in articles related to utilizing IS frameworks for evaluating organizational readiness for change in the implementation of Telehealth or mHealth interventions for chronic disease management. Specific implementation science related keywords were however not included in the search in order to broaden the scope of the search. Also, the search was not limited to any particular time frame in order to enable an exhaustive search. Filters were used in all searches to exclude non-English articles, or articles that were not peer-reviewed.

All titles and abstracts were reviewed by the author using the systematic review software - Covidence, and irrelevant publications were excluded. Then both the author and a study colleague using Covidence conducted a full text review of the selected articles. Study articles were included in the study when the author and the study colleague were in agreement. When they were not in agreement, both the author and the study colleague conducted a second review and subsequently made a decision. If there was doubt, the author conducted another review and subsequently made a decision. Data extraction was conducted with the use of a data extraction form that was developed by the author for the purpose of this review. The data extraction form included parameters that were related to study details such as study design, setting, population, intervention, implementation findings, and organizational factors that affected the implementation and adoption of Telehealth and mHealth interventions. Identified organizational barriers and facilitators of the implementation of Telehealth and mHealth interventions were then organized and analyzed using CFIR's five domains and constructs in order to elicit how these factors affected ORC in the implementation of Telehealth and mHealth interventions for chronic disease management among US adults and older adults. The data extraction was guided by the aims of the review, which is focused on understanding 1) organizational factors that influenced the implementation of Telehealth and mHealth interventions for chronic disease management among US adults and older adults, and, 2) how the elicited organizational factors influenced ORC using the CFIR's five domains and constructs. The identified organizational factors were sorted according to the CFIR's domains and assessed based on CFIR's constructs that corresponded with or matched each elicited factor.

Results

The search generated 10,162 references, and 3753 duplicates were excluded. 6212 irrelevant studies were excluded based on title abstract screening due to the inconsistencies in terminologies used in the literature on Telehealth and mHealth implementation. Also, few numbers of US original studies were identified that were focused on organizational factors that affected implementation or ORC in the implementation of Telehealth or mHealth interventions. 197 full studies were selected for full text evaluation. Following evaluation by the first author, and a study colleague, 13 studies met all the inclusion criteria and were included in the study. (See Figure 1 beneath for details on the selection process).

Figure 1.

Systematic review flow diagram. (Prisma Chart showing the selection process)

All included studies were published between 2004 and 2019. Nine of the studies used qualitative research methods^21-29, three studies used mixed methods approaches^30-32, and one study used quantitative surveys³³. Four of the included studies were pre-implementation or feasibility assessment studies^24,28,30,32, three studies evaluated pilot interventions^21,25,33, four studies were intervention or program evaluation studies and spanned from early to late phases of implementation^23,26,27,29, one study was an end of intervention evaluation³¹, while one study was a prospective study²².

Seven of the studies involved Telemedicine, Telemonitoring, or videoconferencing interventions^{23-25,27,29,31,32}. Three studies involved Telehealth interventions^22,26,33. Two studies involved mHealth interventions^21,30, and one intervention was a Telehealth kiosk²⁸. Five studies occurred in clinics, primary care settings or ambulatory practices that were affiliated with larger academic centers^{21,23,24,30,33}, while three studies involved Veterans Health Affairs (VHA) networks of medical centers and clinics^27,29,32. Three studies involved home care programs^25,26,31. One study involved a senior living facility; and one study involved grant funding agencies and two recipient clinical sites^22,28.

Five of the studies used IS frameworks or organizational theories and frameworks to organize their study, or to guide the analysis and interpretation of implementation study findings and discuss study or implementation outcomes. One study used the diffusion of innovations framework to guide a pilot evaluation which was aimed at implementing telehealth services in a clinic within a large academic center³³. A second study used the CFIR to evaluate barriers and facilitators to the implementation and spread of a video-conferencing intervention and to distinguish between high and low performing sites²⁹. A third study used the conceptual framework on interorganizational relations and resource dependency to organize data collection for an end of program evaluation of a home care Telemedicine program³¹. A fourth study used the Weiner Organizational Theory of Implementation Effectiveness to conduct a pre-implementation study and needs assessment of a Telemedicine program that involved a network of integrated VHA sites³². Lastly, a fifth study used the Realist evaluation approach and user-task-context usability framework to understand the factors associated with a failed pilot in a Federally Qualified Health Center²¹.

Six studies reported the use of implementation strategies prior to or during the implementation of interventions. Some of the reported organizational implementation strategies reported included conducting a needs assessment, establishing a needs-based practice protocol, and staff training³³. Others include, a feasibility assessment of potential recipients and managers; an evaluation of staff acceptance of telemedicine in the early implementation phase; the use of the health belief model to frame participants' perceptions of the intervention and identify barriers and facilitators, and the use of onsite champions, awareness outreach, staff education, and hands-on training^22,24,27,28. Technical implementation strategies included simple app design, feasibility testing, and the use of an accompanying practice model to enable ease of integration into existing workflows³⁰.

All of the studies included, identified, organizational barriers, facilitators or challenges that affect the implementation of Telehealth or mHealth intervention. Nine studies identified barriers and facilitators in the implementation of mHealth or Telehealth interventions. One study identified facilitators mainly and used them in the eventual intervention implementation post pilot phase³³. Another study identified barriers and opportunities, while two studies were focused on identifying implementation challenges mainly^24,25,27.

This study defined ORC as the degree to which organizational structures, environmental settings and members seemed ready to support and facilitate the Telehealth or mHealth intervention. Based on this, the study identified organizational factors that are relevant in the evaluation of ORC in the implementation of Telehealth and mHealth interventions for chronic disease management among US adults and older adults using the CFIR framework. Emerging CFIR constructs in this review were defined based on the facilitators and barriers identified across the studies and then organized and evaluated using the CFIR framework¹⁸

The next section begins with a table showing how the elicited barriers and facilitators were organized and their influence on ORC that was elicited based on the CFIR (Table I). This will be followed by an enumeration of the elicited facilitators and barriers of ORC in each CFIR domain. The discussion section will then describe the importance of these factors in assessing ORC. Finally, based on the elicited facilitators and barriers of Telehealth or mHealth interventions in this review, specific recommendations to implementers on assessing ORC are discussed.

Table 1. Using the CFIRs domains and constructs to elicit ORC.

CFIR Domains	Definition based on this review	Identified CFIR Constructs	Effects on ORC
Intervention Characteristics	Specific factors related to the Telehealth or mHealth intervention that affect its design, implementation and how it is received by end-users.	Design quality and packaging, complexity, cost.	Assesses the fit of the intervention with organizational infrastructure, and recipient populations.
Outer setting	Features of the external environment or context of an organization that can influence successful implementation.	External policy and incentives, Patients needs and resources, and cosmopolitanism.	Assesses external support for the intervention.
Inner setting	The organizational context in which the intervention exists.	Structural characteristics, networks and communications, culture, implementation climate and implementation readiness.	Assesses organizational structures readiness for the intervention.
Process	Course of actions that need to be carried out to achieve the set organizational or individual goals for the intervention.	Planning, engaging, executing, and reflecting and evaluating.	Assesses readiness for smooth intervention implementation and operation.
Characteristics of Individuals	Specific features of individuals that are involved in the implementation and use of the intervention refers to individual related factors of the interventions implementation.	Knowledge and beliefs about the intervention, self-efficacy, individual stage of change, individual identification with the implementing organization, and other personal attributes.	Assesses workforce readiness for the intervention and the expected level of ease of change.

i. Intervention characteristics

The intervention is the specific mHealth or Telehealth solution that is designed to address a health issue or to achieve a desired health related or health care outcome. Intervention characteristics are the specific peculiarities of the Telehealth or mHealth intervention that is related to the intervention's design and can affect how and where it can be implemented³⁴. Based on the studies included in this review, the identified CFIR related intervention characteristics constructs are design quality and packaging, complexity, and cost³⁴.

Design quality and packaging related facilitating factors identified in the review include simplicity of design, ease of use and easy to use clinical guidelines³⁰. Barriers included device usability challenges for providers and patients, lack of usability testing, poor fit between the intervention and end users, and a cumbersome installation process^21,26. Complexity inhibiting factors in this review include easier to use technology platforms, and an informed patient-clinician interaction^26,30. Complexity related barriers include, time consuming processes, difficulties with accessing the intervention, the need to hire new staff, the need to acquire new equipment, and the need to change existing work schedules or job duties to accommodate the intervention,^21,25,27,29. Cost related facilitating factors for this domain include cost minimizing implementation strategies such as the possibility of the use of existing resources, minimal implementation and labor costs, and cost-effective service agreements for technology use^26,33. Identified barriers include budgetary limitations, high cost of implementation, high cost of maintaining technology equipment, and inadequate data for cost benefit analysis^26,27,31.

ii. Outer setting

The outer setting relates to features of the external environment or context of an organization that can influence successful implementation¹⁷. Three outer setting CFIR constructs identified in this review include external policy and incentives; patient needs and resources; and cosmopolitanism.

External policy and incentives related facilitating factor identified in this review includes cooperative regional licensure agreements²². Barriers identified include lack of, inconsistent or limited reimbursements for the intervention, and fiscal constraints from Medicare policy^21,22,26,31. Other barriers include limited external funding, and a lack of strong organizational structures for administrative oversight by Federal agencies providing funds for innovative technology interventions^22,31. Patients' needs and resources related facilitators in the review includes population-specific knowledge and skills by implementing staff such as nurses that directly interface with patients that are using the innovation; quick response to patients' needs within 24 hours; end-user training; and reduced cost of access (e.g. reduced transportation costs for patients)^26,28,30,33. Identified barriers include concerns or skepticism on how the collected data will be utilized, concerns on being able to utilize the intervention appropriately, concerns that technology complexity may limit patients' understanding and ability to use, and lack of patient motivation^27,28,32. Cosmopolitanism refers to how much an organization is networked with other external organizations in order to be able to potentially access or harness resources for growth³⁵. Identified facilitators based of this domain include adequate telecommunications and technology infrastructure irrespective of urban or rural location^30,31. Barriers identified include poor telecommunications infrastructure in rural areas with less economic advantage than urban counterparts, low revenue, and low recovery of implementation costs due to low number of users in rural areas³¹.

iii. Inner setting

The inner setting refers to "the organizational context in which the intervention exists³⁶. Based on this review, the inner setting elicited the highest number of CFIR constructs and implementation facilitators and barriers. Five inner setting constructs were identified, and these include structural characteristics, networks and communications, culture, implementation climate and implementation readiness.

Structural characteristics refers to the age, size, maturity level, and social architecture of the organization³⁵. Identified structural facilitators in this review include the existence of other programs that are supportive of the intervention³². Identified barriers include other programs that are not in alignment with the intervention; existing incompatible payment structures (e.g. a lack of internal reimbursement for the intervention), limited staff capacity, a lack of fit between the intervention, organizational protocols and approaches, and available staff time to use or implement the intervention^21,32. Networks and communications facilitating factors identified across the selected studies include reducing information overload due to the intervention and creating data management plans and platforms that improve communication between intervention providers, physician practices or HCOs, and patients²³. Identified barriers include a lack of awareness of the need to coordinate communication and integration between the intervention provider and physician practice²⁵. Cultural facilitators include an existing culture of research and innovation within the implementing organization, and an alignment between the project or intervention and the mission, and scope of practice of the implementing site^22,32. Cultural barriers include intervention policies and procedures that are not in alignment with already established policies and procedures of implementing site, and a lack of culture of involving implementing staff in contributing to implementation strategies which can result in lack of staff ownership³¹.

The implementation climate is also an inner setting construct that refers to the organization's capacity for a change, the shared receptivity of participants to an intervention, and the extent to which an intervention's use is supported, expected, or rewarded within an organization¹⁸. Implementation climate related facilitating factors identified in this review include staff ownership of intervention, optimal staff training, and the availability of highly skilled staff³¹. Others include the availability of site champion(s) for the intervention, compatibility of the intervention with the organization's mission and structure, and the presence of other programs that are supportive of the intervention^22,32. Staff or people related implementation climate barriers include lack of training for implementing staff, low computer literacy of staff, and a lack of clinician end user input or involvement in decision making about the technology^26,31. Technical challenges include a lack of related technical and software support, licensure issues and the need for technology related infrastructural changes for the intervention to be implemented^22,32.

Readiness for implementation refers to the level of preparedness of an organization to implement an intervention. Facilitators identified in this domain include, the availability of necessary resources for the implementation (such as office space, IT staff, equipment, and a trained and ready work force), the ability to integrate the intervention easily into existing workflows, a basic understanding of the intervention by key stakeholders, the presence of other organizational programs that support the implementation, and a lack of interoperability challenges with technology³². Barriers include inadequate technology infrastructure such as poor connectivity which restricts the use of the intervention, a lack of integration of the intervention into existing workflows or a lack of clearly defined approaches for clinicians to integrate the intervention into existing workflows^21,31,32.

iv. Process

This involves a course of action that needs to be carried out to achieve set organizational goals for the intervention³⁴. Identified CFIR constructs in this domain include planning, engaging, executing, reflecting and evaluating.

Planning related facilitators identified include identifying the right patient population for the intervention, defining the role of implementing staff, and developing population specific guidelines and protocols^23,25,33. Engagement refers to the involvement of key stakeholders in the design and implementation process. Engagement related facilitators include early stakeholder engagement, considering and including clinician perspectives in implementing the intervention, obtaining intervention buy-in at all leadership levels, developing an informed patient-clinician interaction for the intervention, and leadership and upper management buy-in on technology maintenance costs^{22,23,26,28-30,32}. Executing refers to factors associated with the real time implementation of the intervention. Execution related facilitators identified in the review include the ease of integration into existing workflows, and data management infrastructure that reduce the burden of information overload^23,29,30,32. Identified barriers include technological and technical barriers to use, the need to train staff on how to use the intervention, low referral by physicians due to increased workload or dissatisfaction with the implementing platform, a lack of consideration for physicians' off hours, and workflow integration challenges^22,24-27,32. Reflecting and evaluating refer to actions related to taking stock of implementation processes, successes, and failures to enable improvements. Facilitators identified in the review include engaging in reflection and evaluation that can inform adjustments such as conducting surveys^29,30.

v. Characteristics of Individuals

This refers to the characteristics of the individuals that are involved in the implementation and use of the intervention, or the personal or individual related factors of the intervention's implementation that can have an impact on how well the intervention is delivered or received by end-users. Identified CFIR constructs in this domain based on this review include knowledge and beliefs about the intervention, self-efficacy, individual stage of change, and individual identification with the implementing organization.

Knowledge and beliefs about the intervention facilitator identified in this review include the individuals' positive attitude and value toward the intervention, while the barrier for this construct identified in this review is negative attitudes and impressions about the intervention, and low value toward the intervention particularly by implementing site staff or patient end-user populations²⁹. Self-efficacy facilitator identified in the review include a good understanding of the intervention by staff of implementing sites, while identified barriers include lack of understanding of the intervention by staff, extra need for staff or referring provider training on technology use, or appropriate referrals^27,29,32. Individual stage of change related facilitator identified include health providers' acceptance of the intervention and the process, while barriers include staff's resistance to the technology intervention^22,23. Individual identification with the organization facilitator identified includes staff ownership of the intervention²⁵.

Discussion

A good number of implementation failures have been attributed to the failure of organizational leaders to establish the level of ORC prior to the onset of implementation^37,38. Change amenable organizations are not immune to implementation failures, this is because some organizations that are generally change amenable may not be ready for a particular change at a particular point in time. Hence, change management leaders and researchers emphasize the need to establish organizational readiness for a specific change and have recommended the use of frameworks such as the CFIR to assess and prepare for it^15,39. Studies have also observed that a high level of organizational readiness results in organizational members investing more effort in the change process, showing lesser resistance, and displaying a higher level of persistence in overcoming setbacks or impediments⁴⁰.

An evaluation of the external and internal facilitators and barriers of ORC for Telehealth and mHealth interventions as done in this study, proffers an avenue for HCOs seeking to implement new Telehealth or mHealth interventions for this populations to understand factors that are important in assessing ORC and achieving a successful implementation. Using the CFIR framework in this review to evaluate these factors ensured a systematic identification and evaluation of key barriers and facilitators to implementation across the studies included in the review. It also helped to critically assess and interpret the facilitators and barriers identified. An evaluation of the CFIR domain and construct, with the practical examples based on the implementation studies that were identified in the review can be useful for HCOs that seek to implement Telehealth or mHealth for these populations within the US. The availability of such actionable information before or during implementation can assist with assessing the level of organizational readiness of an implementing organization as well as having access to the necessary information that planners and implementers can use to guide each step of the implementing process and increase the likelihood of a successful implementation⁴¹. Based on this, specific recommendations on facilitators and barriers to ORC in the implementation of Telehealth and mHealth interventions for US adults and older adults based on the CFIR framework are discussed.

Recommendations for implementers based on facilitators and barriers of ORC identified in each CFIR domain

Intervention characteristics such as design quality, cost, and complexity have an influence on successful implementation, and hence are key in assessing ORC. Sufficient consideration of the end-user, the socio-technical infrastructure, and budgets or other funding commitments of the implementing site in designing and allocating costs for the intervention will help implementing organizations to assess their level of ORC as regards a particular intervention. A lack of consideration of these factors prior to the onset of designing the intervention will lead to the design of an intervention that is incongruent with the implementing site's infrastructure, end-user population, and budget. Hence, this is a key measure of ORC, and can increase the chances of a more successful intervention.

An understanding of how outer setting constructs such as external policies and incentives (e.g. regional licensure agreements), and external payment or reimbursement policies affect Telehealth or mHealth implementation is key in evaluating ORC. This can assist organizations to understand how well their external environments support the intervention. It can also enable them plan ahead to address and mitigate barriers to successful implementation due to the lack of readiness of some of these factors prior to implementation. Furthermore, an evaluation of the specific needs and peculiarities of the recipient or patient population, such as the specific needs of the adults or older adult population that are the recipients of the intervention can inform increased receptivity toward the intervention and this facilitates successful implementation. Failure to assess the needs of the recipient population or the peculiarities of this population prior to implementation implies a low level of ORC and can lead to implementation challenges. Furthermore, a lack of adequate technology or telecommunications infrastructure due to rural location of the implementation site can also result in poor implementation, and also implies a low level of ORC. Assessing ORC based on these outer setting factors is critical to successful implementation.

Given that the inner settings represent the environment within which the intervention is implemented, inner setting factors are important measures of ORC and are particularly important for implementation success. Within the inner setting domain, the level of alignment of internal payment structures and arrangements, the level of staff or work-force readiness for the intervention, the level of skilled readiness to engage recipient populations such as older adult populations, the level of alignment of the intervention with existing workflows and cultural factors that facilitate successful implementation such as staff involvement in planning or designing the intervention are critical in assessing ORC. A good consideration of these factors in the planning phase shows an appreciable level of ORC for the Telehealth or mHealth intervention and can facilitate successful adoption and implementation.

An evaluation of process related factors is crucial to implementation success and in evaluating ORC in the implementation of Telehealth and mHealth interventions for adults and older adult populations that might need some specific accommodations to be able to successfully use the intervention. Developing population specific guidelines and protocols that take into consideration the needs of these populations, as well as engages them early on in the design process are important components of achieving ORC. A proper assessment of workforce needs, and challenges related to the intervention is also important in assessing ORC.

Characteristics of implementing individuals is key to implementation and in assessing ORC. Attention to this domain by implementers has the potential to result in positive attitudes and intervention buy-in. A good level of acceptance, ownership, confidence and self-efficacy by implementing staff toward the intervention is indicative of an appreciable level of ORC. Hence, assessing the characteristics of involved individuals based on the highlighted factors is key in assessing ORC and achieving a successful implementation.

Given the broad scope of elicited facilitators and barriers of ORC in this review, study limitations include challenges with aligning implementation strategies and terminologies across studies due to differences in the terminologies used across the included studies. Also, the broad and flexible nature of the CFIR which enables its use in different scenarios and settings resulted in some overlap between identified domains and constructs, and clear boundaries a times could not be well defined between the domains and constructs. Furthermore, although the inner setting elicited the largest sets of facilitators and barriers across the included studies, it was challenging to quantifiably assess its level of importance, relative to other domains in assessing ORC. Future studies that are focused on examining the prevalence and importance of specific implementation facilitators and barriers of ORC in the implementation of Telehealth and mHealth interventions across the literature can be helpful.

Conclusion

An understanding of the organizational barriers and facilitators that are important in the implementation of Telehealth and mHealth interventions for chronic disease management among US adults and older adults is key in assessing ORC for these interventions in this population. Contextual factors such as the internal and external facilitators of implementation are key in assessing ORC and can be organized, evaluated, and analyzed using the CFIR Framework. An appropriate level of consideration of the identified factors in this review can guide implementers on understanding and gauging the readiness level of their organization prior to implementation, which has the potential to result in a more successful implementation experience with sustained adoption.