Table 1.

The Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework as applied to an asthma symptom monitoring intervention in primary care

Domain and characteristics of scalable interventions	Pertinent research questions for identifying requirements	Methods used to identify requirements for asthma symptom monitoring intervention in primary care
1. CONDITION: Well-characterized, well-understood, and predictable; few sociocultural factors or comorbidities significantly affect care	Which kinds of symptoms are amenable to between-visit symptom monitoring? What sociocultural factors or comorbidities influence propensity to use intervention?	Determine inclusion/exclusion criteria (eg, exclude patients with COPD) through input from clinical experts Analyze data from prior feasibility study Use UCD to identify relevant factors that affect the intervention (eg, level of asthma control, race/ethnicity, language, health literacy, education)
2. TECHNOLOGY: Direct measurements of medical condition; minimal knowledge or support required to use the technology	Which patient-generated measures most directly measure medical condition? What technology is already used by patients/providers and can be leveraged? What functionalities require minimal training?	Use standard PRO measures Integrate with EHR and clinical workflows Use UCD with patients and providers to ensure intervention works with smartphones and EHRs Consult with usability experts Use simple language with attention to health literacy to ensure technology is as easy to use as possible
3. VALUE PROPOSITION: Clear business case for developer with return on investment (supply-side value); technology is desirable for patients, safe, effective, and affordable	What are potential business models to scale technology? What app functionality will be most effective for a substantial number of patients?	Use standards-based data types and APIs and keep requirements minimal to reduce need for large investment in development and costs to adopt Make intervention desirable for patients (using UCD), feasible to implement (engage stakeholders), and consistent with established evidence-based medical guidelines that recommend symptom monitoring Do not require deployment of a new device or other hardware
4. ADOPTER SYSTEM: Minimal changes required in terms of staff roles or expectations of patients/caregivers	What workflows and functionality would maximize use in the setting of interest (eg, primary care)?	Use UCD and discussions with clinic leadership to ensure workflow and technology fits within existing routines (eg, doesn’t require separate login, callback requests routed to appropriate staff) Design app in English and Spanish
5. ORGANIZATION: Minimal changes required in team interactions or care pathways; minimal work needed to establish shared vision, monitor impact	How do physicians and nurses interact? How are care pathways implemented using the EHR? What protocols exist for making changes to work processes?	Meet with clinic physician and nurse leadership to understand existing team interactions and identify minimal changes needed to implement intervention Work with clinic/hospital leadership to develop or enhance care pathways consistent with existing protocols (eg, nurse-driven asthma triage protocol)
6. WIDER CONTEXT: Financial and regulatory requirements already in place; supportive professional organizations	What kinds of related interventions are already supported by professional bodies? How can the intervention align with anticipated changes in financial incentives?	Ensure intervention is consistent with asthma guidelines (eg, from National Heart Lung and Blood Institute) Work with clinic/hospital leadership to design intervention to help clinics succeed under emerging value-based payment methods (eg, reduce need for emergency visits)
7. ADAPTATION OVER TIME: Strong scope for adapting and embedding the technology as local need or context changes	How can new PROs and other EHR data be added to the app and available at the point of care?	Design technology in modular fashion to allow new PROs to be added and displayed along with other relevant data pending UCD results

Abbreviations: COPD, chronic obstructive pulmonary disease; EHR, electronic health record; PRO, patient-reported outcome; UCD, user-centered design.