Table 2.
Barriers, enablers, and implementation strategies used in case studies
| Country | Clinical setting | Implemented PROMs or PREMs | IS framework or theory | Implementation barriers identified | Implementation enablers identified | Implementation strategies employed |
|---|---|---|---|---|---|---|
| Eastern Canada [30] | Chronic pain network including primary care, rehabilitation care, and hospital-based care | ePROMs |
Primary care Theoretical domains framework (TDF) [36–38] Tertiary care Consolidated framework for implementation research (CFIR) [34, 35] |
Barriers: Primary care: • Well-defined clinical process: barriers at clinician level • Lack knowledge on how to interpret pain PROMs Tertiary care: • Variability in care process: multilevel barriers • Confidentiality concerns • Technology comfort • Perceived increase in workload and time to review PROMs • Perception PROMs may decrease patients’ satisfaction with care • PROMs not integrated in electronic health record • Cost and time to implement |
Enablers • Existing PROM system easy for clinicians to use and accessible on all forms of devices • Rapid access to PROM results • Selected PROMs that are easy to complete and interpret • Top-down decision from clinic leadership to implement • Created business plan with health system and moved money to clinic budgets • Opinion leader support |
Strategies Pre-implementation: • Identify barriers with clinic • Map observed barriers to evidence-based strategies Implementation: • Training workshop with clinic team (half day) • Local opinion leader with PROM knowledge provided coaching • Educational materials • Onsite tech support • Workflow redesign support • Support to help patients complete PROMs Post-implementation: • Examine potential cost savings by triaging patients more efficiently |
| Australia [31] | Medical oncology outpatient department | Paper and electronic PROMs |
Integrated Framework for Promoting Action on Research Implementation in Health Services |
Barriers • Gaps in infrastructure • Varying workflows • Clinics needed more time than anticipated to implement • Staff felt pressured with competing priorities • Past negative experiences with innovations |
Enablers • Dedicated facilitator (implementation support role) • Rapid access to PROM results • Research funding • Peer champions for PROMs emerged naturally |
Strategies Pre-implementation: • Stakeholder engagement about barriers and context assessments • Workflow assessment and redesign assistance Implementation: • Training/information resources • Technical support • Rapid cycle testing Post-implementation: • Audit and feedback to clinics |
|
Netherlands [32] |
Multiple pediatric and adult health conditions | ePROMs | Consolidated Framework for Implementation Research (CFIR) [34, 35] |
Barriers • Some clinics undergoing too many change initiatives • PROMs not integrated in EHR • Stakeholders did not see relative advantage of PROMs • Compatibility • No organizational incentives |
Enablers • Clinicians perceived value • Strong evidence PROMs improve clinical outcomes • Existing online portal is user friendly for patients and clinicians • Existing automated PROM reminders • Existing automatic and direct access to PROM results and visualization for clinicians • Existing ability for multidisciplinary clinic team members to customize PROMs based on patient age, health conditions, etc • Existing clinician self-efficacy |
Strategies Pre-implementation: • Stakeholder engagement • PROM integration in EHR • Provided PROM recommendations based on patients’ age and condition Implementation • Training • Implementation support team available to all clinics Post-implementation: • Annual evaluation meeting with clinics • Reflecting and evaluating on what worked and did not work |
| Western Canada [33] | Primary care: implementing ePREMs for quality improvement | ePREMs |
Barriers • Unclear stakeholder preferences and barriers • Unclear what optimal implementation strategies will be for PREMs and whether they differ from PROM strategies |
Enablers • Research grant support • Collaboration with quality improvement specialists • National policy change: Primary care patient’s medical home encourages patient-centered communication and patient surveys to evaluate effectiveness of practice’s services |
Strategies Pre-implementation • Stakeholder engagement to identify barriers (interviews with clinic teams) • Categorize barriers with theory and map to evidence-based implementation strategies Implementation: • Training clinic teams • Stakeholder engagement • Onsite coaching • Plan-Do-Study-Act rapid testing cycles Post-implementation: • Audit and feedback to clinics • Process evaluation |