Table A1.

Facilitators of and barriers to implementation of a shared electronic cross-facility health record based on CFIR [18].

Adapted CFIR-Construct	Facilitators	Barriers
I. Intervention Characteristics
Intervention Source Perception of users about whether the ECHR is ex- or internally developed.	- feeling positive about being involved in the process	- difficult to give critical feedback
Evidence Strength & Quality Users’ perceptions of the quality and validity of evidence support the belief that the ECHR will have desired outcomes.	- structured treatment documentation - minimized effort through automatic transfer - improves the safety of care - reduces redundancy - allows for a better overview of the patient - transfer of information in compliance with legal data protection regulations
Relative Advantage Users’ perception of the advantage of implementing the ECHR versus an alternative solution.	- current information sharing is problematic (lack of information, confusion about who is the right contact, lack of information overview, duplicate diagnostics, data overload) - complexity is appropriate - clearly designed - cross-system - designed to extend beyond individual stays	- difficult changeover from analog to digital - fear of errors due to too many users of one ECHR
Trialability The ability to test the ECHR on a small scale in the organization and to be able to reverse course (undo implementation) if warranted.	- TA perceived as a workshop for ECHR
Complexity Perceived difficulty of the ECHR, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy, and the number of steps required to implement.		- necessity of introduction and further training - necessity to obtain the parents’ consent to use the system and transmit data - costs - high effort - need for someone to control the ECHR
Design Quality & Packaging Perceived excellence in how the ECHR is bundled, presented, and assembled.	- intuitive use	- fear of data overload
Cost Costs of the ECHR and costs associated with implementing the ECHR include investment, supply, and opportunity costs.		- costs might not be covered
II. Outer Setting
Patient Needs & Resources The extent to which the needs of patients and their relatives, as well as barriers and facilitators, to meet those needs are accurately known and prioritized by the organization.	- availability of all information to all parties - eliminating frequent medical history calls → minimized burden on parents - work together on content across sectors
Cosmopolitanism The degree to which the organization is networked with other external organizations.	- regular exchange with 22 different institutions, individuals, and groups - overview of the respective responsible persons per patient in the ECHR was rated positively
Peer Pressure Mimetic or competitive pressure to implement an ECHR, typically due to the fact that most other key peer or competing organizations have already implemented or are in a bid for a competitive edge.	- Competition can lead to the downfall of all systems - ECHR has been available for a long time	- there is already an ECHR in place, which is not complex enough for PPC
External Policy & Incentives A broad construct includes external strategies for disseminating the ECHR, including policies and regulations (governmental or other central entity), external mandates, recommendations and guidelines, performance-based pay, collaboratives, and public or benchmark reporting.	- data protection regulations and data security are crucial provisions—current data transfer is not always data protection compliant → advantage of the new system.	- uncertainty whether data-exchange complies with data protection requirements
III. Inner Setting
Networks & Communications The nature and quality of social networks and the nature and quality of (in-)formal communications within an organization.	- mails, letters, fax, telephone, and face-to-face meetings - lack of contact persons, unclear responsibilities, and limited accessibility - reasons: referral to specialists, clarification of issues, admission to a facility, and more.
Culture Norms, values, and basic assumptions of the particular organization.		- personal contact is irreplaceable
Implementation Climate The receptivity to change, shared receptivity of involved individuals to an intervention, and the extent to which the use of the ECHR will be rewarded, supported, and expected within the organization.		- affinity for technology is very diverse
Tension for Change The degree to which users find the current situation intolerable or in need of change.	- current situation is time-consuming and unsatisfactory
Compatibility The degree of tangible fit between the meaning and values attached to the intervention by users, how those align with users’ own norms, values, and perceived risks and needs, and how the intervention fits into existing work processes and systems.		- use of the ECHR is not equally intensive for all individuals - some components might be used selectively, especially by family doctors/pediatrists in MO - large amounts of data from in-/outpatient documentation
Relative Priority Users’ shared perception of the importance of the implementation within the organization.	- need for everyone to work with the system
Organizational Incentives & Rewards Extrinsic attractions such as target agreement bonuses, performance appraisals, promotions, and salary increases as well as less tangible attractions such as higher reputation or respect.	- better overview of patients and their disease (history) with ECHR
IV. Characteristics of Individuals
Knowledge & Beliefs about the Intervention Users’ attitudes toward and value of the ECHR as well as familiarity with facts, truths, and principles related to the ECHR.	- TA is helpful to get an impression of the system
Self-efficacy Users’ individual belief in their own capabilities to take action to achieve implementation goals.		- time is scarce in everyone’s daily work; ECHR can save time but involves effort (depending on technology affinity) - assessment of content in TA is sometimes difficult
Individual Stage of Change Characterization of the phase a person is in, as he or she uses the intervention skillfully, enthusiastic, and sustainably.	- ECHR is intuitive to use, not complicated	- better overview in paper documentation; one has to get used to the system
Other Personal Attributes A broad construct includes other personal characteristics such as ambiguity tolerance, intellectual ability, motivation, values, competence, capacity, and learning style.		- older individuals might be less likely to accept ECHR than younger individuals - individuals from other settings suggested that the system was too complex and time-consuming for family doctors to use

Abbreviations: DT, design thinking; ECHR, electronic cross-sectional health record; PPCU, pediatric palliative care unit; PPC, pediatric palliative care; SOPPC, specialized outpatient pediatric palliative care; TA, think-aloud session.