Technology-based innovation requires long-term changes to workforce routines, otherwise practices will not be sustained. The aim of this study was to identify influential factors in the ongoing use of an acute stroke telemedicine programme.
Methods
A new acute stroke telemedicine programme in a regional hospital receiving 375 patients with stroke or transient ischaemic attack per year was used as an exploratory case study. Semi-structured interviews with acute care and emergency department clinicians (n = 25) were conducted at two time-points: after a six-month pilot and then after a further 12-month implementation phase. Interviews (between 12–60 min) were recorded, transcribed and analysed inductively using descriptive thematic analysis. Reported barriers and facilitators were compared with those previously reported pre-implementation (deductive analysis) to identify changes over time. Using an implementation framework and a behaviour change taxonomy, strategies were developed to address influential factors on sustainability.
Results
New facilitators were identified including hospital system changes, benefits to clinicians and telemedicine becoming standard practice. New and ongoing barriers included infrequent use, competing demands and the continued resistance to a specific treatment.
Discussion
Understanding the factors supporting a health service in successfully implementing change can accelerate population benefits. The innovation itself may include barriers to be addressed, and barriers and facilitators can change over time. Individual attitudes remain critical to initial and ongoing success. Strategies proposed included promoting benefits across the organisation and allaying uncertainties with site-specific evidence. The effectiveness of these strategies, however, needs to be evaluated. Strategies sustaining change post-implementation should be considered.
JonesSSRudinRSPerryT, et al.Health information technology: An updated systematic review with a focus on meaningful use. Ann Intern Med2014; 160: 48–54.
2.
AudebertHJSchenkelJHeuschmannPU, et al.Effects of the implementation of a telemedical stroke network: The Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurol2006; 5: 742–748.
3.
FrancSDaoudiAMounierS, et al.Telemedicine and diabetes: Achievements and prospects. Diabetes Metab2011; 37: 463–476.
4.
ChristensenCM. The innovator's dilemma: When new technologies cause great firms to fail, Boston, MA: Harvard Business School Press, 1997.
5.
CheaterFBakerRGilliesC, et al.Tailored interventions to overcome identified barriers to change: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev2010. DOI: 10.1002/14651858.CD005470.pub2.
6.
FrancisLDuntDCadilhacDA. How is the sustainability of chronic disease health programs empirically measured in hosptial and related health care services? A scoping review. BMJ Open2016; 6: 1–18.
7.
FlottorpSOxmanAKrauseJ, et al.A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Sci2013; 8: 35–35.
8.
TriccoACAshoorHMCardosoR, et al.Sustainability of knowledge translation interventions in healthcare decision-making: A scoping review. Implementation Sci2016; 11: 1–10.
9.
MarlerJHFisherSLKeW. Employee self-service technology acceptance: A comparison of pre-implementation and post-implementation relationships. Pers Psychol2009; 62: 327–358–327–358.
10.
SummersDLeonardAWentworthD, et al.Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: A scientific statement from the American Heart Association. Stroke2009; 40: 2911–2944.
11.
WadeVAEliottJAHillerJE. Clinician acceptance is the key factor for sustainable telehealth services. Qual Health Res2014; 24: 682–694.
12.
MoloczijNMosleyIMossKM, et al.Is telemedicine helping or hindering the delivery of stroke thrombolysis in rural areas? A qualitative analysis. Internal Med J2015; 45: 957–964.
13.
PaulDLMcDanielRR. Facilitating telemedicine project sustainability in medically underserved areas: A healthcare provider participant perspective. BMC Health Serv Res2016; 16: 1–14.
14.
SinghRMathiassenLStachuraME, et al.Sustainable rural telehealth innovation: A public health case study. Health Serv Res2010; 45: 985–1004.
15.
BladinCFCadilhacDA. Effect of telestroke on emergent stroke care and stroke outcomes. Stroke2014; 45: 1876–1880.
16.
BagotKLCadilhacDAHandPJ, et al.Telemedicine expedites access to optimal acute stroke care. Lancet2016; 388: 757–758.
17.
UptonDUptonPBusby-GrantJ, et al.Systematic review of thombolysis in acute ischaemic stroke, Canberra: University of Canberra and Health Research Insitute, 2016.
18.
EmbersonJLeesKRLydenP, et al.Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: A meta-analysis of individual patient data from randomised trials. Lancet2014; 384: 1929–1935.
19.
National Stroke Foundation (NSF). Clinical guidelines for stroke management 2010 – recommendations, Melbourne, Australia: NSF, 2010.
AudebertHJSchultesKTietzV, et al.Long-term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the telemedical project for integrative stroke care (TEMPiS). Stroke2009; 40: 902–908.
27.
SchwammLHHollowayRGAmarencoP, et al.A review of the evidence for the use of telemedicine within stroke systems of care: A scientific statement from the American Heart Association/American Stroke Association. Stroke2009; 40: 2616–2634.
28.
WechslerLRDemaerschalkBMSchwammLH, et al.Telemedicine quality and outcomes in stroke: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2016; 48: e3–e25.
29.
BradfordNKCafferyLJSmithAC. Telehealth services in rural and remote Australia: A systematic review of models of care and factors influencing success and sustainability. Rural Remote Health2016; 16: 3808–3808.
30.
FrenchBDayEWatkinsC, et al.The challenges of implementing a telestroke network: A systematic review and case study. BMC Med Inform Decis Mak2013; 13: 125. DOI: 10.1186/1472-6947-13-125.
31.
BagotKLBladinCFVuM, et al.Exploring the benefits of a stroke telemedicine program: An organisational and societal perspective. J Telemed Telecare2016; 22: 489–494.
32.
CadilhacDAVuMBladinCF. Experience with scaling up the Victorian Stroke Telemedicine programme. J Telemed Telecare2014; 20: 413–418.
33.
BagotKLCadilhacDAKimJ, et al.Transitioning from a single-site pilot project to a state-wide regional telehealth service: The experience from the Victorian Stroke Telemedicine programme. J Telemed Telecare2017; 23: 850–855.
34.
ArmfieldNREdirippuligeSKBradfordN, et al.Telemedicine – is the cart being put before the horse?Med J Aust2014; 200: 530–533.
35.
StakeRE. The art of case study research, London: Sage, 1995.
36.
BladinCFMoloczijNErmelS, et al.Victorian Stroke Telemedicine Project: Implementation of a new model of translational stroke care for Australia. Internal Med J2015; 45: 951–956.
37.
CadilhacDAMoloczijNDenisenkoS, et al.Establishment of an effective acute stroke telemedicine program for Australia: Protocol for the Victorian Stroke Telemedicine project. Int J Stroke2014; 9: 252–258.
38.
TongASainsburyPCraigJ. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care2007; 19: 349–357.
39.
Morley E. Bendigo health stroke nurse practitioner proposed model of care. Report for the Department of Health Services, Melbourne, Victoria, September 2009.
40.
RitchieJLewisJElamGDesigning and selecting samples. In: RitchieJLewisJ (eds). Qualitative research practice: A guide for social science students and researchers, London: SAGE, 2003, pp. 77–108.
41.
RitchieJSpencerLO'ConnerWCarrying out qualitative analysis. In: RitchieJLewisJ (eds). Qualitative research practice: A guide for social science students and researchers, London: Sage, 2003, pp. 219–262.
42.
MaysNPopeC. Rigour and qualitative research. BMJ1995; 311: 109–112.
MichieSRichardsonMJohnstonM, et al.The Behavior Change Technique Taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions. Ann Behav Med2013; 46: 81–95.
45.
AbrahamC. Charting variability to ensure conceptual and design precision: A comment on Ogden (2016). Health Psychol Rev2016; 10: 260–264.
46.
CarlfjordSFestinK. Association between organizational climate and perceptions and use of an innovation in Swedish primary health care: A prospective study of an implementation. BMC Health Serv Res2015; 15: 364–364.
47.
GradyJ. CE: Telehealth: A case study in disruptive innovation. Am J Nurs2014; 114: 38–45.
48.
McMullenHGriffithsCLeberW, et al.Explaining high and low performers in complex intervention trials: A new model based on diffusion of innovations theory. Trials2015; 16: 1–16.
49.
RogersEM. Diffusion of innovations, 5th ed. New York: Simon and Schuster, 2003.
50.
CaldwellR. Champions, adapters, consultants and synergists: The new change agents in HRM. HRMJ2001; 11: 39–52.
51.
BagotKLCadilhacDAVuM, et al.Telemedicine in the acute health setting: Unintended consequences for specialists of a disruptive innovation (an example from stroke). J Telemed Telecare2015; 21: 443–448.
52.
McEvoyRBalliniLMaltoniS, et al.A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implementation Sci2014; 9: 1–13.
53.
LégaréFRattéSGravelK, et al.Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions. Patient Educ Couns2008; 73: 526–535.
54.
KaplanHBradyPDritzM, et al.The influence of context on quality improvement success in health care: A systematic review of the literature. Milbank Q2010; 88: 500–559.
55.
FranckeALSmitMCde VeerAJ, et al.Factors influencing the implementation of clinical guidelines for health care professionals: A systematic meta-review. BMC Med Inform Decis Mak2008; 8: 1–11.
56.
RayKNFelmetKAHamiltonMF, et al.Clinician attitudes toward adoption of pediatric emergency telemedicine in rural hospitals. Pediatr Emerg Care2016; 33: 250–257.
57.
JagolinoALJiaJGildersleeveK, et al.A call for formal telemedicine training during stroke fellowship. Neurology2016; 86: 1827–1833.
58.
MeyerJ. Qualitative research in health care: Using qualitative methods in health related action research. BMJ2000; 320: 178–181.
59.
ØvretveitJ. Understanding the conditions for improvement: Research to discover which context influences affect improvement success. BMJ Qual Saf2011; 20: i18–i23.
