Abstract
Objective
Despite promising outcomes from pilot initiatives, the transition to widespread adoption and upscaling of eHealth solutions in the hospital context remains challenging. This study aims to explore the barriers and facilitators influencing the implementation of eCoaches from the perspective of professionals.
Methods
A qualitative research design was employed, involving individual semi-structured interviews with management and healthcare professionals (n = 10) who were involved with an eCoach either for heart failure (HF) or inflammatory bowel disease (IBD). Both eCoaches supported remote monitoring, advisory, educational, and interactive care activities. Interview topics were guided by the Consolidated Framework for Implementation Research (CFIR), including the original five domains and the added domain Patients′ needs and Resources. Data were analyzed thematically.
Results
Barriers and facilitators were identified across all CFIR domains: eCoach design and licensing costs (Intervention Characteristics); financial compensation (Outer Setting); integration into care pathways, Information and Communication Technology (ICT) infrastructure, team dynamics, and task reallocation (Inner Setting); intrinsic motivation, beliefs, and competencies of professionals (Characteristics of Individuals); patient resources and digital literacy (Patients’ Needs and Resources); and availability of evidence and management information (Process of Implementation).
Conclusion
This study underscores the complex nature of implementing eCoaches within the hospital setting, where barriers and facilitators span multiple interrelated domains. To overcome “pilotitis” and achieve the sustainable integration of blended care for patients with chronic conditions, comprehensive implementation strategies that concurrently address all relevant domains are essential. By illuminating the experiences of healthcare professionals, this study offers actionable insights to guide the design, implementation, and upscaling of eCoaches and related eHealth technologies.
Keywords
Introduction
Healthcare in general has experienced significant changes in recent years, driven by demographic and epidemiological shifts, scientific advancements, technological innovations, and evolving patient expectations. 1 In the Netherlands, the healthcare system is increasingly strained by a growing shortage of healthcare professionals alongside rising demand for care, commonly referred to as the healthcare gap. 2 This challenge is particularly pronounced in the southern region of the country, where the population includes a high proportion of individuals living with one or more chronic conditions, often combined with low socioeconomic status and limited health literacy. 3 These factors place additional pressure on the regional healthcare system and underscore the urgent need for innovative and sustainable transformation.3,4
To make healthcare sustainable, various stakeholders from research, policy, and practice view eHealth as a promising solution. 5 eHealth is an emerging field at the intersection of medical informatics, public health, and business, referring to health services and information that are delivered or enhanced through the internet and related technologies. 6 In a broader context, the term can represent not only a technical advancement but also a mindset, a way of thinking, an attitude, and a commitment to improving healthcare locally, regionally, and globally. For disease management purposes, eHealth solutions have been shown to reduce the number of outpatient visits, as well as the frequency and duration of hospital admissions. 6 Furthermore, patients receiving blended care, a model that combines traditional face-to-face care with digital healthcare technologies, such as online therapies, telemedicine, or e-health applications, experience fewer complications and more effective medication use. 7 The goal of blended care is to maintain the benefits of personal interaction while taking advantage of the accessibility, efficiency, and flexibility offered by digital care. This model can range from alternating between online and in-person care to fully integrating digital tools into the treatment process. At the same time, positive effects are observed in patient self-management, empowerment, and satisfaction.8,9 As a result, hospitals are increasingly developing digital strategies and allocating resources toward the implementation of eHealth technologies, especially for patients with chronic conditions like heart failure (HF) and inflammatory bowel disease (IBD), who require extensive and ongoing care. 10
In Dutch hospitals, several blended care solutions have been piloted, using eCoaches for patient self-monitoring of different chronic conditions. These pilots have shown success in reducing healthcare consumption, improving patient satisfaction, and gaining healthcare professionals’ support. 11 Despite these positive findings, scaling up has proven difficult, a challenge commonly referred to as “pilotitis.” This term describes a widespread phenomenon in which healthcare innovations are repeatedly tested in small-scale pilots but rarely make it beyond the pilot phase into full-scale, routine implementation.12,13 While previous research has identified a broad range of barriers to eHealth implementation, ranging from individual and technical to organizational,14–17 most studies focus on general, system-level issues. Yet, a critical gap remains in understanding the practical, day-to-day barriers and facilitators experienced by healthcare professionals, especially in the context of implementing digital coaching tools within hospital settings. Their perspectives are essential, as successful implementation often depends on professional engagement, workflow integration, and clinical usability 18 —areas not sufficiently covered in existing literature.
This qualitative study addresses that gap by exploring the experiences of healthcare professionals with the implementation of two digital eCoaches in a Dutch regional hospital, using the Consolidated Framework for Implementation Research (CFIR) as a guiding framework. The case of these local eCoaching programs serves to explore broader challenges in the upscaling of eHealth interventions. By analyzing the sustainability challenges encountered, this study contributes to the broader discussion on how to effectively scale up eHealth initiatives beyond isolated pilots. Focusing on both barriers and facilitators within the hospital context, study results will inform on how to effectively facilitate the adoption of digital coaches, so they can become a standard part of hospital care processes—moving beyond pilots toward sustainable, system-wide transformation.
Methods
Design
This study followed a qualitative research design of explorative nature. Individual semi-structured interviews were performed with professionals involved in the use of eCoaches for HF and IBD in a Dutch hospital. Ethical approval was obtained from the Medical Ethical Committee Zuyderland Zuyd (Z2022048). The committee reviewed the study protocol and confirmed that it raised no ethical concerns, indicating that participation posed no risk to the participants.
Setting and sample
This study was conducted at Zuyderland Medical Center, a large non-academic hospital in the Southern of the Netherlands with main locations in Heerlen and Sittard-Geleen. The hospital employs around 5000 staff and serves regions marked by low socioeconomic status, limited literacy, and poor health skills. Research took place within the Departments of Cardiology and Internal Medicine, focusing on eCoaches for HF and IBD.
A total of 10 healthcare professionals, including nurse specialists, physicians, and members of hospital management, were recruited through purposive sampling to ensure maximum variation in background, experience, and role. This diverse group provided both clinical and organizational perspectives on the implementation and upscaling of eCoaches. Participants were required to be Dutch-speaking and actively involved in one of the eCoach programs. Recruitment was facilitated through the research team's internal network.
No formal sample size calculation was performed due to the qualitative nature of the study. As all relevant stakeholders were included, the full sample ensured comprehensive insight. Informed, written consent was obtained from all participants prior to the initiation of the study.
Intervention
Both the eCoach for HF and the eCoach for IBD had a similar approach. Each eCoach consisted of two digital applications, being a web application for the professionals and a web or mobile application for the patient. The patient app required patients to fill out regular questionnaires to keep track of their own health status. Moreover, patients were offered information about their illness and/or condition and how to take up self-management. Additionally, patients communicated with a nurse practitioner and vice versa, using text message functionality via text message functionality. On the opposite side, the professional app enabled professionals to monitor, advise, and interact with their patients remotely. Outpatient visits were scheduled only when needed or desired.
eCoach HF
The Department of Cardiology started using the eCoach for HF in a pilot of 10 patients at the end of 2021. The eCoach is introduced to patients shortly after diagnosis or in the early stages of disease when medication titration is the primary focus. Monitoring and follow-up are done by specialized nurses. At the time of the interviews, 150 active patients were included. Previous research on the effectiveness of the eCoach HF found some effects on consumption of care. 19
eCoach IBD
The eCoach for IBD has been used by the Department of Internal Medicine since 2015. At that moment, the hospital participated in a multicenter study focusing on the effectiveness of the eCoach. Based on positive effects on the number of hospital admissions without losing quality or satisfaction, 20 patients using the eCoach are now seen at the outpatient clinic once a year and more often only in case of complaints or symptoms. The team decided to invest in hiring new nurse practitioners and to train current nurses to become nurse practitioners. Most recent figures (as of December 2024) show that 1823 active patients are currently included in the eCoach.
Data collection
Individual semi-structured interviews were conducted either face-to-face or online using secure video conferencing platforms (Microsoft Teams or Zoom). The interviews were guided by a topic list based on the CFIR, which outlines five key domains 21 for understanding implementation: intervention characteristics, outer setting, inner setting, patient needs and resources, characteristics of individuals, and implementation processes. In addition, we incorporated “Patient Needs and Resources” as a sixth domain, following Safaeinili et al. 22 , to better capture the critical role of patient-centered factors in the implementation of eCoaches.
While the core structure of the interviews was maintained, questions and thematic emphases were adapted to suit the context of each participant's role and experience, which may have influenced comparability across cases. To address this, a flexible yet structured interview guide was used, and consistent coding procedures were applied across all transcripts.
All interviews were conducted in Dutch, lasted approximately 60 minutes, and were audio-recorded with participants’ consent. Data collection took place between April and June 2022. Data validation was performed collectively by the project team through validation sessions and confirmed with participants via member checks. Although some phase-specific insights emerged, this was not the primary aim of the study and is considered a secondary finding.
Data analysis
All audio recordings were transcribed verbatim. Following transcription, data analysis was conducted using a deductive thematic approach, supported by the qualitative data analysis software NVivo 12. 23 One researcher systematically read all interview transcripts. The identified codes and themes were organized and interpreted using the domains of the CFIR. We checked on additional codes or themes that occurred directly from the data. Throughout the process, regular team discussions were held to reflect on the themes, resolve ambiguities, and enhance interpretive rigor. Memos were used to document analytical reflections and coding decisions, contributing to transparency and consistency in the analytical process. Relationships and patterns between themes were examined to deepen understanding of key implementation factors. Validity was enhanced through verbatim transcription, member checks, and expert-verified translations. The use of a well-established framework 24 increased construct validity, and peer debriefings contributed to the credibility of the findings. Reliability was supported through consistent coding procedures using analysis software and a detailed documentation of the analysis process to ensure transparency and reproducibility.
Results
Sample
The study population consisted of 10 professionals employed at the hospital, involved in the eCoach either for HF or IBD. Population characteristics are presented in Table 1. Participants had diverse academic backgrounds, professional roles, and varying years of experience using the eCoach.
Population characteristics.
Barriers and facilitators organized by CFIR domain
As a result of the thematic analysis, Table 2 shows an overview of relevant barriers and facilitators organized by the CFIR domains. To support readability, Table 2 focuses on the most frequently cited factors and does not represent the full scope of themes explored in the qualitative analysis. These influencing factors are explained in more detail below. All influencing factors fell within the six CFIR domains used in this study, including the original five domains 21 plus the added domain ‘Patients’ Needs and Resources’; 22 no additional themes emerged outside of this framework.
Barriers and facilitators organized by the CFIR domains.
Intervention characteristics
Most frequently mentioned and a powerful barrier according to all professionals were flaws in eCoach design and the complexity of use, which led to high workload and accompanying work pressure. Monitoring and follow-up tasks related to the eCoach were performed by specialized nurses and nurse practitioners. All nurse practitioners (n = 3) reported that they felt the eCoach is just another task on top of their existing tasks, making them experience a high workload. Many patients used the option to send text messages as a low-threshold communication tool. Processing all these messages took a lot of time (n = 4). It's just another thing that will be added, so higher work pressure. (Nurse practitioner, eCoach IBD)
eCoach optimization was thought to be an important facilitator in reducing the administrative burden and workload of health professionals. It could also ensure larger patient participation when it led to better usability for patients. To reduce administrative burden, the eCoach could be optimized by a no-reply functionality (n = 1), automatic opening and closing sentences (n = 2), and a triage model that referred patients directly to certain information based on their questions (n = 3). As for patient participation, it was also considered important to look at new features, technological progression, and artificial intelligence (AI) in the near future. By connecting wearables such as bathroom scales and blood pressure monitors, remote monitoring would also become available for elderly and/or illiterate patients. Well a triage function makes sure you know where to go with your question. So say you have some kind of filter in advance where that question should go. (Nurse practitioner, eCoach IBD)
Furthermore, high licensing costs were mentioned as a barrier leading to budget problems in interviews with managers.
Outer setting
Lack of (sufficient) financial compensation was the barrier most mentioned in the external setting domain. The respondents stated that the eCoach IBD was still a subsidized project due to collaboration with a foundation related to IBD care, who also facilitated the inclusion of large numbers of patients. For the eCoach HF, there was some form of compensation in the current financing system of healthcare, though not enough (n = 2). Clear arrangements were considered necessary. Managers (n = 2) mentioned that careful consideration had to be given to which tasks related to the eCoach lead to a payment from the health insurer. On that basis, clear agreements with health insurers about structural sustainable financing were thought to be the largest facilitator. The second reason is money. The hospital pays a considerable amount per patient to connect the patient to eHealth. So I hope that the health insurer will compensate for that money. (Manager, eCoach HF)
Inner setting
Although professionals mentioned that the eCoach was a helpful tool for remote patient monitoring, including a lot of information and accessible communication, it also came with a big administrative burden (n = 4), contributing to high workload and work pressure, due to the fact that using the eCoach was not incorporated in their process but used as an add-on. Some professionals (n = 5) mentioned that task reallocation could have improved outcomes and therefore deserved more attention. Furthermore, priority and arrangements were only established during pilots or in research contexts. Processes needed to be adjusted to incorporate the eCoaches, and teams needed to consist of dedicated professionals. Incorporation of eHealth on care pathways was seen as the most important facilitator in overcoming pilotitis, meaning tasks became regular tasks and not extra.
Healthcare professionals reported that the eCoach is not in sync with their electronic patient record (EPR; n = 7). This implied that both systems operated parallel to each other and could not communicate, leading to tasks being executed twice. Incorporation of the eCoach in the corporate IT infrastructure was thought to improve ease of use and decrease administrative burden. In any case, I would look at where the most motivated employee is and I would try to fish him out [select] to get started. Make them enthusiastic and get to work with that. (Nurse, eCoach HF)
Characteristics of individuals
Professionals (n = 2) believed that the eCoach could never replace a real-life consultation and that they expected that patients would prefer to be seen by the nurse at the hospital. Some indicated that they saw no added value of the eCoach (n = 3), whereas others increasingly did (n = 4). Gaining more information on the added value of using the eCoach for patients and for professionals was thought to potentially lead to more adoption and facilitate upscaling. At the start we were a little reluctant because it is new and you have to learn to use it, but along the way we have all become quite positive about using the eCoach. (Nurse, eCoach HF)
According to the professionals, patient participation was one of the factors that influenced their own motivation. When it came to competences, nurses sometimes were not confident with their own abilities when dealing with the eCoach (n = 2). Upscaling could have been facilitated by educating professionals in using the eCoach and by providing insight into why patients would or would not participate. Because no one has learned to do that yet, we all do what we think is right. But words can be so multi-interpreted, which has also sometimes caused agitation, for example. Or that it did not come across as intended and how do you do that well. (Nurse, eCoach IBD).
Patients’ needs and resources
Patient non-participation was an important barrier, caused by patients not being able or not being willing to use the eCoach. Professionals (n = 6) stated that there were patients who simply did not have the financial resources to meet the requirements for using the eCoach, including a computer or smartphone with internet access, or additional tools for monitoring purposes, such as a scale and blood pressure monitor. But also people that just can't buy a scale because they just don't have the money for it. And you also need a phone to be able to use the eCoach. There are just people who don't at all have that kind of stuff. (Nurse, eCoach HF)
Some patients simply could not or would not participate due to low (health) literacy skills. Next to socioeconomic-related factors, age was also of influence, especially for the eCoach HF. The patient population of this eCoach was predominantly over 75 years of age. Several healthcare professionals noted that, in their experience, patients in this age group often encountered more difficulties using the eCoach, which they attributed to limited digital skills (n = 5). Patients could, for instance, have experienced difficulties using the eCoach because of system errors they could not solve, lack of a (stable) internet connection, or losing their credentials (n = 9). The low literacy factor in the region is a thing [is prevalent]. People find it hard, they just don't understand it. […] There are people among them who can't even read you know. They can listen but they can't even, they can't understand it. (Head of department, eCoach HF)
In terms of the patients’ intrinsic motivation, professionals (n = 3) reported that some patients thought using the eCoach was a burden because it took too much effort, while others felt that it was too confronting or that they did not want to feel sick every day (n = 4). Upscaling could have been facilitated by the right communication and education of patients. Once patients knew and had experienced how the eCoach worked, what the role of the nurse was, and which advantages could be expected, patients might have been more willing to use the eCoach.
Process of implementation
Lack of data was frequently mentioned (n = 5), in particular by managers and physicians. The participants mentioned that they missed real-time evidence about the actual effects of the eCoach in terms of both reductions in hospital visits, admissions, or readmissions, as well as quality of care and added value for the patient. The question that always lingers up there, is the patient benefiting from that now? We think so, but is quality of life, and that's especially in heart failure, actually increased? Or does it not work at all? And those are, I think, always the questions that you ask the patient. Is this really what the patient wants? (Medical specialist, eCoach HF)
Because there was no (sufficient) integration with the hospital EPR, managers could not monitor the nurses’ daily activities in using the eCoach or how many billable contacts with patients there had been over a period of time. For them, this inefficiency led to registration problems and difficulties in retrieving management information. Furthermore, participants (n = 4) felt the eCoach had been imposed on them by their management and that they had no choice but to use it, leading to reluctance in its use.
Discussion
This study aimed to explore barriers and facilitators to the sustainable implementation of eHealth interventions, using local eCoaching programs as a case study. While the findings reflect context-specific challenges, they also correspond with issues commonly reported in the broader field of digital health implementation. These insights may help to better understand some of the factors that contribute to the limited scaling of many eHealth initiatives beyond the pilot phase.
Individual semi-structured interviews with different professionals involved in either the eCoach HF or the eCoach IBD revealed an overview of barriers and facilitators for scaling up these interventions. Applying the CFIR, stagnation could be explained across all six domains: intervention characteristics (eCoach design and licensing costs), outer setting (financial arrangements), inner setting (integration into care pathways and ICT infrastructure, team organization), characteristics of individuals (motivation, beliefs, competencies), patient needs and resources (digital access and skills), and the implementation process (availability of performance data).
Although findings within the intervention and inner setting domains were expected to dominate due to the hospital-based focus of this study, barriers and facilitators were found across all CFIR domains, often interrelated. Addressing only one domain will therefore not suffice. 25 For example, although eCoaches are promoted as solutions for high workload and capacity shortages, 11 professionals experienced an increased workload due to eCoach-related activities. Without organizational adaptations, innovations risk becoming an “add-on” rather than a solution, reinforcing pilotitis. During pilot phases, temporary adjustments and allocated time help facilitate adoption; however, once this support is removed, successful integration often struggles.
Different stakeholders—being patients, health professionals, innovators, payers, insurers, and tech companies—require different kinds of evidence to support adoption and upscaling. At present, managers often lack operational data related to eCoach use needed for negotiations with health insurers; doctors lack robust evidence about the clinical added value of using eCoaches beyond study results; and patients rely on peer recommendations and practical support to trust and use eCoaches. 26 In the Netherlands, the absence of standardized methods for assessing the quality of eHealth applications further hampers scaling. 27 Assessment needs vary by stakeholders and contexts; 28 for each eHealth tool it is therefore essential to clarify which technology, in which care process, sector, and user group is evaluated.
Patient-related barriers were substantial, especially considering the overrepresentation of patients with a low socioeconomic status and low (digital) literacy skills in both eCoaches—partly due to the diseases involved as well as the geographical location. Professionals noted barriers such as lack of technological access, low digital literacy, and unwillingness or inability to participate, findings also reported by Støme, Wilhelmsen, & Kværner. 17 Especially for older patients in the eCoach HF group, additional digital support (e.g., onsite instructors, online helpdesks) might be relevant to facilitate engagement. 29
Study results need to be interpreted in the light of some strengths and limitations. A key strength was the use of theory; the CFIR framework informed the development of the interview topic guide and the deductive analysis. The inclusion of diverse professional roles provided both clinical and organizational perspectives. Validity was supported through verbatim transcription, member checks, and peer debriefings. Consistent coding in NVivo12 and systematic documentation of analytical decisions enhanced reliability and transparency.
Limitations include the relatively small sample size (n = 10), the single-institution setting, and recruitment through internal networks, which may have introduced selection bias. We were aware of the possibility of selection bias and/or limited representativeness following from our study design. While these limitations were unavoidable due to the research method used, they were explicitly considered during analysis. In addition, patient perspectives were captured indirectly through professionals, which may not fully reflect patients’ own experiences. These factors were acknowledged and considered in the interpretation of results.
Based on the results and considering the strengths and limitations, some recommendations can be made for further research. Future studies could include a broader sample across multiple hospitals to increase representativeness. Moreover, co-creative approaches involving both professionals and patients—especially with specific needs—during development and evaluation could provide additional insights. 30 In addition, more attention needs to be given to studying eCoaches at various stages of implementation in order to understand differences over time.
Several recommendations can be made to support the upscaling of eCoaches within the hospital context and address the issue of pilotitis—in line with CFIR. In terms of intervention characteristics, it is crucial to develop and continually refine eCoaches in collaboration with end users to effectively address and prioritize usability and feasibility concerns. For the outer setting, establishing long-term financial agreements with health insurers is essential, not only to ensure financial stability but also to foster trust that the time and effort invested by healthcare professionals and patients will be sustained over time. Within the inner setting, eCoaches should be fully integrated into care pathways and IT infrastructures, rather than simply being added as an extra component. Concerning individual characteristics, emphasis should be placed on training and utilizing dedicated and motivated professionals (or “change agents”) to inspire and support the team. Additionally, delegating tasks among current staff and gradually involving outpatient offices or eNurses could help alleviate workload pressures for healthcare professionals. Regarding patients’ resources and needs, providing the necessary equipment and ensuring reliable internet access are crucial for participation in the evolving healthcare landscape. Furthermore, a robust onboarding process for patients should be prioritized, offering both remote and in-person training and support from informal caregivers and home care staff. Finally, when it comes to the implementation process, starting with bottom-up decision-making that includes a small group of patients and healthcare professionals is key. Continuous monitoring of relevant outcomes, tailored to the needs of different stakeholders, as well as sharing and celebrating successes, will be vital.
While this study is grounded in a specific case, the patterns observed speak to systemic issues in the field of eHealth. The persistence of “pilotitis” is not merely a local failure but often reflects broader structural and policy-level challenges. Our findings suggest that a shift is needed in how digital health innovations are evaluated and implemented, moving from isolated pilots toward system-wide integration strategies.
Conclusion
In conclusion, this qualitative study identified key barriers to the upscaling of eCoaches as part of routine clinical care, including design flaws, lack of sustainable funding, poor integration into care pathways and Information and Communication Technology (ICT) systems, patient non-participation, professionals facing high workload and feeling incompetent or unmotivated, top-down decision-making, and insufficient management information. Frequently mentioned facilitators include eCoach optimization, clear financial agreements with health insurers, resources and education for patients, training and task reallocation for professionals, and regular updates on professionals’ time investment and effects on care utilization.
Based on these findings, it is recommended to begin eCoach implementation within the hospital context with a small group of patients, adjust existing processes, employ nurse practitioners or retrain current staff for task delegation, and involve family members or caregivers to support patients with technological literacy challenges. By highlighting both barriers and facilitators, this study offers valuable recommendations for the effective integration of blended care approaches for patients. Addressing the challenges that contribute to pilotitis can significantly enhance the successful upscaling of eCoaches in the hospital setting.
Footnotes
Acknowledgements
The authors would like to thank all health professionals for participating in the study and Laura Janssen for contributing to the recruitment and data collection.
ORCID iDs
Ethical approval
Ethical approval has been granted by the Medical Ethical Committee of Zuyderland: METCZ20220040.
Contributorship
TS, LH, BK and MS conceived the study concept and design. TS was responsible for data collection and management. TS performed the data analysis with input from LH and MS. All authors interpreted the findings. TS, LH and MS drafted the initial manuscript. All authors critically revised the manuscript for important intellectual content. All authors reviewed and approved the final version of the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.