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Facilitators and Barriers to Implementing a Digital Informed Decision Making Tool in Primary Care: A Qualitative StudyFunding The study was funded by U.S. Department of Health and Human Services, National Cancer Institute (R01CA218416), and Wake Forest Comprehensive Cancer Center (P30CA012197).
Background Informed decision aids provide information in the context of the patient's values and improve informed decision making (IDM). To overcome barriers that interfere with IDM, our team developed an innovative iPad-based application (aka “app”) to help patients make informed decisions about colorectal cancer screening. The app assesses patients' eligibility for screening, educates them about their options, and empowers them to request a test via the interactive decision aid.
Objective The aim of the study is to explore how informed decision aids can be implemented successfully in primary care clinics, including the facilitators and barriers to implementation; strategies for minimizing barriers; adequacy of draft training materials; and any additional support or training desired by clinics.
Design This work deals with a multicenter qualitative study in rural and urban settings.
Participants A total of 48 individuals participated including primary care practice managers, clinicians, nurses, and front desk staff.
Approach Focus groups and semi-structured interviews, with data analysis were guided by thematic analysis.
Key Results Salient emergent themes were time, workflow, patient age, literacy, and electronic health record (EHR) integration. Saving time was important to most participants. Patient flow was a concern for all clinic staff, and they expressed that any slowdown due to patients using the iPad module or perceived additional work to clinic staff would make staff less motivated to use the program. Participants voiced concern about older patients being unwilling or unable to utilize the iPad and patients with low literacy ability being able to read or comprehend the information.
Conclusion Integrating new IDM apps into the current clinic workflow with minimal disruptions would increase the probability of long-term adoption and ultimate sustainability.
NIH trial registry number R01CA218416-A1.
N.P.O. developed the interview and focus group guides, conducted interviews and focus groups in Winston-Salem, conducted complete analysis of the data, and was a major contributor in writing the manuscript. M.C. contributed to the interview and focus group guides, conducted interviews and focus groups in Kentucky, conducted complete analysis of the data, and was a major contributor in writing the manuscript. K.L.F. contributed to the interview and focus group guides and was a major contributor in writing the manuscript. M.B.D. and A.D. contributed to the interview and focus group guides and contributed to writing the manuscript. A.C.S. contributed to writing the manuscript. D.P.M. contributed to the interview and focus group guides, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.
Protection of Human and Animal Subjects
Study participants were informed of their rights to participate; risks and benefits and financial disclosures were declared. A waiver of signed informed consent was approved by the IRB. The Wake Forest School of Medicine Institutional Review Board approved this study IRB00048919.
Contributions to the Literature
While there is a body of evidence that suggests strategies for incorporating mHealth tools into health care, there is not a one-size-fits-all strategy for implementation of patient-facing shared decision making tools that may occur in diverse clinic settings and populations.
The few studies that have examined implementation strategies for incorporating health apps into primary care have yielded mixed results, and the optimal strategies remain unknown.
Although we found strategies for general implementation of mHealth tools in the literature, researchers must recognize that there are a wide variety of nuances in clinic and patient barriers which should be identified to better adapt tools for more successful implementation.
We found that the ability to adapt the implementation strategy to protect or improve patient throughput is critical for successful implementation and maintenance. This finding contributes to the literature and will guide others seeking to implement new interventions in busy clinical environments.
Due to the nature of this qualitative study, data sharing is not applicable to this article as no datasets other than transcripts were generated or analyzed during the current study.
Received: 09 March 2021
Accepted: 27 October 2021
05 January 2022 (online)
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