SERIES: eHealth in primary care. Part 4: Addressing the challenges of implementation

Abstract Background The implementation of eHealth applications in primary care remains challenging. Enhancing knowledge and awareness of implementation determinants is critical to build evidence-based implementation strategies and optimise uptake and sustainability. Objectives We consider how evidence-based implementation strategies can be built to support eHealth implementation. Discussion What implementation strategies to consider depends on (potential) barriers and facilitators to eHealth implementation in a given situation. Therefore, we first discuss key barriers and facilitators following the five domains of the Consolidated Framework for Implementation Research (CFIR). Cost is identified as a critical barrier to eHealth implementation. Privacy, security problems, and a lack of recognised standards for eHealth applications also hinder implementation. Engagement of key stakeholders in the implementation process, planning the implementation of the intervention, and the availability of training and support are important facilitators. To support care professionals and researchers, we provide a stepwise approach to develop and apply evidence-based implementation strategies for eHealth in primary care. It includes the following steps: (1) specify the eHealth application, (2) define problem, (3) specify desired implementation behaviour, and (4) choose and (5) evaluate the implementation strategy. To improve the fit of the implementation strategy with the setting, the stepwise approach considers the phase of the implementation process and the specific context. Conclusion Applying an approach, as provided here, may help to improve the implementation of eHealth applications in primary care.

Example of cost as a barrier to implementation In 2008 NHS Lothian implemented a telemonitoring service for people with COPD in the UK. The service enabled patients to record their symptoms online, perform physiological measurements, and transmit their health data to trained support staff [25]. Minor technical issues (such as batteries needing replacing in peripherals) caused problems because the service was set-up without the availability of technical support. The clinical team thus had to spend valuable time resolving technical issues. Although ultimately resolved, the cost of ongoing technical support resulted in unanticipated costs that were not budgeted. It is essential to budget adequately for ongoing support costs, mainly when eHealth is provided for people unfamiliar with technology.
Example of complexity as a barrier to implementation eVita is a personal health record, including self-management support and coaching for patients with diabetes type II in primary care [26]. The eHealth tool had low usage and only 27% of those registered to use the service logged in at least once. It was found that the complexity of the login procedure was a barrier for patients to use the eHealth application. A perceived facilitator, for HCP, was the ease with which the helpdesk could be contacted.

Example of a successful implementation facilitated by intervention characteristics
The mass uptake of a remote consultation service, in the UK, in response to the COVID-19 pandemic was made possible by the availability of a simple, easy-to-use service [27]. See also the second example under domain 2. The positive experiences of HCP with this service may, in turn, positively affect the perceived advantage of using eHealth and promote the uptake of other eHealth services in the future.

Aspects external to the organization
External policies and incentives [14,15,[18][19][20] There are, for example, concerns about the return on investment of eHealth applications (i.e., achieved benefits relative to investment costs). These concerns may be explained by the fact that costs related to eHealth implementation are generally not reimbursed, but often need to be covered by the healthcare organisation.
Lack of recognised standards for eHealth [15,18] Recognised standards for eHealth applications are missing (i.e., technology standards addressing the operability between systems, security and privacy) and this can be considered a barrier. The availability of such standards can impact concerns of HCP related to data safety and professional liability.
Examples of a successful implementation facilitated by external policies and incentives Primary care practices in the UK could join a reimbursement program that incentivised certain aspects of quality care [28]. Indicators were, for example, in clinical areas (e.g. heart failure, asthma), in organisational areas (e.g. education), or related to patient experience of care. Crucially, the practice achievements were assessed via the EHR. Almost all practices voluntarily joined the initiative and most converted to paperless practice (from their previous hybrid status) over a few months.
Although not the primary aim of the program, such a significant policy initiative was able to provide the context for the universal implementation of the EHR in UK primary care.
In response to the COVID-19 pandemic, a significant shift has occurred in primary care from face-toface consultations to remote consultations (especially video consultations). This was important to minimise the risk of infection for patients and healthcare professionals. A new remote consultation service was quickly developed in the UK and 80 percent of the practices were using it [27]. Although the technology was ignored/resisted for years, it was widely accepted and adopted within weeks when it was necessary. The same happened in many other countries within and outside Europe. Can act as a barrier and these concerns can be present in both patients and HCP.
Lack of knowledge and skills [15,19] Can act as a barrier amongst patients and HCP, and limit acceptance and implementation.  [32]. The government believed that there was too much confusion around the EHR to accept the Act of Parliament. In hindsight, the strategy that was used to implement the EHR was regarded as problematic. The Ministry of Health, Welfare and Sport took the lead in the realisation of the EHR and attempted to involve various stakeholders in the development process, such as the national GP association and the data protection college. In practice, however, this turned out differently than intended and, apart from the ministry, there was hardly anyone committed in the healthcare field. The ministry failed to bring the stakeholders together; the opinions were too different which resulted in a rejection of the bill regarding the EHR.

Domain 5. Implementation process Refers to the process of implementation and includes planning
Note. COPD = chronic obstructive pulmonary disease; EHR = electronic health record; HCP = healthcare professionals.