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      Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies

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          Abstract

          Background

          Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level.

          Objective

          Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program.

          Methods

          The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback.

          Results

          The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs.

          Conclusions

          Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.

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          Most cited references131

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          Perceived Usefulness, Perceived Ease of Use, and User Acceptance of Information Technology

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            Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

            Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
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              Information Systems Success: The Quest for the Dependent Variable

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                Author and article information

                Contributors
                Journal
                J Med Internet Res
                J. Med. Internet Res
                JMIR
                Journal of Medical Internet Research
                JMIR Publications (Toronto, Canada )
                1439-4456
                1438-8871
                November 2017
                01 November 2017
                : 19
                : 11
                : e367
                Affiliations
                [1] 1 Department of Primary Care Health Sciences University of Oxford Oxford United Kingdom
                [2] 2 School of Health and Social Work University of Hertfordshire Hatfield United Kingdom
                [3] 3 RAFT Research and Consulting Ltd Clitheroe, Lancs United Kingdom
                [4] 4 Department of Computer Science University of Warwick Coventry United Kingdom
                Author notes
                Corresponding Author: Trisha Greenhalgh trish.greenhalgh@ 123456phc.ox.ac.uk
                Author information
                http://orcid.org/0000-0003-2369-8088
                http://orcid.org/0000-0001-7701-4783
                http://orcid.org/0000-0003-1189-7100
                http://orcid.org/0000-0002-2601-7498
                http://orcid.org/0000-0003-2930-1125
                http://orcid.org/0000-0003-1829-3860
                http://orcid.org/0000-0001-8451-2027
                http://orcid.org/0000-0003-4957-0189
                http://orcid.org/0000-0001-8059-5224
                http://orcid.org/0000-0002-7014-4793
                Article
                v19i11e367
                10.2196/jmir.8775
                5688245
                29092808
                316923d6-7af1-43e4-99a8-acb2df49e7c8
                ©Trisha Greenhalgh, Joseph Wherton, Chrysanthi Papoutsi, Jennifer Lynch, Gemma Hughes, Christine A'Court, Susan Hinder, Nick Fahy, Rob Procter, Sara Shaw. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 01.11.2017.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

                History
                : 17 August 2017
                : 7 September 2017
                : 8 September 2017
                : 23 September 2017
                Categories
                Original Paper
                Original Paper

                Medicine
                diffusion of innovation,scale-up,program sustainability,implementation,complexity of innovations,business planning,nasss framework,nonadoption, abandonment, scale-up, spread, sustainability framework,innovation adoption

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