Sustainable implementation of innovative,technology-based health care practices: A qualitative case study from stroke telemedicine

Abstract

Introduction

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.

Keywords

Behaviour change innovation sustainability implementation health care telemedicine stroke qualitative longitudinal

Introduction

Technology-based interventions are changing the way health care is practised.¹ For example, telemedicine programmes (i.e. clinicians providing health care when remote from patients) are expanding internationally across acute² and chronic conditions.³ Traditionally, health care has been delivered face-to-face; therefore, the use of audio-visual technology to conduct clinical consultations changes the usual model of practice and is considered a disruptive innovation.⁴

The long-term use of technology-based interventions can be enhanced by identifying influential factors in their uptake and then developing strategies to address any site-specific barriers and to leverage identified facilitators.⁵ These strategies may target culture change or include training to support any required workforce and system changes. However, once initiated, implementation-specific support and resources are often reduced, the technology is no longer considered novel, and in turn, its use may diminish or cease.

The identification and evaluation of factors contributing to the long-term sustainability of innovative programmes in health-care settings is rarely conducted.⁶ Sustainability may be difficult to achieve as factors influencing the intervention interact,⁷ settings increase in complexity⁸ and users’ attitudes and beliefs change after exposure to new technology-based innovations.⁹ For example, sustained innovation in fast-paced, highly regulated, life-critical settings, such as hospital emergency departments (EDs), may be difficult to achieve as these settings have formalised procedures and involve multiple disciplines. As such, any proposed change receives significant scrutiny and requires multiple approvals and establishment, and sustainability of a new innovation may prove difficult to achieve over the long-term.¹⁰ Further, clinician acceptance has previously been identified as critical for telehealth sustainability.¹¹ While the perceptions of telemedicine users, such as ED clinicians, may be considered prior to implementation,¹² these users’ perceptions post-implementation are not often evaluated,¹³ despite knowing that users’ perceptions change after experience.⁹ While work has been conducted examining sustainability retrospectively,¹⁴ we were unable to locate a detailed pre- and post-implementation evaluation of clinicians’ experiences of using telemedicine.

Telemedicine programmes for acute stroke have been used to increase access to stroke specialists and to stroke treatments, such as providing intravenous thrombolysis to eligible patients¹⁵ or facilitating access to endovascular clot retrieval.¹⁶ Despite the established benefits of thrombolysis¹⁷ reported in meta-analytic reviews¹⁸ and recommendations for its use in clinical guidelines,¹⁹ there remains some clinical dissonance²⁰ and concerns associated with the potential risk of symptomatic intracerebral haemorrhage and death if provided to ineligible patients.¹⁸ As such, there may be conflicting recommendations of treatment for acute stroke; that is, whether thrombolysis should be provided or not to a patient. These disparate views are evidenced by low thrombolysis rates in Australia.^21–23 These broader factors are important in understanding the initial uptake, or not, of stroke telemedicine.

The clinical effectiveness of stroke telemedicine has been established.^15,24–26 The implementation and sustainability of stroke telemedicine also requires attention. Recommendations and guidelines for implementing this alternate model of acute care have been published and recently updated.^27,28 Factors associated with the sustainability of telemedicine services in Australia have been broadly covered,²⁹ as well as services specific to stroke³⁰ including the development of a toolkit. We have also reported the broader benefits pertaining to clinicians, health services and funders³¹ of a telemedicine service as well as the main factors related to our experience in scaling up acute stroke telemedicine services.^32,33 While the previous research was focused on understanding clinician’s beliefs for telemedicine pre-implementation,¹² clinicians’ perceptions may change once stroke telemedicine is in place, also potentially affecting the longer term sustainability of the service.

A longer-term post-implementation review would support the identification of changing clinician needs,³⁴ and barriers and facilitators that may only be relevant post-implementation. These details can be used to develop strategies for ongoing change management processes. The aim of this study was to identify factors to support the sustainability of an innovative technology-based programme beyond the initial implementation phases.

Methods

A constructivist approach using an exploratory case study³⁵ was undertaken. Interviews with metropolitan and regional clinicians involved in the Victorian Stroke Telemedicine (VST) programme pilot^36,37 were undertaken. We received ethics approval from the hospital Human Research Ethics Committee, and we have followed the consolidated criteria for reporting qualitative research (COREQ).³⁸

Case study setting

The pilot site was a regional hospital, with a catchment population of almost 308,000, approximately 200 km from Melbourne, Australia. The hospital received approximately 375 stroke and transient ischaemic attack ED presentations per year³⁹ and there was not a neurologist on staff.

The intervention (the telemedicine programme)

The VST programme (www.vst.org.au) allows regional clinicians to consult with metropolitan-based neurologists 24/7/365 for patients presenting to the ED within 4.5 h of suspected stroke symptom onset via a secure video-conferencing mobile cart. Neurologists are able to liaise directly with clinicians, patients or relatives and review computerised tomography (CT) scans, required for clinical assessment and diagnosis. The VST programme pilot used a multi-phase implementation protocol with specific support provided during the pre-implementation, six-month pilot and 12-month implementation phases. Service activity data were captured.

Identifying barriers and facilitators during implementation

Participants

Potential respondents were identified using purposive sampling,⁴⁰ with no drop-outs. Regional hospital-based health professionals involved in the telemedicine project and the metropolitan-based neurologists were approached to participate after the pilot and after the implementation phases. Participants were not matched across time-points (i.e. not a closed cohort), due to hospital staff changing over the study period. Maximum variation was used to select a range of professional groups and level of experience with the telemedicine programme. The Bendigo Healthcare Group Human Research Ethics Committee approved the study (HREC/13/B/BHCG/31). Written consent was provided by each individual.

Procedure

Semi-structured interviews were conducted. Pre-implementation interviews were undertaken prior to the telemedicine programme commencing (as previously reported).¹² This article reports on the post-implementation interview time-points – after the six-month pilot phase and after a further 12-month implementation phase – and compares results with those reported from the pre-implementation phase.

Post-implementation interview questions were extended from pre-implementation questions and were related to: (a) the experience of telemedicine involvement; (b) identifying what supports or hinders telemedicine use; (c) suggestions as to how to improve the use of telemedicine; and (d) thrombolysis perceptions, with and without telemedicine.

Interviews were conducted by one of two experienced interviewers (NM, IM) face-to-face or via telephone (12–60 min). Interviews were audio-recorded with participants’ consent and transcribed verbatim.

Analysis

For each post-implementation time-point, interview data were analysed inductively and deductively using descriptive thematic analysis in order to identify common patterns and important themes.⁴¹ Consistent with established procedures,⁴² analysis began with one author (NM) listening to, reading and noting initial thoughts. Next, line-by-line analysis of each transcript was used to generate the initial categories and then grouped into related sub-themes. Finally, sub-themes were sorted, synthesised and organised to identify themes. A combination of writing on the transcript and coding within qualitative analysis software (NVivo version 9)⁴³ was used.

Reliability of analysis⁴² was confirmed through double-coding of over 10% of the transcripts by two independent researchers experienced in qualitative interview research (NM, KBM). Further, the initial research team met (NM, IM, DC, CB) to discuss the findings, clarifying themes and sub-themes and differences in coding were discussed and resolved within these meetings.

Comparisons were then made across time-points to identify consistent and divergent findings (NM, KB, KBM). Similar themes and sub-themes emerged for the six and 12 months post-implementation interveiws, therefore results were combined and presented as a single post-implementation result. The pre- and post-implementation sub-themes within the five themes identified (see Table 1) were compared, deductive analysis (NM, KB, KBM). New and ongoing barriers and facilitators were identified as the factors that negatively and positively influenced clinicians’ continued use of the telemedicine programme.

Table 1.

Themes identified between pre- and post-implementation and corresponding proposed strategies based on behaviour change techniques and determinant of practice.

Themes identified	General strategies developed (with specific examples for acute stroke telemedicine) to improve sustainability of innovative programmes	Applicable behaviour change techniques (BCTs), drawn from 85 BCT categories⁴⁵ (grouped under 16 clusters)⁴⁴	Applicable domain of practice from checklist (7 domains)⁷
Themes identified			Guideline factors	Individual health professional factors	Patient factors	Professional interactions	Incentives and resources	Capacity for organisational change	Social, political and legal factors
1. Perceptions of telemedicine and thrombolysis (i.e. programme focus)	Emphasising more than one goal (e.g. position telemedicine programme goal to be broader than provision of tPA)	Reframing (14)	✓						✓
	Indicating benefits at multiple levels (e.g. patient, clinician and organisational benefits of telemedicine, see Theme 5)	Anticipation of future rewards or removal of punishment (2)					✓
	Adapting to and managing changing expectations as implementation progresses (e.g. identify and support clinical change champions, provide updates via effective local dissemination processes, incorporate telemedicine training into induction programmes for new staff to address medical registrar rotation)	Action planning, including implementation intentions (9) and problem solving/coping planning (9) Restructuring the social environment (4)		✓		✓		✓	✓
2. Perceptions of telemedicine systems and technology	Regularly provide data to address concerns and identified barriers (e.g. showing number of consultations vs technological issues in similar contexts to reinforce reliability)	Other(s) monitoring with awareness (8) Persuasive argument (13)	✓	✓
	Emphasise the simplicity of functions (e.g. using ‘one button’)	Instruction on how to perform a behaviour (15)		✓
	Prepare and outline back-up plans (e.g. telephone rather than video consultation only required in some cases)	Problem solving/coping planning (9)	✓
	Ensure accessibility of IT support and expertise (e.g. through telemedicine machine provider, trained hospital IT or project personnel)	Social support (practical) (10)				✓	✓		✓
	Incorporate into regular work practices to normalise use and maintain experience (e.g. use teledoc and video even if phone only consult applicable clinically; conduct regular mock consult or provide small group education via teledoc), particularly if being used infrequently	Habit formation (3) Exposure (5)		✓				✓	✓
3. Organisational and cultural environment (impact on clinician role)	Develop broader changes within setting to support new programme (e.g. teledoc to be stored in full view and easily accessible, identify admission procedures or when resident specialists should be contacted)	Restructuring the physical environment (4)	✓					✓	✓
	Clearly delineate the impact on current roles (e.g. telemedicine programme is optional, hospital to determine when appropriate to utilise)	Avoidance/changing exposure to cues for the behaviour (4) Verbal persuasion to boost self-efficacy (12)		✓		✓			✓
	Emphasise short- and long-term benefits to those in the current role (e.g. see Theme 5)	Anticipation of future rewards (2)		✓		✓
4. Change in processes of clinical care practice	Conduct education sessions, including evidence-based materials, work shadowing where already implemented (e.g. tPA meta-analyses, personal experiences and current practices in metropolitan sites)	Instruction on how to perform a behaviour (15) Modelling behaviour (11) Information about others’ approval (11)	✓					✓
	Acknowledge risks around change so clinicians’ concerns are heard, but counter with relevant literature and data (e.g. safety and effectiveness of tPA)	Social support (emotional) (10)	✓	✓		✓
	Emphasise how programme reduces risks previously associated (e.g. telemedicine provides access to specialists which reduces the risks with recommending tPA)	Discrepancy between current behaviour and goal standard (9) Persuasive argument (13)	✓				✓
	Recruit clinical champions from within setting	Restructuring the social environment (4)				✓			✓
	Incorporate innovative practices into the medical curriculum	Antecedents (15)	✓						✓
5. Benefits of utilisation; expand over time	Indicate benefits to all those involved (e.g. not only patients, but also clinicians with stroke specialist access via telemedicine)	Anticipation of future rewards (2) Social reward (2) Non-specific reward (2)			✓		✓
	Clinician benefits regardless of experience (e.g. access to other specialists for newly registered medical staff, allows leave/after-hours support for experienced medical staff)	Anticipation of future rewards (2) Social support (practical) (2) Non-specific reward (2)				✓	✓
	Collect and provide data addressing concerns and showing improvements (e.g. safety of treatment, reducing clinical process of care timelines, benefits of thrombolysis and reduced patient transfers)	Review of outcome goal(s) (9) Focus on past success (12)	✓				✓

tPA: tissue plasminogen activator.

Note: The 16 clusters for the behaviour change techniques are: (1) scheduled consequences, (2) reward and threat, (3) repetition and substitution, (4) antecedents, (5) associations, (6) covert learning, (7) natural consequences, (8) feedback and monitoring, (9) goals and planning, (10) social support, (11) comparison of behaviour, (12) self-belief, (13) comparison of outcomes, (14) identity, (15) shaping knowledge and (16) regulation.

Developing strategies to support intervention sustainability

To identify evidence-based strategies for behaviour change that would support ongoing use of the telemedicine programme, a team experienced in the implementation, operation and evaluation of telemedicine reviewed these barriers and facilitators and identified the major barriers for sustainability (KB, KBM, MV, CB, DC). Barriers were addressed with telemedicine-specific strategies. The strategies were reviewed within the Behavior Change Technique (BCT) taxonomy⁴⁴ and the selected implementation checklist by Flottorp and colleagues on determinants of practice.⁷ These strategies were chosen because they targeted influential factors for the ongoing use of the telemedicine programme within each of the five themes identified.

The BCT taxonomy allows reporting of intervention content in a consistent, detailed manner for replication and evaluation⁴⁴ and is also used for intervention development (Table 1). To acknowledge the range of how each BCT may be operationalised, including within our context,⁴⁵ we elected to refer to BCT categories within the BCT clusters.

Flottorp and colleagues’ checklist was used to identify the opportunities where strategies could be implemented to target to change clinicians’ practice.⁷ The framework comprises seven domains (see Table 1) that are used to tailor content to increase the success of implementation of interventions and quality improvement projects.

Results

Participants (n = 25; Table 2) included eight ED doctors, five medical doctors, seven nurses and five neurologists. Forty-nine interviews were conducted (12 post-pilot and 13 post-implementation), with 11 clinicians interviewed at both time points.

Table 2.

Participant demographics.

Demographic		Baseline n = 24^{1 2} n (%)	Post-pilot n = 12 n (%)	Post-one year n = 13 n (%)
Gender	Female	12 (50%)	5 (42%)	4 (31%)
Age (years)	Median	43	40	35
	Range	24–63	29–54	27–51
Professional group
Metropolitan hospitals
Telemedicine neurologists		3 (13%)	2 (17%)	3 (23%)
Regional hospital
Doctors
ED consultant/registrar/HMO		5 (21%)	3 (25%)	5 (39%)
Physician/VMO		6 (25%)	3 (25%)	2 (15%)
CCU consultant		1 (4%)	0	0
Radiographer		1 (4%)	0	0
Nurses
Nurse managers		3 (13%)	1 (8%)	0
ED and ward nurses		5 (21%)	3 (25%)	3 (23%)

CCU: critical care unit; ED: emergency department; HMO: home medical officer; VMO: visiting medical officer.

Participants at baseline were interviewed pre-implementation with 11 participants interviewed at two or more time periods. Figures may not add up to 100% due to rounding.

Between 13 February 2011–2 October 2012, there were 50 telemedicine consultations. On average, there were two telemedicine consultations per month at this site during the study period.

Identification of barriers and facilitators for sustainability

Similar themes were identified post-implementation as pre-implementation.¹² There was one overarching theme of telemedicine and thrombolysis, plus four additional themes: perceptions of telemedicine systems and technology, organisational and cultural environment, processes of clinical care, and benefits of utilisation (Table 3). However, there was variation in the sub-themes. In particular, additional barriers and facilitators were identified in organisational and cultural environment and processes of clinical care. Although the themes are presented separately they do overlap and are inter-related.

Table 3.

Comparison of pre- and post-implementation barriers (–) and facilitators (+).

Overarching theme: Perceptions of thrombolysis Pre and post +/−Level of support for tPA (support vs not) –Perception of evidence +/−Level of confidence in delivering tPA without a neurologist –Avoid/defer making tPA treatment decisions
	Themes and sub-themes
	Perceptions of telemedicine systems and technology				Organisational and cultural environment				Processes of clinical care				Benefits of utilisation
	Pre		Post		Pre		Post		Pre		Post		Pre		Post
–	Reliable technology	+	More reliable experience	−	Regional clinical constraints – workforce rotation	−	Competing demands in ED	−	Perception of clinical need	+/−	Perception of telemedicine programme	+	Patient-related benefits	+	Patient-related benefits
−	User-friendly technology	+	User-friendly process	+	Ability to see the patient for an assessment	−	No unified practice	−	Current hospital processes for acute stroke	+	Becoming standard practice	+	Clinician-related benefits	+	Clinician-related benefits
−	Knowing how to use telemedicine	−	Remembering how to use telemedicine	−	Clinician’s trust and confidence in each other	−	(In)frequency of consultations	+/−	Awareness of telemedicine processes	+	Consultation dynamics	+	Broader and future applications
				−	Balancing the clinical workload with telemedicine commitments			+	Being able to contact a neurologist	+	Hospital system changes
				−	Perceptions about being on camera			+	Maintaining clinical autonomy	+	Transfers and referrals
					Perceptions about being on camera			−	Clinical buy-in for telemedicine	−	Delays in the golden hour

ED: emergency department; tPA: tissue plasminogen activator.

Overarching theme – telemedicine and thrombolysis

The close association of the telemedicine programme and the delivery of tissue plasminogen activator (tPA) identified pre-implementation¹² continued post-implementation. That is, if tPA was not viewed as a beneficial or safe treatment, then clinicians expressed that they did not think telemedicine would be useful.

Similar to pre-implementation, sub-themes included some clinicians still questioning the evidence for tPA and a preference for a stroke specialist’s support with using tPA, although since using the telemedicine programme, some clinicians were more confident in providing tPA.

Theme 1 – perceptions of telemedicine systems and technology

Overall, perceptions changed from concern pre-implementation to greater confidence post-implementation and although there were some issues, it was considered reliable.

A new barrier identified post-implementation was recalling how to initiate the telemedicine programme and use the technology with infrequent use.

Theme 2 – organisational and cultural environment

Pre-implementation aspects such as trust and confidence in skills between the neurologists and remote hospital clinicians, and being able to assess the patient, along with concerns about being on camera were replaced post-implementation. New barriers identified post-implementation were contextual factors impacting the integration of telemedicine into clinical practice. Barriers were also exacerbated by the infrequent use of the system.

Additionally, although there was promotion and education about using stroke telemedicine, individual clinicians ultimately self-elected to initiate the programme.

Theme 3 – processes of clinical care

During the implementation period, changes to internal processes had been successfully executed through amending stroke protocols, clinical pathways and patient admission processes which supported the access and use of telemedicine.

After experiencing the telemedicine programme, sub-themes generally moved from focusing on whether the programme was needed at all or only applicable to junior doctors, to identifying telemedicine as a viable option for clinical input.

Despite amendments to protocols and practices, sustainable use of the telemedicine programme was still perceived to be dependent upon local clinicians supporting and driving its use. Again, variation amongst individuals was reported. For example, the programme was seen as being embedded into clinical care for some participants, but not all.

For some, accepting access to metropolitan-based expertise has revealed other parts of the clinical process, such as transferring patients between regional and metropolitan sites could be improved.

Theme 4 – benefits of utilisation

The benefits of utilisation captured the positive outcomes for different groups. Compared to pre-implementation, fewer direct patient-related benefits and more clinician-related benefits emerged post-implementation.

Strategies targeting barriers and facilitators for ongoing sustainability

Specific strategies to address new and ongoing barriers and leverage facilitators within the five identified themes (per above), and the corresponding BCT category or cluster, and domain of professional practice are outlined in Table 1. Strategies frequently addressed multiple domains of practice. As the focus of this study was on clinician perceptions and experiences of telemedicine, domains associated with patient factors were limited.

Strategies were developed to be relevant across the range of implementation phases and are therefore appropriate for both current and future telemedicine sites’ implementation. Pre-implementation strategies include highlighting multiple aims (BCT category: reframing) and emphasising the ease of the technology (BCT category: instruction on how to perform a behaviour) when introducing the programme. Strategies early in implementation include developing system changes to support the change in practice, including storing the telemedicine equipment where used and easily accessible (BCT category: changing exposure to cues for the behaviour). Strategies for the longer term include data collection and provision of results showing improvements (BCT category: review of outcome goal/s) and incorporating innovative practices into the medical curriculum (BCT category: antecedents).

Discussion

Although clinical effectiveness of utilising telemedicine to support the delivery of tPA is evident, this study highlights the complexity of changing clinical use overtime. We have identified new and ongoing barriers and facilitators to using a telemedicine programme in a regional setting that had been operational for over 12 months. We subsequently proposed specific strategies specific for implementing telemedicine programmes and general strategies for broader technology-driven innovation.

Similar barriers identified

Ongoing concerns reported by clinicians highlight that the implementation and experience of telemedicine did not completely resolve all concerns originally identified. Low use may be due to few patients presenting with stroke-like symptoms within 4.5 h of onset. Additional exposure and experience may be required for some clinicians to accept telemedicine.³⁰

Similar barriers identified pre- and post-implementation included the close association between telemedicine and thrombolysis. When introducing telemedicine, the emphasis of providing access to thrombolysis may inadvertently create negative perceptions of the entire telemedicine programme. It is important to note, however, that our stroke telemedicine service is used to provide an expert diagnosis for patients with ‘suspected stroke’ and can subsequently be used to support clinical decision-making and identify patients ineligible for acute stroke treatment. Moreover, the telemedicine equipment can be (and is encouraged to be) used for other purposes (e.g. for liaising with Adult Retrieval Victoria). This site also uses telemedicine/telehealth services for other conditions (e.g. geriatric, paediatric, psychiatric). Changing the emphasis from health-care delivery to delivering education and empowering regional clinicians has previously been identified for sustainable telemedicine practice.¹³

Similar themes identified over the different time points suggest that changes may occur quickly (less than six months) or take longer (12–18 months). Programmes with higher call frequencies or research two or more years post-implementation could explore this explanation; however, such longitudinal work is rarely conducted.⁸ Preliminary health-care setting research suggests that pre-implementation factors may predict intervention uptake at two years.⁴⁶ Thus, strategies to shape positive attitudes and experiences early are critical.

New barriers identified

Additional barriers emerged including the infrequency of using the telemedicine programme/equipment, competing demands, and continued resistance by specific individuals. Although regional settings can be provided with information regarding the benefits to patients and clinicians, as well as the ease of use of the technology, actual experience remains pivotal in establishing trust and support of the telemedicine programme.³⁰ In addition to clinicians, nursing staff based in ED can play a critical role in introducing and sustaining telemedicine,^30,47 particularly to new rotating employees. Despite the ongoing concerns identified, the acute telemedicine programme is still operational in the hospital more than five years after the initial pilot.

Technology-based innovation depends upon individuals

Our findings emphasise that individuals, and their specific beliefs and attitudes, can make a significant difference to the success of a technology-based programme.⁴⁸ Ongoing barriers may be more readily identified by those clinicians considered late adopters⁴⁹ but early adopters can be change champions or synergists who can lead and drive change within organisations.⁵⁰

However, even those supportive of telemedicine can identify negative effects.⁵¹ Future research should be used to identify effective strategies to normalise⁵² telemedicine use for those cautious in adopting changes to their usual practice.

Importantly, the concerns regarding trusting unknown colleagues reported pre-implementation were not identified post-implementation. Improved patient outcomes are a major contributor to encouraging shared medical decision making,⁵³ therefore the dissemination of benefits¹⁵ may support behaviour change for clinicians early in implementation and facilitate initiating telemedicine consultations.

Organisational culture is hard to change

The fewest positive changes were identified within the organisational and cultural environment theme. The management and organisational culture, including physician involvement, can influence the success of quality improvement initiatives⁵⁴ and support from peers or superiors can affect the implementation of clinical guidelines.⁵⁵ The frequent changeover of the health-care workforce emphasises the importance of including ongoing education about the telemedicine protocol and practices, particularly for new recruits. Repetition of key messages, plus ongoing system resources and tasks, such as, peer education and/or train-the-trainer models is required.³⁰

Facilitating culture change could include communicating identified benefits beyond the patient and clinician involved in the consultation, including hospital-wide improved stroke care co-ordination, capacity building and staff professional development.³¹ Prior work has indicated telemedicine can reduce regional clinicians’ sense of professional isolation.¹³ Building local capacity¹³ and the importance of contextual factors such as shared values and beliefs⁵⁶ have been identified as factors influencing the ongoing uptake of telemedicine. Further, those experienced in telemedicine could provide practical support and feedback. Upstream strategies include incorporating telemedicine in undergraduate curricula and clinical placements.⁵⁷

Clarity of purpose needed to leverage some benefits

Caution needs to be applied when leveraging some of the identified facilitators post-implementation. Benefits such as education and specialist support could be emphasised pre-implementation to promote the programme. However, there is a risk that this approach may be perceived as current clinical practices and expertise are insufficient, and so benefits associated with supporting clinicians need to be sensitively handled. Positioning the programme as an adjunct not a replacement programme would assist in leveraging benefits but infers that use is optional.

Limitations and future research

Despite the single regional site context, there was considerable variation in individuals’ perceptions of the programme, their beliefs about tPA and how the programme was integrated (or not), suggesting that the setting was sufficient for our purpose. This research should be replicated with other sites to determine if additional factors associated with sustainability are relevant to different sites. Strategies were proposed by programme personnel which ensured a clear understanding of implementation practices and opportunities;⁵⁸ however, these strategies await implementation and evaluation. Future research should explore in which contexts or circumstances these strategies are effective.⁵⁹

To ensure the sustainability of technology-based innovative programmes, evaluation beyond the preliminary implementation stage is required. For persistent and newly emerging barriers and facilitators, we have proposed strategies for both workforce and system changes that can be used prior to and throughout a telemedicine programme’s implementation. A combination of targeted strategy content and relevant timing of delivery should support new technology-based health-care practices to become incorporated into routine services.

Footnotes

Acknowledgements

The authors would like to acknowledge and thank members of the VST programme steering and management committees, along with working group members, who provided oversight and direction in relation to this project. They also acknowledge staff involved from the regional hospital, including Peter Disler and Katrina Sparrow, as well as former and current members of the VST programme team and the Florey Institute of Neuroscience and Mental Health for assistance with data management and project support. Finally, they would like to thank Ian Mosley (IM) for conducting some of the interviews and sourcing funding from the Windermere Foundation; and in particular, each of the clinicians who participated. The following author contributions were made: NM and DC conceptualised and designed the study, NM co-ordinated and conducted the interviews, NM and KBM performed the analysis, KB, NM, KBM, CB and DC interpreted the results and KB, KBM, MV, CB and DC developed the reported strategies. KB wrote the manuscript and all co-authors provided edits. All authors reviewed and approved the final manuscript. The datasets used and analyses during the current study are available from the corresponding author on reasonable request.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: Funding bodies had no role in the design of the study and collection, analysis and interpretation of data or writing of the manuscript. This project has been supported through funding from the Windermere Foundation, The State Government of Victoria: Department of Business and Innovation and Department of Health; and The Florey Institute of Neuroscience and Mental Health, University of Melbourne. The Florey Institute of Neuroscience and Mental Health acknowledges the strong support from the Victorian Government and in particular the funding from the Operational Infrastructure Support Grant. DA Cadilhac holds a National Health and Medical Research Council/National Heart Foundation research fellowship (1063761). CF Bladin and DA Cadilhac have received restricted educational grants from Boehringer Ingelheim.

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