This qualitative survey study utilized data collected from health care professionals including pediatricians, pediatric pulmonologists, nurse practitioners, pediatric (respiratory) nurses, and children or their parents [21]. We conducted the study in 14 hospitals (11 general and 3 tertiary, both urban and rural) in The Netherlands between April and December 2015.

The 8 hospitals originally participating in the randomized controlled trial (RCT) [11] were approached to also collaborate in this study. Of these, 6 hospitals agreed to participate, and 2 hospitals declined for logistic reasons. The other hospitals (8 in total) were contacted by email. All hospitals agreed to start with the implementation of the VAC. Finally, a total of 14 hospitals intended to participate in this study. In each hospital, several health care professionals confirmed their willingness to participate including pediatric pulmonologists, pediatricians, pediatric residents, nurse practitioners, or pediatric respiratory nurses. The number of participating health care professionals differed between hospitals. Also, patients (or their parents) were asked to complete a questionnaire about their satisfaction with the VAC after 6 months; they only completed 1 questionnaire at the end of the implementation (at 6 months).

The VAC for children is a Web-based portal for children with asthma. It consists of a general information module and a secure private section where children (or their parents) can log in to communicate easily with their asthma team, download or consult their individual treatment plan, and complete a validated questionnaire for Web-based monitoring of their asthma control. Multimedia Appendix 2 shows different screenshots of the innovation (the individual care plan of a dummy patient).

Implementation of the VAC in pediatric asthma care included the use of the VAC in daily practice without a fixed protocol for the use of this innovation. Despite the existence of a national guideline for pediatric asthma management in The Netherlands, subtle differences between hospitals and health care professionals may exist (eg, provided information about asthma, the frequency of follow-up, preferences of prescribed medication). In addition, use of the VAC was tailored to local (organizational) preferences, for example, whether a nurse practitioner was involved in the use of the VAC or which professional was primarily responsible for contact with the patient. No restrictions were made about the frequency of outpatient visits or Web-based monitoring per patient.

Before implementation of the VAC, a 2-hour introductory visit was planned in each hospital, accessible to all participating professionals. These introductory visits were given by the same person (LvdW) and were aimed at adequately informing professionals about the purpose and details of the study and practical use of the VAC. The information provided was semistructured in each hospital. This visit included a real-time demonstration of the VAC and the different functions within the innovation. Further, questions by professionals were answered, and contact information and user manuals for patients and professionals were provided. Patients (or their parents) were informed about the use of the VAC by their asthma team and also received a written instruction manual. During the implementation process, all professionals could contact the help desk in case of existing problems.

Successful implementation was defined as using the VAC on a regular basis in daily pediatric asthma care, patients using the VAC regularly, and a positive attitude (of all end-users) toward continuing the use of the VAC in the future.

Information about barriers and facilitators for successful implementation were collected by structured Web-based questionnaires (closed survey), which were completed by all professionals at the start of implementation and after 3 and 6 months using the same questionnaire at these different time points. Participation was voluntary, and health care professionals and patients could withdraw from the study at any time for any reason. No incentives were offered. Participants had 1 month to complete the questionnaire before the survey was closed.

Questionnaires were based on the model of Grol and Wensing, proposing that barriers and facilitators could be examined at 6 different levels: innovation, individual professional, patient, social context, organizational context, and economic and political context [20]. Questionnaires consisted of both open and multiple choice questions (see Multimedia Appendix 3). Participants received an email with a link to the questionnaire (email survey). No pilot-testing was done before distribution of these questionnaires, but the usability and technical functionality of the electronic questionnaire had been tested by the research team before fielding the questionnaire. All responses were automatically captured, analyzed, and anonymized.

In case of missing questionnaires, an automatically generated reminder was sent after 1 and 2 weeks. When a professional did not complete the questionnaire after 2 reminders, the link to the questionnaire was closed, and the questionnaire was considered missing. Only completed questionnaires were analyzed (as it was not possible to close the survey when items were missing).

Barriers and facilitators for implementation of the VAC in daily practice were identified from the open-ended questions and assessed using qualitative analysis. Barriers and facilitators were divided into different categories and organized into themes using the adapted model for understanding change at different levels of health care [20]. Two authors (LvdW and WG) identified and categorized the facilitators and barriers independently, based on the answers to the open-ended questions. In cases of disagreement, identification and categorization were discussed to reach consensus.

Descriptive statistics were used to analyze the multiple choice questions (Likert scale responses).

After 6 months, health care professionals were asked to send a questionnaire on patient satisfaction to their patients (or parents) via the VAC. The researchers had no influence on how many patients were reached because they had no access to local clinical data for medicolegal reasons. Therefore, no information was provided about the severity of their asthma and current medication or treatment regimes. Questions were addressed pertaining to the different modules of the VAC (Multimedia Appendix 4), the innovation, the (Children) Asthma Control Test questionnaire for Web-based monitoring disease deterioration, the communication module, the individual treatment plan, privacy and security, and overall satisfaction. Participants completed the questionnaire on a voluntary basis. Results of this questionnaire were used in this study and to update and further develop the VAC according to users’ needs and wishes.

The study was approved by the local medical ethics committee (Commisie Mensgebonden Onderzoek Nijmegen-Arnhem), which waived written informed consent.

Barriers and facilitators were divided into 6 categories and organized into themes using the adapted model for understanding change at different levels of health care [20]. Table 2 provides an overview of the framework with barriers and facilitators in each theme.

Major perceived barriers found in this study included concerns about lack of interoperability of this innovation with other systems, the lack of structural financial reimbursement for Web-based monitoring, the burden of eHealth use on professionals’ workload, and a changing patient-professional relationship (due to less face-to-face contact).

Major perceived facilitators included training and support, a positive attitude of professionals toward eHealth, the advantages for the patients, and the possibility to tailor care to the individual patient (“personalized eHealth”), to substitute tasks between professionals, and to easily deliver care according to current guidelines by using the VAC.

We identified these barriers and facilitators for the implementation of a Web-based portal to monitor asthmatic children as a substitution for routine outpatient visits among a group of health care professionals, patients, and parents in 14 hospitals. These barriers and facilitators were arranged in 6 themes as described by Grol and Wensing: the innovation itself, individual professionals, patients, social context, organizational context, and political and economic context [20]. Although barriers and facilitators differ in scope, context, and strength, most of them were shared by professionals from different hospitals and with different functions. Findings of this study suggest and confirm that issues around implementation are multilevel and complex, and it is important to mention that no single factor was identified as a key barrier or facilitator.

The lack of interoperability is perhaps one of the greatest organizational obstacles to the long-term integration of eHealth infrastructure in health care [16,22,23]. As with most of the existing eHealth networks, the VAC tends to rely on custom-built systems made for specific users operating in specific settings, has a lack of open connectivity with other systems (eg, EMRs), and no information is exchanged automatically. This results in higher than necessary workload for professionals since the EMR has to contain the latest and relevant medical information due to medicolegal reasons. An adequate interface with other ICT systems is essential for acceptance, use, successful implementation, and long-term sustainability of the VAC.

The other significant obstacle for further diffusion of our eHealth innovation is the lack of structural financial reimbursement of Web-based monitoring [14,24]. To date, there is still a lack of payment for electronically delivered care, and funding of the current health system is solely based on reimbursement of face-to-face contacts. Using the VAC as a (partial) substitution for outpatient visits lead to production loss for hospitals and less reimbursement of these outpatient visits. Nevertheless, instead of seeing patients at the outpatient clinic, professionals now have to invest time in using the VAC (eg, completing the individual treatment plans, respond to messages, etc) for the Web-based monitoring of patients. This type of care was not yet reimbursed, and the incentive for professionals to use the VAC was solely based on their goodwill and grants. Logically, this is not sustainable and adequate funding for Web-based monitoring as a substitution for routine care, in combination with supportive policy and political vision toward eHealth, is crucial to acheiving long-term goals.

eHealth innovations have to fit the workflow of professionals to minimize the burden of eHealth use. Otherwise, they experience an extra workload and a time constraint, which are major impediments to implementation [14,16,25,26]. The reason for an extra workload with the introduction of the VAC consisted mostly of a lack of time to learn how to use the VAC, the work involved in transferring information between 2 systems, and an alteration in established professional roles, responsibilities, and work styles. Providing a transition period in which users become familiar with and learn how to use the eHealth innovation has been desirable to facilitate implementation [16,27].

The main methodological limitation of this study is that the data were collected using 3 consecutive questionnaires over a period of 6 months. In-depth interviews to assess more detailed information about the barriers and facilitators perceived by professionals were not used. Further, we had developed a questionnaire based on the model of Grol and Wensing, which was not validated and tested for reliability. However, no valid questionnaire to assess barriers and facilitators for implementation has been published or validated. In addition, we were not able to specify similarities and differences between respondents and nonrespondents as we did not have any data of the latter. Therefore, we cannot rule out some bias. Nevertheless, we consider the response rate (51/76, 67%) as quite acceptable and therefore assume that a bias may be minimal.

For the collection of parents’ and patients’ data, we were dependent on health care professionals sending this questionnaire via the VAC because we were not allowed to have access to patients’ data. This may have influenced the response rate of this questionnaire, as it is possible that professionals did not send this questionnaire or sent it too late. Also, it would be interesting to compare the responses of the health care professionals and patients or parents in future research since their perceptions or viewpoints may be different. Another limitation could be the fact that all 3 questionnaires for professionals were sent in a time period of 6 months after starting to use the VAC. This means that patients monitored over the Web using the VAC were only seen once during this period. This could make it difficult for professionals to develop an objectively based opinion about the importance of the VAC for their daily practice. We could not objectively assess possible changes in time, differences between hospitals, or type of professionals. Also, it is possible that the time period of the study (6 months) was too short to identify all key barriers and facilitators. Nevertheless, most findings were in line with earlier studies.

An overall strength of the VAC is the involvement of health care professionals and patients from the beginning of the project. Participants’ wishes and possible objections against the VAC were used for its development, and after the RCT their feedback was used to update the VAC to optimize their use before wider implementation. Ongoing involvement of key stakeholders (especially end-users) in the design and development of eHealth technologies helps to ensure that systems are likely to be valued and used by professionals (intrinsic motivation) and should be considered as a way of overcoming barriers and facilitating implementation [16,28-31].

Another strength of this implementation study is that the questionnaires were based on factors identified by qualitative research, the model of Grol and Wensing [20], and thereby represent the complete spectrum of important factors related to acceptance and diffusion of an eHealth innovation. Another strong point is the fact that we obtained a representative sample of participants. Professionals from different hospitals, both secondary and tertiary care, participated in the study. Hospitals were located in both rural and urban areas. Further, professionals had different functions in the asthma team (eg, pediatric pulmonologist, pediatricians, nurse practitioners, etc). This gives a good reflection of pediatric asthma care.

Based on the barriers and facilitators found in this study, we propose a list of recommendations when implementing eHealth innovations (Textbox 1). These can be used to tailor organizational improvements to the needs of individuals and organizations.

Therefore, the suitability of the innovation in its context is essential for an innovation to become successful. Professionals can be seen and approached as key holders to achieve change and successful implementation of the innovation [7]. However, management support is essential to encourage professionals to hold on to their innovative behavior, to embrace new strategies for improving health care, to ensure sustainable use of the innovation, and to implement renewal. As mentioned, patients must also be involved in the innovation as cocreators to make them develop feelings of ownership toward the innovation and enhance positive perception of the innovation’s usefulness and user-friendliness. Only when a clear advantage or incentive is perceived by patients, are they inclined to continue to adhere to and use eHealth and, thus, it may sustain. The lower frequency of outpatient clinic visits is probably a major incentive in the case of the VAC. Besides an organizational change within the hospital, other structural changes are also necessary to achieve successful implementation of eHealth. Other stakeholders, such as the Government, policy makers, and insurance companies, have a crucial role in the implementation of eHealth, nowadays and in the future. Without adequate financial reimbursement, the introduction of innovations in health care has been doomed to fail. Sustainable solutions to finance new strategies are necessary to ensure large-scale innovations to conquer a solid place within the current health care system. At an early stage, all stakeholders together have to assess which innovations have the potential to change health care positively, from the perspective of value-based health care, efficiency, and cost savings.

Implementation of an eHealth innovation is a complex, dynamic process influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, and the social, organizational, and economic and political context. Understanding and defining the barriers and facilitators that influence the context appears to be important for the successful implementation and sustainability of an innovation.

Despite serious concerns about structural financial reimbursement and the lack of interoperability of the system, health care professionals, patients, and parents generally expressed enthusiasm about the VAC in our study. In the majority of the participating hospitals, this innovation became part of regular asthma care for children and is it used as a (partial) substitution of traditional outpatient care for children with asthma.