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The number of public eHealth services that support patient self-management is rapidly increasing. However, the implementation of these eHealth services for self-management has encountered challenges.
The purpose of this paper was to analyze the challenges and opportunities of implementing eHealth services for self-management by focusing on the fit between the technical solution and clinical use.
We performed in-depth interviews with 10 clinical project coordinators and managers who were responsible for developing and implementing various eHealth services for self-management interventions in five university hospitals in Finland. The results were analyzed using content analysis and open coding. The Fit between Individuals, Task, and Technology (FITT) framework was used to interpret the findings.
The implementation of self-management services involved many challenges related to technical problems, health professional acceptance, patient motivation, and health organization and management. The implementers identified practices to manage the identified challenges, including improving the design of the technology, supporting health professionals in the adoption of the eHealth services, changing the work processes and tasks, involving patients, and collectively planning the implementation inside an organization. The findings could be mostly attributed to the dimensions of the FITT framework.
The FITT framework helped to analyze the challenges related to the implementation, and most of them were related to poor fit. The importance of patients as stakeholders in eHealth services for patient self-management needs to be highlighted. Thus, we propose that patients should be added as a different type of individual dimension to the FITT framework. In addition, the framework could be extended to include organization and management in a new context dimension.
In many countries, the number of public eHealth services that support patient self-management is rapidly increasing. Barlow et al [
However, many studies also report that the implementation of eHealth services that support self-management has encountered challenges, such as motivating patients and health professionals [
Health care professionals have many concerns related to self-management services and their professional roles in these new situations [
Several literature reviews have identified factors that facilitate or hinder the successful implementation of eHealth services [
Several implementation models can be used to analyze barriers and facilitators that occur during implementation [
The FITT framework is based on the idea that IT adoption in a clinical environment depends on the optimal fit or interaction between the attributes of three fit dimensions: the individual users, the technology, and the clinical tasks and processes [
Compared to other frameworks, such as the Consolidated Framework for Implementation Research (CFIR) [
Tsiknakis and Kouroubali [
In summary, the FITT framework has been useful in analyzing implementation barriers and facilitators in different case studies. However, self-management eHealth services are novel for patients and health care professionals and require complex changes in clinical care [
This paper applies the FITT framework to analyze the implementation experiences of 10 clinical project coordinators and managers who were responsible for implementing digital care paths supporting patient self-management in five university hospitals. In a study by Murray et al [
The aims of this study were (1) to identify the specific challenges to implementing eHealth services for self-management and opportunities to manage these challenges and (2) to evaluate how well the FITT framework explains the identified challenges in the context of self-management eHealth services. The findings provide a better understanding of the factors that influence the implementation of eHealth services for self-management interventions and extend the FITT framework to explain the success of eHealth service adoption.
In Finland, the objective of the national eHealth and eSocial Strategy 2020 is to support the active role of citizens in promoting their own well-being, preventing health problems, self-assessing the need for services, and independent coping [
The coordinating HUS developed the technical platform for developing eHealth services for citizens, patients, and professionals. The joint project provided guidelines for planning the content and implementation. Using the guidelines, the services were developed by a multi-professional team usually including physicians and nurses.
The eHealth portal was developed in two phases. First, an open-access eHealth portal was developed to offer information, advice, self-care instructions, and symptom navigators for Finnish citizens and patients. The portal includes over 20 eHealth services, called hubs, that focus on specific patient or disease groups, such as neurological diseases.
Second, hospital-specific digital care paths only open to invited patients of a care unit were developed [
According to the project coordinators, the main goals of the new digital care paths were to improve the quality of service provided to patients and to support self-management and communication between patients and care personnel. Patients were expected to be better informed and require less guidance when using the paths. Nurses could also receive information from patients, monitor them, and perform preventive interventions when needed. Organizations also aimed to minimize costs by reducing the number of phone calls and moving the communication to digital messaging.
As the digital care paths had been used from 1 to 10 months, the technical platform was still under development, the number of patients using a service remained low, and all services were in the early stage of implementation. The development of the technical platform was continuously developed based on professionals’ and patients’ feedback using an agile approach.
Description of digital care paths.
Digital care path | Functions | Starting date (first patient entered) | Estimated potential number of patients | Real number of patients between the starting date and 11/3/2019 (path ended or still ongoing) |
Mitral valve surgery | Information |
4/2018 | 150 per year | 177 |
Cervical spine surgery | Messaging |
10/2018 piloting | 500 per year | 244 |
Pacemaker surgery | Information before pacemaker implantation and answers to the most frequently asked questions |
12/2018 | 300 per year | 214 |
In vitro fertilization | Appointments and questionnaires |
11/2017 | 400 per year | 597 |
Pregnancy | Appointments |
11/2017 | 10,000 per year | 17,229 |
Gestational diabetes | Messaging, self-management information, diary, tasks, and tests |
1/2019 | 200 per year | 239 |
Spinal cord disability | Messaging and sending pictures |
10/2018 piloting | 200 per year | 200 |
Rheumatology | Information about the clinic and care and answers to the most frequently asked questions |
1/2019 | Thousands per year | 1951 |
The participants were selected by purposive sampling. The goal was to cover a variety of experiences of different eHealth services and contexts from a project management point of view. The inclusion criterion was a responsibility to implement a digital care path in a care unit. Implementers were chosen for this study, as they have experience planning and managing implementation, and they observe factors that influence implementation [
A total of 10 participants were interviewed from five hospitals (see
Details about the study participants.
No. | Role | Expertise | Responsibility | Hospital ID |
1 | Development manager | Economics, change management, and implementation | Managing digitalization of health services | 1 |
2 | Technical product owner and project coordinator | Software engineering | Project manager of digital care paths | 1 |
3 | Physician project manager | Medicine | Planning and implementing a digital care path | 2 |
4 | Nurse project coordinator | Nursing | Planning and implementing a digital care path | 2 |
5 | Nurse project coordinator | Nursing | Planning and implementing a digital care path | 2 |
6 | Nurse project coordinator | Nursing | Planning and implementing a digital care path | 2 |
7 | Nurse project coordinator | Nursing | Planning and implementing a digital care path | 2 |
8 | Nurse project coordinator | Nursing | Planning and implementing a digital care path | 3 |
9 | Nurse project coordinator | Nursing | Planning and implementing a digital care path | 4 |
10 | Nurse project coordinator | Nursing | Planning and implementing a digital care path | 5 |
All the participants were women, and their age ranged from 33 to 53 years. None of the project coordinators or the project manager had previous experience developing or implementing eHealth services.
One interviewer completed semistructured interviews with each participant. In total, 2 participants wanted to have a pair interview. The interviewer met the participants in their office or performed the interviews through videoconferencing. The interview included questions from two main themes:
The challenges of the implementation.
Opportunities to manage these implementation challenges.
In addition, background information about the interviewee; information about the digital care path, planning, and implementation; and patient feedback were collected.
The interviews were conducted by the first author (SK) from May 2018 to November 2019. The interviews lasted from 1 to 2 hours, and they were audio recorded and transcribed for analysis. In addition to interview data, a documented patient feedback survey report was used as an information source.
After each interview, the main observations were recorded as notes. The analysis was performed in two stages. In stage 1, open coding was used to identify themes in the data. Using in vivo coding, the respondents’ words were used to define the themes to ensure that the themes represented the original meaning of the respondents. One of the authors created a coding scheme using a subset of four interviews. The coding scheme was checked by two other authors before it was used to code the rest of the interviews. Any new themes that emerged in subsequent coding were added to the coding scheme. Finally, the number of interviewees mentioning a theme was calculated. As the development manager and technical manager were interviewed together and shared experiences in the same hospital that postponed the implementation of digital care paths, the analysis of their responses was combined.
In stage 2, the FITT framework [
Challenges of implementing eHealth services for self-management.
Dimension and themes | Mentions (n=9), n (%) | |
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Problems with usability, technical problems, and missing functionalities | 8 (89) |
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Resistance, lack of use, and difficulty changing professionals’ work processes | 7 (78) |
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Professionals not informing patients about the eHealth services | 3 (33) |
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Negative previous experiences with information systems | 1 (11) |
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Lack of training | 1 (11) |
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Lack of technical support | 1 (11) |
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Problems with usability and missing functionalities | 7 (78) |
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Lack of use | 4 (44) |
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Lack of active patient participation in planning | 1 (11) |
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Extra work caused by insufficient interoperability | 3 (33) |
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Bad fit with the work processes | 2 (22) |
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Lack of knowledge about the possible technical functionalities | 3 (33) |
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Lack of resources | 3 (33) |
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Lack of management support | 2 (22) |
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Unclear roles during implementation | 1 (11) |
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Failure of the initial technical platform to fit the organization’s goals and processes | 1 (11) |
Practices for managing the challenges of implementation.
Dimension and practices | Mentions (n=9), n (%) | |
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Involving all the stakeholders, professional groups, and a technical expert in planning the service | 2 (22) |
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Testing and piloting the eHealth services before implementation | 4 (44) |
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Repeatedly informing health professionals about the implementation, changes, and the influence of the new services to their work for an extended period via unit meetings, training, personal contacts, and laminated instructions | 4 (44) |
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Proactively responding to health professionals’ concerns | 1 (11) |
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Involving frontline leaders and health professionals in planning the services and implementation is needed to create buy-in | 3 (33) |
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Providing adequate introductory knowledge, repeated training, and personal guidance as well as a test environment, which is required to train professionals | 4 (44) |
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Training a superuser to encourage health professionals and support implementation | 1 (11) |
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Proceeding slowly and gradually, so professionals have time to adjust to and practice using the new services | 2 (22) |
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Reserving extra personnel resources and time for the changing tasks | 1 (11) |
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Providing technical support with a responsible person when needed | 1 (11) |
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Identifying a patient group that can benefit from an eHealth service and having a patient point of view | 2 (22) |
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Involving patients early on and creating new methods needed to motivate patient participation | 2 (22) |
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Informing patients in an interesting way and providing leaflets or other marketing materials | 2 (22) |
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Collecting constant feedback from patients and improving the service through the use of questionnaires, contacting patients for further details to create a partnership, and request for feedback from patients that did not use the service | 3 (33) |
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Encouraging health professionals to discuss the digital service when meeting a patient and to reserve digital appointments with the patient | 2 (22) |
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Offering technical support during problems | 1 (11) |
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Identifying the current work processes and needs | 1 (11) |
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Fitting the eHealth service plans to current care processes to support and ease health professionals’ work, reduce the number of phone calls, increase remote work, and increase interoperability of the systems so that health professionals can view patient information from one system and do not need to record the same information twice | 5 (56) |
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Ensuring the service is quick, easy, and effortless to request and use | 5 (56) |
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Planning changes in the work processes well in advance and piloting the services to test the new processes and show the benefits of the service | 1 (11) |
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Identifying the needs early | 1 (11) |
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Fitting the eHealth service plans to the technical possibilities, including demonstrations and examples of existing services to help illustrate the possibilities | 2 (22) |
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Evaluating the work cost of implementation, a responsible person, resources needed, and the potential benefits | 2 (22) |
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Planning the implementation carefully in advance and defining the roles and responsibilities of the participants, changes, ways of relieving resistance, and solutions to problems | 5 (56) |
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Involving an active multi-professional team | 1 (11) |
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Indicating more than one person as a spokesperson to support the implementation, especially frontline leaders, who were considered important in influencing their subordinates’ commitment and providing resources for implementation | 2 (22) |
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Involving and informing top management to provide support and resources and ensure the availability of spaces and devices | 2 (22) |
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Identifying measures of impacts and making baseline measurements in the very beginning | 1 (11) |
The interviewees received oral and written information about the study and its voluntary nature before the interviews. Written informed consent was obtained from all participants. The study protocol was reviewed and approved by the Ethical Review Board of Aalto University, Finland.
Many of the health professionals were not willing to use the new eHealth services. One of the participants described, “The resistance over changing practices surprised me most and how long it has been continued.” She also said that not all the nurses understood how this service was going to help with their work; hence, their motivation to use it was low. Only 3 of the participants did not mention any professionals’ resistance or lack of use, but their eHealth services were only used by the developing team, which consisted of 2-10 health professionals. Thus, it seemed to be more challenging to introduce a service to larger user groups. In total, 3 participants mentioned that the group of health professionals who had not participated in the development team demonstrated the most resistance.
One interviewee described that it was very challenging to reach and inform all the health care professionals as they worked in three shifts. Physicians forgot to use the digital path as a tool and tell their patients about the new service. In addition, another participant said that physicians used the old paper-based approach and were reluctant to use the digital path, which appeared to be slower. Nurses also forgot to reserve digital appointments for the patients.
The services included a patient feedback survey, and all except one implementation project received feedback from patients through the survey. The feedback provided was positive, and the services were evaluated to be useful. For example, the information received was seen to support preparation for an operation. Patients gave negative feedback related to difficult registration, problems in use, slow or confusing services, and missing functionalities.
In the documented survey, 15 out of 17 patients (88%) rated that they were
The number of patient users was also low in some cases. Health professionals often did not actively use the new eHealth services, and they were also passive in introducing the services to patients and motivating them to use the services. Patients did not provide much feedback, and the number of patients who completed the questionnaires was low. One of the interviewees said that they were not able to find patients who were willing to participate in the design workshops. Thus, in the context of online self-management intervention, patients need to be engaged in both using and designing the services. We, therefore, divided the individual dimension to separately cover health professionals and patients.
Some participants identified fit problems between technology and tasks. Mostly, the lack of interoperability created extra work for health professionals, but in 2 cases, participants identified that the process required by the eHealth service did not fit the work processes.
In addition to the FITT model’s dimensions, there were challenges related to poor fit between the organization and management and the technology. For example, it was unclear how the technical platform could be used in the organization and what benefits exist. In some cases, there was insufficient management support or available resources for implementation. For example, one of the interviewees found it challenging to support others in the implementation, as she did not have reserved work hours for it. She felt that management should also have provided resources for implementation and use and not only for the development of the digital path.
The development of the technical platform was in one hospital at the beginning; the initial version of the platform did not fit the organization’s goals and processes. The usability and interoperability of the customer management system was considered to be poor. Consequently, the implementation of any new eHealth services using the technical platform in this hospital was halted until the platform was further developed.
Participants found that task-technology fit could be improved by aligning the new service to the current work processes and needs and designing a service that is usable and effortless to use. To improve the fit between the organization and the technology, participants saw a need to identify a relevant problem that the technology was able to solve and the benefits that could be produced and to evaluate the costs related to implementation. Many participants also learned that implementation needed to be well planned and organized collectively inside the organization.
The study shows three major findings:
The implementation of self-management services involved many challenges related to technical problems, health professional acceptance, patient motivation, and health organization and management.
The implementers had identified practices to manage the identified challenges by improving the design of the technology, supporting health professionals in the technology adoption, changing the work processes and tasks, involving patients, and planning the implementation collectively inside the organization.
The challenges and practices could be mostly attributed to the dimensions of the FITT framework. However, the findings suggest that patients should be added as a different type of individual dimension, and organizations and management should be added as new dimensions to the FITT framework.
In line with an earlier case study [
Furthermore, the technology needs also fit the organization, and management has an important role, as identified in previous studies [
Most of the identified opportunities to handle the challenges were related to improving the fit between tasks, the technology, and individuals. Better fit can be achieved by designing better technical solutions and usability to support patients, health professionals, and tasks. Therefore, it is important to foster stakeholder involvement and user-centered design in future projects [
In addition, many of the opportunities to handle the identified challenges were related to the management and the organization. As shown by previous studies, the way eHealth services are introduced is also important for implementation success [
Overall, the findings were well interpreted with the dimensions of the FITT framework (see
Extended FITT (Fit between Individuals, Task, and Technology) framework.
In the original FITT framework, the organization is mentioned as one of the attributes of the individual level. However, previous research shows that in complex implementation projects, there are also higher-level contextual factors, such as the health care system, the social climate, and economic and political issues, that are important to consider [
Thus, we propose that organizations and management be represented by a separate context dimension, as shown in
The extensions we proposed to the FITT model are not specific to self-management services. However, these kinds of services influence health professionals’ and patients’ interactions in a novel way; thus, the extensions especially support the analysis of the organizational efforts to engage patients in care.
The combination of the FITT framework and the Clinical Adoption Meta-Model [
Our results highlight the complex relationship between different factors and stakeholders that influence the success of implementation. The larger the number of users, the more complicated the implementation was in this study. In a literature review, Ludwick and Doucette [
In the case of eHealth services for self-management, patients are important stakeholders. Urowitz et al [
Our results imply that although many of the challenges of implementation are similar to those of different eHealth innovations [
A limitation of this study is that we only studied the perspectives of project coordinators and managers who were responsible for implementing the new online self-management services. As our study relied on the implementers’ reporting of health care professionals’ reactions, the health care professionals’ characteristics influencing the implementation were not identified, as they were identified in an interview study by Ciere et al [
The number of interviewees was relatively low. However, the goal was to gain qualitative insight into the challenges and opportunities in the implementation projects, and data saturation was reached, meaning that not much new information (eg, a single new theme) could be identified in an additional interview [
The level of health care professionals’ resistance can vary during implementation [
Consolidated Framework for Implementation Research
Fit between Individuals, Task, and Technology
HUS Helsinki University Hospital
information technology
The authors are grateful to the participating health organizations and interviewees. This work was supported by the Strategic Research Council at the Academy of Finland (decision number 327147).
None declared.