Barriers and Facilitators to the Implementation of Family-Centered Technology in Complex Care: Feasibility Study

Jody L Lin, Bernd Huber, Ofra Amir, Sebastian Gehrmann, Kimberly S Ramirez, Kimberly M Ochoa, Steven M Asch, Krzysztof Z Gajos, Barbara J Grosz, and Lee M Sanders



Background: Care coordination is challenging but crucial for children with medical complexity (CMC). Technology-based solutions are increasingly prevalent but little is known about how to successfully deploy them in the care of CMC. Objective: The aim of this study was to assess the feasibility and acceptability of GoalKeeper (GK), an internet-based system for eliciting and monitoring family-centered goals for CMC, and to identify barriers and facilitators to implementation. Methods: We used the Consolidated Framework for Implementation Research (CFIR) to explore the barriers and facilitators to the implementation of GK as part of a clinical trial of GK in ambulatory clinics at a children's hospital (NCT03620071). The study was conducted in 3 phases: preimplementation, implementation (trial), and postimplementation. For the trial, we recruited providers at participating clinics and English-speaking parents of CMC<12 years of age with home internet access. All participants used GK during an initial clinic visit and for 3 months after. We conducted preimplementation focus groups and postimplementation semistructured exit interviews using the CFIR interview guide. Participant exit surveys assessed GK feasibility and acceptability on a 5-point Likert scale. For each interview, 3 independent coders used content analysis and serial coding reviews based on the CFIR qualitative analytic plan and assigned quantitative ratings to each CFIR construct (--2 strong barrier to +2 strong facilitator). Results: Preimplementation focus groups included 2 parents (1 male participant and 1 female participant) and 3 providers (1 in complex care, 1 in clinical informatics, and 1 in neurology). From focus groups, we developed 3 implementation strategies: education (parents: 5-minute demo; providers: 30-minute tutorial and 5-minute video on use in a clinic visit; both: instructional manual), tech support (in-person, virtual), and automated email reminders for parents. For implementation (April 1, 2019, to December 21, 2020), we enrolled 11 providers (7 female participants, 5 in complex care) and 35 parents (mean age 38.3, SD 7.8 years; n=28, 80{\%} female; n=17, 49{\%} Caucasian; n=16, 46{\%} Hispanic; and n=30, 86{\%} at least some college). One parent-provider pair did not use GK in the clinic visit, and few used GK after the visit. In 18 parent and 9 provider exit interviews, the key facilitators were shared goal setting, GK's internet accessibility and email reminders (parents), and GK's ability to set long-term goals and use at the end of visits (providers). A key barrier was GK's lack of integration into the electronic health record or patient portal. Most parents (13/19) and providers (6/9) would recommend GK to their peers. Conclusions: Family-centered technologies like GK are feasible and acceptable for the care of CMC, but sustained use depends on integration into electronic health records. Trial Registration: NCT03620071;

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Jody L Lin, Bernd Huber, Ofra Amir, Sebastian Gehrmann, Kimberly S Ramirez, Kimberly M Ochoa, Steven M Asch, Krzysztof Z Gajos, Barbara J Grosz, and Lee M Sanders. Barriers and facilitators to the implementation of family-centered technology in complex care: Feasibility study. J Med Internet Res, 24(8):e30902, Aug 2022.