# Customizing workflows for electronic patient-reported outcome (ePRO) symptom monitoring using the action, actor, context, target, time (AACTT) framework

## TL;DR

This paper shows how to create customized workflows for patient symptom monitoring using the AACTT framework to improve implementation in healthcare settings.

## Contribution

A detailed, replicable process for customizing ePRO workflows using the AACTT framework for site-specific implementation.

## Key findings

- A five-step process was developed to create site-specific ePRO workflows using stakeholder input and the AACTT framework.
- Provisional and final workflows were generated with input from 27 participants representing various healthcare roles.
- The AACTT framework effectively guided co-design workshops to align workflows with stakeholder preferences.

## Abstract

Real-time electronic patient-reported outcome (ePRO) symptom monitoring is a complex intervention with few examples of successful implementation at scale. A key challenge is designing a clear ePRO symptom monitoring workflow to support implementation into practice. We aimed to create an empirical and theory-informed site-specific workflow guided by the Action, Actor, Context, Target, Time (AACTT) implementation science framework.

A five-step process was undertaken to customize a generic ePRO symptom monitoring workflow to create a site-specific version: (1) design a generic ePRO symptom monitoring workflow through a qualitative study with key stakeholders; (2) conduct co-design workshops to understand stakeholder preferences regarding a site-specific version; (3) code co-design workshop data using the AACTT framework to produce a provisional site-specific version; (4) conduct a final co-design workshop using the AACTT framework to finalize stakeholder preferences for a site-specific version; and (5) code co-design workshop data using the AACTT framework to produce a final site-specific version.

Participants (n = 27) included nine patients, four caregivers, four oncologists, four nurses, two pharmacists, two clinic administrators, and two Electronic Medical Record (EMR) analysts. Provisional and final site-specific workflows were generated outlining the key AACTT components for each step of ePRO symptom monitoring.

We demonstrated the value in using the AACTT to guide the co-design of a site-specific workflow for ePRO symptom monitoring. By describing this process in detail, we will enable others to replicate this process for creating site-specific workflows not only for ePRO symptom monitoring, but for any complex clinical process.

The online version contains supplementary material available at 10.1007/s11136-025-03995-y.