Facilitators of and Barriers to Implementation of a Tablet-Based Digital Health Program for Colorectal Cancer Screening in Primary Care: Qualitative Pragmatic Implementation Study

TL;DR

This study explores what helped or hindered the use of a tablet-based tool for colorectal cancer screening in primary care clinics.

Contribution

The study identifies key facilitators and barriers to implementing a digital health program for CRC screening in real-world primary care settings.

Findings

Healthcare provider and staff buy-in were major facilitators of the program's implementation.

Perceived lack of need and technical issues were the main barriers to program adoption.

Workflow improvements and potential time savings were seen as important benefits of the program.

Abstract

Colorectal cancer (CRC) incidence and mortality rates continue to be elevated even though effective screening methods are widely available. To increase CRC screening in primary care practices, our team developed a tablet-based digital health program (mPATH) designed to identify patients needing CRC screening, provide education, and empower patients to request a screening test via the program.

This study aimed to qualitatively assess facilitators of and barriers to implementing and maintaining mPATH in primary care clinics.

In a pragmatic implementation trial, clinics were randomized to receive only in-person training and technological support via phone or email (low touch) or added levels of support, such as at-elbow support during launch, regular check-ins, memos, and reports (high touch). After implementation and data collection were concluded, we conducted telephone interviews with health care providers, clinic managers, and front desk and nursing staff recruited from 8 primary care clinics of varying sizes and with varying degrees of implementation of mPATH. The interviews were designed to collect perceived facilitators of and barriers to using mPATH. All interviews were administered via telephone by a single project staff member with no prior contact with participants. Interviews were audio-recorded, and 2 study team members independently coded each interview transcript and developed a codebook to identify meaningful categories in the dataset. The coders met periodically to resolve discrepancies. Data within each category were abstracted and synthesized into themes. Themes were determined inductively by prevalence and salience in the data per the principles of thematic analysis.

A total of 33 interviews were completed between September 2021 and April 2023 with health care providers (n=8, 24.2%), clinic managers (n=9, 27.3%), nursing staff (n=8, 24.2%), and front desk staff (n=8, 24.2%). Interviews averaged 26.7 (SD 4.9) minutes. Barriers and facilitators identified varied among clinic sites and by clinic role. Overall, the primary factors supporting the implementation of mPATH were health care provider and staff buy-in, perceived potential time savings, and workflow improvement. The primary barriers identified were perceived lack of need for the program and technical issues. There was no significant indication that clinic size or randomization to low- or high-touch training and support played a role in the decision to continue or stop using the program.

Implementation of a tablet-based CRC screening tool in primary care practices is feasible with health care provider and staff buy-in and validation of potential time savings and workflow improvements but may be limited by perceived lack of need for the program and technical issues.