title: Using the Consolidated Framework for Implementation Research to Identify Barriers and Facilitators for the Implementation of an Internet-Based Patient-Provider Communication Service in Five Settings: A Qualitative Study.
abstract: BACKGROUND
  Although there is growing evidence of the positive effects of Internet-based patient-provider communication (IPPC) services for both patients and health care providers, their implementation into clinical practice continues to be a challenge.
  
  
  OBJECTIVE
  The 3 aims of this study were to (1) identify and compare barriers and facilitators influencing the implementation of an IPPC service in 5 hospital units using the Consolidated Framework for Implementation Research (CFIR), (2) assess the ability of the different constructs of CFIR to distinguish between high and low implementation success, and (3) compare our findings with those from other studies that used the CFIR to discriminate between high and low implementation success.
  
  
  METHODS
  This study was based on individual interviews with 10 nurses, 6 physicians, and 1 nutritionist who had used the IPPC to answer messages from patients.
  
  
  RESULTS
  Of the 36 CFIR constructs, 28 were addressed in the interviews, of which 12 distinguished between high and low implementation units. Most of the distinguishing constructs were related to the inner setting domain of CFIR, indicating that institutional factors were particularly important for successful implementation. Health care providers' beliefs in the intervention as useful for themselves and their patients as well as the implementation process itself were also important. A comparison of constructs across ours and 2 other studies that also used the CFIR to discriminate between high and low implementation success showed that 24 CFIR constructs distinguished between high and low implementation units in at least 1 study; 11 constructs distinguished in 2 studies. However, only 2 constructs (patient need and resources and available resources) distinguished consistently between high and low implementation units in all 3 studies.
  
  
  CONCLUSIONS
  The CFIR is a helpful framework for illuminating barriers and facilitators influencing IPPC implementation. However, CFIR's strength of being broad and comprehensive also limits its usefulness as an implementation framework because it does not discriminate between the relative importance of its many constructs for implementation success. This is the first study to identify which CFIR constructs are the most promising to distinguish between high and low implementation success across settings and interventions. Findings from this study can contribute to the refinement of CFIR toward a more succinct and parsimonious framework for planning and evaluation of the implementation of clinical interventions.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT00971139; http://clinicaltrial.gov/ct2/show/NCT00971139 (Archived by WebCite at http://www.webcitation.org/6cWeqN1uY).
authors.affiliation: Center for Shared Decision Making and Collaborative Care Research, Oslo University Hospital, Oslo, Norway.
authors.forename: Cecilie
authors.identifier: http://orcid.org/0000-0001-5257-7993
authors.initials: C
authors.lastname: Varsi
authors.forename: Mirjam
authors.identifier: http://orcid.org/0000-0002-4108-391X
authors.initials: M
authors.lastname: Ekstedt
authors.forename: Deede
authors.identifier: http://orcid.org/0000-0002-9676-2442
authors.initials: D
authors.lastname: Gammon
authors.forename: Cornelia M
authors.identifier: http://orcid.org/0000-0001-6521-4884
authors.initials: CM
authors.lastname: Ruland
mesh_terms: D000328:Adult; D003142:Communication; D005260:Female; D006282:Health Personnel; D006801:Humans; D020407:Internet / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research
keywords: CFIR; Consolidated Framework for Implementation Research; Internet; eHealth; electronic mail; implementation; qualitative research; secure Web communication