Innovation summary

The uptake of effective clinical innovations in routine practice remains low, slow and costly1-3. By systematically addressing the factors that impede and facilitate the uptake of such practices and interventions in the context of a local setting, it is expected that innovations can be implemented more quickly and efficiently. Impeding factors include legislative, regulatory and political restrictions, incompatible reimbursement systems, negative attitudes towards internet-based treatment, and limited availability of adequately trained professionals4-10. ImpleMentAll will be one of the first large-scale attempts to address these barriers.

The project proposes to develop and evaluate tailored implementation strategies in the context of ongoing eHealth initiatives across the EU. These will be introduced in different settings at randomly chosen time points, and we will monitor the uptake and level of normalisation of internet-based Cognitive Behavioural Therapy (iCBT) both before and after the introduction of the tailored interventions. 

Impact summary

We expect our innovation to have the following impact:

  • Reach underserved populations in eight European countries, including two Low-and-Middle-Income Countries, and Australia
  • Enable more efficient and rapid normalisation of innovations by seamlessly fitting with the needs and determinants of local practices
  • Deliver a comprehensive toolkit that will guide end users in developing their own tailored strategies for implementing eHealth solutions in routine care practice

 

“This project deals with an important issue: how to better, faster, more effectively and efficiently, change the healthcare system by implementing new technologies. What we want to achieve is no small task and we have an ambitious and complex project ahead of us with a high scientific level of ambition.”
– Claus Duedahl Pedersen, Project Coordinator

Innovation details

In recent decades, large amounts of time and money have been put into the development, testing, and implementation of eHealth for a wide range of health problems, including mental health. Nevertheless, very few eHealth interventions make it into routine care and those that do, take many years to get there. ImpleMentAll aims to provide an evidence-based answer to this problem through the development, application, and evaluation of tailored implementation strategies within ongoing eHealth implementation initiatives (Internet-based Cognitive Behavioural Therapy (iCBT)) in the EU and beyond.

Currently, various iCBT implementation processes are conducted across the world and ImpleMentAll will use this “natural laboratory” to develop, test, and evaluate a toolkit for tailored implementation strategies to determine whether this can make the process of implementation more efficient. Specifically, ImpleMentAll will develop, validate, and deliver a generic Integrated Theory-based Framework for Intervention Tailoring Strategies (ItFits-toolkit) that enables more efficient implementation of evidence-based clinical services in routine healthcare. The ItFits-toolkit will provide the methods and contents for the development of tailored implementation strategies for normalising innovations in local routine healthcare settings. The effectiveness of those tailored implementation strategies will be tested in ongoing practice and projects scaling up throughout Europe. The ItFits-toolkit will enable data-driven evaluation of implementation projects in terms of key performance indicators for process, effectiveness, and efficiency outcomes, allowing us to determine if tailored implementation strategies can make the process of implementation more efficient.

Key drivers

A strong multi-country committee
The ImpleMentAll research team is comprised of world leading institutions and individuals in implementation science, clinical psychology, and eMental health.

Stakeholder-driven tailoring
In the composition of the consortium, great attention has been given to the inclusion of partners with competencies and capacity (links to service providers, health professionals, patients, decision and policy makers, as well as influential interest organizations) that can ensure a high level of visibility, dissemination and scaling of results to communities and stakeholders outside of the consortium.

Having a “natural laboratory” at hand
The implementation sites will provide the necessary test beds for the tailored implementation strategies and will take ambitious steps towards large-scale implementation and normalization of iCBT into routine practice.

Adaptation to different country contexts
The ImpleMentAll consortium consists of 18 partners from seven different EU Member States, one candidate country (Albania), one potential candidate country (Kosovo), and Australia. Two out of ten countries are designated by the World Bank as Low- and Middle Income Countries. The consortium as a whole is balanced over the objectives and is efficient, primarily aimed at achieving synergy and excluding any unnecessary overlap in expertise, geographical location, and resources.

Challenges

ImpleMentAll is a highly ambitious project, and with ambition comes a certain level of risk. A main source of risk is the strong dependency between the practical roll-out of the services in the participating regions and the research process. It is well-known that time frames and plans in real life implementations can change or experience delays. It will be a key issue for the consortium to avoid that situation. 

Continuation

Long-term impact of project outcomes will be ensured by continuous involvement of stakeholders.

A main goal of ImpleMentAll is successful implementation and dissemination of the developed framework and toolkit. If proven successful and being broadly and successfully disseminated across Europe and in LMICs, this is a new, tailored, and cutting edge opportunity and product for the growing eHealth field in Europe.

The EAAD and several consortium members have extensive expertise in dissemination of research results, frameworks, and guidelines across Europe. In collaboration with the rest of the consortium, EAAD will ensure that the results and products, input from various stakeholders, patients and decision-makers, will be translated into innovation by further developing the framework into practice guidelines for Europe and LMIC.

Partners

Funders

  • This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 733025.

Evaluation methods

Evaluation tool: NoMAD

The level of normalisation will be measured using a pragmatic implementation practice oriented questionnaire. This 23-item questionnaire called NoMAD11, is designed to measure implementation processes from the perspective of professionals directly involved in the implementation work and is based on the Normalization Process Theory (NPT)12. NoMAD includes tested items for assessing staff perceptions of factors affecting implementation as represented by the four NPT constructs (coherence, collective action, cognitive participation, reflexive monitoring). The NPT is a theoretical framework for understanding how innovations (can) become part of normal practice concerning three core problems: 1) implementation, 2) embedding, and 3) integration13. The theory focuses on explaining how people act and how they work in the process of implementation.

Evaluation framework: MAST

A multidisciplinary evaluation framework will be used to structure the assessment of other (secondary) key performance indicators, and a process evaluation. This framework will be based on the Model for ASsesment of Telemedicine (MAST)14 and standard approaches to process evaluation. MAST takes a broad view and analysis of the factors and areas to consider when introducing and implementing telemedicine in an existing healthcare setting. The MAST outcome oriented assessment tool is a result from the MethoTelemed Study14 and uses the EUnetHTA Core Health Technology Assessment Model15 as a starting point. The principal elements of MAST consist of three steps. In the first step, a number of preceding considerations are made regarding legislation, reimbursement and maturity of the application. This step enables explicit decision-making regarding the implementation of the targeted innovation. The second step concerns a multidisciplinary assessment of outcomes across seven domains (health problem and characteristics of the intervention, safety, clinical effectiveness, patient and healthcare professional perspectives, economic, organisational, and socio, ethical, and legal aspects). This step is designed to take into account those factors that are found to be relevant when implementing complex interventions in healthcare settings and, as such, sensitises the further design of the present evaluation study. The third and final step addresses the transferability and scalability of the implemented services to other healthcare contexts. In this step, relevant contextual information of the outcomes of the multidisciplinary assessment will be provided in order to enable others to determine the applicability of the findings to their contexts.

Cost of implementation

The total budget adds up to € 7,071,639 (approximately US$ 7,863,380, as of May 2017) for 51 months. Overall, the costs and requested funding reflects both the large effort needed for developing the ItFits-toolkit, testing the effectiveness of the tailored implementation strategies, and preparing for utilisation and its actual dissemination. 

References

  1. Grol R et al. (2003) From best evidence to best practice: effective implementation of change in patients' care. The Lancet362(9391): 1225-1230.
  2. Institute of Medicine (US) Committee on Quality of Health Care in America (2001) Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press (US)
  3. Grol R et al. (2005) Improving patient care: the implementation of change in clinical practice. Oxford, UK: John Wiley & Sons, Ltd.
  4. Fleuren MAH et al. (2014) Towards a measurement instrument for determinants of innovations. International Journal for Quality in Health Care26(5): 501-510.
  5. Flottorp SA et al. (2013) A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Science8(1): 35.
  6. Kazdin AE et al. (2011) Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on psychological science6(1): 21-37.
  7. Emmelkamp PMG et al. (2013) Advancing psychotherapy and evidence‐based psychological interventions. International journal of methods in psychiatric research23(1): 58-91.
  8. McHugh RK et al. (2012) Dissemination and implementation of evidence-based psychological interventions. Oxford University Press.
  9. Ebert DD et al. (2015) Increasing the acceptance of internet-based mental health interventions in primary care patients with depressive symptoms. A randomized controlled trial. Journal of affective disorders176: 9-17.
  10. Baumeister H et al. (2014) Impact of an acceptance facilitating intervention on diabetes patients’ acceptance of Internet-based interventions for depression: a randomized controlled trial. Diabetes research and clinical practice105(1): 30-39.
  11. Finch T et al. (2015) NoMad: Implementation measure based on Normalization Process Tehory. www.normalizationprocess.org
  12. May C et al. (2009) Implementing, embedding, and integrating practices: an outline of normalization process theory. Sociology43(3): 535-554.
  13. Finch T et al. (2013) Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol. Implementation Science8(1): 43.
  14. Kidholm K et al. (2012) A model for assessment of telemedicine applications: mast. International journal of technology assessment in health care28(01): 44-51.
  15. EUnetHTA. European Network for Health Technology Assessment [Internet]. eunethta.eu. [cited 2015 May 27]. Available from: http://www.eunethta.eu
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Albania, Australia, Belgium, Denmark, France, Germany, Italy, Kosovo, Netherlands, Spain, United Kingdom of Great Britain and Northern Ireland

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