JMIR Publications

ABSTRACT

Background:

A telemedicine service enabling remote surgical guidance during Endoscopic Retrograde Cholangio-Pancreatografy (ERCP), had shown promising results. When the practice was to be scaled up, it was unclear how contextual variations between the clinical sites could play out. Few telemedicine innovations progress from the pilot stage to routine use, and while many recognize that contextual factors contribute to implementation outcomes, few telemedicine studies account for contextual factors during implementation in a systematic manner that also accommodates the complexity of healthcare settings. Work domain analysis is a method for modeling and analyzing how the structure of complex work environments shapes performance, and can be a way to investigate contextual factors that may influence telemedicine implementation.

Objective:

We wanted to conduct a work domain analysis in order to systematically characterize the implementation contexts at the clinics participating in the scale-up. This would allow us to identify constraints, such as objects, processes or priorities that shape ERCP work at the implementation sites, and that set the sites apart or might cause interactions that contribute to implementation outcomes. These findings could then be used to inform implementation and subsequent evaluation of teleguidance. The results could also serve as an example of how a the complex sociotechnical context of a clinical work system can be analyzed and represented in a structured way during telemedicine design and implementation.

Methods:

We conducted observations and semi-structured interviews with a variety of stakeholders. Conceptual themes derived from work domain analysis framework directed our analysis towards physical, social and cultural constraints that shape clinical work. An iterative “discovery and modeling” approach allowed us to first focus on one clinic, and readjust the scope and system boundaries as our understanding of the work systems became more refined.

Results:

ERCP practice is embedded in a work system with multiple sets of values and priorities, and we characterized the domain as three distinct facets:the treatment facet, the administrative facet (providing resources for procedures), and the development facet(training, quality improvement and research). A large number of causal constraints, such as medical equipment affecting treatment options, and administrative processes affecting access to staff and facilities were identified. Intentional constraints, such as values and priorities affecting assessments during ERCP and resources for the procedure, were also identified.

Conclusions:

We found that intentional constraints in the treatment facet were largely shared across the implementation sites. There was more variation among the causal constraints, and we identified several factors that might make teleguidance be perceived as clumsy or unpractical. However, if teleguidance matches the values and priorities of the several facets at each site, there may be enough motivation and resources to overcome these types of initial disruptions. By contrasting the devlopment facets at different sites it became clear that some hospitals had less emphasis and resources for training and research. This might allow organizational demands for efficiency and effectiveness to take priority over the training needs or quality efforts that teleguidance answers to, or reduced willingness or ability to accept a service which is not yet fully developed or adapted. Work domain analysis proved to be a way to represent and analyze complex clinical contexts in the face of technological change, and may be a way to increase knowledge about the factors that contribute to the uptake of telemedicine.