JMIR Publications

ABSTRACT

Background:

Clinical Decision Support Systems (CDSS) have potential to improve patient safety and reduce costs in primary care. However, CDSS adoption remains limited due to development and implementation challenges. CDSS are complex interventions involving multiple interacting components, require technological innovation, and behavioral and organizational change. Additionally, the primary care context can be considered a complex system characterized by a high demand in care, fragmentation, and interdependencies between a large number of autonomous care provider organizations. Established determinant frameworks for implementing and scaling up complex healthcare interventions support identification of implementation determinants. However, they offer limited guidance on the underlying processes of these determinants, such as the implementation processes involved in complex interorganizational collaboration in primary care.

Objective:

This study examines how an interorganizational collaboration in a Dutch primary care (Gezonde Zorg, Gezonde Regio, GzGr) achieved an iterative CDSS development and implementation. We aimed to identify the mechanisms that supported the collaboration in overcoming challenges.

Methods:

We performed a qualitative process-level case study. Data were collected through semi-structured interviews based on the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, and triangulated with internal and external documents, and expert input. Using a thematic, inductive approach, we developed a chronological overview of the collaboration and identified mechanisms offering process-level insights into how interorganizational collaborations navigate complexity in the development and implementation of digital health interventions.

Results:

We identified two mechanisms: (1) aligning on shared principles for interorganizational collaboration and CDSS development and (2) iterative, co-creative experimentation that spans development and implementation. First, GzGr was driven by a mission-oriented coalition of the willing (individuals willing to take an extra step), who established shared technical and collaborative principles. These shared principles translated the broad GzGr mission into concrete CDSS development choices, while also guiding strategic expansion by involving mission-aligned, innovative organizations. Organizational commitment to GzGr was strengthened by shared goals and leadership that prioritized collective benefit while respecting individual organizational values. Second, after initial prototypes, GzGr established an iterative learning and improvement experimentation process, for both the technology and collaboration. This process allowed for rapid feedback, validation of added value, and ongoing refinement. Iterative, co-creative experimentation further supported technological advancement and organizational change, by approaching the development and implementation phase as a continuous, adaptive process involving multi-stakeholders.

Conclusions:

This study identified two key mechanisms that support sustained interorganizational collaboration within the complex healthcare setting of GzGr. These mechanisms integrated collaborative and technical changes across people, technology, and business levels, both within and between organizations. This integration enabled technological viability, stakeholder value, organizational embedding of the intervention, and multilevel support. Our findings extend existing determinant frameworks by offering process-level insights into the mechanisms that underlie and connect implementation determinants.