Adoption and implementation of a web-based self-management application “Oncokompas” in routine cancer care: a national pilot study

Cancer and the treatment of cancer often have a negative impact on a cancer survivors’ health-related quality of life (HRQOL). Addressing this requires a multidisciplinary and multichannel approach using different strategies. One of these strategies is self-management, and even though its benefits have been recognized [1‐3], integration in routine cancer care is still in its early stages. There is an important role for healthcare professionals (HCPs) in informing and encouraging self-management in patients, as patients consider their HCP an important source of information [4]. Self-management support has been defined as “the systematic provision of education and supportive interventions by healthcare staff to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support”̛ [5]. HCPs have many options and strategies to choose from when it comes to providing self-management support. An example is informing patients of (web-based) tools that facilitate or enable self-management behaviors of cancer survivors [6‐8].

The web-based self-management application Oncokompas has been designed to facilitate access to supportive cancer care services. Users measure their HRQOL by means of patient-reported outcome measures (PROMs) targeting over 80 different cancer related HRQOL topics, which are processed by the algorithms built into Oncokompas. All algorithm calculations are based on available cut-off scores, or they are defined based on Dutch practice guidelines, literature searches, and/or consensus by teams of experts (consisting of patients, physicians, nurses, researchers, psychologists, and other experts) [6]. This results in red/orange/green scores on the various topics. These scores are accompanied by automatically generated feedback, information, insights, and tips to deal with problem areas, all tailored to the individual patient. Finally, Oncokompas provides options for supportive cancer care for each HRQOL topic. These options range from (online) self-help options (in case of an orange score) to traditional face-to-face care options, such as a psychologist (in case of a red score), accompanied with contact information and map to the nearest psychologist specialized in cancer extracted from the Dutch Cancer Referral Guide [9], based on the user’s postal code.

Participatory design principles were followed to ensure sustainable usage of Oncokompas, meaning that all stakeholders, including cancer survivors, HCPs, healthcare insurance companies, and researchers were involved in each step of the development process [6, 10‐12]. This approach resulted in an eHealth application that fits the needs of cancer survivors and HCPs and is proven to be feasible for usage in clinical practice, combined with good satisfaction rates among cancer survivors ̛ [6, 13]. Oncokompas is designed as a self-help application, based on a feasibility study among HCPs and patients valuing independent use. A supported self-management approach was also explored (blended care), but the importance of empowering the user and respecting their privacy resulted in implementing Oncokompas as a stand-alone self-management tool. Additionally, a supported approach would have led to increased complexity regarding existing working procedures, potentially leading to low uptake. [6, 11, 14]. To stimulate HCP involvement, access to the application occurs via HCPs.

The next step was to implement Oncokompas in Dutch oncology settings. Earlier research has shown that successful implementation of innovations, especially e-health applications in healthcare, is difficult to achieve, and many determinants can be of influence [15‐18]. In order to facilitate the adoption and implementation of Oncokompas in oncology settings, a comprehensive multifaceted implementation strategy was designed, in which we incorporated insights from earlier studies [6, 19] as well as the requirements for implementation of Oncokompas indicated by HCPs, such as designing Oncokompas in a way that enables independent use by patients [11]. Figure 1 shows a generic framework that has been used for the introduction and evaluation of innovations in healthcare [20]. Each of the four main stages in innovation processes can be thought of as critical phase where the desired change may or may not occur. The transition from one stage to the next can be affected, positively or negatively, by various determinants. A detailed understanding of determinants helps to design an innovation strategy that can achieve real change.

The aim of this study was to investigate the adoption and implementation of Oncokompas in clinical practice and to obtain insights in possible determinants of implementation. Study results are relevant to guide and increase future implementation of (online) self-management interventions in oncology settings.

This study describes the first steps of implementing a web-based self-management tool “Oncokompas” in Dutch oncology settings. Adoption rate by hospitals was at 31%, and implementation rate in the adopting hospitals by HCPs was at 72%. However, when viewed in the context of the adoption rate, one could also argue that overall implementation rate was low. For instance, taking the total number of HCPs in the adopting hospitals (n = 205) as denominator, the implementation rate would be 21%. In any case, the results are in line with the finding that many new interventions fail to be widely adopted [25]. The results can also be viewed in light of Roger’s diffusion of innovation theory where the adoption rate follows an S-curve plotted over time (when looking at the complete lifecycle of an innovation) [26]. When viewing the adoption of Oncokompas in this light, one could say the innovators and early adopters (31%) are using Oncokompas at present, while the others (early and late majority and laggards) are still contemplating or waiting.

To be able to reach cancer patients, the multifaceted implementation strategy focused on oncology settings in hospitals, because that is the place where every new patient can potentially be reached. For that to happen, first, the hospitals had to adopt Oncokompas, which is a challenge, because the organization of oncological care in hospitals is multidisciplinary and complex. Even though all stakeholders, including HCPs, were involved in every step of the development of Oncokompas [6, 11, 13], this does not guarantee immediate adoption and implementation. Several reasons were mentioned by hospitals for not adopting Oncokompas, such as a lack of evidence regarding (cost-)effectiveness and uncertainty about reimbursement by the health insurance company in the long-term.

Another barrier to adopt Oncokompas relates to the concept of self-management: some hospitals questioned whether access to an online self-management tool should be provided through a hospital or directly to patients themselves. More research is needed on the organization of self-management (support) in cancer care [27], but a key aspect in providing this support is cooperation between health services [28]. Also, in a previous qualitative study exploring HCP’s perspective regarding Oncokompas implementation, we found that all participants indicated that when Oncokompas was to be implemented in daily clinical practice, it should be offered to survivors through a clinical procedure in a care pathway [11].

Implementation by HCPs in the hospitals that adopted Oncokompas was at 72% and related primarily to innovation-related and user-related determinants. Procedural clarity was lower for those HCPs who did not implement Oncokompas, indicating more training or supportive material is needed. This finding could be an indication of a bad fit with procedures or organization of cancer care pathways, which could lead to delays in implementation [29], although the MIDI determinant “compatibility” in the current study was not significantly different between the two groups. This is important, because if (part of) the intervention is perceived as easy to implement, this will result in higher levels of implementation [30].

HCPs who did not offer Oncokompas also experienced less social support from management, colleagues, the helpdesk, and the Oncokompas team. Studies have shown that support from management is an important facilitator [31, 32]. In the present study, we generally tried to apply a top-down approach through the oncological committees. This often resulted in the committee deciding to first start in a single department or a single HCP implementing Oncokompas, which perhaps contributed towards a feeling of isolation for these HCPs and a perception of less social support.

Self-reported self-efficacy was significantly lower among those who did not offer Oncokompas, which is in line with findings that a higher self-efficacy is associated with higher levels of self-management support [33]. Low confidence is also associated with greater hesitance towards implementing innovations, which in turn could lead to lower implementation levels [34]. The difference in self-efficacy might also be related to social support. If a group as a whole is working towards implementation, perceived collective efficacy might positively interact with individual self-efficacy [35] (MIDI determinant descriptive norm). This in turn calls for central coordination and formal ratification by management (both MIDI determinants) when implementing an innovation. Additionally, taking a top-down approach and implementing an innovation hospital wide, involving all relevant staff, is considered to be crucial for successful implementation and integration.

Interestingly though, the two groups did not differ significantly on organizational related determinants of the MIDI, but one third reported there was no formal ratification by management, while previous studies have shown this to be an important factor [36, 37].

Quantitative insights into implementation of innovation in supportive cancer care are still relatively scarce, and the current study adds to this new body of research. There was however no qualitative follow-up (e.g., interviews), which is common in implementation process studies. Although we believe we captured many essential elements, this could have provided additional insights, such as a deeper understanding of why implementers generally score MIDI determinants higher than non-implementers. The cross-sectional design of the current study also limits the amount of relevant information that can be captured, as implementation is a process that develops over time, strongly influenced by current circumstances. Furthermore, the instructional meeting that was organized in the adopting hospitals was not attended by all HCPs involved, which could have had an effect on the implementation rate. Effects of training were not evaluated in the current study, but this exposure to education on working with the intervention should be captured in future studies. We defined implementers as those HCPs that followed the three steps involved in implementing Oncokompas, but this was based on self-reported answers by HCPs. Future studies should more thoroughly assess the level of implementation of the different components of interventions (and steps involved for the HCP) and measure if these are delivered as intended.

The response rate was low, which we tried to address beforehand by making the questionnaire as short as possible, leaving out demographic variables, such as sex and age. The questionnaire was available online, which might increase response [38]. There could also be a bias in the group of participants, as HCPs that did not implement Oncokompas as intended, were probably less likely to participate in this study.

Future research should aim to capture as many processes and perceptions as possible to be able to assess as much (underling) processes as possible.

The current dissemination strategy of offering Oncokompas through an HCP could be transformed in such a way that allows people to independently register for Oncokompas, but that would also require a shift in the way of thinking among healthcare insurance companies in order to secure reimbursement in order to sustain Oncokompas.

During this 1-year study, nationwide adoption rate of Oncokompas was at 31% at the end of this study and subsequent implementation rate within this study was at 73%. Comparing those HCPs who did and did not implement Oncokompas, the groups differed significantly on innovation-related (procedural clarity, complexity) and user-related determinants (importance of outcome expectations, professional obligation, social support, and self-efficacy). Both groups encountered barriers concerning organization-related determinants. The results of this study contribute to further optimize interventions and strategies to adopt and implement (online) self-management applications in cancer care.