Teledermatology scale-up frameworks: a structured review and critique

Qualitative research methods were used in all but one framework [37] which used mixed methods. In addition research approaches varied from implementation research [35], applied research [34], and action research [30]. The most common data collection instruments were literature reviews (6) [29, 30, 34‐36, 38], interviews (4) [29, 35, 36, 38], workshops (2) [35, 38], and site visits (2) [35, 36] followed by consultations [35], review panel [35], pre-testing [35], online engagement [38], survey [37], and a user and implementation-driven experience approach [37].

There were 10 references to seven frameworks. Diffusion of innovation theory was incorporated in two frameworks – SF [29] and SUF [30]. Others used strategic management (planning, change management, operations) – SUM [34], strategic planning – SUF [30], and social network theory – SF [29]. Practical experience guided the remaining four – MAPS [35], MTT [37], SF [29], and SUF [30]. In addition, reliance was placed on existing models, frameworks and typologies such as Kaiser Permanente’s “pyramid of care” model and risk sharing outcomes based payment models - THD ([38]: p20). Three framework approaches (prerequisites for sustainable ICT development, ICT in low middle income countries, and eReadiness assessment) were adopted by mHA [36], and typologies for scaling up considerations SF [29].

The main components of frameworks were key categories, processes, domains, dimensions or elements, with sub-components such as sections, levels, focus areas and tasks. Sub-components were supported with strategic choices or questions to guide the scale-up process. In addition three frameworks (SF [29], THD [38], and MTT [37]) developed critical success factors and SUF [30] developed attributes of success as additional mechanisms to support scale-up.

THD focused on recommendations for government, the NHS and industry [38]. These formed an action plan for each stakeholder group with critical success factors. mHA adapted three approaches and was based on questions that guided the decision making process on health systems challenges in terms of readiness of government stewardship, and systems on the financial, technical and organisational levels [36]. SF provided implementation success factors made up of opportunities and challenges to consider with critical success factors emphasising learning through action and feedback [29]. SUM’s implementation was guided by a three step process and tasks representing actions and questions on scale-up development and implementation supported with reference tools [34]. The MAPS used requirements for scale-up, partnerships, finance, technology and architecture, operational, monitoring and evaluation areas split into domains that were supported with assessment and planning sections [35]. MTT required that core requirements be met prior to scale-up, based on critical success factors and supporting indicators together with a self-assessment tool [37]. SUF used an open-systems perspective where scaling up was linked with the context in which the innovation was implemented. The design and implementation was driven by seeking “balance among the elements of the framework” and supported key attributes to enhance success ([30]: p4).

Most frameworks were tested for functionality with the intended users, with SUF being recommended for all WHO scale-up programmes [30]. The MAPS [35] and MTT [37] were retrospectively applied to projects of their respective workshop participants and SUM [34] was field tested. The mHA was applied to community-based health data collection and dissemination programmes [36]. THD and SF were developed solely to inform policy planners and makers and there was no evidence of implementation [29, 38].

The detailed results of the TD requirements mapping to identified frameworks are shown elsewhere (see Additional file 2). The identified TD scale-up requirements were mapped against key components of the seven scale-up frameworks. The mapping was done only at a main component level and excluded the detailed activities and reference tools.

The seven identified related scale-up frameworks met many of the requirements to varying degrees, with some scoring three and below (Table 2). In the pre-scale-up phase, two frameworks met the eHealth category ‘Information systems’ together with the TD requirements ‘Architecture’ (MAPS and THD), ‘Information security’ (MAPS and MTT) and ‘User interfaces’ (MAPS and THD). All frameworks partially met the eHealth category ‘Strategy’ together with the TD requirement ‘Clinic setting’. Two frameworks met the eHealth category ‘Benefits’ together with the TD requirement ‘Benefits realisation’ (MTT and THD). None of the frameworks met the eHealth category ‘Scale-up’ and TD requirement ‘Finalisation and close-out’ in the scale-up phase. Only three frameworks met the eHealth category ‘Program management’ together with the TD requirement ‘Risk management’ (MTT, SUF and THD), or the eHealth category ‘Scale-up’ together with the TD requirement ‘Readiness’ (mHA, MTT and THD). Only MAPS and THD met more than 80% of the total requirements.