Evaluation of the nation-wide implementation of ALS home monitoring & coaching: an e-health innovation for personalized care for patients with motor neuron disease
Authors: Dontje M. L. , Kruitwagen-van Reenen E. , van Wijk E. , Baars E. , Visser-Meily J. M. A. , Beelen A. ,   on behalf of the Study Group ALS Home monitoring & Coaching, van Os Jim , van den Berg Leonard , van der Meijden Conny , Cornelissen Vincent , Eimers Marietta , Horemans Anja , Kruitwagen Esther , Sterk Janneke , Peeters Laura , Pirard Evelien , Spendel Trees , Koopman Anne-Wil , Timmermans Remco , Kramer Germaine , Schouten Evert , Focks Rineke Jaspers 
Published: November 2022

Abstract
Background
To improve the care for patients with motor neuron disease an e-health innovation for continuous monitoring of disease progression and patients’ well-being (ALS H&C) was implemented in 10 multidisciplinary rehabilitation settings. The first aim was to evaluate the implementation of ALS H&C by assessing several implementation outcomes, technology acceptance and usability of the innovation according to the end users. The secondary aim was to explore differences in these outcomes between the teams with sustainable and unsustainable implementation.

Methods
The chosen implementation strategy was a combination of the implementation process model by Grol & Wensing and a participatory action research approach. In three meetings with multidisciplinary project groups the innovation was introduced, the expected barriers/facilitators identified, and action plans to resolve each barrier developed. After a 3-month pilot phase, patients and their healthcare providers were asked to complete an online evaluation survey to assess implementation outcomes, based on Proctor’s evaluation framework (i.e., acceptability, feasibility, fidelity, sustainability). Telemedicine technology acceptance was assessed according the technology acceptance model of Chau, and user experiences with the System Usability Scale (SUS). Implementation outcomes of teams with sustainable implementation (continuation after completion of the pilot phase) and unsustainable implementation (discontinuation after the pilot phase) were compared.

Results
The implementation outcomes from the patients’ perspective (N = 71) were positive; they found ALS H&C to be an acceptable and feasible care concept. Patients’ technology acceptance was high, with positive attitudes towards ALS H&C, and positive views on perceived technology control, usefulness, and ease of use. Patients rated their satisfaction with the (web) app on a scale from 1 (not satisfied at all) to 10 (very satisfied) with a 7.0 (median; IQR 1.0). Healthcare providers (N = 76) also found ALS H&C acceptable and appropriate as well, but were less positive about the feasibility and usability of ALS H&C (mean SUS 58.8 [SD 11.3]). ALS H&C has largely been implemented as intended and the implementation was sustainable in 7 teams. Teams who discontinued ALS H&C after the pilot phase (N = 2) had more fidelity issues.

Conclusions
A participatory action research approach supported by theoretical approaches used in implementation science led to a sustainable implementation of ALS H&C in 7 of the participating teams. To improve implementation success, additional implementation strategies to increase feasibility, usability and fidelity are necessary.

Trial registration
Trial NL8542 registered at Netherlands Trial Register (trialregister.nl) on 15th April 2020.