A Clinical Communication Tool (Loop) for Team-Based Care in Pediatric and Adult Care Settings: Hybrid Mixed Methods Implementation Study

Background Communication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record. Objective The objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research. Methods The study was a hybrid type II mixed methods design to simultaneously evaluate Loop’s clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system. Results We recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop’s potential value for engaging the patient and caregiver, and for improving communication within the patient’s circle of care, Loop’s relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care. Conclusions Fundamental structural and implementation challenges persist toward realizing Loop’s potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.


Appendix 1: Standards for Reporting Implementation Studies: the StaRI checklist for completion
The StaRI standard should be referenced as: Pinnock H, Barwick M, Carpenter C, Eldridge S, Grandes G, Griffiths CJ, Rycroft-Malone J, Meissner P, Murray E, Patel A, Sheikh A, Taylor SJC for the StaRI Group. Standards for Reporting Implementation Studies (StaRI) statement. BMJ 2017;356:i6795 The detailed Explanation and Elaboration document, which provides the rationale and exemplar text for all these items is: Pinnock H, Barwick M, Carpenter C, Eldridge S, Grandes G, Griffiths C, Rycroft-Malone J, Meissner P, Murray E, Patel A, Sheikh A, Taylor S, for the StaRI group. Standards for Reporting Implementation Studies (StaRI). Explanation and Elaboration document. BMJ Open 2017 2017;7:e013318 Notes: A key concept of the StaRI standards is the dual strands of describing, on the one hand, the implementation strategy and, on the other, the clinical, healthcare, or public health intervention that is being implemented. These strands are represented as two columns in the checklist.
The primary focus of implementation science is the implementation strategy (column 1) and the expectation is that this will always be completed.
The evidence about the impact of the intervention on the targeted population should always be considered (column 2) and either health outcomes reported or robust evidence cited to support a known beneficial effect of the intervention on the health of individuals or populations. The StaRI standardsrefers to the broad range of study designs employed in implementation science. Authors should refer to other reporting standards for advice on reporting specific methodological features. Conversely, whilst all items are worthy of consideration, not all items will be applicable to, or feasible within every study.

Implementation Strategy
Reported on page # Intervention "Implementation strategy" refers to how the intervention was implemented "Intervention" refers to the healthcare or public health intervention that is being implemented.

Title and abstract
Title 1 1 Identification as an implementation study, and description of the methodology in the title and/or keywords (31) Introduction Introduction 3 2-3 Description of the problem, challenge or deficiency in healthcare or public health that the intervention being implemented aims to address. Rationale 4 2-3 The scientific background and rationale for the implementation strategy (including any underpinning 1-2 The scientific background and rationale for the intervention being implemented (including evidence theory/framework/model, how it is expected to achieve its effects and any pilot work).
about its effectiveness and how it is expected to achieve its effects). Aims and objectives 5 3 The aims of the study, differentiating between implementation objectives and any intervention objectives.

Methods: description
Design 6 3 The design and key features of the evaluation, (cross referencing to any appropriate methodology reporting standards) and any changes to study protocol, with reasons Context 7 3-5 The context in which the intervention was implemented. (Consider social, economic, policy, healthcare, organisational barriers and facilitators that might influence implementation elsewhere). Targeted 'sites' The characteristics of the targeted 'site(s)' (e.g locations/personnel/resources etc.) for implementation and any eligibility criteria.

6-7
The population targeted by the intervention and any eligibility criteria.
Description 9 7-8 A description of the implementation strategy 4-5 A description of the intervention Sub-groups 10 N/A Any sub-groups recruited for additional research tasks, and/or nested studies are described

Methods: evaluation
Outcomes 11 8-9 Defined pre-specified primary and other outcome(s) of the implementation strategy, and how they were assessed. Document any pre-determined targets 9-10 Defined pre-specified primary and other outcome(s) of the intervention (if assessed), and how they were assessed. Document any pre-determined targets Process evaluation 12 9 Process evaluation objectives and outcomes related to the mechanism by which the strategy is expected to work