It’s not all about clinical or symptom outcomes when it comes to doing healthcare well. Without understanding the complexities and procedures surrounding intervention use in services, your amazing intervention, that looked great in research trials will sink in the real world. To this extent, my colleagues on the research team at SilverCloud are probably sick of me prattling on about my passion for Implementation Science and understanding how we can get novel healthcare interventions into the hands of the people who need them.
The European Implementation Event (EIE) took place on the 27th & 28th of May, and I was delighted to be afforded the opportunity to present the results of my research on the experience of stakeholders involved with the implementation of iCBT in services.
The EIE originated from a series of implementation events held in the Netherlands, and saw an online gathering of over 300 individuals working with implementing processes, procedures and interventions from all over the world. Presentations ranged from understanding the impact of context on implementation, designing and tailoring implementation strategies and processes around the scaling of interventions. As an early career researcher working in a field as young and exciting as Implementation Science, I was truly captivated by all the work shared throughout the two days. I have outlined some of my take-home points below, but highly encourage all of those interested to engage with the European Implementation Collaborative for more insights!
De-Implementation
Sara Ingvarsson, the early career keynote speaker from Karolinska Institute in Sweden, presented on the De-Implementation of low value care, that which is neither clinically or cost effective, in primary healthcare settings. Innovations in healthcare tend to replace older practices due to them being improved upon, but those to be replaced are often entrenched in both routine care and are also accepted by patients as the norm in regards to treatment expectancy. Ingvarsson and colleagues found the use of low value care to be associated with three interdependent factors: uncertainty about what not to do, pressure from other stakeholders in the health system, and a desire to achieve some sort of outcome for patients.
The struggle with implementing digital therapies and online CBT is painfully relevant to this work; as psychologists and providers of mental healthcare, we are trained to deliver mental healthcare therapy in the classical, sit-in-this-chair-and-tell-me-your-problems sort of way and our patients have also come to expect this. Alternatives to this paradigm are alien to us, and our rootedness in how things are done can often get in the way of how things can be. Where it is already difficult to implement change in healthcare organisations, considering the de-implementation of less-effective, competing interventions further adds to this ‘complexity’ (a word that all healthcare providers know too well).
For example in a developed mental healthcare system, why would you send someone materials via physical mail when you could provide them with a centralised, online hub of psychotherapeutic materials? Several defences are usually presented in response to this question, but the reality is that we have research evidence to support the effectiveness of online interventions for depression and anxiety for many demographics in various contexts. However, to tackle each and every roadblock along the way, a holistic view and concentrated effort is required to implement your innovation and de-implement other low-value, well-entrenched processes.
Brilliant Failures
Professor Paul Iske, the founder and chief failure officer of the institute of brilliant failures in The Netherlands presented on the art of failing effectively, and the importance of this in both research and implementation activities. For those who are working in industry, failure is hard to tolerate and speaking about it can be triggering; we want to do well by our customers and the patients they serve, and ‘failure’ can often coincide with poor outcomes and the loss of a contract. Iske’s view is that every single failure is a learning point and that the more fantastic the failure, the potential for learnings increases. For example, implementing digital interventions for mental health in new countries, health systems or regions is never clear-cut due to dynamic and changing contexts – numerous setbacks, failures and problem solving sessions become the routine in these instances. Conceptualising failure as the norm that leads to eventual success is more productive (and almost exciting) for those working in the digital health industry, as well as those in services who wish to engage with digital interventions.
Research opportunities
While at EIE2021, I had the opportunity to present my own PhD work on implementation that is being conducted in a joint collaboration between Trinity College and SilverCloud Health. I am principally interested in understanding the implementation of online CBT in order to make a synthesis of both scientific and practical knowledge. This work has already contributed to a lacking area in the online CBT literature, but SilverCloud Health is in a unique position to drive this research agenda forward. We now operate in the USA, Europe, United Kingdom and, soon-to-be, Australia. The sheer number of services that we can draw on in order to understand implementation science and practice presents a unique opportunity that would not typically arise in standard academia. We look forward to exploring this with our current and future partners in research!
Useful Links
European Implementation Collaborative - https://implementation.eu/
Society for Implementation Research Collaboration - https://societyforimplementationresearchcollaboration.org/
Useful references
Ingvarsson, S., Augustsson, H., Hasson, H., Nilsen, P., von Thiele Schwarz, U., & von Knorring, M. (2020). Why do they do it? A grounded theory study of the use of low-value care among primary health care physicians. Implementation Science, 15(1), 1-10.
Norton, W. E., & Chambers, D. A. (2020). Unpacking the complexities of de-implementing inappropriate health interventions. Implementation Science, 15(1), 1-7.
Augustsson, H., Ingvarsson, S., Nilsen, P., von Thiele Schwarz, U., Muli, I., Dervish, J., & Hasson, H. (2021). Determinants for the use and de-implementation of low-value care in health care: a scoping review. Implementation science communications, 2(1), 1-17.
Iske, P. L. (2019). Institute of Brilliant Failures: Make Room to Experiment, Innovate, and Learn.
