BACKGROUND
The starting point for this research was a desire to understand the outcomes of scaling up a telemedicine service, which had shown promising results in a feasibility study. Teleguidance is a practitioner-to-practitioner service for remote surgical guidance during a highly technical endoscopic procedure, called ERCP (Endoscopic retrograde Cholangio-Pancreatografy). Due to numerous differences in how ERCP was conducted at the clinics involved, there was a need to create a fuller picture of what set the implementation sites apart sites in order understand the implementation and outcomes of teleguidance. However, the complexity that characterizes highly specialized clinical work systems made understanding the differences between the implementation contexts a methodological and practical challenge.
There is increasing recognition that the outcomes of complex interventions are determined by dynamic interactions between social, organizational and design factors. While several recent implementation and evaluation frameworks emphasize complexity, they provide little guidance for how to understand or evaluate technological change in complex settings, or identify the interactions that contribute to implementation success and system-level outcomes.
Work Domain Analysis (WDA), a method for analyzing and characterizing complex work settings in systems development, was identified as a candidate method for identifying and charting the contextual factors which shape clinical work during ERCP. However, applying the method was not straightforward, due to a number of methodological issues and practical hurdles: WDA method was initially developed for engineered, industrial systems which contrast to open, adaptive, healthcare systems.
OBJECTIVE
The objective was to investigate whether and how WDA could be applied to a widely defined clinical work system, by applying WDA to a practical case to create a baseline description of the work systems that would be impacted by the telemedicine implementation.
METHODS
As expected outcomes of the implementation had been expressed in terms of clinical, economical and training outcomes, the boundaries of the analysis were set widely. Three iterations of qualitative data collection were conducted at five clinical sites, followed by theoretically guided thematic analysis. Service blueprints were made as intermediary graphical representations during data collection. The common WDA representation, a matrix called the abstraction hierarchy (AH), was then constructed through multiple iterations, during which the results were presented to practitioners and suggestions about how to decompose the work system and to populate the cells of the AH-matrix gradually developed.
RESULTS
Multiple models of the domain representing three facets of the same work system were created. The clinical facet represents “primary” clinical work mainly performed in the operating room, and the administrative and development facets represent the “secondary” work systems providing infrastructure and resources necessary for the clinical procedures. The results show numerous contextual factors on multiple system levels which can come to impact the implementation and use of teleguidance.
CONCLUSIONS
WDA proved to be an efficient way to model the implementation context, providing guidance for qualitative analysis, identifying multiple sources of variability that can influence implementation outcomes. In addition, WDA provided a compact representation that supported multidisciplinary communication.
CLINICALTRIAL
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