Rapid implementation of remote digital primary care in Stockholm and implications for further system-wide implementation: practitioner’s and manager’s experience of the Always Open mobile application

Figures & data

Table 1. Main domains of the NASSS-framework. We aimed to produce a theory-informed, analysis of our findings, and consider all seven domains of the NASSS framework, in order better to understand the constraints and facilitators affecting implementation described by the focus group participants.

NASSS domain	Description
1. The condition	Describes the nature of the illness or condition, and relevant co-morbidities and socio-cultural factors
2. The technology	Describes the technology’s key features, the knowledge it brings, the knowledge required to use the technology, the technology supply chain, and who owns the intellectual property to the technology
3. The value proposition	Describes the developer’s business case (supply-side) and the technology’s desirability, efficacy, safety, and cost-effectiveness to users (demand-side)
4. The adopters	Describes implied changes required in staff roles, practices and identities, expectations on patients and/or immediate carers, and assumptions about extended network of lay carers
5. The organisation	Describes the organisation’s capacity to innovate, its readiness for technology-supported change, decision making processes for adoption and funding, changes needed to team interactions and routines, and work required for implementation
6. The wider system	Describes political context related to the implementation, regulatory context, position of professional bodies, socio-cultural context, and the extent of inter-organisational networking
7. Embedding and adaptation over time	Describes the scope for adapting over time and the organisation’s resilience to handling critical events and adapting to unforseen eventualities

Table 2. Summary of the number of codes assigned to each NASSS domain

NASSS domain	Number of codes
Domain 1: The condition or illness	2
Domain 2: The technology	53
Domain 3: The value proposition	80
Domain 4: The adopter system	51
Domain 5: The organization	53
Domain 6: The wider context	40
Domain 7: Embedding and adaptation over time	6
OTHER	5
TOTAL	290

Table 3. Main NASSS categories and sub-categories derived from analysis of findings

Main categories (based on NASSS domains)	Sub-categories (derived from interview data sorted under specific domain)
Domain 1: The condition	The innovation is not closely connected to any specific condition or specific patient group
	Regardless of the patient's condition, every patient's need ought to dictate how care for him or her is delivered
Domain 2: The technology	The technology works but is perceived as clumsy and needs to improve in functionality
	Always Open's content ought to generate added knowledge
	Always Open experiences tough competition
	Always Open will require continuous maintenance of the required software and hardware
	Further development of Always Open's role in Region Stockholm is hindered because it is not available from a computer
	There is a perceived risk that people will give up on the app
Domain 3: The value proposition	Always Open ought to contribute to accessibility and continuity
	Always Open has resulted in new ways of delivering care
	Always Open provides staff with more detailed patient information
	Always Open has made care visits more accessible to patients
	Digital visits save time and energy for patients
	Digital visits can increase the quality of specific visits
	Digital group visits require more resources than physical ones
	Always Open has affected daily work in a positive way
	Always Open has the possibility to change SLSO's role in Region Stockholm
Domain 4: The adopters	Employees experience a lack of continuity and structure when working with and training in Always Open
	Many patients have adapted well toward a new type of care visits, but health care needs to be attentive to each patient's preferred type visit
Domain 5: The organisation	The organisation's capacity to change
	The organisation's readiness for the technology
	The extent of changes to work routines related to Always Open
Domain 6: The wider system	Regulations may hinder further development of digital care
	Micromanaged reimbursement models may hinder further development of digital care
	Society is stuck on the idea of traditional primary care facilities
	The region's acute hospitals do not have enough knowledge about Always Open and that they can use the app at their own facility
Domain 7: Embedding and adaptation over time	Several improvements were made to the app during the first year of the pandemic

Figure 1. Proposed further development of the NASSS framework.