GetCheckedOnline is a comprehensive internet-based testing service for sexually transmitted and blood-borne infections (STBBIs) available in select communities in British Columbia (BC), Canada, first implemented in 2014. The Digital Sexual Health Initiative team led by Dr. Mark Gilbert at the BC Centre for Disease Control conducted a study to understand the macro-level structural barriers and facilitators to the ongoing implementation of GetCheckedOnline, specifically its scale-up, adaptation, maintenance, and sustainability.
Figure 1. Implementation phases of GetCheckedOnline
This study used the sociological research strategy of institutional ethnography. Twenty-five individual interviews were conducted with provincial and regional implementers of GetCheckedOnline and other stakeholders between April 2019 and February 2020. Observation was done for planning and operations meeting related to GetCheckedOnline implementation. In addition, key documents relevant to the work of implementing GetCheckedOnline and public health services in BC were reviewed.
Provincial and regional service health implementers of GetCheckedOnline and STBBI prevention and testing services working within BC’s health system were tasked with and eager to implement, scale, adapt, maintain, and sustain online STBBI services to address testing access barriers and achieve health equity outcomes. However, the structure of the health system and the technology ecosystem surrounding it brought implementers up against several macro-level structural barriers which varied by implementation phase.
Implementers faced the limits imposed by provincial public health policy centered on biomedical HIV prevention and the funding of comprehensive sexual health services and service gaps.
|Barriers||Navigating tight, targeted budget envelopesSustaining STBBI testing within co-testing policies centered around HIV|
|Facilitators||Space created for implementing GetCheckedOnline in the early years of the new policyMaking use of associated financial and operational resourcesViewing scale-up as an opportunity to fill testing and service gaps|
Implementers navigated limited knowledge of internal information technology (IT) systems and processes, and the trickle-down effects of the internal restructuring of health agencies.
|Barriers||Facing lengthy and obscure health-system IT assessment, decision-making and prioritization processesLearning and relearning about IT processes as they are tackledManaging IT requirements and solutions and preserving equitable access to testingAnticipating and covering changing technology-related costs|
|Facilitators||Evolving understandings of data integrity, security, and retention over timeOrganizational willingness to act on user’s needs and feedback|
Implementers confronted constant change in the wider IT ecosystem and computer system interoperability challenges stemming from maintaining a low-barrier testing services.
|Barriers||Maintaining and updating IT software and hardware platforms that are constantly changingRequiring additional administrative and nursing time to run the serviceDevoting time to manual data entry and work processes that are automated in other clinical area|
|Facilitators||Handling GetCheckedOnline clients and test results in the same way as in-person clients and results from the provincial STI clinicRelying on structured guidance developed specifically for the daily operations of GetCheckedOnlineDrawing on existing nursing scope of practiceTapping into shared public health system responsibilities|
Implementers came up against budgetary processes within organizations and for-profit corporate interests outside the health system.
|Barriers||Submitting business cases and briefing notes proving the need, worth and merit of the serviceRelying on a global budget allocation for public health laboratory testingBalancing partnership and cost containment with the private sector|
|Facilitators||Keeping key service features over time allowing for long-term evaluationCounting on province-wide and community support and demand for service|
Implications for practice
This study demonstrates the value of understanding the context-specific complexities surrounding scaling, adapting, maintaining, and sustaining a service beyond its initial implementation. The findings also offer insights into the implementation of online sexual health and public health services more broadly by highlighting the unique challenges of implementing digital health programs. In particular, the important influence of information technology systems and processes which we propose be considered as a unique contextual domain in implementation science research applied to digital health programs.
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Beyond Initial Implementation: Barriers and facilitators to the scale-up, adaptation, maintenance & sustainability of GetCheckedOnline