Facilitators and challenges of implementing a digital patient education programme for rheumatoid arthritis into clinical practice
Telehealth and digital interventions are increasingly used in rheumatology and have the potential to improve patient care by offering more efficient access to healthcare. However, the adoption of tele-health interventions into clinical practice is often hampered by late implementation . Research has identified factors that may promote or hinder the adoption of various telehealth interventions in rheumatology . To ensure successful implementation of telehealth and maximize the benefits of telehealth it is important to take advantage of its ability to offer increased flexibility, better access to healthcare, various means of communication, and greater patient participation. However, it is also essential to acknowledge the limitations or drawbacks, such as reduced face-to-face contact, potential technical difficulties, various levels of digital literacy, new ways of working, and limitations related to standardized features or content. Only a few studies have focused specifically on the implementation process of digital interventions in rheumatology, although some studies do offer relevant insights into implementation. The European Alliance of Associations for Rheumatology (EULAR) highlights the importance of accessibility and usability of digital self-management applications (apps) in ensuring successful implementation and sustainability in rheumatic and musculoskeletal diseases (RMDs) . A study on the development of telehealth interventions in RMD rehabilitation emphasizes the need for involving users in the development process and tailoring interventions to individual needs. Further, variations in health literacy should be considered to ensure usability, effectiveness, and implementation . Another recent study found that only around 47% of rheumatologist and general practitioners felt confident in using telemedicine for communicating with patients, although they were positive about the potential for future implementation . The study identified a need for training courses to improve telemedicine knowledge . The same was found among physiotherapists delivering telephone-based exercise therapy for knee osteoarthritis . Previously, we have developed a digital patient education (PE) programme for self-management in rheumatoid arthritis (RA), called ‘Know your rheumatoid arthritis’ , and investigated both effectiveness in a randomized controlled trail (RCT)  and the patient’s perspective of using it . The programme takes into account various factors that may increase the likelihood of success in clinical practice, including integration of evidence-based content, self-management and behaviour change theories, incorporation of features to support health literacy, and stakeholder involvement . However, there is a need for a thorough and systematic evaluation of implementation perspectives to ensure integration of the programme into daily clinical practice. In this study, we aimed to explore perspectives crucial to implementation of the digital PE programme in clinical practice. The digital PE programme ‘Know your rheumatoid arthritis’ The programme was designed as a website, primarily optimised for computer or laptop use. It could be assessed on a tablet but was not optimised for smartphone use. In the RCT study , users were granted access to the programme by study nurses via email, and a private username and password were assigned during the system setup process in the Learning Management System (LMS) behind the programme. The programme could be used repeatedly free of charge. Both the digital PE programme and the LMS were external websites, independent of other hospital technologies such as the electronic medical record system. The LMS generated data regarding participants’ utilization of the programme. The programme comprised three modules. The first module was mandatory as it delivered essential disease-specific knowledge necessary for understanding RA, managing medical treatment properly, and responding to symptoms, flares, and potential side-effects. The two remaining modules were optional and provided additional insights into the disease, treatments, potential co-morbidities, examinations, and self-management strategies . 

The programme was designed as a website, primarily optimised for computer or laptop use. It could be assessed on a tablet but was not optimised for smartphone use. In the RCT study , users were granted access to the programme by study nurses via email, and a private username and password were assigned during the system setup process in the Learning Management System (LMS) behind the programme. The programme could be used repeatedly free of charge. Both the digital PE programme and the LMS were external websites, independent of other hospital technologies such as the electronic medical record system. The LMS generated data regarding participants’ utilization of the programme. The programme comprised three modules. The first module was mandatory as it delivered essential disease-specific knowledge necessary for understanding RA, managing medical treatment properly, and responding to symptoms, flares, and potential side-effects. The two remaining modules were optional and provided additional insights into the disease, treatments, potential co-morbidities, examinations, and self-management strategies . 

Design This study used the Non-Adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework , including the Complexity Assessment Tool (CAT)  as an evaluation framework to create a narrative outlining the successes, challenges, and failures of the digital PE programme. The NASSS framework addresses the challenges often faced by technological health interventions when it comes to implementation, including scaling up, spreading, and sustaining them in the long term. It consists of 7 domains covering: the illness or condition, technology, value proposition, adopters, organization, wider system, and embedding and adaptation over time. It provides an approach for identifying and analysing the complexities in technology projects to improve the chances of success and sustainability . Inspired by the study of Abimbola et al.  we based our study on both a primary and a secondary dataset. The primary dataset consisted of qualitative focus group discussions with study nurses, rheumatologists, and leaders from the rheumatology departments in Denmark who had participated in the RCT evaluating the effectiveness of the digital PE programme. The secondary dataset consisted of data from the development process of the PE programme , the RCT , and the qualitative study exploring patients’ perspectives of the programme . This study was reported according to the consolidated criteria for reporting qualitative research (COREQ) (Additional file 1) . Primary dataset Design, study population and recruitment In March and May 2023, two qualitative focus group discussions were conducted, each comprising study nurses, rheumatologists and leaders. These discussions aimed to explore experiences with the digital PE programme and perspectives on its future implementation in clinical practice. Eligible participants were informed about the study by LRK during a meeting between the project group and the rheumatology departments from the RCT. Subsequently, they were contacted by email and provided with written information about the study. Verbal and signed written consent were obtained before inclusion. Participants were purposively selected based on criteria including involvement in the RCT to some extent and having interest in discussing future implementation of digital PE in clinical practice. The NASSS framework was applied, however our analysis primarily provided insights from the perspective of the intended adopters and the organization. Thus, not all domains of the NASSS framework were relevant as some are targeted e.g. technology developers, and business leads. Domain 3 (The value proposition) was evaluated using data from the secondary dataset, and thus not included in the focus group discussions as participants did not have insight into the costs of the technology. Finally, the current analysis did not include domain 7 (adoption over time), as the programme has only been utilized for a limited time in a research setting. Data collection To guide the focus group discussions, we created a questioning route inspired by the interview version of the NASSS-CAT , supplemented by studies addressing opportunities and barriers of using telehealth in rheumatology. Research questions according to the NASSS domains and examples of interview questions appear from Additional file 2. To ensure perspectives beyond this framework, open-ended questions that allowed participants to freely discuss their thoughts on the topic were also included. The initial step in developing the questioning route involved discussions with clinicians and patient research partners (PRPs). Then, LRK drafted the questions, and final agreement on questions was achieved through discussion with AdT and KL, ensuring that clinically relevant topics were covered. The focus group discussions took place at Aarhus University Hospital, with LRK as the facilitator. LRK, experienced in qualitative studies, received assistance from AdT during the interviews, an experienced researcher and supervisor. A PRP was also present to observe and contribute with additional questions from the patient perspective. The discussions were recorded and verbatim transcribed into text by LRK. Data analysis To analyse the primary dataset, we used a deductive content analysis approach  structured by a categorization matrix according to the NASSS domains, and comprising the phases shown in Fig. . An example from the categorization matrix appears from Table . The analysis was organised and managed by LRK using NVivo 12 Pro . Relevant features of NVivo were used to support the analysis process, including file and case classification, coding, memos, and visual features. Secondary dataset Studies included in the secondary dataset were all part of the WebRA project and provided insights of relevance for future implementation. The studies are presented in Table . Selected secondary data were sorted into the categorization matrix. Both positive and negative findings were identified in a process performed by LRK, and continuously discussed with AdT and KL. 

This study used the Non-Adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework , including the Complexity Assessment Tool (CAT)  as an evaluation framework to create a narrative outlining the successes, challenges, and failures of the digital PE programme. The NASSS framework addresses the challenges often faced by technological health interventions when it comes to implementation, including scaling up, spreading, and sustaining them in the long term. It consists of 7 domains covering: the illness or condition, technology, value proposition, adopters, organization, wider system, and embedding and adaptation over time. It provides an approach for identifying and analysing the complexities in technology projects to improve the chances of success and sustainability . Inspired by the study of Abimbola et al.  we based our study on both a primary and a secondary dataset. The primary dataset consisted of qualitative focus group discussions with study nurses, rheumatologists, and leaders from the rheumatology departments in Denmark who had participated in the RCT evaluating the effectiveness of the digital PE programme. The secondary dataset consisted of data from the development process of the PE programme , the RCT , and the qualitative study exploring patients’ perspectives of the programme . This study was reported according to the consolidated criteria for reporting qualitative research (COREQ) (Additional file 1) . 

Design, study population and recruitment In March and May 2023, two qualitative focus group discussions were conducted, each comprising study nurses, rheumatologists and leaders. These discussions aimed to explore experiences with the digital PE programme and perspectives on its future implementation in clinical practice. Eligible participants were informed about the study by LRK during a meeting between the project group and the rheumatology departments from the RCT. Subsequently, they were contacted by email and provided with written information about the study. Verbal and signed written consent were obtained before inclusion. Participants were purposively selected based on criteria including involvement in the RCT to some extent and having interest in discussing future implementation of digital PE in clinical practice. The NASSS framework was applied, however our analysis primarily provided insights from the perspective of the intended adopters and the organization. Thus, not all domains of the NASSS framework were relevant as some are targeted e.g. technology developers, and business leads. Domain 3 (The value proposition) was evaluated using data from the secondary dataset, and thus not included in the focus group discussions as participants did not have insight into the costs of the technology. Finally, the current analysis did not include domain 7 (adoption over time), as the programme has only been utilized for a limited time in a research setting. Data collection To guide the focus group discussions, we created a questioning route inspired by the interview version of the NASSS-CAT , supplemented by studies addressing opportunities and barriers of using telehealth in rheumatology. Research questions according to the NASSS domains and examples of interview questions appear from Additional file 2. To ensure perspectives beyond this framework, open-ended questions that allowed participants to freely discuss their thoughts on the topic were also included. The initial step in developing the questioning route involved discussions with clinicians and patient research partners (PRPs). Then, LRK drafted the questions, and final agreement on questions was achieved through discussion with AdT and KL, ensuring that clinically relevant topics were covered. The focus group discussions took place at Aarhus University Hospital, with LRK as the facilitator. LRK, experienced in qualitative studies, received assistance from AdT during the interviews, an experienced researcher and supervisor. A PRP was also present to observe and contribute with additional questions from the patient perspective. The discussions were recorded and verbatim transcribed into text by LRK. Data analysis To analyse the primary dataset, we used a deductive content analysis approach  structured by a categorization matrix according to the NASSS domains, and comprising the phases shown in Fig. . An example from the categorization matrix appears from Table . The analysis was organised and managed by LRK using NVivo 12 Pro . Relevant features of NVivo were used to support the analysis process, including file and case classification, coding, memos, and visual features. 

In March and May 2023, two qualitative focus group discussions were conducted, each comprising study nurses, rheumatologists and leaders. These discussions aimed to explore experiences with the digital PE programme and perspectives on its future implementation in clinical practice. Eligible participants were informed about the study by LRK during a meeting between the project group and the rheumatology departments from the RCT. Subsequently, they were contacted by email and provided with written information about the study. Verbal and signed written consent were obtained before inclusion. Participants were purposively selected based on criteria including involvement in the RCT to some extent and having interest in discussing future implementation of digital PE in clinical practice. The NASSS framework was applied, however our analysis primarily provided insights from the perspective of the intended adopters and the organization. Thus, not all domains of the NASSS framework were relevant as some are targeted e.g. technology developers, and business leads. Domain 3 (The value proposition) was evaluated using data from the secondary dataset, and thus not included in the focus group discussions as participants did not have insight into the costs of the technology. Finally, the current analysis did not include domain 7 (adoption over time), as the programme has only been utilized for a limited time in a research setting. 

To guide the focus group discussions, we created a questioning route inspired by the interview version of the NASSS-CAT , supplemented by studies addressing opportunities and barriers of using telehealth in rheumatology. Research questions according to the NASSS domains and examples of interview questions appear from Additional file 2. To ensure perspectives beyond this framework, open-ended questions that allowed participants to freely discuss their thoughts on the topic were also included. The initial step in developing the questioning route involved discussions with clinicians and patient research partners (PRPs). Then, LRK drafted the questions, and final agreement on questions was achieved through discussion with AdT and KL, ensuring that clinically relevant topics were covered. The focus group discussions took place at Aarhus University Hospital, with LRK as the facilitator. LRK, experienced in qualitative studies, received assistance from AdT during the interviews, an experienced researcher and supervisor. A PRP was also present to observe and contribute with additional questions from the patient perspective. The discussions were recorded and verbatim transcribed into text by LRK. 

To analyse the primary dataset, we used a deductive content analysis approach  structured by a categorization matrix according to the NASSS domains, and comprising the phases shown in Fig. . An example from the categorization matrix appears from Table . The analysis was organised and managed by LRK using NVivo 12 Pro . Relevant features of NVivo were used to support the analysis process, including file and case classification, coding, memos, and visual features. 

Studies included in the secondary dataset were all part of the WebRA project and provided insights of relevance for future implementation. The studies are presented in Table . Selected secondary data were sorted into the categorization matrix. Both positive and negative findings were identified in a process performed by LRK, and continuously discussed with AdT and KL. 

The focus groups included ten participants: eight females and two males. Five were nurses, two were rheumatologists, and three held leadership positions. Among the participants in leadership positions, some also had clinical roles, while others were primarily managers dedicated to leadership. On average the participants had 22.3 years of professional experience (range: 16 to 33 years), and 18 years (range: 9 to 33 years) in the field of rheumatology. The duration of the focus group discussion was approximately two hours. The inductive analysis revealed an overarching theme termed ‘Future perspectives in digital patient education’ . This theme was subsequently divided into three subthemes; ‘Transitioning from a website to an app’ , ‘New modes of delivering patient education’ , and ‘Forming relationship’ . Themes of the content analysis and illustrative quotes from the focus groups appear from Table . Quotes from the secondary dataset (development study and qualitative study) are not included as these were previously published. Furthermore, Fig. depicts the facilitators and challenges for implementation based on the NASSS domains. We refer to the primary dataset by the label ‘focus groups’, and studies in the secondary dataset are named ‘RCT’, ‘Development study’, and ‘Qualitative study’, respectively. To maintain participants’ anonymity, the perceptions of nurses, rheumatologist or leaders are gathered under the collective term ‘Healthcare providers’ (HCPs). The condition Both the primary and secondary data recognized the diversity within the RA patient group, reflecting varying needs along the patient pathway, including those related to PE. Based on HCPs experiences expressed in focus groups, patients’ age did not seem to hinder participation and use of the programme, but there could be a risk of not reaching all patients, e.g., due to literacy, language difficulties, or simply because some patients need the face-to-face contact. Baseline characteristics in the RCT  also reflected heterogeneity with respect to age, gender, educational levels, and employment statuses. Despite this sociodemographic diversity, the group demonstrated relatively high levels of self-efficacy, knowledge, health literacy, and quality of life, emphasizing the need for also considering non-participants when planning the implementation of the technology into clinical practice. The qualitative study  provided data about the patient groups’ engagement with digital PE. An immediate need for information and knowledge about RA promoted the use of the programme among many patients. In contrast, mental distress following diagnosis could pose barriers to the utilization of digital PE. Lastly, patients shifted between an illness-focused and a wellness-focused perspective , influencing their approach to utilizing the programme. The target group of the digital PE programme was newly diagnosed patients. However, since RA is a chronic disease, ongoing adjustments and coping strategies in everyday life are necessary; certain information may be beneficial at the early stage and other parts of the programme may become more relevant later, for example if patients encounter new challenges or treatment changes. The technology Data from the development study and qualitative study showed that the technology was widely accepted in the patient group because of a simple and intuitive user interface, enabling easy navigation in using the programme. The design was also appreciated for its calming and appealing elements, including attractive colours, graphics and animations . No specific skills or competencies seemed to be needed to use the programme. Minor technical difficulties included login errors or oversight of username and password. In the qualitative study it was suggested to optimize the programme for smartphone and tablet use, as the limitation of the current version, including the login process, could potentially restrict accessibility and limit programme usage . HCPs in focus groups likewise had the impression that patients did not encounter notable difficulties in using the programme, and they also found the LMS, that was used to set up individual patients for the programme, to be user-friendly and easy to navigate in. No challenges were reported regarding the lack of integration between the programme and other electronic systems in the hospital, and no specific competencies were required for HCPs to manage the system. The login process was, however, a drawback, as it prevented HCPs from having access to the patients’ user interface, and thereby provide help in starting the programme and helping them become familiar with its usage. In the qualitative study, it became evident that the lack of this element could pose a potential barrier for certain patients to engage in digital PE, particularly those who expressed hesitancy about using the programme, suggesting a need to incorporate a brief programme introduction . Future implementation would necessitate modified work procedures. For instance, organizing digital PE and allowing space for face-to-face follow-up within the daily tasks of the organization may become more unpredictable if a substantial portion of the patients uses the technology. In contrast to the scheduled face-to-face PE sessions, it may necessitate a more flexible organizational structure to accommodate the potential needs arising during the use of digital PE. Finally, updates and maintenance of the technology and content were discussed in the focus groups. The current version of the programme was developed by researchers at Aarhus University Hospital. To ensure a successful implementation of digital PE outside a research setting, it was suggested that a reorganization of this process by setting a steering group of relevant HCPs and leaders from different rheumatology departments, and technological staff could enhance involvement and ownership, potentially facilitating nationwide adoption of the programme through a collaborative approach. The value propositions The development and evaluation of the digital PE programme took place within a research setting, supported by external funding. Should there be a desire to integrate the programme in the organization in the future, it necessitates either securing additional funding or allocating resources from departmental budgets to cover associated expenses. This could potentially limit the implementation, as regards scaling up and spread of the intervention. Findings from the RCT investigating the effectiveness of the digital PE programme in improving self-management among patients newly diagnosed with RA provided insights into the value of this programme to the patient and the healthcare system. Despite the minimal distinctions between the groups, the programme could be a valuable resource for both patients and the healthcare system. The findings showed that digital PE programme was superior in improving self-efficacy compared to usual care, even though the difference may not be clinically significant . Both groups improved their knowledge, health literacy, and quality of life during the study. Additionally, individuals who received digital PE had fewer contacts with out-patient clinics, suggesting they might be more capable of handling challenges independently before seeking clinical assistance. If this strategy can be maintained, a programme like this holds the potential to contribute to resource allocation, however, further research is needed to determine the costs and benefits . Insights from the qualitative study revealed that the programme’s significance to patients stemmed from the technology, allowing for convenient utilization while minimizing hospital visits. Some patients also appreciated the potential for revisiting and learning within the comfort of learning at home when appropriate. This was enhanced by the programme’s possibility of breaking down information to minor segments. Conversely, drawbacks were associated with diminished face-to-face interactions with HCPs, and occasional delays in programme initiation and responsibility of the patients for learning . The intended adopters As described within the technology domain, users of the programme and LMS found it easy to use. Nevertheless, insights from the focus groups revealed a duality in HCPs’ perceptions, encompassing both reluctance and endorsement of the technology. The reluctance or resistance seems to be linked to concerns about potentially being replaced by automated systems. Concerns regarding patient safety and the potential of overlooking patients’ needs due to the decrease in direct in-person interactions were also highlighted, followed by thoughts that some patients might be likely to decline the programme solely because it’s digital in nature. In general, HCPs acknowledged the potential of the programme, suggesting that it could be an appropriate solution for numerous patients. The availability of information, the ability to supplement their own information, and the fact that the programme could convey more comprehensive information communicated in various forms compared to what can be covered during hospital appointments were emphasized. Some HCPs considered the digital PE programme to be an “add on” to face-to-face PE and expressed discomfort due to the perception of relinquishing the “touch” and “sense” of the patient when not being physically present with the patient. HCPs also expressed that they gained trust in the information provided within the programme and saw it as a reliable source instead of patients relying on random internet pages. The qualitative data showed that digital PE was well-received by patients as regards both the content, amount of information and the various ways it was presented. Patients regarded the programme as a valuable source of information. Most of them expressed appreciation for the opportunity to access it immediately after receiving their diagnosis, when their need for information was substantial, and the usage tended to decrease over time. Some patients found the solution inappropriate due to relational support needs and emotional distress following the diagnosis . The organization and the wider system Overall, HCPs viewed their organizations as prepared to adopt digital solutions like our programme, and the widespread acknowledgement of technologies in society acted as a facilitator for its acceptance and implementation, as this was perceived as an inherent part of everyday life. It was emphasized that any potential resistance should be recognized and considered in the process of implementation. No specific barriers to implementation within the organizations, except for economic concerns, were discussed, and HCPs held the belief that both colleagues and leaders would provide support. Nonetheless, the necessity for assistance during implementation was emphasized. Future perspectives of digital patient education Transitioning from a website to an app The focus groups discussed the possibility of switching the platform into a mobile app solution, and in general, HCPs expressed a favourable response to this idea to enhance availability. Both the participants in the qualitative study  and the focus groups emphasized the importance of keeping a flexible organization of the programme’s content. Despite the standardized content of such a programme, this flexibility is crucial to accommodate individual needs and enables the selection of topics that are relevant to everyone’s specific situation. Data from the RCT showed that patients engaged with all the modules and topics within the programme, albeit to different extents, probably reflecting this individuality . The current version of the programme lacks any interactive functionality with HCPs, but data from the qualitative study introduced the possibility for a chat function . Opinions among HCPs in focus groups regarding this idea were diverse and not unanimous. This diversity of perspectives reflected concerns about the types of questions that could be effectively posed using this approach, and whether the quality of responses though a digital solution would be adequate, and for others this seemed to be straightforward. This could indicate a necessity for well-defined guidelines and alignment of objectives when considering the implementation of such a feature. New modes of delivering patient education An introduction to the digital PE programme could potentially help planning and tailoring care to the patients. Although, a risk of investing more time initially when introducing patients to the programme was present, HCPs regarded this time as well-spent, considering that some patients may not require any specific introduction. The HCPs noted that a reorganization of future PE and implementation of digital PE could potentially reduce the overall burden of PE, and this could lead to a transformation in the organization and mode of delivering PE. This could transform their professional role from teaching to guidance. For example, the current practice of face-to-face PE often implies a firm approach as nurses try to adhere closely to educational guidelines. However, with the implementation of digital PE, follow-up sessions could be provided as needed and customized according to the patient’s preferences and further needs. This shift could potentially make the task of PE more engaging and fulfilling for nurses and could strengthen the partnership between patients and HCPs if patients became more actively engaged. Forming relationships Data from the focus groups highlighted the importance of HCPs being able to establish a relationship with patients before feeling confident to “hand them over” to technology. They also believed that this was important for most patients. Because of the change in relational interactions, both rheumatologists and nurses also felt the necessity to ensure they had provided sufficient information about the disease and treatment, and had taken care of emotional responses, before introducing the technology. This initial interaction could serve as the basis for the decision about whether a patient should be offered digital PE. Hence, several HCPs emphasized the importance of evaluating individual needs related to PE and the need for self-management support when implementing digital PE. 

Both the primary and secondary data recognized the diversity within the RA patient group, reflecting varying needs along the patient pathway, including those related to PE. Based on HCPs experiences expressed in focus groups, patients’ age did not seem to hinder participation and use of the programme, but there could be a risk of not reaching all patients, e.g., due to literacy, language difficulties, or simply because some patients need the face-to-face contact. Baseline characteristics in the RCT  also reflected heterogeneity with respect to age, gender, educational levels, and employment statuses. Despite this sociodemographic diversity, the group demonstrated relatively high levels of self-efficacy, knowledge, health literacy, and quality of life, emphasizing the need for also considering non-participants when planning the implementation of the technology into clinical practice. The qualitative study  provided data about the patient groups’ engagement with digital PE. An immediate need for information and knowledge about RA promoted the use of the programme among many patients. In contrast, mental distress following diagnosis could pose barriers to the utilization of digital PE. Lastly, patients shifted between an illness-focused and a wellness-focused perspective , influencing their approach to utilizing the programme. The target group of the digital PE programme was newly diagnosed patients. However, since RA is a chronic disease, ongoing adjustments and coping strategies in everyday life are necessary; certain information may be beneficial at the early stage and other parts of the programme may become more relevant later, for example if patients encounter new challenges or treatment changes. 

Data from the development study and qualitative study showed that the technology was widely accepted in the patient group because of a simple and intuitive user interface, enabling easy navigation in using the programme. The design was also appreciated for its calming and appealing elements, including attractive colours, graphics and animations . No specific skills or competencies seemed to be needed to use the programme. Minor technical difficulties included login errors or oversight of username and password. In the qualitative study it was suggested to optimize the programme for smartphone and tablet use, as the limitation of the current version, including the login process, could potentially restrict accessibility and limit programme usage . HCPs in focus groups likewise had the impression that patients did not encounter notable difficulties in using the programme, and they also found the LMS, that was used to set up individual patients for the programme, to be user-friendly and easy to navigate in. No challenges were reported regarding the lack of integration between the programme and other electronic systems in the hospital, and no specific competencies were required for HCPs to manage the system. The login process was, however, a drawback, as it prevented HCPs from having access to the patients’ user interface, and thereby provide help in starting the programme and helping them become familiar with its usage. In the qualitative study, it became evident that the lack of this element could pose a potential barrier for certain patients to engage in digital PE, particularly those who expressed hesitancy about using the programme, suggesting a need to incorporate a brief programme introduction . Future implementation would necessitate modified work procedures. For instance, organizing digital PE and allowing space for face-to-face follow-up within the daily tasks of the organization may become more unpredictable if a substantial portion of the patients uses the technology. In contrast to the scheduled face-to-face PE sessions, it may necessitate a more flexible organizational structure to accommodate the potential needs arising during the use of digital PE. Finally, updates and maintenance of the technology and content were discussed in the focus groups. The current version of the programme was developed by researchers at Aarhus University Hospital. To ensure a successful implementation of digital PE outside a research setting, it was suggested that a reorganization of this process by setting a steering group of relevant HCPs and leaders from different rheumatology departments, and technological staff could enhance involvement and ownership, potentially facilitating nationwide adoption of the programme through a collaborative approach. 

The development and evaluation of the digital PE programme took place within a research setting, supported by external funding. Should there be a desire to integrate the programme in the organization in the future, it necessitates either securing additional funding or allocating resources from departmental budgets to cover associated expenses. This could potentially limit the implementation, as regards scaling up and spread of the intervention. Findings from the RCT investigating the effectiveness of the digital PE programme in improving self-management among patients newly diagnosed with RA provided insights into the value of this programme to the patient and the healthcare system. Despite the minimal distinctions between the groups, the programme could be a valuable resource for both patients and the healthcare system. The findings showed that digital PE programme was superior in improving self-efficacy compared to usual care, even though the difference may not be clinically significant . Both groups improved their knowledge, health literacy, and quality of life during the study. Additionally, individuals who received digital PE had fewer contacts with out-patient clinics, suggesting they might be more capable of handling challenges independently before seeking clinical assistance. If this strategy can be maintained, a programme like this holds the potential to contribute to resource allocation, however, further research is needed to determine the costs and benefits . Insights from the qualitative study revealed that the programme’s significance to patients stemmed from the technology, allowing for convenient utilization while minimizing hospital visits. Some patients also appreciated the potential for revisiting and learning within the comfort of learning at home when appropriate. This was enhanced by the programme’s possibility of breaking down information to minor segments. Conversely, drawbacks were associated with diminished face-to-face interactions with HCPs, and occasional delays in programme initiation and responsibility of the patients for learning . 

As described within the technology domain, users of the programme and LMS found it easy to use. Nevertheless, insights from the focus groups revealed a duality in HCPs’ perceptions, encompassing both reluctance and endorsement of the technology. The reluctance or resistance seems to be linked to concerns about potentially being replaced by automated systems. Concerns regarding patient safety and the potential of overlooking patients’ needs due to the decrease in direct in-person interactions were also highlighted, followed by thoughts that some patients might be likely to decline the programme solely because it’s digital in nature. In general, HCPs acknowledged the potential of the programme, suggesting that it could be an appropriate solution for numerous patients. The availability of information, the ability to supplement their own information, and the fact that the programme could convey more comprehensive information communicated in various forms compared to what can be covered during hospital appointments were emphasized. Some HCPs considered the digital PE programme to be an “add on” to face-to-face PE and expressed discomfort due to the perception of relinquishing the “touch” and “sense” of the patient when not being physically present with the patient. HCPs also expressed that they gained trust in the information provided within the programme and saw it as a reliable source instead of patients relying on random internet pages. The qualitative data showed that digital PE was well-received by patients as regards both the content, amount of information and the various ways it was presented. Patients regarded the programme as a valuable source of information. Most of them expressed appreciation for the opportunity to access it immediately after receiving their diagnosis, when their need for information was substantial, and the usage tended to decrease over time. Some patients found the solution inappropriate due to relational support needs and emotional distress following the diagnosis . 

Overall, HCPs viewed their organizations as prepared to adopt digital solutions like our programme, and the widespread acknowledgement of technologies in society acted as a facilitator for its acceptance and implementation, as this was perceived as an inherent part of everyday life. It was emphasized that any potential resistance should be recognized and considered in the process of implementation. No specific barriers to implementation within the organizations, except for economic concerns, were discussed, and HCPs held the belief that both colleagues and leaders would provide support. Nonetheless, the necessity for assistance during implementation was emphasized. 

Transitioning from a website to an app The focus groups discussed the possibility of switching the platform into a mobile app solution, and in general, HCPs expressed a favourable response to this idea to enhance availability. Both the participants in the qualitative study  and the focus groups emphasized the importance of keeping a flexible organization of the programme’s content. Despite the standardized content of such a programme, this flexibility is crucial to accommodate individual needs and enables the selection of topics that are relevant to everyone’s specific situation. Data from the RCT showed that patients engaged with all the modules and topics within the programme, albeit to different extents, probably reflecting this individuality . The current version of the programme lacks any interactive functionality with HCPs, but data from the qualitative study introduced the possibility for a chat function . Opinions among HCPs in focus groups regarding this idea were diverse and not unanimous. This diversity of perspectives reflected concerns about the types of questions that could be effectively posed using this approach, and whether the quality of responses though a digital solution would be adequate, and for others this seemed to be straightforward. This could indicate a necessity for well-defined guidelines and alignment of objectives when considering the implementation of such a feature. New modes of delivering patient education An introduction to the digital PE programme could potentially help planning and tailoring care to the patients. Although, a risk of investing more time initially when introducing patients to the programme was present, HCPs regarded this time as well-spent, considering that some patients may not require any specific introduction. The HCPs noted that a reorganization of future PE and implementation of digital PE could potentially reduce the overall burden of PE, and this could lead to a transformation in the organization and mode of delivering PE. This could transform their professional role from teaching to guidance. For example, the current practice of face-to-face PE often implies a firm approach as nurses try to adhere closely to educational guidelines. However, with the implementation of digital PE, follow-up sessions could be provided as needed and customized according to the patient’s preferences and further needs. This shift could potentially make the task of PE more engaging and fulfilling for nurses and could strengthen the partnership between patients and HCPs if patients became more actively engaged. Forming relationships Data from the focus groups highlighted the importance of HCPs being able to establish a relationship with patients before feeling confident to “hand them over” to technology. They also believed that this was important for most patients. Because of the change in relational interactions, both rheumatologists and nurses also felt the necessity to ensure they had provided sufficient information about the disease and treatment, and had taken care of emotional responses, before introducing the technology. This initial interaction could serve as the basis for the decision about whether a patient should be offered digital PE. Hence, several HCPs emphasized the importance of evaluating individual needs related to PE and the need for self-management support when implementing digital PE. 

The focus groups discussed the possibility of switching the platform into a mobile app solution, and in general, HCPs expressed a favourable response to this idea to enhance availability. Both the participants in the qualitative study  and the focus groups emphasized the importance of keeping a flexible organization of the programme’s content. Despite the standardized content of such a programme, this flexibility is crucial to accommodate individual needs and enables the selection of topics that are relevant to everyone’s specific situation. Data from the RCT showed that patients engaged with all the modules and topics within the programme, albeit to different extents, probably reflecting this individuality . The current version of the programme lacks any interactive functionality with HCPs, but data from the qualitative study introduced the possibility for a chat function . Opinions among HCPs in focus groups regarding this idea were diverse and not unanimous. This diversity of perspectives reflected concerns about the types of questions that could be effectively posed using this approach, and whether the quality of responses though a digital solution would be adequate, and for others this seemed to be straightforward. This could indicate a necessity for well-defined guidelines and alignment of objectives when considering the implementation of such a feature. 

An introduction to the digital PE programme could potentially help planning and tailoring care to the patients. Although, a risk of investing more time initially when introducing patients to the programme was present, HCPs regarded this time as well-spent, considering that some patients may not require any specific introduction. The HCPs noted that a reorganization of future PE and implementation of digital PE could potentially reduce the overall burden of PE, and this could lead to a transformation in the organization and mode of delivering PE. This could transform their professional role from teaching to guidance. For example, the current practice of face-to-face PE often implies a firm approach as nurses try to adhere closely to educational guidelines. However, with the implementation of digital PE, follow-up sessions could be provided as needed and customized according to the patient’s preferences and further needs. This shift could potentially make the task of PE more engaging and fulfilling for nurses and could strengthen the partnership between patients and HCPs if patients became more actively engaged. 

Data from the focus groups highlighted the importance of HCPs being able to establish a relationship with patients before feeling confident to “hand them over” to technology. They also believed that this was important for most patients. Because of the change in relational interactions, both rheumatologists and nurses also felt the necessity to ensure they had provided sufficient information about the disease and treatment, and had taken care of emotional responses, before introducing the technology. This initial interaction could serve as the basis for the decision about whether a patient should be offered digital PE. Hence, several HCPs emphasized the importance of evaluating individual needs related to PE and the need for self-management support when implementing digital PE. 

In this study we identified both the successes, facilitators, and challenges of a digital PE programme, which should be considered when implementing beyond a research setting. While this programme holds promise for a wide range of patients, there is a concern that it may exclude individuals with health literacy and self-management difficulties. Patients and HCPs widely embraced the technology, and its usability did not require specific technical competencies. However, optimizing the programme for smartphones and tablets seems crucial for broader availability. Individual assessments should be conducted to cater varying support needs when enrolling patients into digital PE, and expanding its use necessitates organizational adjustments. Overall, HCPs endorsed digital PE, but there were mixed opinions with some expressing reluctance due to reduced face-to-face contact, including concerns such as fears of automation replacing their roles, potential neglect of patient’s needs, and safety compromises. In the following, we delve into the main challenges of these findings in the context of future implementation. RA is a well-defined disease with established treatment strategies and recognized management guidelines aimed at reducing disease progression and complications . While RA primarily affects females and typically manifests around the sixties, it spans a broad age range , as also demonstrated in our RCT by a median age of 59.0, and an age span of 25 to 82 years . Having clear management guidelines can enhance the likelihood of successfully implementing digital PE. However, the diversity in RA-patients age, the necessity of treatment adherence to ensure disease control, and the various approaches into using digital PE, as revealed in our qualitative study, add complexity to adopting the technology within this patient group. This induces a task of accommodating a diverse group of patients with varying needs in future implementation. Despite our efforts to consider different health literacy levels during program development, we failed to include patients with diverse health literacy levels in the RCT. Moreover, we did not assess eHealth literacy competencies, which involve the ability to seek, find, understand, and evaluate health information from electronic sources to address health problems . A Danish study examining eHealth literacy among individuals with endocrine and gastrointestinal diseases found that patients’ adoption and utilization of digital health services are more influenced by their eHealth literacy than by sociodemographic factors . A systematic review also highlighted that issues related to these competencies are often overlooked in telehealth development for socially disadvantaged groups . Thus, to enhance future implementation of digital PE, it may be advantageous to delve deeper into the realms of health literacy and eHealth literacy to ensure the successful integration of digital PE for a broader patient group than those included in our studies. Although our studies provide valuable insights into the adoption of digital PE from both the perspectives of patients and HCP, a more detailed analysis of the factors contributing to technology acceptance or rejection may improve the implementation process. Assessing technology acceptance using established models, which consider factors like usefulness, ease of use, social influence, organizational support, and technical proficiency , could provide a comprehensive understanding of adoption dynamics. While our studies indicate that digital PE is valued, easy to use, effective and warranted increases the likelihood of its success and adoption, our findings also indicate that integrating digital PE represents a shift in HCPs traditional practices, impacting perceptions of care quality and roles. Training in mastering the programmes use, gaining confidence in the technology, and integrating it in daily practice may help alleviate HCPs concerns. However, by the integration of technologies and artificial intelligence (AI) into healthcare, the models and methods of delivering care constantly undergo transformation. It is crucial to recognize the significance of HCPs roles in this process, including their central role in applying these technologies, working collaboratively with patients, and tailoring their use to meet individual patient needs, for example in a digital PE intervention like ours. Digital health interventions and AI can enhance healthcare and healthcare accessibility , but should not replace essential components like healthcare providers and leadership, and it is important to acknowledge that there are limitations to what digital health can address . Guidance on AI usage also underscores the importance of responsible, effective, and safe use while ensuring inclusivity, with a core principle that humans should remain in control of health-care systems and medical decisions . While the organizations capacity to implement digital PE was considered reasonable, potential challenges may emerge as this novel approach to PE will necessitate changes in work processes and a more adaptable organizational structure to provide various modes of PE tailored to individual needs and preferences. A study focusing on healthcare professionals’ perspectives regarding successful organizational changes in a continuously evolving healthcare system identified some key factors , which could be relevant in planning the implementation of digital PE. Influencing the change through early involvement or initiation, being prepared for change with clear and timely communication, and recognizing the value and benefits of the change for both healthcare professionals and patients were found to be crucial for the successful implementation of changes in healthcare . Another crucial aspect to consider in implementing digital PE or similar digital health technologies is the potential shift of resources from one setting to another. While our RCT showed that patients receiving digital PE had fewer interactions with outpatient clinics across all forms of contact, other studies have reported mixed findings. For example, an internet-based self-management programme for RA and other rheumatic diseases showed no impact on healthcare utilisation , while another study found a significant decrease among RA patients accessing an online educational intervention , and yet another reported an increase in telephone contacts following remote monitoring of RA . Therefore, it is also important to recognize whether the introduction of digital health technologies increases the need for telephone support or healthcare providers to support patients digitally and manage these technologies. Strengths and limitations This study exhibits a robust strength in its utilization of an extensive dataset derived from multiple studies. This dataset has yielded valuable insights into the implementation of digital PE, and although the secondary dataset was originally conducted for different purposes, its incorporation into this study ensured the inclusion of diverse perspectives. Another strength is the application of the NASSS framework, which has facilitated a systematic examination of implementation perspectives by drawing our attention to both the potential successes and challenges associated with digital PE. The framework, including tools like the NASSS-CAT interview version , was instrumental in shaping our questioning route, ensuring the comprehensive coverage of all relevant domains in our focus groups. We acknowledge that a limitation of this study could be the absence of a broader spectrum of stakeholders, e.g., technical staff, top leadership or health economists. The NASSS-CAT interview tool targets different groups of individuals involved in the project, and our analyses predominantly offer insights from the perspective of the intended adopters, i.e., patients, HCPs and leaders. Thus, certain domains may not have been fully explored in our focus groups meaning that a wider group of stakeholders could potentially have provided other insights. 

This study exhibits a robust strength in its utilization of an extensive dataset derived from multiple studies. This dataset has yielded valuable insights into the implementation of digital PE, and although the secondary dataset was originally conducted for different purposes, its incorporation into this study ensured the inclusion of diverse perspectives. Another strength is the application of the NASSS framework, which has facilitated a systematic examination of implementation perspectives by drawing our attention to both the potential successes and challenges associated with digital PE. The framework, including tools like the NASSS-CAT interview version , was instrumental in shaping our questioning route, ensuring the comprehensive coverage of all relevant domains in our focus groups. We acknowledge that a limitation of this study could be the absence of a broader spectrum of stakeholders, e.g., technical staff, top leadership or health economists. The NASSS-CAT interview tool targets different groups of individuals involved in the project, and our analyses predominantly offer insights from the perspective of the intended adopters, i.e., patients, HCPs and leaders. Thus, certain domains may not have been fully explored in our focus groups meaning that a wider group of stakeholders could potentially have provided other insights. 

In conclusion, we found that the design and ease of use of the technology, the program’s effectiveness, its availability as an ongoing resource for self-management support that can complement HCPs guidance, and the potential to release healthcare resources may encourage the implementation of digital patient education. In contrast, challenges associated with implementing this mode of care pertains to the condition and the patient population, user adoption of the technology, and the organization of patient education. 

Below is the link to the electronic supplementary material. Supplementary Material 1. Supplementary Material 2. Supplementary Material 3. 

