Record
GetCheckedOnline is a comprehensive online testing service for sexually transmitted and bloodborne infections (STBBIs) available in select communities in British Columbia (BC), Canada, first implemented in 2014. Digital Sexual Health Initiative The team led by Dr. Mark Gilbert at the BC Center for Disease Control conducted a study to understand structural barriers and macro-level facilitators to the continued implementation of GetCheckedOnline, specifically its scaling, adaptation, maintenance and sustainability.
Figure 1. Implementation phases of GetCheckedOnline
Methods
This study used the sociological research strategy of institutional ethnography. Twenty-five individual interviews were conducted with provincial and regional GetCheckedOnline implementers and other stakeholders between April 2019 and February 2020. A planning and operations meeting on the implementation of GetCheckedOnline was observed. In addition, key documents related to the implementation work of GetCheckedOnline and public health services in BC were reviewed.
Results
GetCheckedOnline and STBBI testing and prevention services provincial and territorial health services working in the BC health system were tasked and willing to implement, scale, adapt, maintain and sustain STBBI online services to address barriers to testing access and achieving health equity outcomes. However, the structure of the health system and the technology ecosystem that surrounds it brought implementers up against many macro-level structural obstacles that varied according to the implementation phase.
During the Upgrade
Implementers faced limits imposed by provincial public health policy focused on biomedical HIV prevention and funding for comprehensive sexual health and gap services.
| Obstacles | Navigating tight, targeted budget allocations Keeping the STBBI test in the context of HIV-focused co-testing policies |
|---|---|
| Facilitators | Space created to implement GetCheckedOnline in the early years of the new policy Use relevant financial and operational resources View scale-up as an opportunity to fill testing and service gaps |
When customizing
Implementers navigated limited knowledge of internal information technology (IT) systems and processes and the implications of internal health service restructuring.
| Obstacles | Dealing with long and dark IT assessment, decision-making and health system prioritization processes Learning and re-learning about IT processes as they are dealt with Managing IT requirements and solutions and maintaining equitable access to testing Anticipating and meeting changing technology-related costs |
|---|---|
| Facilitators | Evolving understanding of data integrity, security and retention over time Organizational willingness to act on user needs and feedback |
During Maintenance
Implementers faced constant changes in the broader IT ecosystem and computer system interoperability challenges that arose from maintaining low-barrier testing services.
| Obstacles | Maintaining and updating constantly changing hardware and software platforms Additional administrative and nursing time required to perform the service Spending time on manual data entry and work processes that are automated in other clinical areas |
|---|---|
| Facilitators | Handling GetCheckedOnline clients and test results in the same way as in-person clients and results from the district STD clinic Relying on structured guidance developed specifically for the day-to-day operations of GetCheckedOnline Leveraging the existing scope of nursing practice Leveraging shared system responsibilities public health |
During Sustainability
Implementers faced budgetary processes within organizations and for-profit corporate interests outside the health system.
| Obstacles | Submitting business cases and briefing notes that demonstrate the need, value and worth of the service Relying on a global budget allocation for public health laboratory testing Balancing collaboration and cost containment with the private sector |
|---|---|
| Facilitators | Maintaining key service characteristics over time that allows for long-term evaluation Building on province-wide and community-wide service demand and support |
Implications for practice
This study demonstrates the value of understanding the context-related complexities surrounding scaling, adapting, sustaining, 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, highlighting the unique challenges of implementing digital health programs. In particular, the significant influence of information technology systems and processes we propose to consider as a unique contextual area in scientific application research applied to digital health programs.
