Table 3 Interpretation and scoring of implementation fidelity elements for interventions in each practice (see separate file)

Experiences of

dispensing protocol

-Liberty facilitating room for an approach more tailored to individual patients

-Confusion concerning expected delivery of care

Vision on tailored care

- Improvement of protocol compliance

- Shifting care to patient preferences

-Encouraging patient involvement

Interven-tion

Emerging themes

Strategies¹

A.3.1 PI 1, NP: The system is very easy. (…) We encountered some problems (…). Often, mobile phone numbers were not saved in the right place in the electronic patient record, and then the SMS service would not get linked to it. (…) [we worked on this with] the whole team: if someone shows up at the front desk, ask them whether they have a cellphone number and then check whether it is saved in the right place. (…). So it does have a sort of start-up phase (…). You really have to be dedicated (…) So we are already paying attention to it as much as possible.

A.3.2 PI 1, NP: And I have to check: How much time does this cost? And thenI possibly [have to] cancel a consultation so that I have more time for that.

2

B3.1, FG 2, GP: We started thinking: how can we do this? (…) To approach a few project participants to attend an externally organised sort of meeting at the practice (…), that was our first step (…). The second step was that we wanted to invite the entire group of participants (…) to provide information about which self-management tools wewould offer as a practice (…) to these patients, and then see if people were keen (…). So we are still in the phase where we don’t know what we will do at all. We will see. I’m curious.

B3.2, PI 1, GP: Regarding our choice in favour of a patient portal, I think that we should give ourselves enough time (…) I think that it will be “yes”, but I think that this needs to be a practice-wide decision.

2

C3.1, PI 1, GP: The primary aim is about putting the patient in control, with eVita as a means to make patients do their homework (…) That is the essence of eVita. So we expect a lot from this.

C3.2, FG 2, GP: The user’s manual for eVita has to be so simple that (…) you can explain everything on single sheet of paper. (…) There will be patients who do not know how to use a computer. They might get a notification: “Write it down [on paper]” and then you have already achieved something. That has to be possible too.

2

D3.1 PI 2, NP: We told a lot of people that they were doing fine and that visiting four times a year was unnecessary;. that once a year was also fine.

0

-Involvement of practice team

-Consideration of patient preferences

-Communication with patients

Coverage¹

A4.1, FG 4, GP: We can now invite people by SMS. And [having started with the study participants], we now want to extend this to all nurse practitioners and all of our diabetes patients.

2

B4.1, FG 2, GP: One is more articulate than the other in the practice (…) FG 5, NP: We invited four patients to join the patient panel.

B4.2, PI 1, GP: A kind of patient meeting where we send a message to all diabetics. Kind of an open invitation (…). Maybe the physical therapist can give some more information. Maybe the dietician can join in. Just to give it some features, raise its profile a bit.

B4.3, FG 5, NP: We sent by post.invitation letters fconcerning the health market to 230 patients

2

C4.1, FG 5, NP: Based on your inclusion criteria, 90 patients were eligible [in our entire T2DM-population] and 33 signed up. 15 people actually used it.

GP: And 10 actually logged in.

1

D4.1, FG 3, NP 2: I feel like I should only let the motivated people take part, otherwise it is just a constant up hill struggle (…) Some say: “Maybe.” Then I think: Well, this one is not motivated.

1

Not applicable

Participant responsiveness¹

A5.1, FG 5, NP: Patients always ask “Will I get a text message again next time? Because I really appreciate it.” (…) Other people are like “well if you hadn’t sent that text, I wouldn’t have come.” (…) You can see that patients do really appreciate it.

2

Patient panel:

B5.1, PI 1, NP: Look, obviously it was a very small group, but I am very happy with what has come out of it. FG 5, NP: People have often told me: “We thought it was a really nice evening, because you could share experiences with each other.”

Health market:

B5.2, FG 5, NP: It was in the late afternoon. But a Thursday or a Friday? (…) Also neighbourhood-wide (…). I think about seventy came. There were fifty who filled in the evaluation forms.

Five or six patients signed up for eVita at the time, but now, I have got three additional registrations. (…) Nine people also registered for a course about ‘Living with diabetes’ (…) Three nights of two and a half hours, for a maximum of 12 people.

B5.3, FG 5, NP: Yes, but afterwards we did hear from people “it was great fun, you should do this more often!” There were also people wo said: “Well... that wasn’t really necessary.” It gave a boost to do something like this again.

2

C5.1, FG 5, NP: Even if you say “This is eVita, you can enter your improvement goals here,” people still need guidance. (…) That it is of no use to them if you say “Okay, we figured it out: you actually have four goals of improvement, now get to work to see which ones you want to work on and then figure out how you want to do that (…).

It is really letting the patients decide for themselves: “Well we have four things that stand out, what would you like to work on? And shall we write that down as a goal for improvement? Then we get back to that the next time.” That is really what works (…) People really have to be motivated and you have to lead them by the hand to maintain self-management.

C5.2, FG 5, NP: No, and not everyone was equally enthusiastic about eVita. Many people felt it was patronising.

1

D5.1, FG 5, NP: Well yeah, you may not want them to visit, but still they want to come. [It must give a feeling] of safety, familiarity. [They are] scared too, that if they don’t visit for a year, it gets a lot worse all of a sudden. What then? So for some patients, it was quite difficult not to have to come anymore.

1

-Variability in response of patients

Quality of delivery²

A6.1, PI 2, NP: First, I created a text message group, which was much faster. But then if someone cancels you can’t remove that person from the group. I find that very patient unfriendly. You can’t do that. (…) Then people get confused “I thought I cancelled?”

+

B6.1, FG 5, NP: Last year was one of the first steps (…) [creating] a patient panel (…). We wanted to keep it neutral, [so] we were not present ourselves. (…) Different things were brought up. (…) For example, the need to look up information and blood results (…), a diabetes course, advice about food (…) and exercise (…) As a result, we organised ahealth information market (…). A range of disciplines of the local area participated (…) Although everyone focused on diabetes care, some also covered care for the elderly.

+

C6.1, PI 2, NP: In my opinion, eVita is not yet where it has to be. (…) I don’t think it is very clear, it is a bit abracadabra. That is also the feedback I get from people. (…) Well some [already encounter problems] upon signing up, but then you have problems really early on. I had a man in here twice saying: (…) “I really want it, but I just can’t do it”. (…)

[In contrast to the desktop version], the [mobile] app only allows the input and display of certain predetermined values. And there you can’t see the videos. That’s a pity.

C6.2, PI 2, GP: And those videos were pretty stupid.

–

D6.1, PI 3, NP: I feel like (…)we didn’t keep going. (…) A person with diabetes attends your consultation hour and our system then states says “Participating in the project.” But the program is not any different. At least, with the people I see, I do the same things I always do.

D6.2, PI 3, NP: No, nothing has changed. NP: I think that some people may have visited less often, but I don’t have an overview of that.

–

-Sensitivity to patients’ needs

- Involvement of practice team

-Negative experiences concerning user-friendliness of the ePortal

Implemen-tation fidelity: sum score

General fidelity