Identifying Implementation Science Characteristics for a Prenatal Oral Health eHealth Application

Introduction

Oral health care remains a missed opportunity during pregnancy. A growing body of evidence supports a potential association between poor oral health and adverse pregnancy, birth, and childhood outcomes, including gestational diabetes (Hartnett et al., 2016; Hunt & Schuller, 2007), low birth weight (Corbella et al., 2016; Ide & Papapanou, 2013), preterm birth (Centers for Disease Control and Prevention, 2011; Ide & Papapanou, 2013), and early childhood caries (Finlayson, Gupta, & Ramos-Gomez, 2017; U.S. Department of Health and Human Services, 2011). Approximately 40% of women experience periodontal disease during pregnancy (Lieff et al., 2004). According to data from the 2015 Pregnancy Risk Assessment Monitoring System, 83.0% of U.S. women reported receiving prenatal care in the first trimester, but only 48.3% visited a dentist or dental clinic during their most recent pregnancy (Centers for Disease Control and Prevention, 2015).

Background

National guidelines, endorsed by both the American College of Obstetricians and Gynecologists and the American Dental Association, have been established for prenatal and oral health providers to promote oral health during pregnancy (Oral Health Care During Pregnancy Expert Workgroup, 2012). Specifically, providers are to assess, advise, refer, and coordinate care (Oral Health Care During Pregnancy Expert Workgroup, 2012). Although prenatal care is a “cornerstone of the health care system for pregnant women” (Kiely & Kogan, 1994) and serves as an opportune time to promote oral health (Boggess et al., 2011), a significant gap exists in translating this guidance into comprehensive and quality prenatal care. Previous research reveals that prenatal providers are generally not aware of the guidelines and do not perform the recommended behaviors, such as taking an oral health history from pregnant patients, visually inspecting pregnant patients’ mouths, referring pregnant patients to oral health providers, and collaborating with oral health providers on patient management and care (Morgan, Crall, Goldenberg, & Schulkin, 2009; Strafford, Shellhaas, & Hade, 2008; Vamos et al., 2015). Explanations cited for this practice gap include lack of information, training, time, and resources to address oral health issues, and difficulty finding an oral health provider to refer pregnant patients (Morgan et al., 2009; Strafford et al., 2008; Vamos et al., 2015).

eHealth technologies offer an innovative mechanism for improving health care processes, outcomes, and quality of care (Lewis, 1999; Renker & Tonkin, 2007; Richter et al., 2008; Thornberry et al., 2002; Wofford, Smith, & Miller, 2005). Providers often use eHealth technologies such as electronic medical records, electronic health records (EHR), personal health records, e-prescribing technology, and health information exchange to store and share relevant health data (National Alliance for Health Information Technology, 2008; Office of the National Coordinator for Health Information Technology, 2013). These eHealth technologies usually incorporate clinical decision support, which provides clinicians with knowledge and patient-specific information, intelligently filtered or presented at appropriate times. Clinical decision support systems have been found to successfully increase provider adherence to recommended treatment and referral guidelines and enhance the delivery of health care (De Angelis et al., 2016; Marasinghe, 2015; McCartney, 2006; Watkins, Wood, Schneider, & Clifford, 2015). eHealth applications (apps) are interactive, incorporate multiple learning strategies, and have greater potential to educate users compared with other methods of health promotion (Bennett, Switzer, Aguirre, Evans, & Barg, 2006).

Based on principles of implementation science, it is critical to understand the clinical systems and structures to maximize the potential for an app to be adopted and integrated into current clinical workflow and processes. Thus, the purpose of this formative study was to identify key implementation science characteristics to inform the development of an eHealth app to assist providers in implementing the prenatal oral health guidelines during prenatal visits.

Method

Conceptual Framework

The Consolidated Framework for Implementation Research (CFIR) guided this formative study (Damschroder et al., 2009) and was used to (1) understand the clinical context, infrastructure, and workflow and (2) identify key characteristics to inform the development of the app and maximize the potential of adoption and use. The CFIR is a “meta-theoretical framework” that compiles and organizes known evidence-based constructs from existing implementation theories across the following system levels or “domains”: (1) inner setting, (2) outer setting, (3) intervention characteristics, (4) characteristics of individuals, and (5) process (Damschroder et al., 2009). The authors of CFIR suggest that researchers use only those constructs that are applicable and salient for the specific innovation, setting, and priority population under investigation. Subsequently, similar to the process used by previous studies employing this framework (Vamos et al., 2016; Vamos et al., 2017), domains and constructs of focus were identified through discussions held among the research team (Investigators and Scientific Advisory Board members) with multidisciplinary expertise (e.g., behavioral theory, implementation science, qualitative methodology, eHealth technology development, patient–provider communication, clinical practice), as well as preliminary discussion held with the clinic administration. As a result, constructs across four out of the five domains were identified to examine during this elicitation research (see Table 1). The process domain was excluded from this phase of the research as these constructs involve factors related to planning and reflecting on an intervention that has been actually implemented.

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Table 1

Brief Descriptions of the Domains Addressed in the Formative Study as Guided by the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009)

CFIR Domain	Brief Description
Intervention characteristics	Essential features of the program or service that increase attractiveness, ease of use, and uptake by the intended audience
Characteristics of individuals	Individual’s knowledge, beliefs, and stages of change regarding the practice behaviors
Inner setting	Structural, network, organizational, and cultural contexts through which the intervention will be implemented
Outer setting	External forces such as external policies and incentives, the degree to which organizations are networked with others, resources available, and perceived patient needs

Interviews and Focus Groups

A series of interviews and focus groups were conducted with different stakeholder groups: (1) clinic staff, (2) prenatal providers, and (3) oral health providers. Interviews were conducted with eight clinic staff members, including administrators, health IT personnel, office staff, nurses, medical assistants, and a doula. Interviews were audio-recorded and lasted approximately 30 to 45 minutes. Sixty-minute interviews (n = 4) were conducted with prenatal care providers (nurse practitioners and midwives). Two 60-minute focus groups (n = 8 per group) were conducted with oral health care staff, including dentists, dental hygienists, and dental assistants (see Table 2).

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Table 2

Participant Demographics (N = 28)

Characteristic	Clinic Staff Interview, n (%)	Oral Health Providers, n (%)	Prenatal Providers, n (%)
Total	8 (29)	16 (57)	4 (14)
Gender
Male	1 (4)	2 (7)	0 (0)
Female	7 (25)	14 (50)	4 (14)
Race
White	5 (18)	7 (25)	3 (11)
Black	1 (4)	0 (0)	1 (4)
Asian	0 (0)	2 (7)	0 (0)
Other	2 (7)	7 (25)	0 (0)
Ethnicity a
Hispanic	7 (25)	8 (29)	0 (0)
Not Hispanic	1 (4)	7 (25)	4 (14)
Highest level of education
High school/GED	0 (0)	3 (11)	0 (0)
Some college	3 (11)	4 (14)	0 (0)
College graduate	4 (14)	5 (18)	0 (0)
Professional/graduate school	1 (4)	4 (14)	4 (14)
Years of employment at FQHC
<1	0 (0)	2 (7)	1 (4)
1-3	1 (4)	10 (35)	2 (7)
4-5	2 (7)	0 (0)	1 (4)
⩾6	5 (18)	4 (14)	0 (0)

NOTE: FQHC = federally qualified health center.

a

Data missing from one record.

Data collection instruments (interview and focus group guides) were developed based on the study’s research questions and the CFIR framework. A member of the organization’s administration team contacted potential participants to introduce the study. Following an agreement to participate, a member of the research team scheduled an interview or focus group where informed consent was obtained.

Results

Overview

Data from the clinical workflow, technology assessment, interviews, and focus groups are presented below by CFIR domain and corresponding themes with supporting quotes presented in Table 3.

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Table 3

Themes and Supporting Quotes by Consolidated Framework for Implementation Research (CFIR) Domain

CFIR Domain	Theme	Supporting Quote
Inner setting	Patient education and communication	“We have an education flow sheet that—if it’s—either the items on that flow sheet are covered by the health educator [doula] that comes in or, if not by that health educator, then they’re covered by the provider. And it’s a checklist, and she goes through that, and then she signs off on that.”—Nursing supervisor
	Organizational and internal communication	“Communication is a big—I don’t wanna say problem, but we could improve on our communication throughout the organization. Maybe a more—we have a standard way of incorporating new policies, but we need better handling on getting that out to everyone, to all of the staff. A lot of times a new procedure will be in place, but not all of the parties involved will be made aware. If there’s a quick memo that goes out, we do try to send it electronically through an e-mail. But I think there’s room for significant improvement in keeping everyone involved and made aware and everyone on the same page.”—Clinic administrator
		“Well I’m not comfortable first of all putting in the notes ’cause we only do the vitals. We don’t do documentation as far as that. I don’t know if I’m supposed to put it in or not.”—Childbirth educator “We don’t issue any kind of referral. We basically tell them, “Hey, you need to go to the dental area,” let’s say. They would probably just pick up the phone and maybe schedule their appointment or call the registration person in that pod and say, “Hey, this patient is a patient of OB [obstetrics]. Can you please get them an appointment for this? This is what’s going on.”—Clinic administrator “I can see the encounters. But the thing is, because we’re not familiar—me as a nurse, I’m not familiar with old terminology, everything, the kind of procedure—I don’t understand everything that they’re doing in there. The only thing that I might know for sure is they were seen. So there is a time where we have to walk into dental department to say, ‘Can you explain that to me, exactly what this patient got done?’”—Registered nurse
	External communication	“We do have a few employees that work in referral department, where they identify what the referral was for and identify what the patient’s insurance situation is, whether they have it or whether they don’t have it. They’ll identify which provider they need to send them to, based on that insurance information. Or if the provider specifies they need to go to X provider, the referral department will contact that facility. They’ll schedule the appointment and give all of the patient information. Then they will contact the patient and say, ‘Hey, we have your referral here. It’s for this date at this time.’”—Registered nurse
	Culture	“No, I think it [our culture] will help, because our employees, they’re always eager to learn. And like I said . . . everybody works as a family. And they’re very—they like to help each other. So they work as a team.”—Clinic administrator
Outer setting	External policy and incentives	“Meaningful use, for certain, I would say, is a big one that would motivate the use of more technology. Let’s say in the patient information. With the newer version, a piece of the meaningful use requires that we obtain an e-mail address for the patient. If one isn’t available, they would like us to try to help the patient create one. So that would grant them access to, let’s say, a patient portal, where the patient would be able to go on a secured format and obtain either lab results or—maybe not lab results, but view their visit from today, or prescriptions that they’re taking, or results of some kind, just so that there’s a better understanding and communication of what—the patient sees what the provider sees.”—Clinic administrator
Characteristics of the intervention	Relative advantage	“They might just become more efficient. Instead of only being able to handle 10 referrals in a day, they might be able to do 20 or something along those lines. Just becoming more efficient with the processes.”—Clinic administrator “As long as it doesn’t delay the patient flow. Because we have appointments. And then of course we have our walk-in clinic. But we have to attend the patients in a timely manner. And sometimes that had happened—when we had a new system come in we adjust the schedule.”—Clinic administrator “I like the way that we are able to track things better with the technology, and the reminders, and the pop-ups that we get. It just seems more organized.”—Nursing supervisor “It’s a reminder system, so it keeps the patients more on track of what they need. Those reminders are always good for the patients. And I think it shows them, too, that we care and that we’re following up on them.”—Nursing supervisor “I love my computer. Everything that I could get done through my computer would be great. I’m not expecting any phone, any smartphone, any iPad, anything.”—Registered nurse “It’s fast. It’s everything in here. . . . it’s easy for me to minimize this screen and open the other one. If I need to look at the patient’s document, I can minimize this, and I got everything, and I can play with the same record. Everything that I might need is in there. I don’t need to step out and look for a chart. I don’t need to step out and look in the fax. I don’t need nothing like that. Everything will be here.”—Registered nurse “This is a combination between what you’re doing with your computer and your customer service. For me, when you’re asking me your question, there’s two different things. I can have the time to do what I need to do in here, but when the patient is an interaction between patient and the nurse, that is when I wanna think about customer service. I’m not gonna be typing in here when you’re talking to me. It’s not only manners; it’s professionalism and it’s customer service.”—Registered nurse
	Adaptability	“It has to be bilingual. A lot of literature in both languages, because a lot of our OB [obstetrical] patients have a lot of—we have quite a bit of migrant workers.”—Clinic administrator“But let’s say that the patient, they don’t read, they don’t read either in Spanish, but they can watch the TV. That part, I really like that.”—Registered nurse“I’m not sure how the MA’s do it, but I think the MA could do it. That’s usually how they do it. They refer and then print the summary.”—Oral health provider
	Complexity	“When you know the system, you’re gonna feel like a fish in the water. It’s easy, because everything is either in a template that you just need to check and go over and review them, or just feel free to text and go to the next step every time. It’s very easy. I love it.”—Registered nurse“I can’t see that a doctor would know what they’re looking at. And then to say ‘and this is what you have’ because no two mouths or situations are that close. If you had a panel of six keep–it-simple pictures . . . I would say [the prenatal provider] can just tell the patient, ‘you may have this, this, or this and there are various consequences for each of these conditions and only a dentist could tell you which one of these you may have’”—Oral health provider
	Design quality and packaging	“I would like it to be in an order so that, you know, if there are some things that don’t particularly pertain to the patient, you can just skip over it. You know, A to B to C to D to E. By the time you’ve done it 50 times, you’ve got it pretty much got it memorized anyway. An order helps you to stay on track and makes sure you cover the things that needs to be covered”—Prenatal provider
Characteristics of individuals	Knowledge and beliefs about the intervention	“I think in medical, everything is so separated and specialized, and everyone works within their own specialty. If you come to me, I’m not going to address your tooth problem, I’m going to say here’s a referral to the dentist. Everything is so specialized, dental isn’t part of prenatal because we don’t know enough about it. That’s why it’s not integrated or included.”—Prenatal provider“I do a visual inspection of the mouth. I would expect a prenatal provider to at least say you need to see a dentist because of the effects oral health can have on the pregnancy.”—Prenatal provider“Bleeding gums increase with pregnancy, increase preterm labor. People need their teeth cleaned and they haven’t brushed their teeth in a long time. I think a lot of us notice the poor oral health, but we have no place to send them.”—Prenatal provider“You can look and see if they have poor dental health or not. That’s all you need to know and then you can send it to the dentist.”—Prenatal provider“For me to say open your mouth, I wouldn’t know what I was looking at if I looked in their mouth.”—Prenatal provider“Providers can’t spend time on referring and what person to refer—front desk should be doing [that].”—Oral health provider
	Personal attributes	“A lot of [staff] are—they’re very comfortable with the technology. Because I guess most of the people have computers now. And with the smartphones you know some people are pretty good when it comes to learning in any new system or advanced system that comes in.”—Clinic administrator“[I am not] computer wise.”—Registered nurse“At our newer clinic, I wanna say that there’s a younger employee population, whereas here we’re one of the more established clinics; we have employees that have been here 25-plus years. And I have noticed that the older employees have a harder time adapting to the change or accepting the change.”—Health information officer“Well, there’s a lot of young staff, and the young staff like technology, but then the older folks are a little bit—anytime you introduce something new, like even when we went to the electronic medical records, there was some resistance and people were kind of afraid that they weren’t gonna get it. So the younger staff helped the older staff, and eventually we all got it.”—Nursing supervisor“It’s something where I see some of the older employees, they have a stronger connection with their patient base, where they will adapt to whatever change is recommended to help the patient, if that makes sense.”—Clinic administrator

Inner Setting

Structural Characteristics

Figure 1 illustrates the findings from the clinic observation, including how a patient navigates and interacts with clinic staff. In general, a patient checks in at the main registration desk, which processes documentation and appointments for all services at the clinic. The patient completes paper forms, and then a medical assistant calls the patient back to take vital signs and/or collect a urine specimen. Finally, the patient is brought into another room to see the prenatal provider. This describes a visit for a returning prenatal care patient, which lasts 15 to 20 minutes on average.

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Figure 1

Clinical Workflow

During a new patient visit, the patient also visits with a licensed practical nurse who provides printed health education materials. In addition, women are encouraged to attend a prenatal class offered once a week by a doula, where oral health information is provided by a dental hygienist. New patient visits last 2 to 3 hours on average.

Networks and Communication

Three themes emerged throughout the data with regard to networks and communications: patient education and communication, organizational and internal communication, and external communication.

Patient education and communication

Doulas were identified as the primary individuals providing health education. Other staff providing information to patients included nurses and nurse midwives. Overwhelmingly, participants identified the provision of “one-on-one” education with patients as an area for improvement.

Organizational and internal communication

Organizational communication focuses on the methods in which policy changes or information are conveyed from the organization’s management to the providers and staff. The most common methods of organizational communication were paper memos and e-mail. Internal communication describes methods of documentation and communication across departments. Participants’ discussions often included the concept of “ownership” of documentation and patient education. For example, medical assistants reported that the documentation and education are the providers’ responsibility, while their responsibility is limited to taking vital signs. Additional discussions included the referral process across departments, specifically from the women’s department to the dental department. Participants mentioned a wide range of referral methods, including physically walking the patient to the dental area to schedule an appointment. Furthermore, although patient records are shared between the two departments, some participants explained that they are not always able to access certain screens within the patient’s EHR or are unable to understand the terminology.

External communication

This theme included the referral process and information communicated with external providers, hospitals, or organizations. The referral process was described as having designated staff person responsible for scheduling “most” of the patients’ appointments with outside organizations.

Culture

Most participants believed that the norms and values of their organizational culture were conducive to implementing innovative processes. Participants discussed how their organization is often perceived as being a leader in testing and implementing health care innovations. Participants also described the organization as “family-like,” indicating a sense of belonging and a desire to provide quality health care services to patients.

Discussion

This study aimed to gather critical formative research to inform the development of an eHealth application to assist prenatal providers in adhering to prenatal oral health guidelines. As guided by CFIR, data from the technology assessment, clinic observations, interviews, and focus groups were triangulated to identify various contextual factors and considerations that will directly inform the development and implementation of this health promotion intervention.

Key processes and observations were documented during the clinical workflow assessment. Specifically, patient education, internal/organization, and external communication were identified as potential areas for future improvement.

Although the initial intended users of an app were prenatal providers, findings identified other opportunities where the intervention could be used by other clinical staff and patients. Furthermore, the culture of the organization was thought to be conducive to testing and implementing new processes, with a sense of being “family-like,” where there is desire to provide good health care services. Since various types of health care professionals are interrelated and integral to the clinic workflow, intervention designs should support the activities of all clinical staff who engage in health promotion activities (Campbell, Guappone, Sittig, Dykstra, & Ash, 2009). Subsequently, research should explore how an eHealth app that is designed to assist prenatal providers in implementing the oral health guidelines into routine prenatal care visits may integrate and coordinate with other health promotion activities, such as those delivered via prenatal care education classes.

With regard to clinical service delivery, participants discussed a sense of documentation “ownership,” with certain staff having the responsibility for eliciting and recording information. There was also a perceived limitation on the sharing and use of the EHR between departments, with some staff unable to view or understand records. Lack of interoperability among EHRs is a perceived major barrier to meaningful use of the systems. An application has the capacity to not only improve patient–provider communication but also improve communication between and within the clinic system. Therefore, technological interventions should consider how to improve interoperability among different systems and improve the ability to share clinical data between medical entities (Meigs & Solomon, 2016).

Several characteristics of the intervention were identified by participants as being advantageous. Participants believed that such an intervention could potentially improve patient–provider communication and positively affect efficiency with regard to time and documentation. Research has shown that technology can improve patient–provider communication by identifying clinical discussion points and empowering patients to take a more active role in their own care (Mirkovic et al., 2016). It was thought that the app could also have the potential to facilitate the adherence to meaningful use guidelines and provide motivation for use given this accountability requirement. On the other hand, such an intervention could negatively affect health care delivery by adding another device to the clinical system if not fully integrated during development efforts.

Issues related to the design, packaging, and complexity were also of concern to participants. Participants prefer a user-friendly application that requires minimum steps to use, includes pictures to guide prenatal providers’ assessments, and serves as a patient education tool. Other interventions that simplify prenatal providers’ efforts to screen and counsel their patients about behavioral risks through cueing (e.g., suggested counseling statements) have encouraged providers to consistently and effectively discuss specific health topics with their patients (Humphreys, Tsoh, Kohn, & Gerbert, 2011; Tsoh, Kohn, & Gerbert, 2010). In addition, participants noted the importance of having this application focus on general oral health promotion rather than serving as a complex oral health diagnostic tool, given prenatal providers’ lack of specialization in oral health care (Curtis, Silk, & Savageau, 2013; George et al., 2012). Participants also desired an app that could be adaptable to their clinic-specific processes and patient population. In addition, given that this organization provides comprehensive and integrated health care services, participants believed that the application should be flexible enough to be used within and across staff roles, departments, and clinical sites.

Participants also discussed several factors related to characteristics of the individuals that need to be considered in the application design. Most participants believed that prenatal providers have limited knowledge, skills, and training on oral health issues, but should be able to educate patients on the importance of oral health during pregnancy. Other attributes were identified at the clinic level, including the ability of this organization to implement new processes and technological innovations. In addition, it was noted that most staff were comfortable with technology but may need additional training and/or may be resistant to a process change.

Several limitations must be noted when considering these findings. This study was completed at one community-based organization, and the clinics were predominantly located in rural areas. Thus, the needs of the providers, clinical staff, and patients may differ from those in other geographic areas and in private practices. Also, the prenatal providers were all nurse practitioners or nurse midwives and therefore may not be representative of views held by other prenatal care providers with medical or osteopathic training. In addition, this organization was unique in that within many of their clinic sites, medical and dental services were provided, making referral and access to dental services more accessible. Furthermore, oral health education is offered by a dental hygienist to patients during their group prenatal care class. As a result, participants may take this into consideration when providing their input into the design of the app. Additionally, given that the clinic staff interviews (n = 8) were professional transcribed, whereas the audio recordings of the interviews and focus groups with the prenatal (n = 4) and oral health providers (n = 16) were not transcribed but the research team took detailed notes to abstract key data, intercoder reliability was not able to be established for this elicitation research. Moreover, although this formative research included diverse clinic participant roles, including patients in future research will be essential to understand from their perspective how best to foster patient–provider communication, patient engagement, and shared decision making.

Nonetheless, there are several strengths to this study, including being guided by consumer-driven, theoretically based principles and processes. Although the initial phase of this intervention is intended for use by prenatal care providers, multiple perspectives were initially gathered by interviewing diverse staff roles (e.g., oral health providers, clinic staff, and administration). Such input will ensure easy adaptability and modifications in future iterations of the technology. Furthermore, this app serves to bridge practice behaviors between two historically distinct disciplines—prenatal and oral health care—and facilitate the implementation of interprofessional practice guidelines. Additionally, the research was conducted by a multidisciplinary team of behavioral scientists in public health and a small business company (technology), with consultation by a national advisory board with comprehensive expertise (i.e., prenatal care, oral health care, maternal and child oral-systemic health, health literacy, and patient—provider communication). Such collaborations ensure that the design and implementation of this intervention are evidence-based and adhere to clinical practice considerations.

Conclusion

This formative, theoretical-based and consumer-driven research provided vital information needed prior to the development of an innovative eHealth application via multiple methods. Findings will directly inform the design and implementation of an eHealth application that aims to facilitate the translation of the interprofessional prenatal oral health guidelines into clinical practice. Specifically, the implementation science characteristics identified in this study can assist in not only guiding the design and components of the intervention but also providing a rich understanding of the complex context that may influence the adoption and experiences of the end users. Additionally, future research should consider and pretest the developed eHealth application in other clinical settings and contexts to assess the broader usability and feasibility capabilities. Last, future research will also need to explore patients’ perspectives, such as the acceptability and satisfaction with regard to how this eHealth application may facilitate patient–provider communication on a topic that is predominantly absent during prenatal care visits. This study also presents an example of a unique multidisciplinary academic–small business partnership while adhering to community-based and implementation science principles, with the ultimate goal of improving quality of care.