Table 1 Implementation approach to dashboard development in MAQI²

1 – Form implementation team

We formed a MAQI² implementation team consisting of a physician with expertise in anticoagulation and thrombosis, stakeholders from the anticoagulation clinic, a project manager, an EHR programmer, and staff.

2 – Identify the implementation intervention

Our goal is to help anticoagulation pharmacist/nurse staff to identify inappropriate DOAC dosing and teach them how to contact prescribers with suggested corrections to dosing. Then, we will implement the DOAC Dashboard within each health system’s EHR system, train the anticoagulation staff on the use of the DOAC Dashboard, and develop clinic policies that encourage regular use the DOAC Dashboard to identify inappropriate DOAC prescriptions and correct inappropriate DOAC prescriptions.

3 – Stakeholder interviews (see methods)

To understand what was and was not effective in a previous implementation, we conducted semi-structured interviews with key stakeholders (n=28) at 22 VA sites selected for having varied levels of DOAC Dashboard use. These interviews assessed for key determinants of successful implementation, focusing on how implementation was achieved, and strategies used by sites to implement and encourage effective use of the Dashboard to guide adoption in MAQI².

Then, to understand situations where MAQI² may differ from VA, we also conducted semi-structured interviews with key stakeholders (n=13) at the participating MAQI² centers. These formative interviews assessed for key anticipated determinants of successful implementation. They jointly focused on information pertinent to the DOAC Dashboard development process and to anticipated barriers and facilitators (negative and positive determinants) for the upcoming implementation work.

4 – Rapid qualitative analysis (see results and Table 3)

We performed rapid qualitative analysis to identify the key determinants of implementation success. Guided by the Consolidated Framework for Implementation Research and Technology Acceptance Model, we identified the most common and impactful determinants from both the VA and MAQI² centers. We also identified suggested implementation strategies from the VA interviews.

5 – Select implementation strategies (see results and Table 4)

We selected potential implementation strategies for MAQI² from both the items identified in the VA interviews, guided by the Expert Recommendations for Implementing Change project. These were priopritized based on the importance of their targeted determinant and perceived feasibility.

6 – Stakeholder feedback on implementation strategies (see results and Table 4)

We gathered stakeholder feedback from MAQI² site leaders and anticoagulation staff about the feasibility and acceptability of individual implementation strategies. Following this, we developed a final implementation intervention plan.

7 - Evaluation

We will evaluate the success of our implementation using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework [18]. We will leverage the existing MAQI² registry for patient-level data and will perform semi-structured interviews with anticoagulation clinic staff and other stakeholders to assess success of implementation.