167 Assessment of the KLIK PROM portal implementation Discussion This paper aimed to retrospectively describe the most prominent determinants of successful KLIK PROM portal implementation using the Consolidated Framework for Implementation Research (CFIR) and to identify current barriers and matching implementation strategies for the KLIK implementation using the CFIR-ERIC Implementation Strategy Matching Tool. This retrospective evaluation shows that the strength of the KLIK PROM portal implementation lies particularly in the following CFIR domains: intervention characteristics (e.g., easy to use, direct feedback), characteristics of individuals (e.g., motivated clinicians), and process of implementation (e.g., support of the KLIK expert team). In addition, the climate of the outer setting is changing and patient-reported outcomes are more valued, which facilitates the implementation of the KLIK PROM portal. On the other hand, barriers in the implementation lie mainly in the domain of the inner setting and the intervention characteristics. Regarding the inner setting, involving and motivating all stakeholders at various levels of the multidisciplinary teams and hospitals is challenging. Regarding the intervention characteristics, mainly the tension field of providing optimal support of the KLIK expert team and the use of the KLIK PROM portal on the one hand and keeping low costs on the other hand is difficult. These findings are in line with another study discussing PROM implementation [38], where the authors describe the same relevant CFIR domains. This implies that the CFIR domain ‘outer setting’ might be less relevant than the other four domains when describing PROM implementation. However, a recent study on PREM implementation did find relevant outcomes regarding the outer setting, or macro level [39], and other literature on PROMs in palliative care also conclude that all CFIR domains need consideration for effective implementation [40]. Most CFIR domains were applicable to implementation of the KLIK PROM portal, showing that CFIR can be used in the context of implementing PROMs. However, the framework is not specifically developed for this context, resulting in insufficient attention for specific parts of the PROM implementation. For example, the content, length, and psychometric properties of PROMs are important factors for successful implementation of PROMs in clinical practice and are not addressed by the CFIR framework. The CFIR is a comprehensive framework based on various published implementation theories [22], resulting in a very extensive framework consisting of many constructs, 6
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