169 Assessment of the KLIK PROM portal implementation strategies are currently being worked on (e.g., tailoring strategies, inform local opinion leaders, and identify barriers in the implementation process). Though, these strategies are difficult to implement and the tool underlines the need to pay more attention to these important strategies. To further improve the KLIK implementation process in daily clinical practice, both the identified current barriers as well as the strategies extracted from the CFIR-ERIC tool can be used, to provide some examples: - Recently, more and more evidence has become available for the relative advantage of implementing PROMs [42,43]. We incorporate this information in the training to clinicians (step 4 in Fig. 2) and in the information we send to interested stakeholders to overcome this barrier. This might also affect the barrier tension for change. - To overcome the barrier of structural characteristics, creating awareness within the board of hospitals to facilitate larger scale implementation can be an opportunity. This might also affect the barrier leadership engagement. - Regarding engaging key stakeholders, patients and patient associations should be more involved in e.g., selecting PROs and PROMs and choices regarding frequency (step 1 in Fig. 2). On the other hand, some current barriers will likely remain or even become more prominent in the future. For example complexity, due to increased privacy legislation, the KLIK PROM portal requires now the use of two-factor authentication, which does not benefit the usability of KLIK for some users. At the time the implementation of the KLIK PROM portal in clinical practice started, a variety of implementation frameworks (including CFIR) and instruments to monitor and evaluate the implementation process from the start were not yet available. Just as we have evolved as a group, implementation science has evolved over the past decade as well. Implementation of the KLIK PROM portal was therefore essentially a process of “learning by doing”. Each time a specific multidisciplinary team showed interest in using KLIK, novel challenges appeared. As a result, a wide range of implementation strategies were used to tackle these particular issues. Notably, without realizing it at the time, many of the principles and strategies that are outlined in the CFIR tool were applied. We recommend groups starting to implement PROMs in their setting to use an implementation science framework, like the CFIR, as knowing which factors need 6
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