Discussion
cancer
CANCER
User engagement is critical to designing acceptable and feasible interventions, but stakeholders are often asked to implement existing evidence-based practices, as was the case in E2C2. Thus, concerns about E2C2 being appropriate for patients and clinical stakeholders were common. We refined the intervention to address stakeholders’ concerns but could not fully address some. Similar to past research, some participants worried that E2C2 was duplicative of existing symptom assessment or management processes [Some stakeholders’ concerns stemmed from perspectives on what constitutes appropriate cancer care and how the research team was managing the usual care phase of the trial. More specifically, some clinical stakeholders wanted a plan for addressing symptoms reported on ePROMs collected during usual care, above and beyond the standard practice protocols already in place for addressing patients’ ePROM responses. Past research has found providers worry about creating false expectations [Stakeholders were concerned the intervention could create extra work or require additional time: a common concern about PROMs in cancer care [Lack of stakeholder engagement during intervention development may have exacerbated existing tensions surrounding the organizational approach to practice improvement. Stakeholders expressed concerns about the lack of collaboration across health system sites and the top-down approach to implementation by the academic medical center. Stakeholders suggested that opinion leaders, who had previously been skeptical but had come to see the value of the intervention, could be particularly effective in helping others overcome concerns and reducing tensions. This approach is consistent with past research noting the importance of clinical champions when implementing PROs [