Literature Collection

BACKGROUND: Implementation strategies often fail to achieve their intended outcomes, yet limited methodological guidance exists for systematically understanding why strategies fail or how to adapt them for new contexts. Causal pathway diagrams (CPDs) are tools that map the mechanisms through which implementation strategies work. This study proposes a methodologic approach to use CPDs both retrospectively to understand implementation failure in one context and prospectively to inform adaptation for a new context. METHODS: We illustrate the proposed methodology using a case study of a failed implementation strategy bundle-including an electronic best practice alert and clinical decision support, provider education, and clinical champion-designed to improve metabolic-associated steatotic liver disease (MASLD) screening in a weight management clinic. Using mixed methods data and realist evaluation principles, we constructed CPDs guided by three theoretical frameworks (i-PARIHS, Theory of Planned Behavior, and Technology Acceptance Model) and post-intervention qualitative interviews to understand failure mechanisms. We then applied insights from these CPDs alongside qualitative interviews with primary care providers to develop predictive CPDs for implementing adapted strategies in the primary care setting. RESULTS: The retrospective CPDs revealed specific failure points not apparent during initial planning. The clinical decision support strategy failed because fundamental preconditions were unmet: only 54.2% of patients had recent laboratory results needed for automated calculations, and the alert placement misaligned with provider workflows. Provider education and clinical champion strategies were undermined by moderators including lack of confidence in the FIB-4 screening tool and competing clinical priorities. The prospective primary care CPDs identified necessary adaptations including replacing best practice alerts with integrated health maintenance reminders, adding content about MASLD complications and treatments to provider education, and selecting multiple champions to ensure adequate coverage. CONCLUSIONS: CPDs provide a systematic framework for transforming implementation failures into actionable insights for future intervention design. The integration of realist evaluation principles with multi-theoretical CPD development offers a replicable methodology for retrospective mechanistic failure analysis and context-adapted prospective implementation. This approach advances implementation science by moving beyond descriptive accounts toward rigorous understanding of how and why implementation strategies work across diverse settings.

BACKGROUND: Despite the recognized benefits of integrating patient perspectives into healthcare design and clinical decision support, theoretical approaches and standardized methods are lacking. Various strategies, such as developing pathways, have evolved to address these challenges. Previous research emphasized the need for a framework for care pathways that includes theoretical principles, extensive user involvement, and data from electronic health records to bridge the gap between different fields and disciplines. Standardizing the representation of the patient perspective could facilitate its sharing across healthcare organizations and domains and its integration into journal systems, shifting the balance of power from the provider to the patient. OBJECTIVES: This study aims to 1) Identify research approaches taken to develop patient-centred, integrated, care pathways supported by electronic health records 2) Propose a socio-technical framework for designing patient-centred care pathways across multiple healthcare levels that integrates the voice of the patient with the knowledge of the care provider and technological perspectives. METHODS: This study conducted a scoping review following the Joanna Briggs Institute guidelines and PRISMA-ScR protocol. The databases PubMed, Scopus, Web of Science, ProQuest, IEEE, and Google Scholar were searched using a key term search strategy including variations of patient-centred, integrated care, pathway, framework and model to identify relevant studies. Eligible articles included peer-reviewed literature documenting methodologies for mapping patient-centred, integrated care pathways in healthcare service design. RESULTS: This review summarizes the application of care pathway modelling practices across various areas of healthcare innovation. The search resulted in 410 studies, with 16 articles included after the full review and grey literature search. CONCLUSIONS: Our research illustrated incorporating patient perspectives into modelling care pathways and healthcare service design. Regardless of the medical domain, our methodology proposes an approach for modelling patient-centred, integrated care pathways across the care continuum, including using electronic health records to support the pathways.