Lessons in complexity learned during a Canadian virtual pragmatic trial for prostate cancer survivorship

Widespread adoption of digital health innovations (DHI) is often plagued with barriers to successful implementation. We share our experiences piloting and implementing our DHI, the Ned Clinic (Ned for “no evidence of disease”), to support prostate cancer survivors. We applied the non-adoption, abandonment, scale-up, spread and sustainability complexity assessment tool (NASSS-CAT) to outline implementation complexities at four cancer centres across Canada. We uncovered underlying factors that contribute to or explain implementation. Factors identified included: service interruptions, costing structure, user experience (acceptability); patient referral, overscheduling, incentivization, timing (appropriateness); competing institutional changes, misaligned value proposition, and requisite digital literacy (adoption). Solutions and changes made that carried into the trial included agile development, shifting responsibilities (e.g. tech support, clinic-personalized recruitment strategies), increasing in-person socialization of Ned Clinics after COVID-19 lockdowns, and enhanced documentation. Implementing new and complex interventions in a complex adaptive system requires an element of trial and error to find what works best. Adaptations between the pilot and trial can compensate for complexity. Ongoing multidisciplinary stakeholder engagement was crucial for project success especially as complexities arose. Our approach has informed how agile adaptations can improve target implementation outcomes and may be transferable to other DHI contexts.