Introduction

The implementation of digital pathology (DIPA) in the Region of Southern Denmark is a first-time achievement in Denmark and one of the first in the Nordic countries [1]. The clinical staffs of the Region’s pathology departments have been faced with a change in their workflow since the official start of the implementation at the end of 2020.

DIPA is an image-based environment that enables the acquisition, management, and interpretation of pathology information generated from a digitised glass slide [2]. In this way, the workflow for the pathologists changes from the traditional manual microscopy to visualising the tissue samples in a high-resolution image on a computer screen. Additionally, the biomedical laboratory scientists (BLS) now operate a scanner, perform quality control digitally, and distribute the tissue samples digitally to the pathologists. The preparation of tissue samples up until scanning remains the same [3, 4]. (See Appendix, Table 6 for full elaboration of changes in the workflow.)

DIPA has shown to be useful in the way pathologists can share tissue samples online and therefore consult with remote colleagues in the region or international specialists instantaneously [5]. DIPA is assumed to be the first step towards integrating artificial intelligence methods, algorithms, and computer-aided diagnostic techniques [6]. This will offer pathologists the tools to support the decision-making process in diagnostics and hopefully relieve them in terms of workload [1]. This is essential to achieve as tissue sampling is expected to increase in the future [1], due to an ageing population and growing referrals and the rise in initiatives to diagnose cancer earlier [6]. However, the number of pathologists is not expected to increase sufficiently to meet the growing demand [1, 7].

It is a strategic and political goal in Denmark to use digital technologies to improve the health sector [8]. It is therefore important to gain knowledge about how staff and management perceive the changes caused by increased digitalisation for other organisations in future implementations to better anticipate and handle the potential challenges.

As described above, implementing DIPA in a department entails a huge organisational change. The implementation of DIPA will have an impact on the daily workflow for numerous employees in the process of implementation. Furthermore, organisational change is considered a potential source of significant stress to employees [9].

Health researchers are increasingly appreciating and recognising the need for implementation science. Implementation science is a multidisciplinary research method created to increase the successful uptake of an intervention or new routine in, e.g., clinical departments, typically by addressing an underutilised practice. The aim of the field is to close the gap from research to practise by addressing the barriers or challenges that may stand in the way of a successful implementation [10]. Through social research, it aims to embrace broader than usual clinical research by including more levels than just the patient level. Levels like the provider team or group level and the organisational level are also thought to be potential barriers to implementation [11]. Implementation science suggests that simply measuring the productivity and effectiveness of implementations is insufficient. Researchers must recognise the need to evaluate not only endpoint outcomes [11], but also pay greater attention to audience and stakeholders’ perspectives as they are frequently overlooked, not acted upon, or reported [12].

Studies have examined the expectations, perceptions, and experiences of the staff towards the implementation of health technologies in a quantitative way [4, 13], but fewer studies in a qualitative way [7, 14] although it enables more in-depth assessment of opinions and attitudes towards, e.g., DIPA. This study is part of a larger ongoing mixed method study assessing the prerequisites and consequences of implementing DIPA [15]. This article will focus on qualitative data.

The aim of this qualitative study was to assess and evaluate personal expectations and experiences towards the implementation of DIPA among the clinical staff in two of the pathology departments in the Region of Southern Denmark. This was done through semi-structured interviews both prior to and during the implementation process of DIPA. The objective of this article is to highlight important facilitators, barriers, and potential benefits and challenges through the staff’s perspective. A second objective is to provide affected staff with sufficient insight into the process and what to expect. In this period of transition, capturing the perspectives of the clinical staff may contribute to a better understanding of the implementation process of digital technologies in health care. Hopefully, this study will help ensure an optimal change management in future implementations of DIPA.

Materials and Methods

Data consists of semi-structured interviews with staff members from two pathology departments in the Region of Southern Denmark. The method used to gain better insight into the development in viewpoints is process evaluation [10] in which data is collected before, during, and after implementation from an observational viewpoint with no interference or feedback from the researcher to the implementation team.

This study will analyse interview data collected over two rounds. The first round was in the period from November 2020 to January 2021, prior to the implementation of DIPA. The second round was from October 2021 to March 2022, during the implementation of DIPA. Data from these rounds are partly used in the larger study [4]. Post-implementation data gathering will occur at a later stage.

DIPA Solution

This regional project commenced with a pre-analytic and planning phase in 2016–2017. During this phase, the project group made international visits with other institutions that had transitioned to DIPA. The project group hosted a visit from an expert who provided insights into the implementation of DIPA in Leeds Teaching Hospitals [16]. The subsequent phase included preparation of requirements from the findings of several user groups, followed by bidding and negotiation rounds with potential system suppliers. For a complete overview of the implementation decision process, see [4] and Table 1.

The selected DIPA solution at the departments consisted of scanners and associated computers, as well as an image management system. The Hamamatsu NanoZoomer S360 Digital slide scanner (RRID:SCR_023761) is used for normal objects glass and Hamamatsu NanoZoomer S60 Digital slide scanner (RRID:SCR_022537) for macro glass. The software for the Hamamatsu scanners NZAcquire allows users to check the quality of the digital tissue samples. All glasses are scanned at × 40 except macro glasses which are scanned at × 20. When the glasses are scanned, they are released to an image management system by Sectra Danmark A/S. The image management system is contextually synchronised with a laboratory pathology system from the Danish company, Sirenia.

Departments

Both pathology departments engage in academic and community practice. They differ in geographic location, size, and specialisation. Annually, the larger department handles just under 60,000 histology cases and employs approximately 45 pathologists, while the other processes around 20,000 histology cases and employs around 10 pathologists. Both departments largely consist of subspecialized pathologists, where the larger department covers more sub-specialised tissue samples. The departments had limited experience with digital pathology in terms of archive scanning only operating in × 20 and frozen section biopsy.

Participants

To represent the entire department, the interviewed staff members consisted of representatives of BLS pathologists, interns, secretaries, and a project lead from the Region. The management was asked to select staff with various seniority across professions and different degrees of involvement in DIPA to join the study. The staff members and managers with time and interest were then interviewed.

Data Collection

The 4th author completed 18 individual interviews prior to implementation in the first round and 18 interviews during the implementation of DIPA in the second round. The 4th author met with each interviewee at his/her workplace or online. Audio recordings of the interviews were captured by use of a Dictaphone.

Interview Guide

The semi-structured interviews were based on an interview guide designed upon the McKinsey 7-S framework. This is a model designed to analyse the effectiveness of an organisational change consisting of seven internal elements that need to align for it to be successful. The designers of the model claim that a successful organisational change is affected by the relationship between Structure, Strategy, Systems, Style, Skills, Staff, and Shared Values [17]. The elements of the model can be divided into Hard S’s and Soft S’s, the first of which is considered easier to manage and change [18]. The McKinsey 7-S framework is suitable as a framework for investigating the implementation of DIPA due to its ability to highlight the internal conditions of the organisation. Based on this model, five themes were created for the interview guide (Table 1).

Table 1 Interview guide structure with McKinsey 7-S framework
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To investigate the different perspectives from the management and the staff, respectively, the interview guide was parted in two. The themes remained the same, but the questions were designed to fit according to the perspectives of the different groups. In the second round, the questions were adjusted to fit the changes during the implementation of DIPA (see Appendix, Tables 7–10 for the entire interview guide).

The interviewees were allowed to diverge from the questions and occasionally asked elaborating or clarifying questions to better portray the opinion of the interviewees.

Data Analysis

The 4th author transcribed the first round of interviews using the verbatim method for further analysis. This researcher transcribed the second round of interviews likewise. The interview data was stored in the secure database OPEN at Odense University Hospital [19].

Data analysis was performed using the NVivo version 14.23.2 (RRID:SCR_014802)—qualitative data analysis software. Coding was initially performed manually using a deductive approach following the structure of the interview guide. First, it was coded into the five themes and afterwards sub-coded into sub-themes. The sub-themes were then inductively coded according to the themes emerging within the answers. Expectations and experiences were then condensed, summarised, and compared within each theme and presented in the results. If an overall tendency or opinion arose around a particular theme, it is presented in the article. In the presence of a particularly relevant quote from an interviewee, it is incorporated to best emphasise and represent the common perception. The quotes were translated from Danish to English in the best way possible to preserve the attitude, character, and opinion of the quote. Participants were offered to review their translated quotes during a round of consent to publish with the possibility to rephrase their quotes. The validity of data was hereby ensured. Only a few participants rephrased their quotes. These quotes were evaluated by the 1st author and accepted due to retained expression.

Results

In both rounds, prior to and during implementation, 18 interviews were conducted. In the second round, 14 of the original interviewees participated again, while three who were lost to follow-up were replaced with three new interviewees. One original interviewee did not respond to consent obtained for this investigation and data therefore consists of 17 interviews in each round (Fig. 1).

Fig. 1
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Study flow chart of who participated in this study over the first and second round of interviews. First round of interviews consisted of 18 interviewees. Three interviewees were lost to follow-up for the second round leaving 15 original interviewees to participate in the second round of interviews. Three new interviewees were enrolled making up for the loss, again totaling 18 interviewees in the second round. While obtaining consent to this study, one original interviewee who participated in both rounds was omitted due to missing consent. Therefore, this study contains 17 interviewees from the first round and 17 interviewees from the second round

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Interviewee Characteristics

Out of the overall 20 interviewees, the majority were women, about two-thirds worked at the largest department. Doctors and BLS were equally represented by profession (Table 2).

Table 2 Sample characteristics of the interviewees (N = 20)
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Expectations Before Implementation

Thoughts on the general purpose of DIPA raised many expectations before implementation according to the staff and the management. The staff described expecting to get increased cooperation between the four departments in the Region of Southern Denmark and potentially all of Denmark or maybe even by time with peers worldwide. They described hoping that DIPA will make it possible to sustain smaller remote departments by relieving and sharing tasks, enabled by the geographic flexibility of digital solutions.

The interviewees expressed prior to the implementation that they were convinced that DIPA would play a vital role in progressing pathology into the future and setting the right direction for the department. The staff described believing that implementing DIPA perhaps will help maintain a higher standard and specialisation of diagnostics with easier and faster consultation. Most staff mentioned artificial intelligence being one of the purposes and goals for implementing DIPA. Nevertheless, they also noted that achieving this goal will take some time, due to the ongoing development needed to effectively integrate AI into the clinical workflow. The staff also expressed the hope of a more modern system attracting younger generations of pathologists.

The excitement in the department was tangible and attitudes towards DIPA were positive. The staff expressed awareness of a potential challenging time ahead, but remained optimistic: Of Course, it will be hard in the beginning…. And it will be a challenge, but I am sure we will get through it (Intern). The staff was able to see the future possibilities but had realistic expectations about what DIPA would provide and that it would take some time to get acquainted to and maximise the potential yield.

Concerns

Some concerns expressed by staff prior to implementation encompassed technical problems, including trust issues with digital solutions and patient safety. Other concerns were centred around their work situation including task changing, possible outsourcing, and especially the secretaries worried if they would still have a function in the future and had trouble seeing the benefits for their profession.

The staff described themselves as passionate about their work and highly aware of the impact it has on patients: You take pride in what you do, so the patient gets a quick and correct answer (BLS). When asked prior to implementation of DIPA, most employees did not assume DIPA would have much influence on what is important for them individually. However, several BLS expressed that they highly value their craftsmanship and worry that the level of craftsmanship will diminish in the future. One BLS answered this could make him identify less as a BLS in the future due to all new technology, whereas the pathologists in general did not think of the microscope as an identity marker.

Prior to implementation, the staff and the management expressed concerns about scepticism from the pathologists towards DIPA and their potential opposition to its implementation. Some of the pathologists wondered about the prematurity and the necessity of DIPA being implemented: The images are really good with high quality… But it is not better than the microscope, and there isn’t any indication in our system or DIPA which provides decision support. Therefore, it just becomes an add-on to the normal diagnostics (Consultant).

Experiences Regarding Implementation

Communication

In general, the staff expressed that they found the transition period challenging, stressful, and chaotic due to a lack of information and proper notice. Some BLS and interns described feeling as though they did not receive enough information, which created uncertainty. They expressed a lack of transparency, as if only a part of the information was carried on from the consultants and senior registrars. I understand that it has been a stressful task for the management to set this in motion. But there really has been a lack of communication. I believe there have been a lot of frustrating incidents (BLS). However, most of the consultants and senior registrars describe feeling sufficiently informed.

One of the senior registrars, who coincidentally alternated departments during the transition period, described thoughts on the communication. The senior registrar’s impression was that there was a surplus of information in the smaller department where everyone was involved in everything, whereas the information did not travel as far in the larger department. However, some staff mentioned that everyone received emails with updates, but these were too long, too broadly encompassing, and not read due to lack of time.

Training

The staff described not feeling sufficiently prepared prior to DIPA and described it as being faced with unknown territory. Likewise, they expressed a lack of information of expected challenges to improve preparedness as well as not receiving enough training prior to DIPA. The pathologists particularly expressed the need for follow-up training or …at least simultaneously (…) it is annoying when you discover some kind of feature that could have saved time, which you find out half a year later (Senior registrar). Furthermore, they expressed interest in getting to know more tools in the system but found it difficult to allocate the time to explore on their own.

Instructions for the BLS took place as “over-the-shoulder”-training which they expressed liking but they described the need for more resources and time allocated to it. Furthermore, the BLS were unsatisfied with the sparse amount of instructions in the quality control since this became a major work task change.

Both BLS and the pathologists confirmed that help was always available from other colleagues or super-users. The staff praised the super-users for their tenacity but wished on their behalf that they had received more training beforehand and had gotten allocated time to help. It has been challenging. (…) I don’t think I had the tools I needed to establish it really well, or to at least train the work team and to train my colleagues and such at home, because among other things we didn’t gain access to the testing system (BLS super-user). The missing test system, originally planned to be installed before implementation, is something many mention as a shame not getting to try out beforehand. The staff thought it would have clarified things and perhaps helped calm the nerves if they could have experienced the system in real life.

Overall, the management echoed the frustration over the absence of the test system and stressed the importance of being able to demonstrate and trial it with staff beforehand. Management attributed some of the deficiency in training to the suboptimal conditions resulting from the COVID-19 situation. However, they conveyed appreciation for the efforts of the dedicated super-users and their valuable contributions to the training.

Workflow/Load

During the transition phase to DIPA, the pathologists were involved in DIPA incrementally. According to the staff, this affected the BLS’ workflow of distributing tissue samples negatively because now there were two groups of pathologists: some working digitally and others still analogously. The BLS described their workflow during this period as being time-consuming and complicated, as it was their responsibility to keep track of which pathologist had transitioned and who had not: … it was *curse* annoying to put it lightly, but I understand that it takes time for the pathologists to get used to it (BLS).

The pathologists, on the other hand, found this period to be relatively problem-free and smooth, mostly complaining about the DIPA system not working smoothly together with the existing pathology system.

The pathologists expressed how the change in workflows due to DIPA led to the workload being the same or less than before. The BLS described a greater workload, while the secretaries experienced less. The management described the same perception as the staff: I think the pathologists are more positive, because they were rewarded with something, whilst the BLS have just gotten more work to do (Project lead).

Furthermore, the management struggled with allocating enough resources for the partially increased workload caused by the DIPA implementation. Management expressed being surprised by how demanding it was for the BLS and how hiring more BLS at that time was unfortunately difficult due to the high recruitment of BLS’ in the COVID-19 effort.

Management/Strategy

The management described that they had not pre-emptively imposed any particular theory of implementation for DIPA. A rapid implementation was mentioned as a high priority, bearing in mind not to overburden the staff. The management explained how they were hesitant to set up the intermediary milestones for implementation success criteria. According to the management, the implementation approach revolved around what was technically possible from the laboratory’s point of view. Furthermore, the management expressed that they consciously involved the BLS: It’s been important for me that it was a joint project between BLS and pathologists (…) and that has proven to be wise, because it’s been a large task and something new for the BLS to become acquainted with, and I believe they’ve made it less complicated because they feel that they’ve had an influence on the process (Consultant). A consultant in the management underlined the importance of the management also working with DIPA during the implementation process to understand the challenges on the same terms as the employees. He further explained the importance of it not being an outside academic trying to lead the department, but rather one from the department.

It was mentioned repeatedly by the management how important it was for them to give time for the staff to adapt to it and be sure to diagnose the same digitally as analogously. The management described being adamant about the way forward, without exceptions: We must be digital and that might take some people longer than others, but the result must be the same (Consultant). This was verified by the staff: The management has persistently backed up that this is what we’re going to do (…) they’ve been good at ensuring that things didn’t decelerate (…) so that everyone is on board, and we don’t miss anything (BLS).

Barriers and Facilitators

The staff and the management were also asked directly to identify barriers and facilitators that made this implementation process more or less optimal (see Table 3). The most highlighted facilitator was key persons who were very dedicated to making things work. Another facilitator was the positive reception by pathologists in contrast to the BLS group that experienced an increased workload and frustration working in a system not optimised for their use case, causing low motivation and excitement, thus categorised as a barrier. Staff also generally expressed that the implementation was aided by inter-regional meetings and sharing experiences midway. The pathologists were happy with the optimal image viewing system and its high quality. A specific barrier mentioned for a smooth implementation in one of the departments was the simultaneous department relocation that caused DIPA to be deprioritised.

Table 3 Facilitators and Barriers would benefit from being horizontally centered
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Experiences with DIPA

Asked about the importance of DIPA for the department, a common belief amongst the staff was that they were now recognised and acknowledged as a more modern workplace. They were proud to be trendsetting, more high tech, and to be the first to implement DIPA in Denmark.

In the current phase of implementation, the staff already had experienced successes in achieving DIPA-related benefits. This included the benefits of having digital tissue samples enabling more rapid sharing of images with colleagues and even remotely located colleagues. This feature was greatly appreciated by the pathologists, expressing excitement to increased levels of cooperation with other departments. This excitement was also shared by the BLS group that further added topics such as remote consultation, easier coverage during holidays, improved survivability for smaller departments due to more accessible remote expertise, and better supervision for interns to the list of benefits that had already had an impact on both departments. Other benefits frequently mentioned by pathologists were the addition of software tools and applications in the digital system, the ability to work from home, and improved ergonomy. (See Table 4 for additional identified benefits and elaborating quotes by staff.)

Table 4 Benefits of DIPA identified by the staff and the management
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When asked about DIPA-related disadvantages, the staff and the management expressed a preference to refer to them as challenges. The challenge that affected the staff the most was the increased turnaround times. The staff attributed this feeling of frustration to the fact that they already had an effective and optimally functioning laboratory, so it was going to be hard to improve. The BLS also expressed having problems keeping up due to scanner and server capacity leading the management to introduce shifted work schedules to increase the active scanner time. Another frequently expressed challenge, mostly mentioned by BLS, was the absence of an established method to assess results of quality control of the scanned tissue samples. This imposed on the BLS’ need to subjectively evaluate the quality control results, generating feelings of uncertainty. A prominent challenge apparent in the interviews with pathologists was their altered workflows and what those alterations brought about. These are challenges such as personal uncertainties regarding proper handling of digital tissue samples compared to working with them physically which they were used to, being more in touch with the process. Other challenges expressed by pathologists included the inconvenient switch between operating two different systems and the loss of the analogue fine adjustment in the microscope. Additionally, they mentioned the possibility that there might arise an expectation of logging on outside regular working hours in the future caused by the combination of increased remote accessibility and shifts in response time patterns. (See Table 5 for additional identified challenges and elaborating quotes by staff.)

Table 5 Challenges with DIPA identified by the staff and the management
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Discussion

Results from this study indicate that the staff at two pathology departments in the Region of Southern Denmark generally had high expectations towards DIPA. Both BLS and pathologists had similar preconceptions of DIPA, expressing interest, excitement, and general positivity of advancements in the field of pathology. The staff also had some concerns regarding the shift in workflow and introducing a new technology.

During implementation, the staff has experienced some benefits of DIPA but also identified some challenges. Lack of communication, resources, training, and a clearly formulated strategy were among experienced challenges. These caused feelings of distress, uncertainty, and insufficient involvement. Despite all this, the current acceptance and persistent positive attitude towards DIPA appear to be dependent on the assumption that the challenges will be solved going forward.

When discussing the perception of the implementation process of DIPA, it is important to keep in mind that these emotions are expressed during the implementation phase. Therefore, frustrations may appear particularly heightened, but it does not imply that these challenges were not addressed or managed. It is merely a momentary snapshot amidst the intense transition.

The research findings of this study indicate that several of the expectations regarding DIPA were indeed met, such as enhanced collaboration with other departments or colleagues. However, notable disparities between anticipated outcomes and actual experiences were encountered, particularly concerning turnaround times. Despite initial expectations of expedited processes, challenges arose during implementation, resulting in difficulties in achieving even baseline turnaround times. This disjunction between expectations and realities emerged as a significant personal concern among staff members.

Regarding contrasting expectations and experience outcomes, an observation emerged. Initial apprehensions centred around potential resistance from pathologists towards the new system. Surprisingly, pathologists exhibited a predominantly positive stance. Conversely, the BLS who encountered a pronounced alteration in their operational procedures and workload experienced a slightly different perception towards DIPA from the original excitement. Perhaps this will change when DIPA becomes more established in the laboratory as experienced in other labs [20].

By use of quantitative analysis, a previous study prior to implementation [4] found overall high expectations, motivation, and readiness for upcoming changes in the pathology departments as well as the perception of no huge barriers ahead. In contrast to these findings, the actual experienced barriers may have caused a more negative attitude during the implementation process. This might have been avoided if the appropriate barriers could have been identified and addressed prior to implementation. The specific barriers may not be universally relevant for other implementations, except exemplifying the influence unexpected barriers can have on the staff.

The findings of this article match multiple findings in other implementation science studies. First to mention is the importance of the individual and how an implementation process affects them. Individuals are carriers of cultural, organisational, professional, and individual mindsets, norms, interest, and affiliations [12, page 5]. This study found that the staff felt greatly impacted by being temporarily obstructed in providing the service they normally practise, affecting a core pride and representing a motivational factor for the staff, which was fast turnaround times and good service for the patients. This was the largest and most frequent basis for the staff’s frustrations and concerns. It is out of the scope of this study to comment on factual turnaround times, but it matches findings in other studies showing worsened turnaround times [21, 22]. However, it is noteworthy that other studies have indicated departments achieving enhanced turnaround times as digital workflows become more established, offering a hopeful prospect for staff members to anticipate and strive towards [23].

Another match with implementation science research is the importance of adaptation of interventions. Without adaptation, interventions usually come to setting as a poor fit, resisted by individuals who will be affected by the intervention [11]. The results of this study indicate a missed realisation of the importance and focus on the BLS’ work tasks, when designing the requirement specifications. This might be due to the management taking inspiration from DIPA implementations from other countries, specifically the task of quality assurance, a task performed by BLS in Denmark, unlike other countries. This poor adaptation of DIPA resulted in the BLS experiencing a more stressful and challenging transition.

Lastly, this study also found communication to be crucial for a successful implementation, resembling other findings in implementation science. The importance of communication is clear. Making staff feel welcome, open feedback and review among peers and across hierarchical levels, clear communication of mission and goals.. to contribute to effective implementation [11, page 8]. The interns and BLS felt a lack of transparency and communication, unlike consultants and senior registrars. This perhaps reinforces the staff’s feeling of information being shared uncoordinatedly across professions and hierarchy, contributing to a sense of exclusion. According to the staff, the management failed to communicate the expected challenges related to DIPA. This is perhaps caused by the unconscious communication of exclusively positive aspects of DIPA originating from the management in an attempt to promote readiness and morale towards DIPA among the staff. The consequence is that lack of communication, unintentional or not, induces misrepresentation. To avoid misrepresentation in future DIPA implementations, the management should give a complete, realistic, and authentic explanation of potentially positive and negative outcomes to reduce the uncertainty of the staff [24].

Using the McKinsey 7-S framework as a guideline for investigating expectations and experiences among the different stakeholders in the pathology departments made it possible to understand the influence that changes caused by the implementation of DIPA had on the staff. McKinsey 7-S framework claims that changes in one element affect the other elements and cause instability, as is confirmed in this study. The changes in hard elements Systems and Structure fx workflow and workload have substantially affected soft elements such as Staff and Shared Values fx integrity, motivation, and pride. To restore balance in the organisation, the department ought to make the adjustments necessary to ensure a better alignment of the 7-S elements. Failing to do so might induce difficulties for staff to appreciate the purpose of DIPA and change perceptions of it.

A limitation of this study using the qualitative method is that the statements are not supported by factual data confirming the correctness. The McKinsey 7-S model also does not encompass organisational effectiveness or performance explicitly, but this is being investigated concurrently in the Region of Southern Denmark and will be analysed and presented in a further study. Another limitation is that selection bias cannot be ruled out because the department managers selected the interviewees. However, it seems the responses were not unilaterally positive or negative only. Furthermore, too few secretaries participated, making it difficult to conclude much on their behalf. Further research on their role in DIPA is needed.

In return, examining the reception of DIPA from a qualitative point of view enabled exploring the implementation process in greater depth and from different perspectives. It induced concrete statements that can be summarised into focus points to keep in mind for other subsequent implementations (Fig. 2). The results identify not only what can be done differently in another implementation of DIPA but also identify the challenges of what needs to be improved in this current implementation. One such consideration is the discovery of the importance of engaging all professions, including the crucial contribution and dependence of the BLS in DIPA.

Fig. 2
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Take-home messages extracted from interviewees’ statements from the second round of interviews

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The findings can provide insight into what the staff and the management can expect when facing an implementation process of DIPA. It should be a priority in an implementation process such as this one, to research the barriers, challenges, shifts in workload, expectation, and feelings identified by other studies. Even if the hurdles are unavoidable, informing and reconciling expectations of the staff may improve the implementation experience.

Using process evaluation provided important insight into expectations prior to implementation to investigate development in attitudes, even though most of the results in this study are derived from data collected during implementation. Therefore, process evaluation is arguably more useful when data will be collected post-implementation in a future study and compared with the findings of this study.

In the future study, data will be collected when DIPA has become routine. The aim of that study will be to investigate whether the perceptions of DIPA have changed and if the challenges identified hitherto have been addressed, new issues emerged, or if more benefits have been realised.

Conclusions

In conclusion, clinical staffs from the two pathology departments in the Region of Southern Denmark were overall found to be optimistic and excited towards transitioning to DIPA. From their point of view, the implementation process was suboptimal. The results in this paper highlight pivotal topics to be addressed. Although still in the implementation phase, the staff already appreciates some DIPA-related benefits, such as the ability to work from home, easier distribution of tissue samples, collaboration inter- and intra-departmentally, and the capability to sustain smaller remote departments.

Based on the findings, it seems to be important to prepare staff through communication of the upcoming challenges of the transition to DIPA, more system-specific training beforehand, more allocation of time and resources in the implementation process and more focus on BLS’ work tasks in the requirement specifications.

Achieving this level of insight into how the implementation of DIPA affects the staff provides important knowledge about the relevance of focusing on change management during implementation of digital health solutions. The findings of this study may inspire staff or managers prior to implementing DIPA in their departments to ensure preparedness and a good transformation.