Attributes Required by Physiotherapists to Increase Adoption and Implementation of Practice Management Software: A Qualitative Study Using Focus Groups

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review your manuscript. The study was developed with a modern subject with practical implications. Currently, and as mentioned, many physiotherapists have not yet made the digital transition, which limits the profession. So, this study may have a real impact on the profession. Therefore, congratulations on its development. Despite being well constructed and relevant, some issues need to be reviewed:

- Major:

. In the methods section, specifically in development of the script, in addition to the literature review and pre-testing on a target population, it should also have been reviewed by an external panel of experts for validation. This step is not described, so if you have done it, please add it.

. In the results section, although it is not obligatory, I would like also to see some quantitative data, namely the words most frequent (plus the word cloud) and word associations (plus the word tree).

. In the discussion section, realizing how limited the literature is on this subject, I would have liked to have seen more exploration, comparison and justification with the literature. So, my recommention is to improving it. 

- Minor:

. In the line 82 is physio-therapists and it should be physiotherapists.

Keep up the good work!

Author Response

• Comment 1: Thank you for the opportunity to review your manuscript. The study was developed with a modern subject with practical implications. Currently, and as mentioned, many physiotherapists have not yet made the digital transition, which limits the profession. So, this study may have a real impact on the profession. Therefore, congratulations on its development. Despite being well constructed and relevant, some issues need to be reviewed:

Response: Thank you very much for your time reviewing this article, we do believe that it is a relevant issue and we really appreciate all your comments and contributions. We have tried to make changes to reflect your observations and recommendations in order to improve the manuscript.

Methods section

• Comment 2: In the methods section, specifically in development of the script, in addition to the literature review and pre-testing on a target population, it should also have been reviewed by an external panel of experts for validation. This step is not described, so if you have done it, please add it.

Response: Thank you very much for your observation, amendments were made in the methods section to clarify this issue.

A software engineer (with experience in designing and developing healthcare management software) and a family doctor (with experience founding and training a healthcare management software) participated and contributed to the preliminary group, changes to the script and guide were made accordingly.

• Comment 3: In the results section, although it is not obligatory, I would like also to see some quantitative data, namely the words most frequent (plus the word cloud) and word associations (plus the word tree).

Response: Thank you very much for your input on this matter. We agree that some quantitative data add value to the research, and we have tried to reflect some quantitative data (frecuency of coded statements and word associations) on the tables of results.

• Comment 4: In the discussion section, realizing how limited the literature is on this subject, I would have liked to have seen more exploration, comparison and justification with the literature. So, my recommention is to improving it.

Response: Thank you very much for your suggestions. We have tried to improve the discussion section with your recommendations, we hope we have been able to adequately reflect your indications.

• Comment 5: In the line 82 is physio-therapists and it should be physiotherapists.

Response: Thank you very much, we have addressed this issue.

Reviewer 2 Report

Comments and Suggestions for Authors

This study aimed to identify the essential attributes of practice management software (PMS) required by physiotherapists. The primary objective was to enhance software design and development, ultimately fostering increased adoption and implementation while minimizing disruptions to clinic workflows. This study holds significant interest for various audiences, including healthcare professionals, software developers, and researchers. For physiotherapists, identifying essential attributes in practice management software (PMS) directly addresses challenges they face in their daily workflows, potentially leading to improved efficiency, better patient care, and increased job satisfaction. Although the publication is relevant, timely and interesting, it can be improved. Below are my comments and questions for each section.

1.      Introduction could be improved by answering the following question:

1)     The introduction mentions a limited evidence base regarding software requirements identified from physiotherapists' participation in design activities. Could you elaborate on the extent of this gap and its implications for the field?

2)     To enhance the reader's understanding, consider explicitly connecting the study's objectives with the challenges identified in the early systematic review. How does examining perceptions align with addressing these challenges?

3)     Connect the aim of the study to the broader issue of slow adoption despite recognized benefits. How does understanding physiotherapists' perceptions contribute to addressing the overall challenge of technology adoption in physiotherapy clinics?

2.      Materials and methods section.

1)     It's clear that the study was conducted in the Valencian community of Spain, mainly among graduated physiotherapists in 2020. Could you provide more context on why this specific region was chosen? Are there unique aspects of the healthcare system or physiotherapy practices in this area that influenced the study?

2)     The decision to stop recruitment when saturation was reached is understandable. Could you provide more details on how saturation was determined? Were there specific criteria or indicators that helped you make this determination?

3)     The demographic characteristics of the participants are summarized, but could you discuss any notable patterns or variations observed within these characteristics later? How did the diversity within the participant pool contribute to the depth of insights?

 3.      Results.

The results also include information from the methodological part. Moreover, they are descriptive. I suggest the authors consider another form of presentation, perhaps a graphical representation or table or other form. it's confusing and difficult enough to read now.

4.      Discussions and conclusions.

1)  Discussions should require repetition of statements.

2)  In the discussion, it is worth highlighting and more clearly defining the manuscript limitations related not only to the methodology but also to the results. After all, the work is still very general, a lot of information is common. A clearer and more concrete discussion of how the obtained results can be useful is required.

 

3)  Conclusions must be specific and clear. Now that's another summary. But it seems normal at this stage, because part of the results is richly descriptive, so the conclusions are not precisely linked to them.

 

 

 

 

Author Response

• Comment 1: This study aimed to identify the essential attributes of practice management software (PMS) required by physiotherapists. The primary objective was to enhance software design and development, ultimately fostering increased adoption and implementation while minimizing disruptions to clinic workflows. This study holds significant interest for various audiences, including healthcare professionals, software developers, and researchers. For physiotherapists, identifying essential attributes in practice management software (PMS) directly addresses challenges they face in their daily workflows, potentially leading to improved efficiency, better patient care, and increased job satisfaction. Although the publication is relevant, timely and interesting, it can be improved. Below are my comments and questions for each section.

Response: Thank you very much for your time reviewing this article, we really value your assessment and contributions to the article. We agree with most of your comments and we have tried to improve the article with your recommendations.

 

Introduction

• Comment 2: The introduction mentions a limited evidence base regarding software requirements identified from physiotherapists' participation in design activities. Could you elaborate on the extent of this gap and its implications for the field?

Response: Thank you very much for your input on this matter. We agree that this gap could be further developed. We have tried to further elaborate the extent of the evidence, the gap and its implications for the field in paragraphs 3 and 4 of the introduction.

• Comment 3: To enhance the reader's understanding, consider explicitly connecting the study's objectives with the challenges identified in the early systematic review. How does examining perceptions align with addressing these challenges?
• Response: Thank you very much for your recommendation. We have tried to address this issue by identifying the challenges in the early systematic review and another reference was included. We tried to align the challenges with the study objectives in the paragraph 4 of the introduction.
• Comment 4: Connect the aim of the study to the broader issue of slow adoption despite recognized benefits. How does understanding physiotherapists' perceptions contribute to addressing the overall challenge of technology adoption in physiotherapy clinics?
• Response: Thank you very for your contribution. We have tried to address this issue by connecting the aim of the study to the challenge of technology adoption by developing the importance of physiotherapists contributions to improve the efficiency and functionality of the software, enhancing the satisfaction of physiotherapists and thus facilitating adoption and implementation.

 

Materials and Methods

• Comment 5: It's clear that the study was conducted in the Valencian community of Spain, mainly among graduated physiotherapists in 2020. Could you provide more context on why this specific region was chosen? Are there unique aspects of the healthcare system or physiotherapy practices in this area that influenced the study?
• Response: Thanks very much for your feedback. The focus groups were carried out in the Valencian community since the researchers come from this region, so the contacts and resources were located mainly in this region. The Valencian Community has no major particularities different from the rest of the country regarding healthcare system or physiotherapy practices, so the physiotherapy situation is representative of the physiotherapy in Spain. We have tried to clarify these issues on the methods section (2.2. Context) and we have also commented on it as a limitation in the discussion section.
• Comment 6: The decision to stop recruitment when saturation was reached is understandable. Could you provide more details on how saturation was determined? Were there specific criteria or indicators that helped you make this determination?

Response: Thank you very much for the observations. We have tried to clarify how saturation was determined at the end of the “Data collection methods” section.

• Comment 7: The demographic characteristics of the participants are summarized, but could you discuss any notable patterns or variations observed within these characteristics later? How did the diversity within the participant pool contribute to the depth of insights?

Response: Thanks very much for your recommendations. The diversity in the demographic characteristics of the participants and their differences in viewpoints and contributions is covered in the Discussion section, where we have added some comments to clarify. We hope that the modifications shed some light on this subject.

 

Results

• Comment 8: The results also include information from the methodological part. Moreover, they are descriptive. I suggest the authors consider another form of presentation, perhaps a graphical representation or table or other form. it's confusing and difficult enough to read now.

Response: Thanks very much for your views, we really appreciate your suggestion. At the time, we considered different possibilities for presenting the results, either in written form or as a table. We understand that a table can be more visual, but the table with the corresponding citations took up a lot of space and was very dense, so we decided to redact the results and add only the most important citations. However, we also have the table of results with the corresponding citations if deemed appropriate.

 

Discussion

Comment 9: Discussions should require repetition of statements.

Response: Thank you very much for your feedback. We have tried to repeat the statements in the Discussion section.

Comment 10: In the discussion, it is worth highlighting and more clearly defining the manuscript limitations related not only to the methodology but also to the results. After all, the work is still very general, a lot of information is common. A clearer and more concrete discussion of how the obtained results can be useful is required.

Response: Thank you very much for your recommendations, we have added a paragraph in the discussion section to cover in more detail the limitations of the study regarding methods and results, as well as the diversity in insights.

 

Conclusion

Comment 7: Conclusions must be specific and clear. Now that's another summary. But it seems normal at this stage, because part of the results is richly descriptive, so the conclusions are not precisely linked to them.

Response: Thanks very much for your views on this section. We have made some changes on the conclusion, but we are not sure we have understood fully your recommendations, so our apologies in advance.

Reviewer 3 Report

Comments and Suggestions for Authors

Software design and development in the clinics are the recent new topic for physiotherapists. Unlike electronic health records (EHR), practice management software (PMS) was initially more focused on business and administrative operations in clinics. Clinicians are starting the application of these methods, and further development of both HER and PMS is required to interact with each other, which is essential. On the other hand, some researchers claimed that adopting these technologies is low and slow over time. The authors investigated the requirement to identify the PMS attributes with 27 graduated physiotherapists with clinical and management expertise and experience in management software for physiotherapy services. 

 

It is a well-written article. However, the reviewer felt that the content is generally shallow because PMS is being enthusiastically developed worldwide. In the reviewers' country in East Asia, some of the PMS systems are well integrated into the EHR system. While the strength of this research should be that experienced physiotherapists did the discussion, it is also the worst weak point in the current draft. 

Although the authors gathered many clinicians, the discussion remained on general issues such as payment or document saving. Discussion leaned to more clinical side should have been facilitated: education, a consultation like telemedicine, patient data as in movie format, application of a variety of clinical scales, and research conduction. 

The absence of experts from other fields like commerce, merchandise, and computer engineering made the discussion generally not broad and in-depth. Therefore, the reviewer considers that the fraction of clinicians, researchers, and developers who benefited from this paper will be few. 

I was sorry that the other new aspects in practice, like AI applications, were not discussed. To the reviewer's knowledge, a recent article reported the potential of Chat-GPT application in the field of rehabilitation.

 

 

Major concern;

Line 107: "Sample size was estimated to 107 be sufficient, based on the principle of theoretical saturation." The details of sample size estimation should be presented.

 

Line 133: A significant drop-out rate will affect the statistical validity. 

 

Line 141 The inconsistency of the demographics of physiotherapists makes the data interpretation difficult.

 

 

Minor concerns;

Line 14, "im-prove", line 23 "pro-grams" etc., there are numerous inappropriate hyphens which might be the residue when it was located at indention.

 

Table 1. This form of Table may not be a general one. 

 

 

 

Author Response

REVIEWER 3

Comment 1: It is a well-written article. However, the reviewer felt that the content is generally shallow because PMS is being enthusiastically developed worldwide. In the reviewers' country in East Asia, some of the PMS systems are well integrated into the EHR system. While the strength of this research should be that experienced physiotherapists did the discussion, it is also the worst weak point in the current draft.

Response: Thank you very much for reviewing our article, we appreciate your dedication and all your comments. We agree that PMS is enthusiastically developed worldwide, so we have added some statistics on the physiotherapy software market growth in contrast to the slow adoption discussed in the literature. We have also added statistics on the information and communication technologies adoption among physiotherapists to add more data.

We have also tried to emphasise the experience of physiotherapists participating in the focus groups throughout the article.

 Comment 2: Although the authors gathered many clinicians, the discussion remained on general issues such as payment or document saving. Discussion leaned to more clinical side should have been facilitated: education, a consultation like telemedicine, patient data as in movie format, application of a variety of clinical scales, and research conduction.

Response: Thanks very much for the observations, we have made some amendments on the article to clarify this issue.

First of all, we have added backup questions which reflect that the content dealt with clinical aspects as well.

Also, we have added the frecuency of coded statements to the “Results” section, where clinical care took most of the discussion time in all focus groups, with more than 60% of the discussion time and coded statements in average.

Issues like telemedicine (videoconference, chat, etc.), patient data registering formats (audio, video, apps, etc.), the use of clinical scales, questionnaires, body maps and other tools, and the gathering of statistic for business analysis or research were mentioned or discussed in some cases. For example, the requirements of videoconference and chat were discussed for telerehabilitation purposes and is reflected as DHI (digital health interventions).

However, although many issues emerged, we tried to synthesize and reflect the most relevant and recurrent ones, so some issues might have been left out. We have added  some comments to discuss this in the Discussion section.

Comment 3: The absence of experts from other fields like commerce, merchandise, and computer engineering made the discussion generally not broad and in-depth. Therefore, the reviewer considers that the fraction of clinicians, researchers, and developers who benefited from this paper will be few.

Response: Thanks very much for your insights, we agree that this point wasn’t clear before. We would like to clarify that a software engineer (with experience in designing and developing healthcare management software) and a family doctor (with experience founding and training a healthcare management software) participated and contributed to the preliminary group, changes to the script and guide were made accordingly. This has been added to the manuscript.

Comment 4: I was sorry that the other new aspects in practice, like AI applications, were not discussed. To the reviewer's knowledge, a recent article reported the potential of Chat-GPT application in the field of rehabilitation.

Response: Thanks very much for the input, it is a very interesting issue and we will certainly include it in future research, since it could offer many options. At the time, the AI field for PMS in physiotherapy was unexplored in Spain, it was not mentioned in the previous software study and it was only mentioned once during the focus groups.

Comment 5: Line 107: "Sample size was estimated to be sufficient, based on the principle of theoretical saturation." The details of sample size estimation should be presented.

Response: Thank you very much for your comment. This has been rephrased and added.

Comment 6: Line 133: A significant drop-out rate will affect the statistical validity. 

Response: Thank you very much. In quantitative studies, to achieve statistical validity it is essential for researchers to have sufficient data and also choose the right statistical approach to analyze that data. In contrast, because this is a qualitative study results were established when saturation of information was achieved.

Comment 7: Line 141 The inconsistency of the demographics of physiotherapists makes the data interpretation difficult.

Response: Thank you so much for your comments. We tried to recruit physiotherapists with different profiles to obtain a greater variety in their responses, and in this way, be able to identify different and more varied needs, within which they were all physiotherapists. Possibly, having a more homogeneous sample would have limited the variety of needs and achieved saturation sooner.

Comment 8: Line 14, "im-prove", line 23 "pro-grams" etc., there are numerous inappropriate hyphens which might be the residue when it was located at indention.

Response: Thank you very much, we have addressed this issue.

Comment 9: Table 1. This form of Table may not be a general one. 

Response: Thank you very much for your comment. We have corrected this.