Power, paradox and pessimism: On the unintended consequences of digital health technologies in primary care

Access systems in general practice: a systematic scoping review

BACKGROUND

Access to GP appointments is increasingly challenging in many high-income countries, with an overstretched workforce and rising demand. Various access systems have been developed and evaluated internationally.

AIM

To systematically consolidate the current international evidence base related to different types of GP access systems.

DESIGN AND SETTING

Scoping review examining international literature.

METHOD

Literature searches were run across relevant databases in May 2022. Title, abstract, and full-text screenings were carried out. Data from included studies were extracted and mapped to synthesise the components and aims within different GP access systems.

RESULTS

In total, 49 studies were included in the review. The majority of these were set in the UK. Some access systems featured heavily in the literature, such as Advanced Access, telephone triage, and online consultations, and others less so. There were two key strategies adopted by systems that related to either changing appointment capacity or modifying patient pathways. Components related to these strategies are summarised and illustrated as a schematic representation. Most rationales behind access systems were practice, rather than patient, focused. 'Add-on' systems and aims for efficiency have become more popular in recent years.

CONCLUSION

This synthesis provides a useful tool in understanding access systems' aims, design, and implementation. With focus on alleviating demand, patient-focused outcomes appear to be underinvestigated and potentially overlooked during design and implementation. More recently, digital services have been promoted as offering patient choice and convenience. But a context where demand outweighs resources challenges the premise that extending choice is possible.

Instant messengers and health professionals' agency in Russian clinical settings

This research examines how Russian healthcare professionals use instant messengers (in particular, the group chat function on instant messengers) for work-related tasks. Based on qualitative interviews with Russian doctors and nurses conducted in spring 2020, the article explores how the informal implementation of instant messenger's group chat function facilitated and shaped health professionals' agency in two key areas of professional control: work regulation and medical knowledge. In the first case, front-line healthcare professionals used instant messengers to make horizontal connections, share relevant regulatory information, and smooth over organizational discrepancies. Hospital management, on the other hand, employed this technology as an additional tool for imposing top-down control on employees. The adoption of instant messengers for medical knowledge dissemination is more consistently linked with professional logic. By utilizing this technology, healthcare personnel not only shared clinical recommendations, publications, and clinical experience, but also fostered solidarity within the country's medical community and forged connections with international medical professionals. These findings support the social science assumption concerning the contextualized character of both professionalism and digital innovations in healthcare. In state-dominated Russian healthcare, instant messengers not only assist structurally disempowered professionals in dealing with pragmatic challenges, but also create more space for their ground-level discretion in the face of intense administrative pressure. Moreover, since the messaging technology helps Russian health workers in navigating and agentially connecting different knowledge and regulatory landscapes, it also fosters a new - trans-local and more reflexive - form of professionalism in post-socialist medicine.

Prenatal testing technologies in Australia: Unintended clinical and emotional complexities in underprepared systems

The past decade has seen technological advances in prenatal screening technologies rapidly integrated into clinical practice. These technologies have revolutionised healthcare and raised complex socio-ethical issues such as equitable access, medical commercialisation, and new eugenics. However, the important issue of the impact of these technologies on healthcare professionals is receiving less attention. Exploring this issue in the Australian context, we conducted a survey from August to November 2022, targeting health and allied health professionals who work with parents in the perinatal period who have received a fetal diagnosis. We received 75 substantive responses from a diversity of professionals, including sonographers, midwives, genetic counsellors and medical providers. In this article, we consider the unintended impacts of prenatal screening technologies on healthcare workers, drawing from Ziebland et al., 's 2021 unintended consequences framework. Our reflexive thematic analysis produced three key themes: "Unintended Clinical Complexities", "Adapting Work Practices to Keep Up in Systems that Lack", and "Unintended Intensification of Emotional Labour". Prenatal testing technologies have intentionally increased early testing and fetal information, offering veiled promises of increased certainty in pregnancy. However, our analysis highlights that these advancing technologies also generate more ambiguous results, creating unintended clinical and emotional complexities for healthcare providers. Workers must manage increased clinical uncertainty and constant change, creating intensified emotional labour in under-prepared systems. We conclude by identifying the need to recognise the impacts of advancing prenatal screening technologies on healthcare workers and for targeted professional training to prepare healthcare professionals for the complexities introduced by these new technologies.

Perceptions of impure innovation: Health professionals' experiences and management of stigmatization when working as digital innovators

The healthcare sector has increasingly adopted digital innovations. Nonetheless, medical professionals have also resisted a variety of digital innovations. While the range of factors driving such resistance to innovation are well documented, less clear is how such resistance is experienced and managed by professionals attempting to innovate. We conducted a qualitative study of English and German 'dual-role' professionals, who worked both as clinical practitioners and digital innovators. Inductively theorizing from our interview data, we explain how individual professionals experience different intensities of stigmatization from colleagues when working with digital innovations. We theorize that the more central a dual-role professional is within an organization and the more their innovation deviates from standard professional duties, the more likely the innovation is to be viewed as impure within a professional group and be the target of stigmatization. We identify a range of professional, social, and personal strategies employed by dual-role innovators to manage their experiences of stigmatization and consider the implications for healthcare innovation.

A manifesto for improving cancer detection: four key considerations when implementing innovations across the interface of primary and secondary care

Improving cancer outcomes through innovative cancer detection initiatives in primary care is an international policy priority. There are unique implementation challenges to the roll-out and scale-up of different innovations, requiring synchronisation between national policy levers and local implementation strategies. We draw on implementation science to highlight key considerations when seeking to sustainably embed cancer detection initiatives within health systems and clinical practice. Points of action include considering the implications of change on the current configuration of responsibility for detecting cancer; investing in understanding how to adapt systems to support innovations; developing strategies to address inequity when planning innovation implementation; and anticipating and making efforts to mitigate the unintended consequences of innovation. We draw on examples of contemporary cancer detection issues to illustrate how to apply these recommendations to practice.

Data driven or data informed? How general practitioners use data to evaluate their own and colleagues' clinical work in clusters

In contemporary policy discourses, data are presented as key assets for improving health-care quality: policymakers want health care to become 'data driven'. In this article, we focus on a particular example of this ambition, namely a new Danish national quality development program for general practitioners (GPs) where doctors are placed in so-called 'clusters'. In these clusters, GPs are obliged to assess their own and colleagues' clinical quality with data derived from their own clinics-using comparisons, averages and benchmarks. Based on semi-structured interviews with Danish GPs and drawing on Science and Technology Studies, we explore how GPs understand these data, and what makes them trust-or question-a data analysis. The GPs describe how they change clinical practices based on these discussions of data. So, when and how do data for quality assurance come to influence their perceptions of quality? By exploring these issues, we carve out a role for a sociological engagement with evidence in everyday medical practices. In conclusion, we suggest a need to move from the aim of being data driven to one of being data informed.

Introducing Point-of-Care PCR technology in general practice: Ambiguities, experiences, and perceptions among health care professionals

In this paper we present findings from a qualitative ethnographic study investigating the experiences and perceptions of general practitioners and other practice staff when introducing a new point of care diagnostic test technology (point of care polymerase chain reaction (POC PCR)) in general practice in Denmark. The ethnographic study was conducted in five general practice clinics, involving observations in four of the clinics and interviews with general practitioners and practice staff in all five clinics. Following an initial analytic phase in which barriers and facilitators in the implementation process of the Point-of-Care test were identified, we developed theoretically informed themes, drawing upon Hartmut Rosa's social theory of technological acceleration. These themes included ambiguous experiences and perceptions of: (i) diagnostic specification and inflation embedded in diagnostic practices; (ii) empowerment and erosion of professional judgment; (iii) strategies of security and insecurity in communication; (iv) the interdependence between professional autonomy and economic structures associated with organizational power; and (v) subjective and organizational time. We discuss how diagnostic technologies simultaneously contribute to and disrupt treatment safety, efficiency, and medical decision-making. Using Rosa's sociological concepts of alienation and resonance, this article furthermore explores how these ambiguous dynamics are experienced in general practice settings. It also examines the implications of navigating a heterogeneous socio-technical and medical landscape and what it means to be a health professional in a contemporary general practice environment that is increasingly shaped by diagnostic technologies.

Implementation of a virtual community of practice to promote the empowerment of middle-aged people with multimorbidity: study protocol of a randomised controlled trial

INTRODUCTION

Empowering people living with multimorbidity (multiple chronic conditions) to gain greater confidence in managing their health can enhance their quality of life. Education focused on self-management is a key tool for fostering patient empowerment and is mostly provided on an individual basis. Virtual communities of practice (VCoP) present a unique opportunity for online education in chronic condition self-management within a social context. This research aims to evaluate the effectiveness/cost-effectiveness of individualised, online self-management education compared with VCoP among middle-aged individuals living with multiple chronic conditions.

METHODS AND ANALYSIS

People aged 30-60, living with ≥2 chronic conditions and receiving care in primary care (PC) centres and outpatient hospital-based clinics in Madrid and Canary Islands will enrol in an 18-month parallel-design, blinded (intervention assessment and data analysts), pragmatic (adhering to the intention-to-treat principle), individually randomised trial. The trial will compare two 12-month web-based educational offers of identical content; one delivered individually (control) and the other with online social interaction (VCoP, intervention). Using repeated measures mixed linear models, with the patient as random effect and allocation groups and time per group as fixed effects, we will estimate between-arm differences in the change in Patient Activation Measure from baseline to 12 months (primary endpoint), including measurements at 6-month and 18-month follow-up. Other outcomes will include measures of depression and anxiety, treatment burden, quality of life. In addition to a process evaluation of the VCoP, we will conduct an economic evaluation estimating the relative cost-effectiveness of the VCoP from the perspectives of both the National Health System and the Community.

ETHICS AND DISSEMINATION

The trial was approved by Clinical Research Ethics Committees of Gregorio Marañón University Hospital in Madrid/Nuestra Señora Candelaria University Hospital in Santa Cruz de Tenerife. The results will be disseminated through workshops, policy briefs, peer-reviewed publications and local/international conferences.

TRIAL REGISTRATION NUMBER

NCT06046326.

Health Technology Access and Peer Support Among Digitally Engaged People Experiencing Homelessness: Qualitative Study

BACKGROUND

Although the effects of digital health are receiving wide scientific attention, very little is known about the characteristics of digitally engaged people experiencing homelessness, especially in Central and Eastern Europe. Our previous research revealed a considerable level of internet use in the homeless population of Budapest, Hungary, for general purposes (350/662, 52.9%) and medical purposes (229/664, 34.6%). Moreover, a digitally engaged subgroup was identified (129/662, 19.5%).

OBJECTIVE

The aim of this exploratory study was to map out the resources, attitudes, and behaviors of digitally engaged homeless individuals in relation to digital technology to set the basis for potential health policy interventions, which will enable better access to health services through strengthening of the digital components of the existing health care system.

METHODS

Between August 18, 2022, and October 27, 2022, a total of 12 in-depth semistructured interviews were conducted in 4 homeless shelters in Budapest, Hungary. Upon analysis by 3 independent evaluators, 2 interviews were excluded. The interviewees were chosen based on purposive sampling with predefined inclusion criteria. Thematic analysis of the transcripts was conducted.

RESULTS

In the thematic analysis, 4 main themes (attitude, access, usage patterns, and solutions for usage problems) emerged. Health-related technology use mostly appeared in health information-seeking behavior. Online search for prescribed medications (5 interviews), active ingredients of medications (4 interviews), medicinal herbs believed to replace certain pills (2 interviews) or foods, and natural materials (1 interview) were mentioned. Moreover, mobile health app use (3 interviews) was reported. The intention to circumvent or check on mainstream health care solutions was mainly associated with previous negative experiences in the health care system. Several gaps in the daily use of technology were identified by the interviewees; however, more than half of the interviewees (6/10) turned out to be contact points for their peers for digital problem-solving or basic digital literacy skill enhancement in the homeless shelters. Furthermore, a lack of institutional support or special programs targeting senior clients was noted.

CONCLUSIONS

Digitally engaged homeless individuals might become mediators between their peers and comprehensive digital health programs. They have the trust of their peers, can recognize and harness the benefits of digital technology, and are able to provide meaningful help in technology- and usage-related issues through experience. Digital health services have great promise in community shelters for managing and preventing health issues, and digitally engaged individuals might be important for the success of such services.

"All hands on deck": a qualitative study of safeguarding and the transition to telemedical abortion care in England and Wales

The COVID-19 pandemic raised significant challenges for in-person healthcare provision, leading healthcare providers to embrace digital health like never before. Whilst changes were made as part of a public health response, many have now become permanent fixtures of the healthcare landscape, significantly altering the way care is provided not only for patients, but also for the healthcare professionals that provide care. In abortion care in England and Wales, previously stringent regulations on in-person care provision were relaxed to permit the use of telemedicine and self-administration of medications at home. These changes have since been made permanent. However, there remains opposition to remote abortion care pathways on the basis of safeguarding. Opponents argue that it is not feasible to effectively safeguard patients accessing abortion care remotely. We conducted a qualitative study using semi-structured interviews with abortion care providers in England and Wales. Participants were asked about their views and experiences of the transition to remote care provision, with a particular focus on how they adapted their safeguarding practice. In this article, we present three themes that highlight the changing roles of healthcare professionals in abortion care: (1) a challenging backdrop and resulting apprehension, (2) adaptive practices, and (3) the continued importance of professional curiosity. Across all three themes, participants reflected significantly on how changes were made and what they experienced in the period of transition to telemedicine. In particular, they discussed the changing nature of their professional roles amidst digitalisation. Our findings provide a basis for reflection on the increasing introduction of digital approaches to healthcare provision, highlighting points for caution and emphasising the need to involve professionals in the transition process to ensure vital buy-in. Through this, we articulate two novel understandings of digitalisation: (1) the impact of speed-associated pressures on professional adaptation during digitalisation, and (2) off-proforma safeguarding through telemedicine as a form of invisible non-routine work.

Public perspectives on the use of different data types for prediction in healthcare

OBJECTIVE

Understand public comfort with the use of different data types for predictive models.

MATERIALS AND METHODS

We analyzed data from a national survey of US adults (n = 1436) fielded from November to December 2021. For three categories of data (identified using factor analysis), we use descriptive statistics to capture comfort level.

RESULTS

Public comfort with data use for prediction is low. For 13 of 15 data types, most respondents were uncomfortable with that data being used for prediction. In factor analysis, 15 types of data grouped into three categories based on public comfort: (1) personal characteristic data, (2) health-related data, and (3) sensitive data. Mean comfort was highest for health-related data (2.45, SD 0.84, range 1-4), followed by personal characteristic data (2.36, SD 0.94), and sensitive data (1.88, SD 0.77). Across these categories, we observe a statistically significant positive relationship between trust in health systems' use of patient information and comfort with data use for prediction.

DISCUSSION

Although public trust is recognized as important for the sustainable expansion of predictive tools, current policy does not reflect public concerns. Low comfort with data use for prediction should be addressed in order to prevent potential negative impacts on trust in healthcare.

CONCLUSION

Our results provide empirical evidence on public perspectives, which are important for shaping the use of predictive models. Findings demonstrate a need for realignment of policy around the sensitivity of non-clinical data categories.

Remote and technology-mediated working during the COVID-19 pandemic: A qualitative exploration of the experiences of nurses working in general practice (the GenCo Study)

AIM

To explore how nurses working in general practice experienced remote and technology-mediated working during the COVID-19 pandemic.

DESIGN

Exploratory qualitative study with nursing team members working in general practices in England and national nurse leaders.

METHODS

Data were collected between April and August 2022. Forty participants took part in either semi-structured interviews or focus groups. Data were analysed using Framework Analysis informed by the PERCS (Planning and Evaluating Remote Consultation Services) Framework. University of York ethics approval [HSRGC/2021/458/I] and Health Research Authority approval were obtained [IRAS:30353. Protocol number: R23982. Ref 21/HRA/5132. CPMS: 51834]. The study was funded by The General Nursing Council for England and Wales Trust.

RESULTS

Participants continued to deliver a significant proportion of patient care in-person. However, remote and technology-mediated care could meet patients' needs and broaden access in some circumstances. When remote and technology-mediated working were used this was often part of a blended model which was expected to continue. This could support some workforce issues, but also increase workload. Participants did not always have access to remote technology and were not involved in decision-making about what was used and how this was implemented. They rarely used video consultations, which were not seen to add value in comparison to telephone consultations. Some participants expressed concern that care had become more transactional than therapeutic and there were potential safety risks.

CONCLUSION

The study explored how nurses working in general practice during the COVID-19 pandemic engaged with remote and technology-mediated working. It identifies specific issues of access to technology, workload, hybrid working, disruption to therapeutic relationships, safety risks and lack of involvement in decision-making. Changes were implemented quickly with little strategic input from nurses. There is now an opportunity to reflect and build on what has been learned in relation to remote and technology-mediated working to ensure the future development of safe and effective nursing care in general practice.

IMPACT

The paper contributes to understanding of remote and technology-mediated working by nurses working in general practice during the COVID-19 pandemic and indicates to employers and policy makers how this can be supported moving forward.

REPORTING METHOD

Standards for Reporting Qualitative Research (O'Brien et al., 2014).

PATIENT OR PUBLIC CONTRIBUTION

This was a workforce study so there was no patient or public contribution.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The paper highlights specific issues which have implications for the development of remote, technology-mediated and blended working for nurses in general practice, care quality and patient safety. These require full attention to ensure the future development of safe and effective nursing care in general practice moving forward.

Speed, accuracy, and efficiency: The promises and practices of digitization in pathology

Digitization is often presented in policy discourse as a panacea to a multitude of contemporary problems, not least in healthcare. How can policy promises relating to digitization be assessed and potentially countered in particular local contexts? Based on a study in Denmark, we suggest scrutinizing the politics of digitization by comparing policy promises about the future with practitioners' experience in the present. While Denmark is one of the most digitalized countries in the world, digitization of pathology has only recently been given full policy attention. As pathology departments are faced with an increased demand for pathology analysis and a shortage of pathologists, Danish policymakers have put forward digitization as a way to address these challenges. Who is it that wants to digitize pathology, why, and how does digitization unfold in routine work practices? Using online search and document analysis, we identify actors and analyze the policy promises describing expectations associated with digitization. We then use interviews and observations to juxtapose these expectations with observations of everyday pathology practices as experienced by pathologists. We show that policymakers expect digitization to improve speed, patient safety, and diagnostic accuracy, as well as efficiency. In everyday practice, however, digitization does not deliver on these expectations. Fulfillment of policy expectations instead hinges on the types of artificial intelligence (AI) applications that are still to be developed and implemented. Some pathologists remark that AI might work in the easy cases, but this would leave them with only the difficult cases, which they consider too burdensome. Our particular mode of juxtaposing policy and practice throws new light on the political work done by policy promises and helps to explain why the discipline of pathology does not seem to easily lend itself to the digital embrace.

Racing the Machine: Data Analytic Technologies and Institutional Inscription of Racialized Health Injustice

Recent scientific and policy initiatives frame clinical settings as sites for intervening upon inequality. Electronic health records and data analytic technologies offer opportunity to record standard data on education, employment, social support, and race-ethnicity, and numerous audiences expect biomedicine to redress social determinants based on newly available data. However, little is known on how health practitioners and institutional actors view data standardization in relation to inequity. This article examines a public safety-net health system's expansion of race, ethnicity, and language data collection, drawing on 10 months of ethnographic fieldwork and 32 qualitative interviews with providers, clinic staff, data scientists, and administrators. Findings suggest that electronic data capture institutes a decontextualized racialization within biomedicine as health practitioners and data workers rely on biological, cultural, and social justifications for collecting racial data. This demonstrates a critical paradox of stratified biomedicalization: The same data-centered interventions expected to redress injustice may ultimately reinscribe it.

Digital nursing practice theory: A scoping review and thematic analysis

AIMS

This scoping review aims to identify existing theories associated with digital nursing practice to add a lens on the future use of digital technologies by nurses.

DESIGN

A review of theories related to digital technology in nursing practice was conducted following the framework described by Arksey and O'Malley. All published literature until 12th May 2022 was included.

DATA SOURCES

Seven databases were utilized including Medline, Scopus, CINAHL, ACM Digital Library, IEEE Xplore, BNI and Web of Science. A Google Scholar search was also performed.

REVIEW METHODS

The search terms included (nurs* AND [digital OR technol* OR e-health or ehealth or digital health or telemedicine or telehealth] AND theory).

RESULTS

The database searches yielded 282 citations. After screening, nine articles were included in the review. These described eight distinct nursing theories.

CONCLUSION

The focuses of the theories included the role of technology in society and nursing. How technology should be developed to support nursing practice, health consumers' use of nursing informatics, the use of technology as an expression of caring and the preservation of humanness and the relationship between human persons and non-human actants and the creation of nursing technologies as caring in addition to existing technologies. Three themes were identified including the role of technology as an agent within the patient environment; nurse interactions with technology to achieve 'knowing' of patients and the necessity of technological competence among nurses. Then, using Actor Network Theory (ANT), a zoom-out lens to map the concepts was proposed (The Lens for Digital Nursing [LDN]). This study is the first to add a new theoretical lens on digital nursing.

IMPACT

This study provides the first synthesis of key concepts of nursing theories to add a theoretical lens to digital nursing practice. This can be used in a functional capacity to zoom-in different entities. No patient or public contribution was made in this study due to it being an early scoping study on a currently understudied area of nursing theory.

Digital Health Interventions to Improve Access to and Quality of Primary Health Care Services: A Scoping Review

Global digital technology advances offer the potential to enhance primary health care (PHC) quality, reach, and efficiency, driving toward universal health coverage (UHC). This scoping review explored how digital health solutions aid PHC delivery and UHC realization by examining the context, mechanisms, and outcomes of eHealth interventions. A comprehensive literature search was conducted, capturing qualitative and quantitative studies, process evaluations, and systematic or scoping reviews. Our analysis of 65 articles revealed that a well-functioning digital ecosystem-featuring adaptable, interoperable digital tools, robust Information and Communications Technology foundations, and enabling environments-is pivotal for eHealth interventions' success. Facilities with better digital literacy, motivated staff, and adequate funding demonstrated a higher adoption of eHealth technologies, leading to improved, coordinated service delivery and higher patient satisfaction. However, eHealth's potential is often restricted by existing socio-cultural norms, geographical inequities in technology access, and digital literacy disparities. Our review underscores the importance of considering the digital ecosystem's readiness, user behavior, broader health system requirements, and PHC capacity for adopting digital solutions while assessing digital health interventions' impact.

Demonstrating Trustworthiness to Patients in Data-Driven Health Care

Patient data is used to drive an ecosystem of advanced digital tools in health care, like predictive models or artificial intelligence-based decision support. Patients themselves, however, receive little information about these technologies or how they affect their care. This raises important questions about patient trust and continued engagement in a health care system that extracts their data but does not treat them as key stakeholders. This essay explores these tensions and provides steps forward for health systems as they design advanced health information-technology (IT) policies and practices. It centers patients, their concerns, and the ways they perceive trustworthiness to reframe advanced health IT in service of patient interests.

Data as symptom: Doctors' responses to patient-provided data in general practice

People are increasingly able to generate their own health data through new technologies such as wearables and online symptom checkers. However, generating data is one thing, interpreting them another. General practitioners (GPs) are likely to be the first to help with interpretations. Policymakers in the European Union are investing heavily in infrastructures to provide GPs access to patient measurements. But there may be a disconnect between policy ambitions and the everyday practices of GPs. To investigate this, we conducted semi-structured interviews with 23 Danish GPs. According to the GPs, patients relatively rarely bring data to them. GPs mostly remember three types of patient-generated data that patients bring to them for interpretation: heart and sleep measurements from wearables and results from online symptom checkers. However, they also spoke extensively about data work with patient queries concerning measurements from the GPs' own online Patient Reported Outcome system and online access to laboratory results. We juxtapose GP reflections on these five data types and between policy ambitions and everyday practices. These data require substantial recontextualization work before the GPs ascribe them evidential value and act on them. Even when they perceived as actionable, patient-provided data are not approached as measurements, as suggested by policy frameworks. Rather, GPs treat them as analogous to symptoms-that is to say, GPs treat patient-provided data as subjective evidence rather than authoritative measures. Drawing on Science and Technology Studies (STS) literature,we suggest that GPs must be part of the conversation with policy makers and digital entrepreneurs around when and how to integrate patient-generated data into healthcare infrastructures.

Digital outcome measures in pulmonary clinical trials

PURPOSE OF REVIEW

We highlight recent advances in the development and use of digital outcome measures in clinical trials, focusing on how to select the appropriate technology, use digital data to define trial endpoints, and glean important lessons from current experiences with digital outcome measures in pulmonary medicine.

RECENT FINDINGS

A review of emerging literature demonstrates that the use of digital health technologies, particularly pulse oximeters, remote spirometers, accelerometers, and Electronic Patient-Reported Outcomes, has surged in both pulmonary practice and clinical trials. Lessons learned from their use can help researchers to design the next generation of clinical trials leveraging digital outcomes to improve health.

SUMMARY

In pulmonary diseases, digital health technologies provide validated, reliable, and usable data on patients in real-world environments. More broadly, digital endpoints have accelerated innovation in clinical trial design, improved clinical trial efficiency, and centered patients. As investigators adopt digital health technologies, it is important to follow a framework informed by both the opportunities and challenges of digitization. Successful use of digital health technologies will transform clinical trials by improving accessibility, efficiency, patient-centricity, and expanding opportunities for personalized medicine.

Trauma-Informed Care in Digital Health Technologies: Protocol for a Scoping Review

BACKGROUND

The use of digital health technologies is becoming increasingly common across the globe as they offer immense potential to enhance health care delivery by promoting accessibility, flexibility, and personalized care, connecting patients to health care professionals, and offering more efficient services and treatments to remote residents. At the same time, there is an increasing recognition of how digital health can inadvertently foment psychological trauma. This phenomenon has led to the adoption of trauma-informed care in designing and deploying digital health technologies. However, how trauma-informed care is defined and characterized, and the various trauma-informed care strategies used in designing and deploying digital health technologies remain unexplored.

OBJECTIVE

This scoping review aims to explore and synthesize the literature on how trauma-informed care is defined and characterized in digital health and the various trauma-informed care principles, strategies, or recommendations used in designing and deploying digital health.

METHODS

This review will draw on the Joanna Briggs Institute's updated methodological guidance for scoping reviews. A search will be conducted on CINAHL, PubMed, Embase, Compendex Engineering Village, Web of Science, Scopus, and PsycINFO. This review will consider published research studies and unpublished work (gray literature). Studies will be included if they applied trauma-informed care in designing or deploying digital health for patients across all geographical locations or provide trauma-informed recommendations on how web developers should develop digital health. Studies will be limited to publications within the past 10 years and studies in all languages will be considered. Two independent reviewers will screen the titles and abstracts, and then perform a full-text review. Data will be extracted into a data extraction tool developed for this study.

RESULTS

The scoping review was undergoing a full search as of April 2023. The main results will synthesize the peer-reviewed and gray literature on adopting trauma-informed care practices in digital health research and development. The study is expected to be completed by December 2023 and the results are expected to be published in a peer-reviewed journal.

CONCLUSIONS

This review is expected to provide the knowledge base on the adoption of trauma-informed care in designing and deploying digital health. This knowledge can lead to more engaging, and likely, more effective digital health interventions that have less potential for harm. A synthesis of the various trauma-informed care strategies in digital health will also provide a trauma-informed language by enabling researchers and digital health developers to consider trauma as a critical factor in each stage of the design process.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46842.

"More" work for nurses: the ironies of eHealth

BACKGROUND

eHealth applications are considered a technological fix that can potentially address some of the grand challenges in healthcare, including burnout among healthcare professionals, the growing burden of patients with chronic conditions, and retaining and recruiting healthcare professionals. However, as the deployment of eHealth applications in healthcare is relatively novel, there is a lack of research on how they affect the work environment of healthcare professionals. This study explores how work evolves-particularly for nurses-during the utilisation of three eHealth applications.

METHODS

The study is a qualitative case study with an interpretive approach. The utilisation of three different eHealth applications was studied. Seventy-five healthcare professionals were interviewed, most of whom were nurses (n = 47). Interviews were transcribed verbatim and qualitative content analysis was used to analyse the text.

RESULTS

Three main themes were identified: work that is ignored and overlooked; actions needed to complete visible work; and more sedentary work activities. The findings suggest that work surrounding the utilisation of eHealth applications in care practices is mostly performed by nurses. While the promise of more efficient workflows resulting from healthcare's digital transformation may be realised to different degrees, the utilisation of eHealth applications creates additional invisible labour for nurses.

CONCLUSION

We identified through our analysis that the extra work created by eHealth applications is invisible at the organisational level. Most of the invisible labour was performed by nurses, who were engaged in utilising the eHealth applications. This needs to be recognised when implementing eHealth applications in care practices.

Implementation, uptake and use of a digital COVID-19 symptom tracker in English care homes in the coronavirus pandemic: a mixed-methods, multi-locality case study

BACKGROUND

COVID-19 spread rapidly in UK care homes for older people in the early pandemic. National infection control recommendations included remote resident assessment. A region in North-West England introduced a digital COVID-19 symptom tracker for homes to identify early signs of resident deterioration to facilitate care responses. We examined the implementation, uptake and use of the tracker in care homes across four geographical case study localities in the first year of the pandemic.

METHODS

This was a rapid, mixed-methods, multi-locality case study. Tracker uptake was calculated using the number of care homes taking up the tracker as a proportion of the total number of care homes in a locality. Mean tracker use was summarised at locality level and compared. Semi-structured interviews were conducted with professionals involved in tracker implementation and used to explore implementation factors across localities. Template Analysis with the Consolidated Framework for Implementation Research (CFIR) guided the interpretation of qualitative data.

RESULTS

Uptake varied across the four case study localities ranging between 13.8 and 77.8%. Tracker use decreased in all localities over time at different rates, with average use ranging between 18 and 58%. The implementation context differed between localities and the process of implementation deviated over time from the initially planned strategy, for stakeholder engagement and care homes' training. Four interpretative themes reflected the most influential factors appearing to affect tracker uptake and use: (1) the process of implementation, (2) implementation readiness, (3) clarity of purpose/perceived value and (4) relative priority in the context of wider system pressures.

CONCLUSIONS

Our study findings resonate with the digital solutions evidence base prior to the COVID-19 pandemic, suggesting three key factors that can inform future development and implementation of rapid digital responses in care home settings even in times of crisis: an incremental approach to implementation with testing of organisational readiness and attention to implementation climate, particularly the innovation's fit with local contexts (i.e. systems, infrastructure, work processes and practices); involvement of end-users in innovation design and development; and enabling users' easy access to sustained, high-quality, appropriate training and support to enable staff to adapt to digital solutions.

A systematic scoping review of digital health technologies during COVID-19: a new normal in primary health care delivery

This scoping review compiled information concerning digital health technologies (DHTs) evolution to support primary health care (PHC) during COVID-19 and lessons for the future of PHC. The identified literature was published during the COVID-19 peak years (2019-2021), retrieved from PubMed, Scopus, and Google Scholar, as well as hand searched on the internet. Predefined inclusion criteria were used, thematic analysis was applied, and reporting followed the PRISMA for Scoping Reviews. A total of 46 studies were included in the final synthesis (40 articles, one book, two book chapters, one working paper, and two technical reports). These studies scrutinized various aspects of DHTs, entailing 19 types of DHTs with 20 areas of use that can be compressed into five bigger PHC functions: general PHC service delivery (teleconsultations, e-diagnosis, e-prescription, etc.); behavior promotion and digital health literacy (e.g., combating vaccine hesitancy); surveillance functions; vaccination and drugs; and enhancing system decision-making for proper follow-up of ongoing PHC interventions during COVID-19. DHTs have the potential to solve some of the problems that have plagued us even prior to COVID-19. Therefore, this study uses a forward-looking viewpoint to further stimulate the use of evidence-based DHT, making it more inclusive, educative, and satisfying to people's needs, both under normal conditions and during outbreaks. More research with narrowed research questions is needed, with a particular emphasis on quality assurance in the use of DHTs, technical aspects (standards for digital health tools, infrastructure, and platforms), and financial perspectives (payment for digital health services and adoption incentives).

Supplementary Information

The online version contains supplementary material available at 10.1007/s12553-023-00725-7.

Building health service management workforce capacity in the era of health informatics and digital health - A scoping review

INTRODUCTION

Health informatics and digital health, two rapidly growing disciplines, are becoming increasingly important to the sustainability of health service provision, highlighted especially through the COVID-19 pandemic. To maximise the benefits of the adoption and growth of health informatics and digital health, health service managers play a critical role in leading and managing the implementation and transformation of the system, both strategically and operationally, whilst still needing to manage 'business as usual'.

OBJECTIVES

The objectives of the paper are to present and discuss the findings from a scoping review identifying: 1) competencies required for health service managers leading the implementation and transformation of informatics and digital technology in the health sector; and 2) factors that are critical to building the management workforce capacity in the era of health informatics and digital health.

METHODS

A scoping review of the literature was conducted in 2020 focussing on identifying empirical articles published in the English language since the year 2000 using a number of keywords such as 'health informatics', 'digital health', 'electronic health', 'competencies', 'capability', 'proficiency', 'qualification', 'certification', 'health manager', 'health executive' and 'health administrator'. The literature search was guided by a PRISMA approach searching within eight databases: Scopus, ProQuest, Web of Science, ACM Digital Library, CINAHL, PubMed, Google Scholar and ProQuest Dissertations.

RESULTS

After duplicates were removed, 941 publications were included for title screening as the result of an initial review. Title screening selected 185 articles to be included for abstract screening by two reviewers confirming 19 papers relevant to the focus of the current paper which were included in data extraction and content analysis. The analysis identified the additional competency of 'information and data management' be included as a core competency for health service managers. The analysis also confirmed additional elements for the following four core management competencies that are important to health service managers working in the digital health context, including: 1) leadership; 2) operational and resource management; 3) personal, interpersonal and professional qualities, and 4) understanding the industry and environment. Factors that are critical to developing the system and organization capacity in the use of health informatics and digital health technology, and leading and managing the adoption in the healthcare organizations were identified in three categories: 1) policy/system; 2) organizational structure and processes; and 3) people factors.

CONCLUSIONS

This paper has taken an important step in confirming the competency requirements for health services managers that are relevant to leading and managing in the health informatics and digital health space, consequently indicating the directions for developing a competent workforce in meeting the existing and emerging healthcare delivery challenges, both now and in the future.

Unintended consequences of patient online access to health records: a qualitative study in UK primary care

BACKGROUND

Health systems are seeking to harness digital tools to promote patient autonomy and increase the efficiency of care worldwide. The NHS Long Term Plan created the right for patients to access 'digital first' primary care by 2023-2024, including online patient access to full medical records.

AIM

To identify and understand the unintended consequences of online patient access to medical records.

DESIGN AND SETTING

Qualitative interview study in 10 general practices in South West and North West England.

METHOD

Semi-structured individual interviews with 13 patients and 16 general practice staff with experience of patient online access to health records.

RESULTS

Online access generated unintended consequences that negatively impacted patients' understanding of their health care, with patients finding surprising or difficult to interpret information. Online access impacted GPs' documentation practices, such as when GPs pre-emptively attempted to minimise potential misunderstandings to aid patient understanding of their health care. In other cases, this negatively impacted the quality of the records and patient safety when GPs avoided documenting speculations or concerns. Contrary to assumptions that workload would be reduced, online access introduced extra work, such as managing and monitoring access, and taking measures to prevent possible harm to patients.

CONCLUSION

The unintended consequences described by both staff and patients show that, to achieve the intended consequences set out in NHS policy, additional work is necessary to prepare records for sharing and to prepare patients about what to expect. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access, now that it is the default position. A table of potential unintended consequences and mitigation measures is provided to aid practice managers and clinicians implementing online access.

Patient-initiated cardiovascular monitoring with commercially available devices: How useful is it in a cardiology outpatient setting? Mixed methods, observational study

BACKGROUND

The availability, affordability and utilisation of commercially available self-monitoring devices is increasing, but their impact on routine clinical decision-making remains little explored. We sought to examine how patient-generated cardiovascular data influenced clinical evaluation in UK cardiology outpatient clinics and to understand clinical attitudes and experiences with using data from commercially available self-monitoring devices.

METHODS

Mixed methods study combining: a) quantitative and qualitative content analysis of 1373 community cardiology clinic letters, recording consultations between January-September 2020 including periods with different Covid-19 related restrictions, and b) semi-structured qualitative interviews and group discussions with 20 cardiology-affiliated clinicians at the same NHS Trust.

RESULTS

Patient-generated cardiovascular data were described in 185/1373 (13.5%) clinic letters overall, with the proportion doubling following onset of the first Covid-19 lockdown in England, from 8.3% to 16.6% (p < 0.001). In 127/185 (69%) cases self-monitored data were found to: provide or facilitate cardiac diagnoses (34/127); assist management of previously diagnosed cardiac conditions (55/127); be deployed for cardiovascular prevention (16/127); or be recommended for heart rhythm evaluation (10/127). In 58/185 (31%) cases clinicians did not put the self-monitored data to any evident use and in 12/185 (6.5%) cases patient-generated data prompted an unnecessary referral. In interviews and discussions, clinicians expressed mixed views on patient-generated data but foresaw a need to embrace and plan for this information flow, and proactively address challenges with integration into traditional care pathways.

CONCLUSIONS

This study suggests patient-generated data are being used for clinical decision-making in ad hoc and opportunistic ways. Given shifts towards remote monitoring in clinical care, accelerated by the pandemic, there is a need to consider how best to incorporate patient-generated data in clinical processes, introduce relevant training, pathways and governance frameworks, and manage associated risks.

Perceptions and experiences of blood pressure self-monitoring during hypertensive pregnancy: A qualitative analysis of women's and clinicians' experiences in the OPTIMUM-BP trial

BACKGROUND

Self-monitoring of blood pressure (BP) has been shown to be effective at improving BP control in the general population. The OPTIMUM-BP feasibility study was a prospective randomised controlled trial of self-monitoring of BP (SMBP) during hypertensive pregnancy.

OBJECTIVE

To explore experiences, perceptions, and use of the OPTIMUM-BP self-monitoring intervention.

STUDY DESIGN

Qualitative study within the OPTIMUM-BP feasibility trial. Semi-structured interviews with a purposive sample of pregnant women with chronic hypertension (n = 24) and their clinicians (n = 8) as well as 38 ethnographic observations of antenatal visits.

RESULTS

Women found self-monitoring of BP feasible and acceptable and were highly motivated and pro-active in their monitoring, reporting greater control and knowledge of BP and reassurance. Women's persistence with SMBP was driven by a perceived need to safeguard the pregnancy, particularly among those taking antihypertensive medication. Clinicians also described the intervention as acceptable, though BP variability could cause uncertainty. Clinicians used different heuristics to integrate home and clinic readings. Observations suggested close working relationships between women and clinicians were key for confident integration of self-monitoring.

CONCLUSIONS

Self-monitoring of BP was acceptable both to pregnant women with hypertension and their clinicians. More research is needed to understand BP variability within pregnancy to help interpret and integrate home BP readings for improved BP management. Clinical pathways that use BP self-monitoring should aim to maintain the continuity of care and relationships that are valued and appear pivotal for the confident and safe use of self-monitoring in pregnancy.

Materiality and the mediating roles of eHealth: A qualitative study and comparison of three cases

Against the backdrop of eHealth solutions increasingly becoming a part of healthcare professionals’ ways of doing care work, this paper questions how the solutions mediate the experience of healthcare professionals when deployed. We undertook a qualitative study of three eHealth solutions, conducting qualitative interviews with a diverse sample of 102 healthcare professionals from different care settings across the south of Sweden. Materiality and postphenomenology serve as analytic tools for achieving an understanding of the mediating roles of eHealth solutions. The analysis emphasises the mediating roles consisting of interrelated paradoxes: (1) changing and perpetuating boundaries between patients and professional groups, (2) (dis)enabling augmented information and knowledge processes and (3) reconfiguring professional control over work. This contribution provides critical insights into materiality as a category of analysis in studies on the deployment of eHealth solutions, as these technologies have both intended and unintended consequences for care work. Our study identified general positive consequences of all three solutions, such as the increased feeling of closeness to patients and colleagues over time and space; increased ‘understanding’ of patients through patient-generated data; and increased autonomy, due to the fact that asynchronous communication makes it possible to decide when and which patient to attend to. We also identified general unintended consequences of the solutions, such as maintenance of power relations maintained due to organisational structures and professional relations, disabled information and knowledge processes due to the lack of non-verbal clues, reduced professional autonomy due to technical scripts determining what data is collected and how it is categorised, and uneven workload due to the dependency on patient input and compliance.

Adaptation and Resilience: Lessons Learned From Implementing a Combination Health and Education Intervention for Adolescent Girls and Young Women in South Africa During the COVID-19 Pandemic

The COVID-19 pandemic has been associated with reduced access to health services and worsening health outcomes for HIV and sexual and reproductive health (SRH). Through the analysis of data from an evaluation study of a combination intervention for adolescent girls and young women (AGYW) in South Africa, we sought to examine the way in which implementation and service provision were impacted by the COVID-19 pandemic and related restrictions, describing the adaptation implementers made to respond to this context. The intervention was implemented from 2019 in South African districts identified as high priority, given the high rates of HIV and teenage pregnancy amongst AGYW. The South African government introduced the first COVID-19 lockdown in March 2020. We conducted in-depth interviews with 38 intervention implementers in the period from November 2020 to March 2021. Respondents described various ways in which the COVID-19 pandemic and related restrictions had limited their ability to implement the intervention and provide services as planned. As a result, AGYW intervention beneficiary access to SRH and psychosocial services was disrupted. Implementers described several ways in which they attempted to adapt to the pandemic context, such as offering services remotely or door-to-door. Despite attempts to respond to the context and adapt services, overall COVID-19 negatively affected implementation and service provision, and heightened issues around community acceptability of the programs. Our findings can help to inform efforts to reduce health service disruption, increase health system resilience, and ensure continuous SRH service provision to AGYW in times of pandemics and other crises.