The duality of health technology in chronic illness: how designers envision our future

Acceptability and usability of a nurse-assisted remote patient monitoring intervention for the post-hospital follow-up of patients with long-term illness: A qualitative study

Background

Patients living with long-term chronic illnesses often need ongoing medical attention, lifestyle adjustments, and psychosocial support beyond the initial diagnosis and treatment phases. Many experience illness deterioration and subsequently require hospitalisation, especially in the transition period after hospital discharge. A promising strategy for managing long-term conditions is promoting self-management. eHealth interventions involving remote patient monitoring have the potential to promote self-management and offer a more seamless bridge between the hospital and the patient´s home environment. However, such interventions can only significantly impact health and health care if they are effective, accepted and adopted by users, normalised into routine practice and everyday life, and able to be widely implemented. Feasibility studies are used to determine whether an intervention is suitable for the target population and effective in achieving its intended goal. They may also provide critical information about an intervention´s acceptability and usability.

Objectives

We aimed to evaluate the acceptability and usability of a nurse-assisted remote patient monitoring intervention for the post-hospital follow-up of patients with long-term illnesses by use of the core constructs of normalisation process theory.

Design

A descriptive and explanatory qualitative approach was used, with patients observed during training and semi-structured interviews conducted with patients and nurses after study completion.

Settings

Participants were recruited from two university hospitals in Norway between December 2021 and February 2023.

Participants

Ten patients were observed during training, and 27 patients and eight nurses were interviewed after study completion.

Methods

Structured and overt observations were made while the patients received training to operate the remote patient monitoring service, guided by an observation guide. Semi-structured interviews were conducted with patients and nurse navigators about their experiences of remote follow-up care, guided by open ended questions. Data analysis followed a stepwise deductive inductive method.

Results

`Achieving acceptance and usability through digital social interaction´ emerged as a unifying theme that bridged the experiences of patients with long-term illnesses and the nurse navigators. This overarching theme was illustrated by four sub-themes, which all reflected the usability and acceptability of the nurse-assisted remote patient monitoring service in various ways.

Conclusion

Acceptability and usability are critical factors to consider when evaluating remote patient monitoring interventions. In this study, the most important feature for promoting acceptability and usability was the interaction between patients and nurse navigators. Therefore, the intervention´s feasibility and implementation potential rested upon the relationship between its deliverer and receiver.

Living Ambivalently with Chronic Illness

Mobile health smartphone applications (mHealth apps) enable patients to monitor how chronic illness interconnects with their everyday life. I explore, through focus group discussions, how such monitoring makes sense to pediatric and young patients and parents in Denmark. These groups explicate how they live both with and without chronic illness by distinguishing between when to focus on which aspects of it. I argue that this relationship with chronic illness produces parent's, children's, and young people's ambivalent attitudes toward mHealth apps that promote illness monitoring "anywhere" and at "any time."

Experiences With Wearable Activity Data During Self-Care by Chronic Heart Patients: Qualitative Study

Background

Most commercial activity trackers are developed as consumer devices and not as clinical devices. The aim is to monitor and motivate sport activities, healthy living, and similar wellness purposes, and the devices are not designed to support care management in a clinical context. There are great expectations for using wearable sensor devices in health care settings, and the separate realms of wellness tracking and disease self-monitoring are increasingly becoming blurred. However, patients’ experiences with activity tracking technologies designed for use outside the clinical context have received little academic attention.

Objective

This study aimed to contribute to understanding how patients with a chronic disease experience activity data from consumer self-tracking devices related to self-care and their chronic illness. Our research question was: “How do patients with heart disease experience activity data in relation to self-care and chronic illness?”

Methods

We conducted a qualitative interview study with patients with chronic heart disease (n=27) who had an implanted cardioverter-defibrillator. Patients were invited to wear a FitBit Alta HR wearable activity tracker for 3-12 months and provide their perspectives on their experiences with step, sleep, and heart rate data. The average age was 57.2 years (25 men and 2 women), and patients used the tracker for 4-49 weeks (mean 26.1 weeks). Semistructured interviews (n=66) were conducted with patients 2–3 times and were analyzed iteratively in workshops using thematic analysis and abductive reasoning logic.

Results

Of the 27 patients, 18 related the heart rate, sleep, and step count data directly to their heart disease. Wearable activity trackers actualized patients’ experiences across 3 dimensions with a spectrum of contrasting experiences: (1) knowing, which spanned gaining insight and evoking doubts; (2) feeling, which spanned being reassured and becoming anxious; and (3) evaluating, which spanned promoting improvements and exposing failure.

Conclusions

Patients’ experiences could reside more on one end of the spectrum, could reside across all 3 dimensions, or could combine contrasting positions and even move across the spectrum over time. Activity data from wearable devices may be a resource for self-care; however, the data may simultaneously constrain and create uncertainty, fear, and anxiety. By showing how patients experience self-tracking data across dimensions of knowing, feeling, and evaluating, we point toward the richness and complexity of these data experiences in the context of chronic illness and self-care.

Health technology identities and self. Patients' appropriation of an assistive device for self-management of chronic illness

In recent years, assistive technologies have gained acceptance as tools for supporting chronically ill patients in achieving improvements in physical activity. However, various healthcare and sociological studies show contradicting results regarding the physical and social impact of using such devices. This paper explores real-time user appropriation of an assistive monitoring/tracking device, the pedometer, in a healthcare intervention, with a particular focus on the technology identities users attribute to the pedometer. The study site was a rehabilitation programme at a local Danish health centre supporting patients with chronic obstructive pulmonary disease. As part of this empirical study, six focus-group interviews were conducted with patients before and after they used pedometers. The analysis of respondents' accounts shows that monitoring devices become part of users' complex socio-technical ensembles in which the use of the device and its tracking of activity is constantly negotiated through experimentation with type and frequency of use; interpretation of knowledge and experience gained via the device; and negotiation of expectations, wellbeing, and the value of quantified knowledge for the management of chronic illness. On the basis of these findings the paper brings together and advances sociological scholarship on chronic illness, embodiment, the quantified self and technology adoption.

Sensor-Based Passive Remote Monitoring and Discordant Values: Qualitative Study of the Experiences of Low-Income Immigrant Elders in the United States

BACKGROUND

Remote monitoring technologies are positioned to mitigate the problem of a dwindling care workforce and disparities in access to care for the growing older immigrant population in the United States. To achieve these ends, designers and providers need to understand how these supports can be best provided in the context of various sociocultural environments that shape older adults' expectations and care relationships, yet few studies have examined how the same remote monitoring technologies may produce different effects and uses depending on what population is using them in a particular context.

OBJECTIVE

This study aimed to examine the experiences and insights of low-income, immigrant senior residents, family contacts, and staff of housing that offered a sensor-based passive monitoring system designed to track changes in movement around the home and trigger alerts for caregivers. The senior housing organization had been offering the QuietCare sensor system to its residents for 6 years at the time of the study. We are interested in adoption and discontinuation decisions and use over time, rather than projected acceptance. Our research question is how do cultural differences influence use and experiences with this remote monitoring technology? The study does not draw generalizable conclusions about how cultural groups interact with a given technology, but rather, it examines how values are made visible in elder care technology interactions.

METHODS

A total of 41 participants (residents, family, and staff) from 6 large senior housing independent living apartment buildings were interviewed. Interviews were conducted in English and Korean with these participants who collectively had immigrated to the United States from 10 countries.

RESULTS

The reactions of immigrant older adults to the passive monitoring system reveal that this tool offered to them was often mismatched with their values, needs, and expectations. Asian elders accepted the intervention social workers offered largely to appease them, but unlike their US-born counterparts, they adopted reluctantly without hope that it would ameliorate their situation. Asian immigrants discontinued use at the highest rate of all residents, and intergenerational family cultural conflict contributed to this termination. Social workers reported that none of the large population of Russian-speaking residents agreed to use QuietCare. Bilingual and bicultural social workers played significant roles as cultural navigators in the promotion of QuietCare to residents.

CONCLUSIONS

This research into the interactions of culturally diverse people with the same monitoring technology reveals the significant role that social values and context play in shaping how people and families interact with and experience elder care interventions. If technology-based care services are to reach their full potential, it will be important to identify the ways in which cultural values produce different uses and responses to technologies intended to help older adults live independently.

The Bright Elusive Butterfly of Value in Health Technology Development Comment on "Providing Value to New Health Technology: The Early Contribution of Entrepreneurs, Investors, and Regulatory Agencies"

The current system of health technology development is characterised by multiple misalignments. The "supply" side (innovation policy-makers, entrepreneurs, investors) and the "demand" side (health policy-makers, regulators, health technology assessment, purchasers) operate under different - and conflicting - logics. The system is less a "pathway" than an unstable ecosystem of multiple interacting sub-systems. "Value" means different things to each of the numerous actors involved. Supply-side dynamics are built on fictions; regulatory checks and balances are designed to assure quality, safety and efficacy, not to ensure that technologies entering the market are either desirable or cost-effective. Assessment of comparative and cost-effectiveness usually comes too late in the process to shape an innovation's development. We offer no simple solutions to these problems, but in the spirit of commencing a much-needed public debate, we suggest some tentative ways forward. First, universities and public research funders should play a more proactive role in shaping the system. Second, the role of industry in forging long-term strategic partnerships for public benefit should be acknowledged (though not uncritically). Third, models of "responsible innovation" and public input to research priority-setting should be explored. Finally, the evidence base on how best to govern inter-sectoral health research partnerships should be developed and applied.

Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies

BACKGROUND

Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level.

OBJECTIVE

Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program.

METHODS

The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs-video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing-using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback.

RESULTS

The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs.

CONCLUSIONS

Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.

Active subjects of passive monitoring: responses to a passive monitoring system in low-income independent living

Passive monitoring technology is beginning to be reimbursed by third-party payers in the United States of America. Given the low voluntary uptake of these technologies on the market, it is important to understand the concerns and perspectives of users, former users and non-users. In this paper, the range of ways older adults relate to passive monitoring in low-income independent-living residences is presented. This includes experiences of adoption, non-adoption, discontinuation and creative 'misuse'. The analysis of interviews reveals three key insights. First, assumptions built into the technology about how older adults live present a problem for many users who experience unwanted disruptions and threats to their behavioural autonomy. Second, resident response is varied and challenges the dominant image of residents as passive subjects of a passive monitoring system. Third, the priorities of older adults (e.g. safety, autonomy, privacy, control, contact) are more diverse and multi-faceted than those of the housing organisation staff and family members (e.g. safety, efficiency) who drive the passive monitoring intervention. The tension between needs, desires and the daily lives of older adults and the technological solutions offered to them is made visible by their active responses, including resistance to them. This exposes the active and meaningful qualities of older adults' decisions and practices.

Detecting deterioration in patients with chronic disease using telemonitoring: navigating the 'trough of disillusionment'

OBJECTIVES

To examine the evidence base for telemonitoring designed for patients who have chronic obstructive pulmonary disease and heart failure, and to assess whether telemonitoring fulfils the principles of monitoring and is ready for implementation into routine settings.

DESIGN

Qualitative data collection using interviews and participation in a multi-path mapping process.

PARTICIPANTS

Twenty-six purposively selected informants completed semi-structured interviews and 24 individuals with expertise in the relevant clinical and informatics domains from academia, industry, policy and provider organizations and participated in a multi-path mapping workshop.

RESULTS

The evidence base for the effectiveness of telemonitoring is weak and inconsistent, with insufficient cost-effectiveness studies. When considered against an accepted definition of monitoring, telemonitoring is found wanting. Telemonitoring has not been able so far to ensure that the technologies fit into the life world of the patient and into the clinical and organizational milieu of health service delivery systems.

CONCLUSIONS

To develop effective telemonitoring for patients with chronic disease, more attention needs to be given to agreeing the central aim of early detection and, to ensure potential implementation, engaging a wide range of stakeholders in the design process, especially patients and clinicians.