Implementing solutions to improve and expand telehealth adoption: participatory action research in four community healthcare settings

Telehealth Transformation: A Mixed-Methods Study on Organizational Change Processes and Outcomes in a Private Medical Practice

BACKGROUND

 This mixed-methods case study investigated the impacts, costs, barriers, and facilitators associated with implementing telehealth services across a private pediatric clinic system. The research examined the effects of telehealth on provider engagement and financial performance.

METHODOLOGY

 Twenty-three clinicians, administrators, and staff across the pediatric clinics were interviewed before and after enterprise-level telehealth adoption to examine change processes amid this innovation. Twelve months of pre- and post-implementation financial records underwent statistical analysis to assess revenue and cost dynamics. Quantitative outcome measures encompassed expenses, revenues, and telehealth visit utilization rates, while qualitative analysis of interviews and focus groups revealed key implementation themes through rigorous inductive coding of participant narratives.

RESULTS

Results showed significantly increased costs (44%) and revenues (47%) at clinics following virtual care expansion. Monthly telehealth visits per provider exponentially rose over 450%. Qualitatively, 83% of providers appreciated scheduling flexibility benefits, but 68% of staff cited workflow disruptions.

CONCLUSIONS

Interpretatively, findings demonstrated catalyzed financial and productivity transformations and nuanced perceived disruption amid pronounced appointment capacity expansions. Recommendations encompass updated care coordination protocols, enhanced training and support resources, incentivizing provider usage, and modulating implementation pacing responding to user feedback during large-scale organizational innovation.

Mobilizing pilot-based evidence for the spread and sustainability of innovations in healthcare: The role of innovation intermediaries

An endemic challenge facing healthcare systems around the world is how to spread innovation more widely and sustainably. A common response to this challenge involves conducting pilot implementation studies to generate evidence of the innovation's benefits. However, despite the key role that such studies play in the local adoption of innovation, their contribution to the wider spread and sustainability of innovation is relatively under-researched and under-theorized. In this paper we examine this contribution through an empirical examination of the experiences of an innovation intermediary organization in the English NHS (National Health Service). We find that their work in mobilizing pilot-based evidence involves three main strands; configuring to context; transitioning evidence; and managing the transition. Through this analysis we contribute to theory by showing how the agency afforded by intermediary roles can support the effective transitioning of pilot-based evidence across different phases in the innovation journey, and across different occupational groups, and can thus help to create a positive feedback loop from localized early implementers of an innovation to later more widespread adoption and sustainability. Based on these findings, we develop insights on the reasons for the unnecessary repetition of pilots - so-called 'pilotitis'- and offer policy recommendations on how to enhance the role of pilots in the wider spread and sustainability of innovation.

Best Practices and Lessons Learned for Action Research in eHealth Design and Implementation: Literature Review

BACKGROUND

Action research (AR) is an established research framework to introduce change in a community following a cyclical approach and involving stakeholders as coresearchers in the process. In recent years, it has also been used for eHealth development. However, little is known about the best practices and lessons learned from using AR for eHealth development.

OBJECTIVE

This literature review aims to provide more knowledge on the best practices and lessons learned from eHealth AR studies. Additionally, an overview of the context in which AR eHealth studies take place is given.

METHODS

A semisystematic review of 44 papers reporting on 40 different AR projects was conducted to identify the best practices and lessons learned in the research studies while accounting for the particular contextual setting and used AR approach.

RESULTS

Recommendations include paying attention to the training of stakeholders' academic skills, as well as the various roles and tasks of action researchers. The studies also highlight the need for constant reflection and accessible dissemination suiting the target group.

CONCLUSIONS

This literature review identified room for improvements regarding communicating and specifying the particular AR definition and applied approach.

Establishing Clinical Swallowing Assessment Services via Telepractice: A Multisite Implementation Evaluation

Purpose While research has confirmed the feasibility and validity of delivering clinical swallowing evaluations (CSEs) via telepractice, challenges exist for clinical implementation. Using an implementation framework, strategies that supported implementation of CSE services via telepractice within 18 regional/rural sites across five health services were examined. Method A coordinated implementation strategy involving remote training and support was provided to 18 sites across five health services (five hub and spoke services) that had identified a need to implement CSEs via telepractice. Experiences of all 10 speech-language pathologists involved at the hub sites were examined via interviews 1 year post implementation. Interview content was coded using the Consolidated Framework for Implementation Research (CFIR) and constructs were rated for strength and direction of influence, using published CFIR coding conventions. Results Services were established and are ongoing at all sites. Although there were site-specific differences, 10 CFIR constructs were positive influencing factors at all five sites. The telepractice model was perceived to provide clear advantages for the service, and clinicians were motivated by positive patient response. Strategies used to support implementation, including having a well-organized implementation resource and an external facilitator who worked closely with the local champions, were highly valued. Two CFIR constructs, Structural Characteristics and Available Resources, were challenges for all sites. Conclusions A complex interplay of factors influenced service implementation at each site. A strong local commitment to improving patient care, and the assistance of targeted strategies to support local implementation were viewed as central to enabling implementation.

Core health-components, contextual factors and program elements of community-based interventions in Southeast Asia - a realist synthesis regarding hypertension and diabetes

Background

In Southeast Asia, diabetes and hypertension are on the rise and have become major causes of death. Community-based interventions can achieve the required behavioural change for better prevention. The aims of this review are 1) to assess the core health-components of community-based interventions and 2) to assess which contextual factors and program elements affect their impact in Southeast Asia.

Methods

A realist review was conducted, combining empirical evidence with theoretical understanding. Documents published between 2009 and 2019 were systematically searched in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar and PsycINFO and local databases. Documents were included if they reported on community-based interventions aimed at hypertension and/or diabetes in Southeast Asian context; and had a health-related outcome; and/or described contextual factors and/or program elements.

Results

We retrieved 67 scientific documents and 12 grey literature documents. We identified twelve core health-components: community health workers, family support, educational activities, comprehensive programs, physical exercise, telehealth, peer support, empowerment, activities to achieve self-efficacy, lifestyle advice, activities aimed at establishing trust, and storytelling. In addition, we found ten contextual factors and program elements that may affect the impact: implementation problems, organized in groups, cultural sensitivity, synergy, access, family health/worker support, gender, involvement of stakeholders, and referral and education services when giving lifestyle advice.

Conclusions

We identified a considerable number of core health-components, contextual influences and program elements of community-based interventions to improve diabetes and hypertension prevention. The main innovative outcomes were, that telehealth can substitute primary healthcare in rural areas, storytelling is a useful context-adaptable component, and comprehensive interventions can improve health-related outcomes. This extends the understanding of promising core health-components, including which elements and in what Southeast Asian context.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11244-3.

Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality.

OBJECTIVES

To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data).

SEARCH METHODS

We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021.

SELECTION CRITERIA

Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed-methods studies to identify themes.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed-methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations.

MAIN RESULTS

Quantitative studies We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land-based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type. Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates. Intervention versus usual care Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) -10.85, 95% confidence interval (CI) -12.66 to -9.04; 1 study, 70 participants; low-certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.60; 1 study, 70 participants, moderate-certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD -6.90, 95% CI -9.56 to -4.24; moderate-certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low-certainty evidence). For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent interventions at 38 to 52 weeks (low-certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality. Intervention versus active comparator We included one study comparing water-based and land-based exercise (30 participants). We found no evidence for quality of life or exacerbations. There may be little to no difference between water- and land-based exercise for 6MWD (MD 5 metres, 95% CI -22 to 32; 38 participants; very low-certainty evidence). Qualitative studies One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long-term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment. Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall.

AUTHORS' CONCLUSIONS

Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take-home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities. Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.

Using an Activity Tracker in Healthcare: Experiences of Healthcare Professionals and Patients

Despite the increased use of activity trackers, little is known about how they can be used in healthcare settings. This study aimed to support healthcare professionals and patients with embedding an activity tracker in the daily clinical practice of a specialized mental healthcare center and gaining knowledge about the implementation process. An action research design was used to let healthcare professionals and patients learn about how and when they can use an activity tracker. Data collection was performed in the specialized center with audio recordings of conversations during therapy, reflection sessions with the therapists, and semi-structured interviews with the patients. Analyses were performed by directed content analyses. Twenty-eight conversations during therapy, four reflection sessions, and eleven interviews were recorded. Both healthcare professionals and patients were positive about the use of activity trackers and experienced it as an added value. Therapists formulated exclusion criteria for patients, a flowchart on when to use the activity tracker, defined goals, and guidance on how to discuss (the data of) the activity tracker. The action research approach was helpful to allow therapists to learn and reflect with each other and embed the activity trackers into their clinical practice at a specialized mental healthcare center.

Evaluating health service outcomes of public involvement in health service design in high-income countries: a systematic review

BACKGROUND

Internationally, it is expected that health services will involve the public in health service design. Evaluation of public involvement has typically focused on the process and experiences for participants. Less is known about outcomes for health services. The aim of this systematic review was to a) identify and synthesise what is known about health service outcomes of public involvement and b) document how outcomes were evaluated.

METHODS

Searches were undertaken in MEDLINE, EMBASE, The Cochrane Library, PsycINFO, Web of Science, and CINAHL for studies that reported health service outcomes from public involvement in health service design. The review was limited to high-income countries and studies in English. Study quality was assessed using the Mixed Methods Appraisal Tool and critical appraisal guidelines for assessing the quality and impact of user involvement in health research. Content analysis was used to determine the outcomes of public involvement in health service design and how outcomes were evaluated.

RESULTS

A total of 93 articles were included. The majority were published in the last 5 years, were qualitative, and were located in the United Kingdom. A range of health service outcomes (discrete products, improvements to health services and system/policy level changes) were reported at various levels (service level, across services, and across organisations). However, evaluations of outcomes were reported in less than half of studies. In studies where outcomes were evaluated, a range of methods were used; most frequent were mixed methods. The quality of study design and reporting was inconsistent.

CONCLUSION

When reporting public involvement in health service design authors outline a range of outcomes for health services, but it is challenging to determine the extent of outcomes due to inadequate descriptions of study design and poor reporting. There is an urgent need for evaluations, including longitudinal study designs and cost-benefit analyses, to fully understand outcomes from public involvement in health service design.

Process evaluation of the implementation of a decision support system to prevent and treat disease-related malnutrition in a hospital setting

Background

Malnutrition is present in 30% of hospitalized patients and has adverse outcomes for the patient and the healthcare system. The current practice for nutritional care is associated with many barriers. The MyFood decision support system was developed to prevent and treat malnutrition.

Methods

This paper reports on a process evaluation that was completed within an effectiveness trial. MyFood is a digital tool with an interface consisting of an app and a website. MyFood includes functions to record and evaluate dietary intake. It also provides reports to nurses, including tailored recommendations for nutritional treatment. We used an effectiveness-implementation hybrid design in a randomized controlled trial. The RE-AIM (Reach, Efficiency, Adoption, Implementation, Maintenance) framework was used to perform a process evaluation alongside the randomized controlled trial, using a combination of quantitative and qualitative methods. An implementation plan, including implementation strategies, was developed to plan and guide the study.

Results

Reach: In total, 88% of eligible patients consented to participate (n = 100). Adoption: Approximately 75% of the nurses signed up to use MyFood and 50% used the reports. Implementation: MyFood empowered the patients in their nutritional situation and acted as a motivation to eat to reach their nutritional target. The compliance of using MyFood was higher among the patients than the nurses. A barrier for use of MyFood among the nurses was different digital systems which were not integrated and the log-in procedure to the MyFood website. Despite limited use by some nurses, the majority of the nurses claimed that MyFood was useful, better than the current practice, and should be implemented in the healthcare system.

Conclusions

This study used a process evaluation to interpret the results of a randomized controlled trial more in-depth. The patients were highly compliant, however, the compliance was lower among the nurses. MyFood empowered the patients in their nutritional situation, the usability was considered as high, and the experiences and attitudes towards MyFood were primarily positive. Focus on strategies to improve the nurses’ compliance may in the future improve the MyFood system’s potential.

Trial registration

The trial was registered in ClinicalTrials.gov 26/01/2018 (NCT03412695).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06236-3.

Stagewise Overview of Issues Influencing Organizational Technology Adoption and Use

This paper provides a stagewise overview of the important issues that play a role in technology adoption and use in organizations. In the current literature, there is a lack of consistency and clarity about the different stages of the technology adoption process, the important issues at each stage, and the differentiation between antecedents, after-effects, enablers, and barriers to technology adoption. This paper collected the relevant issues in technology adoption and use, mentioned dispersedly and under various terminologies, in the recent literature. The qualitative literature review was followed by thematic analysis of the data. The resulting themes were organized into a thematic map depicting three stages of the technology adoption process: pre-change, change, and post-change. The relevant themes and subthemes at each stage were identified and their significance discussed. The themes at each stage are antecedents to the next stage. All the themes of the pre-change and change stages are neutral, but the way they are managed and executed makes them enablers or barriers in effect. The thematic map is a continuous cycle where every round of technology adoption provides input for the subsequent rounds. Based on how themes have been addressed and executed in practice, they can either enhance or impair the subsequent technology adoption. This thematic map can be used as a qualitative framework by academics and practitioners in the field to evaluate technological changes.

A conceptual model to guide research on the activities and effects of innovation champions

BACKGROUND

The importance of having a champion to promote implementation efforts has been discussed in the literature for more than five decades. However, the empirical literature on champions remains underdeveloped. As a result, health organizations commonly use champions in their implementation efforts without the benefit of evidence to guide decisions about how to identify, prepare, and evaluate their champions. The goal of this article is to present a model of champion impact that draws upon previous literature and is intended to inform future research on champions and serve as a guide for practitioners serving in a champion role.

METHODS

The proposed model is informed by existing literature, both conceptual and empirical. Prior studies and reviews of the literature have faced challenges in terms of operationalizing and reporting on champion characteristics, activities, and impacts. The proposed model addresses this challenge by delineating these constructs, which allows for consolidation of factors previously discussed about champions as well as new hypothesized relationships between constructs.

RESULTS

The model proposes that a combination of champion commitment and champion experience and self-efficacy influence champion performance, which influences peer engagement with the champion, which ultimately influences the champion's impact. Two additional constructs have indirect effects on champion impact. Champion beliefs about the innovation and organizational support for the champion affect champion commitment.

CONCLUSION

The proposed model is intended to support prospective studies of champions by hypothesizing relationships between constructs identified in the champion literature, specifically relationships between modifiable factors that influence a champion's potential impact. Over time, the model should be modified, as appropriate, based on new findings from champion-related research.

Accelerating Telemedicine for Cerebral Palsy During the COVID-19 Pandemic and Beyond

The effects of COVID-19 extend beyond the pandemic and are expected to transform healthcare in various ways, many of which remain unknown. With social distancing, telemedicine may become the preferred communication channel between caregivers and patients. Implications for cerebral palsy (CP) children are that this will pose a challenge within this transformation. CP, as a discreet entity, is not considered a risk factor. However, specific comorbidities in individuals with CP, such as chronic lung disease, are known as COVID-19 risk factors. The overall risk for the CP population is probably a factor of age and comorbidities. Staying at home for CP children is both a challenge and an opportunity. Escalation of behavioral conflicts or improved participation and equality within the household may emerge. Interestingly, restricted mobility for the general population narrows existing gaps of ambulation. Telemedicine is the primary way of providing services for chronic conditions during the pandemic and is expected to expand beyond pre-Coronavirus era use. The advantages of telemedicine vary, more so during pandemic times, according to severity, restrictions, and availably of telemedicine. A multidisciplinary therapeutic presence is more accessible with telemedicine, bringing together various specialties and approaches to the child's natural environment. Accessible, continuous care is expected to lower comorbidities, as demonstrated for other chronic conditions. Enhanced monitoring is crucial for younger children as devastating complications, such as hip dysplasia, could be minimized. Last but not least, we will discuss digital health care as an accelerator for participatory medicine, including networked patients and families, as responsible drivers of their health as full partners.

Feasibility of an integrated multidisciplinary geriatric rehabilitation programme for older stroke patients: a process evaluation

Background

Almost half of the stroke patients admitted to geriatric rehabilitation has persisting problems after discharge. Currently, there is no evidence based geriatric rehabilitation programme available for older stroke patients, combining inpatient rehabilitation with adequate aftercare aimed at reducing the impact of persisting problems after discharge from a geriatric rehabilitation unit. Therefore, we developed an integrated multidisciplinary rehabilitation programme consisting of inpatient neurorehabilitation treatment using goal attainment scaling, home based self-management training, and group based stroke education for patients and informal caregivers. We performed a process evaluation to assess to what extent this programme was performed according to protocol. Furthermore, we assessed the participation of the patients in the programme, and the opinion of patients, informal caregivers and care professionals on the programme.

Methods

In this multimethod study, process data were collected by means of interviews, questionnaires, and registration forms among 97 older stroke patients, 89 informal caregivers, and 103 care professionals involved in the programme.

Results

A part of patients and informal caregivers did not receive all key elements of the programme. Almost all patients formulated rehabilitation goals, but among two thirds of the patients the goal attainment scaling method was used. Furthermore, the self-management training was considered rather complex and difficult to apply for frail elderly persons with stroke, and the percentage of therapy sessions performed in the patients’ home environment was lower than planned. In addition, about a quarter of the patients and informal caregivers attended the education sessions. However, a majority of patients, informal caregivers and care professionals indicated the beneficial aspects of the programme.

Conclusion

This study revealed that although the programme in general is perceived to be beneficial by patients, and informal and formal caregivers, the feasibility of the programme needs further attention. Because of persisting cognitive deficits and specific care needs in our frail and multimorbid target population, some widely used methods such as goal attainment scaling, and self-management training seemed not feasible in their current form. To optimize feasibility of the programme, it is recommended to tailor these elements more optimally to the population of frail older patients.

Designing a multifaceted telehealth intervention for a rural population using a model for developing complex interventions in nursing

BACKGROUND

Telehealth interventions offer an evidenced-based approach to providing cost-effective care, education, and timely communication at a distance. Yet, despite its widespread use, telehealth has not reached full potential, especially in rural areas, due to the complex process of designing and implementing telehealth programs. The objective of this paper is to explore the use of a theory-based approach, the Model for Developing Complex Interventions in Nursing, to design a pilot telehealth intervention program for a rural population with multiple chronic conditions.

METHODS

In order to develop a robust, evidenced based intervention that suits the needs of the community, stakeholders, and healthcare agencies involved, a design team comprised of state representatives, telehealth experts, and patient advocates was convened. Each design team meeting was guided by major model constructs (i.e., problem identification, defining the target population and objectives, measurement theory selection, building and planning the intervention protocol). Overarching the process was a review of the literature to ensure that the developed intervention was congruent with evidence-based practice and underlying the entire process was scope of practice considerations.

RESULTS

Ten design team meetings were held over a six-month period. An adaptive pilot intervention targeting home and community-based Medicaid Waiver Program participants in a rural environment with a primary objective of preventing re-institutionalizations was developed and accepted for implementation. To promote intervention effectiveness, asynchronous (i.e., remote patient monitoring) and synchronous (i.e., nursing assessment of pain and mental health and care coordination) telehealth approaches were selected to address the multiple comorbidities of the target population. An economic evaluation plan was developed and included in the pilot program to assess intervention cost efficiency.

CONCLUSIONS

The Model for Developing Complex Interventions in Nursing provided a simple, structured process for designing a multifaceted telehealth intervention to minimize re-institutionalization of participants with multiple chronic conditions. This structured process may promote efficient development of other complex telehealth interventions in time and resource constrained settings. This paper provides detailed examples of how the model was operationalized.

Features of a mobile health intervention to manage chronic obstructive pulmonary disease: a qualitative study

BACKGROUND

The use of mobile health (mHealth) interventions has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes. Further research is needed to determine which mHealth features are required to potentially enhance COPD self-management.

AIM

The aim of this study was to explore the potential features of an mHealth intervention for COPD management with healthcare providers (HCPs) and patients with COPD. It could inform the development and successful implementation of mHealth interventions for COPD management.

METHODS

This was a qualitative study. We conducted semi-structured individual interviews with HCPs, including nurses, pharmacists and physicians who work directly with patients with COPD. Interviews were also conducted with a diverse sample of patients with COPD. Interview topics included demographics, mHealth usage, the potential use of medical devices and recommendations for features that would enhance an mHealth intervention for COPD management.

RESULTS

A total of 40 people, including nurses, physicians and pharmacists, participated. The main recommendations for the proposed mHealth intervention were categorised into two categories: patient interface and HCP interface. The prevalent features suggested for the patient interface include educating patients, collecting baseline data, collecting subjective data, collecting objective data via compatible medical devices, providing a digital action plan, allowing patients to track their progress, enabling family members to access the mHealth intervention, tailoring the features based on the patient's unique needs, reminding patients about critical management tasks and rewarding patients for their positive behaviours. The most common features of the HCP interface include allowing HCPs to track their patients' progress, allowing HCPs to communicate with their patients, educating HCPs and rewarding HCPs.

CONCLUSION

This study identifies important potential features so that the most effective, efficient and feasible mHealth intervention can be developed to improve the management of COPD.The reviews of this paper are available via the supplemental material section.

Using telehealth in motor neuron disease to increase access to specialist multidisciplinary care: a UK-based pilot and feasibility study

OBJECTIVES

Care of patients with motor neuron disease (MND) in a specialist, multidisciplinary clinic is associated with improved survival, but access is not universal. We wanted to pilot and establish the feasibility of a definitive trial of a novel telehealth system (Telehealth in Motor neuron disease, TiM) in patients with MND.

DESIGN

An 18-month, single-centre, mixed-methods, randomised, controlled pilot and feasibility study.

INTERVENTION

TiM telehealth plus usual care versus usual care.

SETTING

A specialist MND care centre in the UK.

PARTICIPANTS

Patients with MND and their primary informal carers.

PRIMARY AND SECONDARY OUTCOME MEASURES

Recruitment, retention and data collection rates, clinical outcomes including participant quality of life and anxiety and depression.

RESULTS

Recruitment achieved the target of 40 patients and 37 carers. Participant characteristics reflected those attending the specialist clinic and included those with severe disability and those with limited experience of technology. Retention and data collection was good. Eighty per cent of patients and 82% of carer participants reported outcome measures were completed at 6 months. Using a longitudinal analysis with repeated measures of quality of life (QoL), a sample size of 131 per arm is recommended in a definitive trial. The methods and intervention were acceptable to participants who were highly motivated to participate to research. The low burden of participation and accessibility of the intervention meant barriers to participation were minimal. However, the study highlighted difficulties assessing the associated costs of the intervention, the challenge of recruitment in such a rare disease and the difficulties of producing rigorous evidence of impact in such a complex intervention.

CONCLUSION

A definitive trial of TiM is feasible but challenging. The complexity of the intervention and heterogeneity of the patient population means that a randomised controlled trial may not be the best way to evaluate the further development and implementation of the TiM.

TRIAL REGISTRATION NUMBER

ISRCTN26675465.

Implementation Strategies to Enhance the Implementation of eHealth Programs for Patients With Chronic Illnesses: Realist Systematic Review

BACKGROUND

There is growing evidence of the positive effects of electronic health (eHealth) interventions for patients with chronic illness, but implementation of such interventions into practice is challenging. Implementation strategies that potentially impact implementation outcomes and implementation success have been identified. Which strategies are actually used in the implementation of eHealth interventions for patients with chronic illness and which ones are the most effective is unclear.

OBJECTIVE

This systematic realist review aimed to summarize evidence from empirical studies regarding (1) which implementation strategies are used when implementing eHealth interventions for patients with chronic illnesses living at home, (2) implementation outcomes, and (3) the relationship between implementation strategies, implementation outcomes, and degree of implementation success.

METHODS

A systematic literature search was performed in the electronic databases MEDLINE, Embase, PsycINFO, Scopus, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library. Studies were included if they described implementation strategies used to support the integration of eHealth interventions into practice. Implementation strategies were categorized according to 9 categories defined by the Expert Recommendations for Implementing Change project: (1) engage consumers, (2) use evaluative and iterative strategies, (3) change infrastructure, (4) adapt and tailor to the context, (5) develop stakeholder interrelationships, (6) use financial strategies, (7) support clinicians, (8) provide interactive assistance, and (9) train and educate stakeholders. Implementation outcomes were extracted according to the implementation outcome framework by Proctor and colleagues: (1) acceptability, (2) adoption, (3) appropriateness, (4) cost, (5) feasibility, (6) fidelity, (7) penetration, and (8) sustainability. Implementation success was extracted according to the study authors' own evaluation of implementation success in relation to the used implementation strategies.

RESULTS

The implementation strategies management support and engagement, internal and external facilitation, training, and audit and feedback were directly related to implementation success in several studies. No clear relationship was found between the number of implementation strategies used and implementation success.

CONCLUSIONS

This is the first review examining implementation strategies, implementation outcomes, and implementation success of studies reporting the implementation of eHealth programs for patients with chronic illnesses living at home. The review indicates that internal and external facilitation, audit and feedback, management support, and training of clinicians are of importance for eHealth implementation. The review also points to the lack of eHealth studies that report implementation strategies in a comprehensive way and highlights the need to design robust studies focusing on implementation strategies in the future.

TRIAL REGISTRATION

PROSPERO CRD42018085539; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=85539.

Evaluating a telehealth intervention for urinalysis monitoring in children with neurogenic bladder

Telehealth as a community-monitoring project within children's urology care is an innovative development. There is limited evidence of the inclusion of staff and parents in the early-stage development and later adoption of telehealth initiatives within routine urological nursing care or families' management of their child's bladder. The aim was to explore the experiences of key stakeholders (parents, clinicians, and technical experts) of the proof of concept telehealth intervention in terms of remote community-based urinalysis monitoring by parents of their child's urine. A concurrent mixed-methods research design used soft systems methodology tools to inform data collection and analysis following interviews, observation, and e-surveys with stakeholders. Findings showed that the parents adopted aspects of the telehealth intervention (urinalysis) but were less engaged with the voiding diary and weighing. The parents gained confidence in decision-making and identified that the intervention reduced delays in their child receiving appropriate treatment, decreased the time burden, and improved engagement with general practitioners. Managing the additional workload was a challenge for the clinical team. Parental empowerment and self-efficacy were clear outcomes from the intervention. Parents exercised their confidence and control and were selective about which aspects of the intervention they perceived as having credibility and which they valued.

User-Centered Adaptation of an Existing Heart Failure Telemonitoring Program to Ensure Sustainability and Scalability: Qualitative Study

BACKGROUND

Telemonitoring interventions for the management of heart failure have seen limited adoption in Canadian health systems, but isolated examples of telemonitoring programs do exist. An example of such a program was launched in a specialty heart failure clinic in Toronto, Canada, and a recent implementation evaluation concluded that reducing the cost of delivering the program is necessary to ensure its sustainability and scalability.

OBJECTIVE

The objectives of this study were to (1) understand which components of the telemonitoring program could be modified to reduce costs and adapted to other contexts while maintaining program fidelity and (2) describe the changes made to the telemonitoring program to enable its sustainability within the initial implementation site and scalability to other health organizations.

METHODS

Semistructured interviews probed the experiences of patients (n=23) and clinicians (n=8) involved in the telemonitoring program to identify opportunities for cost reduction and resource optimization. Ideas for adapting the program were informed by the interview results and prioritized based on (1) potential impact for sustainability and scalability, (2) feasibility, and (3) perceived risks to negatively impacting the program's ability to yield desired health outcomes.

RESULTS

A total of 5 themes representing opportunities for cost reduction were discussed, including (1) Bring Your Own Device (BYOD), (2) technical support, (3) clinician role, (4) duration of enrollment, and (5) intensity of monitoring. The hardware used for the telemonitoring system and the modalities of providing technical support were found to be highly adaptable, which supported the decision to implement a BYOD model, whereby patients used their own smartphone, weight scale, and blood pressure cuff. Changes also included the development of a website aimed at reducing the burden on a technical support telehealth analyst. In addition, the interviews suggested that although it is important to have a clinician who is part of a patient's circle of care monitoring telemonitoring alerts, the skill level and experience were moderately adaptable. Thus, a registered nurse was determined to be more cost-effective and was hired to replace the existing nurse practitioners in the frontline management of telemonitoring alerts and take over the technical support role from a telehealth analyst.

CONCLUSIONS

This study provides a user-centered example of how necessary cost-reduction actions can be taken to ensure the sustainability and scalability of telemonitoring programs. In addition, the findings offer insights into what components of a telemonitoring program can be safely adapted to ensure its integration in various clinical settings.

Acceptability and willingness to pay for telemedicine services in Enugu state, southeast Nigeria

Background

This study examines the level of awareness, acceptability and consumers’ willingness to pay (WTP) for telemedicine services using the contingent valuation method (CVM). This work is important as it elicits the value that consumers attach to telemedicine given there is a gap in this knowledge in many sub-Saharan countries such as in Nigeria.

Methods

The study was based on primary data obtained through an interviewer-administered questionnaire of 370 individuals including both males and females from 25 years and over, to collect data on respondents’ awareness of, acceptability of, and WTP for telemedicine, using the bidding game question format. A socioeconomic status (SES) index was created, based on information on household assets, and was used to categorize respondents into SES quartiles. The data were analyzed using a combination of descriptive techniques, logistics and the Tobit regression model (Tobit Type 1) methods.

Results

The study found that majority of the people (58.9%) had no knowledge of telemedicine. However, 48.7% of the respondents were willing to pay for telemedicine. The mean WTP for a telemedicine was US$2.04 for each visit. Tobit regression analysis showed that respondents’ socioeconomic status (SES) was the main statistically significant variable that explained their WTP for telemedicine.

Conclusion

The study has shown that there is a low-level awareness of and WTP for telemedicine services in Enugu State, South East of Nigeria. The finding of a positive relationship between SES and WTP implies that the poor may not be able to pay for telemedicine and may need government subsidies to be able to benefit from such service. Also, government and their partners need to undertake wide scale campaign before the introduction of telemedicine.

Understanding heart failure; explaining telehealth - a hermeneutic systematic review

BACKGROUND

Enthusiasts for telehealth extol its potential for supporting heart failure management. But randomised trials have been slow to recruit and produced conflicting findings; real-world roll-out has been slow. We sought to inform policy by making sense of a complex literature on heart failure and its remote management.

METHODS

Through database searching and citation tracking, we identified 7 systematic reviews of systematic reviews, 32 systematic reviews (including 17 meta-analyses and 8 qualitative reviews); six mega-trials and over 60 additional relevant empirical studies and commentaries. We synthesised these using Boell's hermeneutic methodology for systematic review, which emphasises the quest for understanding.

RESULTS

Heart failure is a complex and serious condition with frequent co-morbidity and diverse manifestations including severe tiredness. Patients are often frightened, bewildered, socially isolated and variably able to self-manage. Remote monitoring technologies are many and varied; they create new forms of knowledge and new possibilities for care but require fundamental changes to clinical roles and service models and place substantial burdens on patients, carers and staff. The policy innovation of remote biomarker monitoring enabling timely adjustment of medication, mediated by "activated" patients, is based on a modernist vision of efficient, rational, technology-mediated and guideline-driven ("cold") care. It contrasts with relationship-based ("warm") care valued by some clinicians and by patients who are older, sicker and less technically savvy. Limited uptake of telehealth can be analysed in terms of key tensions: between tidy, "textbook" heart failure and the reality of multiple comorbidities; between basic and intensive telehealth; between activated, well-supported patients and vulnerable, unsupported ones; between "cold" and "warm" telehealth; and between fixed and agile care programmes.

CONCLUSION

The limited adoption of telehealth for heart failure has complex clinical, professional and institutional causes, which are unlikely to be elucidated by adding more randomised trials of technology-on versus technology-off to an already-crowded literature. An alternative approach is proposed, based on naturalistic study designs, application of social and organisational theory, and co-design of new service models based on socio-technical principles. Conventional systematic reviews (whose goal is synthesising data) can be usefully supplemented by hermeneutic reviews (whose goal is deepening understanding).

Identifying "ownership" through role descriptions to support implementing universal colorectal cancer tumor screening for Lynch syndrome

Purpose

Lynch Syndrome cases are under-identified, and universal colorectal cancer tumor screening for Lynch Syndrome (UTS) has been recommended. UTS implementation is challenging and few successful examples exist to date, and colorectal cancer patients and at-risk family members exhibit low uptake of genetic services. This study sought to identify the elements that could guide the choice of specialties to implement UTS through three main stages: initiating the screen, returning positive screen results, and providing follow-up.

Methods

To understand stakeholder views on the UTS process, twenty semi-structured interviews were conducted with clinicians from six medical specialties crucial for implementing UTS. Data were analyzed using directed content analysis and additional thematic analysis across content categories.

Results

Several clinical specialties could fill necessary roles at each of the main stages of UTS implementation. Participants suggested owners based on attributes of specialty roles, clinical settings, and the routes patients take through the system.

Conclusion

UTS is considered possible in a range of healthcare settings, with tailoring. Health systems need to choose who best fills the role’s needs based on local resources and processes. These results offer implementation guidance based on role needs, not clinical specialty, in resolving the issue of UTS “ownership.”

Adoption of routine telemedicine in Norwegian hospitals: progress over 5 years

Background

Although Norway is well known for its early use of telemedicine to provide services for people in rural and remote areas in the Arctic, little is known about the pace of telemedicine adoption in Norway. The aim of the present study was to explore the statewide implementation of telemedicine in Norwegian hospitals over time, and analyse its adoption and level of use.

Methods

Data on outpatient visits and telemedicine consultations delivered by Norwegian hospitals from 2009 to 2013 were collected from the national health registry. Data were stratified by health region, hospital, year, and clinical specialty.

Results

All four health regions used telemedicine, i.e. there was 100 % adoption at the regional level. The use of routine telemedicine differed between health regions, and telemedicine appeared to be used mostly in the regions of lower centrality and population density, such as Northern Norway. Only Central Norway seemed to be atypical. Twenty-one out of 28 hospitals reported using telemedicine, i.e. there was 75 % adoption at the hospital level. Neurosurgery and rehabilitation were the clinical specialties where telemedicine was used most frequently. Despite the growing trend and the high adoption, the relative use of telemedicine compared to that of outpatient visits was low.

Conclusions

Adoption of telemedicine is Norway was high, with all the health regions and most of the hospitals reporting using telemedicine. The use of telemedicine appeared to increase over the 5-year study period. However, the proportion of telemedicine consultations relative to the number of outpatient visits was low. The use of telemedicine in Norway was low in comparison with that reported in large-scale telemedicine networks in other countries. To facilitate future comparisons, data on adoption and utilisation over time should be reported routinely by statewide or network-based telemedicine services.