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Iqbal FM, Aggarwal R, Joshi M, King D, Martin G, Khan S, Wright M, Ashrafian H, Darzi A. Barriers to and Facilitators of Key Stakeholders Influencing Successful Digital Implementation of Remote Monitoring Solutions: Mixed Methods Analysis. JMIR Hum Factors 2024; 11:e49769. [PMID: 37338929 PMCID: PMC11106697 DOI: 10.2196/49769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 01/26/2024] [Accepted: 04/07/2024] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Implementation of remote monitoring solutions and digital alerting tools in health care has historically been challenging, despite the impetus provided by the COVID-19 pandemic. To date, a health systems-based approach to systematically describe barriers and facilitators across multiple domains has not been undertaken. OBJECTIVE We aimed to undertake a comprehensive mixed methods analysis of barriers and facilitators for successful implementation of remote monitoring and digital alerting tools in complex health organizations. METHODS A mixed methods approach using a modified Technology Acceptance Model questionnaire and semistructured interviews mapped to the validated fit among humans, organizations, and technology (HOT-fit) framework was undertaken. Likert frequency responses and deductive thematic analyses were performed. RESULTS A total of 11 participants responded to the questionnaire and 18 participants to the interviews. Key barriers and facilitators could be mapped onto 6 dimensions, which incorporated aspects of digitization: system use (human), user satisfaction (human), environment (organization), structure (organization), information and service quality (technology), and system quality (technology). CONCLUSIONS The recommendations proposed can enhance the potential for future remote sensing solutions to be more successfully integrated in health care practice, resulting in more successful use of "virtual wards." TRIAL REGISTRATION ClinicalTrials.gov NCT05321004; https://www.clinicaltrials.gov/study/NCT05321004.
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Affiliation(s)
| | - Ravi Aggarwal
- Division of Surgery, Imperial College London, London, United Kingdom
| | - Meera Joshi
- Division of Surgery, Imperial College London, London, United Kingdom
| | - Dominic King
- Division of Surgery, Imperial College London, London, United Kingdom
| | - Guy Martin
- Division of Surgery, Imperial College London, London, United Kingdom
| | - Sadia Khan
- West Middlesex University Hospital, London, United Kingdom
| | - Mike Wright
- Innovation Business Partner, Chelsea and Westminster NHS Trust, London, United Kingdom
| | - Hutan Ashrafian
- Division of Surgery, Imperial College London, London, United Kingdom
| | - Ara Darzi
- Division of Surgery, Imperial College London, London, United Kingdom
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Price C, Suhomlinova O, Green W. Researching big IT in the UK National Health Service: A systematic review of theory-based studies. Int J Med Inform 2024; 185:105395. [PMID: 38442664 DOI: 10.1016/j.ijmedinf.2024.105395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE To identify and discuss theory-based studies of large-scale health information technology programs in the UK National Health Service. MATERIALS AND METHODS Using the PRISMA systematic review framework, we searched Scopus, PubMed and CINAHL databases from inception to March 2022 for theory-based studies of large-scale health IT implementations. We undertook detailed full-text analyses of papers meeting our inclusion criteria. RESULTS Forty-six studies were included after assessment for eligibility, of which twenty-five applied theories from the information systems arena (socio-technical approaches, normalization process theory, user acceptance theories, diffusion of innovation), twelve from sociology (structuration theory, actor-network theory, institutional theory), while nine adopted other theories. Most investigated England's National Program for IT (2002-2011), exploring various technologies among which electronic records predominated. Research themes were categorized into user factors, program factors, process outcomes, clinical impact, technology, and organizational factors. Most research was qualitative, often using a case study strategy with a longitudinal or cross-sectional approach. Data were typically collected through interviews, observation, and document analysis; sampling was generally purposive; and most studies used thematic or related analyses. Theories were generally applied in a superficial or fragmentary manner; and articles frequently lacked detail on how theoretical constructs and relationships aided organization, analysis, and interpretation of data. CONCLUSION Theory-based studies of large NHS IT programs are relatively uncommon. As large healthcare programs evolve over a long timeframe in complex and dynamic environments, wider adoption of theory-based methods could strengthen the explanatory and predictive utility of research findings across multiple evaluation studies. Our review has confirmed earlier suggestions for theory selection, and we suggest there is scope for more explicit use of such theoretical constructs to strengthen the conceptual foundations of health informatics research. Additionally, the challenges of large national health informatics programs afford wide-ranging opportunities to test, refine, and adapt sociological and information systems theories.
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Affiliation(s)
- Colin Price
- University of Leicester, School of Business, 266 London Road, Leicester LE2 1RQ, United Kingdom.
| | - Olga Suhomlinova
- University of Leicester, School of Business, 266 London Road, Leicester LE2 1RQ, United Kingdom
| | - William Green
- University of Leicester, School of Business, 266 London Road, Leicester LE2 1RQ, United Kingdom
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Dakin FH, Rybczynska-Bunt S, Rosen R, Clarke A, Greenhalgh T. Access and triage in contemporary general practice: A novel theory of digital candidacy. Soc Sci Med 2024; 349:116885. [PMID: 38640742 DOI: 10.1016/j.socscimed.2024.116885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 03/13/2024] [Accepted: 04/12/2024] [Indexed: 04/21/2024]
Abstract
To access contemporary healthcare, patients must find and navigate a complex socio-technical network of human and digital actors linked in multi-modal pathways. Asynchronous, digitally-mediated triage decisions have largely replaced synchronous conversations between humans. In this paper, we draw on a large qualitative dataset from a multi-site study of remote and digital technologies in general practice to understand widening inequities of access. We theorise our data by bringing together traditional candidacy theory (in particular, concepts of self-assessment, help-seeking, adjudication and negotiation) and socio-technical and technology structuration theories (in particular, concepts of user configuration, articulation, distanciation, disembedding, and recursivity), thus producing a novel theory of digital candidacy. We propose that both human and technological actors (in different ways) embody social structures which affect how they 'act' in social situations. Digital technologies contain inbuilt assumptions about users' capabilities, needs, rights, and skills. Patients' ability to self-assess as sick, access digital platforms, self-advocate, and navigate multiple stages in the pathway, including adapting to and compensating for limitations in the technology, vary widely and are markedly patterned by disadvantage. Not every patient can craft an accurate digital facsimile on which the subsequent adjudication decision will be made; those who create incomplete, flawed or unpersuasive digital facsimiles may be deprioritised or misdirected. Staff who know about such patients may use articulation measures to ensure a personalised and appropriate access package, but they cannot identify or fully mitigate all such cases. The decisions and actions of human and technological agents at the time of an attempt to access care can significantly influence, disrupt, and reconstitute candidacy both immediately and recursively over time, and also recursively shape the system itself. These findings underscore the need for services to be (co-)designed with attention to the exclusionary tendencies of digital technologies and technology-supported processes and pathways.
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Affiliation(s)
- Francesca H Dakin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | | | | | - Aileen Clarke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Baxter L, Wright C. The importance of rhythms for maintaining consent in diagnostic encounters to detect cervical cancer. SOCIOLOGY OF HEALTH & ILLNESS 2024. [PMID: 38251766 DOI: 10.1111/1467-9566.13752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 12/12/2023] [Indexed: 01/23/2024]
Abstract
Diagnostic encounters can be seen as complex socio-material processes. Drawing on the new materialist ideas of Barad, we studied how an innovative technology became part of the intra-actions between different human and non-human materialities in a cervical cancer diagnostic process. While researching the development of a technology intended to improve cervical cancer detection, we carried out a series of observations of diagnostic encounters involving clinicians, patients and the device in a hospital. The intra-actions between the different materialities had rhythmic properties, repeated activities and timings that varied in intensity, for example, movements, exchanged looks, and talk that helped co-produce the diagnosis and maintain consent. Sadly, the device interfered with the rhythms, undermining the clinicians' desire to adopt it, despite it being more accurate at diagnosing ill health than previous assistive technologies. Studying rhythms as part of diagnostic encounters could help with the design and subsequent integration of novel technologies in healthcare, because they encompass relationships created by human and non-human materialities. Importantly, highlighting the role of rhythms contributes another way diagnostic encounters are co-produced between clinicians and patients, and how they can be disrupted, improving the understanding of how consent is maintained or lost.
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Affiliation(s)
- Lynne Baxter
- School for Business and Society, University of York, York, UK
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5
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Milone V, Fusco A, De Feo A, Tatullo M. Clinical Impact of "Real World Data" and Blockchain on Public Health: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:95. [PMID: 38248558 PMCID: PMC10815190 DOI: 10.3390/ijerph21010095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 01/23/2024]
Abstract
The digitisation of healthcare has allowed a significant rethinking of the previous clinical protocols, improving their interoperability through substantial standardisation. These technological advances have ensured that data are comparable, as they are obtained from 'reliable' and certified processes; however, there are billions of data that are neither structured nor quality-controlled. They are collectively referred to as 'Real World Data' (RWD). Blockchain (BC) is a procedure with specific characteristics and algorithms that ensure that the stored data cannot be tampered with. Nowadays, there is an increasing need to rethink blockchain in a one-health vision, making it more than just a 'repository' of data and information, but rather an active player in the process of data sharing. In this landscape, several scholars have analysed the potential benefits of BC in healthcare, focusing on the sharing and safety of clinical data and its contact tracing applications. There is limited research on this matter; moreover, there is a strategic interest in managing RWD in a reliable and comparable way, despite the lack of knowledge on this topic. Our work aims to analyse systematically the most impacting literature, highlighting the main aspects of BC within the context of the new digital healthcare, and speculating on the unexpressed potential of RWD.
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Affiliation(s)
- Virginia Milone
- Department of Economics, Management and Business Law, University of Bari “Aldo Moro”, P.ce Umberto I, 70121 Bari, Italy; (V.M.); (A.D.F.)
| | - Antonio Fusco
- Department of Economics, Management and Business Law, University of Bari “Aldo Moro”, P.ce Umberto I, 70121 Bari, Italy; (V.M.); (A.D.F.)
| | - Angelamaria De Feo
- Department of Economics, Management and Business Law, University of Bari “Aldo Moro”, P.ce Umberto I, 70121 Bari, Italy; (V.M.); (A.D.F.)
| | - Marco Tatullo
- Department of Translational Biomedicine and Neuroscience—DiBraiN, University of Bari “Aldo Moro”, P.ce G. Cesare, 70124 Bari, Italy
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Poduval S, Kamal A, Martin S, Islam A, Kaviraj C, Gill P. Beyond Information Provision: Analysis of the Roles of Structure and Agency in COVID-19 Vaccine Confidence in Ethnic Minority Communities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7008. [PMID: 37947565 PMCID: PMC10650583 DOI: 10.3390/ijerph20217008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/29/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
People from Black and Asian backgrounds are more likely to die from COVID-19 but less likely to be vaccinated, threatening to exacerbate health inequalities already experienced by ethnic minority groups. The literature suggests that mistrust rooted in structural inequality (including socioeconomic position and experience of racism) may be a key barrier to COVID-19 vaccine uptake. Understanding and addressing structural inequality is likely to lead to longer-term impacts than information alone. The aim of this study is to draw on health and sociological theories of structure and agency to inform our understanding of how structural factors influence vaccine confidence. We conducted qualitative interviews and focus groups with 22 people from London and the surrounding areas from December 2021 to March 2022. Fourteen participants were members of the public from ethnic minority backgrounds, and seven were professionals working with the public to address concerns and encourage vaccine uptake. Our findings suggest that people from ethnic minority backgrounds make decisions regarding COVID-19 vaccination based on a combination of how they experience external social structures (including lack of credibility and clarity from political authority, neglect by health services, and structural racism) and internal processes (weighing up COVID-19 vaccine harms and benefits and concerns about vaccine development and deployment). We may be able to support knowledge accumulation through the provision of reliable and accessible information, particularly through primary and community care, but we recommend a number of changes to research, policy and practice that address structural inequalities. These include working with communities to improve ethnicity data collection, increasing funding allocation to health conditions where ethnic minority communities experience poorer outcomes, greater transparency and public engagement in the vaccine development process, and culturally adapted research recruitment processes.
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Affiliation(s)
- Shoba Poduval
- UCL Research Department of Primary Care & Population Health, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Atiya Kamal
- School of Social Sciences, Birmingham City University, 4 Cardigan Street, Birmingham B4 7BD, UK;
| | - Sam Martin
- Rapid Research Evaluation and Appraisal Lab (RREAL), Department of Targeted Intervention, University College London (UCL), Charles Bell House, 43–45 Foley Street, London W1W 7TY, UK;
- Vaccines and Society Unit, Oxford Vaccine Group, Oxford University, Oxford OX3 7LE, UK
| | - Amin Islam
- Patient and Public Involvement Authors, UCL Research Department of Primary Care & Population Health, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Chandrika Kaviraj
- Patient and Public Involvement Authors, UCL Research Department of Primary Care & Population Health, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Paramjit Gill
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK;
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Grigorovich A, Kontos P, Popovic MR. Rehabilitation professionals' perspectives and experiences with the use of technologies for violence prevention: a qualitative study. BMC Health Serv Res 2023; 23:899. [PMID: 37612649 PMCID: PMC10464386 DOI: 10.1186/s12913-023-09789-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 07/05/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND There is growing public policy and research interest in the development and use of various technologies for managing violence in healthcare settings to protect the health and well-being of patients and workers. However, little research exists on the impact of technologies on violence prevention, and in particular in the context of rehabilitation settings. Our study addresses this gap by exploring the perceptions and experiences of rehabilitation professionals regarding how technologies are used (or not) for violence prevention, and their perceptions regarding their efficacy and impact. METHODS This was a descriptive qualitative study with 10 diverse professionals (e.g., physical therapy, occupational therapy, recreation therapy, nursing) who worked across inpatient and outpatient settings in one rehabilitation hospital. Data collection consisted of semi-structured interviews with all participants. A conventional approach to content analysis was used to identify key themes. RESULTS We found that participants used three types of technologies for violence prevention: an electronic patient flagging system, fixed and portable emergency alarms, and cameras. All of these were perceived by participants as being largely ineffective for violence prevention due to poor design features, malfunction, limited resources, and incompatibility with the culture of care. Our analysis further suggests that professionals' perception that these technologies would not prevent violence may be linked to their focus on individual patients, with a corresponding lack of attention to structural factors, including the culture of care and the organizational and physical environment. CONCLUSIONS Our findings suggest an urgent need for greater consideration of structural factors in efforts to develop effective interventions for violence prevention in rehabilitation settings, including the design and implementation of new technologies.
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Affiliation(s)
- Alisa Grigorovich
- Recreation and Leisure Studies, Brock University, St Catharines, Canada.
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Canada.
| | - Pia Kontos
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Milos R Popovic
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
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Sidhu M, Walton H, Crellin N, Ellins J, Herlitz L, Litchfield I, Massou E, Tomini SM, Vindrola-Padros C, Fulop NJ. Staff experiences of training and delivery of remote home monitoring services for patients diagnosed with COVID-19 in England: A mixed-methods study. J Health Serv Res Policy 2023:13558196231172586. [PMID: 37366220 PMCID: PMC10300624 DOI: 10.1177/13558196231172586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Remote home monitoring services for patients at risk of rapid deterioration introduced during the COVID-19 pandemic had important implications for the health workforce. This study explored the nature of 'work' that health care staff in England undertook to manage patients with COVID-19 remotely, how they were supported to deliver these new services, and the factors that influenced delivery of COVID-19 remote home monitoring services for staff. METHODS We conducted a rapid mixed-methods evaluation of COVID-19 remote home monitoring services during November 2020 to July 2021 using a cross-sectional survey of a purposive sample of staff involved in delivering the service (clinical leads, frontline delivery staff and those involved in data collection and management) from 28 sites across England. We also conducted interviews with 58 staff in a subsample of 17 sites. Data collection and analysis were carried out in parallel. We used thematic analysis to analyse qualitative data while quantitative survey data were analysed using descriptive statistics. RESULTS A total of 292 staff responded to the surveys (39% response rate). We found that prior experience of remote monitoring had some, albeit limited benefit for delivering similar services for patients diagnosed with COVID-19. Staff received a range of locally specific training and clinical oversight along with bespoke materials and resources. Staff reported feeling uncertain about using their own judgement and being reliant on seeking clinical oversight. The experience of transitioning from face-to-face to remote service delivery led some frontline delivery staff to reconsider their professional role, as well as their beliefs around their own capabilities. There was a general perception of staff being able to adapt, acquire new skills and knowledge and they demonstrated a commitment to continuity of care for patients, although there were reports of struggling with the increased accountability and responsibility attached to their adapted roles at times. CONCLUSIONS Remote home monitoring models can play an important role in managing a large number of patients for COVID-19 and possibly a range of other conditions. Successful delivery of such service models depends on staff competency and the nature of training received to facilitate effective care and patient engagement.
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Affiliation(s)
- Manbinder Sidhu
- Associate Professor, Health Services Management Centre, School of Social Policy, University of Birmingham, UK
| | - Holly Walton
- Research Fellow, Department of Applied Health Research, University College London, UK
| | | | - Jo Ellins
- Senior Fellow, Health Services Management Centre, School of Social Policy, University of Birmingham, UK
| | - Lauren Herlitz
- Research Fellow, Population, Policy and Practice, Great Ormond Street Institute of Child Health, University College London, UK
| | - Ian Litchfield
- Senior Research Fellow, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Efthalia Massou
- Research Associate, Department of Public Health and Primary Care, University of Cambridge, UK
| | - Sonila M Tomini
- Assistant Professor, Global Business School for Health, University College London, UK
| | - Cecilia Vindrola-Padros
- Professorial Research Fellow, Department of Targeted Intervention, University College London, UK
| | - Naomi J Fulop
- Professor of Health Care Organisation and Management, Department of Applied Health Research, University College London, UK
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Ganapathi S, Duggal S. Exploring the experiences and views of doctors working with Artificial Intelligence in English healthcare; a qualitative study. PLoS One 2023; 18:e0282415. [PMID: 36862694 PMCID: PMC9980725 DOI: 10.1371/journal.pone.0282415] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/14/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND The National Health Service (NHS) aspires to be a world leader of Artificial Intelligence (AI) in healthcare, however, there are several barriers facing translation and implementation. A key enabler of AI within the NHS is the education and engagement of doctors, however evidence suggests that there is an overall lack of awareness of and engagement with AI. RESEARCH AIM This qualitative study explores the experiences and views of doctor developers working with AI within the NHS exploring; their role within medical AI discourse, their views on the implementation of AI more widely and how they consider the engagement of doctors with AI technologies may increase in the future. METHODS This study involved eleven semi-structured, one-to-one interviews conducted with doctors working with AI in English healthcare. Data was subjected to thematic analysis. RESULTS The findings demonstrate that there is an unstructured pathway for doctors to enter the field of AI. The doctors described the various challenges they had experienced during their career, with many arising from the differing demands of operating in a commercial and technological environment. The perceived awareness and engagement among frontline doctors was low, with two prominent barriers being the hype surrounding AI and a lack of protected time. The engagement of doctors is vital for both the development and adoption of AI. CONCLUSIONS AI offers big potential within the medical field but is still in its infancy. For the NHS to leverage the benefits of AI, it must educate and empower current and future doctors. This can be achieved through; informative education within the medical undergraduate curriculum, protecting time for current doctors to develop understanding and providing flexible opportunities for NHS doctors to explore this field.
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Affiliation(s)
- Shaswath Ganapathi
- University of Birmingham Medical School, Birmingham, United Kingdom
- * E-mail:
| | - Sandhya Duggal
- University of Birmingham Medical School, Birmingham, United Kingdom
- The Strategy Unit, Midlands Lancashire Commissioning Support Unit, Leyland, United Kingdom
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Perdacher E, Kavanagh D, Sheffield J, Healy K, Dale P, Heffernan E. Using the Stay Strong App for the Well-being of Indigenous Australian Prisoners: Feasibility Study. JMIR Form Res 2022; 6:e32157. [PMID: 35394444 PMCID: PMC9034424 DOI: 10.2196/32157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/18/2021] [Accepted: 01/24/2022] [Indexed: 01/04/2023] Open
Abstract
Background The gap between mental health needs and resources for Aboriginal and Torres Strait Islander people, the Indigenous people of Australia, is most marked in the prison population. Indigenous people are overrepresented in Australian prisons. In prison, this group experiences mental disorders to a greater degree than non-Indigenous prisoners. This group has also been found to experience mental disorder at a higher rate than Indigenous people in the community. In addition to pre-existing determinants of poor mental health, these high prevalence rates may reflect poor engagement in mainstream interventions or the efficacy of available interventions. In community populations, the use of digital mental health resources may help to increase access to well-being support. However, culturally appropriate digital tools have not been available to Indigenous people in prisons. The absence of feasibility and efficacy studies of these tools needs to be addressed. Objective The aim of this study is to determine the feasibility of the Stay Strong app as a digital well-being and mental health tool for use by Indigenous people in prison. Methods Dual government agency (health and corrective services) precondition requirements of implementation were identified and resolved. This was essential given that the Stay Strong app was to be delivered by an external health agency to Indigenous prisoners. Then, acceptability at a practice level was tested using postuse qualitative interviews with clients and practitioners of the Indigenous Mental Health Intervention Program. All Indigenous Mental Health Intervention Program practitioners (10/37, 27%) and client participants who had completed their second follow-up (review of the Stay Strong app; 27/37, 73%) during the study period were invited to participate. Results Owing to the innovative nature of this project, identifying and resolving the precondition requirements of implementation was challenging but provided support for the implementation of the app in practice. Acceptability of the app by clients and practitioners at a practice level was demonstrated, with nine themes emerging across the interviews: satisfaction with the current Stay Strong app, supported client goal setting, increased client self-insight, improved client empowerment, cultural appropriateness, enhanced engagement, ease of use, problems with using an Android emulator, and recommendations to improve personalization. Conclusions The Stay Strong Custody Project is a pioneering example of digital mental health tools being implemented within Australian prisons. Using the app within high-security prison settings was found to be feasible at both strategic and practice levels. Feedback from both clients and practitioners supported the use of the app as a culturally safe digital mental health and well-being tool for Aboriginal and Torres Strait Islander people in prison.
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Affiliation(s)
- Elke Perdacher
- Queensland Forensic Mental Health Service, Brisbane, Australia.,Forensic Mental Health Group, Queensland Centre for Mental Health Research, Brisbane, Australia.,School of Psychology, The University of Queensland, Brisbane, Australia
| | - David Kavanagh
- School of Psychology, The University of Queensland, Brisbane, Australia.,Centre for Children's Health Research and School of Psychology & Counselling, Queensland University of Technology, Brisbane, Australia
| | - Jeanie Sheffield
- School of Psychology, The University of Queensland, Brisbane, Australia
| | - Karyn Healy
- Queensland Forensic Mental Health Service, Brisbane, Australia.,QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Penny Dale
- Queensland Forensic Mental Health Service, Brisbane, Australia
| | - Edward Heffernan
- Queensland Forensic Mental Health Service, Brisbane, Australia.,Forensic Mental Health Group, Queensland Centre for Mental Health Research, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Abstract
This article draws on research and clinical experience to discuss how and when to use video consultations in mental health settings. The appropriateness and impact of virtual consultations are influenced by the patient's clinical needs and social context, as well as by service-level socio-technical and logistical factors.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
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12
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TAM-UTAUT and the acceptance of remote healthcare technologies by healthcare professionals: A systematic review. INFORMATICS IN MEDICINE UNLOCKED 2022. [DOI: 10.1016/j.imu.2022.101008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Shaw SE, Hughes G, Wherton J, Moore L, Rosen R, Papoutsi C, Rushforth A, Morris J, Wood GW, Faulkner S, Greenhalgh T. Achieving Spread, Scale Up and Sustainability of Video Consulting Services During the COVID-19 Pandemic? Findings From a Comparative Case Study of Policy Implementation in England, Wales, Scotland and Northern Ireland. Front Digit Health 2021; 3:754319. [PMID: 34988546 PMCID: PMC8720935 DOI: 10.3389/fdgth.2021.754319] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022] Open
Abstract
Requirements for physical distancing as a result of COVID-19 and the need to reduce the risk of infection prompted policy supporting rapid roll out of video consulting across the four nations of the UK-England, Northern Ireland, Scotland and Wales. Drawing on three studies of the accelerated implementation and uptake of video consulting across the four nations, we present a comparative and interpretive policy analysis of the spread and scale-up of video consulting during the pandemic. Data include interviews with 59 national level stakeholders, 55 health and social care staff and 30 patients, 20 national documents, responses to a UK-wide survey of NHS staff and analysis of routine activity data. Sampling ensured variations in geography, clinical context and adoption progress across the combined dataset. Comparative analysis was guided by theory on policy implementation and crisis management. The pandemic provided a "burning platform" prompting UK-wide policy supporting the use of video consulting in health care as a critical means of managing the risk of infection and a standard mode of provision. This policy push facilitated interest in video consulting across the UK. There was, however, marked variation in how this was put into practice across the four nations. Pre-existing infrastructure, policies and incentives for video consulting in Scotland, combined with a collaborative system-level approach, a program dedicated to developing video-based services and resourcing and supporting staff to deliver them enabled widespread buy-in and rapid spread. In England, Wales and Northern Ireland, pre-existing support for digital health (e.g., hardware, incentives) and virtual care, combined with reduced regulation and "light touch" procurement managed to override some (but by no means all) cultural barriers and professional resistance to implementing digital change. In Northern Ireland and Wales, limited infrastructure muted spread. In all three countries, significant effort at system level to develop, review and run video consulting programs enabled a substantial number of providers to change their practice, albeit variably across settings. Across all four nations ongoing uncertainty, potential restructuring and tightening of regulations, along with difficulties inherent in addressing inequalities in digital access, raise questions about the longer-term sustainability of changes to-date.
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Affiliation(s)
- Sara E. Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gemma Hughes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Lucy Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Alex Rushforth
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Joanne Morris
- Joint Research Management Office, Barts Health NHS Trust, London, United Kingdom
| | - Gary W. Wood
- Independent Research Consultant, Birmingham, United Kingdom
| | - Stuart Faulkner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Anderson E, Rinne ST, Orlander JD, Cutrona SL, Strymish JL, Vimalananda VG. Electronic consultations and economies of scale: a qualitative study of clinician perspectives on scaling up e-consult delivery. J Am Med Inform Assoc 2021; 28:2165-2175. [PMID: 34338797 DOI: 10.1093/jamia/ocab139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/18/2021] [Accepted: 06/21/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To explore Veterans Health Administration clinicians' perspectives on the idea of redesigning electronic consultation (e-consult) delivery in line with a hub-and-spoke (centralized) model. MATERIALS AND METHODS We conducted a qualitative study in VA New England Healthcare System (VISN 1). Semi-structured phone interviews were conducted with 35 primary care providers and 38 specialty care providers, including 13 clinical leaders, at 6 VISN 1 sites varying in size, specialist availability, and e-consult volume. Interviews included exploration of the hub-and-spoke (centralized) e-consult model as a system redesign option. Qualitative content analysis procedures were applied to identify and describe salient categories. RESULTS Participants saw several potential benefits to scaling up e-consult delivery from a decentralized model to a hub-and-spoke model, including expanded access to specialist expertise and increased timeliness of e-consult responses. Concerns included differences in resource availability and management styles between sites, anticipated disruption to working relationships, lack of incentives for central e-consultants, dedicated staff's burnout and fatigue, technological challenges, and lack of motivation for change. DISCUSSION Based on a case study from one of the largest integrated healthcare systems in the United States, our work identifies novel concerns and offers insights for healthcare organizations contemplating a scale-up of their e-consult systems. CONCLUSIONS Scaling up e-consults in line with the hub-and-spoke model may help pave the way for a centralized and efficient approach to care delivery, but the success of this transformation will depend on healthcare systems' ability to evaluate and address barriers to leveraging economies of scale for e-consults.
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Affiliation(s)
- Ekaterina Anderson
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Seppo T Rinne
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jay D Orlander
- Medical Service, VA Boston Healthcare System, Boston, Massachusetts, USA.,Evans Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sarah L Cutrona
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Judith L Strymish
- Medical Service and Section of Infectious Diseases, VA Boston Healthcare System, Boston, Massachusetts, USA.,Harvard Medical School, Cambridge, Massachusetts, USA
| | - Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Section of Endocrinology, Diabetes, and Metabolism, Boston University School of Medicine, Boston, Massachusetts, USA
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Kocanda L, Fisher K, Brown LJ, May J, Rollo ME, Collins CE, Boyle A, Schumacher TL. Informing telehealth service delivery for cardiovascular disease management: exploring the perceptions of rural health professionals. AUST HEALTH REV 2021; 45:241-246. [PMID: 33715764 DOI: 10.1071/ah19231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 05/12/2020] [Indexed: 11/23/2022]
Abstract
Objective To explore the perceptions of rural health professionals who use telehealth services for cardiovascular health care, including the potential role of telehealth in enhancing services for this patient group. Methods Semi-structured interviews were conducted with ten rural health professionals across a range of disciplines, including medicine, nursing and allied health. All study participants were based in the same rural region in New South Wales, Australia. Results Participant responses emphasised the importance of including rural communities in ongoing dialogue to enhance telehealth services for cardiovascular care. Divergent expectations about the purpose of telehealth and unresolved technology issues were identified as factors to be addressed. Rural health professionals highlighted the importance of all stakeholders coming together to overcome barriers and enhance telehealth services in a collaborative manner. Conclusion This study contributes to an evolving understanding of how health professionals based in regional Australia experience telehealth services. Future telehealth research should proceed in collaboration with rural communities, supported by policy that actively facilitates the meaningful inclusion of rural stakeholders in telehealth dialogue. What is known about the topic? Telehealth is frequently discussed as a potential solution to overcome aspects of rural health, such as poor outcomes and limited access to services compared with metropolitan areas. In the context of telehealth and cardiovascular disease (CVD), research that focuses on rural communities is limited, particularly regarding the experiences of these communities with telehealth. What does this paper add? This paper offers insight into how telehealth is experienced by rural health professionals. The paper highlights divergent expectations of telehealth's purpose and unresolved technological issues as barriers to telehealth service delivery. It suggests telehealth services may be enhanced by collaborative approaches that engage multiple stakeholder groups. What are the implications for practitioners? The use and development of telehealth in rural communities requires a collaborative approach that considers the views of rural stakeholders in their specific contexts. To improve telehealth services for people living with CVD in rural communities, it is important that rural stakeholders have opportunities to engage with non-rural clinicians, telehealth developers and policy makers.
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Affiliation(s)
- Lucy Kocanda
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia. ; ; and Department of Rural Health, Faculty of Health and Medicine, University of Newcastle, Tamworth, NSW 2340, Australia. ; ; ; and Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia; and Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia. ; ; and Corresponding author.
| | - Karin Fisher
- Department of Rural Health, Faculty of Health and Medicine, University of Newcastle, Tamworth, NSW 2340, Australia. ; ;
| | - Leanne J Brown
- Department of Rural Health, Faculty of Health and Medicine, University of Newcastle, Tamworth, NSW 2340, Australia. ; ; ; and Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia; and Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia. ;
| | - Jennifer May
- Department of Rural Health, Faculty of Health and Medicine, University of Newcastle, Tamworth, NSW 2340, Australia. ; ;
| | - Megan E Rollo
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia. ; ; and School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Clare E Collins
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia. ; ; and School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Andrew Boyle
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia. ; ; and Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Tracy L Schumacher
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia. ; ; and Department of Rural Health, Faculty of Health and Medicine, University of Newcastle, Tamworth, NSW 2340, Australia. ; ; ; and Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia; and Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia. ;
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The implementation, use and sustainability of a clinical decision support system for medication optimisation in primary care: A qualitative evaluation. PLoS One 2021; 16:e0250946. [PMID: 33939750 PMCID: PMC8092789 DOI: 10.1371/journal.pone.0250946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/17/2021] [Indexed: 11/19/2022] Open
Abstract
Background The quality and safety of prescribing in general practice is important, Clinical decision support (CDS) systems can be used which present alerts to health professionals when prescribing in order to identify patients at risk of potentially hazardous prescribing. It is known that such computerised alerts may improve the safety of prescribing in hospitals but their implementation and sustainable use in general practice is less well understood. We aimed to understand the factors that influenced the successful implementation and sustained use in primary care of a CDS system. Methods Participants were purposively recruited from Clinical Commissioning Groups (CCGs) and general practices in the North West and East Midlands regions of England and from the CDS developers. We conducted face-to-face and telephone-based semi-structured qualitative interviews with staff stakeholders. A selection of participants was interviewed longitudinally to explore the further sustainability 1–2 years after implementation of the CDS system. The analysis, informed by Normalisation Process Theory (NPT), was thematic, iterative and conducted alongside data collection. Results Thirty-nine interviews were conducted either individually or in groups, with 33 stakeholders, including 11 follow-up interviews. Eight themes were interpreted in alignment with the four NPT constructs: Coherence (The purpose of the CDS: Enhancing medication safety and improving cost effectiveness; Relationship of users to the technology; Engagement and communication between different stakeholders); Cognitive Participation (Management of the profile of alerts); Collective Action (Prescribing in general practice, patient and population characteristics and engagement with patients; Knowledge);and Reflexive Monitoring (Sustaining the use of the CDS through maintenance and customisation; Learning and behaviour change. Participants saw that the CDS could have a role in enhancing medication safety and in the quality of care. Engagement through communication and support for local primary care providers and management leaders was considered important for successful implementation. Management of prescribing alert profiles for general practices was a dynamic process evolving over time. At regional management levels, work was required to adapt, and modify the system to optimise its use in practice and fulfil local priorities. Contextual factors, including patient and population characteristics, could impact upon the decision-making processes of prescribers influencing the response to alerts. The CDS could operate as a knowledge base allowing prescribers access to evidence-based information that they otherwise would not have. Conclusions This qualitative evaluation utilised NPT to understand the implementation, use and sustainability of a widely deployed CDS system offering prescribing alerts in general practice. The system was understood as having a role in medication safety in providing relevant patient specific information to prescribers in a timely manner. Engagement between stakeholders was considered important for the intervention in ensuring prescribers continued to utilise its functionality. Sustained implementation might be enhanced by careful profile management of the suite of alerts in the system. Our findings suggest that the use and sustainability of the CDS was related to prescribers’ perceptions of the relevance of alerts. Shared understanding of the purpose of the CDS between CCGS and general practices particularly in balancing cost saving and safety messages could be beneficial.
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Aminoff H, Meijer S, Arnelo U, Frennert S. Telemedicine for Remote Surgical Guidance in Endoscopic Retrograde Cholangiopancreatography: Mixed Methods Study of Practitioner Attitudes. JMIR Form Res 2021; 5:e20692. [PMID: 33427670 PMCID: PMC7834938 DOI: 10.2196/20692] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/02/2020] [Accepted: 10/26/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Telemedicine innovations are rarely adopted into routine health care, the reasons for which are not well understood. Teleguidance, a promising service for remote surgical guidance during endoscopic retrograde cholangiopancreatography (ERCP) was due to be scaled up, but there were concerns that user attitudes might influence adoption. OBJECTIVE Our objective was to gain a deeper understanding of ERCP practitioners' attitudes toward teleguidance. These findings could inform the implementation process and future evaluations. METHODS We conducted semistructured interviews with ERCP staff about challenges during work and beliefs about teleguidance. Theoretical constructs from the technology acceptance model (TAM) guided the thematic analysis. Our findings became input to a 16-item questionnaire, investigating surgeons' beliefs about teleguidance's contribution to performance and factors that might interact with implementation. RESULTS Results from 20 interviews with ERCP staff from 5 hospitals were used to adapt a TAM questionnaire, exchanging the standard "Ease of Use" items for "Compatibility and Implementation Climate." In total, 23 ERCP specialists from 15 ERCP clinics responded to the questionnaire: 9 novices (<500 ERCP procedures) and 14 experts (>500 ERCP procedures). The average agreement ratings for usefulness items were 64% (~9/14) among experts and 75% (~7/9) among novices. The average agreement ratings for compatibility items were somewhat lower (experts 64% [~9/14], novices 69% [~6/9]). The averages have been calculated from the sum of several items and therefore, they only approximate the actual values. While 11 of the 14 experts (79%) and 8 of the 9 novices (89%) agreed that teleguidance could improve overall quality and patient safety during ERCP procedures, only 8 of the 14 experts (57%) and 6 of the 9 novices (67%) agreed that teleguidance would not create new patient safety risks. Only 5 of the 14 experts (36%) and 3 of the 9 novices (33%) were convinced that video and image transmission would function well. Similarly, only 6 of the 14 experts (43%) and 6 of the 9 novices (67%) agreed that administration would work smoothly. There were no statistically significant differences between the experts and novices on any of the 16 items (P<.05). CONCLUSIONS Both novices and experts in ERCP procedures had concerns that teleguidance might disrupt existing work practices. However, novices were generally more positive toward teleguidance than experts, especially with regard to the possibility of developing technical skills and work practices. While newly trained specialists were the main target for teleguidance, the experts were also intended users. As experts are more likely to be key decision makers, their attitudes may have a greater relative impact on adoption. We present suggestions to address these concerns. We conclude that using the TAM as a conceptual framework can support user-centered inquiry into telemedicine design and implementation by connecting qualitative findings to well-known analytical themes.
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Affiliation(s)
- Hedvig Aminoff
- Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Sebastiaan Meijer
- Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Urban Arnelo
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Frennert
- Department of Computer Science and Media Technology, Internet of Things and People Research Center, Malmö University, Malmö, Sweden
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Bidmead E, McShane C. Barriers and Facilitators to Implementation of Digital Solutions. Health (London) 2021. [DOI: 10.4236/health.2021.1311097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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20
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Hind D, Drabble SJ, Arden MA, Mandefield L, Waterhouse S, Maguire C, Cantrill H, Robinson L, Beever D, Scott A, Keating S, Hutchings M, Bradley J, Nightingale J, Allenby MI, Dewar J, Whelan P, Ainsworth J, Walters SJ, Wildman MJ, O'Cathain A. Feasibility study for supporting medication adherence for adults with cystic fibrosis: mixed-methods process evaluation. BMJ Open 2020; 10:e039089. [PMID: 33109661 PMCID: PMC7592300 DOI: 10.1136/bmjopen-2020-039089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/27/2020] [Accepted: 09/29/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To undertake a process evaluation of an adherence support intervention for people with cystic fibrosis (PWCF), to assess its feasibility and acceptability. SETTING Two UK cystic fibrosis (CF) units. PARTICIPANTS Fourteen adult PWCF; three professionals delivering adherence support ('interventionists'); five multi-disciplinary CF team members. INTERVENTIONS Nebuliser with data recording and transfer capability, linked to a software platform, and strategies to support adherence to nebulised treatments facilitated by interventionists over 5 months (± 1 month). PRIMARY AND SECONDARY MEASURES Feasibility and acceptability of the intervention, assessed through semistructured interviews, questionnaires, fidelity assessments and click analytics. RESULTS Interventionists were complimentary about the intervention and training. Key barriers to intervention feasibility and acceptability were identified. Interventionists had difficulty finding clinic space and time in normal working hours to conduct review visits. As a result, fewer than expected intervention visits were conducted and interviews indicated this may explain low adherence in some intervention arm participants. Adherence levels appeared to be >100% for some patients, due to inaccurate prescription data, particularly in patients with complex treatment regimens. Flatlines in adherence data at the start of the study were linked to device connectivity problems. Content and delivery quality fidelity were 100% and 60%-92%, respectively, indicating that interventionists needed to focus more on intervention 'active ingredients' during sessions. CONCLUSIONS The process evaluation led to 14 key changes to intervention procedures to overcome barriers to intervention success. With the identified changes, it is feasible and acceptable to support medication adherence with this intervention. TRIAL REGISTRATION NUMBER ISRCTN13076797; Results.
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Affiliation(s)
- Daniel Hind
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Sarah J Drabble
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | | | - Simon Waterhouse
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Chin Maguire
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Hannah Cantrill
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Louisa Robinson
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Daniel Beever
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Alex Scott
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Sam Keating
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Marlene Hutchings
- Sheffield Adult Cystic Fibrosis Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, Sheffield, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute For Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Julia Nightingale
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark I Allenby
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jane Dewar
- Wolfson Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Pauline Whelan
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - John Ainsworth
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Stephen J Walters
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Martin J Wildman
- School of Health and Related Research, University of Sheffield, Sheffield, UK
- Sheffield Adult Cystic Fibrosis Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, Sheffield, UK
| | - Alicia O'Cathain
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Bidmead E, Marshall A. Covid-19 and the 'new normal': are remote video consultations here to stay? Br Med Bull 2020; 135:16-22. [PMID: 32827250 PMCID: PMC7499498 DOI: 10.1093/bmb/ldaa025] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION During the UK Covid-19 lockdown, video consultations (telemedicine) were encouraged. The extent of usage, and to which concerns to earlier implementation were set aside, is unknown; this is worthy of exploration as data becomes available. SOURCES OF DATA Sources of data are as follows: published case studies, editorials, news articles and government guidance. AREAS OF AGREEMENT Video can be clinically effective, especially where patients cannot attend due to illness or infection risk. Patients are positive, and they can benefit from savings in time and money. Adoption of telemedicine is hindered by a range of known barriers including clinician resistance due to technological problems, disrupted routines, increased workload, decreased work satisfaction and organizational readiness. AREAS OF CONTROVERSY Despite policy impetus and successful pilots, telemedicine has not been adopted at scale. GROWING POINTS Increased use of telemedicine during the Covid-19 crisis presents opportunities to obtain robust evidence of issues and create service transformation effectively. AREAS TIMELY FOR DEVELOPING RESEARCH Examination of telemedicine use during the Covid-19 crisis to ensure that the benefits and usage continue into the post-lockdown, 'new normal' world.
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Affiliation(s)
- Elaine Bidmead
- Centre for Research in Health and Society, Institute of Health, University of Cumbria, Carlisle, Cumbria, UK
| | - Alison Marshall
- Centre for Research in Health and Society, Institute of Health, University of Cumbria, Carlisle, Cumbria, UK
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RUSHFORTH ALEX, GREENHALGH TRISHA. Personalized Medicine, Disruptive Innovation, and "Trailblazer" Guidelines: Case Study and Theorization of an Unsuccessful Change Effort. Milbank Q 2020; 98:581-617. [PMID: 32433825 PMCID: PMC8454330 DOI: 10.1111/1468-0009.12455] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Policy Points For complex reasons, the promise of "precision medicine" based on molecular pathways remains unrealized for many conditions. Clinical practice guidelines (theoretically, at least) can act as "trailblazers" to introduce tests and treatments that reflect precision medicine discoveries. We describe a detailed case study from the United Kingdom in which such an attempt was (so far) unsuccessful and show how this case provides generalizable lessons. Policymakers should be wary of using clinical practice guidelines as the sole, or even the primary, lever for introducing precision medicine. CONTEXT Precision medicine, which addresses underlying molecular mechanisms of disease, depends on new technologies that measure specific biomarkers, leading (it is anticipated) to more accurate diagnosis, patient stratification, and tailored treatment. These technologies can be disruptive-that is, they make possible, and often require, radical changes to clinical practice and service organization-thereby improving quality, safety, or efficiency of care. Clinical practice guidelines may act as "trailblazers," introducing and legitimizing novel technologies and practices. METHODS We describe a case study of an attempt by academic researchers to radically change asthma management in the United Kingdom using a precision medicine biomarker (fractional exhaled nitric oxide, FeNO), measured using a portable breath device. We collected a wide-ranging data set that included more than 100 documents, 61 interviews, and 150 hours of ethnographic observation, and we analyzed it using technology-enhanced strong structuration theory (TESST). FINDINGS Our study describes a so-far unsuccessful attempt by academic respiratory medicine researchers to pave the way for a precision medicine approach to asthma using a government-endorsed national guideline. These researchers considered asthma management, especially in primary care, to be characterized by overdiagnosis and poor tailoring of treatment; engaged a national guideline development body in an effort to fix this problem; and ensured that the guideline required primary care clinicians to use FeNO technology for diagnosis and monitoring. However, clinicians working outside the tertiary referral centers did not accept, or agree to enact, the vision of precision medicine inscribed in the guideline-for multiple professional, operational, and economic reasons. CONCLUSIONS "Trailblazer" guidelines, in which new technologies are recommended, may succeed as catalysts of change only in a limited way for interested individuals and groups. In the absence of a wider program of professionally led and adequately resourced change efforts, such guidelines will lack meaning, legitimacy, and authority among intended users and may be strongly resisted.
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Jeffries M, Gude WT, Keers RN, Phipps DL, Williams R, Kontopantelis E, Brown B, Avery AJ, Peek N, Ashcroft DM. Understanding the utilisation of a novel interactive electronic medication safety dashboard in general practice: a mixed methods study. BMC Med Inform Decis Mak 2020; 20:69. [PMID: 32303219 PMCID: PMC7164282 DOI: 10.1186/s12911-020-1084-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving medication safety is a major concern in primary care settings worldwide. The Salford Medication safety dASHboard (SMASH) intervention provided general practices in Salford (Greater Manchester, UK) with feedback on their safe prescribing and monitoring of medications through an online dashboard, and input from practice-based trained clinical pharmacists. In this study we explored how staff working in general practices used the SMASH dashboard to improve medication safety, through interactions with the dashboard to identify potential medication safety hazards and their workflow to resolve identified hazards. METHODS We used a mixed-methods study design involving quantitative data from dashboard user interaction logs from 43 general practices during the first year of receiving the SMASH intervention, and qualitative data from semi-structured interviews with 22 pharmacists and physicians from 18 practices in Salford. RESULTS Practices interacted with the dashboard a median of 12.0 (interquartile range, 5.0-15.2) times per month during the first quarter of use to identify and resolve potential medication safety hazards, typically starting with the most prevalent hazards or those they perceived to be most serious. Having observed a potential hazard, pharmacists and practice staff worked together to resolve that in a sequence of steps (1) verifying the dashboard information, (2) reviewing the patient's clinical records, and (3) deciding potential changes to the patient's medicines. Over time, dashboard use transitioned towards regular but less frequent (median of 5.5 [3.5-7.9] times per month) checks to identify and resolve new cases. The frequency of dashboard use was higher in practices with a larger number of at-risk patients. In 24 (56%) practices only pharmacists used the dashboard; in 12 (28%) use by other practice staff increased as pharmacist use declined after the initial intervention period; and in 7 (16%) there was mixed use by both pharmacists and practice staff over time. CONCLUSIONS An online medication safety dashboard enabled pharmacists to identify patients at risk of potentially hazardous prescribing. They subsequently worked with GPs to resolve risks on a case-by-case basis, but there were marked variations in processes between some practices. Workload diminished over time as it shifted towards resolving new cases of hazardous prescribing.
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Affiliation(s)
- Mark Jeffries
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Wouter T. Gude
- Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Richard N. Keers
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Denham L. Phipps
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Richard Williams
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Health eResearch Centre, School of Health Sciences, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Benjamin Brown
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Health eResearch Centre, School of Health Sciences, University of Manchester, Manchester, UK
| | - Anthony J. Avery
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Niels Peek
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Health eResearch Centre, School of Health Sciences, University of Manchester, Manchester, UK
| | - Darren M. Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
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Alami H, Lehoux P, Gagnon MP, Fortin JP, Fleet R, Ag Ahmed MA. Rethinking the electronic health record through the quadruple aim: time to align its value with the health system. BMC Med Inform Decis Mak 2020; 20:32. [PMID: 32066432 PMCID: PMC7027292 DOI: 10.1186/s12911-020-1048-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 02/11/2020] [Indexed: 11/10/2022] Open
Abstract
Electronic health records (EHRs) are considered as a powerful lever for enabling value-based health systems. However, many challenges to their use persist and some of their unintended negative impacts are increasingly well documented, including the deterioration of work conditions and quality, and increased dissatisfaction of health care providers. The “quadruple aim” consists of improving population health as well as patient and provider experience while reducing costs. Based on this approach, improving the quality of work and well-being of health care providers could help rethinking the implementation of EHRs and also other information technology-based tools and systems, while creating more value for patients, organizations and health systems.
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Affiliation(s)
- Hassane Alami
- Center for Public Health Research (CreSP), Université de Montréal, P.O. Box 6128, Branch Centre-Ville, Montreal, Quebec, H3C 3J7, Canada. .,Institute for Excellence in Health and Social Services (INESSS), Montreal, QC, Canada. .,Department of Health Management, Evaluation and Policy, École de santé publique de l'Université de Montréal, Montreal, Quebec, Canada.
| | - Pascale Lehoux
- Center for Public Health Research (CreSP), Université de Montréal, P.O. Box 6128, Branch Centre-Ville, Montreal, Quebec, H3C 3J7, Canada.,Department of Health Management, Evaluation and Policy, École de santé publique de l'Université de Montréal, Montreal, Quebec, Canada
| | - Marie-Pierre Gagnon
- Research Center on Healthcare and Services in Primary Care, Institute of Health and Social Services in Primary Care, Université Laval, Quebec City, Quebec, Canada.,Faculty of Nursing Science, Université Laval, Quebec City, Canada
| | - Jean-Paul Fortin
- Research Center on Healthcare and Services in Primary Care, Institute of Health and Social Services in Primary Care, Université Laval, Quebec City, Quebec, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Richard Fleet
- Research Center on Healthcare and Services in Primary Care, Institute of Health and Social Services in Primary Care, Université Laval, Quebec City, Quebec, Canada.,Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada.,Research Chair in Emergency Medicine Université Laval-CHAU Hôtel-Dieu de Lévis, Lévis, Quebec, Canada
| | - Mohamed Ali Ag Ahmed
- Research Chair on Chronic Diseases in Primary Care, Université de Sherbrooke, Chicoutimi, QC, Canada
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Abimbola S, Patel B, Peiris D, Patel A, Harris M, Usherwood T, Greenhalgh T. The NASSS framework for ex post theorisation of technology-supported change in healthcare: worked example of the TORPEDO programme. BMC Med 2019; 17:233. [PMID: 31888718 PMCID: PMC6937726 DOI: 10.1186/s12916-019-1463-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evaluation of health technology programmes should be theoretically informed, interdisciplinary, and generate in-depth explanations. The NASSS (non-adoption, abandonment, scale-up, spread, sustainability) framework was developed to study unfolding technology programmes in real time-and in particular to identify and manage their emergent uncertainties and interdependencies. In this paper, we offer a worked example of how NASSS can also inform ex post (i.e. retrospective) evaluation. METHODS We studied the TORPEDO (Treatment of Cardiovascular Risk in Primary Care using Electronic Decision Support) research programme, a multi-faceted computerised quality improvement intervention for cardiovascular disease prevention in Australian general practice. The technology (HealthTracker) had shown promise in a cluster randomised controlled trial (RCT), but its uptake and sustainability in a real-world implementation phase was patchy. To explain this variation, we used NASSS to undertake secondary analysis of the multi-modal TORPEDO dataset (results and process evaluation of the RCT, survey responses, in-depth professional interviews, videotaped consultations) as well as a sample of new, in-depth narrative interviews with TORPEDO researchers. RESULTS Ex post analysis revealed multiple areas of complexity whose influence and interdependencies helped explain the wide variation in uptake and sustained use of the HealthTracker technology: the nature of cardiovascular risk in different populations, the material properties and functionality of the technology, how value (financial and non-financial) was distributed across stakeholders in the system, clinicians' experiences and concerns, organisational preconditions and challenges, extra-organisational influences (e.g. policy incentives), and how interactions between all these influences unfolded over time. CONCLUSION The NASSS framework can be applied retrospectively to generate a rich, contextualised narrative of technology-supported change efforts and the numerous interacting influences that help explain its successes, failures, and unexpected events. A NASSS-informed ex post analysis can supplement earlier, contemporaneous evaluations to uncover factors that were not apparent or predictable at the time but dynamic and emergent.
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Affiliation(s)
- Seye Abimbola
- School of Public Health, University of Sydney, Sydney, NSW, 2006, Australia
- Centre for Health Systems Science, The George Institute for Global Health, University of New South Wales, Level 5/1 King St, Newtown, NSW, 2042, Australia
| | - Bindu Patel
- Centre for Health Systems Science, The George Institute for Global Health, University of New South Wales, Level 5/1 King St, Newtown, NSW, 2042, Australia
| | - David Peiris
- Centre for Health Systems Science, The George Institute for Global Health, University of New South Wales, Level 5/1 King St, Newtown, NSW, 2042, Australia
| | - Anushka Patel
- Centre for Health Systems Science, The George Institute for Global Health, University of New South Wales, Level 5/1 King St, Newtown, NSW, 2042, Australia
| | - Mark Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Tim Usherwood
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Trisha Greenhalgh
- Centre for Health Systems Science, The George Institute for Global Health, University of New South Wales, Level 5/1 King St, Newtown, NSW, 2042, Australia.
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
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Ladan MA, Wharrad H, Windle R. eHealth adoption and use among healthcare professionals in a tertiary hospital in Sub-Saharan Africa: a Qmethodology study. PeerJ 2019; 7:e6326. [PMID: 31041146 PMCID: PMC6476286 DOI: 10.7717/peerj.6326] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/20/2018] [Indexed: 01/22/2023] Open
Abstract
Background The aim of the study was to explore the viewpoints of healthcare professionals (HCPs) on the adoption and use of eHealth in clinical practice in sub-Saharan Africa (SSA). Information and communication technologies (ICTs) including eHealth provide HCPs the opportunity to provide quality healthcare to their patients while also improving their own clinical practices. Despite this, previous research has identified these technologies have their associated challenges when adopting them for clinical practice. But more research is needed to identify how these eHealth resources influence clinical practice. In addition, there is still little information about adoption and use of these technologies by HCPs inclinical practice in Sub-Saharan Africa. Method An exploratory descriptive design was adopted for this study. Thirty-six (36) HCPs (18 nurses and 18 physicians) working in the clinical area in a tertiary health institution in SSA participated in this study. Using Qmethodology, study participants rank-ordered forty-six statementsin relation to their adoption and use of eHealth within their clinical practice.This was analysed using by-person factor analysis and complemented with audio-taped interviews. Results The analysis yielded four factors i.e., distinct viewpoints the HCPs hold about adoption and use of eHealth within their clinical practice. These factors include: “Patient-focused eHealth advocates” who use the eHealth because they are motivated by patients and their families preferences; “Task-focused eHealth advocates” use eHealth because it helps them complete clinical tasks; “Traditionalistic-pragmatists” recognise contributions eHealth makes in clinical practice but separate from their routine clinical activities; and the “Tech-focused eHealth advocates” who use the eHealth because they are motivated by the technology itself. Conclusion The study shows the equivocal viewpoints that HCPs have about eHealth within their clinical practice. This, in addition to adding to existing literature, will help policymakers/decision makers to consider HCPs views about these technologies prior to implementing an eHealth resource.
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Affiliation(s)
- Muhammad Awwal Ladan
- Digital Innovations in Education and Healthcare (DICE), School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Heather Wharrad
- Digital Innovations in Education and Healthcare (DICE), School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Richard Windle
- Digital Innovations in Education and Healthcare (DICE), School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
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Hind D, Drabble SJ, Arden MA, Mandefield L, Waterhouse S, Maguire C, Cantrill H, Robinson L, Beever D, Scott AJ, Keating S, Hutchings M, Bradley J, Nightingale J, Allenby MI, Dewar J, Whelan P, Ainsworth J, Walters SJ, O’Cathain A, Wildman MJ. Supporting medication adherence for adults with cystic fibrosis: a randomised feasibility study. BMC Pulm Med 2019; 19:77. [PMID: 30975206 PMCID: PMC6458785 DOI: 10.1186/s12890-019-0834-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 03/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preventative medication reduces hospitalisations in people with cystic fibrosis (PWCF) but adherence is poor. We assessed the feasibility of a randomised controlled trial of a complex intervention, which combines display of real time adherence data and behaviour change techniques. METHODS Design: Pilot, open-label, parallel-group RCT with concurrent semi-structured interviews. PARTICIPANTS PWCF at two Cystic Fibrosis (CF) units. Eligible: aged 16 or older; on the CF registry. Ineligible: post-lung transplant or on the active list; unable to consent; using dry powder inhalers. INTERVENTIONS Central randomisation on a 1:1 allocation to: (1) intervention, linking nebuliser use with data recording and transfer capability to a software platform, and behavioural strategies to support self-management delivered by trained interventionists (n = 32); or, (2) control, typically face-to-face meetings every 3 months with CF team (n = 32). OUTCOMES RCT feasibility defined as: recruitment of ≥ 48 participants (75% of target) in four months (pilot primary outcome); valid exacerbation data available for ≥ 85% of those randomised (future RCT primary outcome); change in % medication adherence; FEV1 percent predicted (key secondaries in future RCT); and perceptions of trial procedures, in semi-structured interviews with intervention (n = 14) and control (n = 5) participants, interventionists (n = 3) and CF team members (n = 5). RESULTS The pilot trial recruited to target, randomising 33 to intervention and 31 to control in the four-month period, June-September 2016. At study completion (30th April 2017), 60 (94%; Intervention = 32, Control =28) participants contributed good quality exacerbation data (intervention: 35 exacerbations; control: 25 exacerbation). The mean change in adherence and baseline-adjusted FEV1 percent predicted were higher in the intervention arm by 10% (95% CI: -5.2 to 25.2) and 5% (95% CI -2 to 12%) respectively. Five serious adverse events occurred, none related to the intervention. The mean change in adherence was 10% (95% CI: -5.2 to 25.2), greater in the intervention arm. Interventionists delivered insufficient numbers of review sessions due to concentration on participant recruitment. This left interventionists insufficient time for key intervention procedures. A total of 10 key changes that were made to RCT procedures are summarised. CONCLUSIONS With improved research processes and lower monthly participant recruitment targets, a full-scale trial is feasible. TRIAL REGISTRATION ISRCTN13076797 . Prospectively registered on 07/06/2016.
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Affiliation(s)
- Daniel Hind
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Sarah J. Drabble
- School of Health and Related Research, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Madelynne A. Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Collegiate Crescent, Sheffield, S10 2BQ UK
| | - Laura Mandefield
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Simon Waterhouse
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Chin Maguire
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Hannah Cantrill
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Louisa Robinson
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Daniel Beever
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Alexander J. Scott
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Sam Keating
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Marlene Hutchings
- Sheffield Adult Cystic Fibrosis Unit Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, S5 7AU UK
| | - Judy Bradley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, 97 Lisburn Road, Belfast, BT9 7BL UK
| | - Julia Nightingale
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire SO16 6YD UK
| | - Mark I. Allenby
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire SO16 6YD UK
| | - Jane Dewar
- Wolfson Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, City Hospital, Hucknall Road, Nottingham, NG5 1PB UK
| | - Pauline Whelan
- Health eResearch Centre - Farr Institute, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - John Ainsworth
- Health eResearch Centre - Farr Institute, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Stephen J. Walters
- School of Health and Related Research, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Alicia O’Cathain
- School of Health and Related Research, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - Martin J. Wildman
- Sheffield Adult Cystic Fibrosis Unit Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, S5 7AU UK
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McGovern M, Quinlan M, Doyle G, Moore G, Geiger S. Implementing a National Electronic Referral Program: Qualitative Study. JMIR Med Inform 2018; 6:e10488. [PMID: 30021709 PMCID: PMC6070727 DOI: 10.2196/10488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/23/2018] [Accepted: 05/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Electronic referrals or e-referrals can be defined as the electronic transmission of patient data and clinical requests between health service providers. National electronic referral systems have proved challenging to implement due to problems of fit between the technical systems proposed and the existing sociotechnical systems. In seeming contradiction to a sociotechnical approach, the Irish Health Service Executive initiated an incremental implementation of a National Electronic Referral Programme (NERP), with step 1 including only the technical capability for general practitioners to submit electronic referral requests to hospital outpatient departments. The technology component of the program was specified, but any changes required to embed that technology in the existing sociotechnical system were not specified. OBJECTIVE This study aimed to theoretically frame the lessons learned from the NERP step 1 on the design and implementation of a national health information technology program. METHODS A case study design was employed, using qualitative interviews with key stakeholders of the NERP step 1 (N=41). A theory-driven thematic analysis of the interview data was conducted, using Barker et al's Framework for Going to Full Scale. RESULTS The NERP step 1 was broadly welcomed by key stakeholders as the first step in the implementation of electronic referrals-delivering improvements in the speed, completeness of demographic information, and legibility and traceability of referral requests. National leadership and digitalized health records in general practice were critical enabling factors. Inhibiting factors included policy uncertainty about the future organizational structures within which electronic referrals would be implemented; the need to establish a central referral office consistent with these organizational structures; outstanding interoperability issues between the electronic referral solution and hospital patient administration systems; and an anticipated need to develop specialist referral templates for some specialties. A lack of specification of the sociotechnical elements of the NERP step 1 inhibited the necessary testing and refinement of the change package used to implement the program. CONCLUSIONS The key strengths of the NERP step 1 are patient safety benefits. The NERP was progressed beyond the pilot stage despite limited resources and outstanding interoperability issues. In addition, a new electronic health unit in Ireland (eHealth Ireland) gained credibility in delivering national health information technology programs. Limitations of the program are its poor integration in the wider policy and quality improvement agenda of the Health Service Executive. The lack of specification of the sociotechnical elements of the program created challenges in communicating the program scope to key stakeholders and restricted the ability of program managers and implementers to test and refine the change package. This study concludes that while the sociotechnical elements of a national health information technology program do not need to be specified in tandem with technical elements, they do need to be specified early in the implementation process so that the change package used to implement the program can be tested and refined.
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Affiliation(s)
- Marcella McGovern
- Applied Research for Connected Health, University College Dublin, Dublin, Ireland
| | - Maria Quinlan
- Applied Research for Connected Health, University College Dublin, Dublin, Ireland
| | - Gerardine Doyle
- Applied Research for Connected Health, University College Dublin, Dublin, Ireland.,UCD College of Business, University College Dublin, Dublin, Ireland
| | - Gemma Moore
- Applied Research for Connected Health, University College Dublin, Dublin, Ireland
| | - Susi Geiger
- Applied Research for Connected Health, University College Dublin, Dublin, Ireland.,UCD College of Business, University College Dublin, Dublin, Ireland
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Atherton H, Brant H, Ziebland S, Bikker A, Campbell J, Gibson A, McKinstry B, Porqueddu T, Salisbury C. The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06200] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BackgroundThere is international interest in the potential role of different forms of communication technology to provide an alternative to face-to-face consultations in health care. There has been considerable rhetoric about the need for general practices to offer consultations by telephone, e-mail or internet video. However, little is understood about how, under what conditions, for which patients and in what ways these approaches may offer benefits to patients and practitioners in general practice.ObjectivesOur objectives were to review existing evidence about alternatives to face-to-face consultation; conduct a scoping exercise to identify the ways in which general practices currently provide these alternatives; recruit eight general practices as case studies for focused ethnographic research, exploring how practice context, patient characteristics, type of technology and the purpose of the consultation interact to determine the impact of these alternatives; and synthesise the findings in order to develop a website resource about the implementation of alternatives to face-to-face consultations and a framework for subsequent evaluation.DesignMixed-methods case study.SettingGeneral practices in England and Scotland with varied experience of implementing alternatives to face-to-face consultations.ParticipantsPatients and practice staff.InterventionsAlternatives to face-to-face consultations include telephone consultations, e-mail, e-consultations and internet video.Main outcome measuresHow context influenced the implementation and impact of alternatives to the face-to-face consultation; the rationale for practices to introduce alternatives; the use of different forms of consultation by different patient groups; and the intended benefits/outcomes.Review methodsThe conceptual review used an approach informed by realist review, a method for synthesising research evidence regarding complex interventions.ResultsAlternatives to the face-to-face consultation are not in mainstream use in general practice, with low uptake in our case study practices. We identified the underlying rationales for the use of these alternatives and have shown that different stakeholders have different perspectives on what they hope to achieve through the use of alternatives to the face-to-face consultation. Through the observation of real-life use of different forms of alternative, we have a clearer understanding of how, under what circumstances and for which patients alternatives might have a range of intended benefits and potential unintended adverse consequences. We have also developed a framework for future evaluation.LimitationsThe low uptake of alternatives to the face-to-face consultation means that our research participants might be deemed to be early adopters. The case study approach provides an in-depth examination of a small number of sites, each using alternatives in different ways. The findings are therefore hypothesis-generating, rather than hypothesis-testing.ConclusionsThe current low uptake of alternatives, lack of clarity about purpose and limited evidence of benefit may be at odds with current policy, which encourages the use of alternatives. We have highlighted key issues for practices and policy-makers to consider and have made recommendations about priorities for further research to be conducted, before or alongside the future roll-out of alternatives to the face-to-face consultation, such as telephone consulting, e-consultation, e-mail and video consulting.Future workWe have synthesised our findings to develop a framework and recommendations about future evaluation of the use of alternatives to face-to-face consultations.Funding detailsThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Helen Atherton
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Heather Brant
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annemieke Bikker
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - John Campbell
- Collaboration for Academic Primary Care (APEx), University of Exeter, Exeter, UK
| | - Andy Gibson
- Health and Social Sciences, University of the West of England, Bristol, UK
| | - Brian McKinstry
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Tania Porqueddu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, Hanson P, Campbell-Richards D, Ramoutar S, Collard A, Hodkinson I, Greenhalgh T. Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06210] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BackgroundThere is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.Objective(s)To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.DesignMultilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).SettingThree contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.Data collection and analysisMacro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.ResultsPolicy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.ConclusionsVirtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.LimitationsThe focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.Future researchFurther studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | | | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A'Court C, Hinder S, Procter R, Shaw S. Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework. BMC Med 2018; 16:66. [PMID: 29754584 PMCID: PMC5950199 DOI: 10.1186/s12916-018-1050-6] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Failures and partial successes are common in technology-supported innovation programmes in health and social care. Complexity theory can help explain why. Phenomena may be simple (straightforward, predictable, few components), complicated (multiple interacting components or issues) or complex (dynamic, unpredictable, not easily disaggregated into constituent components). The recently published NASSS framework applies this taxonomy to explain Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability. This paper reports the first empirical application of the NASSS framework. METHODS Six technology-supported programmes were studied using ethnography and action research for up to 3 years across 20 health and care organisations and 10 national-level bodies. They comprised video outpatient consultations, GPS tracking technology for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organising software and integrated case management via data warehousing. Data were collected at three levels: micro (individual technology users), meso (organisational processes and systems) and macro (national policy and wider context). Data analysis and synthesis were guided by socio-technical theories and organised around the seven NASSS domains: (1) the condition or illness, (2) the technology, (3) the value proposition, (4) the adopter system (professional staff, patients and lay carers), (5) the organisation(s), (6) the wider (institutional and societal) system and (7) interaction and mutual adaptation among all these domains over time. RESULTS The study generated more than 400 h of ethnographic observation, 165 semi-structured interviews and 200 documents. The six case studies raised multiple challenges across all seven domains. Complexity was a common feature of all programmes. In particular, individuals' health and care needs were often complex and hence unpredictable and 'off algorithm'. Programmes in which multiple domains were complicated proved difficult, slow and expensive to implement. Those in which multiple domains were complex did not become mainstreamed (or, if mainstreamed, did not deliver key intended outputs). CONCLUSION The NASSS framework helped explain the successes, failures and changing fortunes of this diverse sample of technology-supported programmes. Since failure is often linked to complexity across multiple NASSS domains, further research should systematically address ways to reduce complexity and/or manage programme implementation to take account of it.
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Affiliation(s)
- Trisha Greenhalgh
- Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK.
| | - Joe Wherton
- Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Chrysanthi Papoutsi
- Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Jenni Lynch
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Gemma Hughes
- Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Christine A'Court
- Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Sue Hinder
- RAFT Research consultancy, Clitheroe, UK
| | - Rob Procter
- Department of Computer Science, University of Warwick, Coventry, UK
| | - Sara Shaw
- Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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Greenhalgh T, Fahy N, Shaw S. 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". Int J Health Policy Manag 2018; 7:81-85. [PMID: 29325407 PMCID: PMC5745872 DOI: 10.15171/ijhpm.2017.65] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 05/20/2017] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Shaw J, Shaw S, Wherton J, Hughes G, Greenhalgh T. Studying Scale-Up and Spread as Social Practice: Theoretical Introduction and Empirical Case Study. J Med Internet Res 2017; 19:e244. [PMID: 28687532 PMCID: PMC5522581 DOI: 10.2196/jmir.7482] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/24/2017] [Accepted: 05/08/2017] [Indexed: 11/30/2022] Open
Abstract
Background Health and care technologies often succeed on a small scale but fail to achieve widespread use (scale-up) or become routine practice in other settings (spread). One reason for this is under-theorization of the process of scale-up and spread, for which a potentially fruitful theoretical approach is to consider the adoption and use of technologies as social practices. Objective This study aimed to use an in-depth case study of assisted living to explore the feasibility and usefulness of a social practice approach to explaining the scale-up of an assisted-living technology across a local system of health and social care. Methods This was an individual case study of the implementation of a Global Positioning System (GPS) “geo-fence” for a person living with dementia, nested in a much wider program of ethnographic research and organizational case study of technology implementation across health and social care (Studies in Co-creating Assisted Living Solutions [SCALS] in the United Kingdom). A layered sociological analysis included micro-level data on the index case, meso-level data on the organization, and macro-level data on the wider social, technological, economic, and political context. Data (interviews, ethnographic notes, and documents) were analyzed and synthesized using structuration theory. Results A social practice lens enabled the uptake of the GPS technology to be studied in the context of what human actors found salient, meaningful, ethical, legal, materially possible, and professionally or culturally appropriate in particular social situations. Data extracts were used to illustrate three exemplar findings. First, professional practice is (and probably always will be) oriented not to “implementing technologies” but to providing excellent, ethical care to sick and vulnerable individuals. Second, in order to “work,” health and care technologies rely heavily on human relationships and situated knowledge. Third, such technologies do not just need to be adopted by individuals; they need to be incorporated into personal habits and collaborative routines (both lay and professional). Conclusions Health and care technologies need to be embedded within sociotechnical networks and made to work through situated knowledge, personal habits, and collaborative routines. A technology that “works” for one individual in a particular set of circumstances is unlikely to work in the same way for another in a different set of circumstances. We recommend the further study of social practices and the application of co-design principles. However, our findings suggest that even if this occurs, the scale-up and spread of many health and care technologies will be neither rapid nor smooth.
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Affiliation(s)
- James Shaw
- Women's College Hospital, Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gemma Hughes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Lennon MR, Bouamrane MM, Devlin AM, O'Connor S, O'Donnell C, Chetty U, Agbakoba R, Bikker A, Grieve E, Finch T, Watson N, Wyke S, Mair FS. Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the United Kingdom. J Med Internet Res 2017; 19:e42. [PMID: 28209558 PMCID: PMC5334516 DOI: 10.2196/jmir.6900] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/08/2016] [Accepted: 01/13/2017] [Indexed: 11/18/2022] Open
Abstract
Background Digital health has the potential to support care delivery for chronic illness. Despite positive evidence from localized implementations, new technologies have proven slow to become accepted, integrated, and routinized at scale. Objective The aim of our study was to examine barriers and facilitators to implementation of digital health at scale through the evaluation of a £37m national digital health program: ‟Delivering Assisted Living Lifestyles at Scale” (dallas) from 2012-2015. Methods The study was a longitudinal qualitative, multi-stakeholder, implementation study. The methods included interviews (n=125) with key implementers, focus groups with consumers and patients (n=7), project meetings (n=12), field work or observation in the communities (n=16), health professional survey responses (n=48), and cross program documentary evidence on implementation (n=215). We used a sociological theory called normalization process theory (NPT) and a longitudinal (3 years) qualitative framework analysis approach. This work did not study a single intervention or population. Instead, we evaluated the processes (of designing and delivering digital health), and our outcomes were the identified barriers and facilitators to delivering and mainstreaming services and products within the mixed sector digital health ecosystem. Results We identified three main levels of issues influencing readiness for digital health: macro (market, infrastructure, policy), meso (organizational), and micro (professional or public). Factors hindering implementation included: lack of information technology (IT) infrastructure, uncertainty around information governance, lack of incentives to prioritize interoperability, lack of precedence on accountability within the commercial sector, and a market perceived as difficult to navigate. Factors enabling implementation were: clinical endorsement, champions who promoted digital health, and public and professional willingness. Conclusions Although there is receptiveness to digital health, barriers to mainstreaming remain. Our findings suggest greater investment in national and local infrastructure, implementation of guidelines for the safe and transparent use and assessment of digital health, incentivization of interoperability, and investment in upskilling of professionals and the public would help support the normalization of digital health. These findings will enable researchers, health care practitioners, and policy makers to understand the current landscape and the actions required in order to prepare the market and accelerate uptake, and use of digital health and wellness services in context and at scale.
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Affiliation(s)
- Marilyn R Lennon
- Digital Health and Wellness Group, Computer and Information Sciences, University of Strathclyde, Glasgow, United Kingdom
| | - Matt-Mouley Bouamrane
- Digital Health and Wellness Group, Computer and Information Sciences, University of Strathclyde, Glasgow, United Kingdom
| | - Alison M Devlin
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Siobhan O'Connor
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Catherine O'Donnell
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Ula Chetty
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Ruth Agbakoba
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Annemieke Bikker
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Eleanor Grieve
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8RZ, UK, United Kingdom
| | - Tracy Finch
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne NE2 4AX, United Kingdom
| | - Nicholas Watson
- School of Social and Political Sciences, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Sally Wyke
- School of Social and Political Sciences, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Frances S Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Atherton H, Ziebland S. What do we need to consider when planning, implementing and researching the use of alternatives to face-to-face consultations in primary healthcare? Digit Health 2016; 2:2055207616675559. [PMID: 29942570 PMCID: PMC6001190 DOI: 10.1177/2055207616675559] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/23/2016] [Indexed: 11/26/2022] Open
Abstract
Objectives Communications technologies are variably utilised in healthcare. Policymakers globally have espoused the potential benefits of alternatives to face-to-face consultations, but research is in its infancy. The aim of this essay is to provide thinking tools for policymakers, practitioners and researchers who are involved in planning, implementing and evaluating alternative forms of consultation in primary care. Methods We draw on preparations for a focussed ethnographic study being conducted in eight general practice settings in the UK, knowledge of the literature, qualitative social science and Cochrane reviews. In this essay we consider different types of patients, and also reflect on how the work, practice and professional identities of different members of staff in primary care might be affected. Results Elements of practice are inevitably lost when consultations are no longer face-to-face, and we know little about the impact on core aspects of the primary care relationship. Resistance to change is normal and concerns about the introduction of alternative methods of consultation are often expressed using proxy reasons; for example, concerns about patient safety. Any planning or research in the field of new technologies should be attuned to the potential for unintended consequences. Conclusions Implementation of alternatives to the face-to-face consultation is more likely to succeed if approached as co-designed initiatives that start with the least controversial and most promising changes for the practice. Researchers and evaluators should explore actual experiences of the different consultation types amongst patients and the primary care team rather than hypothetical perspectives.
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Affiliation(s)
- Helen Atherton
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford Radcliffe Observatory Quarter, Oxford, UK
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Greenhalgh T, Shaw S, Wherton J, Hughes G, Lynch J, A'Court C, Hinder S, Fahy N, Byrne E, Finlayson A, Sorell T, Procter R, Stones R. SCALS: a fourth-generation study of assisted living technologies in their organisational, social, political and policy context. BMJ Open 2016; 6:e010208. [PMID: 26880671 PMCID: PMC4762149 DOI: 10.1136/bmjopen-2015-010208] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Research to date into assisted living technologies broadly consists of 3 generations: technical design, experimental trials and qualitative studies of the patient experience. We describe a fourth-generation paradigm: studies of assisted living technologies in their organisational, social, political and policy context. Fourth-generation studies are necessarily organic and emergent; they view technology as part of a dynamic, networked and potentially unstable system. They use co-design methods to generate and stabilise local solutions, taking account of context. METHODS AND ANALYSIS SCALS (Studies in Co-creating Assisted Living Solutions) consists (currently) of 5 organisational case studies, each an English health or social care organisation striving to introduce technology-supported services to support independent living in people with health and/or social care needs. Treating these cases as complex systems, we seek to explore interdependencies, emergence and conflict. We employ a co-design approach informed by the principles of action research to help participating organisations establish, refine and evaluate their service. To that end, we are conducting in-depth ethnographic studies of people's experience of assisted living technologies (micro level), embedded in evolving organisational case studies that use interviews, ethnography and document analysis (meso level), and exploring the wider national and international context for assisted living technologies and policy (macro level). Data will be analysed using a sociotechnical framework developed from structuration theory. ETHICS AND DISSEMINATION Research ethics approval for the first 4 case studies has been granted. An important outcome will be lessons learned from individual co-design case studies. We will document the studies' credibility and rigour, and assess the transferability of findings to other settings while also recognising unique aspects of the contexts in which they were generated. Academic outputs will include a cross-case analysis and progress in theory and method of fourth-generation assisted living technology research. We will produce practical guidance for organisations, policymakers, designers and service users.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joe Wherton
- Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Gemma Hughes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jenni Lynch
- Department of Politics and International Studies, University of Warwick, Warwick, UK
| | - Christine A'Court
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sue Hinder
- Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Nick Fahy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Byrne
- Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Alexander Finlayson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tom Sorell
- Department of Politics and International Studies, University of Warwick, Warwick, UK
| | - Rob Procter
- Department of Computer Science, University of Warwick, Warwick, UK
| | - Rob Stones
- Sociology and Criminology Department, University of Western Sydney, Sydney, Australia
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Kelly MP, Heath I, Howick J, Greenhalgh T. The importance of values in evidence-based medicine. BMC Med Ethics 2015; 16:69. [PMID: 26459219 PMCID: PMC4603687 DOI: 10.1186/s12910-015-0063-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 09/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence-based medicine (EBM) has always required integration of patient values with 'best' clinical evidence. It is widely recognized that scientific practices and discoveries, including those of EBM, are value-laden. But to date, the science of EBM has focused primarily on methods for reducing bias in the evidence, while the role of values in the different aspects of the EBM process has been almost completely ignored. DISCUSSION In this paper, we address this gap by demonstrating how a consideration of values can enhance every aspect of EBM, including: prioritizing which tests and treatments to investigate, selecting research designs and methods, assessing effectiveness and efficiency, supporting patient choice and taking account of the limited time and resources available to busy clinicians. Since values are integral to the practice of EBM, it follows that the highest standards of EBM require values to be made explicit, systematically explored, and integrated into decision making. Through 'values based' approaches, EBM's connection to the humanitarian principles upon which it was founded will be strengthened.
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Affiliation(s)
- Michael P Kelly
- Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK.
| | - Iona Heath
- Royal College of General Practitioners, London, UK.
| | - Jeremy Howick
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
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