Barriers to – and enablers of - adoption of technology enabled care

services

North West Coast Connected Health Ecosystem eventAlison Marshall, 13th September 2016

Outline

Scope and definitions

Understanding the environment for innovation in healthcare

Barriers to and enablers of technology adoption: our work and findings

Conclusion

Scope and definitions

Our research interests and work

A bit about the Cumbrian Centre for Health Technologies (CaCHeT)Applied research and consultancy in technology adoption, innovation and stakeholder engagement

Funding and sponsorship from:• Academic Health Science Networks• NHS Trusts and Services• Private companies• Strategic partnership entitites (eg. Lancashire Digital Health Board)

Supporting postgraduate teaching in Digital Health and Social Care http://www.cumbria.ac.uk/research/centres/cachet/digital-health-and-social-care-education-and-training/

More information on our website www.cumbria.ac.uk/cachet

Scope: digital innovations in health and social care

And emerging technologies

Internet of ThingsNovel sensor technologiesDiagnostics, monitoring, self-careLifestyle and consumer applications

Understanding the environment for innovation in healthcare

Change and disruption

21st century healthcare

Ageing populationLimited resourcesConnected society – changing lifestyles

Digital health = use of (consumer) technology to enable patients to interact with health professionals remotely

• Changing clinician-patient relationship (empowered patient – or unsupported?)

• Disrupting points of access to the healthcare system• Crossover to lifestyle/wellbeing management

Enter the consumer?

How does technology adoption work in a health service?Evidence based medicine

Risk avoidance

Development Piloting Evaluation Adoption

Problem – an infinite loop is set uparound piloting and evaluation . We never get to adoption.

The technology adoption process

Why are digital health innovations different?

Digital solutions are complexThere is a new type of user – the patient (or their carers, families…)More than one professional group may be involvedCo-operation is required between different statutory (and non-statutory) providersSome elements of the solution may not be owned by the providers at all

Barriers to and enablers of technology adoption: our work and findings

The Stakeholder Empowered Adoption Model (StEAM)

Professional clinical staff

New technologyHealthcare organisation

Patients

High quality clinical outcomes, with

greater convenience and efficiency

A. Marshall. Designing telemedicine apps that health commissioners will adopt. Proceedings of the 14th Conference of Open Innovations Association FRUCT, Finland November 2013, p 63 – 68. Published by IEEE

StEAM technology adoption case studies• Remote video-linked swallowing assessments for nursing home residents• E. Bidmead, T. Reid, A. Marshall, V. Southern. ‘Teleswallowing’: a case study of

remote swallowing assessment. Clinical Governance: an International Journal, 2015. 20:3. Open access online at http://www.emeraldinsight.com/doi/abs/10.1108/CGIJ-06-2015-0020

• Renal telemedicine: video-link specialist nurses to self-managing home dialysis patients

• Patient health records and portal system for managing self care in stable gastroenterology patients

• E. Bidmead, A. Marshall. ‘A case study of stakeholder perceptions of patient held records: the Patients Know Best (PKB) solution’. Digital Health, Sage UK, 2016. In press.

• Video-enabled shared ultrasound consultations between a district general hospital and a tertiary specialist service

Enablers and barriers - technology

Many technical solutions exist and have been validatedExpertise exists within IT services in NHS.

• Choice of technology depends on use case – using NHS premises or home, patient access or clinician only, support availability to user, resolution and quality requirements etc.

• Many small scale pilots have built experience and knowledge of suppliers

BarriersConnectivity can be a problem (but getting better)Digital skills (patients and staff)Dire levels of interoperability, lack of standards and protocolsMany innovations come from small companies with limited resources for demonstrating evidenceDesigns are often not fit for the unique needs of a service and staff find it hard to modify

Barriers – staff perceptions and confidence

“I think initially you come up with lots of thoughts, is the clarity of the picture going to be good enough? Are the staff going to be trained enough? Initially I think […] A kind of a letting go sort of thing. Do I really want to let someone else be in charge of my swallow assessment? I want to be there and in control, It is, it’s control isn’t it? (SLT2 – Blackpool study)”.

“I want to see the real patient, I don’t just want to look at a computer screen (SLTFG1 – Blackpool study)”.

“I feel incompetent [when being directed remotely by a specialist consultant]” (Sonographer – Fetal telemed study)

 

Staff and telemedicineConcerns about being able to use technology

• Need to allow a lot of time to ironing out technical problems, including time for staff to experiment. They do not want to do this in front of the patients

Concerns about their changing job role. Telemedicine changes how they interact with the patient and sometimes involves another member of staff. They need to depend more on IT and this can be challenging.

• Need to allow time for staff to voice these issues and work through themFeeling threatened about their job security. Telemedicine interventions can happen at times when cuts are being made and there is understandable suspicion.Front line staff are already very stressed and cannot always see the bigger picture

• Need to allow time and for them to feel in control of the changes• There can be skills development benefits possibly reducing numbers of

referrals over timeNegative perceptions can delay or block good telemedicine interventions

Staff enablers

Innovative individuals who drive and motivate

Understanding the benefits to patients

“When patients first go home, we do like a step-down process from what we do in the room here. The system allows us to do that quicker,” (renal nurse). “I can see it instantly what the problem was just by beaming in the machine,” (renal nurse).

Appropriate education and training

Support from managers and executive sponsorship

Patient attitudes and perceptions

Patients are most often the direct beneficiaries and tend to accept the technology readily“There was one resident […] we asked for consent because he had capacity and he thought it was really good and he was quite happy to do it and he was really, really pleased to do it (NH-Nurse3 – teleswallowing study)”.They may not have received the conventional service so do not even realise that this is new. They will usually be pleased if it means they can be seen more quickly.

Time saving and convenience"Because this is a web based programme we’ve been contacted by people with flare ups on cruise ships in the Mediterranean; we’ve been contacted by people who had been admitted to other hospitals who are checking if their new medication clashed with the IBD medication; we’ve had people getting married [abroad] who couldn’t speak [the language] and were able to open their website and the GP understood some of the medical terminology and was able to treat their flare" (Consultant Gaastroenterologist – PKB study).

But not suitable for everyone

Initial work has been done on patient selection for telehealth (ref Fylde Coast Vanguard: Assessing Options for Telehealth)

Review of literature indicated various ‘dimensions’ that need to be considered, including patient activation, health literacy, digital/IT literacy, clinical and social suitability, access and connectivity.

Coaching, training and support can address some of these issues, but not all. Need to offer digital services as ‘one of the tools in the toolkit’

Management barriers and enablers

EnablersExternal policies for change Commissioning incentives

BarriersPoor quality evidence that is not relevantCost benefit not clearPerverse incentivesAvoidance of conflict internallyDistrust of new suppliers

Resisting change – some emerging themes

The health professional is concerned that the patient will be more demanding if they are able to be in contact at any time.

- The patient may become obsessed with their illness, due to an ability to micro-analyse the data.

The way in which the service is delivered has to change. It may affect more than one professional service (eg. emergency care, physiotherapy, community nursing).

Digital innovations may generate data that it is nobody’s job to look at.− Automated analyses can have risks, may not be trusted, need validation.

The mode of use may modify the solution (can be positive or negative).

Conclusion

…and further work…

Adopting new ideas

The Diffusion of Innovations - Everett Rogers, 5th ed 2003

Digital technologies in health and social care

Geoffrey Moore, Crossing the Chasm, 1991

Agile vs conventional development

Influencing change

Engaging stakeholders to understand the evidence they need to make decisions

• Readiness for change (Telehealth Readiness Tool)• Appropriate evaluation• Training and education (Digital Health and Social Care Course)

Supporting companies to innovate effectively in healthcare• Appropriate evaluation• Co-design and agile development techniques

Influencing policy makers • A better environment for innovation• Appropriate funding

alison.marshall@cumbria.ac.uk