An organisational analysis of the implementation of telecare and telehealth: the whole systems demonstrator

A mixed model approach to estimate the survivor average causal effect in cluster-randomized trials

In many medical studies, the outcome measure (such as quality of life, QOL) for some study participants becomes informatively truncated (censored, missing, or unobserved) due to death or other forms of dropout, creating a nonignorable missing data problem. In such cases, the use of a composite outcome or imputation methods that fill in unmeasurable QOL values for those who died rely on strong and untestable assumptions and may be conceptually unappealing to certain stakeholders when estimating a treatment effect. The survivor average causal effect (SACE) is an alternative causal estimand that surmounts some of these issues. While principal stratification has been applied to estimate the SACE in individually randomized trials, methods for estimating the SACE in cluster-randomized trials are currently limited. To address this gap, we develop a mixed model approach along with an expectation-maximization algorithm to estimate the SACE in cluster-randomized trials. We model the continuous outcome measure with a random intercept to account for intracluster correlations due to cluster-level randomization, and model the principal strata membership both with and without a random intercept. In simulations, we compare the performance of our approaches with an existing fixed-effects approach to illustrate the importance of accounting for clustering in cluster-randomized trials. The methodology is then illustrated using a cluster-randomized trial of telecare and assistive technology on health-related QOL in the elderly.

New and emerging technology for adult social care - the example of home sensors with artificial intelligence (AI) technology

Background

Digital technology is a focus within the NHS and social care as a way to improve care and address pressures. Sensor-based technology with artificial intelligence capabilities is one type of technology that may be useful, although there are gaps in evidence that need to be addressed.

Objective

This study evaluates how one example of a technology using home-based sensors with artificial intelligence capabilities (pseudonymised as 'IndependencePlus') was implemented in three case study sites across England. The focus of this study was on decision-making processes and implementation.

Design

Stage 1 consisted of a rapid literature review, nine interviews and three project design groups. Stage 2 involved qualitative data collection from three social care sites (20 interviews), and three interviews with technology providers and regulators.

Results

• It was expected that the technology would improve care planning and reduce costs for the social care system, aid in prevention and responding to needs, support independent living and provide reassurance for those who draw on care and their carers. • The sensors were not able to collect the necessary data to create anticipated benefits. Several technological aspects of the system reduced its flexibility and were complex for staff to use. • There appeared to be no systematic decision-making process in deciding whether to adopt artificial intelligence. In its absence, a number of contextual factors influenced procurement decisions. • Incorporating artificial intelligence-based technology into existing models of social care provision requires alterations to existing funding models and care pathways, as well as workforce training. • Technology-enabled care solutions require robust digital infrastructure, which is lacking for many of those who draw on care and support. • Short-term service pressures and a sense of crisis management are not conducive to the culture that is needed to reap the potential longer-term benefits of artificial intelligence.

Limitations

Significant recruitment challenges (especially regarding people who draw on care and carers) were faced, particularly in relation to pressures from COVID-19.

Conclusions

This study confirmed a number of common implementation challenges, and adds insight around the specific decision-making processes for a technology that has been implemented in social care. We have also identified issues related to managing and analysing data, and introducing a technology focused on prevention into an environment which is focused on dealing with crises. This has helped to fill gaps in the literature and share practical lessons with commissioners, social care providers, technology providers and policy-makers.

Future work

We have highlighted the implications of our findings for future practice and shared these with case study sites. We have also developed a toolkit for others implementing new technology into adult social care based on our findings (https://www.birmingham.ac.uk/documents/college-social-sciences/social-policy/brace/ai-and-social-care-booklet-final-digital-accessible.pdf). As our findings mirror the previous literature on common implementation challenges and a tendency of some technology to 'over-promise and under-deliver', more work is needed to embed findings in policy and practice.

Study registration

Ethical approval from the University of Birmingham Research Ethics Committee (ERN_13-1085AP41, ERN_21-0541 and ERN_21-0541A).

Funding

This project was funded by the National Institute of Health and Care Research (NIHR) Health Services and Delivery Research programme (HSDR 16/138/31 - Birmingham, RAND and Cambridge Evaluation Centre).

Successful implementation of self-management health innovations

Background

Literature on self-management innovations has studied their characteristics and position in healthcare systems. However, less attention has been paid to factors that contribute to successful implementation. This paper aims to answer the question: which factors play a role in a successful implementation of self-management health innovations?

Methods

We conducted a narrative review of academic literature to explore factors related to successful implementation of self-management health innovations. We further investigated the factors in a qualitative multiple case study to analyse their role in implementation success. Data were collected from nine self-management health projects in the Netherlands.

Results

Nine factors were found in the literature that foster the implementation of self-management health innovations: 1) involvement of end-users, 2) involvement of local and business partners, 3) involvement of stakeholders within the larger system, 4) tailoring of the innovation, 5) utilisation of multiple disciplines, 6) feedback on effectiveness, 7) availability of a feasible business model, 8) adaption to organisational changes, and 9) anticipation of changes required in the healthcare system. In the case studies, on average six of these factors could be identified. Three projects achieved a successful implementation of a self-management health innovation, but only in one case were all factors present.

Conclusions

For successful implementation of self-management health innovation projects, the factors identified in the literature are neither necessary nor sufficient. Therefore, it might be insightful to study how successful implementation works instead of solely focusing on the factors that could be helpful in this process.

Acute medical units during the first wave of the COVID-19 pandemic: a cross-national exploratory study of impact and responses

BACKGROUND

The COVID-19 pandemic represents one of the greatest ever challenges for healthcare. In the UK and beyond, acute medical units (AMUs) are the first point of assessment and care for the majority of medical inpatients. By their design and systems, they inevitably played an important role in the COVID-19 response but to date little has been published on how the COVID-19 pandemic has affected how AMUs have reorganised their resources, processes and structure.

METHODS

This retrospective study in August 2020 of 10 AMUs across Europe and Australasia used a standardised questionnaire to investigate existing practice and structure of AMUs, the national context of local hospital experience, changes to practice during the COVID-19 pandemic and views regarding future practice.

RESULTS

Changes to AMU structure, process and organisation are described in two contexts: preventing and controlling the spread of COVID-19 and adding value to the patient's acute care journey in the local context. We describe novel practices that have arisen and highlight areas of concern.

CONCLUSIONS

The AMUs were able to adapt to meet the demands of acute care delivery during the first wave of the COVID-19 pandemic. Operational planning and prioritisation of resources must be optimised to ensure sustainability of these services for future waves.

Home telemonitoring for chronic disease management: Perceptions of users and factors influencing adoption

Home telemonitoring has been used as a solution to support the care of individuals living with chronic disease. While effectiveness of telemonitoring have been widely studied, more research is needed to understand the perceptions among patients and clinicians in incorporating telemonitoring into their daily routine and practices. This paper presents an investigation of patients' and clinicians' experiences in a care augmenting telemonitoring service, their perceived impact delivered through the service, and clinicians' perceptions on how the service was introduced in their organizations. This work was embedded in a large multi-site trial of home telemonitoring using a mixed method approach for evaluation. Interviews with clinicians involved in the study were conducted at multiple time points during the trial. Questionnaires were administered to clinicians and patients at the end of the trial. Results showed that both patients and clinicians recognized the benefits of patient empowerment through telemonitoring, and patient-clinician interactions. Results identified the needs of a dedicated telemonitoring clinical care coordinator role, guidelines that translate telemonitoring services into clinical pathways and engagement of different healthcare providers, especially general practitioners, to support the integration of telemonitoring into chronic disease management programs and long-term organizational strategic plans.

Understanding the general practice of telemonitoring integrated care: a qualitative perspective

Developed in partnership with GPs, a new telehealth model of care using remote monitoring, known as telemonitoring (TM), was introduced in South Western Sydney (SWS) in 2015, transmitting clinical readings taken at home to telehealth coordinators. This study explored the experiences, beliefs and attitudes of general practice staff to identify barriers to and facilitators of the SWS TM model. Responses were collected from a purposive sample of 10 participants via semistructured interviews (n=9 interview sessions) and the resulting transcripts were analysed thematically. Four themes were identified: lack of understanding and involvement; patient-centred care and empowerment; clinical practice and process factors; and system-wide communication and collaboration. Participants recognised some actual and potential benefits of TM, but barriers to TM were identified across all themes. Feedback provided by participants has informed the ongoing formulation of a more 'GP-led' model of TM.

Near Me at Home: codesigning the use of video consultations for outpatient appointments in patients' homes

Reforming the delivery of outpatient appointments (OPA) was high on the healthcare policy agenda prior to COVID-19. The current pandemic exacerbates the financial and associated resource limitations of OPA. Videoconsulting provides a safe method of real-time contact for some remotely residing patients with hospital-based clinicians. One factor in failing to move from introduction of service change to its general adoption may be lack of patient and public involvement. This project, based in the largest Island in the Inner Hebrides of Scotland, aimed to codesign the use of the NHS Near Me video consulting platform for OPA to take place in the patient’s home. A codesign model was used as a framework. This included: step 1—presenting a process flow map of the current system of using Near Me to public participants and establishing their ideas on various steps in the process, step 2—conducting numerous Plan, Do, Study, Act (PDSA) tests and creating a current process flow diagram based on learning and step 3—conducting telephone interviews and thematic analysis of transcripts (n=7) to explore participants’ perceptions of being involved in the codesign process. Twenty-five adaptations were made to the Near Me at Home video appointment process from participants’ PDSA testing. Four themes were identified from thematic analysis of participants’ feedback of the codesign process, namely: altruistic motivation, valuing community voices, the usefulness of the PDSA cycles and the power of ‘word of mouth’. By codesigning the use of Near Me with people living in a remote area of Scotland, multiple adaptations were made to the processes to suit the context in which Near Me at Home will be used. Learning from testing and adapting with the public will likely be useful for others embarking on codesign approaches to improve spread and sustainability of quality improvement projects.

Factors influencing the implementation of self-management solutions in healthcare: an interview study with NHS managers

Background/aims

Research focusing on the perspectives of healthcare managers, who are often key in devising strategies for the implementation of self-management solutions, is limited. This study aimed to investigate the barriers to the implementation of technology-based self-management solutions in an NHS organisation and how this affects project delivery.

Methods

Semi-structured interviews were held with 15 NHS employees in various managerial roles from one organisation. As initial findings suggested that managers were not fully aware of how to approach the different stages of project delivery, a second analysis was conducted to explore their approaches and insights at various stages of a self-management project.

Findings

Participants were highly knowledgeable about key decision-making processes in the initial phases of a project, but clearly struggled during the organisation and implementation phases.

Conclusions

To support the successful implementation of projects, managers should focus more on unpacking the later stages of project delivery and addressing the contextual factors that influence them.

Remote care technologies, older people and the social care crisis in the United Kingdom: a Multiple Streams Approach to understanding the ‘silver bullet’ of telecare policy

The policy announcement in November 2018 by the Secretary of State for Health and Social Care that: ‘from today, let this be clear: tech transformation is coming’ indicates that confidence in care technologies, so apparent over the past decade in policy circles, remains unabated. This article suggests, based on evidence of significant limitations in technological solutions to care needs, that this confidence is misplaced. The focus is on remote care technologies – primarily telecare – which involve the passive or real-time monitoring of recipients, the majority of whom will be older people. These information and communication technologies (ICT) have been heralded by politicians, policy makers and industry interests alike as a solution to the challenges of demographic change and social care demand. While the research evidence suggests telecare works well for some people, in some circumstances, there are also significant complexities in its use, challenges presented to care relationships, and conflicting interpretations around its efficacy and cost-effectiveness. These critical issues have been marginalised in the mainstream discourse around telecare policy. This article explores the dissonance between this policy and the available evidence, drawing on a Multiple Streams Approach to analyse the emergence of, and continued confidence in, telecare policy based on a congruence of views across policy interests. To the extent that social care for older people is now in crisis, the article argues that the discourse around telecare represents an example of ‘silver bullet’ thinking: that is, too much focus on a single policy solution to address complex problems. Accordingly, the crisis in social care has deepened, without alternative policy proposals being available to address it. The renewed push for ICT-based solutions to this crisis in social care ought therefore to be viewed with some concern.

Health Care Personnel's Perspective on Potential Electronic Health Interventions to Prevent Hospitalizations for Older Persons Receiving Community Care: Qualitative Study

Background

The use of electronic health (eHealth) interventions is suggested to help monitor and treat degenerative and chronic diseases through the use of sensors, alarms, and reminders and can potentially prevent hospitalizations for home-dwelling older persons receiving community care. It is increasingly recognized that the health care personnel’s acceptance of a technological application remains a key challenge in adopting an intervention, thus interventions must be perceived to be useful and fit for purpose by the actual users.

Objective

The aim of this study was to identify and explore the perspectives of managers and health care personnel in community care regarding the use of eHealth interventions in terms of prevention of hospitalizations for home-dwelling older persons receiving community care.

Methods

A case study with a qualitative approach was carried out in community care in a Norwegian municipality, comprising individual interviews and focus group interviews. A total of 5 individual interviews and 2 focus group interviews (n=12) were undertaken to provide the health care personnel’s and managers’ perspective regarding the use of eHealth interventions, which could potentially prevent hospitalizations for home-dwelling older persons receiving community care. Data were analyzed by way of systematic text condensation, as described by Malterud.

Results

The data analysis of focus group interviews and individual interviews resulted in 2 categories: potential technological applications and potential patient groups. Discussions in the focus groups generated several suggestions and wishes related to technical applications that they could make use of in their day-to-day practice. The health care personnel warranted tools and measures to enhance and document their clinical observations in contact with patients. They also identified patient groups, such as patients with chronic obstructive pulmonary disease or dehydration or urinary tract infections, for whom hospitalizations could potentially have been prevented.

Conclusions

We have shown that the health care personnel in community care warrant various technological applications that have the potential to improve quality of care and resource utilization in the studied municipality. We have identified needs and important matters in practice, which are paramount for acceptance and adoption of an intervention in community care.

Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review

Background

Governments and health care providers are keen to find innovative ways to deliver care more efficiently. Interest in electronic consultation (e-consultation) has grown, but the evidence of benefit is uncertain.

Objective

This study aimed to assess the evidence of delivering e-consultation using secure email and messaging or video links in primary care.

Methods

A systematic review was conducted on the use and application of e-consultations in primary care. We searched 7 international databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, EconLit, and Web of Science; 1999-2017), identifying 52 relevant studies. Papers were screened against a detailed inclusion and exclusion criteria. Independent dual data extraction was conducted and assessed for quality. The resulting evidence was synthesized using thematic analysis.

Results

This review included 57 studies from a range of countries, mainly the United States (n=30) and the United Kingdom (n=13). There were disparities in uptake and utilization toward more use by younger, employed adults. Patient responses to e-consultation were mixed. Patients reported satisfaction with services and improved self-care, communication, and engagement with clinicians. Evidence for the acceptability and ease of use was strong, especially for those with long-term conditions and patients located in remote regions. However, patients were concerned about the privacy and security of their data. For primary health care staff, e-consultation delivers challenges around time management, having the correct technological infrastructure, whether it offers a comparable standard of clinical quality, and whether it improves health outcomes.

Conclusions

E-consultations may improve aspects of care delivery, but the small scale of many of the studies and low adoption rates leave unanswered questions about usage, quality, cost, and sustainability. We need to improve e-consultation implementation, demonstrate how e-consultations will not increase disparities in access, provide better reassurance to patients about privacy, and incorporate e-consultation as part of a manageable clinical workflow.

Exploring the Impact of a Telehealth Care System on Organizational Capabilities and Organizational Performance from a Resource-Based Perspective

This study explored the effects of information technology (IT) resources-in conjunction with IT infrastructure and organizational resources-on organizational capabilities and performance. The study further analyzed the mediating effect of organizational capabilities on the relationship between IT resources and organizational performance. A cross-sectional research design was adopted, and questionnaire copies were administered to senior care supervisors of Taiwanese day care centers, care institutions, and hospitals. In total, 328 valid questionnaire responses were obtained. The study results are summarized as follows: (1) A direct effect analysis revealed that IT infrastructure significantly affected service performance and financial performance; organizational resources significantly affected service performance but did not significantly affect financial performance. (2) A mediation model analysis indicated that organizational capabilities exerted a mediating effect on the relationship between IT resources and organizational performance. These results can serve as a reference for medical care organizations in developing strategies for reviewing internal IT resources, integrating internal and external capabilities, creating a competitive advantage, and boosting their performance.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Role of Artificial Intelligence within the Telehealth Domain

Objectives : This paper provides a discussion about the potential scope of applicability of Artificial Intelligence methods within the telehealth domain. These methods are focussed on clinical needs and provide some insight to current directions, based on reports of recent advances.

Methods : Examples of telehealth innovations involving Artificial Intelligence to support or supplement remote health care delivery were identified from recent literature by the authors, on the basis of expert knowledge. Observations from the examples were synthesized to yield an overview of contemporary directions for the perceived role of Artificial Intelligence in telehealth.

Results : Two major focus areas for related contemporary directions were established. These were first, quality improvement for existing clinical practice and service delivery, and second, the development and support of new models of care. Case studies from each focus area have been chosen for illustration purposes.

Conclusion : Examples of the role of Artificial Intelligence in delivery of health care remotely include use of tele-assessment, tele-diagnosis, tele-interactions, and tele-monitoring. Further developments of underlying algorithms and validation of methods will be required for wider adoption. Certain key social and ethical considerations also need consideration more generally in the health system, as Artificial-Intelligence-enabled-telehealth becomes more commonplace.

Integrating health and care in the 21st century workforce

Purpose

The NHS needs to adapt as never before to maintain and plan for an integrated and sustainable multi-professional workforce, spanning all health and care sectors. This cannot happen without system leaders embracing workforce transformation at scale and enabling system-wide collaboration and support for multi-professional learning and role development. “By learning together, we learn how to work together”. The paper aims to discuss these issues.

Design/methodology/approach

The case studies included in this paper provide evidence of the ability of NHS systems to adopt integrated workforce models at scale. The case studies were chosen to demonstrate how system-wide change is possible, but still requires a partnership approach to innovation, strategic workforce planning and commissioner support for new models of care.

Findings

With partnership working between arm’s length bodies, commissioners, educators and workforce planners, the NHS is more than capable of generating a transformed workforce; a workforce able to continue providing safe, effective and joined-up person-centred care.

Research limitations/implications

The focus of this paper is integrated workforce development undertaken by Health Education England from 2017 to the date of drafting. The case studies within this paper relate to England only and are a cross-section chosen by the authors as a representative of Health Education England activity.

Practical implications

The NHS needs to find ways to use the wider health and care workforce to manage an ever-increasing and diverse patient population. Silo working, traditional models of workforce planning and commissioning no longer provide an appropriate response to increasing patient need and complexity.

Social implications

The evolution of the NHS into a joined-up, integrated health and social care workforce is essential to meet the aspirations of national policy and local workforce need – to centre care holistically on the needs of patients and populations and blur the boundaries between primary and secondary care; health and social care; physical and mental health.

Originality/value

This paper contains Health Education England project work and outcomes which are original and as yet unpublished.

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

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

The effectiveness of exercise-based telemedicine on pain, physical activity and quality of life in the treatment of chronic pain: A systematic review

Introduction The aim of this study was to systematically review the evidence on the effectiveness of exercise-based telemedicine in chronic pain. Methods We searched the Cochrane, PubMed, MEDLINE, EMBASE, CINAHL and PEDRO databases from 2000 to 2015 for randomised controlled trials, comparing exercise-based telemedicine intervention to no intervention or usual care in adults with chronic pain. Primary outcome data were pooled using random effect meta-analysis. Primary outcomes were pain, physical activity (PA), limitations in activities of daily living (ADL) and quality of life (QoL). Secondary outcomes were barriers, facilitators and usability of telemedicine. Results Sixteen studies were included. Meta-analyses were performed in three subgroups of studies with comparable control conditions. Telemedicine versus no intervention showed significantly lower pain scores (MD -0.57, 95% CI -0.81; -0.34), but not for telemedicine versus usual care (MD -0.08, 95% CI -0.41; 0.26) or in addition to usual care (MD -0.25, 95% CI -1.50; 1.00). Telemedicine compared to no intervention showed non-significant effects for PA (MD 19.93 min/week, 95% CI -5.20; 45.06) and significantly diminished ADL limitations (SMD -0.20, 95% CI -0.29; -0.12). No differences were found for telemedicine in addition to usual care for PA or for ADL (SMD 0.16, 95% CI -0.66; 0.34). Telemedicine versus usual care showed no differences for ADL (SMD 0.08, 95% CI -0.37; 0.53). No differences were found for telemedicine compared to the three control groups for QoL. Limited information was found on the secondary outcomes. Conclusions Exercise-based telemedicine interventions do not seem to have added value to usual care. As substitution of usual care, telemedicine might be applicable but due to limited quality of the evidence, further exploration is needed for the rapidly developing field of telemedicine.

Digitized patient-provider interaction: How does it matter? A qualitative meta-synthesis

Sociological interest in the digitization of health has predominantly been studied using qualitative approaches. Research in this field has grown steadily since the late 1990's but to date, no synthesis has been conducted to integrate this now rather comprehensive corpus of data. In this paper we present a meta-ethnography of 15 papers reporting qualitative studies of digitally mediated patient - professional interactions. By dissecting the detailed descriptions of digitized practices in this most basic relationship in health care, we explore how these studies can illuminate important aspects of social relations in contemporary society. Our interpretative synthesis enables us to reassert a sociological view that places changes in social structures and interaction at the core of questions about the digitization of health care. Our synthesis of this literature identifies four key concepts that point at structural processes of change. We argue that when patient-professional interactions are digitized, relations are respatialized, and there are reconnections of relational components. These lead to empirically specific reactions, which can be characterized as reconstitutions and renegotiations of social practices which in turn are related to the reconfiguration of basic social institutions. We propose a new direction for exploring the digitalization of health care to illuminate how digital health is related to contemporary social change.

Using telemonitoring to support personal care planning for adults with learning disabilities

INTRODUCTION

We report on an evaluation of the Just Right approach for planning care for adults with learning disabilities and how it can support culture change. Just Right combines installing a telemonitoring system with training for care managers in person-centred care planning and the interpretation of charts that summarise activity data for their setting. By providing insights into the needs of individuals Just Right allows existing care provision to be reviewed to ensure it is 'just right'. The Just Right approach can also potentially identify over-care and resources that can released.

METHODS

A mixed-methods approach was used, triangulating qualitative and quantitative baseline and follow-up data. Qualitative data were collected before and after implementation from focus groups on barriers, enablers, success outcomes and impacts. A theory of change was developed. Detailed data on individual adults with learning disabilities were collected before and after installation of equipment using a linked online survey completed by their care managers.

RESULTS

Nine commissioning local authorities were recruited with 33 care providers serving 417 adults with learning disabilities. Issues relating to implementation included staff acceptance, culture, consent, safeguarding, local authority engagement, interpretation of data and residential setting. Changes to care were identified for 20.3% of individuals, with 66% of providers not identifying any changes because Just Right confirmed that they were providing the right level of support.

DISCUSSION

By combining telemonitoring and person-centred care planning, Just Right provides a holistic approach and necessary information for conversations amongst stakeholders about the care needs of adults with learning disabilities. Depending on how it is introduced, and the nature of conversations held, the Just Right approach can potentially change culture, leading to improved outcomes.

Cost-Effectiveness Analysis in Telehealth: A Comparison between Home Telemonitoring, Nurse Telephone Support, and Usual Care in Chronic Heart Failure Management

OBJECTIVES

To assess the cost effectiveness of home telemonitoring (HTM) and nurse telephone support (NTS) compared with usual care (UC) in the management of patients with chronic heart failure, from a third-party payer's perspective.

METHODS

We developed a Markov model with a 20-year time horizon to analyze the cost effectiveness using the original study (Trans-European Network-Home-Care Management System) and various data sources. A probabilistic sensitivity analysis was performed to assess the decision uncertainty in our model.

RESULTS

In the original scenario (which concerned the cost inputs at the time of the original study), HTM and NTS interventions yielded a difference in quality-adjusted life-years (QALYs) gained compared with UC: 2.93 and 3.07, respectively, versus 1.91. An incremental net monetary benefit analysis showed €7,697 and €13,589 in HTM and NTS versus UC at a willingness-to-pay (WTP) threshold of €20,000, and €69,100 and €83,100 at a WTP threshold of €80,000, respectively. The incremental cost-effectiveness ratios were €12,479 for HTM versus UC and €8,270 for NTS versus UC. The current scenario (including telenurse cost inputs in NTS) yielded results that were slightly different from those for the original scenario, when comparing all New York Heart Association (NYHA) classes of severity. NTS dominated HTM, compared with UC, in all NYHA classes except NYHA IV.

CONCLUSIONS

This modeling study demonstrated that HTM and NTS are viable solutions to support patients with chronic heart failure. NTS is cost-effective in comparison with UC at a WTP of €9000/QALY or higher. Like NTS, HTM improves the survival of patients in all NYHA classes and is cost-effective in comparison with UC at a WTP of €14,000/QALY or higher.

Implementing new care models: learning from the Greater Manchester demonstrator pilot experience

Background

Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various ‘new models of care’, including general practice offering ‘additional availability’ appointments during evenings and at weekends. In Greater Manchester, six ‘demonstrator sites’ were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes.

Methods

Semi-structured interviews, with the data subjected to thematic analysis.

Results

Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants.

Conclusions

The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care.

A Conceptual Measurement Model for eHealth Readiness: a Team Based Perspective

Despite the shift towards collaborative healthcare and the increase in the use of eHealth technologies, there does not currently exist a model for the measurement of eHealth readiness in interdisciplinary healthcare teams. This research aims to address this gap in the literature through the development of a three phase methodology incorporating qualitative and quantitative methods. We propose a conceptual measurement model consisting of operationalized themes affecting readiness across four factors: (i) Organizational Capabilities, (ii) Team Capabilities, (iii) Patient Capabilities, and (iv) Technology Capabilities. The creation of this model will allow for the measurement of the readiness of interdisciplinary healthcare teams to use eHealth technologies to improve patient outcomes.

Telemedicine: Is it really worth it? A perspective from evidence and experience

BACKGROUND

 Although the formal evidence base is equivocal, practical experience suggests that implementations of technology that support telemedicine initiatives can result in improved patient outcomes, better patient and carer experience and reduced expenditure.

OBJECTIVE

To answer the questions "Is an investment in telemedicine worth it?" and "How do I make a telemedicine implementation work?"

METHODS

 Summary of systematic review evidence and an illustrative case study. Discussion of implications for industry and policy.

RESULTS

Realisation of telemedicine benefits is much less to do with the technology itself and much more around the context of the implementing organisation and its ability to implement.

CONCLUSION

 We recommend that local organisations consider deployment of telemedicine initiatives but with a greater awareness of the growing body of implementation best practice. We also recommend, for the NHS, that the centre takes a greater role in the collation and dissemination of best practice to support successful implementations of telemedicine and other health informatics initiatives.

Stimulating whole system redesign: Lessons from an organizational analysis of the Whole System Demonstrator programme

OBJECTIVES

Whole system integration of health and social care has been positioned as key to improving care, increasing efficiency and controlling costs. However, evidence for the benefits of whole system integration is scarce. Drawing on organizational theory, this study uses the implementation of remote care services, viewed as an enabler for whole system working, to explore the reality of achieving this policy objective.

METHODS

Qualitative, longitudinal data were collected across nine UK sites adopting remote care over three years. Three sites formed the Department of Health's Whole Systems Demonstrator (WSD) programme for remote care. In addition, the implementation of remote care was explored in six other sites unconstrained by the randomized control trial procedures of the WSD programme. The methods were ethnographic (including 235 hours of observations and 184 interviews). Participants were health and social care staff and Government policy makers.

RESULTS

Remote care did not lead to system redesign; however, local 'ownership' of new services did lead to more collaborative practices across the care system. Lack of integration was an enduring and endemic challenge across all sites, relating to differences in statutory responsibilities, absence of shared budgets and hybrid organizational roles, differences in work practices and organizational philosophies, and ambiguity around what 'whole system working' actually entailed.

CONCLUSIONS

Policy initiatives like the WSD programme provide opportunities to phase in collaborative practices and create an awareness of the need for joint working. However, the progress observed suggests that the concept of whole system redesign around remote care is currently unrealistic.

An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

Background

Oral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.

Research questions

Can an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?

Design

A mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.

Setting

The ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.

Participants

Patients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.

Interventions

A consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.

Main outcome measures

Diagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.

Results

In the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.

Conclusions

Implementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.

Study limitations

The geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.

Future work

The findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The Emergence and Unfolding of Telemonitoring Practices in Different Healthcare Organizations

Telemonitoring, a sub-category of telemedicine, is promoted as a solution to meet the challenges in Western healthcare systems in terms of an increasing population of people with chronic conditions and fragmentation issues. Recent findings from large-scale telemonitoring programs reveal that these promises are difficult to meet in complex real-life settings which may be explained by concentrating on the practices that emerge when telemonitoring is used to treat patients with chronic conditions. This paper explores the emergence and unfolding of telemonitoring practices in relation to a large-scale, inter-organizational home telemonitoring program which involved 5 local health centers, 10 district nurse units, four hospitals, and 225 general practice clinics in Denmark. Twenty-eight interviews and 28 h of observations of health professionals and administrative staff were conducted over a 12-month period from 2014 to 2015. This study's findings reveal how telemonitoring practices emerged and unfolded differently among various healthcare organizations. This study suggests that the emergence and unfolding of novel practices is the result of complex interplay between existing work practices, alterations of core tasks, inscriptions in the technology, and the power to either adopt or ignore such novel practices. The study enhances our understanding of how novel technology like telemonitoring impacts various types of healthcare organizations when implemented in a complex inter-organizational context.

Towards an ethics for telehealth

Over the last two decades, a public rationale for the implementation of telehealth has emerged at the interplay of specialised literature and political orientations. Despite the lack of consistent findings on the magnitude of its benefits, telehealth is nowadays presented as a worthy solution both for patients and healthcare institutions. Far from denying the potential advantages of telehealth, the main objective of this work is to provide a critical assessment on the spread of the remote services as a vector of positive transformation of contemporary health systems. For pursuing this objective, the EU agenda for the promotion of telehealth will be retraced, and the main evidences alleged to sustain the implementation of remote care services will be assessed. Furthermore, it will be evaluated the attempt made by the European Commission to establish an ethical framework for guiding the use of telehealth in daily practice, and a roadmap of the most relevant legal and ethical issues posed by the spread of telehealth will be traced. In the conclusions, it will be argued that the radical transformations induced by this form of technological innovation call on to a new, ad hoc ethics through which critically evaluate benefits and implications of telehealth services, with a view to keep high the standard of healthcare against the economic interests of private stakeholders and ICTs' vendors.

Telehealth: misconceptions and experiences of healthcare professionals in England

OBJECTIVES

This study aims to look at telehealth awareness and experiences among healthcare professionals (HCPs) from different disciplines, in addition to factors impeding its adoption in healthcare delivery.

METHODS

Qualitative semi-structured interviews were conducted with 36 HCPs from different disciplines such as pharmacists, nurses and doctors in South London. A convenience sampling technique was used whereby HCPs working in local trusts, community pharmacies and general practitioners surgeries were approached for participation. Thematic analysis was used to identify key themes using the NVIVO 10 software.

KEY FINDINGS

The four main themes that emerged were awareness and understanding of telehealth, experiences and benefits of telehealth, barriers and facilitators of telehealth and misconceptions about telehealth. The study showed mixed response regarding telehealth awareness. Lack of telehealth experience was reported mainly among HCPs working in primary care. The barriers identified were cost and lack of funding and resources, whereas facilitators were raising awareness among staff and the public and investment in resources. Misconceptions identified were fear of losing face-to-face contact with patients and vital care information, patients' beliefs and confidence in using technology.

CONCLUSIONS

This study showed experience and awareness level to be still low especially among HCPs working in primary care. Barriers and misconceptions identified are still the same as those reported in the literature which highlights that they have not yet been addressed to facilitate telehealth implementation in the UK.

Validity of the Model for Assessment of Telemedicine: A Delphi study

Introduction

In 2009, the Model for Assessment of Telemedicine (MAST) was developed within the MethoTelemed project as a framework for description of the effectiveness of telemedicine applications. The goal was for the assessments to be used as basis for decision-making in healthcare systems. Since then, MAST has been used in many European telemedicine studies and is now the most widely used model for assessment of telemedicine. The aim of this study was to assess the face validity of MAST.

Methods

A modified Delphi process was carried out and included a workshop with a sample of healthcare decision makers. A total of 56 decision makers and experts in telemedicine were invited and 19 persons participated in the two Delphi rounds. Thirteen hospitals or regional health authorities from 12 European countries and six research organisations were represented in the final sample. The participants were asked to assess the importance of the different domains and topics in MAST on a 0–3 Likert scale.

Results

All respondents completed the two rounds. Based on the answers, the face validity of all MAST domains was confirmed, since all domains were considered moderately or highly important by more than 80% of the respondents.

Discussion

Even though the study confirmed the validity of MAST, a number of supplements and improvements regarding study design and data collection were suggested. When considering the results it should be noticed that the sample size was small and larger studies are needed to confirm the results.

Making Telecare desirable rather than a last resort

Despite reported benefits of Telecare use for older adults, uptake of Telecare in the United Kingdom remains relatively low. Non-users of Telecare are an under-researched group in the Telecare field. We conducted 22 qualitative individual semi-structured interviews to explore the views and opinions of current non-users of Telecare regarding barriers and facilitators to its use, and explored considerations which may precede their decision to accept, or reject, Telecare. Framework analysis identified a number of themes which influence the outcome and timing of this decision, including peace of mind (for the individual and their family), the strength and composition of an individual's support network, the impact of changing personal and health circumstances, and lack of communication about Telecare (e.g.advertising). A cost–benefit decision process appears to take place for the potential user, whereby the benefit of peace of mind is weighed against perceived ‘costs’ of using Telecare. Telecare is often perceived as a last resort rather than a preventative measure. A number of barriers to Telecare use need to be addressed if individuals are to make fully informed decisions regarding their Telecare use, and to begin using Telecare at a time when it could provide them with optimal benefit. Although the study was set in England, the findings may be relevant for other countries where Telecare is used.

'Massive potential' or 'safety risk'? Health worker views on telehealth in the care of older people and implications for successful normalization

BACKGROUND

Telehealth technologies, which enable delivery of healthcare services at distance, offer promise for responding to the challenges created by an ageing population. However, successful implementation of telehealth into mainstream healthcare systems has been slow and fraught with failure. Understanding of frontline providers' experiences and attitudes regarding telehealth is a crucial aspect of successful implementation. This study aims to examine healthcare worker views on telehealth, and their implications for implementation to mainstream healthcare services for older people. The study includes a focus on two further dimensions of urban versus rural services and level of clinician experience with telehealth.

METHODS

Seven semi-structured focus groups were conducted with a total of 44 healthcare workers providing services to older people in the areas of rehabilitation and allied health, residential aged care and palliative care. Focus groups included both telehealth experienced and inexperienced groups. Of the experienced groups, two provided services to both urban and rural patients, and two to rural patients. Inexperienced groups included one rural and two urban. Thematic analysis was undertaken to identify predominant themes. Between-group differences and agreement in viewpoints for each of these themes are discussed and mapped to the theoretical constructs of Normalization Process Theory.

RESULTS

The views of participants varied with the extent of telehealth experience and perception of accessibility of healthcare services. Four themes describing clinician attitudes and perceptions that could impact on successful implementation of telehealth services are outlined: 1) Workability of telehealth: exponential growth in access or decay in the quality of healthcare? 2) What is an acceptable level of risk to patient safety with telehealth? 3) Shifting responsibilities and recalibrating the team; and 4) Change of architecture required to enable integration of telehealth service delivery.

CONCLUSIONS

The use of telehealth technologies to provide healthcare services to older people may be more readily normalized in areas where existing services are limited. Though exposure to telehealth may be a factor, changes to the perceived feasibility of telehealth in relation to conventional services, as well as supportive infrastructure and training and skill recalibration may be more critical to successful normalization of telehealth services for older people.

Mixed methods for telehealth research

Mixed methods research is important to health services research because the integrated qualitative and quantitative investigation can give a more comprehensive understanding of complex interventions such as telehealth than can a single-method study. Further, mixed methods research is applicable to translational research and program evaluation. Study designs relevant to telehealth research are described and supported by examples. Quality assessment tools, frameworks to assist in the reporting and review of mixed methods research, and related methodologies are also discussed.

Theoretical frameworks in telemedicine research

The purposive use of theory is a foundational component of research, which underpins the design, methodology, measures, interventions, and interpretation of the research project. This should be considered from the time the nascent idea of the research is born, until the final interpretation of results and write up of the discussion. Several theories relevant to telemedicine are described, discussed, and linked to typical research questions in the field.

Transitioning a home telehealth project into a sustainable, large-scale service: a qualitative study

Background

This study was a component of the Flinders Telehealth in the Home project, which tested adding home telehealth to existing rehabilitation, palliative care and geriatric outreach services. Due to the known difficulty of transitioning telehealth projects services, a qualitative study was conducted to produce a preferred implementation approach for sustainable and large-scale operations, and a process model that offers practical advice for achieving this goal.

Methods

Initially, semi-structured interviews were conducted with senior clinicians, health service managers and policy makers, and a thematic analysis of the interview transcripts was undertaken to identify the range of options for ongoing operations, plus the factors affecting sustainability. Subsequently, the interviewees and other decision makers attended a deliberative forum in which participants were asked to select a preferred model for future implementation. Finally, all data from the study was synthesised by the researchers to produce a process model.

Results

19 interviews with senior clinicians, managers, and service development staff were conducted, finding strong support for home telehealth but a wide diversity of views on governance, models of clinical care, technical infrastructure operations, and data management. The deliberative forum worked through these options and recommended a collaborative consortium approach for large-scale implementation. The process model proposes that the key factor for large-scale implementation is leadership support, which is enabled by 1) showing solutions to the problems of service demand, budgetary pressure and the relationship between hospital and primary care, 2) demonstrating how home telehealth aligns with health service policies, and 3) achieving clinician acceptance through providing evidence of benefit and developing new models of clinical care. Two key actions to enable change were marketing telehealth to patients, clinicians and policy-makers, and building a community of practice.

Conclusions

The implementation of home telehealth services is still in an early stage. Change agents and a community of practice can contribute by marketing telehealth, demonstrating policy alignment and providing potential solutions for difficult health services problems. This should assist health leaders to move from trials to large-scale services.

Personalized Telehealth in the Future: A Global Research Agenda

As telehealth plays an even greater role in global health care delivery, it will be increasingly important to develop a strong evidence base of successful, innovative telehealth solutions that can lead to scalable and sustainable telehealth programs. This paper has two aims: (1) to describe the challenges of promoting telehealth implementation to advance adoption and (2) to present a global research agenda for personalized telehealth within chronic disease management. Using evidence from the United States and the European Union, this paper provides a global overview of the current state of telehealth services and benefits, presents fundamental principles that must be addressed to advance the status quo, and provides a framework for current and future research initiatives within telehealth for personalized care, treatment, and prevention. A broad, multinational research agenda can provide a uniform framework for identifying and rapidly replicating best practices, while concurrently fostering global collaboration in the development and rigorous testing of new and emerging telehealth technologies. In this paper, the members of the Transatlantic Telehealth Research Network offer a 12-point research agenda for future telehealth applications within chronic disease management.

Effect of telehealth on hospital utilisation and mortality in routine clinical practice: a matched control cohort study in an early adopter site

OBJECTIVES

To assess the effects of a home-based telehealth intervention on the use of secondary healthcare and mortality.

DESIGN

Observational study of a mainstream telehealth service, using person-level administrative data. Time to event analysis (Cox regression) was performed comparing telehealth patients with controls who were matched using a machine-learning algorithm.

SETTING

A predominantly rural region of England (North Yorkshire).

PARTICIPANTS

716 telehealth patients were recruited from community, general practice and specialist acute care, between June 2010 and March 2013. Patients had chronic obstructive pulmonary disease, congestive heart failure or diabetes, and a history of associated inpatient admission. Patients were matched 1:1 to control patients, also selected from North Yorkshire, with respect to demographics, diagnoses of health conditions, previous hospital use and predictive risk score.

INTERVENTIONS

Telehealth involved the remote exchange of medical data between patients and healthcare professionals as part of the ongoing management of the patient's health condition. Monitoring centre staff alerted healthcare professionals if the telemonitored data exceeded preset thresholds. Control patients received usual care, without telehealth.

PRIMARY AND SECONDARY OUTCOME MEASURES

Time to the first emergency (unplanned) hospital admission or death. Secondary metrics included time to death and time to first admission, outpatient attendance and emergency department visit.

RESULTS

Matched controls and telehealth patients were similar at baseline. Following enrolment, telehealth patients were more likely than matched controls to experience emergency admission or death (adjusted HR 1.34, 95% CI 1.16 to 1.56, p<0.001). They were also more likely to have outpatient attendances (adjusted HR=1.25, 1.11 to 1.40, p<0.001), but mortality rates were similar between groups. Sensitivity analyses showed that we were unlikely to have missed reductions in the likelihood of an emergency admission or death because of unobserved baseline differences between patient groups.

CONCLUSIONS

Telehealth was not associated with a reduction in secondary care utilisation.

DG Connect Funded Projects on Information and Communication Technologies (ICT) for Old Age People: Beyond Silos, CareWell and SmartCare

Information and communication technologies (ICT) are promising for the long-term care of older and frequently frail people. These innovations can improve health outcomes, quality of life and efficiency of care processes, while supporting independent living. However, they may be disruptive innovations. As all European member states are facing an increasing complexity of health and social care, good practices in ICT should be identified and evaluated. Three projects funded by DG CNECT are related to Active and Healthy Ageing (AHA) and frailty: (i) BeyondSilos, dealing with independent living and integrated services, (ii) CareWell, providing integrated care coordination, patient empowerment and home support and (iii) SmartCare, proposing a common set of standard functional specifications for an ICT platform enabling the delivery of integrated care to older patients. The three projects described in this paper provide a unique pan-European research field to further study implementation efforts and outcomes of new technologies. Below, based on a description of the projects, the authors display four domains that are in their views fundamental for in-depth exploration of heterogeneity in the European context: 1. Definition of easily transferable, high level pathways with solid evidence-base; 2. Change management in implementing ICT enabled integrated care; 3. Evaluation and data collection methodologies based on existing experience with MAST and MEDAL methodologies; and 4. Construction of new models for delivery of health and social care. Understanding complementarity, synergies and differences between the three unique projects can help to identify a more effective roll out of best practices within a varying European context.

A multi-level qualitative analysis of Telehomecare in Ontario: challenges and opportunities

BACKGROUND

Despite research demonstrating the potential effectiveness of Telehomecare for people with Chronic Obstructive Pulmonary Disease and Heart Failure, broad-scale comprehensive evaluations are lacking. This article discusses the qualitative component of a mixed-method program evaluation of Telehomecare in Ontario, Canada. The objective of the qualitative component was to explore the multi-level factors and processes which facilitate or impede the implementation and adoption of the program across three regions where it was first implemented.

METHODS

The study employs a multi-level framework as a conceptual guide to explore the facilitators and barriers to Telehomecare implementation and adoption across five levels: technology, patients, providers, organizations, and structures. In-depth semi-structured interviews and ethnographic observations with program stakeholders, as well as a Telehomecare document review were used to elicit key themes. Study participants (n = 89) included patients and/or informal caregivers (n = 39), health care providers (n = 23), technicians (n = 2), administrators (n = 12), and decision makers (n = 13) across three different Local Health Integration Networks in Ontario.

RESULTS

Key facilitators to Telehomecare implementation and adoption at each level of the multi-level framework included: user-friendliness of Telehomecare technology, patient motivation to participate in the program, support for Telehomecare providers, the integration of Telehomecare into broader health service provision, and comprehensive program evaluation. Key barriers included: access-related issues to using the technology, patient language (if not English or French), Telehomecare provider time limitations, gaps in health care provision for patients, and structural barriers to patient participation related to geography and social location.

CONCLUSIONS

Though Telehomecare has the potential to positively impact patient lives and strengthen models of health care provision, a number of key challenges remain. As such, further implementation and expansion of Telehomecare must involve continuous assessments of what is working and not working with all stakeholders. Increased dialogue, evaluation, and knowledge translation within and across regions to understand the contextual factors influencing Telehomecare implementation and adoption is required. This can inform decision-making that better reflects and addresses the needs of all program stakeholders.

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

Background

Adoption of telehealth has been slower than anticipated, and little is known about the service improvements that help to embed telehealth into routine practice or the role of frontline staff in improving adoption. This paper reports on participatory action research carried out in four community health settings using telehealth for patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure.

Methods

To inform the action research, in-depth case studies of each telehealth service were conducted (May 2012–June 2013). Each service was then supported by researchers through two cycles of action research to implement changes to increase adoption of telehealth, completed over a seven month period (July 2013–April 2014). The action research was studied via observation of multi-stakeholder workshops, analysis of implementation plans, and focus groups.

Results

Action research participants included 57 staff and one patient, with between eight and 20 participants per site. The case study findings were identified as a key source of information for planning change, with sites addressing common challenges identified through this work. For example, refining referral criteria; standardizing how and when patients are monitored; improving data sharing; and establishing evaluation processes. Sites also focused on raising awareness of telehealth to increase adoption in other clinical teams and to help secure future financial investment for telehealth, which was required because of short-term funding arrangements. Specific solutions varied due to local infrastructures, resources, and opinion, as well as previous service developments. Local telehealth champions played an important role in engaging multiple stakeholders in the study.

Conclusions

Action research enabled services to make planned changes to telehealth and share learning across multiple stakeholders about how and when to use telehealth. However, adoption was impeded by continual changes affecting telehealth and wider service provision, which also hindered implementation efforts and affected motivation of staff to engage with the action research, particularly where local decision-makers were not engaged in the study. Wider technological barriers also limited the potential for change, as did uncertainties about goals for telehealth investment, thereby making it difficult to identify outcomes for demonstrating the added value over existing practice.

Factors influencing the adoption of self-management solutions: an interpretive synthesis of the literature on stakeholder experiences

Background

In a research context, self-management solutions, which may range from simple book diaries to complex telehealth packages, designed to facilitate patients in managing their long-term conditions, have often shown cost-effectiveness, but their implementation in practice has frequently been challenging.

Methods

We conducted an interpretive qualitative synthesis of relevant articles identified through systematic searches of bibliographic databases in July 2014. We searched PubMed (Medline/NLM), Web of Science, LISTA (EBSCO), CINAHL, Embase and PsycINFO. Coding and analysis was inductive, using the framework method to code and to categorise themes. We took a sensemaking approach to the interpretation of findings.

Results

Fifty-eight articles were selected for synthesis. Results showed that during adoption, factors identified as facilitators by some were experienced as barriers by others, and facilitators could change to barriers for the same adopter, depending on how adopters rationalise the solutions within their context when making decisions about (retaining) adoption. Sometimes, when adopters saw and experienced benefits of a solution, they continued using the solution but changed their minds when they could no longer see the benefits. Thus, adopters placed a positive value on the solution if they could constructively rationalise it (which increased adoption) and attached a negative rationale (decreasing adoption) if the solution did not meet their expectations. Key factors that influenced the way adopters rationalised the solutions consisted of costs and the added value of the solution to them and moral, social, motivational and cultural factors.

Conclusions

Considering ‘barriers’ and ‘facilitators’ for implementation may be too simplistic. Implementers could instead iteratively re-evaluate how potential facilitators and barriers are being experienced by adopters throughout the implementation process, to help adopters to retain constructive evaluations of the solution. Implementers need to pay attention to factors including (a) cost: how much resource will the intervention cost the patient or professional; (b) moral: to what extent will people adhere because they want to be ‘good’ patients and professionals; (c) social: the expectations of patients and professionals regarding the interactive support they will receive; (d) motivational: motivations to engage with the intervention and (e) cultural: how patients and professionals learn and integrate new skills into their daily routines, practices and cultures.

An Approach to Assess Generalizability in Comparative Effectiveness Research: A Case Study of the Whole Systems Demonstrator Cluster Randomized Trial Comparing Telehealth with Usual Care for Patients with Chronic Health Conditions

BACKGROUND

Policy makers require estimates of comparative effectiveness that apply to the population of interest, but there has been little research on quantitative approaches to assess and extend the generalizability of randomized controlled trial (RCT)-based evaluations. We illustrate an approach using observational data.

METHODS

Our example is the Whole Systems Demonstrator (WSD) trial, in which 3230 adults with chronic conditions were assigned to receive telehealth or usual care. First, we used novel placebo tests to assess whether outcomes were similar between the RCT control group and a matched subset of nonparticipants who received usual care. We matched on 65 baseline variables obtained from the electronic medical record. Second, we conducted sensitivity analysis to consider whether the estimates of treatment effectiveness were robust to alternative assumptions about whether "usual care" is defined by the RCT control group or nonparticipants. Thus, we provided alternative estimates of comparative effectiveness by contrasting the outcomes of the RCT telehealth group and matched nonparticipants.

RESULTS

For some endpoints, such as the number of outpatient attendances, the placebo tests passed, and the effectiveness estimates were robust to the choice of comparison group. However, for other endpoints, such as emergency admissions, the placebo tests failed and the estimates of treatment effect differed markedly according to whether telehealth patients were compared with RCT controls or matched nonparticipants.

CONCLUSIONS

The proposed placebo tests indicate those cases when estimates from RCTs do not generalize to routine clinical practice and motivate complementary estimates of comparative effectiveness that use observational data. Future RCTs are recommended to incorporate these placebo tests and the accompanying sensitivity analyses to enhance their relevance to policy making.

Experiences of front-line health professionals in the delivery of telehealth: a qualitative study

BACKGROUND

Telehealth is an emerging field of clinical practice but current UK health policy has not taken account of the perceptions of front-line healthcare professionals expected to implement it.

AIM

To investigate telehealth care for people with long-term conditions from the perspective of the front-line health professional.

DESIGN AND SETTING

A qualitative study in three sites within the UK (Kent, Cornwall, and the London Borough of Newham) and embedded in the Whole Systems Demonstrator evaluation, a large cluster randomised controlled trial of telehealth and telecare for patients with long-term and complex conditions.

METHOD

Semi-structured qualitative interviews with 32 front-line health professionals (13 community matrons, 10 telehealth monitoring nurses and 9 GPs) involved in the delivery of telehealth. Data were analysed using a modified grounded theory approach.

RESULTS

Mixed views were expressed by front-line professionals, which seem to reflect their levels of engagement. It was broadly welcomed by nursing staff as long as it supplemented rather than substituted their role in traditional patient care. GPs held mixed views; some gave a cautious welcome but most saw telehealth as increasing their work burden and potentially undermining their professional autonomy.

CONCLUSION

Health care professionals will need to develop a shared understanding of patient self-management through telehealth. This may require a renegotiation of their roles and responsibilities.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Towards a shared service centre for telemedicine: Telemedicine in Denmark, and a possible way forward

Although evidence of the effectiveness of telemedicine is accumulating, knowledge of how to make best use of telemedicine is limited. This article presents results from a multi-stakeholder project that developed a new concept, a ‘shared service centre’ for telemedicine that is envisioned as working across different telemedical initiatives to support the implementation and wider adoption of telemedicine. One year of participatory design and analysis of the shared service centre concept involved stakeholders, such as clinicians, patients, technicians, policy makers, lawyers, economists and information technology architects. More than 100 people contributed to the findings. Most of the ideas generated for potential centre support for telemedicine could be categorised under four service categories. The need for such support services was verified in the cases investigated, and by agreement among stakeholders from regional health authorities, municipalities, and general practice. Therefore, it is probable that a shared service centre could help enable the wider deployment of telemedicine.

Co-production in practice: how people with assisted living needs can help design and evolve technologies and services

Background

The low uptake of telecare and telehealth services by older people may be explained by the limited involvement of users in the design. If the ambition of ‘care closer to home’ is to be realised, then industry, health and social care providers must evolve ways to work with older people to co-produce useful and useable solutions.

Method

We conducted 10 co-design workshops with users of telehealth and telecare, their carers, service providers and technology suppliers. Using vignettes developed from in-depth ethnographic case studies, we explored participants’ perspectives on the design features of technologies and services to enable and facilitate the co-production of new care solutions. Workshop discussions were audio recorded, transcribed and analysed thematically.

Results

Analysis revealed four main themes. First, there is a need to raise awareness and provide information to potential users of assisted living technologies (ALTs). Second, technologies must be highly customisable and adaptable to accommodate the multiple and changing needs of different users. Third, the service must align closely with the individual’s wider social support network. Finally, the service must support a high degree of information sharing and coordination.

Conclusions

The case vignettes within inclusive and democratic co-design workshops provided a powerful means for ALT users and their carers to contribute, along with other stakeholders, to technology and service design. The workshops identified a need to focus attention on supporting the social processes that facilitate the collective efforts of formal and informal care networks in ALT delivery and use.

Telecare for diabetes, CHF or COPD: effect on quality of life, hospital use and costs. A randomised controlled trial and qualitative evaluation

OBJECTIVES

To assess the effect of telecare on health related quality of life, self-care, hospital use, costs and the experiences of patients, informal carers and health care professionals.

METHODS

Patients were randomly assigned either to usual care or to additionally entering their data into a commercially-available electronic device that uploaded data once a day to a nurse-led monitoring station. Patients had congestive heart failure (Site A), chronic obstructive pulmonary disease (Site B), or any long-term condition, mostly diabetes (Site C). Site C contributed only intervention patients - they considered a usual care option to be unethical. The study took place in New Zealand between September 2010 and February 2012, and lasted 3 to 6 months for each patient. The primary outcome was health-related quality of life (SF36). Data on experiences were collected by individual and group interviews and by questionnaire.

RESULTS

There were 171 patients (98 intervention, 73 control). Quality of life, self-efficacy and disease-specific measures did not change significantly, while anxiety and depression both decreased significantly with the intervention. Hospital admissions, days in hospital, emergency department visits, outpatient visits and costs did not differ significantly between the groups. Patients at all sites were universally positive. Many felt safer and more cared-for, and said that they and their family had learned more about managing their condition. Staff could all see potential benefits of telecare, and, after some initial technical problems, many staff felt that telecare enabled them to effectively monitor more patients.

CONCLUSIONS

Strongly positive patient and staff experiences and attitudes complement and contrast with small or non-significant quantitative changes. Telecare led to patients and families taking a more active role in self-management. It is likely that subgroups of patients benefitted in ways that were not measured or visible within the quantitative data, especially feelings of safety and being cared-for.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12610000269033.

Implementing a telehealth service: nurses' perceptions and experiences

BACKGROUND

Telehealth is defined as the remote surveillance of a patient's health to aid early diagnosis and timely intervention. Understanding how the stakeholders perceive telehealth can influence its acceptability and diffusion.

INTRODUCTION

A primary care trust (PCT) in south London has been providing telehealth services for chronic obstructive pulmonary disease (COPD) and heart-failure patients for the past 22 months. The aim of this study was to elicit practice nurses' perceptions of the telehealth service provided by this PCT.

MATERIALS AND METHODS

A descriptive qualitative design was chosen to elicit practice nurses' perceptions. A semi-structured email interview was used to investigate their experiences of the service to date and their views about the future of the service.

RESULTS

Seven nurses, working on telehealth for an average of 15 months and providing the service to 34 patients, were interviewed. Overall, the nurses described their experience with telehealth to be positive. Lack of resources, organisational support, patient selection criteria and technical support were identified as barriers to effective implementation of telehealth. Additional team members, more input and training, and expanded patient selection criteria were suggested by the nurses to enhance and ensure the success of telehealth.

DISCUSSION AND CONCLUSIONS

The challenges and barriers to the implementation of telehealth identified by the practice nurses need to be addressed by health services to ensure its continuity and success.