Professor Alison Marshall, Health Technology & Innovation, University of Cumbria discusses the processes behind adopting technology enabled care services.

1. Barriers to – and enablers of -
adoption of technology enabled care
services
North West Coast Connected Health Ecosystem event
Alison Marshall, 13th
September 2016

2. Outline
Scope and definitions
Understanding the environment for innovation in healthcare
Barriers to and enablers of technology adoption: our work and findings
Conclusion

3. Scope and definitions
Our research interests and work

4. A bit about the Cumbrian Centre for Health
Technologies (CaCHeT)
Applied research and consultancy in technology adoption, innovation and
stakeholder engagement
Funding and sponsorship from:
• Academic Health Science Networks
• NHS Trusts and Services
• Private companies
• Strategic partnership entitites (eg. Lancashire Digital Health Board)
Supporting postgraduate teaching in Digital Health and Social Care
http://www.cumbria.ac.uk/research/centres/cachet/digital-health-and-social-
care-education-and-training/
More information on our website www.cumbria.ac.uk/cachet

5. Scope: digital innovations in health and social
care

6. And emerging technologies
Internet of Things
Novel sensor technologies
Diagnostics, monitoring, self-care
Lifestyle and consumer applications

7. Understanding the environment for
innovation in healthcare
Change and disruption

8. 21st
century healthcare
Ageing population
Limited resources
Connected society – changing lifestyles
Digital health = use of (consumer) technology to enable
patients to interact with health professionals remotely
• Changing clinician-patient relationship (empowered
patient – or unsupported?)
• Disrupting points of access to the healthcare system
• Crossover to lifestyle/wellbeing management

9. Enter the consumer?

10. How does technology adoption work in a health
service?
Evidence based medicine
Risk avoidance
Development Piloting Evaluation Adoption
Problem – an infinite loop is set up
around piloting and evaluation .
We never get to adoption.
The technology
adoption process

11. Why are digital health innovations different?
Digital solutions are complex
There is a new type of user – the patient (or their carers, families…)
More than one professional group may be involved
Co-operation is required between different statutory (and non-statutory)
providers
Some elements of the solution may not be owned by the providers at all

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

13. The Stakeholder Empowered Adoption Model (StEAM)
Professional
clinical staff
New technologyHealthcare
organisation
Patients
High quality clinical
outcomes, with
greater convenience
and efficiency
A. Marshall. Designing telemedicine apps that health
commissioners will adopt. Proceedings of the 14th
Conference of Open Innovations Association FRUCT,
Finland November 2013, p 63 – 68. Published by IEEE

14. StEAM technology adoption case studies
• Remote video-linked swallowing assessments for nursing home residents
• E. Bidmead, T. Reid, A. Marshall, V. Southern. ‘Teleswallowing’: a case study
of remote swallowing assessment. Clinical Governance: an International
Journal, 2015. 20:3. Open access online at
http://www.emeraldinsight.com/doi/abs/10.1108/CGIJ-06-2015-0020
• Renal telemedicine: video-link specialist nurses to self-managing home
dialysis patients
• Patient health records and portal system for managing self care in stable
gastroenterology patients
• E. Bidmead, A. Marshall. ‘A case study of stakeholder perceptions of patient
held records: the Patients Know Best (PKB) solution’. Digital Health, Sage
UK, 2016. In press.
• Video-enabled shared ultrasound consultations between a district general
hospital and a tertiary specialist service

15. Enablers and barriers - technology
Many technical solutions exist and have been validated
Expertise exists within IT services in NHS.
• Choice of technology depends on use case – using NHS premises or
home, patient access or clinician only, support availability to user,
resolution and quality requirements etc.
• Many small scale pilots have built experience and knowledge of suppliers
Barriers
Connectivity can be a problem (but getting better)
Digital skills (patients and staff)
Dire levels of interoperability, lack of standards and protocols
Many innovations come from small companies with limited resources for
demonstrating evidence
Designs are often not fit for the unique needs of a service and staff find it hard
to modify

16. Barriers – staff perceptions and confidence
“I think initially you come up with lots of thoughts, is the clarity of the picture
going to be good enough? Are the staff going to be trained enough? Initially I
think […] A kind of a letting go sort of thing. Do I really want to let someone
else be in charge of my swallow assessment? I want to be there and in control,
It is, it’s control isn’t it? (SLT2 – Blackpool study)”.
“I want to see the real patient, I don’t just want to look at a computer screen
(SLTFG1 – Blackpool study)”.
“I feel incompetent [when being directed remotely by a specialist consultant]”
(Sonographer – Fetal telemed study)

17. Staff and telemedicine
Concerns about being able to use technology
• Need to allow a lot of time to ironing out technical problems, including
time for staff to experiment. They do not want to do this in front of the
patients
Concerns about their changing job role. Telemedicine changes how they
interact with the patient and sometimes involves another member of staff. They
need to depend more on IT and this can be challenging.
• Need to allow time for staff to voice these issues and work through them
Feeling threatened about their job security. Telemedicine interventions can
happen at times when cuts are being made and there is understandable
suspicion.
Front line staff are already very stressed and cannot always see the bigger
picture
• Need to allow time and for them to feel in control of the changes
• There can be skills development benefits possibly reducing numbers of
referrals over time
Negative perceptions can delay or block good telemedicine interventions

18. Staff enablers
Innovative individuals who drive and motivate
Understanding the benefits to patients
“When patients first go home, we do like a step-down process from what we do
in the room here. The system allows us to do that quicker,” (renal nurse).
“I can see it instantly what the problem was just by beaming in the machine,”
(renal nurse).
Appropriate education and training
Support from managers and executive sponsorship

19. Patient attitudes and perceptions
Patients are most often the direct beneficiaries and tend to accept the
technology readily
“There was one resident […] we asked for consent because he had capacity and
he thought it was really good and he was quite happy to do it and he was
really, really pleased to do it (NH-Nurse3 – teleswallowing study)”.
They may not have received the conventional service so do not even realise
that this is new. They will usually be pleased if it means they can be seen more
quickly.
Time saving and convenience
"Because this is a web based programme we’ve been contacted by people with
flare ups on cruise ships in the Mediterranean; we’ve been contacted by people
who had been admitted to other hospitals who are checking if their new
medication clashed with the IBD medication; we’ve had people getting married
[abroad] who couldn’t speak [the language] and were able to open their
website and the GP understood some of the medical terminology and was able
to treat their flare" (Consultant Gaastroenterologist – PKB study).

20. But not suitable for everyone
Initial work has been done on patient selection for telehealth (ref Fylde Coast
Vanguard: Assessing Options for Telehealth)
Review of literature indicated various ‘dimensions’ that need to be considered,
including patient activation, health literacy, digital/IT literacy, clinical and social
suitability, access and connectivity.
Coaching, training and support can address some of these issues, but not all.
Need to offer digital services as ‘one of the tools in the toolkit’

21. Management barriers and enablers
Enablers
External policies for change
Commissioning incentives
Barriers
Poor quality evidence that is not relevant
Cost benefit not clear
Perverse incentives
Avoidance of conflict internally
Distrust of new suppliers

22. Resisting change – some emerging themes
The health professional is concerned that the patient will be more demanding if
they are able to be in contact at any time.
- The patient may become obsessed with their illness, due to an ability to
micro-analyse the data.
The way in which the service is delivered has to change. It may affect more
than one professional service (eg. emergency care, physiotherapy, community
nursing).
Digital innovations may generate data that it is nobody’s job to look at.
− Automated analyses can have risks, may not be trusted, need
validation.
The mode of use may modify the solution (can be positive or negative).

23. Conclusion
…and further work…

24. Adopting new ideas
The Diffusion of
Innovations -
Everett Rogers, 5th
ed 2003

25. Digital technologies
in health and social
care
Geoffrey Moore, Crossing the
Chasm, 1991

26. Agile vs conventional development

27. Influencing change
Engaging stakeholders to understand the evidence they need to make
decisions
• Readiness for change (Telehealth Readiness Tool)
• Appropriate evaluation
• Training and education (Digital Health and Social Care Course)
Supporting companies to innovate effectively in healthcare
• Appropriate evaluation
• Co-design and agile development techniques
Influencing policy makers
• A better environment for innovation
• Appropriate funding

28. alison.marshall@cumbria.ac.uk