Tag Archive for: Embedding Technology in Practice

Digital Change in Health and Social Care

Digital change in health and social care – a report by the King’s Fund

Reviewed By: Dr Adam Hoare

Digital change in health and social care King's Fund Bayswater Institute
Digital change in health and social care

This report by the King’s Fund, presented at the Digital Health and Care Congress 2018, usefully draws out some of the challenges in adopting and scaling digital health and care interventions through consideration of five significant case studies. It begins by recognising some of the unique challenges of digital change and goes on to identify some key themes. The report is a practical and timely contribution to the practical understanding of digital change and not only references some of the work that The Bayswater Institute (BI) members have been involved in for many years but raises many of the issues that the BI come into contact with on a daily basis.

The report recognises several challenges around large-scale digital change. The negative memories around the National Programme for IT (The Implications of e-health System Delivery Strategies for Integrated Healthcare) and the inability to undertake such change whilst under pressures of current demand on resources being key issues.

The Evidence About Managing Digital Change

The report references the Wachter review (Making IT Work) which identifies the need for change processes using digital technology to be ‘adaptive’ and ‘technical.’ That “Adaptive change is change that relies on human behaviour for its success.” At the heart of this challenge lies approaches that are central to the BI way – action research and sociotechnical systems. Action research involves iterating towards a solution and sociotechnical systems thinking recognises that the solution is a collaboration of people working with technology. This recognition represents a significant departure from the “big-bang” approach to system change where it is assumed everything is known up-front. It signifies a shift to more “test and learn” thinking that underpins so much successful innovation in other industries and endeavours.

The report goes on to recognise the productivity paradox identified by Brynjolfsson (Beyond the Productivity Paradox.) That efficiency gains accompanying widespread digitisation is often absent in the traditional indicators. Our work indicates that it is often necessary to expand the range of indicators and evidence to understand how new practice is being enabled and what that means. This means that the evaluation approach must evolve with the intervention.

The work of Prof. Eason (a member of the BI) is discussed with regard to the tensions between top-down and bottom-up approaches in digital innovation (Bottom-up & Middle-out Approaches to Electronic Patient Information Systems.) The benefits of a middle-out approach are recognised in trying to link front-line change to national standards and frameworks. The work of Eason goes on to recognise that large-scale digital change is challenging and frequently fails (Getting the Benefit from Electronic Patient Information that Crosses Organisational Boundaries – Final report NIHR service delivery organisation programme)

In considering the barriers to successful digital change the work of Greenhalgh is cited (Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies ) which distinguishes between complicated and complex interventions. Complexity in this sense arises from systems that are interconnected and dynamic and produce emergent behaviour. Too often solutions are assumed to be complicated and fail because they do not address the complexity. In discussing the use of telephone triage in primary care the report refers to the absence of clear evidence of benefits but that some practices improved their ability to cope with demand. The same intervention in a different sociotechnical implementation could yield completely different results. Further, the originally identified benefit may not always be the useful benefit found in practice. This complexity again goes back to the need for a “test and learn” approach. This situational complexity and lack of a one-size-fits all approach underlies the challenges of the Whole System Demonstrator which saw the intervention as fixed and tried to generate an economic value (or QALY) for the intervention. Although the value of telehealth in reducing emergency admissions and better managing patients is generally recognised (Reduced Cost and Mortality Using Home Telehealth to Promote Self-Management of Complex Chronic Conditions: A Retrospective Matched Cohort Study of 4,999 Veteran Patients) it is highly situationally dependent and cannot be implemented as a black box approach as it is a sociotechnical intervention. The report reiterates that digital change is adaptive and does not lead to static states for testing – it evolves.

The report goes on to explore five different digital interventions across very different sites and applications. It identifies five key themes that are highly correlated to themes we see recurring in our BI work.

Leadership and Management

A key theme here was that personalities count. Often, selecting the right person to lead on a particular aspect was central to success. This is reinforced by the observation in the report that technology implementations should not be seen as IT projects but as a cultural change that is highly dependent upon good leadership. This leadership is most effective when clinically driven. At the BI our experience shows that many digital projects are approached as linear implementations that do not seek to learn or understand what is working and what is not. The need to build collaborations, often across organisational boundaries, is underestimated. In our work we regularly see digital projects pigeonholed as IT and lacking in the attention to culture change and leadership identified in the report.

User Engagement

The report recognised that a common approach across the case study sites was to recognise user engagement not as a single event but as a continual collaborative process involving users of the technology. The work we did at the BI in the BOLD-TC (Better Outcomes for People with Learning Disabilities – Transforming Care) project was based on just such an ethos involving not just the front-line practitioners across health and social care but also people with learning disabilities and their families. The move to a more collaborative, ongoing engagement with users is essential if services are going to evolve.

Information Governance

The case study sites focused on cultural rather than the technical aspects of information governance. By creating the right environment for partners to come together and solve the problems of sharing data it was found that collaboration, in general, was increased. Leadership and approaching information governance as a framework rather than trying to solve each problem as it occurred led to sustainable approaches.

Partnerships

It was identified that the right supplier could act as a facilitator for change by coordinating actors and change processes. Our experience at the BI is very similar. The ability of a supplier to see all of the challenges being addressed by the organisations coming together in pursuit of a common digital solution puts them in a key coordinating role. By providing each of the stakeholders in the intervention with valuable reporting and evidence specific to their needs they can act as the glue that binds the intervention. However, this requires an open supplier that sees the long-term benefits in building trust and collaboration. As the report points out choosing suppliers is a significant contribution to the success of the approach.

Resourcing and Skills

For the project to succeed the resources and skills need to be there, over and above what is required to keep the engine of delivery going. For large-scale digital interventions this is challenging in the current environment. Recognition was given to starting small and evolving solutions in a phased way. This was particularly important when crossing organisational boundaries. Trying to do too much at once absorbed resources and slowed progress. Our experience reflects this. Developing solutions that can have an impact on day-one but evolve over time to cross boundaries is essential and, again, part of the ongoing “test and learn” approach.

Evaluation

Although not a separate heading the importance of evaluation was noted. Significantly, the importance of evaluating success and failure was recognised. One of the quotes equated randomised control trials with a lack of rigour recognising that iterating understanding and learning was essential. At the BI we are committed to evaluation that engages with complexity and evolves with the intervention to develop learning and understanding. This requires formative evaluation and an understanding of the challenges the collaboration partners are facing.

Conclusion

The report is a significant contribution to understanding the challenges of implementing digital change. The use of case studies that demonstrate both the barriers and how they were overcome is the most useful way to share learning and understanding. At the BI we hope to see more of this kind of sharing and a move to learning “what works for who and under what circumstances.”

In my work with Airedale NHS Foundation Trust we addressed the issues of one-size-fits-all, the black box view of technology and the need to embrace complexity. Beginning in 2008 as part of the Assisted Living Innovation Platform (ALIP) we worked with Airedale NHS Foundation Trust and partners to use video in the home to address a range of care scenarios. Over a period of eight years Red Embedded Systems Ltd. developed the v-connect service. We developed a communication platform that could facilitate a range of care scenarios including video calls through the TV and delivery of educational content. We implemented interventions for long-term conditions, social care interventions such as virtual visiting, support for people with renal failure and remote support for people with learning disabilities. We integrated ambient monitoring, remote physical measurements, evidence collection and reporting (A Socio-technical Approach to Evidence Generation in the use of Video-conferencing in Care Delivery and Factors Affecting the Move to an eSystems Approach to remote Care delivery.) Many of the challenges discussed here were addressed in working with a broad range of partners in care delivery. We overcame barriers in all of the key themes identified but failed to make the commissioning case in every situation. Digital interventions have the potential to prevent and reduce current activity in the care system. Better educated and managed patients are more independent, and this reduces the need for care. For people with learning disabilities, remote support enables them to live more independent and confident lives. Prevention reduces need for care, independence and confidence all reduce the amount that the current providers are paid. This raises significant issues for leaders and for culture change. Often the right thing to do for the patient or client is the wrong thing for the financial standing of the organisations involved. This requires leadership at the policy and Governmental level. The focus of this report is on how successful digital interventions can be against the resource and skills challenges in the current climate. Imagine how successful they could be if there was a strategy and funding to facilitate a market in solutions.

We can only hope that future initiatives such as the Industrial Strategy Challenge Fund on Healthy Ageing (Industrial Strategy Challenge Fund: for research and innovation) and the recently announced £487m Transformation Fund for Healthcare will begin by taking notice of what we know and not try to reinvent the wheel.

 

 

Transforming care and health through information and technology: Local Investment Programme – Interim Report

By Dr Adam Hoare

Local Government Association – Local Investment Programme

Local Government Association Local Investment Programme Interim Report

Local Investment Programme – Interim Evaluation Report

In 2017 the Local Government Association in collaboration with NHS Digital introduced the Local Investment Programme. The programme recognised that the imperative for local care services to transform has never been greater due to rising needs, citizen demands and expectations alongside sustained pressure on resources. Although technology will never be a replacement for the delivery of care it can, if used appropriately, support people to live at home for longer, enable professionals to work more effectively together and help commissioners target services where they have the greatest impact. The Local Investment Programme (LIP) supported transformation through one-off local investment funding of up to £50,000 for projects that seek to use information and technology to improve adult social care and health outcomes and deliver financial savings as well as supporting more resilient care services and in improving outcomes, including people’s experience of care.

The programme was underpinned by a number of key principles:

  • encouraging open and replicable approaches which enable other LAs to adopt digital ways of working
  • supporting innovation and new thinking within adult social care and health, assisting its digital maturity within a challenging financial environment
  • assisting cross-council or multi-agency use of information and technology
  • developing an evidence-base and tools to support ongoing local digital investment in adult social care and health.

It was expected that the outputs and learning from these projects would be reusable and replicable, enabling them to be shared and implemented widely across the sector.

Councils who were successful in their bids for funding received support from an external partner organisation to help evaluate benefits, capture learning and support dissemination to assist other local areas. Participating local authorities were required to actively support this work, over the course of the programme, including in the development of guidance and tools for the sector.

The Bayswater Institute and OPM Group (now Traverse) were successful in winning the opportunity to evaluate the 19 technology interventions funded by the programme. In April 2018 an interim report was produced capturing the learning on the ground as well as considering the programme itself.

 

People and Computers: Emerging Work Practice in the Information Age

A chapter in the book ‘Psychology at Work’ reviewing the impact of information technology on work practice and the link between people and work

 

Psychology at work Ken Eason People and computers emerging work practice in the information age

Amazon Book Link

EASON K.D. People and Computers: Emerging Work Practice in the Information Age. In P.B.Warr (ed) ‘Psychology at Work’ Penguin, London, 5th Edition pp 77-99 ISBN 0-14-100010-4

Bottom up & Middle Out Approaches to Electronic Patient Information Systems: A Focus on Healthcare Pathways

Published in ‘Journal Of Innovation in Health Informatics’

Background
A study is reported that examines the use of electronic health record (EHR) systems in two UK local health communities.

Objective
These systems were developed locally and the aim of the study was to explore how well they were supporting the coordination of care along healthcare pathways that cross the organisational boundaries between the agencies delivering health care.

Results
The paper presents the findings for two healthcare pathways; the Stroke Pathway and a pathway for the care of the frail elderly in their own homes. All the pathways examined involved multiple agencies and many locally tailored EHR systems are in use to aid the coordination of care. However, the ability to share electronic patient information along the pathways was patchy. The development of systems that enabled effective sharing of information was characterised by sociotechnical system development, i.e. associating the technical development with process changes and organisational changes, with local development teams that drew on all the relevant agencies in the local health community and on evolutionary development, as experience grew of the benefits that EHR systems could deliver.

Conclusions
The study concludes that whilst there may be a role for a national IT strategy, for example, to set standards for systems procurement that facilitate data interchange, most systems development work needs to be done at a ‘middle-out’ level in the local health community, where joint planning between healthcare agencies can occur, and at the local healthcare pathway level where systems can be matched to specific needs for information sharing.

BCS Journal Link

2012 EASON K. D., DENT M., WATERSON P., TUTT D., AND THORNETT A. Bottom up and middle out approaches to electronic patient information systems: A focus on healthcare pathways Informatics in Primary Care 20:1 51-56

Getting the Benefit from Electronic Patient Information that Crosses Organisational Boundaries – Final Report NIHR Service Delivery and Organisation Programme

Final Report National Institute for Health Research Service Delivery and Organisation Programme

Executive Summary Conclusions

Within the two LHCs studied, there are areas in which substantial progress has been made in creating working forms of integrated care in healthcare pathways. These islands of progress have produced solutions that are quite different from one another and they are the result of evolutionary processes over several years in the face of many difficulties. As a result, there are parts of the systems development process that are mature in the ways in which the challenge of integrated design is tackled. We would single out, for example, the long tradition that has now built up for engaging ‘hybrids’ as the go-betweens in the endless dialogue between informatics specialists and the healthcare user community. However, current electronic support for integrated care can only be described as patchy and, to build on what is already in place, there is a need to create more mature systems development processes that can cope with the many challenges of bringing together a diverse set of stakeholder interests across a number of different healthcare agencies to create the sociotechnical systems necessary to serve the specific needs of healthcare pathways.

Link to PDF

Eason K. D., Dent M., Waterson P., Tutt D., Hurd P. and Thornett A. Getting the benefit from electronic patient information that crosses organisational boundaries – Final Report NIHR Service Delivery and Organisation Programme, November 2012

The Implications of e-health System Delivery Strategies for Integrated Healthcare: Lessons from the UK & Elsewhere

Abstract:

Purpose
This paper explores the implications that different technical strategies for sharing patient information have for healthcare workers and, as a consequence, for the extent to which these systems provide support for integrated care.

Methods
Four technical strategies were identified and the forms of coupling they made with healthcare agencies were classified. A study was conducted in England to examine the human and organizational implications of systems implemented by these four strategies. Results were used from evaluation reports of two systems delivered as part of the NPfIT (National Programme for Information Technology) and from user responses to systems delivered in two local health communities in England. In the latter study 40 clinical respondents reported the use of systems to support integrated care in six healthcare pathways.

Results
The implementation of a detailed care record system (DCRS) in the NPfIT was problematic because it could not meet the diverse needs of all healthcare agencies and it required considerable local customization. The programme evolved to allow different systems to be delivered for each local health community. A national Summary Care Record (SCR) was implemented but many concerns were raised about wide access to confidential patient information. The two technical strategies that required looser forms of coupling and were under local control led to wide user adoption. The systems that enabled data to be transferred between local systems were successfully used to support integrated care in specific healthcare pathways. The portal approach gave many users an opportunity to view patient data held on a number of databases and this system evolved over a number of years as a result of requests from the user community.

Conclusions
The UK national strategy to deliver single shared database systems requires tight coupling between many users and has led to poor adoption because of the diverse needs of healthcare agencies. Sharing patient information has been more successful when local systems have been developed to serve particular healthcare pathways or when separate databases are viewable through a portal. On the basis of this evidence technical strategies that permit the local design of tight coupling are necessary if information systems are to support integrated care in healthcare pathways.

Highlights

  • Links between electronic patient databases and healthcare agencies are defined in terms of tightness of coupling, range and scale.
  • The English Detailed Care Record System was unable to serve the diverse needs of healthcare agencies and was not successfully deployed.
  • Tight coupling was successfully deployed at a local level between agencies engaged in integrated care in healthcare pathways.
  • Widespread uptake was also found when portal systems were deployed that permitted viewing of a range of patient databases.
  • Adoption of patient databases was greater when there was middle-out design and technical strategies delivered looser forms of coupling.

Link to PDF

Science Direct Link

Eason K.D. and Waterson P.E. (2013) The Implications of e-health system delivery strategies for integrated healthcare: lessons from the UK and elsewhere. International Journal of Medical Informatics. 85(5) 96-106 Doi:10.1016/j.ijmedinf.2012.11.004

Fitness For Purpose When There Are Many Different Purposes: Who Are Electronic Patient Records For?

The use of the electronic patient record in supporting e-health care pathways

Abstract:
Electronic patient record systems serve many purposes for many different kinds of users. Four case studies are reported of the use made by healthcare staff of electronic patient record systems that supported healthcare pathways. The results demonstrate that the systems fit the purposes of strategic and managerial users of the record, but they are problematic as tools for use by the frontline staff delivering care. As a result, these staff frequently resort to workarounds to accomplish their work goals. An analysis of the design processes that created these systems shows that the specification of the systems was based on strategic and managerial requirements and there was no formal assessment of the needs of frontline users. Efforts to address the needs of frontline staff in the provisions of electronic systems were most often made after the main system was implemented.

Sage Journal Link

Eason K.D. and Waterson P.E. Fitness for purpose when there are many different purposes: who are electronic patient records for? Health Informatics Journal 20 (3) 189-198 1460458213501096

How to Fail When Introducing Electronic Technologies into Organisations

The challenges of large scale IT projects viewed through the National Programme for IT – NPfIT

Abstract:
The history of computer applications is littered with examples of large and expensive IT systems failing when they were implemented in organisations. This paper illustrates how this happens by describing the case of the NPfIT, the National Programme for IT, in the UK National Health Service. It was introduced with a great fanfare in 2004 to standardize electronic patient records across the NHS and was ‘dismantled’ in 2011 having cost somewhere between £12 and £20 billion.

The paper concludes this programme encountered major problems because it adopted a top down, technocentric approach that led to a ‘one size does not fit all’ response from health agencies of widely different types. A major lesson is that these developments have to be treated not just as technical developments but as sociotechnical developments, i.e. the organisational and technical changes have to be treated in parallel and as interdependent entities. The paper offers six principles for the implementation of new technology into organisations that may improve the chances of users being able to harness the potential of new technology.

IEEE Explore Link

Eason K.D. How to fail when introducing electronic technologies into organisations. Proceedings of DESE 2016 (Developments in eSystems Engineering’, Liverpool September

 

Local Sociotechnical System Development in the NHS National Programme for Information Technology

National Programme for IT Electronic Health Records – User Perspectives

Abstract:
The National Programme for IT is implementing standard electronic healthcare systems across the National Health Service Trusts in England. This paper reports the responses of the Trusts and their healthcare teams to the applications in the programme as they are being implemented. It concludes that, on the basis of the data available, it is likely that the emergent behaviour of healthcare staff will serve to minimise the impact of the systems. The paper looks at the opportunities within the programme to undertake local sociotechnical system design to help staff exploit the opportunities of the new electronic systems. It concludes that there are opportunities and offers one case study example in a Mental Health Trust. However, it concludes that there are many aspects of the technical systems themselves and also of the approach to implementation, that limit the opportunities for local sociotechnical systems design work.

Local Sociotechnical System Development in the NHS National Programme for IT Ken Eason

Springer Link

EASON K.D. Local sociotechnical system development in the NHS National Programme for Information Technology, Journal of Information Technology 22 (3) 257-264

A Socio-Technical Approach to Evidence Generation in the Use of Video Conferencing in Care Delivery

Evidence of outcomes across multiple uses of video conferencing in health and social care delivery – a socio-technical perspective

Video conferencing in care delivery telemedicine socio-technical v-connect Adam Hoare

Use of Video Connection Platform in Multiple Verticals of Care Delivery

Abstract:
Care and support services need to respond to the rapidly changing demands of the population and available resources. The authors will present evidence that video conferencing can underpin many of the aspirations for future care delivery. However, if the necessary scale and pace are to be achieved a new model for evidence generation needs to be found. Using the experience of deploying video across health and social care a new model of evidence generation will be proposed based on a socio-technical approach where complexity and human capabilities are features of the intervention. A practice-based approach utilising action research will be used. The model will focus on four dimensions that are key to the success of an intervention using video: Practice, Outcomes, Technology and Evidence. Addressing the interactions between these four dimensions promotes a system that can evolve services that, in cooperation with the video technology platform, can satisfy changing care demands

The effects of current economic and demographic pressures on care and support systems are well documented. The need to do more with less is an established requirement of new models of care. However, there are significant barriers to the innovation of new ways of working in care delivery. Some of these barriers will be described through the experiences of one of the authors (AH) in deploying video conferencing to support people in their own homes or in a care environment.

The current use of video in care delivery is predominantly clinician-to-clinician communication between care organisations. Established examples are stroke or cancer networks. When developing a strategy for deploying a video intervention targeted at people in a residential environment it soon became clear that there was not a precedent to follow. In terms of Porter’s Five Forces the intervention was neither a new entrant to an industry that already exists or a substitute for a current product. Clearly any adoption of the video approach was going to disrupt internal systems in the care organisation and result in changes to practice. From a resources and capabilities point of view any strategy to deploy video requires close collaboration between the resources of the care organisation and the video service provider. This is a challenging engagement for care providers as they are more accustomed to transactional approaches where products or services are bought to a specification. Hence, each video deployment required sensitivity to the resources and capabilities of the customer and a collaborative approach to lowering the barriers to use of the technology. For example, modifying the user interfaces of the video conferencing equipment could lower some barriers and this has been done extensively to improve the experience of the people receiving care and of the clinicians providing it.

A further challenge to any deployment of video conferencing is the initial modelling of the economic benefits. As each deployment creates a network of contacts there is no template for a specific intervention. Within health care, each disease, e.g. diabetes, has its own ‘silo’, i.e. has its own care pathway, its own specialists, seeks its own technical support and is evaluated in terms of its ability to meet disease-specific outcomes. Engaging with a particular silo is very dependent upon the context of the engagement and each deployment raises its own challenges. Therefore, before video can be deployed in the residential environment its benefits and cost effectiveness within current siloes of care have to be proved.

IGI Global Link

Hoare, Adam and Ken Eason.  A Socio-Technical Approach to Evidence Generation in the Use of Video Conferencing in Care Delivery. IJSKD 6.2 (2014): 36-52. Web. 2 Nov. 2017. doi:10.4018/ijskd.2014040103