A paper published in Frontiers in Digital Health by authors Matthew Cripps and Harry Scarbrough examines the challenges of effectively implementing and creating sustainable digital health solutions.
The paper, “Making Digital Health ‘Solutions’ Sustainable in Healthcare Systems: A Practitioner Perspective” advocates for change to the way that digital transformation is approached.
“The evidence for the limitations of a technology-driven approach in healthcare is extensive,” the paper begins. “Many of the past failings of EHR (Electronic Health Record) systems, for example, were attributed to the lack of user-centered design. Such systems met the needs of the hospital administrators, but were not seen as meeting the needs of clinicians.”
Instead, the authors write that “a proper sustainable approach requires a shift in both thinking and practice when it comes to the spread and adoption of such technologies. Our thinking needs to shift from a focus on the technology itself to how we bring about the changes needed to deliver efficient and more effective care.”
The paper outlines the NHS Sustainable Healthcare Approach, through which “new digital applications are integrated into a wider process of change which begins in the early stages of development and extends through to the long run sustainable implementation of an innovation or intervention.” The approach rejects the traditional linear model in favour of an interactive model where implementation is the primary focus of co-design efforts.
Change is applied by injecting four pillars of insight: clinical insight (not losing sight of the ultimate purpose of innovation), behavioural insight (using psychology, sociology and data sciences to understand how people might respond to new technologies), process engineering (to make the process of applying the new technology as explicit, simple and comprehensible) and knowledge management (providing valuable insight on the evidence underpinning the need for change, and how best to deliver it). The pillars “build from the outset an understanding of the likely responses and motivations of the ‘end users’ of the technology”.
The authors write that end users are too often an afterthought, with developers more concerned with functionality than ease of use. “This risks resistance or poor take up of new digital tools,” they state, “not by intention but by failing to consider the users’ needs and responses.” In contrast, the Sustainable Healthcare approach identifies the target audience or population early, engages with them to develop understanding of their needs and behaviours, and allows this to informs the technology’s design.
“The need for this approach is reinforced where the user population is more diverse and less homogeneous,” the paper continues. “Neurological diversity may be an important challenge, for example; people with autism, dyspraxia, and dyslexia might be unintentionally prevented from interacting with a digital app if it is not designed to account for their needs.”
In addition, the context in which technologies operate can often make change difficult. The paper describes how failure to anticipate contextual influences can undermine solutions; for example, the COVID-19 pandemic necessitated the widespread introduction of virtual consultations, which produced positive benefits for patients in terms of easy access, but “spread and sustainability may ultimately be dependent on its financial consequences.”
The paper argues that the change approach works best when the NHS Sustainable Healthcare team are involved in technology development from the earliest stage, though they are sometimes brought in later in the process to address barriers to adoption and use, bringing in a sharper focus on how end users are responding to the technology and how change moves through different levels such as the frontline staff, the wider population, and media teams who communicate the change.
“This approach has produced excellent outcomes in a number of cases,” the authors write. “But it has to be applied in a reflective and adaptable way. One technique used by the team to ensure this is called ‘pre mortem planning’. The aim is to encourage team members to tease out prospectively the kind of problems or unintended effects in a change process which would normally only be picked up retrospectively, by virtue of the effort to leverage change being unsuccessful, or less successful than aimed for. It permits a project team to imagine, pre-emptively, that their planned approach does not work and ask the question; how did this project fail?”
The paper moves on to discuss how the approach to change “represents a response to the specific challenges of implementing and sustaining digital health innovations in NHS England”, whilst also echoing experiences with digital innovations emerging globally.
The authors note that global studies have highlighted “the importance of policy-level barriers which may reinforce other challenges such as the mobilisation of evidence for innovation.” With more evidence available on the impact of digital innovation programmes across the globe, it is possible to build a “more holistic appreciation of the scope of the wider changes involved in making them successful and sustainable, including ‘systems integration’ to ensure implementation support, and ultimately the creation of a supportive digital health ecosystem.”
The paper acknowledges that these findings from the global health field raise important questions about the sustainability of digital health solutions once they have been adopted. The fact that the Sustainable Healthcare approach pays specific attention to context “reinforces the finding… that a supportive context is vital to the scalability and sustainability of digital innovations.”
This brings up the question of “whether this focus on context requires the Sustainable Healthcare team to apply a different approach to digital vs. non-digital innovations,” the authors write. Noting that the approach is based around behavioural and contextual features more than the characteristics of the innovation itself, it is suggested that it may be “viewed as being agnostic toward the particular form of technology being deployed within a process of change.” The authors also note that it is important to recognise that digital technologies have distinctive features which in themselves can reinforce or lower barriers to use, particularly where the technologies are being introduced into an analog world where policies and practices have not already adapted to the potential of digital health.
With much of the approach focusing on the ‘front end’ of innovation – the authors move on to focus on adoption from the perspective of end users and the wider public, to highlight a greater focus is required on how new tools and solutions are used and how they can be scaled and spread as widely as possible. “This may involve placing a much greater emphasis on the usability and accessibility of digital health solutions—having the right infrastructures and skills in place, for example—and much less on the cutting-edge properties of the solution itself,” the authors write.
Moving away from the front end focus also raises questions about healthcare policies, namely whether they are sufficiently attuned to the challenges of scaling digital health solutions in a sustainable way. “Worryingly, policy-makers attracted to the progressive imagery of new digital technologies may be more likely to allocate resources to their front end development than to the more complex downstream challenges of putting them into practice,” the paper comments. “We need to remember that many innovative technologies and treatments have been introduced into healthcare without ever being spread widely or used effectively, despite ample evidence of their benefits to patients.”
To read the paper, Cripps M and Scarbrough H (2022) Making Digital Health “Solutions” Sustainable in Healthcare Systems: A Practitioner Perspective. Front. Digit. Health 4:727421. doi: 10.3389/fdgth.2022.727421, please click here.
