Lost in translation? : negotiating technological innovation in healthcare

Technological innovation in healthcare is growing at a rapid pace. Developments in genetics, stem cell research, bioinformatics, imaging and screening techniques have broadened out the arena of health technology. These developments in sophisticated technology, it is suggested, have the potential to revolutionize the practices of medicine and healthcare by providing more proactive and powerful tools for the diagnosis, treatment, and prevention of illness and disease (Liddell et al, 2008; Webster, 2002). In support of such claims, available research findings suggest that the adoption of new innovative health technologies (IHTs) can result in reducing healthcare costs, increasing productivity, healthcare effectiveness, and improving the patient’s experience of care by better management of chronic diseases (Liddell et al, 2008; Healthcare Industries Task Force, 2004). At the same time, new innovative health technologies present many challenges. Evidence indicates that patient safety and proven clinical effectiveness are insufficient to ensure the adoption and implementation of new clinical technologies. The prevailing organizational and policy context is crucially important as this may present barriers which slow or even prevent uptake (Lehoux 2006). In recent years there has been a continuing debate around issues of clinical resistance, organizational/clinical restructuring, procurement and commissioning, public trust, and, more widely, around the ethical and social implications of techno-scientific innovations in medicine and health (Williams and Dickinson, 2008; Webster, 2006; Ferlie et al., 2005). Moreover, cost-effectiveness evidence is now required to inform decisions about the funding and procurement of new healthcare services and technologies (Fitzgerald et al., 2002). Overall, the value of the innovation has to be clearly evident to a number of different stakeholders if technologies are to be embedded into actual work practices. These potential barriers have given rise to questions related to the diffusion and adoption of emerging medical and healthcare innovations. This paper examines the dynamics and complexity of innovation adoption processes in the context of a rapidly changing healthcare policy landscape. Drawing upon the inherently socially negotiated character of meaning, this paper illustrates the ambivalent nature of technological innovation by examining the complex ongoing interplay of heterogeneous discourses in shaping the adoption of innovative health technologies (Law, 1987, 1994). Drawing upon Rye and Kimberly (2007) adoption is here understood as a distinct organizational process related to an organization’s potential interest in implementing a technological innovation. In so doing, this paper draws on the findings of a three year research project which examines the adoption of innovative clinical technologies in the UK NHS. In particular, we explore the nature, role and dynamics of heterogeneous discourses (technological, managerial/professional, clinical), in shaping the adoption of a retinal imaging technology in a UK hospital Trust. In this regard, we contribute to the development of alternative ways of describing, analysing, and theorizing the process of technological innovation in healthcare

Evidence-based primary health care and local research: a necessary but problematic partnership

Background Front-line NHS staff undertake small research projects to answer questions about local patients and services, but these projects often face considerable challenges. This paper reports on one such project. Aims and methods of study The study used structured interviews in order to find out about the knowledge of nutrition among Bangladeshis using an NHS Walk-in Centre. Development of the study Time constraints posed considerable difficulties in progressing and completing the study; flaws in the methodology emerged; and underpinning assumptions about health promotion and ethnic minority health beliefs were open to challenge. Learning from the study Despite this, some findings were valuable and have considerable potential as a stimulus to critical thinking among practitioners about their own attitudes, as well as raising issues that future research would find it useful to addres

Facilitating the implementation of clinical technology in healthcare : what role does a national agency play?

Background: Accelerating the implementation of new technology in healthcare is typically complex and multi-faceted. One strategy is to charge a national agency with the responsibility for facilitating implementation. This study examines the role of such an agency in the English National Health Service. In particular, it compares two different facilitation strategies employed by the agency to support the implementation of insulin pump therapy. Methods: The research involved an empirical case study of four healthcare organisations receiving different levels of facilitation from the national agency: two received active hands-on facilitation; one was the intended recipient of a more passive, web-based facilitation strategy; the other implemented the technology without any external facilitation. The primary method of data collection was semi structured qualitative interviews with key individuals involved in implementation. The integrated-PARIHS framework was applied as a conceptual lens to analyse the data. Results: The two sites that received active facilitation from an Implementation Manager in the national agency made positive progress in implementing the technology. In both sites there was a high level of initial receptiveness to implementation. This was similar to a site that had successfully introduced insulin pump therapy without facilitation support from the national agency. By contrast, a site that did not have direct contact with the national agency made little progress with implementation, despite the availability of a web-based implementation resource. Clinicians expressed differences of opinion around the value and effectiveness of the technology and contextual barriers related to funding for implementation persisted. The national agency’s intended roll out strategy using passive web-based facilitation appeared to have little impact. Conclusions: When favourable conditions exist, in terms of agreement around the value of the technology, clinician receptiveness and motivation to change, active facilitation via an external agency can help to structure the implementation process and address contextual barriers. Passive facilitation using web-based implementation resources appears less effective. Moving from initial implementation to wider scale-up presents challenges and is an issue that warrants further attention

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

Evidence-based primary health care and local research: a necessary but problematic partnership

Background: Front-line NHS staff undertake small research projects to answer questions about local patients and services, but these projects often face considerable challenges. This paper reports on one such project. Aims and methods of study:The study used structured interviews in order to find out about the knowledge of nutrition among Bangladeshis using an NHS Walk-in Centre. Development of the study: Time constraints posed considerable difficulties in progressing and completing the study; flaws in the methodology emerged; and underpinning assumptions about health promotion and ethnic minority health beliefs were open to challenge. Learning from the study: Despite this, some findings were valuable and have considerable potential as a stimulus to critical thinking among practitioners about their own attitudes, as well as raising issues that future research would find it useful to address

Analysing the role of complexity in explaining the fortunes of technology programmes : Empirical application of the NASSS framework

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background: Failures and partial successes are common in technology-supported innovation programmes in health and social care. Complexity theory can help explain why. Phenomena may be simple (straightforward, predictable, few components), complicated (multiple interacting components or issues) or complex (dynamic, unpredictable, not easily disaggregated into constituent components). The recently published NASSS framework applies this taxonomy to explain Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability. This paper reports the first empirical application of the NASSS framework. Methods: Six technology-supported programmes were studied using ethnography and action research for up to 3 years across 20 health and care organisations and 10 national-level bodies. They comprised video outpatient consultations, GPS tracking technology for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organising software and integrated case management via data warehousing. Data were collected at three levels: micro (individual technology users), meso (organisational processes and systems) and macro (national policy and wider context). Data analysis and synthesis were guided by socio-technical theories and organised around the seven NASSS domains: (1) the condition or illness, (2) the technology, (3) the value proposition, (4) the adopter system (professional staff, patients and lay carers), (5) the organisation(s), (6) the wider (institutional and societal) system and (7) interaction and mutual adaptation among all these domains over time. Results: The study generated more than 400 h of ethnographic observation, 165 semi-structured interviews and 200 documents. The six case studies raised multiple challenges across all seven domains. Complexity was a common feature of all programmes. In particular, individuals' health and care needs were often complex and hence unpredictable and 'off algorithm'. Programmes in which multiple domains were complicated proved difficult, slow and expensive to implement. Those in which multiple domains were complex did not become mainstreamed (or, if mainstreamed, did not deliver key intended outputs). Conclusion: The NASSS framework helped explain the successes, failures and changing fortunes of this diverse sample of technology-supported programmes. Since failure is often linked to complexity across multiple NASSS domains, further research should systematically address ways to reduce complexity and/or manage programme implementation to take account of it.Peer reviewedFinal Published versio

What matters to older people with assisted living needs? A phenomenological analysis of the use and non-use of telehealth and telecare

Telehealth and telecare research has been dominated by efficacy trials. The field lacks a sophisticated theorisation of [a] what matters to older people with assisted living needs; [b] how illness affects people's capacity to use technologies; and [c] the materiality of assistive technologies. We sought to develop a phenomenologically and socio-materially informed theoretical model of assistive technology use. Forty people aged 60–98 (recruited via NHS, social care and third sector) were visited at home several times in 2011–13. Using ethnographic methods, we built a detailed picture of participants' lives, illness experiences and use (or non-use) of technologies. Data were analysed phenomenologically, drawing on the work of Heidegger, and contextualised using a structuration approach with reference to Bourdieu's notions of habitus and field. We found that participants' needs were diverse and unique. Each had multiple, mutually reinforcing impairments (e.g. tremor and visual loss and stiff hands) that were steadily worsening, culturally framed and bound up with the prospect of decline and death. They managed these conditions subjectively and experientially, appropriating or adapting technologies so as to enhance their capacity to sense and act on their world. Installed assistive technologies met few participants' needs; some devices had been abandoned and a few deliberately disabled. Successful technology arrangements were often characterised by ‘bricolage’ (pragmatic customisation, combining new with legacy devices) by the participant or someone who knew and cared about them. With few exceptions, the current generation of so-called ‘assisted living technologies’ does not assist people to live with illness. To overcome this irony, technology providers need to move beyond the goal of representing technology users informationally (e.g. as biometric data) to providing flexible components from which individuals and their carers can ‘think with things’ to improve the situated, lived experience of multi-morbidity. A radical revision of assistive technology design policy may be needed

Designing assisted living technologies 'in the wild' : preliminary experiences with cultural probe methodology

Background There is growing interest in assisted living technologies to support independence at home. Such technologies should ideally be designed ‘in the wild’ i.e. taking account of how real people live in real homes and communities. The ATHENE (Assistive Technologies for Healthy Living in Elders: Needs Assessment by Ethnography) project seeks to illuminate the living needs of older people and facilitate the co-production with older people of technologies and services. This paper describes the development of a cultural probe tool produced as part of the ATHENE project and how it was used to support home visit interviews with elders with a range of ethnic and social backgrounds, family circumstances, health conditions and assisted living needs. Method Thirty one people aged 60 to 98 were visited in their homes on three occasions. Following an initial interview, participants were given a set of cultural probe materials, including a digital camera and the ‘Home and Life Scrapbook’ to complete in their own time for one week. Activities within the Home and Life Scrapbook included maps (indicating their relationships to people, places and objects), lists (e.g. likes, dislikes, things they were concerned about, things they were comfortable with), wishes (things they wanted to change or improve), body outline (indicating symptoms or impairments), home plan (room layouts of their homes to indicate spaces and objects used) and a diary. After one week, the researcher and participant reviewed any digital photos taken and the content of the Home and Life Scrapbook as part of the home visit interview. Findings The cultural probe facilitated collection of visual, narrative and material data by older people, and appeared to generate high levels of engagement from some participants. However, others used the probe minimally or not at all for various reasons including limited literacy, physical problems (e.g. holding a pen), lack of time or energy, limited emotional or psychological resources, life events, and acute illness. Discussions between researchers and participants about the materials collected (and sometimes about what had prevented them completing the tasks) helped elicit further information relevant to assisted living technology design. The probe materials were particularly helpful when having conversations with non-English speaking participants through an interpreter. Conclusions Cultural probe methods can help build a rich picture of the lives and experiences of older people to facilitate the co-production of assisted living technologies. But their application may be constrained by the participant’s physical, mental and emotional capacity. They are most effective when used as a tool to facilitate communication and development of a deeper understanding of older people’s needs