Digital transformation at the system level

Centre for Health Technology

There is general optimism that the digital future will be one of improved health outcomes, increased efficiency, a more sustainable system and ultimately reduced health-care expenditure. Evidence for these system improvements is currently lacking. Part of the problem is that the uptake of DHTs in the NHS and British social care has been relatively slow and uneven. Against this background, an important focus of CHT has been to address implementation barriers to digital acceleration. For example, the aim of the multi-million eHealth Productivity and Innovation in Cornwall and the Isles of Scilly project (EPIC) was to both increase demand for, and supply of innovative eHealth & social care products and services. Part of this has involved close work with citizens, who require trust and reassurance about using DHTs; and health and care staff who, due to concerns about increased workload, the ethics of data sharing, the evidence base of new products, may demonstrate cultural resistance to change. Our growing pedagogic offer is contributing to the aim of ‘winning hearts and minds’. Developers too need focus support to understand the complex and confusing NHS market and identify who the right stakeholders are, how to get innovations piloted and approved and who pays for what.
D-PACT: Carer and elderly woman communicating remotely on tablet

The e-citizen
An essential requirement of shifting the balance of care from the hospital to prevention, early diagnosis and care within people’s homes is the ‘e-citizen’ (electronic, equipped, enabled, empowered, engaged and expert). Many people are already using the internet and other technologies to diagnose their own problems and manage their treatments. However, there are concerns that such digital engagement is subject to inequality by age and socio-economic status. It is also important the engagement supports informed decisions and does not increase anxiety and demand. 
CHT has been involved in a wealth of projects engaging the e-citizen, such as e-coachER, an NIHR-funded multi-centred randomised controlled trial that investigated the effects of adding web-based coaching to an exercise referral scheme; the Health Technology Community Pop-up in Stonehouse, Plymouth , which was shortlisted by the Royal Society of Public Health for its prestigious Health & Wellbeing Award; the ESRC-funded Generating Older Active Lives Digitally (GOALD) project, which is examining how to design and deliver digital resources to provide and engage older people in structured activity programmes and improve health and wellbeing; and the EPSRC-fundedIntergenerational Codesign of Novel technologies In Coastal communities (ICONIC) project, which aims to improve digital inclusion for older and younger people living in coastal and rural areas and help them to connect to their communities and digital activity. 

Recent publications
Baines R, Bradwell H, Edwards K, Stevens S, Prime S, Tredinnick-Rowe J, Sibley M & Chatterjee A (2022) 'Meaningful patient and public involvement in digital health innovation, implementation and evaluation: A systematic review' Health Expectations , DOI Open access
Bradwell H, Baines R, Edwards KJ, Stevens S, Atkinson K, Wilkinson E, Chatterjee A & Jones RB (2022) 'Exploring Patient and Staff Experiences With Video Consultations During COVID-19 in an English Outpatient Care Setting: Secondary Data Analysis of Routinely Collected Feedback Data' JMIR Formative Research 6, (3) , DOI Open access
Carter H, Hanks S, Gale T (2020) A qualitative study using hybrid simulation to explore the impacts of human factors e-learning on behaviour change ADVANCES IN SIMULATION Vol.5   10.1186/s41077-020-00136-y http://hdl.handle.net/10026.1/16376 
Goodman S, Skirton H, Jackson L, Jones RB (2021) Development of a Secure Website to Facilitate Information Sharing in Families at High Risk of Bowel Cancer—The Familyweb Study CANCERS Vol.13 Iss.10 10.3390/cancers13102404  
Milne-Ives M, Lam C, Van Velthoven MH & Meinert E (2020) 'Mobile Apps for Health Behavior Change: Protocol for a Systematic Review' JMIR Research Protocols 9, (1) e16931-e16931 , DOI
Milne-Ives M, Swancutt D, Burns L, Pinkney J, Tarrant M, Calitri R, Chatterjee A, Meinert E (2021) The effectiveness and usability of online, group-based interventions for people with severe obesity: Systematic review protocol JMIR RESEARCH PROTOCOLS Vol.10 Iss.6 10.2196/26619 http://hdl.handle.net/10026.1/16920 
Williams M, Barclay Y, Harper L, Marchant C, Seamark L, Hickson M (2020) Feasibility, acceptability and cost efficiency of using webinars to deliver first‐line patient education for people with Irritable Bowel Syndrome as part of a dietetic‐led gastroenterology service in primary care JOURNAL OF HUMAN NUTRITION AND DIETETICS Vol.33 Iss.6 10.1111/jhn.12799 http://hdl.handle.net/10026.1/16368 
Wright H, Martin F, Clyne W, Clark CCT, McGillion M, Matouskova G, Turner A (2020) A Digital Program (Hope) for People Living With Cancer During the COVID-19 Pandemic: Protocol for a Feasibility Randomized Controlled Trial JMIR RESEARCH PROTOCOLS Vol.9 Iss.12 10.2196/24264 http://hdl.handle.net/10026.1/17982 

Remote consultation
The COVID-19 pandemic posed multiple challenges to the provision of health services. Researchers in the Community and Primary Care Research Group have been undertaking a number of research projects in this area. Dr Sarah Rybczynska-Bunt and Professor Richard Byng led the Plymouth site of the ESRC funded 'Remote by Default’ COVID-19 project.  Led by Professor Trish Greenhalgh, this examined digital communications between patients and primary care practices in light of the need to limit face-to-face appointments.

Recent publications
Anil K, Bird AR, Bridgman K, et al. Telehealth competencies for allied health professionals: A scoping review. Journal of Telemedicine and Telecare. 2023;0(0). , DOI
Baines R, Tredinnick-Rowe J, Jones R, Chatterjee A (2020) Barriers and Enablers in Implementing Electronic Consultations in Primary Care: Scoping Review.  Journal of Medical Internet Research Vol.22 Iss.11 10.2196/19375  
Greenhalgh T, Rosen R, Shaw SE, Byng R, Faulkner S, Finlay T, Grundy E, Husain L, Hughes G & Leone C (2021) 'Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics' Frontiers in Digital Health 3, , DOI Open access
Greenhalgh T, Shaw SE, Alvarez Nishio A, Booth A, Byng R, Clarke A, Dakin F, Davies R, Faulkner S & Hemmings N (2022) 'Protocol: Remote care as the ‘new normal’?  Multi-site case study in UK general practice' NIHR Open Research 2, 46-46 , DOI
Greenhalgh T, Shaw SE, Alvarez Nishio A, Byng R, Clarke A, Dakin F, Faulkner S, Hemmings N, Husain L & Kalin A (2022) 'Remote care in UK general practice: baseline data on 11 case studies' NIHR Open Research 2, 47-47 , DOI
Jones RB, Tredinnick-Rowe J, Baines R, Maramba IDC & Chatterjee A (2022) 'Use and usability of GP online services: a mixed-methods sequential study, before and during the COVID-19 pandemic, based on qualitative interviews, analysis of routine eConsult usage and feedback data, and assessment of GP websites in Devon and Cornwall, England' BMJ Open 12, (3) , DOI Open access
Rosen R, Wieringa S, Greenhalgh T, Leone C, Rybczynska-Bunt S, Hughes G, Moore L, Shaw S, Wherton J & Byng R (2022) 'Clinical risk in remote consultations in general practice: findings from in-Covid-19 pandemic qualitative research' BJGP Open , DOI Open access

Supporting system change
There is significant inequality with respect to digital maturity across the NHS and social care. Thus, reflecting previous waves of investment, metropolitan areas such as London, Leeds and Greater Manchester are galloping ahead with respect to their digital health ecosystems and attracting further investment from both Government and industry. By contrast, the South-West Peninsula makes relatively little use of digital and other technologies. Indeed, many of our hospital trusts do not even have comprehensive electronic health platforms.  While some of these use smaller-scale electronic systems in individual departments, several continue to rely on largely paper-based patient records. This, together with a range of evidential and cultural factors has presented a barrier to digital acceleration in coastal areas such as the South-West.
The CHT team does a lot of work, some unfunded, quite a lot of it unpublished, in essentially providing a ‘management consultancy’ service to local health and care partners to address the many barriers to implementation across the innovation pipeline. This is work that we are particularly proud of and are always keen to share our learning on.

Recent publications
Asthana, S, Sheaff R, Jones R, Chatterjee, A. (2020). eHealth technologies and the know-do gap: exploring the role of knowledge mobilisation. Evidence & Policy A Journal of Research Debate and Practice. DOI: 10.1332/174426420X15808912803267
Asthana, S. Jones, J. Sheaff, R. (2019). Why does the NHS lag behind other health care systems with respect to eHealth? A review of macro, meso and micro factors. BMC Health Services Research 19, Article number: 984. 
Austin D, Andrade J, May J, Jones R (2020) Delivering digital health: The barriers and facilitators to University-Industry Collaboration HEALTH POLICY AND TECHNOLOGY Vol.10 Iss.1 10.1016/j.hlpt.2020.10.003 http://hdl.handle.net/10026.1/16531 
Blease C, Kharko A, Annoni M, Gaab J, Locher C (2021) Machine Learning in Clinical Psychology and Psychotherapy Education: A Mixed Methods Pilot Survey of Postgraduate Students at a Swiss University FRONTIERS IN PUBLIC HEALTH Vol.9   10.3389/fpubh.2021.623088 http://hdl.handle.net/10026.1/17032 
Blease C, Torous J, Dong Z, Davidge G, DesRoches C, Kharko A, Turner A, Jones R, Hägglund M & McMillan B (2022) 'Patient Online Record Access in English Primary Care: A Qualitative Study of General Practitioners’ Views (Preprint)' Journal of Medical Internet Research , DOI
Farahnaz Sadoughi, Taleb Khodaveisi, Hossein Ahmadi, The used theories for the adoption of electronic health record: A systematic literature review, Health and Technology, Volume 9, pages383–400, 21 November 2019. https://link.springer.com/article/10.1007/s12553-018-0277-8
Hossein Ahmadi, Mehrbakhsh Nilashi, Leila Shahmoradi, Othman Ibrahim, Farahnaz Sadoughi, Mojtaba Alizadeh, Azadeh Alizadeh, Moderating effect of hospital size on inter and intra-organizational factors of hospital information system adoption, Technological Forecasting and Social Change. Volume 134, September 2018, Pages 124-149. https://www.sciencedirect.com/science/article/pii/S0040162517303001
Meinert E, Reeves S, Eerens J, Banks C, Maloney S, Rivers G, Ilic D, Walsh K, Majeez A, Car J (2021) Exploring the cost of eLearning within the field of health professions education: Scoping Review JMIR MEDICAL EDUCATION Vol.7 Iss.1 10.2196/13681 http://hdl.handle.net/10026.1/16762 
Milne-Ives M, Lam C, van Velthoven M, Meinert E (2020) The Impact of Brexit on the Pharmaceutical Supply Chain of the United Kingdom: Scoping Review Protocol JMIR RESEARCH PROTOCOLS Vol.9 Iss.9 10.2196/17684  
Milne-Ives M, Leyden J, Maramba I, Chatterjee A & Meinert E (2022) 'The potential impacts of a digital preoperative assessment service on appointments, travel-related carbon dioxide emissions, and user experience: a case study' JMIR Perioperative Medicine , DOI Open access
Milne-Ives M, Rehman N, Sharif R, Meinert E (2021) Distributed Ledger Infrastructure to Verify adverse Event Reporting (DeLIVER): Proposal for a proof-of-concept study JMIR RESEARCH PROTOCOLS Vol.10 Iss.6 10.2196/28616 http://hdl.handle.net/10026.1/17058 
Nelis JLD, Tsagkaris AS, Dillon MJ, Hajslova J, Elliott CT (2020) Smartphone-based optical assays in the food safety field TRAC TRENDS IN ANALYTICAL CHEMISTRY Vol.129   10.1016/j.trac.2020.115934 http://hdl.handle.net/10026.1/17801 
Sohrab Almasi, Kambiz Bahaadinbeigy, Hossein Ahmadi, Solmaz Sohrabei, Usability Evaluation of Dashboards: A Systematic Literature Review of Tools, BioMed Research International, Volume 2023. https://www.hindawi.com/journals/bmri/2023/9990933/