EHealth: What is it and What are the Challenges Frances S Mair Professor of Primary Care Research Un

1
E-Health What is it and What are the
Challenges? Frances S MairProfessor of Primary
Care Research University of Glasgow
E-mailfm46c_at_clinmed.gla.ac.uk
2
Drawing on Programme of e-Health Research

• Examining the evidence base
• Investigating implementation and normalisation
  issues
• Studies of evaluation of e-health as a complex
  intervention
• Clinical trials
• Funding DoH (NHSE, ICT, modernisation, SDO)
  ESRC, industry

3
What is E-Health?

• .. todays tool for substantial productivity
  gains, while providing tomorrows instrument for
  restructured, citizen-centred health care systems
  and, at the same time, respecting the diversity
  of Europes multi-cultural, multi-lingual health
  care traditions.
• European Commission definition 2004
  (http//europa.eu.int/information_society/doc/qual
  if/health/COM_2004_0356_F_EN_ACTE.pdf)

4
4 E-Health Domains

• Management systems. Including electronic
  medical record systems (for example the systems
  being implemented within NPfIT (connecting for
  health).

5
Communication Systems

• Including synchronous and asynchronous
  information and communications systems used for
  clinical information sharing, ranging from e-mail
  through telemedicine and telecare systems

6
Decision Support Systems

• Including computerised/automated systems used
  to support health professionals in adhering to
  clinical guidelines and importantly to promote
  shared decision making between clinicians and
  patients and promote evidence based care.

7
Information Systems

• Including web-based resources or e-health
  portals for information retrieval.

8
Enthusiasm for New Technologies in Health Care
Delivery

• The possibilities that new technologies present
  to health care systems practitioners, and carers
  and patients are considerable.
• Policymakers have been quick to recognise the
  possibilities of new technologies in the health
  service.

9
Policy Context

• Delivering for Health. 2005
• NHS Plan. 1998
• Information for health an information strategy
  for the modern NHS. 1998
• Delivering the NHS plan Taking NHS information
  technology into the 21st century. 2002
• Building Telecare in England. 2005

10
Resistance

• While new technologies are subject to
• very rapid development, the professional,
• organizational and institutional terrain on
• which this technology is set in play is
• much less amenable to change.

11
Areas of Difficulty With Regard to Implementation

• The policy background.
• Technological issues.
• Organisational issues.
• Issues surrounding professional roles and
  boundary crossing.
• Effects on the soft technology of
  communications skills in providerpatient
  interaction.
• Risk management.

12
Policy Background

• New services are not promoted within a social and
  political vacuum.
• Many e-Health services are conceived through high
  level central or local health policy support.

13

• I mean this policy, I presume it was from
• the top, Downing Street or wherever,
• these places, politics come from. I
• suppose it must have been because it
• would not have had this commissioner
• geezer come into my office and say you
• have got to do some (teledermatology),
• but that's effectively what he said..
• (Consultant dermatologist-T10)

14
Technology Issues A Broad Term

• Includes
• Development/Procurement
• Standards
• Contracts and maintenance
• Training
• Relationship with supplier
• General IT support issues.

15
Technology Can Be Problematic

• Equipment that might seem suitable for a
  clinical project can prove less than ideal given
  the frequently, unsatisfactory circumstances in
  which NHS staff can sometimes find themselves
  situated.1
• Mair, Hibbert, May et al. In Whitten P, Cook D
  eds. Understanding Health Communications
  Technologies A Case Study Approach.
• San Francisco, Jossey-Bass Inc.
  20043-10.

16
Organisational Issues

• Integration of new technologies into routine
  service provision is time consuming and can be
  resisted. Organisational issues include
• Redefinition of roles and responsibilities of
  personnel.
• Heavy workload commitments
• Scheduling and training issues.

17
Professional concerns about communication

• Telehealthcare interventions can be construed,
  as having negative effects on the consultation
  and can be viewed as second rate compared with
  traditional care. There is a suggestion that
  health care professionals may themselves feel
  cheated by these types of interaction.1,2
• Its not as satisfying as seeing patients
• Hibbert, Mair, May et al. JTT 200410(4)226-30.
• May C, Gask L, Atkinson T, Ellis N, Mair F,
  Esmail A. Soc Sci Med 2001 52 1889-1901.

18
Perceived Benefit Related Commitment

• e-Health services require much investment in time
  and effort when introduced.
• The full impact of a range of e-Health services
  on working practices often only becomes apparent
  to participants once they start working with the
  system in practice, and begin the process of
  identifying and resolving problems as necessary
  to make the system function as reqd.

19
Reconfiguring Services

• Frequently, the equipment was over-emphasised.
• Whereas the crucially important issue was the
  ways in which the ways of working needed to be
  adapted to make the new systems work in practice.

20
Professional Roles and Boundary Crossing

• Traditional boundaries of responsibility
  affected by new e-Health services.
• At the individual level, professionals such as
  nurses and consultants needed to embrace changes
  or adjustments to their (traditionally perceived)
  professional roles in order to make the new
  systems work.

21

• If telemedicine works in one area how many
  more areas will there become. and are they (GPs)
  really as equipped to deal with this addition to
  their, to their existing role, er that may be
  something which some GPs might consider to be you
  know, this is, this is just one step too far you
  know. Telemedicine for dermatology one minute
  then ENT then, then you know. Em and oh you
  know, 'what's the hospital doing then? you know
• (Teledermatology project manager-AOD pilot)

22
Risk Management

• Potential concern that the e-Health systems may
  increase the risk to patients.
• May not be seen as a progressive extension of
  professional practice.
• May be viewed as something that takes
  doctors/nurses away from a more holistic model
  of health care provision.
• Mair FS Shiels C, Boland A, Goldstein
  P, May C, Roberts C, Angus R, OConnor J, Haycox
  A, Capewell S. JTT 2005 11(Suppl 1)95-97.

23
Key Points

• If equipment was simply parachuted into an
  existing clinical context, the chances for
  successful introduction and integration of the
  system as reconfigured practice were severely
  compromised.

24
Resistance to Change

• A major part of the conflict around service
  provision and evaluation concerned the management
  of risk.
• For clinicians the introduction of e-Health
  systems and its evaluation highlighted the
  possibility of increased risk from what they
  perceived as new forms of practice.

25
Concluding Thoughts

• Flexibility essential.
• Interplay of Social and Technical and how this is
  accommodated both by health care professionals
  and the organisations in which they work.
• Implementation requires attention to broad
  organisational/educational issues.

26
Challenges

• New telecommunications technologies within the
  health care setting remain unstable and
  constantly developing.
• Partnerships need to be established to develop
  skills and capacity in operating the new
  technologies within the NHS.