Quality in Primary Care Open Access

Keywords

complex interventions, health inno-vation, knowledge, primary care, social media, translation

How this fits in with quality in primary care

What do we know?

There is an urgent need to increase the capacity of the primary care sector to serve patients with chronic, complex and life-limiting illness. Information technology (IT) will play a pivotal role in this process.

What does this paper add?

IT o?ers the opportunity to innovate primary care for population health in the relative safety of a simulated environment. However, e?ective IT innovations require end-user involvement from the outset, rather than simply as customers.

Background

Most countries are experiencing a growing demand for health care and experts agree that demand will continue to rise.[1–3] The population is ageing, the birth rate is falling, people are living longer and medical technology is o?ering more scope for successful treat-ment.[4] Additionally, sedentary lifestyles and the con-sumption of high-calorific foods are virtually the norm so that between 1980 and 2008, the mean body mass index (BMI) worldwide increased by 0.4 kg/m² per decade.[5] It is expected that 75% of Australians will be obese or overweight by 2020; this represents both a health and an economic phenomenon.[6] Although demography will have an important impact on health-care costs, the magnitude of these costs will be dwarfed by the increasing cost of medical treatment. For example, the demand for more expensive but less invasive procedures will increase much more than the cheaper options now in vogue.[4,7] Such trends have significant implications, as the incidence of multiple chronic diseases including dementia, cancer, diabetes and atheromatous vascular disease, is likely to rise to unprecedented levels.[8] These illnesses will require multidisciplinary teamwork from a health sector often characterised by siloed working practices.[9,10] If pri-mary care is to respond to these (and other) challenges e?ectively and e?ciently, novel approaches to service design and delivery are required and new technologies appear to o?er such opportunities.

Information technology (IT) has changed the way individuals interact with services, service providers and each other.[11] Information is now freely and readily available, partly due to the increasing accessibility and a?ordability of technology.[12] For instance, most Australians have access to a home computer and 46% own a Smartphone.[13,14] The increase in exposure to electronic and social media reflects the rising promi-nence of cyber-consumerism,[15] as evidenced by online banking, online takeaway ordering, self-service super-markets and self-service travel bookings. A recent report indicates that 53% of Australians aged over 15 years shop online[16] – online retail is now the norm, rather an activity undertaken by a select few. Many consumers are no longer willing to queue for service – they want (near) instant attention and a failure to deliver risks a loss in clientele. This has implications for healthcare services as these trends also shape patient expectations.[17]

In this epoch of instant gratification,[18] the health-care sector includes ‘a swell of new players’, many of whom are now considering the commercial oppor-tunities that technology a?ords.[19,20] For instance, following its interviews with 32 chief executive o?cers of private or public healthcare organisations across 18 nations, PricewaterhouseCoopers found three key forces were transforming the healthcare market – namely, the revolution in care, regulatory reform and the march of science.[21] This suggests that there is much opportunity to enable primary care clinicians to fulfil their broad role in prevention, early inter-vention and connected care.[22] The challenge is to harness these opportunities to foster innovation in primary care. This was the focus of a recent workshop hosted at the 2012 Health Informatics Society of Australia (HISA) annual conference. A team of inno-vators from the Curtin Health Innovation Research Institute at Curtin University and a representative from the Industry and Innovation Studies Research Group at the University of Western Sydney facilitated a discussion with approximately 50 delegates, findings from which are reported here.

Methods

Delegates represented the government, not-for-profit and private sectors, and held various appointments. They included (but were not limited to) clinicians, regulatory agencies, innovators and academics. The authors delivered brief presentations on examples of innovations in primary care. This included (for in-stance) the use of video and internet technology to deliver continuing professional development to gen-eral practitioners in the form of simulated patient care; this example demonstrated a way to enhance clinician capacity to provide aftercare to patients, following major surgery. Following these brief pres-entations, delegates were invited to form three groups, co-facilitated by two authors per group.

The evidence pipeline model, devised by Glasziou and Haynes,[23] formed the framework for discussions. This framework proposes seven critical points at which the translation from research evidence to prac-tice is at most risk – these include the points of: clinician awareness, clinician acceptance, clinician application, clinician ability, clinician recall in situ, patient agreement and patient adherence. Reflecting on this framework, delegates were invited to consider and discuss the following key questions:

• Which health problems can we solve now or facilitate management of with IT?

• What experiences have delegates had with the implementation of IT?

• How can IT be used to engage clinicians?

• How can IT help to access hard-to-reach groups?

• What are the considerations and implications of social media for health service providers?

With consent from those present, discussions were documented and/or digitally recorded. Notes were then prepared by the facilitators and analysed in conjunction with the digital recordings. Delegates were not o?ered recompense for their contribution to this project.

Using an iterative process,[24] each facilitator inde-pendently analysed and interpreted the field notes and audio-recording associated with the discussion that they co-facilitated. Guided by the aforesaid key ques-tions, this involved repeated exposure to the research material[25] to generate, develop and revise categories.[26] The authors then compared and contrasted con-structed themes and synthesised interpretations.

Through the analytic phase of the project, the data were found to cluster around a number of core themes, as the delegates described their perceptions and constructed their own meanings of situations during the discussion. Using a reflective, iterative process, theme content was then interrogated to explore relationships between and within the themes. The process enabled the authors to engage in a systematic method of analysis using an eclectic pro-cess, whilst remaining open to alternative explana-tions for the findings.[24]

The final task of the team was to compare the changes in stakeholder perceptions from this work-shop with one conducted a number of years ago to ascertain any similarities and di?erences that may have occurred over time.[27]

Results

Solvable or manageable health problems

The need to improve clinical outcomes and reduce the economic burden of ill health was identified as the greatest impetus to the deployment of innovation. It was noted, for example, that outcomes in some of the commonest chronic conditions including mental ill-ness, diabetes and atheromatous vascular disease were unsatisfactory. The reasons for poor outcomes are complex and not exclusively related to a failure to implement so-called ‘evidence-based guidelines’. How-ever, there is little doubt that much of the research evidence is not readily applied and a user-friendly, ‘normalised’ innovation may assist. In some areas of practice, technology is already deployed, albeit there is still a need to innovate for wider deployment. For example, the introduction of computerised appoint-ment schedules has streamlined processes within busy surgeries. Specifically designed templates and tailored programs are also now available for clinical practice with patients now able (in some cases) to make their own appointments online. Other IT innovations that have assisted in the better management of health problems include: consultations with doctors via the internet, sharing of patient information between para-digmatically di?erent services, empowerment of con-sumers to take control of their chronic and complex conditions, bolstering of health promotion e?orts to target and tailor messages about healthy lifestyle choices accordingly, as well as monitoring of at-risk and frail patients in their own homes.

There is robust evidence for the e?cacy of online treatments for chronic conditions, such as mental illness. However, there is concern that contextual variations limit the value of these innovations for consumers; for instance, they may be ine?ective for particular patients at particular time-points. Further-more, mobile technologies are not necessarily more accessible; for example, some patients prefer to access technology in the privacy of their own home and on full computer screens, rather than while on the move on relatively small devices.

A major stumbling block to the development of e?ective technology in health care is the recruitment and retention of participants to test innovations. Where funding is available to provide support to prac-titioners or incentives to clients, recruitment during a trial or pilot period is relatively successful. However, where funded time for involvement in research is not provided or is limited during a trial period, recruit-ment and retention were particularly di?cult. Fur-thermore, workshop participants found that changes in behaviour and/or practice observed throughout a trial usually ceased when supporting funds ceased. Use of ‘champions’ to promote and support change were found to be very e?ective and led to prolonged changes in practice if positive outcomes of value to service providers and consumers were demonstrated.

Harnessing technology – implementation experiences

The delegates acknowledged that not everyone had access to technology or was in broadband range. Even where IT was relatively well-established, many del-egates noted the limited availability of current, accu-rate and streamlined patient data, a problem that is exacerbated by a complex health system with many entry and exit points across the public and private sectors. Innovations to promote information sharing were constrained by the interoperability of software systems, privacy legislation, patient preference, con-fidentiality issues and limited clinician willingness (or ability) to enter data at each patient encounter. It is therefore unlikely that a shared patient record system implemented within current protocols, would com-prehensively catalogue patient experiences of the healthcare system. According to some delegates, empowering patients to be the primary custodians of their own health records may also introduce bias and, in turn, reduce the comprehensiveness of current health record databases.

For clinicians in primary care depending on a fee-for-service, funding is the key impetus for the adoption of innovation. A monetary incentive was suggested to be essential, particularly when end-user e?ort is required. Conversely, as was demonstrated by the team in their preamble, IT use in research is helping to reduce the burden on participants and hence the cost. As such, clinicians may be more inclined to embrace innovation. Researchers are using video and web-based technologies to e?ciently test hypoth-eses with standardised or simulated patients or to deliver education in the virtual clinic environment. This will assist in the investigation of research ques-tions where it is di?cult to recruit bona fide patients (e.g. patients with rare or embarrassing conditions) or test clinical decision making without risk of harm to ‘real’ patients.

In general, IT has been deployed piecemeal and largely for commercial interests; therefore it has often not delivered on promise. Examples of successful deployments in primary care are still relatively un-common. There is little evidence that software tools have delivered significant or sustained and measure-able clinical improvements. Although data extraction tools help to understand the public health landscape, these data do not necessarily lead to the necessary action to enact and sustain change. Into this vacuum come burgeoning businesses o?ering technological interventions that have not been empirically tested or evaluated prior to market release. A key factor is a failure to enlist the end-user as an advisor to the development team. There is therefore a risk that many innovations will be obsolete because they ‘leak’ at every point through Glasziou and Haynes’ pipeline.[23] New innovation also requires pump prime funding of ideas that may have limited (if any) commercial value, yet add to current understandings of, and e?ciencies in health care. Such projects do not readily fit into government research funding schemes, nor are they necessarily appropriate for private ventures. Never-theless, without this investment, progress will con-tinue to be disappointing.

Although the introduction of innovation is import-ant, so too is continued monitoring of its impact. Only then can the return on investment, be it economical or social, be determined. This might be facilitated by the post-marketing surveillance of new tools. Delegates stressed the need for leadership in Australia from medical practitioners with experience in coordinating research projects within practices and across the nation. They also noted that there must be a willing-ness to change based on evidence.

Engaging clinicians and hard-to-reach groups

It was generally acknowledged that IT has not been readily adopted by all clinicians or at least not to its full potential. In primary care, technology may be used to schedule appointments, print prescriptions or for patient billing; yet, it is not typically used to maintain medical records, communicate with colleagues, in-form clinical practice or consult patients online. Clin-ician engagement with IT was said to reflect change management theories, which recognise the import-ance of early adopters.[28] Working with local cham-pions and professional bodies to promote uptake was strongly emphasised, as was the need to promote the benefits of technological innovation specifically in reducing workload; this again reflects change man-agement theory.[29] These themes reflect ideas from a similar workshop at this conference as reported in this journal in 2011. The authors of that paper concluded, ‘The greatest areas of disagreement or misunderstand-ing were ... the return on investment for commercial partners; the timelines for academic outputs; and the potential for disruption of clinical practice routines’.[27]

According to some delegates, particular consumer groups are excluded from reaping the benefits asso-ciated with healthcare innovation. These include indi-genous people, people from culturally and linguistically diverse backgrounds, people from a low socio- economic background, high-risk youth and people who are homeless, or at risk of becoming so. Although older people are often added to this list, some delegates reported exceptions where many seniors were now ‘IT savvy’. Reasons for limited IT engagement among some consumer groups include geographical remote-ness, limited means and a preference to opt out of innovative interventions. It was therefore suggested that innovators be mindful of these (and other) barriers and tailor their wares accordingly to ensure all consumers can benefit. A failure to do so is likely to exacerbate current public health inequity and in turn further inflate healthcare costs.[30]

Social media – considerations and implications for service providers

Social media is fast becoming a significant part of the landscape in which individuals seek health infor-mation and engage in services. The delegates discussed the use of social media to promote health literacy and foster patient empowerment, while also considering limitations and potential dangers. The global reach of social networks, and the speed at which they can disseminate information, are seen as key advantages. For example, computational analysts at the University of Rochester have developed systems to track geotagged tweets (posts on the social media service Twitter) that relate to occurrences of a range of infectious diseases, including flu. Their systems produce highly accurate heat maps showing outbreaks as they emerge, and their models have clear implications for disease man-agement, and for developing our understanding of the spread of infectious diseases.[31]

Of course, this speed of dissemination can also be a negative factor, particularly if the information is incorrect or lacks credibility. Researchers report that some individuals find it increasingly di?cult to dif-ferentiate between credible, evidence-based informa-tion from expert sources, and that which has no basis other than general folksonomies and ‘crowd-think’.[32] Indeed, many individuals may not understand, or even care about, the distinction.

Issues of privacy and confidentiality were raised. As service providers increasingly look to engage with users of electronic media, including social media, the risk of data and privacy compromise becomes corre-spondingly greater. In cases where third party social media sites such as Facebook are used, the service provider may have limited control over confidentiality policies and considerations. These sites regularly up-date their policies and adjust their default settings; subsequent changes may result in the unforeseen exposure of information.

Delegates agreed on the importance of thorough empirical testing of IT initiatives before en masse deployment to understand their impact on behaviour and the end-user experience. One systematic review of social media interventions in the area of sexual health identified 178 activities that met their inclusion cri-teria, with only one reported in published scientific literature.[33] The authors concluded that much more work is needed to evaluate and understand the impact of these activities – a conclusion that was endorsed by the delegates.

Also important to the delegates was the subsequent delivery of end-user training. It was also noted that innovators needed to be aware of, and be able to discern ‘the wisdom of the crowd’ from the ‘voices of the most vocal’.

Delegates indicated possible ways to use social media to benefit health including using private interest to drive innovation and employing a coordi-nator to oversee integration of social media inno-vations into practice. This again reflected the thoughts from a previous workshop, which concluded that the most e?ective lead organisation in driving innovation is the one that is best-positioned to negotiate the needs of each stakeholder group.[27]

Conclusions

Within the context of Glasziou and Haynes’ frame-work,[23] innovators are challenged on several fronts. Clinicians are not necessarily aware of the potential o?ered by IT; they are rarely part of teams that develop innovations, thus limiting the relevance of inno-vations to clinical practice; the limited interoperability of IT systems diminishes information exchange; fur-thermore, technology is not routinely evaluated before market release, or re-evaluated thereafter.

Consumers could also be better engaged in the development and use of IT for primary care. There is still patchy access to the necessary technology and to broadband. Concerns about privacy continue to be a major stumbling block as do cultural issues and failures to adapt the technology to the end-user.

Despite these challenges, delegates largely agreed on two key points. First, IT has much to o?er the primary care sector and has the potential to bolster its capacity to meet patient demand. Second, to realise this poten-tial, leadership in developing IT innovations remains paramount, with the organisation best able to nego-tiate with the key stakeholders at the helm. Given that delegates represented the government, not-for-profit and private sectors, and o?ered perspectives from each Australian state and territory, these findings make a significant contribution to current under-standings of IT use in primary care.

However, four limitations moderate the con-clusions that can be drawn. First, the participants were self-selecting and this diminishes generalis-ability. Second, reliance on self-reports means that participant perceptions could not be verified. Third, while this paper reflects notes taken in each discussion group, it may still not encapsulate the perceptions voiced by all the participants. Fourth, the participants provided a snapshot of their views, which might alter over time.

Findings from this research suggest that the health of the primary care sector may be bolstered by an injection of IT innovation. However, to optimise relevance to clinical care and patients, this will require end-user involvement from the outset as well as the stewardship of an organisation that can lead and orchestrate innovation across the government, not-for-profit and private sectors.

Acknowledgements

The team would like to acknowledge the contribution of the following participants: Megan Kennedy, Alex McLaren, Renato Iannella, Adam Dunn, Hugo Leroux, Stuart Brown, Sami I Al-Akeel, Stephen Royce, Chris Swarts, John Hilton, Lynne Everett and Mitchell Burger.

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Funding

None.

Ethical Approval

Not required.

Peer Review

Not commissioned; externally peer reviewed.

Conflicts of Interest

None.