Unveiling the heterogeneous utilisation of the same digital patient management platform: case studies in primary healthcare in Sweden.

BACKGROUND: The utilisation of digital technology in primary healthcare, particularly digital patient management platforms, has gained prominence, notably due to the global pandemic. These platforms are positioned as substitutes for face-to-face consultations and telephone triage. They are seen as a potential solution to the escalating costs associated with an aging population, increasing chronic conditions, and a shrinking healthcare workforce. However, a significant knowledge gap exists concerning the practical aspects of their implementation and their effect on the utilisation of digital patient management in primary healthcare. METHODS: This study addresses this gap by conducting a comprehensive analysis of three case studies involving the implementation of a specific digital patient management platform. Over a period of three years, we examine how the practicalities of implementation shape the adoption and utilisation of a digital patient management platform in three different clinics. RESULTS: Our findings revealed that differences in implementation strategies directly influenced variations in utilisation. The successful utilisation of the platform was achieved through a bottom-up decision-making process that involved the employees of the primary healthcare clinics. Onsite training, close collaboration with the eHealth provider, and a structured patient onboarding process played crucial roles in this utilisation. In contrast, a top-down approach at two of the primary healthcare clinics led to limited utilisation of the platform into daily workflows. Furthermore, making the platform a part of everyday work meant putting accessibility, by working as a team of physicians, at the forefront of continuity of care, with patients being managed by their designated physician. Additionally, it was observed that digital patient management proved most effective for addressing simple patient issues such as skin rashes, rather than complex cases, and did not reduce the demand for phone triage. CONCLUSION: Only one of the three clinics studied effectively integrated digital patient management into its daily operations, and did so by aligning objectives among management and all categories of healthcare professionals, employing a bottom-up decision-making process, collaborating with the eHealth service provider for regular platform adjustments to clinic needs, and implementing active patient onboarding. This sociotechnical integration resulted in high platform utilisation. In contrast, the other two clinics faced challenges due to incoherent objectives among diverse healthcare professional employees and top management, a top-down decision-making approach during implementation, limited collaboration with the eHealth service provider, and passive patient onboarding. The findings indicate that these factors negatively affected utilisation and led to low platform adoption as well as disrupted the sociotechnical balance.

Designing Virtual Natural Environments for Older Adults: Think-Aloud Study.

BACKGROUND: Spending time in natural environments is beneficial for human health, but many older adults have limited or no access to natural environments. Virtual reality technology may be a means to facilitate nature experiences, and so, there is a need for knowledge on how to design virtual restorative natural environments for older adults. OBJECTIVE: The aim of this study was to identify, implement, and test older adults' preferences and ideas regarding virtual natural environments. METHODS: A total of 14 older adults (mean age 75, SD 5.9 years) participated in an iterative process to design such an environment. We used think-aloud protocols and qualitative content analysis and established questionnaires that targeted usability, affective aspects, and side effects. These data guided the design decisions for incremental implementations of a prototype. RESULTS: The participants' preferences included trueness to reality in terms of rendition and behavior; traces of human activity and natural processes that trigger the imagination and provide believability; the ability to roam, explore, and interact with the environment; and a familiar, relatable environment that evokes memories. The iterative design process resulted in a prototype featuring many of the participants' ideas and preferences, including a seated locomotion technique, animals, a boat ride, the discovery of a boat wreck, and apple picking. The questionnaire results indicated high perceived usability, interest, and enjoyment; low pressure and tension; moderate value and usefulness; and negligible side effects. CONCLUSIONS: We suggested 3 principles for virtual natural environments for older adults: realness, interactivity, and relatedness. Virtual natural environments should also provide a diversity of content and activities to accommodate the heterogeneity in older adults' preferences. These results can contribute to a framework for designing virtual natural environments for older adults. However, these findings need to be tested and potentially revised in future studies.

"More" work for nurses: the ironies of eHealth.

BACKGROUND: eHealth applications are considered a technological fix that can potentially address some of the grand challenges in healthcare, including burnout among healthcare professionals, the growing burden of patients with chronic conditions, and retaining and recruiting healthcare professionals. However, as the deployment of eHealth applications in healthcare is relatively novel, there is a lack of research on how they affect the work environment of healthcare professionals. This study explores how work evolves-particularly for nurses-during the utilisation of three eHealth applications. METHODS: The study is a qualitative case study with an interpretive approach. The utilisation of three different eHealth applications was studied. Seventy-five healthcare professionals were interviewed, most of whom were nurses (n = 47). Interviews were transcribed verbatim and qualitative content analysis was used to analyse the text. RESULTS: Three main themes were identified: work that is ignored and overlooked; actions needed to complete visible work; and more sedentary work activities. The findings suggest that work surrounding the utilisation of eHealth applications in care practices is mostly performed by nurses. While the promise of more efficient workflows resulting from healthcare's digital transformation may be realised to different degrees, the utilisation of eHealth applications creates additional invisible labour for nurses. CONCLUSION: We identified through our analysis that the extra work created by eHealth applications is invisible at the organisational level. Most of the invisible labour was performed by nurses, who were engaged in utilising the eHealth applications. This needs to be recognised when implementing eHealth applications in care practices.

Interactive robots for health in Europe: Technology readiness and adoption potential.

Introduction: Social robots are accompanied by high expectations of what they can bring to society and in the healthcare sector. So far, promising assumptions have been presented about how and where social robots are most relevant. We know that the industry has used robots for a long time, but what about social uptake outside industry, specifically, in the healthcare sector? This study discusses what trends are discernible, to better understand the gap between technology readiness and adoption of interactive robots in the welfare and health sectors in Europe. Methods: An assessment of interactive robot applications at the upper levels of the Technology Readiness Level scale is combined with an assessment of adoption potential based on Rogers' theory of diffusion of innovation. Most robot solutions are dedicated to individual rehabilitation or frailty and stress. Fewer solutions are developed for managing welfare services or public healthcare. Results: The results show that while robots are ready from the technological point of view, most of the applications had a low score for demand according to the stakeholders. Discussion: To enhance social uptake, a more initiated discussion, and more studies on the connections between technology readiness and adoption and use are suggested. Applications being available to users does not mean they have an advantage over previous solutions. Acceptance of robots is also heavily dependent on the impact of regulations as part of the welfare and healthcare sectors in Europe.

Moral distress and ethical decision-making of eldercare professionals involved in digital service transformation.

AIM: Technology affects almost all aspects of modern eldercare. Ensuring ethical decision-making is essential as eldercare becomes more digital; each decision affects a patient's life, self-esteem, health and wellness. METHODS: We conducted a survey and interviews with eldercare professionals to better understand the behavioural ethics and decision making involved in the digital transition of eldercare. CONCLUSION: Our qualitative analysis showed three recurrent roles among eldercare professionals in regard to digital service transformation; makers, implementers and maintainers. All three encountered challenging and stressful ethical dilemmas due to uncertainty and a lack of control. The matter of power relations, the attempts to standardize digital solutions and the conflict between cost efficiency and if digital care solutions add value for patients, all caused moral dilemmas for eldercare professionals. The findings suggest a need for organizational infrastructure that promotes ethical conduct and behaviour, ethics training and access to related resources.Implications for rehabilitationThe transition to digital care service is not neutral, but value-laden. Digital transformation affects ethical behaviour and decision-making.The decision as to which digital services should be developed and deployed must include eldercare professionals and not lay solely in the hands of managers, technologists and economists.We must move away from attempting to fit standardized solutions to a heterogenous group of older patients; accommodating the pluralism of patients' needs and wants protects their dignity, autonomy and independence.As digital care practices evolve, so too must organizational structures that promote ethical conduct.

'It increases my ability to influence my ways of working': A qualitative study on digitally mediated patient management in primary healthcare.

BACKGROUND: Digitally mediated primary healthcare is increasingly influencing working conditions, raising questions about how digitally mediated patient management is experienced. AIM: The aim of this study was to generate insights, through the lens of postphenomenology, into how digitally mediated primary healthcare affects the work and working environment, by gathering perspectives from primary healthcare professionals who regularly manage patient errands through a digital platform. METHODS: Two rounds of interviews were conducted with a diversified sample of primary healthcare professionals at a primary healthcare centre. The first round of interviews was conducted during the initial phase of the deployment of a digital platform for patient management, with the second round conducted a year later (n = 24). The interview transcripts were analysed using reflexive thematic analysis. RESULTS: Four themes relating to digitally mediated care work were identified: 'positive feelings towards digitally mediated primary healthcare', 'seeing a positive work atmosphere as a prerequisite for change', 'experiencing increased control over the pace of workflow' and 'reconfiguration of previous problems'. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Building on postphenomenology, our study adds to the understanding of how material and symbolic aspects mutually affect the mediating role of a digital platform for patient management. Thus, the results indicate that the experience of using digitally mediated care processes is conditioned by the discourse towards digitalisation at the workplace and the management's approach to and inclusion of employees in the digital transition of primary healthcare, as well as the usefulness and usability of the digital platform. The findings can inform both practice and policy.

Materiality and the mediating roles of eHealth: A qualitative study and comparison of three cases.

Against the backdrop of eHealth solutions increasingly becoming a part of healthcare professionals' ways of doing care work, this paper questions how the solutions mediate the experience of healthcare professionals when deployed. We undertook a qualitative study of three eHealth solutions, conducting qualitative interviews with a diverse sample of 102 healthcare professionals from different care settings across the south of Sweden. Materiality and postphenomenology serve as analytic tools for achieving an understanding of the mediating roles of eHealth solutions. The analysis emphasises the mediating roles consisting of interrelated paradoxes: (1) changing and perpetuating boundaries between patients and professional groups, (2) (dis)enabling augmented information and knowledge processes and (3) reconfiguring professional control over work. This contribution provides critical insights into materiality as a category of analysis in studies on the deployment of eHealth solutions, as these technologies have both intended and unintended consequences for care work. Our study identified general positive consequences of all three solutions, such as the increased feeling of closeness to patients and colleagues over time and space; increased 'understanding' of patients through patient-generated data; and increased autonomy, due to the fact that asynchronous communication makes it possible to decide when and which patient to attend to. We also identified general unintended consequences of the solutions, such as maintenance of power relations maintained due to organisational structures and professional relations, disabled information and knowledge processes due to the lack of non-verbal clues, reduced professional autonomy due to technical scripts determining what data is collected and how it is categorised, and uneven workload due to the dependency on patient input and compliance.

Embedding and Integrating a Digital Patient Management Platform Into Everyday Primary Care Routines: Qualitative Case Study.

BACKGROUND: Traditional primary care is characterized by patient consultations via phone and physical visits. However, the current development in Swedish primary care is to blend digital solutions with traditional solutions. This paper addresses this development by examining the normalization of embedding and integrating a digital health care platform into everyday care routines in a primary care clinic. The digital health care platform enables both synchronous (video calls) and asynchronous (chat) communication, as well as self-registration of patient data using automated questions and forms requiring the patient's input. OBJECTIVE: This study aims to explore the work that health care professionals (HCPs) have to undertake to implement and sustain a digital health care platform as part of their everyday work practice. METHODS: HCPs were observed and interviewed to assess their individual and collective engagement and the mechanisms involved in the implementation of the digital platform and its effects on everyday work routines. The normalization process theory (NPT) was used to frame the data analysis. RESULTS: The analysis identified several themes related to the four NPT constructs: coherence, cognitive participation, collective action, and reflexive monitoring. The use of these constructs enabled the analysis to identify ways of supporting implementation. For example, it showed the benefits of having implementation champions and scheduling work hours for HCPs to use the platform. The analysis also revealed a theme of materiality that deviated from the NPT constructs, as NPT gives ontological priority to human actors and social structures. CONCLUSIONS: Digital health care platform implementation is a complex process. Our findings provide insights into how individual and collective actions can be supported to embed and integrate a digital platform into everyday care routines. Primary health care organizations need to involve HCPs throughout the implementation process by reorganizing work and providing frequent feedback loops. HCPs are more likely to engage with and commit to changing practices if they perceive the digital platform to be beneficial compared with the current practice. However, they also need resources (eg, time, training, and continuous support) to put the platform into practice. Patient engagement and appraisal are important elements in implementation. Unless patients are willing to use the platform, there is no motivation for HCPs to embed the digital platform into everyday care practice.

Gender blindness: On health and welfare technology, AI and gender equality in community care.

Digital health and welfare technologies and artificial intelligence are proposed to revolutionise healthcare systems around the world by enabling new models of care. Digital health and welfare technologies enable remote monitoring and treatments, and artificial intelligence is proposed as a means of prediction instead of reaction to individuals' health and as an enabler of proactive care and rehabilitation. The digital transformation not only affects hospital and primary care but also how the community meets older people's needs. Community care is often provided by informal and formal care-givers, most of whom are women. Gender equality is at the heart of many national strategies, but do all genders have equal rights, responsibilities and opportunities when it comes to community care and its digital transformation? The digital transformation of community care is entangled with how care is provided to older people and the working conditions of community-care professionals. Current and, even more so, future community-care systems are and will be partly constituted by networks of technological artefacts. These health and welfare technological artefacts and the discourse surrounding them mediate and constitute social relations and community care. This article looks into how health and welfare technology and artificial intelligence-based devices and systems mediate and constitute gender relations in community care and presents an argument for reflexivity, embodiment, pluralism, participation and ecology as an alternative strategy to treating community care as one-size-fit-all and being blind to gender-related issues.

Telemedicine for Remote Surgical Guidance in Endoscopic Retrograde Cholangiopancreatography: Mixed Methods Study of Practitioner Attitudes.

BACKGROUND: Telemedicine innovations are rarely adopted into routine health care, the reasons for which are not well understood. Teleguidance, a promising service for remote surgical guidance during endoscopic retrograde cholangiopancreatography (ERCP) was due to be scaled up, but there were concerns that user attitudes might influence adoption. OBJECTIVE: Our objective was to gain a deeper understanding of ERCP practitioners' attitudes toward teleguidance. These findings could inform the implementation process and future evaluations. METHODS: We conducted semistructured interviews with ERCP staff about challenges during work and beliefs about teleguidance. Theoretical constructs from the technology acceptance model (TAM) guided the thematic analysis. Our findings became input to a 16-item questionnaire, investigating surgeons' beliefs about teleguidance's contribution to performance and factors that might interact with implementation. RESULTS: Results from 20 interviews with ERCP staff from 5 hospitals were used to adapt a TAM questionnaire, exchanging the standard "Ease of Use" items for "Compatibility and Implementation Climate." In total, 23 ERCP specialists from 15 ERCP clinics responded to the questionnaire: 9 novices (<500 ERCP procedures) and 14 experts (>500 ERCP procedures). The average agreement ratings for usefulness items were 64% (~9/14) among experts and 75% (~7/9) among novices. The average agreement ratings for compatibility items were somewhat lower (experts 64% [~9/14], novices 69% [~6/9]). The averages have been calculated from the sum of several items and therefore, they only approximate the actual values. While 11 of the 14 experts (79%) and 8 of the 9 novices (89%) agreed that teleguidance could improve overall quality and patient safety during ERCP procedures, only 8 of the 14 experts (57%) and 6 of the 9 novices (67%) agreed that teleguidance would not create new patient safety risks. Only 5 of the 14 experts (36%) and 3 of the 9 novices (33%) were convinced that video and image transmission would function well. Similarly, only 6 of the 14 experts (43%) and 6 of the 9 novices (67%) agreed that administration would work smoothly. There were no statistically significant differences between the experts and novices on any of the 16 items (P<.05). CONCLUSIONS: Both novices and experts in ERCP procedures had concerns that teleguidance might disrupt existing work practices. However, novices were generally more positive toward teleguidance than experts, especially with regard to the possibility of developing technical skills and work practices. While newly trained specialists were the main target for teleguidance, the experts were also intended users. As experts are more likely to be key decision makers, their attitudes may have a greater relative impact on adoption. We present suggestions to address these concerns. We conclude that using the TAM as a conceptual framework can support user-centered inquiry into telemedicine design and implementation by connecting qualitative findings to well-known analytical themes.

The concept of welfare technology in Swedish municipal eldercare.

PURPOSE: An ageing population presents a challenge for municipal eldercare in Sweden due to difficulties recruiting staff and there being a strained economy. A strategy involving welfare technology is presented as one such solution. An important group to carry out this strategy involves those who work with welfare technology in municipal eldercare. In this paper we describe their perception of welfare technology, and the challenges and opportunities they perceive in utilizing it. METHODS: A self-administered online questionnaire was distributed to all Swedish municipalities and answered by 393 respondents. Analyses show that the respondents were representative of the different professions who work with welfare technology within municipal eldercare. RESULTS: Welfare technology was perceived as being more reliable and safer than humans with regards to supervisions and reminders. The respondents acknowledged factors that slowed down the implementation of welfare technology in municipal eldercare organizations, such as resistance to change, lack of finances, lack of supporting evidence, lack of infrastructure, high staff turnover, difficulties with procurement and uncertainties about responsibility and laws. CONCLUSIONS: We found that the people who work with and make decisions about welfare technology in municipal eldercare organizations were generally very positive about the deployment and use of such technology, but there appear to be problems within municipal eldercare organizations to realize this vision. The lack of structured implementation processes and coherent evaluation models indicates inequality of the access to welfare technology and, as a result, even though Swedish eldercare is publicly funded, the availability of welfare technologies and their usage differ between municipalities.IMPLICATIONS FOR REHABILITATIONThe research findings show that implementing welfare technologies in municipal eldercare must include transformed working processes and long-term strategies or they may lead to conflicts of priorities or unstructured implementation processes.Structured implementation processes and coherent evaluation models are needed for equality of access and availability of welfare technologies in municipal eldercare.High staff turnover negatively affects the deployment of welfare technology and the root cause of high staff turnover needs to be addressed.

Hitting a moving target: digital transformation and welfare technology in Swedish municipal eldercare.

INTRODUCTION: This article contributes to the discussion on digital transformation and welfare technology in municipal eldercare. The aim of welfare technology solutions is to exceed the current welfare system and to meet the challenges of an ageing population through technological innovations and applications that help people to better cope with health issues and strengthen their participation, activity and independence regarding their own healthcare. METHODS: First, this article outlines a number of different perspectives on technological and social change. Against this backdrop, this article portrays the challenges faced by Swedish municipal eldercare organizations due to the moving targets of digital transformation and the development of welfare technologies. CONCLUSION: In this context, eldercare organizations are at risk of becoming victims of the fast pace at which technology develops and the rhetoric of technological determinism; they may try to pursue the latest technological innovation at the expense of their stakeholders' needs. The implementation and deployment of welfare technology become a real-world social experiment. Without proper tools for evaluation, welfare technology might be implemented and deployed as an end in itself, instead of as means for better ageing or improved eldercare. This article concludes by framing a set of questions to help increase the understanding of welfare technology implementation and deployment in order to mitigate risks and improve outcomes. IMPLICATIONS FOR REHABILITATION Analysis of different perspectives regarding technological and social change. Identification of the challenges faced by municipal eldercare organizations due to digital transformation. Presentation of evaluation questions to increase the understanding of welfare technology implementation and deployment in order to mitigate risks and improve outcomes.

Views of Swedish Elder Care Personnel on Ongoing Digital Transformation: Cross-Sectional Study.

BACKGROUND: Swedish municipalities are facing demographic challenges due to the growing number of older people and the resulting increased need for health care services. Welfare technologies are being launched as possible solutions for meeting some of these challenges. OBJECTIVE: The aim of this study was to explore the perception, experimentation, evaluation, and procurement of welfare technology practices among professionals working in municipal elder care in relation to their gender, age, and profession. METHODS: Data for this explorative cross-sectional study were collected from 393 responses to a web-based survey on municipal elder care in Sweden. Chi square tests were performed to determine the associations. RESULTS: The results revealed gender, age, and professional differences in perspectives of municipal elder care workers. Differences were particularly evident in attitudes toward technology, both the use of technology in general and in the workplace, and involvement and participation in decision making regarding the procurement of new welfare technologies. Men (37/53, 70%) expressed a more positive attitude toward and curiosity regarding new technologies than women (157/336, 46.7%) (P=.03). Regarding age, the younger respondents (18-24 years old) perceived the digital transformation in the workplace as "too slow" (4/4, 100%), whereas the majority of older respondents (65-74 years old) perceived it as happening at the "right pace" (4/7, 57%). The elder care personnel felt encouraged by management to explore and experiment with new welfare technologies, but never did so either for management or with patients. Even though the majority of the respondents were women, more men (4/7, 57%) were involved in the procurement process for welfare technology devices and solutions than women (98/336, 29.2%) (P<.001). CONCLUSIONS: Personnel working within municipal elder care were generally very positive toward new technologies. However, both gender and age differences may influence these perspectives such as the personnel's resistance to welfare technology and patients' participation in welfare technology usage and deployment. Different levels of participation in the decision-making process regarding new technology deployment may negatively affect the overall digital transformation within municipal elder care.

Lost in digitalization? Municipality employment of welfare technologies.

Introduction: Swedish municipalities face a number of daunting challenges; an aging population, the public's increased demands and expectations on municipality services, and a strained economy to mention some. Welfare technology, a Scandinavian concept launched to promote digitalization, is seen as one solution to meet these challenges. Objective: Despite these promises, few welfare technology applications are offered by local Swedish municipalities and care organizations. Numerous studies have shown that Swedish municipalities have a great interest in welfare technologies. Methods: In this article, we draw on empirical research in one Swedish municipality. Through two case studies it is illustrated how technological change and municipality employment of welfare technologies are employed. Results: These case studies show how core values of care are being lost in the quest for digitalization due to the lack of organizational skills and knowledge in transforming the relationship of caregiving and care-receiving through the use of digital technology. Conclusions: Digitalization and welfare technologies deployed ought to represent and support the core values of caregiving and to receive care. Thus, digital transformation most likely will transform conditions for care receivers and working conditions for care workers. New work processes will evolve, which in turn produce new meanings of home help service work and caregiving. IMPLICATIONS FOR REHABILITATION Digitalization and the use of new digital technologies imply changes in care value creation. New digital activities deviate from classic caregiving, which in turn can offer opportunities to expand and enrich the experience of receiving care but it can also have negative effects on the received care if incorrectly employed. Digitalization must be regarded as an evolutionary process, in which mistakes and failures are allowed and corrected. Long-term strategies, infrastructure, clear goals and commitments are key for successful digitalization of eldercare.

What happens when seniors participate in new eHealth schemes?

This article adds empirical depth to our understanding of seniors' involvement in the making of eHealth systems. Multi-sited interviews and observations were conducted at seniors' homes before an eHealth system was installed, during the home trials and post-removal of the system. Our findings indicate that although the senior participants chose to participate in the home trials, the choice itself was configured by the stigmatization of seniors as technophobes, fear of "falling behind" and the association of technology with youth, the future and being up-to-date. Being a participant in home trials of an eHealth system became an identity of its own, representing a forward thinking and contemporary person who embraced changes and new technology. Implications for Rehabilitation This article highlights the importance of understanding the participants' drive to participate in field trials and the impact this motivation has on how, during field trials, they perceive using an eHealth system and its perceived usefulness. When studying eHealth systems "in the making at senior" participants' homes, the seniors become part of the research team. The senior participants' learning and knowledge transfer evolves from the dialogue with the research team. For equal participation and power there is a need for ethical, mutual and equal power-relations in the research team (between researchers from different paradigms such as engineers and sociologists) as well as between the researchers' and the participants'.