Boundaries and e-health implementation in health and social care.

BACKGROUND: The major problem facing health and social care systems globally today is the growing challenge of an elderly population with complex health and social care needs. A longstanding challenge to the provision of high quality, effectively coordinated care for those with complex needs has been the historical separation of health and social care. Access to timely and accurate data about patients and their treatments has the potential to deliver better care at less cost. METHODS: To explore the way in which structural, professional and geographical boundaries have affected e-health implementation in health and social care, through an empirical study of the implementation of an electronic version of Single Shared Assessment (SSA) in Scotland, using three retrospective, qualitative case studies in three different health board locations. RESULTS: Progress in effectively sharing electronic data had been slow and uneven. One cause was the presence of established structural boundaries, which lead to competing priorities, incompatible IT systems and infrastructure, and poor cooperation. A second cause was the presence of established professional boundaries, which affect staffs' understanding and acceptance of data sharing and their information requirements. Geographical boundaries featured but less prominently and contrasting perspectives were found with regard to issues such as co-location of health and social care professionals. CONCLUSIONS: To provide holistic care to those with complex health and social care needs, it is essential that we develop integrated approaches to care delivery. Successful integration needs practices such as good project management and governance, ensuring system interoperability, leadership, good training and support, together with clear efforts to improve working relations across professional boundaries and communication of a clear project vision. This study shows that while technological developments make integration possible, long-standing boundaries constitute substantial risks to IT implementations across the health and social care interface which those initiating major changes would do well to consider before committing to the investment.

Exploring public perspectives on e-health: findings from two citizen juries.

BACKGROUND: Interest and investment in e-health continue to grow world-wide, but there remains relatively little engagement with the public on this subject, despite calls for more public involvement in health-care planning. DESIGN: This study used two modified citizen juries to explore barriers and facilitators to e-health implementation and the priorities for future e-health research from the perspective of health service users and lay representatives. Citizen juries bring together a group of people to deliberate over a specific issue. They are given information and invited to 'cross-examine' witnesses during the process. RESULTS: Jurors were very keen for lay views to be included in e-health development and embraced the citizen jury approach. They agreed unanimously that e-health should be developed and thought it was in many ways inevitable. Although there was much enthusiasm for a health-care system which offered e-health as an option, there was as much concern about what it might mean for patients if implemented inappropriately. E-health was preferred as an enhancement rather than substitute for, existing services. Lack of universal access was seen as a potential barrier to implementation but problems such as lack of computer literacy were seen as a temporary issue. Participants emphasized that e-health research needed to demonstrate both clinical and economic benefits. CONCLUSION: There was broad support from the citizen juries for the development of e-health, although participants stressed that e-health should enhance, rather than substitute, face-to-face services. One-day citizen juries proved a practical method of public engagement on this subject.

The influence of context and process when implementing e-health.

BACKGROUND: Investing in computer-based information systems is notoriously risky, since many systems fail to become routinely used as part of everyday working practices, yet there is clear evidence about the management practices which improve the acceptance and integration of such systems. Our aim in this study was to identify to what extent these generic management practices are evident in e-health projects, and to use that knowledge to develop a theoretical model of e-health implementation. This will support the implementation of appropriate e-health systems. METHODS: This study consisted of qualitative semi-structured interviews with managers and health professionals in Scotland, UK. We contacted the Scottish Ethics Committee, who advised that formal application to that body was not necessary for this study. The interview guide aimed to identify the issues which respondents believed had affected the successful implementation of e-health projects. We drew on our research into information systems in other sectors to identify likely themes and questions, which we piloted and revised. Eighteen respondents with experience of e-health projects agreed to be interviewed. These were recorded, transcribed, coded, and then analysed with 'Nvivo' data analysis software. RESULTS: Respondents identified factors in the context of e-health projects which had affected implementation, including clarity of the strategy; supportive structures and cultures; effects on working processes; and how staff perceived the change. The results also identified useful implementation practices such as balancing planning with adaptability; managing participation; and using power effectively. CONCLUSION: The interviews confirmed that the contextual factors that affect implementation of information systems in general also affect implementation of e-health projects. As expected, these take place in an evolving context of strategies, structures, cultures, working processes and people. Respondents also confirmed that those managing such projects seek to change these contexts through observable implementation processes of planning, adaptation, participation and using power. This study confirms that research to support the delivery of appropriate e-health projects can usefully draw on the experience of information systems in other sectors.