Patient-Centred, Technology-Based Interventions for High Treatment Burden: An Overview of the State of the Art.

This study provides an overview of recent efforts to develop technology-based interventions for patients with high treatment burden. Adoption of a technological intervention for high treatment burden will depend on a range of factors, including: the reliability and accessibility of the technology, patient factors including age, socio-economic factors, technology literacy, overall health status and personal priorities - as well as the perceived benefits provided by the technology intervention, from the perspectives of both patients and clinicians.

Evaluation of remote digital postoperative wound monitoring in routine surgical practice.

Remote digital postoperative wound monitoring provides an opportunity to strengthen postoperative community care and minimise the burden of surgical-site infection (SSI). This study aimed to pilot a remote digital postoperative wound monitoring service and evaluate the readiness for implementation in routine clinical practice. This was a single-arm pilot implementational study of remote digital postoperative wound monitoring across two tertiary care hospitals in the UK (IDEAL stage 2b, clinicaltrials.gov: NCT05069103). Adults undergoing abdominal surgery were recruited and received a smartphone-delivered wound assessment tool for 30-days postoperatively. Patients received 30-day postoperative follow-up, including the Telehealth Usability Questionnaire (TUQ). A thematic mixed-methods approach was used, according to the WHO framework for monitoring and evaluating digital health interventions. 200 patients were enroled, of whom 115 (57.5%) underwent emergency surgical procedures. Overall, the 30-day SSI rate was 16.5% (n = 33/200), with 72.7% (n = 24) diagnosed post-discharge. Usage of the intervention was 83.0% (n = 166/200), with subsequently 74.1% (n = 123/166) TUQ completion. There were no issues reported with feasibility of the technology, with the reliability (3.87, 95% CI: 3.73-4.00) and quality of the interface rated highly (4.18, 95%: 4.06-4.30). Patient acceptance was similarly high with regards to ease of use (4.51, 95% CI: 4.41-4.62), satisfaction (4.27, 95% CI: 4.13-4.41), and usefulness (4.07, 95% CI: 3.92-4.23). Despite the desire for more frequent and personalised interactions, the majority viewed the intervention as providing meaningful benefit over routine postoperative care. Remote digital postoperative wound monitoring successfully demonstrated readiness for implementation with regards to the technology, usability, and healthcare process improvement.

Dynamic Prediction of Patient Outcomes in the Intensive Care Unit: A Scoping Review of the State-of-the-Art.

INTRODUCTION: Intensive care units (ICUs) are high-pressure, complex, technology-intensive medical environments where patient physiological data are generated continuously. Due to the complexity of interpreting multiple signals at speed, there are substantial opportunities and significant potential benefits in providing ICU staff with additional decision support and predictive modeling tools that can support and aid decision-making in real-time.This scoping review aims to synthesize the state-of-the-art dynamic prediction models of patient outcomes developed for use in the ICU. We define "dynamic" models as those where predictions are regularly computed and updated over time in response to updated physiological signals. METHODS: Studies describing the development of predictive models for use in the ICU were searched, using PubMed. The studies were screened as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and the data regarding predicted outcomes, methods used to develop the predictive models, preprocessing the data and dealing with missing values, and performance measures were extracted and analyzed. RESULTS: A total of n = 36 studies were included for synthesis in our review. The included studies focused on the prediction of various outcomes, including mortality (n = 17), sepsis-related complications (n = 12), cardiovascular complications (n = 5), and other complications (respiratory, renal complications, and bleeding, n = 5). The most common classification methods include logistic regression, random forest, support vector machine, and neural networks. CONCLUSION: The included studies demonstrated that there is a strong interest in developing dynamic prediction models for various ICU patient outcomes. Most models reported focus on mortality. As such, the development of further models focusing on a range of other serious and well-defined complications-such as acute kidney injury-would be beneficial. Furthermore, studies should improve the reporting of key aspects of model development challenges.

Readiness for implementation of novel digital health interventions for postoperative monitoring: a systematic review and clinical innovation network analysis.

An increasing number of digital health interventions (DHIs) for remote postoperative monitoring have been developed and evaluated. This systematic review identifies DHIs for postoperative monitoring and evaluates their readiness for implementation into routine health care. Studies were defined according to idea, development, exploration, assessment, and long-term follow-up (IDEAL) stages of innovation. A novel clinical innovation network analysis used coauthorship and citations to examine collaboration and progression within the field. 126 DHIs were identified, with 101 (80%) being early stage innovations (IDEAL stage 1 and 2a). None of the DHIs identified had large-scale routine implementation. There is little evidence of collaboration, and there are clear omissions in the evaluation of feasibility, accessibility, and the health-care impact. Use of DHIs for postoperative monitoring remains at an early stage of innovation, with promising but generally low-quality supporting evidence. Comprehensive evaluation within high-quality, large-scale trials and real-world data are required to definitively establish readiness for routine implementation.

Validation of a vascular access specific quality of life measure (VASQoL).

BACKGROUND: A self-administered 11 item vascular access specific quality of life measure (VASQoL) was previously derived from detailed qualitative interviews with adult patients with kidney failure who have experienced vascular access using the Capabilities Approach as a theoretical base. This study reports the psychometric validation of the VASQoL measure including its reliability, content validity and responsiveness to change. METHODS: Cognitive interviews were conducted with 23 adult patients with kidney failure after completion of the VASQoL measure. Focus group discussion with a vascular access professional multidisciplinary team was undertaken (n = 8) and subsequently a further 101 adult kidney failure patients with vascular access (TCVC, AVF or AVG) completed the digital VASQoL measure, EQ-5D and SF-36 questionnaires in a longitudinal study with prospectively recorded vascular access events. RESULTS: Transcript analysis of cognitive interviews after VASQoL completion indicated that the content was comprehensive and well understood by participants. Assessment of Internal reliability for the VASQoL measure was high (Cronbach's alpha 0.858). Test-retest reliability of the overall VASQoL measure was high (intra class correlation coefficient 0.916). In those patients who experienced a vascular access event, significant differences were observed in paired analysis of the VASQoL physical domain questions and vascular access function domain questions and in the EQ-5D usual activities, pain and anxiety domains. In those with no vascular access event, variation was observed in longitudinal analysis in VASQoL questions relating to worry about VA function and capability domains, whilst no variation was observed in the EQ5D measure. CONCLUSION: The VASQoL measure has good internal consistency, test-retest reliability, convergent validity and responsiveness to change for clinically relevant vascular access outcomes. This provides a validated, vascular access specific quality of life measure that can be used in future trials of vascular access, evaluation of new technologies and routine use as a patient reported outcome measure (PROM).

Definition and Classification of Postoperative Complications After Cardiac Surgery: Pilot Delphi Study.

BACKGROUND: Postoperative complications following cardiac surgery are common and represent a serious burden to health services and society. However, there is a lack of consensus among experts on what events should be considered as a "complication" and how to assess their severity. OBJECTIVE: This study aimed to consult domain experts to pilot the development of a definition and classification system for complications following cardiac surgery with the goal to allow the progression of standardized clinical processes and systems in cardiac surgery. METHODS: We conducted a Delphi study, which is a well-established method to reach expert consensus on complex topics. We sent 2 rounds of surveys to domain experts, including cardiac surgeons and anesthetists, to define and classify postoperative complications following cardiac surgery. The responses to open-ended questions were analyzed using a thematic analysis framework. RESULTS: In total, 71 and 37 experts' opinions were included in the analysis in Round 1 and Round 2 of the study, respectively. Cardiac anesthetists and cardiac critical care specialists took part in the study. Cardiac surgeons did not participate. Experts agreed that a classification for postoperative complications for cardiac surgery is useful, and consensus was reached for the generic definition of a postoperative complication in cardiac surgery. Consensus was also reached on classification of complications according to the following 4 levels: "Mild," "Moderate," "Severe," and "Death." Consensus was also reached on definitions for "Mild" and "Severe" categories of complications. CONCLUSIONS: Domain experts agreed on the definition and classification of complications in cardiac surgery for "Mild" and "Severe" complications. The standardization of complication identification, recording, and reporting in cardiac surgery should help the development of quality benchmarks, clinical audit, care quality assessment, resource planning, risk management, communication, and research.

Patients' and Clinicians' Perspectives on the Acceptability of Completing Digital Quality of Life Questionnaires During Routine Haemodialysis Clinics: A Mixed-Methods Study.

Advanced chronic kidney disease is a serious and common medical condition with significant treatment choices incurring varying high treatment burdens. Better understanding on how to best collect quality of life (QoL) in this unique situation may help guide critical decisions. This study investigates the acceptability of digital QoL questionnaires completed during routine haemodialysis sessions. Qualitative data was collected from patient (n=23) and clinical researcher (n=2) interviews alongside analysis of data from questionnaires completed by patients (n=101) during a 6-week validation study. Interviews refined the content and format of digital QoL questionnaires and provided novel insights regarding how patients assessed and completed QoL questions. This study suggests collecting QoL data using digital tablet technology during routine haemodialysis clinics is both feasible and acceptable to patients and has provided novel insights that are not routinely available with traditional methods.

Alternative and Augmentative Communication Technologies for Supporting Adults With Mild Intellectual Disabilities During Clinical Consultations: Scoping Review.

BACKGROUND: People with intellectual disabilities (IDs) face significant communication barriers when accessing health care services; they find it difficult to identify and describe conditions clearly enough to support practitioners in making an accurate diagnosis. In addition, medical professionals generally have little knowledge and understanding of the needs of people with ID, which may result in the use of consultation techniques that do not cater to their patients' skills. OBJECTIVE: This review aims to identify and synthesize the literature on alternative and augmentative communication technologies that are used to support adults with mild ID during the exchange of information with medical practitioners. METHODS: We performed a scoping review of studies published in English that describe the technologies that are used to promote communication with patients with mild ID during medical consultations. The databases searched were PubMed, ACM Digital Library, and Google Scholar. A qualitative framework-based approach was used to synthesize the data and discern key recurring themes across the identified literature. RESULTS: Of the 1557 articles screened, 15 (0.96%) met our inclusion criteria. The bulk of the communication aids used focused on low-tech solutions, including patient passports, note-based prompts, Talking Mats, health diaries, and easy-read information sheets. Their influence on current practice ranged from advancing medical professionals' knowledge of the health and communication needs of people with ID to increasing interagency collaboration, patient advocacy skills, and health promotion activities. The major barriers to the implementation of low-tech aids were a lack of portability and increased maintenance efforts. Only 3 studies explored the use of mobile apps to promote communication. Their findings indicated that high-tech solutions offer greater customization with regard to the accessibility and health care needs of people with ID. CONCLUSIONS: Alternative and augmentative communication technologies have the potential to increase the quality of care provided to patients with mild ID; however, little work has been carried out in this area. Greater emphasis must be placed on (high-tech) two-way communication aids that empower patients to become involved in decisions regarding their care. Quantitative evaluation methods should be used to discern the true benefits of such aids, and researchers should describe their study protocols in depth to promote replication and generalizability.

Characteristics and Hospital Activity of Elderly Patients Receiving Admission Avoidance Home Visits: A Population-Level Record Linkage Study.

As pressures on healthcare systems increase, due to an ageing population, hospital admission avoidance interventions have been emphasised. These interventions can be difficult to objectively evaluate due to non-randomised roll-out, requiring observational methods with carefully selected control groups. This study aims to identify the defining characteristics of elderly patients receiving admission avoidance home visits. We conducted a record linkage study using routinely collected data to compare characteristics and outcomes of the general elderly population and a subset of high-risk patients. Intervention patients were found to have significantly different demographics and admission rates compared to the general population, having four times higher admission rates at baseline. However, they share similarities with high-risk patients, particularly in that after a period of increased admissions, both groups experienced a reduction in the following year. Identifying defining characteristics of the target intervention population can guide the careful selection of a control group for evaluation.

Experts Views on the Use of Mobile Devices to Support Patients with Mild Learning Disabilities During Clinical Consultations.

Due to several factors including time and budget constraints, General Practitioners (GPs) are often under-trained on the communication needs of patients with learning disabilities (LDs). As such, they may find it difficult to extract accurate information from these patients. Digital technologies have the potential to alleviate communication barriers, yet their use in this context remains vastly unexplored. Hence, we conducted 2 focus groups with 12 experts in LDs to investigate how tablet applications may be used to promote the information exchange process between GPs and patients with mild LDs. The experts identified an initial set of design criteria for the future implementation of these technologies and were enthusiastic about the potential impact they may have on primary care. In addition, they also discussed a potential model for extracting medical information from this population, which focused on breaking the overall consultation down into smaller, less cognitively challenging segments.

Design Requirements for a Digital Aid to Support Adults With Mild Learning Disabilities During Clinical Consultations: Qualitative Study With Experts.

BACKGROUND: Adults with mild learning disabilities (MLDs) face a plethora of obstacles when accessing effective health care. Central to many of these barriers is communication, with medical practitioners often remaining untrained on how to interact with patients who have learning disabilities (LDs). To date, research on how to promote this communication has largely centered on the development of low-tech aids. OBJECTIVE: The objective of this study was to assess the feasibility of utilizing tablet technologies to promote communication between general practitioners and patients with MLDs. We achieved this by identifying a set of design requirements from experts in LDs. METHODS: A set of design guidelines was formed during a 2-phase process. Phase 1 involved conducting a series of requirements-gathering interviews with 10 experts in LDs-the protocol of which emerged from the results of a separate scoping review. The interviews were subjected to a framework analysis to discern the key requirements discussed by the experts, and these were embedded within a technology probe. In phase 2, this probe was presented to a subset (n=4) of the experts during a round of usability studies, and the feedback received was used to update the requirements identified in phase 1. RESULTS: An initial set of design requirements has been produced that may assist in the development of clinical Alternative and Augmentative Communication technologies for adults with MLDs. Factors that must be considered range from the health, physical and cognitive needs of stakeholders, to the more individual needs of users. CONCLUSIONS: The experts involved in the study were optimistic about the proposed app. They believe that such technologies can help to alleviate time constraints and promote communication by presenting information in a form understood by both practitioners and patients.

Valuing Mobile Health: An Open-Ended Contingent Valuation Survey of a National Digital Health Program.

BACKGROUND: Changing population demographics and technology developments have resulted in growing interest in the potential of consumer-facing digital health. In the United Kingdom, a £37 million (US $49 million) national digital health program delivering assisted living lifestyles at scale (dallas) aimed to deploy such technologies at scale. However, little is known about how consumers value such digital health opportunities. OBJECTIVE: This study explored consumers' perspectives on the potential value of digital health technologies, particularly mobile health (mHealth), to promote well-being by examining their willingness-to-pay (WTP) for such health solutions. METHODS: A contingent valuation study involving a UK-wide survey that asked participants to report open-ended absolute and marginal WTP or willingness-to-accept for the gain or loss of a hypothetical mHealth app, Healthy Connections. RESULTS: A UK-representative cohort (n=1697) and a dallas-like (representative of dallas intervention communities) cohort (n=305) were surveyed. Positive absolute and marginal WTP valuations of the app were identified across both cohorts (absolute WTP: UK-representative cohort £196 or US $258 and dallas-like cohort £162 or US $214; marginal WTP: UK-representative cohort £160 or US $211 and dallas-like cohort £151 or US $199). Among both cohorts, there was a high prevalence of zeros for both the absolute WTP (UK-representative cohort: 467/1697, 27.52% and dallas-like cohort: 95/305, 31.15%) and marginal WTP (UK-representative cohort: 487/1697, 28.70% and dallas-like cohort: 99/305, 32.5%). In both cohorts, better general health, previous amount spent on health apps (UK-representative cohort 0.64, 95% CI 0.27 to 1.01; dallas-like cohort: 1.27, 95% CI 0.32 to 2.23), and age had a significant (P>.00) association with WTP (UK-representative cohort: -0.1, 95% CI -0.02 to -0.01; dallas-like cohort: -0.02, 95% CI -0.03 to -0.01), with younger participants willing to pay more for the app. In the UK-representative cohort, as expected, higher WTP was positively associated with income up to £30,000 or US $39,642 (0.21, 95% CI 0.14 to 0.4) and increased spending on existing phone and internet services (0.52, 95% CI 0.30 to 0.74). The amount spent on existing health apps was shown to be a positive indicator of WTP across cohorts, although the effect was marginal (UK-representative cohort 0.01, 95% CI 0.01 to 0.01; dallas-like cohort 0.01, 95% CI 0.01 to 0.02). CONCLUSIONS: This study demonstrates that consumers value mHealth solutions that promote well-being, social connectivity, and health care control, but it is not universally embraced. For mHealth to achieve its potential, apps need to be tailored to user accessibility and health needs, and more understanding of what hinders frequent users of digital technologies and those with long-term conditions is required. This novel application of WTP in a digital health context demonstrates an economic argument for investing in upskilling the population to promote access and expedite uptake and utilization of such digital health and well-being apps.

Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the United Kingdom.

BACKGROUND: Digital health has the potential to support care delivery for chronic illness. Despite positive evidence from localized implementations, new technologies have proven slow to become accepted, integrated, and routinized at scale. OBJECTIVE: The aim of our study was to examine barriers and facilitators to implementation of digital health at scale through the evaluation of a £37m national digital health program: ?Delivering Assisted Living Lifestyles at Scale" (dallas) from 2012-2015. METHODS: The study was a longitudinal qualitative, multi-stakeholder, implementation study. The methods included interviews (n=125) with key implementers, focus groups with consumers and patients (n=7), project meetings (n=12), field work or observation in the communities (n=16), health professional survey responses (n=48), and cross program documentary evidence on implementation (n=215). We used a sociological theory called normalization process theory (NPT) and a longitudinal (3 years) qualitative framework analysis approach. This work did not study a single intervention or population. Instead, we evaluated the processes (of designing and delivering digital health), and our outcomes were the identified barriers and facilitators to delivering and mainstreaming services and products within the mixed sector digital health ecosystem. RESULTS: We identified three main levels of issues influencing readiness for digital health: macro (market, infrastructure, policy), meso (organizational), and micro (professional or public). Factors hindering implementation included: lack of information technology (IT) infrastructure, uncertainty around information governance, lack of incentives to prioritize interoperability, lack of precedence on accountability within the commercial sector, and a market perceived as difficult to navigate. Factors enabling implementation were: clinical endorsement, champions who promoted digital health, and public and professional willingness. CONCLUSIONS: Although there is receptiveness to digital health, barriers to mainstreaming remain. Our findings suggest greater investment in national and local infrastructure, implementation of guidelines for the safe and transparent use and assessment of digital health, incentivization of interoperability, and investment in upskilling of professionals and the public would help support the normalization of digital health. These findings will enable researchers, health care practitioners, and policy makers to understand the current landscape and the actions required in order to prepare the market and accelerate uptake, and use of digital health and wellness services in context and at scale.

Factors Affecting Participation in the eRedBook: A Personal Child Health Record.

A personal child health record called the eRedBook was recently piloted in the United Kingdom. A qualitative exploratory case study was used to examine how public health nurses engaged or recruited parents and what factors hindered participation. Interviews and focus groups were conducted with those implementing the eRedBook and those taking part in the pilot study. A range of project documentation was also reviewed. Thematic analysis using the framework approach was applied to draw out themes. Numerous socio-technical factors such as the usability of the software, concerns over data protection and costs, poor digital literacy skills and a lack of Internet connectivity emerged. These barriers need to be addressed before the eRedBook is implemented nationwide.

Barriers to Co-Designing Mobile Technology with Persons with Dementia and Their Carers.

Mobile applications can be used to help manage different aspects of long-term illnesses but many are not designed to meet the specific needs of people with dementia or their carers. This case study explores the barriers experienced when co-producing a memory and reminiscence app. A focus group and interviews were conducted with patient/carer dyads, an occupational therapist, project manager and software engineer involved in the design of the app. Data was analysed thematically using the framework approach. Several limitations such as poor technical knowledge and skills, negative attitudes and inaccurate perceptions of people with dementia slowed down or changed how the mobile app was developed. Compromises also had to be made over the final design of the app. More research to explore how mobile apps are co-designed with patients is needed.

Combining transcranial ultrasound with intelligent communication methods to enhance the remote assessment and management of stroke patients: Framework for a technology demonstrator.

With over 150,000 strokes in the United Kingdom every year, and more than 1 million living survivors, stroke is the third most common cause of death and the leading cause of severe physical disability among adults. A major challenge in administering timely treatment is determining whether the stroke is due to vascular blockage (ischaemic) or haemorrhage. For patients with ischaemic stroke, thrombolysis (i.e. pharmacological 'clot-busting') can improve outcomes when delivered swiftly after onset, and current National Health Service Quality Improvement Scotland guidelines are for thrombolytic therapy to be provided to at least 80 per cent of eligible patients within 60 min of arrival at hospital. Thrombolysis in haemorrhagic stroke could severely compound the brain damage, so administration of thrombolytic therapy currently requires near-immediate care in a hospital, rapid consultation with a physician and access to imaging services (X-ray computed tomography or magnetic resonance imaging) and intensive care services. This is near impossible in remote and rural areas, and stroke mortality rates in Scotland are 50 per cent higher than in London. We here describe our current project developing a technology demonstrator with ultrasound imaging linked to an intelligent, multi-channel communication device - connecting to multiple 2G/3G/4G networks and/or satellites - in order to stream live ultrasound images, video and two-way audio streams to hospital-based specialists who can guide and advise ambulance clinicians regarding diagnosis. With portable ultrasound machines located in ambulances or general practices, use of such technology is not confined to stroke, although this is our current focus. Ultrasound assessment is useful in many other immediate care situations, suggesting potential wider applicability for this remote support system. Although our research programme is driven by rural need, the ideas are potentially applicable to urban areas where access to imaging and definitive treatment can be restricted by a range of operational factors.

Implementation factors affecting the large-scale deployment of digital health and well-being technologies: A qualitative study of the initial phases of the 'Living-It-Up' programme.

Little is known about the factors which facilitate or impede the large-scale deployment of health and well-being consumer technologies. The Living-It-Up project is a large-scale digital intervention led by NHS 24, aiming to transform health and well-being services delivery throughout Scotland. We conducted a qualitative study of the factors affecting the implementation and deployment of the Living-It-Up services. We collected a range of data during the initial phase of deployment, including semi-structured interviews (N = 6); participant observation sessions (N = 5) and meetings with key stakeholders (N = 3). We used the Normalisation Process Theory as an explanatory framework to interpret the social processes at play during the initial phases of deployment.Initial findings illustrate that it is clear - and perhaps not surprising - that the size and diversity of the Living-It-Up consortium made implementation processes more complex within a 'multi-stakeholder' environment. To overcome these barriers, there is a need to clearly define roles, tasks and responsibilities among the consortium partners. Furthermore, varying levels of expectations and requirements, as well as diverse cultures and ways of working, must be effectively managed. Factors which facilitated implementation included extensive stakeholder engagement, such as co-design activities, which can contribute to an increased 'buy-in' from users in the long term. An important lesson from the Living-It-Up initiative is that attempting to co-design innovative digital services, but at the same time, recruiting large numbers of users is likely to generate conflicting implementation priorities which hinder - or at least substantially slow down - the effective rollout of services at scale.The deployment of Living-It-Up services is ongoing, but our results to date suggest that - in order to be successful - the roll-out of digital health and well-being technologies at scale requires a delicate and pragmatic trade-off between co-design activities, the development of innovative services and the efforts allocated to widespread marketing and recruitment initiatives.

Delivering digital health and well-being at scale: lessons learned during the implementation of the dallas program in the United Kingdom.

OBJECTIVE: To identify implementation lessons from the United Kingdom Delivering Assisted Living Lifestyles at Scale (dallas) program-a large-scale, national technology program that aims to deliver a broad range of digital services and products to the public to promote health and well-being. MATERIALS AND METHODS: Prospective, longitudinal qualitative research study investigating implementation processes. Qualitative data collected includes semi-structured e-Health Implementation Toolkit-led interviews at baseline/mid-point (n = 38), quarterly evaluation, quarterly technical and barrier and solutions reports, observational logs, quarterly evaluation alignment interviews with project leads, observational data collected during meetings, and ethnographic data from dallas events (n > 200 distinct pieces of qualitative data). Data analysis was guided by Normalization Process Theory, a sociological theory that aids conceptualization of implementation issues in complex healthcare settings. RESULTS: Five key challenges were identified: 1) The challenge of establishing and maintaining large heterogeneous, multi-agency partnerships to deliver new models of healthcare; 2) The need for resilience in the face of barriers and set-backs including the backdrop of continually changing external environments; 3) The inherent tension between embracing innovative co-design and achieving delivery at pace and at scale; 4) The effects of branding and marketing issues in consumer healthcare settings; and 5) The challenge of interoperability and information governance, when commercial proprietary models are dominant. CONCLUSIONS: The magnitude and ambition of the dallas program provides a unique opportunity to investigate the macro level implementation challenges faced when designing and delivering digital health and wellness services at scale. Flexibility, adaptability, and resilience are key implementation facilitators when shifting to new digitally enabled models of care.

Implementing a National Scottish Digital Health & Wellbeing Service at Scale: A Qualitative Study of Stakeholders' Views.

Digital technologies are being used as part of international efforts to revolutionize healthcare in order to meet increasing demands such as the rising burden of chronic disease and ageing populations. In Scotland there is a government push towards a national service (Living It Up) as a single point of reference where citizens can access information, products and services to support their health and wellbeing. The aim of the study is to examine implementation issues including the challenges or facilitators which can help to sustain this intervention. We gathered data in three ways: a) participant observation to gain an understanding of LiU (N=16); b) in-depth interviews (N=21) with stakeholders involved in the process; and c) analysis of documentary evidence about the progress of the implementation (N=45). Barriers included the need to "work at risk" due to delays in financing, inadequate infrastructure and skill-set deficiencies, whilst facilitators included trusted relationships, champions and a push towards normalisation. The findings suggest that a Scottish ehealth service is achievable but identifies key considerations for future large scale initiatives.

Engaging in large-scale digital health technologies and services. What factors hinder recruitment?

Implementing consumer oriented digital health products and services at scale is challenging and a range of barriers to reaching and recruiting users to these types of solutions can be encountered. This paper describes the experience of implementers with the rollout of the Delivering Assisted Living Lifestyles at Scale (dallas) programme. The findings are based on qualitative analysis of baseline and midpoint interviews and project documentation. Eight main themes emerged as key factors which hindered participation. These include how the dallas programme was designed and operationalised, constraints imposed by partnerships, technology, branding, and recruitment strategies, as well as challenges with the development cycle and organisational culture.