Health app policy: international comparison of nine countries' approaches.

An abundant and growing supply of digital health applications (apps) exists in the commercial tech-sector, which can be bewildering for clinicians, patients, and payers. A growing challenge for the health care system is therefore to facilitate the identification of safe and effective apps for health care practitioners and patients to generate the most health benefit as well as guide payer coverage decisions. Nearly all developed countries are attempting to define policy frameworks to improve decision-making, patient care, and health outcomes in this context. This study compares the national policy approaches currently in development/use for health apps in nine countries. We used secondary data, combined with a detailed review of policy and regulatory documents, and interviews with key individuals and experts in the field of digital health policy to collect data about implemented and planned policies and initiatives. We found that most approaches aim for centralized pipelines for health app approvals, although some countries are adding decentralized elements. While the countries studied are taking diverse paths, there is nevertheless broad, international convergence in terms of requirements in the areas of transparency, health content, interoperability, and privacy and security. The sheer number of apps on the market in most countries represents a challenge for clinicians and patients. Our analyses of the relevant policies identified challenges in areas such as reimbursement, safety, and privacy and suggest that more regulatory work is needed in the areas of operationalization, implementation and international transferability of approvals. Cross-national efforts are needed around regulation and for countries to realize the benefits of these technologies.

Lessons of the month 1: Shoshin beriberi: A case report of fulminant cardiovascular collapse, intractable hyperlactatemia and deteriorating consciousness.

Shoshin beriberi is a fulminant variant of thiamine deficiency, often presenting with severe lactic acidosis and cardiogenic shock. Due to the sparsity of this condition, delays in diagnosis can lead to fatality. However, rapid reversal of symptoms can be easily achieved through intravenous thiamine replacement.In this case report, we discuss a 57-year-old woman, who was previously fit and well, who presented to the emergency department with a 3-day history of extreme malaise, breathlessness and abdominal pain, with marked hypotension and tachycardia requiring vasopressor support and a severe rising lactic acidosis. Upon further questioning, a history of alcohol excess was noted. Rapid reversal of the marked haemodynamic instability was achieved upon administration of intravenous thiamine and the patient was discharged within 48 hours.

[Leaders as intermediates between economic incentive models and professional motivation]. / Ledaren ­ viktig länk mellan styrmodell och medarbetare - Olika strategier för att förena ekonomiska krav med vårdpersonalens drivkraft att ge god vård.

The application of economic incentives to providers in health care governance is debated. Advocates argue that it drives efficiency and improvement, opponents claim that it leads to unintended consequences for patients and professionals. Research shows that incentives can increase well-defined activities and targets, but there is a lack of substantial evidence that applications in health care lead to desired outcomes. The motivational literature acknowledges internal sources of motivation as important determinants of behavior, and the literature about professions suggests that professional values of serving patient needs is a key motivator. The management literature identifies the important role of leaders in aligning external demands and rewards to staff preferences, using their own management and leadership skills. Findings in health services research confirm the vital role of leaders for successful implementation and improvement work. In sum, internal motivators and the role of leaders are important to acknowledge also when understanding how economic governance models are put into practice.Our recently published qualitative case study provides empirical examples of how clinical leaders function as intermediaries between a local care choice model, including financial incentives, and the motivation of staff. The strategies deployed by the leaders aimed to align the economic logics of the model to the professional focus on increasing patient value. The main conclusion from these empirical examples, as well as previous research, is that health care managers play a key role in aligning economic incentive models with professional values and in translating such models in to feasible tasks related to the provision of high quality care.

The performativity of numbers in illness management: The case of Swedish Rheumatology.

While there is a proliferation of numerical data in healthcare, little attention has been paid to the role of numbers in constituting the healthcare reality they are intended to depict. This study explores the performativity of numbers in the microlevel management of rheumatoid disease. We draw on a study of patients' and physicians' use of the numbers in the Swedish Rheumatology Quality Registry, conducted between 2009 and 2014. We show how the numbers performed by constructing the disease across time, and by framing action. The numerical performances influenced patients and physicians in different ways, challenging the former to quantify embodied disease and the latter to subsume the disease into one of many possible trajectory standards. Based on our findings, we provide a model of the dynamic performativity of numbers in the on-going management of illness. The model conceptualises how numbers generate new possibilities; by creating tension and alignment they may open up new avenues for communication between patients and physicians.

Persons with rheumatoid arthritis challenge the relevance of the health assessment questionnaire: a qualitative study of patient perception.

BACKGROUND: The Stanford Health Assessment Questionnaire-Disability Index (HAQ) is widely used to measure functional ability in persons with Rheumatoid Arthritis (RA). The instrument was developed with limited involvement from persons with RA, and their perception of the instrument has not been studied in depth. The aim of this study was to explore how persons with RA experience the use of the HAQ in care. METHODS: The study used secondary data analysis. Persons with RA participated in semi-structured interviews in previous research projects. Thirty-nine interviews were included based on data fit, and thematic analysis applied. RESULTS: The participants questioned the relevance of the HAQ but nevertheless experienced that the instrument had a profound effect on their understanding of health and how care is delivered. The analysis resulted in three themes: Problems with individual items, meaning of the summative score, and effects on care and health perceptions. CONCLUSIONS: To make the HAQ relevant to persons with RA, it needs to be revised or to include an option to select items most meaningful to the respondent. To ensure relevance, the HAQ update should preferably be co-created by researchers, clinicians and persons with RA.

Managerial strategies to make incentives meaningful and motivating.

Purpose Policy makers are applying market-inspired competition and financial incentives to drive efficiency in healthcare. However, a lack of knowledge exists about the process whereby incentives are filtered through organizations to influence staff motivation, and the key role of managers is often overlooked. The purpose of this paper is to explore the strategies managers use as intermediaries between financial incentives and the individual motivation of staff. The authors use empirical data from a local case in Swedish specialized care. Design/methodology/approach The authors conducted an exploratory qualitative case study of a patient-choice reform, including financial incentives, in specialized orthopedics in Sweden. In total, 17 interviews were conducted with professionals in managerial positions, representing six healthcare providers. A hypo-deductive, thematic approach was used to analyze the data. Findings The results show that managers applied alignment strategies to make the incentive model motivating for staff. The managers' strategies are characterized by attempts to align external rewards with professional values based on their contextual and practical knowledge. Managers occasionally overruled the financial logic of the model to safeguard patient needs and expressed an interest in having a closer dialogue with policy makers about improvements. Originality/value Externally imposed incentives do not automatically motivate healthcare staff. Managers in healthcare play key roles as intermediaries by aligning external rewards with professional values. Managers' multiple perspectives on healthcare practices and professional culture can also be utilized to improve policy and as a source of knowledge in partnership with policy makers.

The evolution of weak standards: the case of the Swedish rheumatology quality registry.

Research in sociology suggests that the effects of standards are not nearly as straightforward or as homogenising as they first appear. The present study extends these insights by demonstrating how even standards designed simply to collect data can produce extensive and unanticipated effects in medical fields as their uses evolve across actors and contexts. We draw on an embedded case study exploring the multifaceted consequences of the use of a practice-driven voluntary documentation standard: the Swedish rheumatology quality registry from 1995-2014. Data collection included document analysis; 100 interviews with specialists, patients and stakeholders in the field; fieldwork; and observations of physician-patient encounters. Our findings show that the scope and influence of the registry increased over time, and that this standard and its evolution contributed to changes in rheumatologist clinical practice, research practice, and governmental practice. These findings suggest that even initially 'weak', voluntary forms of standardisation can generate far-reaching and unpredictable consequences for the performance and delivery of care as well as for the development of a medical field. Future work about how standards can contribute both to uniformity and diversity is warranted.

Value-Based Health Care for Chronic Care: Aligning Outcomes Measurement with the Patient Perspective.

BACKGROUND: Value-based health care is increasingly used for developing health care services by relating patient outcomes to costs. A hierarchical value scorecard for creating outcome measurements has been suggested: the 3-tier model. The objective of this study was to test the model against the patient's view of value in a chronic care setting. METHODS: Semistructured interviews with 22 persons with rheumatoid arthritis were conducted, transcribed, and analyzed using qualitative content analysis. Themes were extracted, and the model was critically applied and revised. RESULTS: The study validates existing dimensions in the model but suggests adding information, social health, predictability, and continuity to make it more useful and representative of patients' preferences. CONCLUSION: Although the model aims to focus on outcomes relevant to patients, it lacks dimensions important to individuals with rheumatoid arthritis. The data illustrate difficulties in finding patients' preferred outcomes and imply tactics for arriving at meaningful measurements.

Continuous innovation: developing and using a clinical database with new technology for patient-centred care--the case of the Swedish quality register for arthritis.

OBJECTIVE: We describe and explain the development of a clinical quality database and its use for different clinical, management and patient empowerment purposes. DESIGN: A longitudinal case study covering 1993-2009. SETTING: Rheumatology departments in Swedish hospitals. PARTICIPANTS: Those involved in developing the clinical database and its applications and a limited number of users. INTERVENTION(S): Different methods for inputting and storing clinical and patient data and for analysing and presenting the data to providers and patients. MAIN OUTCOME MEASURE(S): Participants' perceptions of the value of different applications and of influences, which helped and hindered the development of the system. RESULTS: Different innovations were introduced at different times continually to increase the ultility of the clinical data and the clinic- and patient coverage of the clinical data system. Limited interview data show postive patient and provider perceptions of the latest application to collect and present data as time trend visual display in the clinical consultation. CONCLUSIONS: A longitudinal perspective revealed how a clinical quality register was developed and how new technologies not imagined in the early 1990s continue to increase the ultility and value of the clinical database. This historical perspective provided limited evidence of impact, but does provide lessons for current strategies for innovation for quality in health care and of the need to consider innovolution processes, rather than discrete innovations, given the rapid pace of change in new technologies. More evidence is needed of the impact of such registers, and of enhancements, on providers and patients and on costs.

Innovation as emergence in healthcare: unpacking change from within.

The contemporary healthcare literature suffers from a disproportionate focus on 'given' externally created innovations, and belief in ordered, planned and well-funded implementation processes. As an alternative, the present paper highlights the potential of emergent change processes, using the continuous invention and re-invention of the Rheumatology Quality Registry in Sweden as an example. This 19 year long process, which is still ongoing, does not exhibit the sequential steps that are allegedly determinants of success in the innovation and implementation literature. Yet, it has produced system-wide improvements. We draw on more than 100 informal and formal meetings with practitioners involved in the process studied, observations, documentation analysis and quantitative registry-data. A total of 67 interviews with registry-users and external stakeholders were also performed. The dissipative structures model (complexity theory) was used to analyze the data. The studied process illustrates an ongoing, practice-driven improvement process, which was sparked by abstract and indirect energies that interacted with more concrete innovations such as new drugs. For example, participants tapped new information technologies, changing perspectives and governmental priorities to challenge current ways of working and introduce new ideas. Ideas were realized and spread through various self-organized processes that involved the re-arrangement of existing resources rather than acquisition of new resources. Taken together, these processes brought Swedish rheumatology to new levels of functioning 1992-2011. An important implication of our work is that incremental and practice-driven change processes can significantly transform care systems in the long run. Policy makers need to acknowledge and foster such ongoing innovation processes at micro-level, rather than focusing exclusively on innovations as externally created 'things' that await 'implementation'.

New e-service development in the homecare sector: beyond implementing a radical technology.

PURPOSE: This paper explores the constituents of and challenges related to the innovation of technology-based services in the long-term homecare sector. METHODS: This research used purposeful extreme case sampling, a mixed methods approach to research that included focus groups and interviews, to learn from the experiences of an innovative telehomecare project. The paper uses a framework that integrates service management; information systems innovation and medical informatics theory. RESULTS: The findings indicate that the claimed and the rather abstract benefits of the technology espoused by information technology vendors were difficult to transform into a service concept. The organization studied is still struggling with conflicts between technological possibilities on the one hand, and the prevailing service delivery systems and user preferences on the other. Decisions about the extent to which the service needs to be reengineered, what non-technology resources are required, what should be the role of the consumer in the new care process and identifying who is actually the primary beneficiary and user of the new service remain. CONCLUSIONS: A comprehensive development model and 'mindfulness' is necessary for radical service innovation in the long-term homecare sector. Creating new services that exploit the capability of radical technical innovations requires organizational development and the use of many non-technology innovations and resources. To understand what combinations of technological and non-technological resources can provide sustainable benefit, all key internal and external stakeholders must be involved from the beginning of the project.

The two facets of electronic care surveillance: an exploration of the views of older people who live with monitoring devices.

Scholars are increasingly questioning the notion that electronic surveillance merely constrains individuals' liberty and privacy. However, illustrations of alternative perspectives are few and there is a need for empirical research exploring the actual experience of surveilled subjects. This study, carried out in Sweden, seeks to offer a nuanced account of how senior citizens experience electronic care surveillance in relation to their privacy. It is based on in-depth interviews with 17 seniors who have participated in a telemonitoring project and who have experience of being continuously activity monitored in their own homes. The findings suggest that senior citizens can perceive electronic care surveillance as freeing and as protecting their privacy, as it enables them to continue living in their own home rather than moving to a nursing home. One individual, however, experienced a privacy violation and the surveillance service was interrupted at her request. This illustrates the importance of built-in possibilities for subjects to exit such services. In general, the study highlights that e-surveillance can be not only constraining but also enabling. Hence, it supports the view of the dual nature of surveillance. The study also illustrates the agency of the surveilled subject, extending the argument that various agents actually participate in the construction of surveillance practices. It analyzes the indirect role and responsibility of the surveilled subject, and thereby questions the traditional roles ascribed to the agents and targets of surveillance.