New Framework to Guide the Evaluation of Technology-Supported Services

Heath and care providers are looking to digital technologies to enhance care provision and fill gaps where resource is limited. There is a very large body of research on their use, brought together in reviews, which among many others, include, establishing effectiveness in behaviour change for smoking cessation and encouraging adherence to ART,[1] demonstrating improved utilisation of maternal and child health services in low- and middle-income countries,[2] and delineating the potential for improvement in access to health care for marginalised groups.[3] Frameworks to guide health and care providers when considering the use of digital technologies are also numerous. Mehl and Labrique’s framework aims to help a low- or middle-income country consider how they can use digital mobile health innovation to help succeed in the ambition to achieving universal health coverage.[4] The framework tells us what is somewhat obvious, but by bringing it together it provides a powerful tool for thinking, planning, and countering pressure from interest groups with other ambitions. The ARCHIE framework developed by Greenhalgh, et al.[5] is a similar tool but for people with the ambition of using telehealth and telecare to improve the daily lives of individuals living with health problems. It sets out principles for people developing, implementing, and supporting telehealth and telecare systems so they are more likely to work. It is a framework that, again, can be used to counter pressure from interest groups more interested in the product than the impact of the product on people and the health and care service. Greenhalgh and team have now produced a further framework that is very timely as it provides us with a tool for thinking through the potential for scale-up and sustainability of health and care technologies.[6]

Greenhalgh, et al. reviewed 28 previously published technology implementation frameworks in order to develop their framework, and use their own studies of digital assistive technologies to test the framework. Like the other frameworks this provides health and care providers with a powerful tool for thinking, planning and resisting. The Domains in the Framework include, among others, the health condition, the technology, the adopter system (staff, patients, carers), the organisation, and the Domain of time – how the technology embeds and is adapted over time. For each Domain in the Framework the question is asked whether it is simple, complicated or complex in relation to scale-up and sustainability of the technology. For example, the nature of the condition: is it well understood and predictable (simple), or poorly understood and unpredictable (complex)? Asking this question for each Domain allows us to avoid the pitfall of thinking something is simple when it is in reality complex. For example, there may be a lot of variability in the health condition between patients, but the technology may have been designed with a simplified textbook notion of the condition in mind. I suggest that even where clinicians are involved in the design of interventions, it is easy for them to forget how often they see patients that are not like the textbook, as they, almost without thinking, deploy their skills to adapt treatment and management to the particular patient. Greenhalgh, et al. cautiously conclude that “it is complexity in multiple domains that poses the greatest challenge to scale-up, spread and sustainability”. They provide examples where unrecognised complexity stops in its tracks the use of a technology.

— Frances Griffiths, Professor of Medicine in Society

References:

  1. Free C, Phillips G, Galli L. The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med. 2013;10:e1001362.
  2. Sondaal SFV, Browne JL, Amoakoh-Coleman M, Borgstein A, Miltenburg AS, Verwijs M, et al. Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review. PLoS One. 2016;11(5):e0154664.
  3. Huxley CJ, Atherton H, Watkins JA, Griffiths F. Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice. Br J Gen Pract. 2015;65(641):e813-21.
  4. Mehl G, Labrique A. Prioritising integrated mHealth strategies for universal health coverage. Science. 2014;345:1284.
  5. Greenhalgh T, Procter R, Wherton J, Sugarhood P, Hinder S, Rouncefield M. What is quality in assisted living technology? The ARCHIE framework for effective telehealth and telecare services. BMC Medicine. 2015;13(1):91.
  6. Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A’Court C, et al. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies. J Med Internet Res. 2017;19(11):e367.
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