title: Implementing solutions to improve and expand telehealth adoption: participatory action research in four community healthcare settings.
abstract: BACKGROUND
  Adoption of telehealth has been slower than anticipated, and little is known about the service improvements that help to embed telehealth into routine practice or the role of frontline staff in improving adoption. This paper reports on participatory action research carried out in four community health settings using telehealth for patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure.
  
  
  METHODS
  To inform the action research, in-depth case studies of each telehealth service were conducted (May 2012-June 2013). Each service was then supported by researchers through two cycles of action research to implement changes to increase adoption of telehealth, completed over a seven month period (July 2013-April 2014). The action research was studied via observation of multi-stakeholder workshops, analysis of implementation plans, and focus groups.
  
  
  RESULTS
  Action research participants included 57 staff and one patient, with between eight and 20 participants per site. The case study findings were identified as a key source of information for planning change, with sites addressing common challenges identified through this work. For example, refining referral criteria; standardizing how and when patients are monitored; improving data sharing; and establishing evaluation processes. Sites also focused on raising awareness of telehealth to increase adoption in other clinical teams and to help secure future financial investment for telehealth, which was required because of short-term funding arrangements. Specific solutions varied due to local infrastructures, resources, and opinion, as well as previous service developments. Local telehealth champions played an important role in engaging multiple stakeholders in the study.
  
  
  CONCLUSIONS
  Action research enabled services to make planned changes to telehealth and share learning across multiple stakeholders about how and when to use telehealth. However, adoption was impeded by continual changes affecting telehealth and wider service provision, which also hindered implementation efforts and affected motivation of staff to engage with the action research, particularly where local decision-makers were not engaged in the study. Wider technological barriers also limited the potential for change, as did uncertainties about goals for telehealth investment, thereby making it difficult to identify outcomes for demonstrating the added value over existing practice.
authors.affiliation: Department of Health Sciences, University of York, Area 4, 2nd Floor, ARRC Building, Heslington, York, YO10 5DD, UK. jo.taylor@york.ac.uk.|School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK. jo.taylor@york.ac.uk.
authors.forename: Johanna
authors.initials: J
authors.lastname: Taylor
authors.affiliation: School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK. e.coates@sheffield.ac.uk.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Coates
authors.affiliation: Department of Sociological Studies, University of Sheffield, Elmfield, Northumberland Road, Sheffield, S10 2TU, UK. b.wessels@sheffield.ac.uk.
authors.forename: Bridgette
authors.initials: B
authors.lastname: Wessels
authors.affiliation: School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK. g.a.mountain@sheffield.ac.uk.
authors.forename: Gail
authors.initials: G
authors.lastname: Mountain
authors.affiliation: School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK. mark.hawley@sheffield.ac.uk.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Hawley
mesh_terms: D003153:Community Health Services; D055812:Community-Based Participatory Research; D004059:Diffusion of Innovation; D006302:Health Services Research; D006801:Humans; D033181:Information Dissemination; D007858:Learning; D036301:Qualitative Research; D017216:Telemedicine / Q000706:statistics & numerical data*