title: Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the United Kingdom.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Digital Health and Wellness Group, Computer and Information Sciences, University of Strathclyde, Glasgow, United Kingdom.
authors.forename: Marilyn R
authors.identifier: 0000-0003-3271-2400
authors.initials: MR
authors.lastname: Lennon
authors.affiliation: Digital Health and Wellness Group, Computer and Information Sciences, University of Strathclyde, Glasgow, United Kingdom.
authors.forename: Matt-Mouley
authors.identifier: 0000-0002-1416-751X
authors.initials: MM
authors.lastname: Bouamrane
authors.affiliation: General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Alison M
authors.identifier: 0000-0002-9407-6465
authors.initials: AM
authors.lastname: Devlin
authors.affiliation: School of Health and Social Care, Edinburgh Napier University, Edinburgh, United Kingdom.
authors.forename: Siobhan
authors.identifier: 0000-0001-8579-1718
authors.initials: S
authors.lastname: O'Connor
authors.affiliation: General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Catherine
authors.identifier: 0000-0002-5368-3779
authors.initials: C
authors.lastname: O'Donnell
authors.affiliation: General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Ula
authors.identifier: 0000-0001-9420-7843
authors.initials: U
authors.lastname: Chetty
authors.affiliation: General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Ruth
authors.identifier: 0000-0002-9798-6157
authors.initials: R
authors.lastname: Agbakoba
authors.affiliation: General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Annemieke
authors.identifier: 0000-0002-5188-055X
authors.initials: A
authors.lastname: Bikker
authors.affiliation: Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8RZ, UK, United Kingdom.
authors.forename: Eleanor
authors.identifier: 0000-0002-4115-2882
authors.initials: E
authors.lastname: Grieve
authors.affiliation: Institute of Health and Society, Newcastle University, Newcastle Upon Tyne NE2 4AX, United Kingdom.
authors.forename: Tracy
authors.identifier: 0000-0001-8647-735X
authors.initials: T
authors.lastname: Finch
authors.affiliation: School of Social and Political Sciences, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Nicholas
authors.identifier: 0000-0002-0364-427X
authors.initials: N
authors.lastname: Watson
authors.affiliation: School of Social and Political Sciences, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Sally
authors.identifier: 0000-0002-7509-8247
authors.initials: S
authors.lastname: Wyke
authors.affiliation: General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Frances S
authors.identifier: 0000-0001-9780-1135
authors.initials: FS
authors.lastname: Mair
mesh_terms: D005069:Evaluation Studies as Topic; D006801:Humans; D008137:Longitudinal Studies; D009313:National Health Programs / Q000458:organization & administration* / Q000592:standards; D006113:United Kingdom
keywords: community health services; diffusion of innovation; electronic health records; health plan implementation; health services research; instrumentation; medical informatics; qualitative research; telemedicine