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The successful implementation and uptake of health technologies in real-world settings remain an ongoing challenge. Clinicians have an essential role to play in facilitating successful digital health design and implementation.
Technology has transformed many domains and industries; health is no exception. It is no longer possible for health professionals to work without using some form of technology to support their day-to-day work. Digital health encompasses, for example, artificial intelligence, analytics, dashboards, web portals, mobile applications, virtual care and wearables, which are increasingly being applied for diagnosis, treatment and care management.
However, the successful implementation and uptake of health technologies in real-world settings remain an ongoing challenge. This is known as the “last mile” problem where digital technologies are designed and developed but not successfully implemented, sustained and scaled over time. This last mile problem is the result of a myriad of factors, many relating to technology designers not adopting a user-centred approach.
Consequently, the resulting technology typically fails to meet the expectations of end users, leads to poor user experience, poor uptake, and a waste of resources. These well known challenges are not new. However, it remains unclear why health care stakeholders fail to learn from previous digital health implementation failures. To avoid history repeating itself, our research unpacks the essential role of clinicians in facilitating successful digital health design and implementation, and how health service leaders need to support clinicians in adopting this role.
Clinicians lead the way
Clinicians must lead the design and implementation of health care technologies to ensure their relevance, usability and long term success. When clinicians drive these processes, systems are designed to target relevant clinical problems or support processes in need, minimising disruption and fostering trust. Our team’s recent systematic review showed that clinician involvement in design of Clinical Decision Support (CDS) led to better integration with existing workflows, higher adoption and reductions in medication errors.
On the flipside, the absence of clinician involvement in the design and implementation has consistently limited the benefits achieved from digital health technologies. A noted case is the implementation of the Enterprise Patient Administration System (EPAS) hospital software in Australia, which caused disruptions in hospital operations. The system, criticised by staff for being inefficient and increasing workload, failed primarily due to the lack of meaningful clinician engagement during its design and rollout. This example underscores how poor usability and increased burden on clinicians, when clinicians are excluded from the process, can lead to failure in digital health initiatives.
The experience of deploying machine learning tools during the COVID-19 pandemic further highlights the pitfalls of technology-centric approaches. Although many algorithms showed promise in retrospective studies, they failed to deliver anticipated outcomes in real-world clinical settings. One significant reason was the lack of early clinician involvement, which resulted in poor integration with existing workflows and tools that did not meet the practical needs of frontline health care providers. One of the most significant outcomes of early and sustained clinician involvement is fostering trust in tools that they helped create, knowing that these solutions are practical, effective and aligned with patient care goals.
Critical role of health care leaders and policy makers
Health care leaders must provide clinicians with protected time to co-design technologies with vendors to make the technologies more meaningful and fit for purpose. In our study of health information technology (HIT) implementation processes during the COVID-19 pandemic, findings revealed that clinicians had insufficient time to participate in the co-design of HITs, although it was acknowledged that pandemic patient care is, and should be, their priority. For clinicians who wish to transition from the role of “clinicians as users” to “clinicians as co-designers”, health service organisations must consider how to better provide the required support to facilitate varying levels of clinician involvement in HIT designs.
In addition, health service organisations must provide vendors with better access to end users without creating a middleman problem, where information technology staff who should serve as a bridge between the clinicians and vendors become gatekeepers (ie, those who control access and filter information between both parties). The middleman problem is a significant challenge as user requirements become lost in translation between the end users and the vendor. Sufficient clinician involvement can be a challenge if the health service organisation fails to provide protected time and the vendor fails to provide clarity on the expectation of time commitment. Our study found that there was limited clarity on the time commitment required of clinicians when designing a dashboard. Participants reported that they “spent 12 months altering [the dashboard] and customising it for [a new patient cohort] in the most laborious and arduous process that’s required a huge amount of clinical time and input. And had I known what we’re being asked to do … there’s no way I would have agreed to do it.” Therefore, when thinking about co-design and engaging end users, health care organisations need to clearly outline the time commitments and expectations around user engagement.
Government and policy makers must provide timely policies that can support ongoing HIT implementations. Existing guidelines that encourage healthy relationships between vendors and end users, such as the Safety Assurance Factors for EHR Resilience (SAFER) guides and the EHR developer code of conduct, only target electronic health records (EHRs). The code of conduct, however, indicates that users can participate in EHR design but does not mandate this, thus providing opportunities for technologies to be designed based on clinician work-as-imagined by the vendor rather than work-as-done. The digital health procurement guideline being developed by the Australian Digital Health Agency provides some principles and standards that guide the sourcing process for technology solutions but makes no mention of the need for vendors to provide evidence of efforts made to understand the workflow of end users.
Learning from digital health failures is essential
Finally, it is important to note the publication bias against failed digital health implementations, a global trend affecting HIT projects in North America, Europe and Australasia. There are many examples across the globe of large HIT implementations not meeting set budgets, scope, timeline or expected benefit targets but these are rarely published in academic journals, which limits the ability to openly share important lessons. One exception is the journal Applied Clinical Informatics (ACI) that encourages the publication of case studies that describe IT failures, but this is not yet common across other medical informatics journals. Stigmatising and rejecting manuscripts on HIT failures will discourage researchers from writing on such topics, preventing others from learning from them.
To tackle the last mile challenge in digital health, clinicians need to move beyond just using technologies and take on a bigger role as co-designer, and health service organisations need to support them. When clinicians help shape these tools, they’re more likely to trust them, find them easy to use, and see them fit smoothly into their workflows. By focusing on clinician-led design and learning from what has not worked in the past, we can ensure digital health solutions deliver on their promise and make a real difference in patient care.
Dr Adeola Bamgboje-Ayodele is a Research Fellow in human factors at the University of Sydney. Her research seeks to understand how to better design and implement digital health technologies with, and for, end-users. She has a keen interest in evaluating and improving the usability of digital health technologies to improve uptake while ensuring that the intended benefits are realised.
A/Prof Amina Tariq is a digital health expert within the school of public health and social work at QUT. Her research strengthens the global digital health agenda, enabling health stakeholders to adopt an evidence-based approach to mitigate patient safety risks associated with technology while maximising efficiency benefits.
Professor Melissa Baysari leads the Digital Health Human Factors Group at the University of Sydney. Her research seeks to understand and improve the interactions between health care providers, health technologies and organisations, and she is particularly interested in evaluating and ensuring the usability and safety of health technologies, and minimising unintended consequences following implementation.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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