Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the United Kingdom

Background 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. Objective 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. Methods 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. Results 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. Conclusions 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.


Living it Up (LiU)
Overview: Living it Up is a digitally enabled community of opportunities (aimed primarily at people over the age of 50 and people living with long term health conditions) to support better health, wellbeing and active lifestyles in Scotland. A key activity was co-design in the community and a key output was a web based portal signposting people to health and wellness services across Scotland.

Liu Portal
A web based portal acting as a single access points to the range of services offered by LiU (https://portal.livingitup.org.uk/)

Shine
An online profiling service to identify individuals' skills and expertise along with encouraging members to help others to share their own skills and "talents" in their communities. (https://shine.livingitup.org.uk/)

Connect
A means for people to remain 'connected' with their friends, family and caregivers via Skype or Cisco Jabber Client video conferencing (VC) suite. (https://portal.livingitup.org.uk/connect)

Discover
An online portal with access to information on a range of health and social care products and services available in local communities. (https://shine.livingitup.org.uk/discover/Searching).

Flourish
Suite of interactive tools to support self-management of long term conditions ('experience guides', NHS resources, a home monitoring service and a text messaging service. (https://flourish.livingitup.org.uk)

Get Active
A service developed in collaboration with Storm Health which aims to promote and support healthy activity for targeted individuals.

More Independent (Mi)
Overview: More Independent (Mi) is a Liverpool based partnership led by Liverpool (NHS) Clinical Commissioning Group. Mi aimed to enable citizens take control of their health, well-being and lifestyle. Key outputs include the role of both lay champions and clinical champions in increasing uptake and use of digital health and self-management.

Mi Awareness
People invited to engage in community events, and join both virtual and physical community interest groups.

Mi Health and Care Technology
Scaling the deployment of health and care technology across to enable more people to live healthier independent lives and give families (inc carers) peace of mind. www.moreindependent.co.uk/wp-content/uploads/Mi-Telehealth-Report.pdf

Mi Plans
Online tools (i.e. personal health records) to increase people's ability to manage lifeenhancing plans to support self-care.

Mi Retail
An initiative is to improve the visibility and availability of Digital Technologies to local communities by engaging with the retail sector in Liverpool. www.moreindependent.co.uk/wp-content/uploads/Mi-Retail-Report.pdf

Mi LET helpline
A telephone hotline to provide advice on health and wellbeing technologies and services.

Mi Champions
Active volunteer citizens who work in local areas to promote and advise people of the telehealth and telecare services available to them. www.moreindependent.co.uk/news/mi-community-champions/

Mi Digital Inclusion
Initiative to reduce digital exclusion by creating digital hubs in areas of low digital access.
www.publictechnology.net/articles/features/delivering-health-care-digitallyexcluded A (real and virtual) Demonstrator Smart House equipped with a wide variety of

Mi Smart House
technology to make life easier. www.moreindependent.co.uk/news/come-and-visit-the-mi-smarthouse/

Mi 'House of Memories' App
App designed to support people living with dementia and their families. www.moreindependent.co.uk/news/mi-house-of-memories/

Mi Health Innovation
Supporting local business to innovate, opening up new forms of finance to support growth, up-skilling the workforce and digitally including citizens.

(d) Year Zero (YZ)
Overview: Year Zero is an industry led consortia bringing together expertise in healthcare, design, media and technology to develop user-centred tools that will deliver new digital healthcare services and enable citizens to take greater control of their own health and wellbeing. A central objective was to test the utility of new services designed around personal health records and digital interactions between citizens and service providers.

eRedBook (eRB)
A digital version of the printed Redbook (a Personal Child Health Record (PCHR) that logs a child's healthcare information such as developmental growth and milestones, vaccinations, and other information from birth. http://www.eredbook.org.uk/

Health United Birmingham HuB
The roll-out of remote live consultation and extending out of hours services with the Vitality Partnership in Birmingham. www.digitallifesciences.co.uk/digital-lifesciences-helps-improve-patient-access-to-gps/

A Better Plan (ABP)
A care planning application that is designed to help healthcare professionals and patients to collaboratively consider and set a range of health, wellbeing and personal http://www.digitallifesciences.co.uk/ive-got-better-plan/