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High-level policy barriers impede widespread adoption for even the most well-positioned innovations. Most of the work in this field assumes rather than analyzes the driving forces of health innovation. Objective: The aim of this study was to explore the challenges and opportunities experienced by health system stakeholders in the implementation of digital health innovation in Ontario.
The aim of this study was to explore the challenges and opportunities experienced by health system stakeholders in the implementation of digital health innovation in Ontario.
We completed semistructured interviews with 10 members of senior leadership across key organizations that are engaged in health care–related digital health activities. Data were analyzed using qualitative description.
A total of 6 key policy priorities emerged, including the need for (1) a system-level definition of innovation, (2) a clear overarching mission, and (3) clearly defined organizational roles. Operationally, there is a need to (4) standardize processes, (5) shift the emphasis to change management, and (6) align funding structures.
These findings emphasize the critical role of the government in developing a vision and creating the foundation upon which innovation activities will be modeled.
Digital health innovation is the cornerstone of health care modernization efforts in a number of countries internationally [
Guiding principles for the Ontario digital health strategy.
Principlea | Description |
Put patients first | Focus efforts on faster access to care, innovative and integrated care, empower patients and caregivers, and ensure a fiscally sustainable public health care system |
Adopt a “Digital First” philosophy | Approach new and existing programs and discussions by asking, “How can we do it with digital health?” |
Make solutions about quality care | Design new policies, care models, funding structures, and workflows that are best for patients and providers—then think about how technology can help |
Be transparent | Use open, evidence-based standards to guide governance and investment decisions; report progress publicly and regularly |
Be innovative | Use the full scope of creativity of what is possible with contemporary technology to support patient and provider decision making, virtualize processes, and deliver services |
Build on what we have already | Leverage existing assets as a starting point when possible |
Be pragmatic | Strive for solutions that are “good enough” and processes, such as governance, that are not needlessly burdensome |
aAdapted from Bell R. Ontario’s Patients First: Digital Health Strategy. Canada Health Infoway Partnership Conference 2016 [
Obstacles in the digital health innovation process stem from features of the innovation itself and the broader implementation context, which includes the divergent interests of a variety of stakeholder groups [
Greenhalgh et al [
The major contributions to the body of literature on
Our approach was informed by a constructivist paradigm [
Our study was conducted in the province of Ontario, Canada, where the majority of health care is publicly funded and privately delivered. However, despite the fact that our data collection took place in a single Canadian province, we focused our analytic strategy on identifying challenges and opportunities that apply to health care systems across high-income countries.
A purposive sampling strategy was used to select participants, whereby the research team generated a preliminary list of key organizations that are engaged in health care–related digital health activities in Ontario, Canada. Participants were required to occupy a position of senior leadership within their organization to ensure their ability to speak to system-level barriers. This list was then circulated to a broader advisory group to elicit suggestions to ensure a wide range of perspectives. A total of 9 potential participants were then sent an introductory email, outlining the purpose of the study and requesting their participation or asking them to identify an appropriate alternative within their organization. All 9 potential participants expressed interest and contacted the study authors directly to be scheduled for an interview.
Interviews were conducted in person by 2 experienced qualitative scientists (LD and JS). A semistructured interview guide was used (see
A total of 10 participants were interviewed across 9 interviews (1 participant invited a colleague to their interview), with an average duration of 40 min (range 21-61 min). Participants included representatives of key organizations within the digital health landscape (see
Participants were unanimous in their belief that “what we’re doing at a system level is not working.” The importance of strong leadership at an organizational and system level was viewed as critical for the successful implementation of digital health innovation, with an emphasis on establishing a culture of innovation. Participants described 6 key priorities requiring action at the policy level to catalyze digital health innovation, including the following: (1) a system-level definition of innovation, (2) a clear overarching mission for digital health innovation, and (3) clearly defined organizational roles. Operationally, there is a need to (4) provide guidance on standardized processes, (5) shift the emphasis to change management, and (6) align funding structures. A participant summarized the problem as follows:
It’s still not a case of build it and they will come. I’ve been working in this space for 20 years and truly if you look at the penetration of virtual care—there’s still tremendous opportunity at the system level ...you know we are a broken system.
Organizational representation.
Organization | Descriptiona |
Ontario MOHLTCb | Provincial ministry responsible for administering the health care system and providing services to the province of Ontario |
Ontario MD | Helping physician practices advance electronic medical records, products, and services so that we collectively enhance the delivery of patient care |
Ontario Telemedicine Network | Develop and support telemedicine solutions that enhance access and quality of health care in Ontario and inspire adoption by health care providers, organizations, and the public |
Canada Health Infoway | Improve the health of Canadians by working with partners to accelerate the development, adoption, and effective use of digital health solutions across Canada |
MaRS EXCITEc | Foster the adoption of innovative health technologies in Ontario and leverage those successes and experiences into global markets |
aDescriptions reflect organizational missions taken directly from respective organizational websites where available.
bMOHLTC: Ministry of Health and Long-Term Care.
cEXCITE: Excellence in Clinical Innovation Technology Evaluation.
Innovation was defined differently across participants in our sample, with each definition exhibiting unique nuances that reflected the participant’s past experience and organizational perspective. For example, one arm’s-length policy organization was focused on understanding and modifying components of the health innovation system that could better promote the generation, testing, and ultimate adoption of new technologies:
The real innovation for us is the way of aligning all of the bits and pieces of the sector—from everything from policy and payment all the way down to the actual solution.
In contrast, a representative from yet another organization took an even broader approach, defining innovation simply as changing processes of problem solving:
People are now understanding that innovation is just doing things differently—right, like changing your process, changing you’re approach, changing how you think about the problem and what you do to solve that problem.
These varied definitions of innovation across key stakeholders are a consequence of a nonexistent, shared conceptual foundation for both digital health innovation and what the health system is supposed to do more broadly. This lack of shared understanding about the nature of health innovation impedes effective communication and collective action, making it extremely difficult to achieve alignment across activities.
Drivers of innovation varied across participants and were largely reflective of their organization’s current direction and leadership. Approaches to virtual care were primarily driven by the needs of these individual organizations (ie, reduced cost or improved efficiency). The importance of patient experience was highlighted by several participants, but it was rarely highlighted as the primary driver for innovation. The tension between system needs and patient benefit was accentuated by the nature of a publicly funded health care system, where the distinction between payer and end user complicated the value proposition:
It’s classic virtual care things where the benefits accrue to the patient largely but the patient doesn’t pay. So any time you’ve got that not perfect alignment in incentives, then you’ve got work to do. To try and figure out how to get people motivated to grow the service.
Virtual care initiatives were characterized by a top-down approach, despite the recognition that a “grassroots” or “frontline” approach to innovation is more likely to support effective problem solving and adoption. Despite highlighting clinician resistance as a key barrier to adoption, participants often described decision-making processes that failed to engage relevant end users (ie, clinicians and/or patients):
One of the biggest groups that resists process is clinicians. The way they function—they’re workflow, is disrupted when you put in a disruptive technology—so that’s one of the difficult groups [...] so you know that is sort of one area that we would be struggling with likely in all our technologies is the end user of the technology.
Participants described a poorly organized system with respect to the introduction, adoption, and scale of virtual care innovations. The key players within the system’s virtual care space are fragmented and function strategically and operationally as independent organizations. Participants felt that unclear roles and responsibilities perpetuated this fragmentation, and they proposed effective governance and accountability as a potential solution:
I think—in Ontario—this is a real problem is because ownership is often not taken or not clear, and so who’s driving that agenda is not clear- and [who is] accountable for it and when they do become accountable for that. [Organizations] take a very narrow space of it, where it’s just their thing that they can do and that’s a problem.
The MOHLTC’s Digital Health Board, an advisory committee tasked with providing advice with respect to priorities, was described as a “sponsor” of the province’s digital health strategy but devoid of “any formal accountability.” Participants emphasized that, although priority setting begins to address the issue, a general lack of accountability persists, which hinders collaboration and progress. In extreme cases, this leads to organizations having competing or overlapping priorities, resulting in an inefficient use of system resources:
There’s another layer around prioritization around the big agencies in this eHealth space, and the ministry did say these are your roles in a letter last year to all of us, that has never been enforced, we’re kind of still figuring it out.
The fragmented nature of processes and infrastructure related to virtual care was attributed to the operational silos that characterize virtual care organizations and health care institutions. Fragmentation results in a virtual care landscape that includes a heterogeneous assortment of technologies with limited interoperability, driven by disparate, institutionally specific procurement processes that are widely acknowledged as onerous and not conducive to early-stage innovations:
Every different hospital is different, taking a different approach, working with different partners, and in some respects, that’s promoted by the chief innovation officer of programs is that they do want institutional partnership between institutions and innovators—but that ends up being less collaborative across institutions.
In the absence of a shared vision and shared processes, organizations engage in procurement decisions independent of one another, which contributes to the lack of interoperability among technological innovations within the broader system. This was unanimously viewed as a significant barrier to a virtually enabled health care system, complicating the landscape for new innovations for which interoperability is fundamental to their functionality and value proposition.
The existence of microcultures within organizations (and therefore the system) presents both an opportunity and a challenge, as some of these microcultures push for change, whereas others try to maintain the status quo. Strategies to enable a broader culture shift included collaborative approaches to innovation, entry-level education, and modifications to existing incentives:
Basically they are different elements of the system and different structures in the system and any time you try to make change there is a tendency for those individual structures or nodes to try to revert back to the current state—the status quo. So, there’s a kind of system stability. I think that it’s possible to give sufficient pushes at different nodes and changing the incentives at each node to move to the different state within the system.
Establishing buy-in from clinicians is “
Just changing the care model—or the payment model—will not make that happen, you have to actually have an adoption plan and you know to actually promote that to occur and so there really has to be change management strategies to make that occur—so you have to have both of them to make that actually happen.
Siloed funding for virtual care initiatives and innovation further contributes to the fragmentation of activities across the sector. Siloed program funding creates a barrier to establishing a business case, as many virtual solutions that are designed for one setting (eg, the community) will result in savings realized in another setting (eg, acute care):
There aren’t many mechanisms in place where they can flow budget from one group to another and when you’ve got these silos around the way dollars flow, that can be a real hurdle in how innovation is taken up.
The primary funding mechanisms for organizations interested in innovation are institutional operating budgets or public grant funding through national agencies (ie, Canadian Institutes of Health Research). Unfortunately, institutional budgets are considerably strained, and
Our results build on previous literature by illustrating how a lack of system guidance, both conceptually and structurally, contributes to the inability of many digital health innovations to move beyond local success to realize their impact at scale. Despite technological advances and rapidly accumulating evidence on the value of digital health, the development of policy-level guidance has lagged behind. Against the backdrop of Ontario’s
Health care organizations’ pursuit of their missions is often fraught with complexity. Failure to achieve full realization often extends beyond funding issues and is attributable to organizational structures and interactions or competing policy pressures [
Articulating a vision and establishing a clear direction are central to the ability to achieve health care transformation [
The interactions among individuals, institutions, and organizations contribute to coherent trajectories of system change over time [
Taking these policy-level implications of our research down to the level of the organization, we observed the following: “One-size-fits-all” strategies often translate into suboptimal engagement, underscoring the need for a change management approach that tailors implementation strategies to the varied needs of end users [
It is important to note that the findings of this study depict a cross-sectional state in time. Organizations and systems are dynamic (and not time invariant); therefore, their activities are linked and informed by a grid of evolving connections. Notwithstanding, our results highlight the current system gaps, and we propose related policy-level activities that will promote the broader uptake of digital health innovation.
Although we achieved theoretical saturation in our sample, participants were mainly from urban organizations in Ontario; therefore, our findings may not reflect the challenges of implementing digital health innovations in rural organizations. Our results are not intended to be generalizable to every example of digital health innovation in Ontario, and future work would benefit from the validation or refinement of these themes from the perspectives of those responsible for technology adoption (ie, patients and health care providers). Although these findings reflect the local health system context in Ontario, Canada, many health care systems are pursuing increased quality through innovative modification of current delivery systems [
System and organizational activities to facilitate the adoption of digital health innovation.
Despite much policy-level talk of triggering a revolution in service delivery and many small-scale proof-of-concept examples, digital health innovations are rarely mainstreamed or sustained [
Interview guide.
Ministry of Health and Long-Term Care
The authors wish to acknowledge the individuals who participated in this study for their forthright contributions.
None declared.