Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies
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Open Access
- 1 November 2017
- journal article
- research article
- Published by JMIR Publications Inc. in Journal of Medical Internet Research
- Vol. 19 (11), e367
- https://doi.org/10.2196/jmir.8775
Abstract
Background: Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level. Objective: Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program. Methods: The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback. Results: The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs. Conclusions: Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.Keywords
This publication has 110 references indexed in Scilit:
- The Digital Divide Among Low-Income Homebound Older Adults: Internet Use Patterns, eHealth Literacy, and Attitudes Toward Computer/Internet UseJournal of Medical Internet Research, 2013
- Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measuresImplementation Science, 2013
- The organising vision for telehealth and telecare: discourse analysis: Table 1BMJ Open, 2012
- Scope of Policy Issues in eHealth: Results From a Structured Literature ReviewJournal of Medical Internet Research, 2012
- A Holistic Framework to Improve the Uptake and Impact of eHealth TechnologiesJournal of Medical Internet Research, 2011
- Why Do Evaluations of eHealth Programs Fail? An Alternative Set of Guiding PrinciplesPLoS Medicine, 2010
- Evaluating eHealth Interventions: The Need for Continuous Systemic EvaluationPLoS Medicine, 2009
- Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation scienceImplementation Science, 2009
- Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process TheorySociology, 2009
- Diffusion of Innovations in Service Organizations: Systematic Review and RecommendationsThe Milbank Quarterly, 2004