Delivering the digital ambition: Exploring how we can design, implement and evaluate digital technologies in healthcare.

Digital health technologies (DHT) comprise a broad range of applications such as telehealth, wearable devices and smart-phone and tablet applications (apps). However, whilst national and international policies present ambitious plans for DHT to revolutionise healthcare, there has been little consideration of how they can be successfully integrated into healthcare systems and processes. This is important as many reports show that even well designed DHT fail to be adopted or are quickly abandoned in clinical practice, meaning that their potential to transform healthcare is lost.

Stroke rehabilitation presents an ideal opportunity to use DHT to improve patient outcomes. Pressures on services mean that the amount of rehabilitation that can be directly delivered by staff, particularly for the arm, falls far short of that known to be beneficial resulting in sub-optimal outcomes for many people and reduced quality of life. With the numbers of people surviving a stroke set to double in the next 15 years, DHT provides an attractive, innovative, practical and engaging way for staff to prescribe additional rehabilitation and improve recovery for people after stroke, within current service constraints. However, DHT are not widely used in rehabilitation and the factors that influence their use in clinical practice are not known.

This project seeks to identify and understand the factors that will influence the use of DHT in healthcare. It will employ this knowledge to design, implement and evaluate a DHT intervention, using rehabilitation after stroke as a case example.

The project has 3 initial phases.

In phase 1, the evidence considering if and how DHT are used in healthcare will be reviewed, to explore the factors influencing their use. A national survey, observations of practice, questionnaires and interviews will describe current practice and explore the behaviours and beliefs of people after stroke, rehabilitation staff and service managers about using DHT. This information will be used to develop a theory about, and framework of, the factors influencing the use of DHT in healthcare rehabilitation.

In phase 2, the theory and framework will be used to co-design, create and undertake initial testing of an app and intervention to supplement routine rehabilitation for the arm after stroke with rehabilitation staff, stroke survivors and DHT developers from our in-house innovation lab.

In phase 3, the initial feasibility, acceptability and costs of the app and intervention to supplement stroke rehabilitation at a single NHS trust will be evaluated. Data from interviews, questionnaires and generated by the app will investigate how it was used in practice. These findings will be used to further refine the theory and framework developed in Phase 1 and the app and intervention developed in Phase 2.

In the second period of the fellowship (Phase 4), a multi-site feasibility study of the app and intervention will be conducted. The project outputs will also be used to guide and assess the use of other forms of DHT (e.g. virtual reality) in stroke rehabilitation and their transferability to support and evaluate DHT in other healthcare settings will be evaluated.

This project will transform how DHT can be used in healthcare by generating a clear theory and framework and providing practical tools which detail the factors that must be considered in the design, implementation and evaluation of DHT. It will provide guidance on how patients and healthcare staff can co-design DHT and design a future trial of the effectiveness of the app and intervention. Its results will benefit technology developers and researchers by helping them design and utilise DHT to improve patient outcomes and enable healthcare organisations and policy-makers to consider the vital processes and resources required to realise the vision of a truly innovative and DHT-enabled healthcare service.

Digital health technologies (DHT) hold significant promise to promote and protect health. Over 200 new health applications (apps) come to market each day and the UK DHT market is estimated to be worth £28 billion. However, despite their clear potential and wide availability, DHT have repeatedly failed to be successfully implemented in clinical practice. This constitutes a significant challenge in realising the ambition for DHT to transform healthcare.

This fellowship project will address this challenge by developing and evaluating a programme theory and framework that brings together engineers, clinicians and healthcare organisations to design, implement and evaluate DHT interventions in the NHS, with the ultimate aim of increasing the success of DHT implementation in healthcare. These initial outputs will be developed and evaluated using stroke rehabilitation as a case example; by the end of the fellowship the validated programme theory, framework and associated tools will be ready for use to develop and evaluate DHT for use in other healthcare settings.

Tangible outputs include:
A. a programme theory, framework, tool-kit and road-map that describes the active ingredients and processes of DHT implementation and evaluation in healthcare
B. a critically evaluated and clearly articulated process to inform DHT co-design;
C. a co-designed DHT application (app) and intervention.

Based on a stakeholder analysis, the beneficiaries of this research are:

-Healthcare organisations: NHS Confederation, The King's Fund, The Health Foundation, commissioners and NHS trusts
-Funders of research: e.g. the NIHR and UKRI councils
-Policy influencers, makers and enactors: All Parliamentary Group on Stroke, NHS digital, NHSX, NICE, Department of Health and Social Care.
-Innovation industry: the local and national Innovation Agencies, digital technology companies, digital health groups
-Professional and training bodies and the staff they represent: Health Education England, NHS leadership academy, Chartered Society for Physiotherapy, Royal College of Occupational Therapists and Royal College of Nursing
-Patients: People after stroke, their carers and the bodies that represent them e.g. the Stroke Association.

The timed impact goals, with reference to the key outputs (listed above and denoted by the letter in brackets), are to:

Medium to long term (Phase 2 and beyond):
1. Support the innovation industry to produce DHT with high usability and acceptability by ensuring that the needs of users can be incorporated in their design. This will provide competitive advantages and economic benefits as products have a greater likelihood of being widely and sustainably used (B)
2. Use DHT to provide beneficial, supplementary rehabilitation for thousands of people after stroke in the UK and millions worldwide (A, C)
3. Enable professional bodies to plan and develop the healthcare workforce by describing the behaviors, resources and training required to use DHT and increase the workforce's experience and expertise in using DHT (A)

Long term (Phase 3,4 and beyond):
1. Empower policy-makers to realise their ambition of using DHT to revolutionise healthcare by enabling them to articulate the procedural processes of how DHT are designed, implemented and evaluated, ultimately increasing their use in clinical practice in the NHS and globally (A, B)
2. Support healthcare organisations to identify the factors in their service that influence the success of DHT implementation (A)
3. Produce time and cost savings by designing and managing DHT projects to actively reduce the risk of failure and enabling learning from failure by the innovation industry and healthcare organisations (A)
4. Facilitate research funders and innovation agencies to judiciously invest into DHT development and/or evaluation by enabling them to assess the stage of DHT development and readiness for successful implementation into healthcare settings (A).