Embracing technology?
Embracing technology? Health and social care professionals’ attitudes to the deployment of e-health initiatives in elder care services in Catalonia and Ireland
Lolich L., Riccò I., Deusdad B., Timonen, V. (2019) Embracing technology? Health and social care professionals’ attitudes to the deployment of e-health initiatives in elder care services in Catalonia and Ireland. Technological Forecasting & Social Change https://doi.org/10.1016/j.techfore.2019.06.012
Introduction
This article examines health and social care professionals’ views, acceptance and resistance to e-health initiatives in elder care in Ireland and Catalonia (Spain). It aims to give an insight into the kinds of enablers and barriers that professionals encounter and anticipate when thinking about and trying to work with technologies intended to improve care services administration and delivery. We demonstrate a considerable gulf between the rhetoric and reality in the realm of technology use in care services for older adults. The majority of studies regarding the successful implementation and use of technology have focused on specific technologies, e.g. telecare services (Aceros, Pols, & Domenech, 2015). Few studies investigate the views and ideas of health-care professionals regarding the implementation and use of e-health in care services administration and delivery of home care services for older adults, i.e. without focusing on one or more specific technologies. By not focusing on specific technologies per se, but on e-health, a more in-depth and holistic view emerges of the implementation of technologies in home care services in Ireland and Catalonia.
The term e-health (electronic health) serves as a generic umbrella term encompassing multiple domains (Della Mea, 2001; Wernhart, Gahbauer & Haluza, 2019) including the use of electronic tools in delivering health care (Bates & Wright, 2009). E-health refers to the use of information and communication technologies (ICT) in health products, services and processes, combined with organisational change in healthcare systems and new skills to improve health, efficiency and productivity in healthcare delivery. The European Commission (2012, p.3) states that e-health covers the interaction between patients and health-service providers, institution-to-institution transmission of data, and peer-to-peer communication between patients and/or health professionals.
There are major differences in e-health deployment at a national, regional and local level in the European Union (European Council, 2013). Differences are evident at policy level, where a few countries (e.g. some Nordic and Baltic States and Scotland) have e-health strategies in place linking up national, regional and local stakeholders, while in the majority of EU member states, e-health implementation is still focused on the introduction of electronic health records (EHR) (Quaglio et al., 2016). Access to and expertise in the use of technology is a major barrier for effective implementation of e-health strategies. Differences in the use of ICT are evident across the health sector, for example, between different general practitioners (GPs) and hospitals (Codagnone & Lupiañez-Villanueva, 2013). Differences in e-health deployment among EU countries situate health and social care professionals’ work in specific national and regional contexts, determined by IT infrastructures and potential scope for using technology. In turn, this creates different work flows and determines – to a large extent – the choices, information and tools that health and social care professionals have at their disposal (Marschang, 2014).
ICT can reduce care professionals’ bureaucratic burden (Cordella & Tempini, 2015; Author C & Author B, 2018) and help to control government’s health care expenditure. Within elder care, ICT are heavily promoted within a nexus of demographic ageing, limited healthcare and social care budgets and technological ambition (Mort et al., 2013). It is believed that ICT can not only bring savings to public service provision but that it can also help to improve older adults’ quality of life (Algar & Valdes, 2014; CARDI, 2011; Sponselee, 2013) by increasing choice, efficiency, quality, and safety of health and social care (Chaudhry et al., 2006). However, it has also been reported that the use of ICT in the care of older people can increase feelings of dehumanization (Pritchard & Brittain, 2015) and an emphasis on instrumental efficiency to the detriment of personal care and emotional support (Locsin, 2001). E-health is an emerging field of medical informatics, referring to the organisation and delivery of health services and information using the Internet and related technologies. The term characterises not only a technical development, but also ‘a new way of working, an attitude and a commitment for networked global thinking to improve health care locally, regionally, and worldwide by using information and communication technology’ (Eysenbach, 2001, p. 1). E-health is rapidly emerging as an international priority in countries at all levels of development, yet its benefits and priorities have not been clearly defined (Boogerd, Arts, Engelen and van de Belt, 2015; De Raeve, Gomez, Hughes, Lyngholm, Sipila, Kilanska, Hussey and Xyrichis, 2017).
The academic literature has primarily focused on issues in the adoption and diffusion of specific e-health technologies, such as electronic health records (Angst & Agarwal, 2009), health information exchanges (HIEs), and telemedicine (Rogove, McArthur, Demaerschalk, & Vespa, 2012), along with their various benefits and barriers (Feldman & Horan, 2011). At the EU policy level, the link between health and IT is often discussed in the context of how ICT can improve healthcare in the face of current and future challenges. In 2014, the EU developed the first e-health Action Plan; its main thrust was to encourage all EU Member States to work together to promote e-health (Currie & Seddon, 2014 p. 784). Despite growing international interest in e-health (Fichman, Kohli, & Krishnan, 2011), relatively few studies have examined the enablers and barriers to the acceptance or rejection of e-health initiatives in different countries. This article aims to shed light on the factors that have the potential to affect Ireland’s and Catalonia’s successful deployment of e-health.
The contextual factors of e-health: Ireland and Catalonia
Examining professionals’ attitudes towards e-health in Ireland and Spain, specifically Catalonia, combines methodological and analytical advantages and disadvantages. Ireland and Spain are similarly developed in terms of e-health and ICT infrastructure but there are some differences in the integration of digital technology, with Ireland rated 5.9 and Spain 5.4 in the Digital Technology and Society Index (DESI) ranking (EDRP, 2017). Both countries have relatively low levels of infrastructure and penetration of ICTs, but are making progress with e-health and mobile health (m-health) is developing at rapid pace (Currie & Seddon, 2014). Countries with less developed health and e-health systems tend to leapfrog the normal ICT pathway (such as investing in conventional ICT e.g. personal computers) and leap directly towards mobile devices. Mobile devices offer a fast and cheap method of transferring and receiving health data (e.g. GP appointments, prescriptions, test results). One potential advantage for both Spain and Ireland is that less-developed health infrastructures may allow for greater opportunities for creativity and innovation, unlike in more established e-health systems (Currie & Seddon, 2014).
However, Spain and Ireland differ greatly in the organisation of their public health systems. Since the early 1980s, Spain has been setting up a gradual process of health care decentralisation whereby an increasing number of region-states (so-called Comunidades Autónomas) have taken over health care responsibilities (Costa-i-Font & Gil, 2008). Some of these regions, notably Catalonia, outperform other regions in e-health (Currie & Seddon, 2014 p. 793). In Ireland, the Health Service Executive (HSE) centrally manages the country’s health care system and provides long-term care services through its Social Care Division. The Social Care Division funds residential placements in nursing homes through the Nursing Home Support Scheme (NHSS) and also home support services known as Home Help (HH) and Home Care Packages (HCPs).
Ireland
In 2013, the Irish Government published the ‘e-Health Strategy for Ireland’ (Health Service Executive, 2013) and established e-Health Ireland (ehealthireland.ie) to target the development of ICT solutions for the Irish healthcare system. This document was followed up with the Knowledge and Information Strategy (CIO, 2015) which builds upon the e-health vision for Ireland and outlines how integrated information and enabling technology can be used to deliver better quality care. The report describes key features of the context within which this strategy needs to be delivered. These include a growing population, increase in chronic diseases, multiple co-morbidities, growing cost of health care provision and insufficient technology investment.
The strategy focuses on a set of five capabilities that are key to facilitate a seamless delivery of healthcare across integrated care pathways and all stages of care. The first capability, Care Delivery Enablement, focuses on digitising processes and allowing electronic data capture; examples include Appointment Management and eReferral systems. The second capability, Electronic Health Records (EHR), refers to creating and enriching patients’ EHR at each setting, storing detailed care information, and aiming for better care and patient experience. The third capability, Cross Setting Information Integration, delivers the integration, information flows and process standardisation across care settings. It is proposed that the patients will have an Individual Health Identifier (IHI) unique to them throughout their lifetime and across all healthcare settings. The fourth capability, National Support Systems, provides the national backbone for the core support service – finance, procurement and HR. Finally, Health Services Insight delivers the information management, reporting and analysis which provides timely, reliable information and decision support for all stakeholders. This includes a comprehensive data repository as a ‘single source of truth’ (CIO, 2015, p.17).
At the moment there is a national ICT system to manage the finances associated with the nursing home support scheme and experimentation with using the Single Assessment Tool (SAT)[1], but neither of these systems has a customer-facing interface. Furthermore, a strategic approach to telecare across agencies and departments is lacking in Ireland; this is despite a policy commitment to the use of information and communication technology to improve older persons’ quality of life and to assist them in independent living (Care Alliance Ireland, 2015). However, use of first-generation telecare[2] in the Republic of Ireland is relatively high compared to the rest of Europe (Cullen, Kubtischke, & Rauhala, 2009). Telecare services are mainly provided by private suppliers, some of which are not-for-profit organisations. There has been very limited take-up of the more advanced generations of telecare in Ireland (Delaney, 2011).
In Ireland, it is estimated that, in 2017, 46% of individuals in the 60-74 age group had never used the Internet. There are no figures available for the 75 and older category; however, it can be assumed that the level of connectedness is lower still. There are also major disparities in Internet access between Dublin and other parts of the country (CSO, 2017). On the other hand, Ireland scores 73% for use of computers in GP practices and 63% for electronic recording and storage of individual administrative patient data (Currie & Seddon, 2014 p.790). Ireland has a relatively strong ICT profile but scores lower on e-health indicators compared with other countries (Currie & Seddon 2014).
Catalonia
The EHR (Historia Clínica Compartida de Catalunya, HC3) and Personal Health Record (PHR) represent the main initiatives on e-health in Catalonia. The introduction of the EHR in 2005 has been very successful and as early as in 2009, the EHR in Catalonia provided information on 6.4 million people (Marimon-Suñol, Rovira-Barbera, Acedo-Anta, Nozal-Baldajos, & Guanyabens-Calvet, 2010) which represented 86% of the population. The EHR is managed by health and social care professionals, whereas the PHR is managed by the patient who can securely access a wide range of information e.g. his or her health care team, clinical reports, diagnosis, vaccinations, medicines, prescriptions and waiting lists. This is akin to Ireland’s plan to develop an Individual Health Identifier (IHI). The main aim of the PHR is to promote patient empowerment and autonomy. There is also access to administrative tasks such as changing GPs and rescheduling follow-up visits.
In 2015, a pilot service called eConsulta started in several Primary Health Care (CAP) centres in Catalonia. eConsulta is a tool for digital communication between service users and healthcare professionals that complements face-to-face interaction. It allows users to send queries to their physician and nurse, and to receive a response within a 48-hour period during working days. Users can also attach relevant photographs and documents to their communication. However, “figures show that its use among Catalan citizens is still very low” (CHSO, 2016, p. 139).
There are also different ICT tools for professionals such as I-S3 (to refer a patient from Primary Care to a consultant); eCAP (a clinical management tool that offers a holistic view on a patient’s health); and eXAT (communication tool among health professionals concerning a patient’s health condition). The use of these tools is still limited but increasing rapidly from 1,033 people in 2014 to 49,950 at the beginning of 2016 (Berruezo et al., 2016). Similarly to Ireland, one of the most popular technologies implemented through social services for older adults living alone in Catalonia is the Telecare System. A total of 769,336 people over 65 years use Telecare in Spain, which means a coverage rate of 8.89 at the beginning of 2016. There are differences among regions and some are above this rate. For instance, Catalonia at 12.79 is above the Spanish average (IMSERSO, 2016). Furthermore, Catalonia’s digitalization for social and care services is also well ahead of other regions. The HESTIA programme (which is responsible for the digitalization of social services) is being deployed in all municipal social services in Catalonia.
The study
The material reported here was taken from the Irish and Spanish strands in the [anonymised] project titled [anonymised]. The [anonymised] project seeks to respond to the needs of the growing ageing populations in Europe by improving the accessibility and responsiveness of social and care services with the help of ICT by means of a co-creation methodology. The project aims to address gaps in the area of social services by introducing a multi-stakeholder platform for the co-creation, and later deployment, of long-term care services (see [anonymised]). The materials used here pertain to an early stage in the project, conducted in spring 2018 to explore policy planners’ and health and social care professionals’ views of the enablers and barriers to further roll-out of e-health in home care services for older adults. As discussed in the previous section, Spain has a decentralised system of health care and therefore this article focuses on the Catalonian region. Both Catalonia and Ireland are relatively under-developed in systematic introduction and take-up of technology to date in the realm of social care, but have considerable ambitions in this regard. Nevertheless, Catalonia appears more advanced in the area of e-health and digitalisation of Primary Care.
Data collection and analysis in Ireland
The data collection was done in parallel in Ireland and Catalonia between January and August 2018. The research team in Ireland conducted the focus groups (FG) mostly in the Dublin area [anonymised region], where 13% of the population are aged 65 years of age and over (broadly in line with the share of 65+ in the general population across Ireland). In Catalonia, fieldwork was completed in four districts: Vilanova i la Geltrú (Garraf district) and Viladecans (Baix Llobregat district) in the province of Barcelona, and Tarragona (Tarragonés district), Reus and Cambrils (Baix Camp district) in the province of Tarragona. The percentages of older adults from 65 to 84 years old in these areas ranged from 13.8% to 14.8% and the percentages of older adults over 84 is between 2.2% to 2.6%.
In both sites, university-based researchers worked closely with the local health and social care services. These relationships were crucial in allowing access to health and social care professionals. Ethics approval for the study was obtained from the respective universities in Ireland and Catalonia. In Ireland 104 participants took part in 21 FGs and 3 in-depth interviews, while in Catalonia 59 participants took part in 10 FGs and 8 in-depth interviews(I). The participants were diverse, ranging from older adults using or potentially using care services, to policy planners, and a wide range of professionals (home care workers, community nurses, care agency managers, social workers) as well as family carers and volunteers in the community services for older people. The number of participants in each group ranged from three to eight. Interviews with one or two people were carried out where there were insurmountable difficulties in bringing a group together (family carers with limited time) and senior policy makers whose schedules were difficult to reconcile and who were more informative in an interview context.Purposive sampling was utilised to recruit participants who corresponded to different stakeholder groups: service users and service providers. The results presented in this paper comprise sub-samples of 23 (Ireland) and 29 (Catalonia) social care, health-care professionals and policy planners (see Table 2 & 3); these sub-sample were used to focus on professionals’ and policymakers’ experiences and views on e-health initiatives.
Table 1 – Characteristics of Participants in Ireland
| Participant category | Gender (f/m) | Method (number) |
| Social workers | (4/0) | Focus group (FGI11) |
| Health care professionals (geriatrician, public health nurse, clinical case manager and advanced nurse practitioner) | (4/0) | Focus group (FGI7) |
| Nurses | (9/0) | Focus group (FGI1 & FGI3) |
| Policy planners | (0/2) | Interviews (II17 & II20) |
| Multi-disciplinary primary care team (physiotherapist, occupational therapist, private home-care manager, community nurse) | (4/0) | Focus group (FGI2) |
Table 2 – Characteristics of Participants in Catalonia
| Participant category | Gender (f/m) | Method (number) |
| Social workers | (9/2) | Focus group (FGC1 & FGC2) |
| Health care professionals (geriatrician and general practitioners) | (2/2) | Focus group (FGC4) |
| Nurses | (4/0) | Focus group (FGC8) |
| Policy planner | (0/1) | Interview (CI15) |
| Suppliers (public care manager, private home-care manager, private nursing home care manager) | (5/0) | Focus group (FGI10) |
| Care workers | (4/0) | Focus group (FGC3) |
We opted for focus groups as the primary data collection method, as the topic is amenable to homogeneous group conversations where different groups (e.g. social workers; agency managers; older adults) can share their experiences with peers, sparking new themes and conversations. Focus groups were held at times and locations convenient for participants. Written informed consent was obtained from all participants prior to participation. The research teams used lightly structured interview guides and remaining flexible through the data collection. All team members participated in the data collection and there were always at least two researchers present; the moderator and observer. Focus group discussions and interviews lasted 60-120 minutes each; all were audio-recorded, professionally transcribed verbatim, and anonymised. Reflexive memos were written shortly after each FG. Each transcript was read and analysed, looking for similarities and differences between conditions and consequences surrounding key events and patterns in the data (Author D et al., 2018).
Findings
Both in Ireland and Catalonia, participants mentioned the need for better communication and coordination among professionals. In both contexts, most professionals appreciated the use of technology as supportive of better time use and as a way to reduce their administrative burden (Cordella & Tempini, 2015; Author C & Author B, 2018). Professionals could see technology’s contribution to the quality of their working lives, and ultimately quality of care, by providing specific advantages such as alerts, information access, storage and sharing. Participating professionals identified training and support as key enablers for the acceptance and successful implementation of technology. They thought it was important that technology would not compromise their values or interfere with good quality care. Overall, therefore, the professionals were positive about the role of technology in care and their hopes for technology use were in line with national strategies. However, their day-to-day experiences did not always live up to the ambitions of the strategies. We will now turn to looking at current challenges, technology enablers and barriers identified by the participants.
Challenges in the current system
Retrieving, sharing and communicating information
In Ireland, the mode of file storage, the internal and external communications within which professionals currently work is startlingly out of date: it revolves around paper-based records, filing cabinets and archives, faxes, postal letters, and phone calls. Not surprisingly, all care professionals mentioned the need for a shared repository of patients’ files that was easily accessible by all members of the care team. One participant, encapsulating widespread work practices in the Irish context, likened looking for information to ‘doing detective work’, having to ‘trawl’ through piles of paper and computer files (FGI1).
There was a general sense of a convoluted system to communicate about a patient. Professionals agreed that they could benefit from the use of technology to improve communication between care-team members and wished for a system where information could be accessed in a timely and effective manner. There is widespread reliance on email communication to request vital information about patients; as one nurse explained, this involves waiting and hoping that you do not get an email back saying: ‘I’m on annual leave’. Sometimes the reply is a fax and the ‘thing comes in blurred’ raising the question: ‘what are they trying to say to me?’ (FGI7). A health care professional explained the overwhelming reliance on individually held records and emails going back and forth:
… I email them, they email me back. I have it on my notes. So, then everything I’ve gathered, I have it, so like say, the public health nurse won’t have it. Now I will send back an email to the public health nurse saying what I did, what I got, you know how I was involved with the lady [the patient] and what my plan of action is for her and I’ll keep her updated. And if there’s any change in the meantime she will contact me… (FGI7– Health care professionals)
Many participants in Ireland expressed frustration at the difficulties and the amount of time they spend ‘going around ringing people’ and ‘trying to bring the pieces of the string together’ (FGI7). Professionals working in home-care services spend a lot of their time out and about ‘on the road’ (e.g. visiting clients) and therefore trying to get in contact with each other and sharing files becomes a particularly challenging task.
In contrast in Catalonia, many health and social care professionals who work in multidisciplinary teams pointed out how digitalisation and e-health platforms, such as the EHR, have improved information exchange, allowing them rapid access to and sharing of patients’ information:
In our day-to-day work in the hospital, we have access to the EHR […]. I can see what the community social worker has written [on the computer], and she can see what I have written. [I can see] what the social worker, the doctor or any member of the team has written. Both they and I can see it, and also [this information is available to] some other hospitals in the healthcare network. So, it acts as a platform, with all the health information. Personally, I think it works very well. When you first get a case, you want to find the referrals, if someone has intervened at the level of ‘dependency’ [health care], you can consult it … (FGC1 Social Worker)
In the Catalan long-term care (LTC) system, coordination between the Health Department and the Social Service Department is crucial. The implementation and follow-up of benefits and services is done by the social workers at the local Social Services, but it is also necessary to add a medical report from the GP.
Time wasting
In Catalonia, it is difficult for a GP to access a patient’s LAPAD (Spain’s LTC law of Promotion of Personal Autonomy of and Care for Dependent People, Law 39/2006) information and assigned dependency classification. Equally, for a social worker it is difficult to access a patient’s medical records. GPs waste time trying to find out which LAPAD procedures have already been applied for and end-users and their families waste time and energy completing unnecessary paperwork and journeys back and forth between different professionals. As a GP reported (FGC4, medical professionals), end-users become ‘couriers’, going back and forth between the GP and the social worker.
In Ireland, professionals underlined how the repetition and duplication of work not only wastes their time but also takes a toll on their patients: ‘older people will tell us, I am tired of having a line of practitioners coming to me and asking me the same questions over and over and over. Do you people not talk to each other?’ (II20). Some participants reported that the duplication of work is not just limited to form filling but also to lab-test requests. As professionals are not communicating with each other, sometimes different professionals can order the same lab tests for the same patient in a very short period of time. Professionals should be able to upload tests and access results in a common repository (the proposed EHR) that would provide clear benefits at an individual and system level. .
Current responses to the challenges
Both in Ireland and Catalonia there was an overwhelming belief that communication and coordination between social and health care services could and should be better. Health and social care professionals had different reactions to the challenges posed by the current system, ranging from frustration to rebelling as a coping mechanism.
Frustration
Both in Catalonia and Ireland, lengthy forms are filled by hand, each time repeating many of the same questions and basic information. Participants struggled to understand why these forms could not be saved on their computers and subsequently updated. A social worker in Ireland explained how, in order to apply for someone to go with a client to an out-patient appointment, she had to complete an extensive form that could take her up to two hours to do. Invariably the same patient would have another hospital appointment and the whole time-consuming, hand-written form-filling process had to start again (FGI11).
In Catalonia, participants complained about the useless repetition of bureaucratic tasks and nonsensical process of having ‘to write several times the patient’s name, National Identity Document number and so on’(FGC2- social workers). Social workers felt that the use of paper communication is no longer relevant in this day and age:
This is a process…that if you think about it, in this day and age… with the number of tweets, mobiles, smartphones, that we still need to do everything following this procedure [paper work] … Can you imagine telling a girl or boy that in some years from now they will still need to print a paper, make a copy, get it stamped… post a letter… (FGC2-social workers)
Rebelling as a coping mechanism
In some cases, professionals rebelled against what they felt was a nonsensical system, taking matters in their own hands to do their job more effectively. One participant in the Irish context recounted how she had hired someone to create an electronic copy of the medical forms she needs to use in a regular basis. Now, she can fill in these forms directly on the computer and email them to the necessary people. Below, she explains in a humorous manner how things would be if she had not taken this initiative:
If I was to do what the HSE want me to do I would fill them in by hand, I would take a two-day camel ride over there to a scanner, scan them to myself so that I can email them from my email address to you, so that I have a record that I sent it to you. (FGI7- Health care professionals)
Professionals in Catalonia highlighted the long waiting time to access long-term care benefits as a major inefficiency of the system. From the time you apply until you access the benefits the process can take from six months to a year. This leads to some professionals starting the application procedure before it is officially allowed (a patient cannot apply for long-term care benefit until they are out of hospital). These delays also force some social workers to look for solutions in the black market for those patients who are waiting to receive public benefits but cannot afford to pay for private home care services.
Other participants explained how they attempt to make the electronic application process for long-term care more efficient by overriding access rights to patients’ EHR. For instance, the social worker below has access to patients’ information officially only available to a senior manager:
… one of the difficulties I have is that I need to coordinate all time with Pepe [long-term care manager], when I need to cope with patients’ queries. Most people don’t know at which stage their application is. If it has already been submitted, it is still pending… Therefore, we agreed with Pepe that I could make searches on the Generalitat [regional government] database, but only specifically about what stage the user’s application is at, so as to be more efficient and obtain an immediate answer [for the patient] (FGI1-social workers)
In spite of – or maybe because of – all these obstacles, many participants felt a great sense of achievement and pride on the quality of their work – they felt that they did the best they could with the tools they had, under testing circumstances. There was no sense of giving up and doing the bare minimum in a system described as having little to offer to them or their patients.
Enablers and barriers to acceptance and implementation of e-health
Some key drivers emerged from the Irish and Catalonian data regarding factors that would help professionals to fully endorse technology. Most professionals were open to extensive use of e-health if it could support their duties and not substitute aspects of their role they considered important such as face-to-face contact and professional autonomy in decision-making.
Enabler 1: Technology as a support tool to deliver better care
Technology was supported if it helped professionals to deliver better quality of care and simplified administrative duties. In Ireland, nurses for example, would be welcoming of the automation of alerts that could tell staff when a patient was last seen, which is considered an important aspect of quality of care. Trying to do this at moment is ‘all very manual’ (FGI1), requiring a lot of effort and is not always timely.
The direct use of e-health with patients is still in its preliminary phase in Catalonia, but some digitalisation of health services has already been put into practice as the following comment illustrates:
The virtual appointment can be made either by a GP or a nurse or midwife … You can write down the name of the patient … and there is a box with some space where you can write … that the patient needs to renew a prescription or get some results. Then you write down the information for another professional. Afterwards, it shows up as ‘virtual appointment’. You know the patient will not come, it is not a real appointment but works as an appointment for addressing a problem […]. If it is suitable you can do it virtually and if you need to see the patient you can call them and give them an appointment. The virtual appointment works quite well (FGC8-nurses)
One of the main aims of e-health is to facilitate and improve communication between professionals and patients. For example, the use of eConsulta allows for doctors and patients to have a more fluid communication and avoiding repeated phone calls.
What we know is that it [technology] avoids unnecessary journeys. As a patient […] you are saving petrol, you don’t need to take time off work to be able to go to your medical appointment. As a doctor you may not avoid appointments but […] you can use your time more efficiently and self-manage your diary. […]. What we are seeing is that the number of appointments is not going down. We already knew that this would not happen, but they [doctors] are replacing one type of appointment with another… The eConsulta […] is replacing a telephone call. You avoid certain situations like ‘I have called you’, ‘I could not find you’, and until you find the doctor, you have made four different calls in different moments (II8-Policy planner interview).
Enabler 2: Technology that respects professionals’ values
Technology was supported if professional values were respected (not compromised) by the use of technology. For example, it was important for professionals to be able to maintain eye contact with the patient, to establish a meaningful connection and for patients not to feel professionals are ‘just ticking a box’ (FGI3). Participants highlighted that technology should not give way to dehumanizing care or replace person-to-person contact (see also Pritchard & Brittain, 2015). There was a fear in Ireland that with the introduction of technology, family members could pull away. One participant explained how a family member might say: ‘I know where she [older relative] is on the tracker [GPS] or I can see her on this, so I don’t need to go over’ (FGI11). All professionals approved of technology, however, many felt there was fine line between assisting or supplementing care and replacing human care altogether.
Similar feelings were echoed in Catalonia were professionals explained that technology should support care and not replace face-to-face contact. This was highlighted as especially important because there are still many people (especially older adults) with low levels of digital literacy (Author C & Author B, 2018). Changes to eligibility requirements for benefits change often and require professional intervention and judgement to make a final decision:
There are a lot of processes that can be speeded up through the use of technology but I believe that behind any [digital] resource there must always be a person who can clarify things face-to-face. I think that in some particular cases human contact is very important, because there are regulations, which inherently are very subjective [and can be interpreted differently] …How can this be approached? How do you understand them? How do you apply them? There is no problem with very specific things, but other aspects [of care] that can change every day: new regulations, new laws […] I believe that for these matters, face-to-face interaction is a must (FGC10-suppliers)
Barriers to the implementation of technology
If implemented correctly, e-health can produce benefits for health professionals by improving communication and efficiency (e.g. avoiding duplication of information) in their work. However, the data shows that there are some reservations and doubts about the successful implementation of e-health polices and technologies for care. Some of the main barriers identified were resistance and lack of consultation on new initiatives, lack of system integration and fears around data privacy.
Barrier 1: Resistance and lack of consultation on technology initiatives
Some participants mentioned resistance from staff to new technologies or initiatives. One policy planner in Ireland implied that there was reluctance among front-line staff to take part in and collaborate with potential solutions because of a perceived added workload. He described staff as taking a back-seat approach and hoping someone else will take the responsibility: ‘…you find they sit back, you find people sit back and say, ah your man’s [someone else has] done that sure’ (II20). He emphasised the importance of cultural change, where staff felt empowered and had a sense of achievement by having helped to create a better system.
Conversely, other participants felt that technology initiatives were imposed top-down, with little consultation with people on the ground, poorly planned, half-heartedly implemented, and usually ultimately abandoned. There was a general sense that this had been happening for some time, especially with reference to the proposal of a Single Assessment Tool (SAT) in Ireland: ‘back then, a huge amount of resources were put into it [SAT]. And it never …really happened (FGI2). In general, participants felt there was a lack of prioritising and proper budget allocation in ICT initiatives. Failed technological initiatives in the health sector have left a legacy of scepticism about all attempts to introduce technology. As a result, staff do not always take initiatives seriously due to recollection of unsuccessful past initiatives. Participants felt that there was great potential for technology to be introduced and their job to be paperless, however, they perceived this as a huge undertaking and especially in Ireland, professionals were sceptical that it could be accomplished.
Participants also felt that in order for technology to be implemented successfully, additional resourcing for training and change management were necessary. This was specifically pertinent to particular skills in technology, process design and communication. Most professionals mentioned that the digital divide is not only applicable to clients but to staff as well. Training and IT support were required for technology to be successful. Some staff commented that due to lack of training and support, they had to teach themselves how to use new technology:
And the idea is getting people used to just having devices. But I’m saying you really need to give them something to help them. Because it’s intuitive alright, it might be intuitive for younger people that are more used to it. [..] But to an average person, they’d be ringing the helpdesk and nobody knows what’s going on. (II17 – Policy planner)
Training did not just refer to operating devices but also prioritising data for entry and making sure that the important facts were easy to find. A geriatrician in Ireland mentioned the importance of staff knowing how to report an incident and that when writing a report, it is not necessary to say a patient ‘had a cup of tea and all that’, otherwise you could end up with ‘narratives and narratives and narratives and narratives’ (FGI7).
New technology has the potential to foster better service-user and health professional relationships by freeing up time and making services more accessible. However, it is important not to underestimate the need for a culture and behaviour change in some institutions (Office of the CIO, 2015). Many participants admitted that they needed to be more proactive in learning about and using new technology. This is particularly important where paper and electronic records are kept side by side. Below a group of young social workers discuss how a cultural change is needed among medical teams. They explained how it was necessary for them to put a ‘nice big pink sticker’ in a patient’s (paper) file to let the doctors know that information about the patient is available electronically and to avoid duplication of work:
Social worker 1: And like a culture change […] there is a real resistance of getting away from writing in the paper chart, like we [social workers in hospital] don’t do it, like our social work notes are all on the computer because like that’s just the culture we’ve kind of become accustomed to, but I feel like, you know, like with the medical teams and that, like I’d say there’d be real resistance to getting, moving away from a paper chart, I don’t know.
Social worker 2: I’d say so.
Social worker 1: We literally put a sticker in the chart to say ‘see the computer for our notes’, and that’s it, that’s kind of our intervention basically in the charts.
[…]
Social worker 1: A nice big pink sticker.
(FGI11- Social workers)
Participants in Catalonia also felt that a cultural change and training were necessary. Virtual medical appointments work well to solve patients’ doubts and to speed up the process, but it is mostly used by younger generations. Furthermore, not all patients have direct access to eConsulta; variables such as education, age, and main profession mark digital boundaries (Lengsfeld, 2011). In addition, there is still not widespread adoption of eConsulta among practitioners:
Communication campaigns have been made [about eConsulta] … a press release was made … […]. However, we were not prepared to do a big media campaign, because not all professionals are using this tool yet. […] if we do a big media campaign and then what happens is that I go to the doctor and they don’t want to use eConsulta because they are 65 years old and already at the point of retirement: ‘Please, don’t confuse me with eConsulta’. So, this needs some time to be implemented, but at the end of the year it will be launched… (CI15 – Policy planner)
Training professionals and giving them time to learn how to use the new tools is necessary. It gives professionals the possibility of testing and deciding whether new technologies are worth the investment of time and effort. In order for these innovations to be successfully adopted, they need to be perceived as reducing professionals’ burden and be highly intuitive and easy to use. The same could be said about service users, as they also need varying levels of training and support on how to use technology. Communication between patients/families and professionals could be made more efficient with the use of technology. Nevertheless, even when people use some digital technologies every day, this does not guarantee the effectiveness of communication with professionals:
We ask for an email address when they join the Day Care Centre. [So] you can send announcements, information about renovations … and [then] you see that many people do not know it [about the information sent on the email]. You realize that they have just not seen it [the information]. You cannot be certain about whether they have read the e-mail or not.
(FGC10 private suppliers)
Barrier 2: Data security and data privacy
Data security and privacy were seen as important issues influencing professionals’ attitudes towards the use of e-health, especially within the current context of hackers, commercialization of private data and more recently, the use of social media users’ data to influence elections. Some participants felt that this was especially relevant when the data belong to older people who are not computer literate.
In Ireland there was a sense that in principle most participants would approve of EHR or something similar. However, there were also many concerns that reflect a deep-set cultural problem with regard to data privacy in Ireland, where at present there is no national personal identification number. The Government first introduced the Public Services Card (PSC) in 2012 as part of a trial to provide a safe and easy way for people over the age of 18 to access public services across Ireland. This was a controversial initiative and attempts in 2017 to extend the PSC use to other services, such as driving licenses and passport renewal, were met with widespread resistance.
The policy planners in Ireland acknowledged that there is a fear around technology. As the EHR has ‘a cradle to grave focus’, this presents challenges in a context where people are mistrustful of central records keeping and sharing (II20). From the patient’s perspective, it is important to clarify who should get the right to access patients’ records in the case of a patient who is unable to use the EHR. The view was expressed that where patients do not have the knowledge or capacity to process all the information, it might be better for the patient not to get access to all of his or her records, as this can generate undue anxiety. Participants agreed that in general, current cohorts of older people have a fear around technology and this can become a barrier to engagement with new initiatives.
In Catalonia, the majority of participants were open to the use of technology, especially in terms of management and exchange of information. However, there were some reservations regarding data security. In the public sector, professional are quite careful about sharing private information (e-mail, phone number) with patients ‘because there is not enough information out there about where all this data – collected through e-health technologies – is stored and how it will be used’ (FGC10- suppliers). In addition, they explained that email communication should be encrypted and this is not always possible when sending emails to family members. The care workers interviewed, who are working in the public sector, are not allowed to give their personal telephone number to their patients:
I have the telephone number of a son from one of the homes where I work. He said to me: ‘I give you my number in case something happens’ but I have to call him from the user’s home, I cannot call him from my private mobile. If I am in the patient’s home, I might call him: ‘look, there is something missing here’, or whatever. I can call him but I cannot give him my telephone number
(FGC3-care workers)
In the private sector the use of digital communication is becoming more frequent. Family members and suppliers use WhatsApp groups to exchange information because it is a direct and agile form of contact (Author C & Author B, 2018). However, some managers at private day care centres expressed concerns about using WhatsApp for communication and the ‘potential for data breaches’ (FGC10-suppliers).
4.4.3 Barrier 3: System integration and standardisation
In Ireland, professionals spoke about lack of interoperability at semantic, technical and system levels. There were descriptions of different generations of systems and devices (e.g. fax machines) that cannot ‘speak to each other’, sometimes even within the same institution or department. Fundamentally, the issue was the lack of system-wide thinking. Obstacles imposed by concerns around data protection and privacy also play a major role. For example, all confidential information about a patient transmitted via email to an email address outside of the HSE domain must be encrypted. This includes certain hospitals and most general practitioners (GPs), as the majority of GPs in Ireland operate in a private practice. These extremely cautious practices can generate delays and lead to loss of important documentation.
Similar issues were experience by participants in Catalonia, who pointed out that the EHR is not sharedbetween the public and private sector. This means that a geriatrician working in a private institution cannot access all data from his or her patients. A home care director explains that having access to a patients’ EHR can be summarised in some cases as being ‘lucky’. If the doctor works in a Primary Care Centre or in a hospital, their access to the patient’s EHR is generally guaranteed, however, if the doctor works in the private sector ‘they can be a doctor with their degree and all their experience’ and they still won’ t be able to access the patient’s information (FGC-10). The lack of exchange of information between public and private sector has been highlighted, particularly in difficult situations, when a patient is seriously ill in a nursing home and access to medical records is needed:
Then there is another issue with the [patient’s] EHR, which is linked between the public healthcare system and the nursing homes. It often happens in nursing homes that when we [nursing home’s professionals] need a doctor at three o´clock in the morning, we do not have one; sometimes we do not even have a nurse [on-site]. […] sometimes the patient begins to feel unwell and they only need medication to manage their symptoms, but if we call any emergency service, they will be sent to A&E. Once in the hospital, the professionals there will ask us “Why is this patient here? They are at the end of their life, [what they need] is end of life care …” […] I think that with a bit more support or by having access to the EHR [there would be greater clarity] … (FGC-10 private suppliers).
Professionals who work in private nursing homes do not have access to the EHR. When faced with the need to work as a team with other care providers, they have difficulties in sharing data and information. Interoperability has not yet been achieved, but work in Catalonia has already begun. For example, interoperability between health care and social services departments is being piloted in three districts of Barcelona city council.
Conclusion
We have identified some important enablers and barriers to professionals’ acceptance of e-health initiatives in Ireland and Catalonia. The comparison between these regions showed some commonalities and differences. Both contexts presented similar challenges in the current system centred on ineffective communication and time wasting for professionals and service users, which have a significant impact on the quality of care that can be provided. Ireland can be characterised as a ‘laggard’ in the use of e-health; in contrast to Catalonia Ireland is highly conservative in its approach to data privacy and this has delayed the widespread use of EHR. Catalonia is more advanced than Ireland in the use of e-Health, through the implementation of EHR which has fostered professionals’ sense of efficiency and pride in their jobs, although clearly issues still remain in cross-sector sharing of information. For instance, the city of Barcelona has pioneered a plan to improve interoperability between the EHR and the social service data, which allows social workers and health professionals to have access to both records simultaneously, facilitating coordination among professionals and providing a faster and better quality of services. Nonetheless, both systems need clearer policies and structures in relation to data protection, patient confidentially and privacy.
Professionals in both Catalonia and Ireland are supportive of technology that simplifies their administrative burden and helps to deliver better care. However, professionals also emphasise that for technology to be embraced, it should not replace face-to-face contact or be a substitute for professionals’ autonomy in decision making with regards to care. It would be helpful if e-health initiatives could be introduced alongside the offline (paper) option for a period of time, to allow clients who are not familiar with ICT a transition period to catch up. Alternatively or additionally, resources should be invested into informing, educating and assisting people who are not familiar with ICT, for instance through citizens’ information centres where free assistance with filing in electronic applications is provided. It would be important also that professional associations and regulatory bodies establish clear boundaries within which professional autonomy in decision-making is preserved, overriding ICT solutions if necessary.
Professionals also highlighted the need for training and support for professionals and service users to accompany any e-health initiative. Similarities were found in Catalonia and Ireland concerning key points around system integration, involving all stakeholders in the development of technology and training on ICT skills. Our data show that professionals view e-health as a necessary tool to exchange information, speed up processes and avoid bureaucratic burden but it currently falls short of these promises, largely due to systemic issues.
Our findings indicate that for technology initiatives to work, there needs to be a system-wide thinking approach. While it is important that all stakeholders including patients, carers, and professionals are consulted in the development of a national e-health strategy, this type of strategy needs clear leadership from government. E-health strategy needs to be a national or at least at a regional initiative as considerable resources and infrastructure are needed. Strong links between health and social services are essential to create greater synergies and integration from all relevant public, private and not-for-profit care providers across primary, secondary and tertiary care sectors. It is important that the relationships and interconnections between care settings are explored, looking at both enablers and barriers for the implementation of technologies intended to improve administration and delivery of care services. E-Health tools should be user-friendly for professionals and service users, including people with basic ICT skills. Strong leadership is needed and consideration should be given to introducing incentives and penalties to encourage administrative units in the take-up of e-health services and tools. Finally, resources should be allocated to support e-health literacy to develop the necessary skills to use the tools and technologies effectively. It is hoped that by demonstrating the need for a system-wide approach this paper contributes to the successful adoption of technology to improve the quality of care services for older adults.
[1] The Single Assessment Tool is a comprehensive IT based standardised assessment used to assess the health and social care needs of people (primarily those over the age of 65 years) who may be looking for support under the Nursing Home Support Scheme or Home Help
[2] First generation systems, including personal alarm systems and emergency response telephones, are designed to reduce anxiety among older patients and reduce the use of primary healthcare services. Second generation telecare involves the enhancements of a basic alarm model with the addition of sensors for monitoring falls or temperature. Third generation telecare involves more advanced systems that gather large amounts of information from the person and home in order to support pro-active care service interventions (CARDI, 2011).
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