Extending a framework for understanding the early phases of eHealth implementation: the Digital Health Engagement Model (DIEGO)

Problem

Ageing populations combined with rising numbers of people with chronic conditions has placed huge burdens on patients, families and primary care systems worldwide. A range of mobile, online, wearable and sensor technologies are being utilised to support healthy lifestyles and encourage patient self-management. However, these electronic tools are often difficult to implement in the real-world. Engaging patients and the public in digital health and getting them signed up to these technologies is challenging as barriers can affect deployment in community settings. This study aimed to explore how patients and the public engaged with and enrolled in all types of digital health interventions (DHIs). It also aimed to refine and extend a Digital Health Engagement Model (DIEGO) developed from a systematic review to improve eHealth implementation going forward.

Approach

A large (£37 million) digital innovation programme called Delivering Assisted Living Lifestyles at Scale (dallas) ran in the United Kingdom from June 2012 – 2015. It undertook a large-scale roll out of many kinds of DHIs with different populations of patients and people who were healthy. These included telehealth and telecare systems, mobile health applications, wearable and assisted living devices and online health and wellbeing portals. This exploratory study conducted secondary analysis on baseline, midpoint and endpoint interviews (n=47) with numerous stakeholders implementing these technologies. Primary data collection included focus groups (n=5) with patients, carers and clinicians and interviews (n=14) with them and some of those implementing the DHIs. Analysis followed the framework approach and was guided by Normalization Process Theory.

Findings

Numerous factors seemed to affect how patients and the public engaged and enrolled in digital health products and services. Building on the results of the systematic review, these were grouped into five themes; 1) personal perceptions and agency, 2) personal lifestyle and values, 3) digital accessibility, 4) implementation strategy and 5) quality of the DHI. New concepts including the cost of technology and how it is funded, its integration with health service providers and digital infrastructure came to the fore, while others such as personal values and tailored support were strengthened enabling a more in-depth understanding of implementation. An extended taxonomy of engagement and enrolment strategies was also created.

Consequences

Disentangling the early phases of implementation and offering clearer distinctions between engaging and enrolling patients and the public in DHIs is critical to improve how this is done. As a framework, DIEGO was developed to help researchers, clinicians, companies and policy makers appreciate the dynamics of deploying digital health products and services, to help minimise barriers while maximising the factors that facilitate the process. These findings confirm the validity of the constructs in the initial DIEGO model and identified further elements that will be important to consider to enhance engagement with digital health long-term.