The eHealth readiness of Australia's medical specialists - Final Report

Possible adoption intervention levers

Page last updated: 30 May 2011

Given the insights into infrastructural, aptitudinal and attitudinal readiness described above, it is clear that interventions that focus solely on, for example, educating and training the individual practitioner would be insufficient. Necessarily, they would fail to address some of the more fundamental barriers to adoption, such as real concerns about the suitability or limitation of the sets of eHealth solutions and how they are delivered, or the network- or environment-based constraints and influencers.

Drawing on the experience of the pharmaceutical industry and its approach to major product launches in the healthcare system, we believe that an effective approach to eHealth adoption by medical specialists and across the health system needs to simultaneously consider interventions along three complementary axes:

  • Shaping the eHealth products, i.e. the eHealth solutions as a whole, including any IT hardware, software, delivery and support
  • Shaping the demand for those applications among medical specialists, and
  • Shaping the health ecosystems in which those specialists work.

This section briefly defines a range of interventions in each of these three areas that would each be necessary, and together would be sufficient, to secure widespread adoption of particular eHealth solutions. In each area, some interventions will work better with some clusters than others. Further, the interventions will need to be staggered through the natural phases of the strategy: its establishment period, a time in which momentum is built, and a time for consolidating real change. This section concludes with an indication of when best to engage each intervention, and with which clusters.

Shaping eHealth products

A number of barriers to adoption of eHealth stem from concerns about the eHealth ‘product’ itself, such as the security, privacy, suitability, interoperability, usability, reliability or cost (of installation and operation) of the solutions. Therefore an effective adoption strategy cannot be limited to engaging or shaping the demand. Interventions are needed to lower the product-related barriers (real or perceived), thereby tailoring the product or its delivery to the differentiated needs of the medical specialists.

The surveys and interviews clearly identified a number of real and perceived concerns about the eHealth solutions or ‘products’ themselves, spanning their suitability, interoperability, usability, security, reliability or cost (of installation and operation). Some effort has to be made to ensure that the offered solutions are appealing to their users and effective for health outcomes. Any adoption strategy therefore needs explicit interventions focused on the ‘product’ itself, and not be limited to engaging or shaping the demand. These interventions would aim to tailor products to the differentiated needs of both specialties and clusters, and to reduce the product-related barriers (real or perceived) analysed in Section 5.

  • Establish basic standards and certification criteria based on core use objectives. These standards should apply to products used by practitioners across the entire health space, not just those used by medical specialists, to lay the groundwork for system-wide connectivity and information exchange
    • Address compatibility concerns by spearheading coordination between standards organisations, software vendors, and other relevant bodies to promote adherence to clear interoperability standards
    • Develop and institute an accreditation program to certify products that meet these guidelines, and create a certification logo or other clear identifier so specialists can easily find certified systems. In the short-term, work with early adopters to prioritise interoperability needs and identify alternative/intermediate modes of interoperability, e.g. allowing flexibility or an evolution path for less mature systems, users or organisations (however, these need to be carefully considered to avoid interim solutions becoming ‘permanent’ for some users). In the long-term, require use of certified systems to receive Medicare reimbursement

Target clusters

Rationale

eHealth entrepreneurs30% of cluster 1 (eHealth entrepreneurs) strongly agree that external compatibility is a barrier, and 26% for internal compatibility. These are the two largest perceived barriers, stemming from this cluster’s already strong use of eHealth solutions. Leaders from this cluster should be actively engaged in identifying the highest priority interoperability needs and challenges, and identify options to overcome them in the short-term and longer-term
Network adopters32% of cluster strongly agrees that internal compatibility is a barrier, and 19% for external compatibility. Although this cluster tends to be more internally focused at the present time, as a larger number of practitioners outside the hospital setting gain the ability to connect, external connectivity will rise in importance

Network adopters have the strongest interest in access to shared records (82% strongly agree). Resolving their barriers to record sharing will be critical for achieving rapid uptake in accessing and using shared patient health records.

Capable but unconvincedEfforts to enhance compatibility and technical stability will also reduce barriers for this cluster, but will not be sufficient to drive widespread change. 15% of cluster strongly agree that internal compatibility is a barrier, and 10% external compatibility. Although these are two of the greatest barriers, they are much less significant for this cluster as compared with perceptions among specialists in general (32% and 23%, respectively).
Apprehensive followers45% of apprehensive followers strongly agree that internal compatibility is a barrier, and 33% for external compatibility. These are just two of many perceived barriers for this cluster, so while addressing compatibility is important, it is unlikely to be sufficient for driving significant change
    • Identify ways to make adoption easy for specialists, with a focus on minimising workflow disruptions, improving user-friendliness of products, increasing the relevance of products to specialists’ needs, and increasing access to eHealth solutions. Possible mechanisms to achieve these improvements include:
      • Connect early adopters with vendors to identify improvements and enhancements. Provide incentives for early adopters to pilot or trial new products since they are much less likely to be discouraged by unexpected issues and can help resolve problems before the systems are shared with their more risk-averse peers
      • Publically recognise strong products for specific specialty needs and/or offer optional certification for systems that have the appropriate functionality for a specific specialty segment
      • Add a ‘cloud’ platform option for delivery of some solutions, especially for the more isolated small practices
      • Aggregate data and feedback from users to provide specialists with peer reviews that can help inform purchase and usage decisions
      • Incorporate usability ratings into publically available product reviews to motivate vendors to improve user-friendliness of systems and help practitioners find systems that are considered easy to operate by others in their specialty.

    Target clusters

    Rationale

    Network adoptersThe two leading responses to the open ended question, ‘What single factor would persuade you the most to increase your adoption of eHealth solutions’ were ease of use/user friendliness (12%) and increased efficiency (12%)
    Capable but unconvincedDespite access to resources, sufficient IT support, and the ability to select and implement new systems, some members of this cluster are concerned with the poor usability of existing systems (21% cited improved ease of use/user friendliness as the single factor that would most persuade them to increase adoption)
    Apprehensive followers13% cited improved ease of use/ user friendliness as the single factor that would most persuade them to increase adoption. Practitioners also discussed problems with usability during interviews. One specialist cited a recent example where someone new to her practice accidentally pressed a button that deleted several months’ worth of appointments and billing records.
    Uninterested27% of cluster strongly agrees that they can’t find a solution that meets their needs; many of the specialists in this cluster are surgeons and psychiatrists, whose needs frequently differ from the typical GP or internal medicine user

    6% cited improved ease of use/ user friendliness as the single factor that would most persuade them to increase adoption

    • Provide solutions to mitigate risk of malfunctions or downtime (and improve other non-functional requirements such as latency, etc). A number of measures can be considered, either to improve performance, mitigate the consequences of lapses in performance, or address the perceptions of performance. These could include:
      • Communicate transparently on system performance metrics (including uptime and malfunctions) and issue resolution response times
      • Communicate transparently on user experience and feedback of systems (via surveys or online/virtual forums)
      • Factor initial transitory productivity dips in resource plans when the new solutions are introduced in larger care settings (such as hospitals), ( temporarily over-staff or reduce caseload in the days/weeks when the solution is introduced, so that initial productivity dips due to initial learning phase does not translate into patient experience or quality impacts)
      • Appoint and communicate the availability of an on-call emergency IT support team to ensure rapid issue resolution and improve accessibility of IT support for private practitioners. This could be delivered as a shared service at a local level (e.g. by a local health network or by a large hospital)
      • Implement safety precautions by providing practitioners with information and risk management solutions such as regular back-ups of data
      • Coordinate with IT vendors to track technical malfunctions and determine the causes and solutions in a timely manner. Provide certification ‘kitemark’ to vendors meeting support level standards and/or impose penalties on vendors that are unresponsive to technical issues or repeatedly launch software without adequate issue-resolution support

        Target clusters

        Rationale

        eHealth entrepreneursIncreased/improved IT support was cited by 14% of cluster as the single factor that would most persuade them to increase their use of eHealth
        Network adoptersMalfunctions or downtime are also perceived as a large barrier (23%). ‘System proven to be reliable’ was cited as the single most important factor in driving increased for approximately 11% of the cluster
        Apprehensive followersMalfunctions or downtime are perceived as a large barrier for this cluster (58% strongly agree, the largest across all segments). 51% strongly agree that they prefer to wait until technology-based systems are proven before adopting them. 14% listed increased/improved IT support as the single factor that would most persuade them to increase their use of eHealth.

    Shaping eHealth demand

    The research identifies wide variations in the intended use of eHealth solutions, and in the attitudinal underpinnings of these variations. The clusters have markedly different perceptions of the benefits, costs and risks of eHealth. The effort to shape the demand for eHealth solutions must be grounded in the needs profiles identified in the research: by specialty and by cluster. Examples of demand-shaping interventions are outlined below, focused on defining and proving tailored value propositions, and stimulating awareness and early adoption.

    As well as ensuring the eHealth solution will be effective, the strategy will need to respond to current specialist attitudes towards eHealth, and help shape their future ones. Among specialists, there are wide variations in the intended use of particular eHealth solutions, driven by diverse perceptions of their benefits, costs and risks. To make those perceptions more positive, interventions are needed that more clearly communicate measured benefits, both to practice efficiency and to healthcare outcomes. This effort must be guided to meet the specific concerns of individual specialties and clusters. Practitioners, and others whom they trust, will be needed to demonstrate successful eHealth solutions, talking to both their benefits and the ways in which barriers and risks are managed. Some examples of demand-shaping interventions are outlined below, which define, prove and communicate the case for adoption, and stimulate awareness and early adoption.

    • Establish a measurement and evaluation framework to track desired outputs and outcomes. Communicate evidence that reinforce both patient-related and efficiency-related eHealth benefits, by:
      • Defining the value propositions that are most relevant to each cluster and specialty
      • Identifying short-term usage metrics that are easy to track and monitor (e.g. number of specialists using ePrescribing) and connecting them with long-term outcomes (e.g. reduction in hospitalisations due to fewer prescription errors) to provide compelling evidence for change
      • Create credible evidence via relevant use case implementations (actively shaping these to make sure they ‘meet the bar’, in terms of level of evidence required). Use pilot implementation sites to build an evidence case for change and refine solutions prior to a full-scale rollout
      • Determining the most effective channels for communicating evidence to each cluster (e.g. academic publication, professional body, patient representation body, peers)

        Target clusters

        Rationale

        eHealth entrepreneurs72% of eHealth entrepreneurs strongly agree that continuity of care will be a benefit of eHealth. 70% strongly agree with efficiency, and 65% with collaboration.

        15% of this cluster cited either ‘a guarantee of better patient outcomes’ or ‘if it were shown to increase practice efficiency’ as the single factor that would most persuade them to increase adoption

        Network adoptersPromote examples of successful use by other practitioners and change champions and use peers to specifically reinforce messages of collaboration, continuity of care, and quality of care

        Single largest driver of adoption is use of technology by other practitioners – 16% of segment strongly agree this will drive behaviour and adoption.

        77% strongly agree that collaboration is a benefit of eHealth, 71% of segment with continuity of care, and 65% strongly agree with quality of care

        Capable but unconvincedThe primary goal for this segment is to shift their perceptions of eHealth. Just 9% (vs. 30% for all specialists) strongly believe that it will increase patient safety and 15% (vs. 35% for all specialists) strongly believe that it will improve quality of care. In the absence of perceived benefits, these specialists see little reason to adopt the new solutions. Nearly 15% of this cluster cited either ‘a guarantee of better patient outcomes’ or ‘if it were shown to increase practice efficiency’ as the single factor that would most persuade them to increase adoption. 41% strongly believes that eHealth will improve efficiency, which was the most commonly perceived benefit
        Apprehensive followers11% of this cluster cited ‘if it were shown to increase practice efficiency’ as the single factor that would most persuade them to increase adoption. A further 7% cited ‘a guarantee of better patient outcomes’ as the single factor that would most persuade them to increase adoption.
        Uninterested8% of this cluster cited ‘if it were shown to increase practice efficiency’ as the single factor that would most persuade them to increase adoption. A further 8% cited ‘a guarantee of better patient outcomes’ as the single factor that would most persuade them to increase adoption

    • Disseminate accurate information and education on product use and risks, relevant to the specific needs and concerns of practitioner groups. This will serve two primary objectives. First, it will raise awareness of eHealth among the clusters that have not moved towards adoption. Second, it will help address the existing misconceptions around eHealth risks (breaches of privacy) and help practitioners feel confident that these risks can be mitigated. Some channels for spreading information include:
      • Medico-legal groups, which reach a large number of specialists and are well-positioned to offer guidelines, training programs, and possibly premium discounts for practitioners using eHealth in ways that reduce their legal liability risk
      • Specialist colleges, which can offer information on best-practice usage guidelines targeted towards specific specialty segments, incorporate eHealth into specialist training programs, reinforce messages about eHealth benefits and offer continuing professional development courses specifically related to eHealth
      • Conferences, which frequently attract specialists within specific practice and interest areas. Interactive exhibits provide the opportunity to demonstrate product use and offer specialists free trial versions of certain eHealth products (on a USB stick or as iPhone apps). Additionally, eHealth entrepreneurs can be invited to present and share their experiences and innovative solutions with like-minded peers
      • Clinical leaders, who can share information with specialists and provide support on a one-on-one basis. This is one of the most effective channels for persuasion, but the trade-off for greater depth of impact is reduced breadth.

    Target clusters

    Rationale

    eHealth entrepreneurs50% of eHealth entrepreneurs strongly agree that professional bodies will influence their uptake of eHealth solutions. This is by far the highest across all segments – professional bodies have tremendous potential to exert influence with this group
    Network adopters16% strongly agree that requests from other practitioners would influence them to increase their uptake of eHealth, which is the strongest driver for this cluster

    47% strongly agree that concerns about breaches of patient privacy are a barrier

    Apprehensive followers17% strongly agree that professional bodies will strongly influence them. Since this cluster is less comfortable with eHealth technology, it frequently looks to peers and professional bodies for advice on which systems to adopt
    Uninterested33% of segment strongly agree with patient privacy being a barrier

    7% stated that a guarantee of safety / data confidentiality is the single factor that would most persuade them to increase their use of eHealth solutions


  • Recognise and promote successful use cases. Unlike GPs, medical specialists often work in niche areas with very specific needs and uses for technology. Customisation is therefore more difficult, but essential nonetheless. By publically sharing innovative approaches, other practitioners may be better able to identify similar ways to use the solutions within their practice. Also, IT vendors will gain a better perspective on the needs and ideal use cases for this specialised customer base. Specific options for disseminating this information include:
    • Formally recognise innovative and promising uses of eHealth technology and appoint an innovations team to identify ways to replicate these programs across Australia. Provide eHealth entrepreneurs with public recognition for their efforts and also share their innovative solutions to encourage further adoption
    • Create opportunities for members of target clusters to directly experience or observe the benefits of eHealth implementation (via simulations, continuous education, exposure in a care setting in which they occasionally or regularly practice, exposure to peers in their practice who are already adopters).

Target clusters

Rationale

eHealth entrepreneursA relatively small but still significant percentage (21%) of eHealth entrepreneurs strongly agree that they are influenced by respect and recognition, and this type of program will resonate strongly with this subset
Network adoptersSimilar to the eHealth entrepreneurs, the widespread use of eHealth in this cluster positions it well to communicate and share benefits across the medical ecosystem. 24% are already using telehealth (vs. an average of 9% across all specialties) and 53% are using electronic health records (vs. an average of 42%).
Capable but unconvincedAs adoption and usage rates begin to rise, this cluster is more likely to respond to peers as compared with other potential influences. 12% of cluster strongly agrees that requests from other practitioners will drive their use of eHealth

  • Provide assurance on the intended use of practitioner performance data. With the increased availability of information, some practitioners are concerned about the implications if data on their performance or medical decisions is made publically available. Some steps to mitigate this concern could include:
    • Inviting practitioners to discuss and align on the most important and relevant performance metrics in their specialty or sub-specialty
    • Providing reassurance that data will not be used for punitive purposes, access will be restricted and confidentiality will be enforced
    • Sharing data at the appropriate level of detail, i.e. providing information on a practitioner’s performance quartile rather than on their specific score
    • Using performance data in ways that benefit practitioners, by providing anonymous benchmarking so that they can compare their performance to peers in a non-threatening way.

Target clusters

Rationale

Apprehensive followers26% strongly agree that the risks associated with increased visibility of practitioner performance data are a barrier
Uninterested31% strongly agree that the risks associated with increased visibility of practitioner performance data are a barrier

  • Embed eHealth solution deployment in the context of a broader change initiative to improve the care delivery model or process that has directly perceived benefits to the targeted cluster. For example, fund or set up a program to improve the stroke pathway, requiring the inclusion of the relevant required enabling technologies.

Target clusters

Rationale

eHealth entrepreneursThis cluster cares about patient outcomes, and will likely be motivated by an initiative that is seen to advance patient care. Additionally, they are already excited about eHealth and will help lead adoption in their network
Capable but unconvincedConnecting eHealth deployment with an initiative viewed as beneficial to this cluster attaches value to the eHealth solution, which may be sufficient to spur adoption
Apprehensive followersApprehensive followers may be more easily sold on the greater initiative, and if the eHealth solution is a small part of the picture than the barriers may be perceived as less when compared with the impact of the initiative as a whole
UninterestedEven though they are uninterested in eHealth, if an eHealth application were tied to something of strong interest, they may be willing to adopt the eHealth component to achieve better outcomes


    Shaping the health ecosystem

    Introducing eHealth solutions that affect care delivery models require coordinated approaches across the healthcare system. The research has confirmed that medical specialists are influenced by overall system changes and benefits. The eHealth adoption strategy therefore needs to help create the conditions in the ecosystem which influence and support adoption, within and across clusters. This includes a regulatory and incentive environment in which vendors, professional bodies and practitioners can develop and adopt the right solutions.

    Even where effective eHealth solutions are in demand, their adoption must be coordinated across the healthcare system to maintain the integrity of care delivery. The eHealth readiness research has confirmed that quality care delivery across the health ecosystem does influence adoption by individual specialists, so long as it does not compromise their own practice efficiency. The eHealth adoption strategy must therefore include interventions to create ecosystem conditions that support adoption, and to ensure care delivery benefits are secured by those adoptions. Many of these interventions must be guided from the top – governments must establish the regulatory and incentive environment before vendors and professional bodies can respond, with individual practitioners being the final tier.
    • Cultivate eHealth pioneers as change champions to drive more widespread adoption. eHealth entrepreneurs are generally excited to engage and share their experiences, especially those who have spent significant amounts of time developing and implementing their own proprietary systems, are thus a valuable source of information and insights. However, due to their busy schedules they are also time-constrained and may be difficult (or costly) to engage on a long-term basis. Some options for engaging with them include:
    • Form an online panel of eHealth entrepreneurs to maintain a strong connection with this critical group, test and get feedback on potential engagement strategies, capture and document best-practices for use, and help track benefits
    • Give formal system deployment roles to senior tech-savvy practitioners since they are more likely to have both the time and the interest to help progress eHealth adoption, and will also be well-known and respected by their peers.

    Target clusters

    Rationale

    eHealth entrepreneursOther practitioners rank as one of the most significant sources of influence among the other clusters. One cluster member provided an example of how she was able to effect change in her hospital. She was so excited about computerised decision-making algorithms related to her specialty that she carried around USB drives with the time-saving tools and handed them out to her peers. Because the tools were relevant, easy to use, and endorsed by an experienced and well-respected peer, they were quickly adopted.
    Apprehensive followersForm a group of influential early adopters from this cluster that interfaces with and therefore has the ability to influence hospital-based specialists across other disciplines. 75% of this cluster is hospital based, and although they are typically localised within three segments, these segments often interface with groups that are more difficult to influence (e.g. surgeons).
  • Identify and target critical adoption ‘nodes’ (care settings where many specialists practice occasionally, to ensure broad exposure of eHealth solution to many specialists), or care settings with high intensity of interaction with specialist practice settings. Additionally, target specialists who frequently interact with other practitioners and therefore have multiple influence points, such as the radiologists and pathologists Some specific examples related to pathology include:
    • Collaborate with pathologists to identify ways to increase ease of use for referring doctors. For instance, the pathology group at a hospital in South Australia developed an app for all the doctors affiliated with the hospital so that they can receive alerts and test results from the pathology department on their iPhones
    • Provide pathologists with information and training that can be used to help overcome specialists’ concerns (explain how electronic notifications will work so that specialists don’t overlook a critical diagnosis and explain the benefits of using computerised systems to provide guidelines for test requests)
    • Coordinate with pathologists to overcome potential challenges associated with increased information sharing, interpreting results from different laboratories (using different reference ranges) on the same electronic record.
  • Design and offer training workshops targeting support staff. Although support staff will not train specialists, they often have a key role in influencing adoption and use in the practice, and they also use the systems themselves (by entering information in a structured format after a specialist dictates their notes). Strong knowledge of the systems also helps them respond quickly if specialists have questions or concerns.

    Target clusters

    Rationale

    eHealth entrepreneurs23% of eHealth entrepreneurs strongly agree that support staff will influence their use of eHealth. Although this is a small percentage relative to other drivers, it still reflects a significant lever for influence. Conversations with practitioners suggest that practice managers play a key role in influencing adoption due to their ability to provide information on potential systems and their role in providing training and support once systems are implemented
    Capable but unconvinced9% strongly agrees that requests from support staff will influence them to increase adoption
    UninterestedDespite low computer use and interest in eHealth, 73% of this cluster use electronic billing systems. It is likely a practice manager or supporting staff role that is responsible for these systems and who could influence adoption of future eHealth applications
  • Offer incentives for eHealth use targeting small private practices that lack the scale to justify large-scale IT investments. Tie financial rewards or reimbursement to evidence that eHealth solutions are being used in a way that advances health outcomes.

    Target clusters

    Rationale

    eHealth entrepreneurs56% of eHealth entrepreneurs strongly agree that financial incentives will influence their uptake of eHealth solutions, the highest of all segments. Since there are many alternative influence levers for eHealth entrepreneurs, however, financial incentives may not be necessary to drive change
    Apprehensive followersFinancial incentives are important for this segment. 30% strongly agree that financial incentives will influence adoption

    19% cited financial incentives as the single factor that would most influence them to increase adoption. A further 5% cited ‘Appropriate Medicare rebates/remuneration for time’ as the single factor that would most influence them to increase adoption. Practitioners mentioned during interviews that costs are an especially large burden on small practice groups

  • Create transparency on adoption levels and momentum within healthcare communities in which specialists participate, and publicise commitments to future adoption timing by practice/specialist.

    Target clusters

    Rationale

    Apprehensive followers28% of apprehensive followers strongly agrees that there aren’t enough people using eHealth systems for them to provide a benefit. 51% prefers to wait until technology-based systems are proven before adopting them. Anecdotal evidence from interviews with specialists in this cluster suggest that they will adopt something new when they perceive that everyone else is already doing it
    Uninterested24% of uninterested cluster strongly agrees that there aren’t enough people using eHealth systems for them to provide a benefit. 36% prefers to wait until technology-based systems are proven before adopting them, and 8% of cluster responded that if they weren’t approaching retirement they would be more likely to change

Enforce system-wide measures to mitigate privacy risk. Provide practitioners with information, training and support so that they understand how to minimise risk of privacy breaches and maintain security of information in their practices. Audit practices to ensure that these measures are being adhered to. Although this solution is intended to remove barriers for the network adopters and uninterested, interventions will need to be applied universally to ensure that the entire health network is safe and secure.

Target clusters

Rationale

Network adopters47% strongly agree that concerns about breaches of patient privacy are a barrier to adoption
Uninterested33% of segment strongly agree that patient privacy is a barrier

7% stated that a guarantee of safety/data confidentiality is the single factor that would most persuade them to increase their use of eHealth solutions


Require mandatory participation in eHealth programs.

Target clusters

Rationale

Apprehensive followersSome members of this cluster may be unwilling to change unless they perceive no other alternatives. For example, one practitioner explained that the only reason she used computerised records was because she didn’t have a choice. When her practice decided to move to an electronic record keeping system, they make it nearly impossible for her to access paper-based files. She soon realised that scribing notes on small pieces of paper wasn’t an effective way to track her patients over time, so she made the change to computerised records
UninterestedThis cluster is uniformly negative in their perspective of influencing drivers, and 13% responded ‘nothing’ when asked what single factor would most persuade them to adopt and use eHealth solutions

Actively coordinate simultaneous adoption within targeted healthcare delivery communities or pathways in which specialists participate, to actively address concerns/barriers related to lack of peer or network participation. Focus on a specific patient cohort, a condition, or a type of provider-provider relationship and then address the full spectrum of participants in that network to demonstrate the full potential for improved information sharing and coordination of care. This intervention will be effective across all clusters, and achieving a balance between them will help ensure that the more enthusiastic adopters are able to influence and bring along their more hesitant counterparts.