How can technology adoption be speeded up in the NHS?

Technological innovation has long been central to improvements in healthcare. Whether in the form of new products, procedures and treatments, or health-related application of ICT systems, new technologies can help to make patient care more flexible and responsive, and ensure efficiency in use of scarce public sector resources.

Furthermore, technology ‘adoption’ by decision makers and professionals is increasingly supported by an evidence base relating to the effectiveness and cost effectiveness of new interventions.

Repositories of systematic reviews and economic evaluations are available from sources such as the Cochrane Collaboration, the National Institute for Health and Clinical Excellence (NICE) technology appraisals and clinical guidelines programmes, and the NHS Economic Evaluation Database.

Although uneven, these sources of research and analysis have gradually spread to non-pharmaceutical technologies and methods for assessing a greater range of innovations are being constantly refined. What’s more, recent times have seen a burgeoning literature focussing on how health care organisations and systems can respond to innovation in technology production.

The momentum behind the evidence-based movement in healthcare has been supported and promoted in government policy and independent reviews of NHS performance including Wanless 2004 [1], Cooksey 2006 [2] and Darzi 2007 [3].

The rationale for improving rates of technology adoption has a number of strands. Replacing outdated practices with more effective innovations will help deliver on the UK government’s plans for a ‘world class’ NHS which is at the forefront of quality in healthcare. New developments in telecare also promise to aid the shift from an acute-based service to one in which prevention, self-care and patient choice are to the fore.

The increasing need to make efficiency improvements in the NHS is also supported by investment in cost saving interventions and implementation of ICT-based record keeping and decision making systems. Underpinning each of these aspirations is the importance of technology in shifting from a monolithic and risk-averse system to one in which learning and innovation are actively encouraged in the pursuit of evidence-based practice.

Despite this context and an estimated annual spend of some £3 billion on medical devices, the rate of adoption of technology into healthcare practice in the UK is commonly considered to be poor. The English NHS is considered to lag behind adoption in non-healthcare sectors as well as healthcare systems elsewhere.

This has led to an increasing recognition that whilst generating an evidence base may be a necessary condition of technology adoption, more needs to be done. This is reflected in both the recently instituted ‘NHS Technology Adoption Hub’ and in the focus on implementation of best practice within NICE. Despite these developments, the adoption gap remains stubbornly in place. Research in this area suggests the existence of a number of barriers preventing the routine uptake of potentially beneficial and cost-saving innovations.

Individuals

Features of technologies themselves can trigger or inhibit adoption. Put simply, the message is that usefulness and ease of use are key factors. If the benefits of new practices are not clearly visible and/or its adoption requires substantial changes to professional practice, it will struggle to make an impact.

This is a tricky issue to negotiate as clearly one of the key objectives of technological advancement is to disrupt and, in time, to replace outdated practices.

However, the message remains clear: the extent to which new technologies require significant changes to job roles and practices will affect patterns of resistance and acceptance. If individuals believe their work will be adversely affected as a result of the technology, or if it is perceived to be difficult to implement, there is an increased likelihood that they will reject the new technology.

Indeed, research suggests that patients and the public are generally ‘readier’ for change than are those providing care. There are good reasons for this resistance. The range and volume of both information and reform that healthcare professionals are required to manage has increased at a phenomenal rate, leading to a reported overload. Subsequent uncertainty and fatigue will inevitably make adopters risk-averse. These concerns are often reinforced by concerns over the nature of the proposed implementation.

Organisations

Individual adoption is only one component of the diffusion of technologies and a number of aspects of organisational context have been found to impact on adoption.

Although organisational context is understood in different ways by different research traditions, all agree that it is central to achieving change in line with best practice or evidence. There needs to be a fit between the technology and the prevailing decision making environment, and with: existing technologies; workflow; the environment, and; other social systems.

Healthcare organisations are complex and difficult to change. Without a clear vision of how all aspects of the organisation are implicated in the introduction of new practices, it is difficult if not impossible to make the necessary changes. Path dependence at both organisational and institutional level can be a powerful antidote to change.

Once the system has ‘locked onto’ a specific path it is difficult to change direction. As such, services may have a tendency to continue to operate in a particular way, rather than adopting what might seem rationally to be a useful innovation to adopt.

Bridging the gap

Evidence dissemination

A number of strategies are available for disseminating evidence about the benefits of new innovations. These include conferences or workshops to disseminate best practice in the adoption of technologies, and more commonly, guidelines for practitioners.

Of these, the evidence suggests that clinical guidelines are marginally more effective in facilitating behaviour change amongst professional groups, although little is known about their cost effectiveness.

More recently, electronic support for technology adoption has been developed, including electronic guidelines, medical informatics, decision support and reminder systems, and computer-based record keeping.

These offer some extra benefits when compared to traditional paper-based approaches. However, although it is notoriously difficult to measure the impact of such strategies (primarily due to the complexity of healthcare organisations) the overall message appears to be that they do not adequately overcome the aforementioned barriers to adoption.

Networks and knowledge exchange

One of the keys to triggering greater rates of adoption appears to be moving from transfer of knowledge to facilitation of knowledge exchange.

A number of studies and reviews have indicated that social interaction is a key catalyst of change management and best practice dissemination.

Direct interaction with researchers and product manufacturers is thus likely to be critical in overcoming uncertainty and resistance. Furthermore, the reassurance provided by ongoing interaction with peers and experts might address concerns relating to the risk of technology adoption.

Successful adoption depends on individuals’ capacity to buy into the changes required and this cannot be wholly imposed through a top-down model of dissemination.

Skills and leadership development

It seems likely that improving the information-processing capacity of implementing organisations will help to overcome some of the current barriers to information access, interpretation and evaluation of technology outputs.

Well designed training programs have been shown to promote end user acceptance of technology both through improved understanding and increased feeling of involvement in decision making. The identification and nurturing of adoption ‘champions’ and ‘leaders’ will also help to overcome resistance to change.

Implications for manufacturers

Overall, the evidence suggests that adoption depends on the creation of a receptive context. The ability of organisations to absorb and act on new knowledge will be influenced by effective leadership, strong networks (both formal and informal) and an appropriate knowledge and skills base.

A compatible strategic vision and a favourable approach to risk taking and experimentation are also important. Investment should be targeted towards multi-level tools and frameworks for technology adoption which take enhancing ‘absorptive capacity’ as their primary focus.

Development of technology-adoption training should also be investigated, alongside programmes for nurturing adoption champions and leaders.

However, there is also a role for the technology-manufacturing sector. Firstly, it is important to recognise that developing an evidence base is only the start. Ease of implementation is of equal if not greater importance.

Technology producers should incorporate the principles of knowledge management in the design and production of innovations and actively plan for adoption and implementation.

Key questions to ask prior to introduction of new technologies are:

• what is the value added of the innovation?
• is it easily evident to those who carry it out as well as to those for whose benefit the innovations have been introduced?
• can the added value be demonstrated?

Learning from the diffusion of innovation literature suggests that adoption strategies need to engage those responsible for adoption as active change agents rather than passive implementers.

People actively seek out, experiment with, evaluate, learn about, work around, discuss and modify technologies, and each of these activities will influence both feelings and behaviour regarding adoption. End-user participation in all stages of technology design and implementation will make adoption far easier.

Iestyn Williams
Lecturer, Health Services Management Centre, University of Birmingham, UK

References

1. The 'Wanless Report': Securing Good Health for the Whole Population, 2004. www.hm-treasury.gov.uk/Consultations_and_Legislation/
wanless/consult_wanless04_final.cfm

2. The 'Cooksey Review': A Review of Health Research Funding, 2006
www.hm-treasury.gov.uk/independent_reviews/
cooksey_review/cookseyreview_index.cfm

3. The Darzi Report: Our NHS Our future: NHS next stage review — interim report, 2007.
www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/dh_079077