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Modeling the Implementation Context of a Telemedicine Service: Work Domain Analysis in a Surgical Setting
KTH, School of Engineering Sciences in Chemistry, Biotechnology and Health (CBH), Biomedical Engineering and Health Systems, Health Informatics and Logistics.ORCID iD: 0000-0001-8747-9277
KTH, School of Engineering Sciences in Chemistry, Biotechnology and Health (CBH), Biomedical Engineering and Health Systems, Health Informatics and Logistics.ORCID iD: 0000-0003-1126-3781
2021 (English)In: JMIR Formative Research, E-ISSN 2561-326X, Vol. 6, no 5, article id e26505Article in journal (Refereed) Published
Abstract [en]

Background:A telemedicine service enabling remote surgical consultation had shown promising results. When the service was to be scaled up, it was unclear how contextual variations among different clinical sites could affect the clinical outcomes and implementation of the service. It is generally recognized that contextual factors and work system complexities affect the implementation and outcomes of telemedicine. However, it is methodologically challenging to account for context in complex health care settings. We conducted a work domain analysis (WDA), an engineering method for modeling and analyzing complex work environments, to investigate and represent contextual influences when a telemedicine service was to be scaled up to multiple hospitals.

Objective:We wanted to systematically characterize the implementation contexts at the clinics participating in the scale-up process. Conducting a WDA would allow us to identify, in a systematic manner, the functional constraints that shape clinical work at the implementation sites and set the sites apart. The findings could then be valuable for informed implementation and assessment of the telemedicine service.

Methods:We conducted observations and semistructured interviews with a variety of stakeholders. Thematic analysis was guided by concepts derived from the WDA framework. We identified objects, functions, priorities, and values that shape clinical procedures. An iterative “discovery and modeling” approach allowed us to first focus on one clinic and then readjust the scope as our understanding of the work systems deepened.

Results:We characterized three sets of constraints (ie, facets) in the domain: the treatment facet, administrative facet (providing resources for procedures), and development facet (training, quality improvement, and research). The constraints included medical equipment affecting treatment options; administrative processes affecting access to staff and facilities; values and priorities affecting assessments during endoscopic retrograde cholangiopancreatography; and resources for conducting the procedure.

Conclusions:The surgical work system is embedded in multiple sets of constraints that can be modeled as facets of the system. We found variations between the implementation sites that might interact negatively with the telemedicine service. However, there may be enough motivation and resources to overcome these initial disruptions given that values and priorities are shared across the sites. Contrasting the development facets at different sites highlighted the differences in resources for training and research. In some cases, this could indicate a risk that organizational demands for efficiency and effectiveness might be prioritized over the long-term outcomes provided by the telemedicine service, or a reduced willingness or ability to accept a service that is not yet fully developed or adapted. WDA proved effective in representing and analyzing these complex clinical contexts in the face of technological change. The models serve as examples of how to analyze and represent a complex sociotechnical context during telemedicine design, implementation, and assessment.

Place, publisher, year, edition, pages
JMIR Publications Inc. , 2021. Vol. 6, no 5, article id e26505
Keywords [en]
Work Domain Analysis; telemedicine; context; implementation
National Category
Medical Ergonomics
Research subject
Medical Technology; Human-computer Interaction
Identifiers
URN: urn:nbn:se:kth:diva-297778DOI: 10.2196/26505ISI: 000853672100016PubMedID: 34152278Scopus ID: 2-s2.0-85108822880OAI: oai:DiVA.org:kth-297778DiVA, id: diva2:1570855
Note

QC 20210623

Available from: 2021-06-22 Created: 2021-06-22 Last updated: 2023-09-21Bibliographically approved
In thesis
1. Unpacking the Sociotechnical Complexity of a Surgical Setting: Capturing the Context of Use to Inform Design and Evaluation
Open this publication in new window or tab >>Unpacking the Sociotechnical Complexity of a Surgical Setting: Capturing the Context of Use to Inform Design and Evaluation
2022 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis focuses on how the implementation context for a surgical telementoringservice can be understood as a complex, adaptive sociotechnical system.Teleguidance was a service for remote surgical consultation in Endoscopic RetrogradeCholangiopancreatography (ERCP), a highly specialized clinical procedure.The solution had been developed in a participatory design setting andhad also been successfully trialed in a pilot study. It was to be deployed atfour additional hospitals, but differences between the implementation contextswould make it challenging to understand clinical outcomes, and could also affectmatters such as adoption.This thesis includes four papers which converge on user needs and the sociotechnicalimplementation context for teleguidance. The aim was to demonstratehow a sociotechnical systems oriented approach could be used to identifyfactors that could interact with the implementation. The first paper describesan investigation of attitudes and expectations among end-users and other stakeholders.The second paper shows how modelling the sociotechnical work systemmade it possible to investigate and proactively identify issues that might influenceimplementation and adoption. The third paper explicates methodologicalaspects of modeling the domain. The fourth paper describes a study designed tocapture early reactions to working with the system. Seen together, the researchrepresents a design science approach, that proposes that the implementationcontext can be viewed as a complex, adaptive system, and provides examplesthat show how focusing on user and stakeholder needs and wider context ofuse is a viable approach for supporting the implementation and evaluation oftelemedicine systems in complex settings.

Abstract [sv]

Denna avhandling växte fram ur ett större telemedicinprojekt vid Karolinska Universitetssjukhuset, Innovationshubben för vård på distans. Där hade man utvecklat en tjänst kallad teleguidance. Teleguidance utformades för att möjliggöra kirurgisk konsultation på distans i ERCP, en högspecialiserad endoskopisk procedur. Lösningen hade utvecklats i en deltagande designmiljö och hade också framgångsrikt testats i en pilotstudie. Den skulle sättas in på ytterligare fyra sjukhus, och en klinisk studie planerades för att utvärdera resultaten. Det var dock uppenbart att det fanns skillnader i hur ERCP genomfördes på de olika sjukhusen, vilket med stor sannolikhet skulle påverka införandet.

 

De fyra artiklarna som ingår i avhandlingen är konvergerande studier om det organisatoriska och sociala sammanhang i vilket teleguidance skulle introduceras. Syftet var att ta fram en flernivåanalys av de faktorer som påverkar arbetet med ERCP, och som kan förväntas samverka med implementeringen av teleguidance. Det första steget var att undersöka attityder och förväntningar hos slutanvändare och andra intressenter. Det andra steget var att modellera det sociotekniska arbetssystemet för att undersöka och proaktivt identifiera faktorer som kan påverka implementering och införandet av telemedicintjänsten. Det tredje steget var att fånga tidiga reaktioner på att arbeta med systemet. Sammantaget representerar forskningen ett proaktivt tillvägagångssätt för att identifiera organisatoriska konsekvenser av att introducera nya digitala tjänster i en komplex vårdmiljö.

Studierna visar exempel på tillvägagångssätt för att aktivt få en djupare kunskap av användarnas och intressenternas behov samt implementeringskontexten vid teknikinförande, vilket är avgörande för att stödja de anpassningar som krävs för framgångsrik implementering i komplexa miljöer. Resultaten är avsedda att bidra till området digital hälsa genom att ge praktiska exempel på hur sociotekniska metoder kan bidra vid design, implementering och utvärdering av nya teknologier som är avsedda att driva förändringar i sjukvården.

Place, publisher, year, edition, pages
Stockholm: KTH Royal Institute of Technology, 2022. p. 93
Series
TRITA-CBH-FOU ; 2022:8
Keywords
Telemedicine, Implementation, Complexity, Sociotechnical systems, Design Science
National Category
Human Computer Interaction
Research subject
Technology and Health
Identifiers
urn:nbn:se:kth:diva-307612 (URN)978-91-8040-136-4 (ISBN)
Public defence
2022-02-22, Rum 9504, Hälsovägen 11c, Zoom: https://kth-se.zoom.us/j/69050531209, Flemingsberg, 13:00 (English)
Opponent
Supervisors
Note

QC 2022-02-02

Available from: 2022-02-02 Created: 2022-02-01 Last updated: 2022-06-25Bibliographically approved

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Aminoff, HedvigMeijer, Sebastiaan

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