RESEARCH Open Access

Using information communication technology in models of integrated community-based primary health care: learning from the iCOACH case studies Carolyn Steele Gray1,2* , Jan Barnsley2, Dominique Gagnon3, Louise Belzile4, Tim Kenealy5, James Shaw2,6, Nicolette Sheridan7, Paul Wankah Nji8 and Walter P. Wodchis2,9

Abstract

Background: Information communication technology (ICT) is a critical enabler of integrated models of community- based primary health care; however, little is known about how existing technologies have been used to support new models of integrated care. To address this gap, we draw on data from an international study of integrated models, exploring how ICT is used to support activities of integrated care and the organizational and environmental barriers and enablers to its adoption.

Methods: We take an embedded comparative multiple-case study approach using data from a study of implementation of nine models of integrated community-based primary health care, the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study. Six cases from Canada, three each in Ontario and Quebec, and three in New Zealand, were studied. As part of the case studies, interviews were conducted with managers and front-line health care providers from February 2015 to March 2017. A qualitative descriptive approach was used to code data from 137 interviews and generate word tables to guide analysis.

Results: Despite different models and contexts, we found strikingly similar accounts of the types of activities supported through ICT systems in each of the cases. ICT systems were used most frequently to support activities like care coordination by inter-professional teams through information sharing. However, providers were limited in their ability to efficiently share patient data due to data access issues across organizational and professional boundaries and due to system functionality limitations, such as a lack of interoperability.

Conclusions: Even in innovative models of care, managers and providers in our cases mainly use technology to enable traditional ways of working. Technology limitations prevent more innovative uses of technology that could support disruption necessary to improve care delivery. We argue the barriers to more innovative use of technology are linked to three factors: (1) information access barriers, (2) limited functionality of available technology, and (3) organizational and provider inertia.

Keywords: Health information technology, Integrated health care systems, Implementation, Disruptive innovation, Chronic illnesses, Multi-morbidity

* Correspondence: [email protected] 1Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 1 Bridgepoint Drive, Toronto M4M 2B5, Canada 2Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, Ontario M5T 3M6, Canada Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Steele Gray et al. Implementation Science (2018) 13:87 https://doi.org/10.1186/s13012-018-0780-3

Background Older adults with complex care needs are among the highest users in health care systems worldwide [1–4]. This high use is not just about their complex health and social care needs which are more intensive as compared to other patient populations, but it is also due to health care systems lacking the necessary structure to effectively and efficiently support this population [5]. Although no one definition of complex care needs is available in the litera- ture, we define this group as individuals with multiple chronic conditions (e.g., multi-morbidity), commonly accompanied by socio-economic deprivation, and a largely unpredictable, changing evolution of care need, that makes the management of their illness particularly chal- lenging [6–10]. Integrated care delivery, which brings together and co-

ordinates services from across the health and social system, has been identified as critical to meet the needs of this patient population [11], preventing unnecessary use of health and social care resources. Information and communication technology (ICT) has been identified as an important enabler to support delivery of integrated and coordinated primary health care [12–17]. ICT enabled information sharing across professional and organizational boundaries is arguably one of the most crucial aspects of successful models of integrated care [13, 15]. While suggestions describing optimal ICT systems are

common in the literature, to our knowledge, there are few studies that have explored how ICT is used to enable the activities necessary for integrated care. We do not have a clear understanding of how ICT has been adopted in practice in real-world implementations of integrated community-based primary health care and how organizational environments play a role in that implementation. To address this gap, this study draws on qualitative data from an international study of models integrated care to answer two research questions:

1) What functionality, use, and role does ICT play to enable activities of integrated models of community-based primary health care?

2) What are the implementation enablers and challenges in adopting ICT across different organizational contexts?

To address the first question, we need to clearly iden- tify integrated care activities after which we can determine the role of ICT systems in enabling the implementation of those activities. Wagner’s Chronic Care Model has been used as a guide to deliver care to individuals with chronic and complex disease in primary care settings [18]. The model includes elements that are well aligned to core activities and components of inte- grated care including self-management, multi-disciplinary

teamwork, and decision supports [19]. Over the years, the Chronic Care Model (CCM) has been revised, expanded, and enhanced in multiple ways to address identified gaps or apply the model to new contexts (Wager’s expanded model in 2003 for example [20]). A useful augmentation to the model for our purposes is the eHealth Enhanced CCM (hereafter referred to as the eCCM), a framework identifying how ICT tools can be incorporated into the CCM and used by providers and patients in the delivery of care [21]. The eCCM is built on a core assumption that sharing information will generate knowledge and collective wisdom among health care providers and managers which can be used to improve health outcomes for patients. Several types of ICT tools used to exchange health

information are identified in the eCCM and broader eHealth literature including (1) electronic medical and health records (EMRs/EHRs), (2) patient personal health records (PHRs), (3) telemonitoring systems (using phone, mobile, and sensor-based technology), and (4) web-based resources (e.g., educational sites and social networks) [22– 27]. Table 1 summarizes Wagner’s CCM elements and con- nects them to ICT enhancements suggested in the eCCM. While the eCCM is a useful guide regarding how we

might expect ICT to be used as part of integrated models for patients with complex care needs, it mainly offers a high-level view with few examples of specific provider and organizational level activities associated with these elements. Our study takes the next step by exploring how the activities associated with each of the CCM elements are, or are not, enhanced through the adoption of ICT systems. Our second research question seeks to understand

why ICT is or is not used to support these activities. There are a number of organizational change and imple- mentation theories that have been applied to better under- stand the adoption of ICT and eHealth technologies. In our review of the literature, we identified five theories of implementation science which have been used to explore implementation of ICT in similar health care settings (Roger’s Diffusion of Innovation; Normalization Process Theory; the Reach, Effectiveness, Adoption, Implementa- tion, and Maintenance framework; the Fit between Indi- vidual Task and Technology; and the Consolidated Framework for Implementation Research) [28–37]. While some other theories have been adopted, these five were most prominent in our search of the literature at the time the analysis was conducted for this study. The five models and theories differ in terms of spe-

cific constructs and theoretical underpinnings. For instance, Diffusion of Innovation theory stems from the organizational behavior and change literatures, whereas Normalization Process Theory focuses on the social organization of work. Constructs included in these different frameworks offer different perspectives on a

Steele Gray et al. Implementation Science (2018) 13:87 Page 2 of 14

similar concept. Taking the individual characteristics constructs across theories for example, we see in the Consolidated Framework for Implementation Research an emphasis on individual level processes such as knowledge and beliefs and their degree of commitment to the organization [32], whereas Normalization Process Theory focuses on the interaction between indi- viduals and their social environment or “material prac- tices” that may become routine [29]. The Fit between Individual Task and Technology, on the other hand, acknowledges the role of the individual in relation to their work, but specifically with how a new model fits to existing practices [31]. Each theory suggests a differ- ent perspective of the individual in the implementation. Our previous work in concept mapping to inform the iCOACH study has shown that drawing on different theoretical perspectives will allow for a more in-depth and varied understanding of meanings and values assigned to seemingly similar constructs [38]. Combining theoretical frameworks ensures we are not missing these varied per- spectives of participants in our analysis of findings.

Looking across the theoretical frameworks, we sought to consolidate constructs into core domains expected to influence ICT adoption in models of integrated care. To develop the domains, we looked across theories at how constructs are defined and operationalized in previous studies of ICT adoption in health care. A table was gener- ated mapping constructs from the theories to the domains and was agreed upon by the co-authors. We have used similar methods of concept mapping when adopting mul- tiple theoretical frameworks [38]. Using this method, we identified four core domains: (1) characteristics of individ- uals adopting technology, (2) the organizational and (3) external environment, and (4) the characteristics of the technology. Table 2 presents a summary of these domains and examples of factors which are pulled from across the five different theoretical frameworks. Using the four core domains, we are able to explore which implementation factors have an essential or peripheral role in the adoption of ICT systems in real-world environments where models of care are often implemented without an explicit ICT strategy in place to support the core activities and aims.

Table 1 Summary of ICT-supported elements of the CCM

CCM element Description ICT-supported elements

Community resources and policies Providers connecting patients to community programs through partnerships that expand health system services beyond primary care. Providers promote patient self-help strategies, including connecting to real and virtual social networks.

Health-related social networks and eCommunities that support health and social care connections.

Health system Designing health systems to support organizations and providers in their interactions with patients around chronic disease care. Organizational and senior leadership support creating a culture of safety and improvement across all organizations that make up the health system. Including supporting data sharing across the system to improve chronic disease care.

EHRs, PHRs, mHealth and Telehealth, online resources/systems that support quality improvement and patient engagement.

Delivery system design Adopting a proactive patient management approach through care coordination and case management, especially for complex patients. Includes provider team members having clear roles and responsibilities, ensuring regular follow-up, and care that patients understand, find acceptable and fits with their cultural background.

EHRs, PHRs, mHealth and Telehealth that enable information sharing and span the system.

Self-management support Supporting patients with chronic illnesses to make decisions and engage in actions that improve their health (self-management). Providers collaborate with patients to define problems, set goals, and create treatment plans (self-management support strategies).

PHRs, online resources/systems, mHealth and Telehealth, and applications that support patient- provider interactions.

Decision supports Supporting the use of evidence-based guidelines into daily practice which can be shared with patients. Education and training for providers and integration of specialist expertise included in this element. New models of provider education in particular eHealth Education (added in the eHealth enhanced CCM): encourages the development of eHealth skills for patients and providers that can enhance all six elements of CCM.

Electronic access to evidence-based guidelines, protocols, standing orders, and reminders for providers and patients, through EMRs, EHRs, or online resources. Appropriate training for providers and patients on eHealth Education systems.

Clinical information systems Information systems providing ready access to key data on individual patients—reminders for services and data to track and plan care—and at the practice level, population data to monitor performance and improve quality, in particular for relevant subpopulations.

EMRs, EHRs, and PHRs that support coordinated care and monitoring performance at the individual level and practice level.

Steele Gray et al. Implementation Science (2018) 13:87 Page 3 of 14

Methods Approach and design Our study takes an embedded comparative multiple-case study approach [39, 40] using data collected as part of the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study. The iCOACH project is a multi-year international study exploring the implementation of nine models of integrated community-based primary health care across three juris- dictions, Ontario and Quebec in Canada and New Zea- land. Background on this study is available in a special issue of the International Journal of Integrated Care published in June 2017 [41]. Cases that had imple- mented integrated community-based primary health care were selected for the broader iCOACH study [42]. While there are some key examples where technology has been developed alongside the model of care [43], the iCOACH study did not select cases based on this strategy. As such, these cases provide examples of how existing technologies have been used to enable the im- plementation of models of integrated care, offering a unique opportunity to explore our research questions. While the broader case study includes qualitative as well as quantitative data sources, for the study presented in this paper, we draw on qualitative interviews with managers and front-line health care providers collected between February 2015 and March 2017 with the majority of inter- views conducted in 2015 (Quebec case data collection ran a bit later than Ontario and New Zealand).

To answer our first research question, we use an em- bedded cross-case analysis, looking across the different models of integrated care within each jurisdiction to identify and describe activities of providers and man- agers that are (or are not) enabled by the use of ICT. We then conduct a cross-jurisdictional exploratory ana- lysis, allowing us to take into consideration both organizational and external environments in the investi- gation of implementation enablers and barriers address- ing our second research question.

Setting: the nine cases In-depth descriptions of all nine cases and three jurisdic- tional policy environments are available through other iCOACH publications [44, 45]. This section offers a brief summary of key contextual factors relevant to our analysis with additional data presented in Table 3. Con- sistent across all three cases are strong legislative and regulatory policies protecting personal health informa- tion privacy and security, as well as a general interest by regional and national governments to adopt technology to support health system delivery. Ontario community-based primary health care includes

services from both health and social care sectors [45]. Services in Ontario are often siloed with few integrating mechanisms available. Fragmentation in the delivery system extends to health information systems [46], which is exacer- bated by Ontario’s low rules policy environment (allowing multiple vendors to compete for contracts across health

Table 2 Domains of implementation of information communication technology in health care settings

Domain Definition and origin Examples of factors/determinants

Characteristics of individuals Individual-level knowledge, beliefs, self-efficacy, and cognitive process that influence understanding, trust, and adoption of technology NPT (emphasis on social processes and cognition), FITT, CFIR, DOI, and RE-AIM

Knowledge, beliefs, attitudes, and norms Self-efficacy eHealth literacy/training Personal traits (motivation, values) Participation/engagement Task/work coherence Adherence

Organizational environment Characteristics of the organization such as organizational-level culture and availability of resources that influence ICT adoption. DOI, CFIR, FITT, NPT

Technical support Organizational size Organizational culture and climate Readiness for change Routinization of use Organization of tasks and activities and complexity of task

External environment Macro-level features surrounding organizations and networks including political, economic, and social contexts. DOI, CFIR

Regulations and policies around ICT use Funding Organizational interdependence Location (urban vs. rural setting) Patient and population health needs

Characteristics of technology Attributes of the technology which will (or will not) fit with the needs of users and the attributes of the organization and environment. FITT, DOI, RE-AIM, CFIR, NPT (characteristics of intervention more broadly)

Usability (effectiveness, efficiency, learnability, satisfaction) Functionality (including adaptability of features) Cost Integration Available technical infrastructure Availability

NPT Normalization Process Theory; FITT Fit between Individual, Task and Technology; CFIR Consolidated Framework for Implementation Research; DOI Diffusion of Innovation; RE-AIM Reach, Effectiveness, Adoption, Implementation, and Maintenance

Steele Gray et al. Implementation Science (2018) 13:87 Page 4 of 14

Ta b le

3 iC O A C H ca se

ch ar ac te ris tic s

O nt ar io

Q ue be

c N ew

Ze al an d

C as es

C om

m un

ity ag en

cy le ad

(c as e 1)

Pr im

ar y ca re

an d ho

m e ca re

(c as e 2)

C om

m un

ity he

al th

ce nt er

(c as e 3)

H ig hl y

ur ba n

(c as e 1)

U rb an

(c as e 2)

Ru ra l( ca se

3) N et w or k m od

el (c as e 1)

M āo ri

(in di ge

no us )

N G O (c as e 2)

PH O

ho m e vi si tin

g pr og

ra m

(c as e 3)

M od

el Si ng

le or ga ni za tio

n M ul tip

le se rv ic es

av ai la bl e in cl ud

in g

pr im

ar y ca re

se rv ic es

Pa rt ne

rs hi ps

w ith

ho sp ita ls an d ho

m e

ca re

de liv er y ar ou

nd co nt ra ct s an d/ or

pr oj ec ts

Pa rt ne

rs hi p m od

el M ul ti- di sc ip lin ar y

pr im

ar y ca re

pr ac tic e

an d ho

m e ca re

de liv er y ag en

cy St ro ng

co nn

ec tio

ns to

lo ca lh

os pi ta l,

em er ge

nc y se rv ic es ,

an d co m m un

ity ag en

ci es

Si ng

le or ga ni za tio

n M ul tip

le se rv ic es

un de

r on

e ro of

in cl ud

in g pr im

ar y ca re

C om

m un

ity -fo

cu se d

w ith

an em

ph as is on

so ci al de

te rm

in an ts

of he

al th

C o- lo ca tio

n th ro ug

h hu

bs w ith

co m m un

ity se rv ic e pa rt ne

rs

Re gi on

al m od

el w ith

1 ho

sp ita l,

3 lo ng

-t er m

ca re

fa ci lit ie s,

an d 2 lo ca l

co m m un

ity he

al th

ce nt er s

(C LS C )

C on

ne ct s to

pr im

ar y he

al th

ca re ,c om

m un

ity ag en

ci es ,r eh

ab ,

ph ar m ac ie s,

an d pr iv at e

re si de

nc es

Re gi on

al m od

el w ith

4 lo ng

-t er m

ca re

fa ci lit ie s an d 4

lo ca lc om

m un

ity he

al th

ce nt er s

(C LS C )

C on

ne ct s to

un iv er si ty

te ac hi ng

ho sp ita l,

pr im

ar y he

al th

ca re ,c om

m un

ity ag en

ci es ,r eh

ab ,

ph ar m ac ie s, an d

pr iv at e re si de

nc es

Re gi on

al m od

el w ith

1 ho

sp ita l, 1 lo ng

-t er m

ca re

fa ci lit y, an d 1

lo ca lc om

m un

ity he

al th

ce nt er

(C LS C )

C on

ne ct s to

pr im

ar y

he al th

ca re ,c om

m un

ity ag en

ci es ,r eh

ab ,

ph ar m ac ie s, an d

pr iv at e re si de

nc es

N et w or k of

ur ba n an d ru ra l

pr ac tic es

w ith

in a si ng

le di st ric t

he al th

bo ar d

Pr og

ra m s cr ea te

co ns en

su s ca re

pa th w ay s w ith

im pl em

en ta tio

n ac ro ss

pr im

ar y

ca re

an d se co nd

ar y

ca re .

M ul ti- di sc ip lin ar y

pr im

ar y/ co m m un

ity ca re

pr ov id er s

Se rv ic es

to su pp

or t

in te gr at ed

ca re

fo r ol de

r ad ul ts

w ith

co m pl ex

co nd

iti on

s (e .g .,

ho m e se rv ic es

to en

ab le ea rly

ho sp ita ld

is ch ar ge

)

C om

m un

ity –

ow ne

d N G O

pr ov id in g pu

bl ic

he al th

an d

pr im

ar y ca re

se rv ic es

to ur ba n

an d se m i-r ur al

po pu

la tio

ns ex pe

rie nc in g

hi gh

m at er ia l

de pr iv at io n.

In te r- pr of es si on

al te am

(d oc to r,

nu rs e pr ac tit io ne

r, nu

rs e, ph

ar m ac is t,

na vi ga to r)

W ha na u (fa m ily )

na vi ga to r w or ks

w ith

pa tie nt s an d

fa m ili es

to ac ce ss

he al th

an d so ci al

se rv ic es

C hr on

ic ca re

m an ag em

en t pr og

ra m

fo r pa tie nt s in

1 of

6 ru ra lo

r se m i-r ur al

pr im

ar y ca re

pr ac tic es

Te am

s of

a nu

rs e

an d a ka ia w hi na

(c om

m un

ity he

al th

w or ke r) ho

m e vi si t

pa tie nt s to

pr ov id e

cl in ic al as se ss m en

t, ed

uc at io n,

an d

co or di na te

he al th

an d so ci al se rv ic es

Se rv ic e ty pi ca lly

of fe re d fo r 6 m on

th s

Pr ov id er

in te rv ie w s

8 8

7 14

8 7

4 7

8

M an ag er

in te rv ie w s

8 10

6 12

9 11

6 2

Related Tags

Academic APA Assignment Business Capstone College Conclusion Course Day Discussion Double Spaced Essay English Finance General Graduate History Information Justify Literature Management Market Masters Math Minimum MLA Nursing Organizational Outline Pages Paper Presentation Questions Questionnaire Reference Response Response School Subject Slides Sources Student Support Times New Roman Title Topics Word Write Writing