Master Thesis:
How technological innovations can contribute to the optimal implementation of inhaler instructions by the Greek healthcare
system
Authors Nikolaos Papadimitriou (S4130855)
University University of Groningen
Faculty Faculty of Economics and Business
Programme MSc BA Health
College year 2019 - 2020
Supervisor-Co-supervisor Esther Metting-Marjolein van Offenbeek Date and place of publication Groningen, 20-7-2020
Table of Contents
Abstract ... 3
Introduction ... 5
Research Question ... 6
Theoretical Background ... 6
Characteristics of the Greek healthcare system ... 6
Technology Infrastructure………....…………7
Technology adaptation barriers in Greek Healthcare System…………..…….…7
Technology adaptation in Greek Healthcare System………9
Cehres Roadmap ... 9
CFIR model ... 12
Methodology ... 14
Coding ... 16
Results ... 19
Healthcare and Technology………22
Cehres Roadmap ... 28
CFIR model ... 28
Discussion ... 33
Conclusion ... 39
References ... 40
Interview Plan ... 43
Interview Transcripts ... 46
Abstract
Background
Due to the digitalization of the world, the use of technology has increased and many healthcare organisations are using it. Most of them are focusing on delivering better health for patients with the aim to increase his self-management skill and to control better health. Video calling could be an intervention that could help both patients and healthcare provider to build better relationship through the instant contact and communication. Asthma and COPD are diseases that require on going self- management and the monitoring of the doctor through the video calling could have a positive impact on the progress of the patient.
Objective
This study aimed to obtain and present an overview of patients and healthcare providers perception about technology and investigate how video-calling instructions could meet the needs of the patient with asthma or COPD and improve their progress.
Methods
For the need of the study I performed semi-structured interviews in 3 patients with asthma, 2 with COPD, two pharmacists, a cardiologist, a pulmonologist and a clinic manager who currently live in the area of Athens. The aim of the study is to get an overall patients view in terms of their characteristics, for that reason the patients had different dates of birth. Three patients was under 58 years old (58-54-51) and the other two was over 65 years old (68-65), two of them were males and three of females. Every participant was Greek and the interviews were in Greek language. The transcripts of the interviews are translated and included on the appendices part. The main interviews topics was to investigate how change through technology intervention could help on implementing better inhaler instructions, what would be the best way for feasible and effective implementation of online real-life video inhaler instructions in the health care organization in Greece, who is currently responsible for the instructions, and what are the patients view about their existing practice and the technological impact in the healthcare sector. Data were analysed with coding software and the consolidated criteria for reporting qualitative research were followed when conducting the study.
Results
In general, both patients and healthcare providers were positive about having access to video calling, and communicate instantly. The most useful and effective way for
the implementation of the video calling intervention, both agreed that is better to have the first visit in doctor’s office which can help the doctor to deliver better instructions and give to the patient more feel of security and then the video calling can intervene and be an effective tool to monitor the progress of the patient and also to give the opportunity to ask any question to the doctor if need it, directly. However patients seems positive for this innovation but they also mention that is always risk confusing the patient if he has not the required technological knowledge to follow this intervention. Furthermore, Cehres and Damschroder model is used to present how the intervention could be implemented.
Conclusion
Participants were positive about video calling instructions and considered it as a productive step for healthcare. People nowadays are more adapted and educated with technology, which can also help them to be more informed about their disease. Video calling could support patients with asthma and COPD to have better health control by having the opportunity to contact their doctor any time and mostly to reduce their errors using inhaler machines.
Introduction
According to the World Health Organization, 235 million people suffer from asthma and 65 million from Chronic Obstructive Pulmonary Disease (COPD).
(WHO, 2000). The goal of asthma and COPD treatment is controlling the disease and achieving a better quality of life. However, patients are restricted in their activities, frequent exacerbations and poor quality of life (Baddar et al 2014). Despite the availability of effective therapies, these diseases appear not to be controlled at 50% - 70%, with patients' errors in using their inhalers playing an important role,resulting in inadequate control of these diseases, increased morbidity / mortality and increased financial costs (Rabe et.al 2009),
Asthma imposes a high economic burden on society and the healthcare system in Greece, according the study of Katerina Velopoulou. Therefore, greater investment in interventions aimed at asthma control and prevention of acute exacerbations may reduce the overall burden of asthma in Greece (Velopoulou et. Al 2017). A 1992 survey of smoking in European Union (EU) countries reported that Greece had the highest prevalence of heavy smokers. (WHO report 2004). In addition, in the early 1990s, Greece was found to have the highest per capita cigarette consumption in the EU, averaging approximately 3,600 cigarettes. The strong relation between smoking and COPD is well documented (WHO report 2004). For that reason I believe that a research for better implementation of inhaler instructions in Greece will be appropriate. In Greece an analysis of the inhalation instructions for asthma and COPD compared with the technology impact is not done before and we will reach this gap is this study.
I will investigate how the technology regarding real life online instructions impact can be seen as an opportunity for innovation and educational intervention to reduce errors and to work as a tool for the patients in order to understand correctly the process of the inhaler. Furthermore I will investigate the barriers of the technology adaptation, specifically in the Greek healthcare system, and also, more generally, I will explore the concept of technology acceptance from the people and how the impact of the technology regarding real life online instructions can influence the healthcare system’s performance. Moreover, I will provide some future recommendations, based on the results of the analysis. I will collect different opinions through interviews from
patients and healthcare providers about the current situation and I will come up with the aim to propose a change on the current model and on the way that the inhalers instructions can be delivered to the patients with the use technology regarding real life online instructions.
Research Question
What would be the best way for feasible and effective implementation of online real-life video inhaler instructions in the health care organization in Greece?
Theoretical background
Characteristics of the Greek healthcare system
Greek healthcare system characterized as unbalanced and sometimes unfair in access and coverage for health. Due to the economic crisis the policies implemented increased the level of existing issues regarding accessibility, availability, acceptability and effective health coverage of the Greek population. For the need of this study the concept of technology acceptance and technology adaptation will be used in order to identify whether the intervention of video calling could be implemented in the Greek healthcare system. Technology adaptation is the choice to acquire and use new invention or innovation, in simple words is the intended use of a technology or service that sometimes changed or adapted by people or organizations in practice. On the other hand technology acceptance is the adaptation process and a system that is claimed to be due to different variables by the user of new technology. More specifically, is the negative or positive perception of people of change and to accept the new technology-innovation (Lahiri et al. 2018).
Regarding the treatment of asthma in Greece, the doctor, and more specifically the pulmonologist is responsible for the diagnosis of asthma and also for the right medication for the patient. However, the cardiologists can also have the role to advice the patient if identify any symptom and suggest him to visit the pulmonologist for
inhalers, patients must do repeat visits to the doctors office or the pharmacists to ensure that they use the inhaler correctly. The repeat visits to doctor’s office increases the medication costs for patients and the need for change is required. To ensure the health’s system viability and the right treatment of chronic diseases such us asthma and COPD, effective out-of-hospital management need to be adapted (Kourlaba et al. 2018).
Technology infrastructure in Greece
Technology plays an important role in our life nowadays and people are using the internet and different types of devices in daily basis. A Eurostat study shows that in EU, and especially in Greece more than half of all households had broadband access at home and also at least 9 out of every 10 adults made daily use of the Internet. A major issue that has huge impact on technology access, and more specifically in Internet connection is the connectivity. The graph below presents the percentage of connectivity for every country in EU, and Greece has one of the lower numbers (68%) of connectivity (Eurostat 2017).
In order to catch up with the other EU countries, Greece needs investments into information and communication technology and energy infrastructures. Major issues for companies could be created due to the insufficient higher speed broadband. The insufficient speed broadband could be an issue for platform or a website that requires good connectivity for the best use but for the implementation of the video calling is not a limitation. Video calling can work with phone number or even with low data Internet, which makes it more accessible and helpful for the patient (Eurostat 2020).
Barriers on technology adaptation in Greek Healthcare System
Greece will face some crucial barriers in implementing technology interventions as belongs to the low and middle-income countries. Health systems in low- and middle-
income countries continue to face considerable challenges in providing high-quality, affordable and universally accessible care. In response, policy-makers, donors and programme implementers are searching for innovative approaches to eliminate the geographic and financial barriers to health (Hugh 2012).
Implementers have pointed out problems with end-user acceptance of the technology attributable to factors such as the user’s lack of familiarity with the technology, a lack of cultural appropriateness or a lack of incentive to adopt new tools. Another key concern is the lack of the necessary infrastructure to provide reliable electricity and Internet access. One implementer cited this as a key reason for moving from computers to mobile phones, for which the necessary infrastructure is more readily available. Costs, both initial and on going, also surfaced as a key impediment to technology implementation. Such considerations may determine if, when, and how a technology is incorporated into a programme (Hugh 2012).
Moreover, another critical concept is the nature of the education delivered. The most effective patient training technique in correct inhaler use has been found to be verbal instruction combined with physical demonstration (Kocks et al. 2018). Repeating this education over time increases the proportion of patients returning to follow-up visits who maintain the correct technique (Axtell et al. 2017).
However, this study will present how the technology adaptation can solve the issue of the wrong use of inhaler devices. Some studies have been proposed to support patients and healthcare providers inhaler technique by adding technology interventions. A more promising approach especially in rural areas is the implication of real life online instructions. Videos with instructions and not suited to provide inhaler instructions however real life instructions through the Internet are promising.
The difference between them is that real life instructions contain feedback from a health care provider about the technique of the patient. The instructor can actually
from the healthcare provider or to ask any questions. This intervention could easily bring closely the healthcare providers and patients and improve their communication.
Technology Adaptation in Greek Healthcare System
For efficient and effective implementation of technology it's important that the Healthcare system is capable of changing the current organisation towards the new practice. Moreover, people who are going to work with this development need to accept the change of technology. There is two models who can support the implementation of technology in inhaler instruction: the Cehres Roadmap and the CFIR (Consolidated Framework for Implementation Research) model of Damschroder. The Cehres roadmap can be refer to new technologies that are developed for the scratch or to the improvements of existing technologies. In this study it will be used as a practical guideline to help plan, coordinate and execute the development process of new eHealth intervention, the video calling. A possible solution to health support and well being could be the technology. The cehres roadmap could help this study to guide the process of development, evaluation and implementation of video calling.
On the other hand, a useful tool for this study is the CFIR model of Damschroder, that it will be used to design the implementation strategy. This framework will be used for this study in order to identify barriers and facilitators for the implementation of the video calling instructions and then to tailored strategy to mitigated these barriers but also to leverage facilitators. Both Cehres Roadmap and CFIR are usefull tools for the adaptation of video calling intervention. Cehres road map focus on the designing of the action plan and the CFIR focus on the implementation diagnosis. The solution of these two models will provide the best and effective way to adapt the video calling intervention in the Greek Healthcare system.
Cehres Roadmap
The CeHRes Roadmap assists the development team in planning, coordinating and executing the development process of eHealth technologies. More specifically in this case will be designed to present how technology can be implemented into the healthcare system and also to have a positive impact (Ludwig et al. 2017). The output of the CEHRES model in this study is the development of a plan for the introduction
of the provision of inhaler instruction through the Internet in the Greek Healthcare system.
Moreover I will explain how the technology adaptation could be achieved in Greek healthcare system through the 5 steps of Cehres model.
Contextual Inquiry
The purpose in this phase is to identify the strong and the weak points of the current situation in order to plan the strategy. As I mention above the strong points of the current provision of care is that many studies support that the interactive contact with the patient is the best way to give the instructions of the inhalers (Dima et al 2016).
But the issue still exists if the instructions are not delivered in the right way. For that reason the implementation of technology systems can be a very important factor to deal with this issue, though the interactive contact with the patient still needs to be present. The evaluation of the contextual enquiry in this study will provide an overview of the added values of the new technology along with an overview of rules, possibilities, conditions, regulations and ethical issues of the context.
Value specification
The next step is to elaborate on the issues mentioned in the contextual inquiry and determine which values the different stakeholders deem important. These goals, values and prospective users’ needs and wishes need to be translated into user requirements. In this case we will identify the most important values for the stakeholders such as amount of target population reached by this method, level of
requirements need to be described in a business model. Needs regarding software hardware contents and design should be taken into account. The values should be translated into the technological requirements for the tool and will serve as a blueprint for new technology.
Design: Based on the stakeholder’s value mapping
In this step the values will be translated into the patient’s requirements and by that will be developed the technology change model. The usability of the technology should constantly be evaluated full stop the requirements and needs from the value Maps should be taken into account. The design of this new technology should include persuaded cues to stimulate to use. The designed application can be either on a website online or in an app or in video screen and it will contain all the principles that mentioned above. The platform also depends on the outcomes of the stakeholder evaluation (Agbo et al. 2019). After that the patient will have an opportunity to practice everyday and overall will seriously reduce the errors on inhalers use.
Operationalization
In this phase the introduction and adoption of the new technology will be planned.
Marketing plans will be set into motion, and organizational working procedures are put into practice. The information from the previous phases will be used as the basis for the implementation. It's going to be helpful too to use current implementation theories in this Phase 2 to optimise the level off implementation and acceptance of the new technology (Mostahari 2014).
Summative Evaluation
In this study the new health technology will not actually be developed and implemented. Therefore this phase of the model is not applicable for this study.
However a plan will be provided that can be used by managers in the future to evaluate the impact of the technology on the context and stakeholders to evaluate the uptake of this new technology.
CFIR model (Consolidated Framework for Implementation Research)- Damschroder
CFIR can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings. In this study we choose to use this model because this model gave us the opportunity to select constructs from the CFIR that are most relevant for their particular study setting and use these to guide diagnostic assessments of implementation context, evaluate implementation progress, and help explain findings in research studies or quality improvement initiatives (Damschroder et al. 2013).
Healthcare providers must be clear and deliver easy to understand video instructions in order to help patients to solve their issue with the wrong use of inhalers. They should focus on follow up each patient situation and provide him with the necessary feedback, by that patients will also feel more safety and the percentage of the people who are making mistakes on the use of the respiratory devices, will be extremely reduced.
Adaptability
Important for this study is to identify whether this technology intervention could be adapted in the Greek healthcare system by analysing the stakeholders and patients needs and values.
Trialability
Trialability plays a major role as the online video instructions must be tested and evaluated many times before will be delivered on the patients hands. Testing must be effective in order to avoid to deliver misunderstand instructions and also audio and screening check must be tested as well.
Complexity
Cost
Healthcare providers will be able to save more time and also to have the opportunity to practice the patient without booking any appointment. This will help him to focus in other responsibilities without loosing his contact with the patients. On the other hand this could also help patients to save money and time, as they will be able to avoid frequent doctors visits and also to gain knowledge and instructions online from home.
Inner setting
In tis study networks and communications will be main tools for the implementation of the technology intervention in the Greek healthcare system. The nature and quality of webs of social networks and the nature and quality of formal and informal communications between patient and doctor or pharmacist, will play an important role for the successful implementation.
Outer setting
Patients’ needs and resources as well as barriers and facilitators to meet those needs by the healthcare providers is major factor.
Individuals involved
Important role-plays the knowledge and beliefs about the intervention. Skill in using the intervention is a primarily cognitive function that relies on adequate how to knowledge of underlying principles or rationale for adapting the intervention.
Implementation process
In our case it is very important to provide frequent feedback for the improvements of the instruction delivery by both patients and healthcare providers in order to achieve short term the best implementation for the technology intervention through the Greek healthcare system and long term to achieve better health status and avoiding of inhaler use mistakes.
Methodology
This study is a qualitative research study that will examine how technology interventions could have positive impact on the implementation of online instructions.
Also I will analyse the different views and opinions from patients and healthcare professionals and what they believe/think about technology innovation. This method explores complex situations and phenomena, which faced by health care providers, and patients. The main interviews topics was to investigate how change through technology intervention could help on implementing better inhaler instructions, what would be the best way for feasible and effective implementation of online real-life video inhaler instructions in the health care organization in Greece, who is currently responsible for the instructions, and what are the patients view about their existing practice and the technological impact in the healthcare sector. Data were analysed with coding software and the consolidated criteria for reporting qualitative research were followed when conducting the study.
Data Collection
In-depth semi-structured interviews will be used to answer our research questions. It is expected that saturation will be reached after interviewing 5 patients and 5
are often used in qualitative research in order to identify the experiences and meanings of the disease, and to explore personal and sensitive themes. They can also help to identify potentially modifiable factors for improving health care and promote technology innovations. The in-depth interviews, which will be held, will help me to draw conclusions about feelings, actions and reactions of patients who taking inspiratory devices and the healthcare providers as well as their opinion about online instructions. The interview is a good method to identify potential modifiable factors for improvement of healthcare and technical inhalation and also could help to identify ways to implement better the concept of the online instructions. Since patients have special knowledge about the daily use of inhaled drug it is also important to obtain information from them (Roggeri et. al 2016). This information can be used for prospects quantitative studies aiming at improving the technique s inhalation.
Another crucial issue is to identify and to understand the opinion of the health providers about the technique of the inhaler and the implementation of the online instructions. This will help me to understand better the situation and to find out better ways of implementation of online instructions and better training for patients. For the analysis part of my thesis, Cehres Roadmap and Damschroder models will be used in order to investigate how technology could have positive impact on the implementation of inhaler instructions within the Greek healthcare system.
Mapping Stakeholders
According to McLoughlin definition, ‘’stakeholders are those who share a particular set of understandings and meanings concerning the development of a given innovation’’. More specifically, stakeholders translating an idea or invention into value creation. In this study in order to identify the most relevant stakeholders, network approach is being used. In network approach the stakeholders are actors in the network, which means that they are relate, and also their interest and power is interactive and depend on a specific context. More specifically the treatment and the process of asthma includes actors such us the patients, the hospital, the doctors, the pharmacists and the company of the inhaler devices. All of these stakeholders are relate due to the fact that everyone needs to follow the specific instruction that the company of the inhaler is giving. However the doctors are responsible on giving the right dosage and medication to the patient and both pharmacists and doctors are responsible for the delivery of the right use instructions. For the reasons I mentioned
above, I chose to interview five healthcare providers from different sectors and different specialities (Pulmonologist, Clinic Manager, Cardiologist and two pharmacists), in order to create a better view of the current situation and also to investigate how the concept of the video calling could be implemented.
Study Population
In qualitative studies, must be achieving to collect a range of views in the target population. It is therefore important to have sufficient variation in the study population. For this purpose I will include on this research patients with asthma / COPD belonging to a different age groups. Also the interviews for the healthcare providers will be conducted for healthcare providers with different specialities. This will help me to investigate in more depth the need of change within the Greek healthcare system and how the implementation of online instruction could be achieved. The healthcare providers who participate on the interviews are working in the hospital in Athens (Attiki Iatriki) and were really interesting on helping me on my research. The healthcare providers also suggest me to interview some of their patients for the need of my study, and they help me to find participants, which was really hard due to corona outbreak.
Coding
Coding is being used in order to organize my qualitative data and help me to identify different themes and relationships between them. It also a helpful tool that guide me to write my results section by assigning labels to phrases that are important for the analysis of my data. The process of coding was first to identify the key concepts of the interviews by analyzing different opinions by the participants and then to investigate possible solution for the best implementation of the video calling through the patients and the healthcare providers opinion and their needs.
Figure 1: Responsibility for the instructions-Perceptions analysis
Figure 2: Perception of healthcare providers and patients about
technology and video calling intervention in healthcare sector and
possible solution
Results
The results section provides an overview of the qualitative results. The qualitative results are divided into the main research topics. Textbox 1 and 2 summarizes the content of the results section.
Interviews Characteristics
I included 10 Greek-speaking adults, with different characteristics for the need of this this study. Five of them were patients who have differences on their diseases, age and technology knowledge. The other five were different healthcare providers, pulmonologist, cardiologist, hospital manager and two pharmacists. The aim of this study was to collect as many as possible opinions from healthcare providers with different specialities. The perception of the healthcare providers about the concept of the digitalization, differentiate in terms of their age and their existing knowledge about the technology, as well as the patients do.
Daily Life Restrictions
All participants experienced restrictions in daily life, especially in physical activities:
‘’ In my daily life I am afraid of not walking much or doing anything and I get tired and then I get shortness of breath.’’
Several patients, describe that the effects of asthma or COPD increased when the patient has ill or he is cold.
‘’ It affects me a lot, for me it is a big problem. Sometimes when you may be a little cold you feel much worse because of COPD, sometimes I feel like a person with special needs’’.
Another notice is that many people are not responsible with their own medication.
They are start taking the process seriously when they are really feel scared about their health.
‘’I did not have any symptoms until I was 40, then I started working at the bank and we did the first check-up. Then I did my first spirometer and it appeared that I have asthma but without any symptoms. Also after I found out I continued not to take any medication since I did not have any symptoms for about 10 years until it started to bother me and then I started the medication.’’
Patients Perspective about their training
Most of the patients report that they feel, their training by the doctor were sufficient, several patients also mention that after the visit with the doctor they did not feel secure or that the doctor did not give too much attention on the instructions. Patients trust their doctors and pharmacists when they follow up the patient in order to have the best results on using the inhaler device.
‘’From the beginning I made good use of the inhaler, my doctor is very good and showed me step by step how to use it, of course the pharmacists I went they did the same. They always gave me the correct instructions for the device. Because there are many devices, sometimes I had to consult pharmacists besides my doctor’’.
It is also noticed that some patients have the feeling that the doctor did not give too much attention on the instructions, which result on driving the patient to search the instructions from different providers, such us pharmacists and internet, which can easily confused him.
‘’My doctor did a little training, most of it I learned on my own by reading the instructions of the device that was not so understandable there but I learned to make the right use over time. Sometimes I had to search the Internet for the right use.’’
Who is responsible for the instructions?
In Greece, responsible for the delivery of the instructions are both, pharmacists and the doctors. Some patients are positive about it, as they feel more secure, knowing that they can be advised from both, in the other hand several patients mention that sometimes pharmacists gave different instructions from the doctor, which can easily confused them. I Interview patients, doctors and pharmacists in order to understand their views about the topic and also to find out who has to be responsible for the best of the patient.
Patients perception about the responsibility of the instructions
This study showed that some patients prefer to have two providers who can deliver
‘’I believe that the doctor should be responsible and on the other hand the right pharmacist should tell the patient that he should follow the doctor's instructions and not give instructions, regardless of whether he knows the use and the dosage because the doctor may give different doses for the inhaler depending on the case. This procedure can also confuse the patient. In the end the doctor will be responsible for his course’’.
‘’I believe that the doctor should be responsible. Of course it helps some who do not know to be able to consult the pharmacist but the most confidential instructions for use and especially for dosing are from the doctor.’’
Most of the patients mention that only the doctor has to be responsible for the delivery of the instruction. This will make them feel more safety and also more trust on their medication process.
‘’Finally, I believe that the doctor should be responsible for giving the instructions because he is the one who has trusted your health and is obliged to give you the right instructions’’.
‘’I believe that the doctor should be responsible. Many times pharmacists give different instructions than the doctor and this results in the patient getting confused.’’
‘’Surely the doctor should be responsible and he should give the instructions, the pharmacist on the other hand should have the role of simply advising the patient’’.
Doctors perception about the responsibility of the instructions
The cardiologist believes that any one who has the knowledge to deliver instructions must be able to do it. That means that pharmacists improving the process of delivering instructions.
‘’ I believe that anyone who has the knowledge for this then can give the instructions certainly the doctor is primarily responsible but it does not mean that pharmacists can not give the instructions’’.
The other two doctors (pulmonologist and the manager) believe that only the doctor has to be responsible for the instructions. They mention that pharmacists sometimes give different instructions from doctors, which result on confusing the patient.
‘’I believe that the doctor should be responsible and on the other hand the right pharmacist should tell the patient that he should follow the doctor's instructions and not give instructions, regardless of whether he knows the use and the dosage because the doctor may give different doses for the inhaler depending on the case. This
procedure can also confuse the patient. In the end the doctor will be responsible for his course.’’
‘’ As I said before I had a patient who I gave instructions to him by phone and he probably did not understand them and went to a pharmacist, the pharmacist showed him the wrong use and that result to confuse my patient and his treatment was not effective. It would be best for pharmacists not to give instructions to the patient because they are often wrong and thus confuse him.’’
Pharmacists perception about the responsibility of the instructions
One pharmacist believe that doctor is responsible to give the instructions for the use of inhaler but they can act as an advisor and tell their opinion to the patients if need it.
‘’In the first phase, I believe for sure the doctor and if necessary then the pharmacist can also intervene. I need to know that the patient use the device properly and be prepared to give instructions if asked’’.
The other pharmacists mention that she has the skill and the knowledge to deliver the instruction, so her opinion is that both pharmacists and doctors can be responsible.
‘’Theoretically the use of the device is one so it cannot be much different what I will show with what the doctor will show. We both have to follow the instructions of the inhaler company. In the dosage I can say my opinion if I see something that is not normal but because the doctor decides on the dosage, even in this case I must first talk with the doctor and then to the patient. Finally I believe they can both be responsible for giving instructions for the inhaler’’.
Healthcare and Technology
Healthcare Providers: Technology Positive Perception
In general healthcare providers have positive perception about technology and the impact that can have in the healthcare sector. Healthcare providers also mention the positive impact that technology already has in the sector.
‘’Certainly technology can help health in many ways, initially it facilitates both the
‘’I believe that technology can often make the patient's life simpler and easier to understand how to behave based on his illness’’.
That means that technology makes patients life simpler without time limits, more control and better knowledge. Moreover, it is also noticed the impact that technology already has on diagnose level and on helping pharmacists to deliver medications.
‘’I think it helps a lot, now most things are done through technology, ie electronic prescribing, patient information and the way of orders. Of course technology helps a lot’’.
‘’Technology in general and medical technology in particular has certainly helped and will help. I believe that medicine and more specifically some specialties would not have reached this level of effectiveness’’.
‘’In recent years we have realized how necessary the use of technology is at the level of diagnostics and therapies, so it is a part of our daily practice’’.
Healthcare Providers: Technology Negative Perception
Furthermore, healthcare providers also view some barriers on adapting technology innovations. In practical ways technology may help but is also important to control the costs of the innovation.
‘’Of course, a huge factor for the application of a new technology is the cost and I can not ignore it, also it should cost less for the patient but also be profitable for the doctor’’.
Another factor for the best implementation of technology is that the people who are willing to make this innovation to have the proper knowledge in order to deliver accurate and useful features to patients and not to confused them.
‘’Nevertheless, I believe that those who support technology should know it well so that they can interpret their experience and knowledge in the right way, because many times the patient can be confused and in the end this method is not so effective’’.
Healthcare Providers: Video Calling Instructions: Positive Perception
In order to find a solution for better delivery instructions, this study suggest the video calling as a tool for both doctors and patients. In general healthcare providers found this concept very interesting for them and also effective for patients.
‘’I think that because when instructions are given in an office under time pressure this can negatively affect the patient but if there was a possibility to give instructions at home he might understand them better’’.
‘’It would definitely help because having the image of the patient trying to put the instructions into practice I can at that moment guide him and help him use the device properly’’.
Due to the digitalization of the world the concept of the video calling could easily have impact on the patients life and also could prevent patients of moving when they are vulnerable or in pandemic situations (Corona virus).
‘’For example, like today with corona, we do not want vulnerable groups to circulate too much outside and if there was Internet monitoring it would help us a lot.’’
Healthcare providers also notice that video calling will also help them to gain more experience on patient’s errors and also to practicing the skills in order to minimize their own errors. A pharmacist also believe that could also help on preparing the instructions for the patient by reading the company’s instruction before speaking with him.
‘’Yes, I definitely believe that it would help me because I could search and see the instructions in more detail before delivering them to the patient. Also the repeated use of different devices would give me a very useful experience since there are so many different devices’’.
‘’Yes, it would definitely help me, the more I believe that the continuous repetitions would help me to understand the patient's psychology and to be able to know how I should approach him in order for him to properly understand the use of the device’’.
Healthcare Providers: Video Calling Instructions: Negative Perception
Video calling in general is welcome by healthcare providers but it is also has some limitations that probably will result on confusing or lost the relationship with the patient. This can easily drive on lost trust with the patient and can have a negative impact on doctors job.
Healthcare providers also mention that issue for the implementation of the video calling instructions will be the lack of technology knowledge of elderly people. Most elderly people belongs to the category of asthma or COPD which means that may face some difficulties on understanding the process.
‘’It is a percentage of people who do not have the ability to follow the technology and will have a hard time’’.
Furthermore healthcare providers also notice that is not only elderly people who may not be able to follow technology but also are people with low education level that may never use technology before.
‘’It depends on whether the patient will have an experience in the field of technology and understand some basic things; this of course can also depend on his level of education. If he does not have the required knowledge he should visit the doctor's office’’.
Patients: Technology Positive Perception
In general patients feel that technology could have positive impact on their medication. Most of the patients are already adapted with the concept of technology and they are able to follow any innovation. Patients also mention that through technology are able to have better communication through the instant contact with their doctors.
‘’I believe that technology can have a positive effect on health in various ways such as direct contact with the doctor’’.
Another technology feature is that patients are able to gain knowledge about their disease, have better health control and feel more safety.
‘’I believe that technology would be a great help to health. This is because we can learn through the Internet a lot of health information that we did not know and become more responsible for our health. It would also help in direct communication with the doctor who would offer better safety to me. As for my knowledge of technology I consider it sufficient and if I have to learn something new I think it will be easy for me’’.
Patients: Technology Negative Perception
On the other hand, patient mention that the concept of technology may scare them because doesn’t have the required knowledge to follow. At the same time this patient believe that technology may have positive impact in healthcare sector, in general.
‘’Listening about technology scares me a little because I feel that I do not have enough knowledge to use it but on the other hand I believe that in general technology can facilitate health in things like communication and information’’.
Patients: Video Calling Instructions: Positive Perception
Patients, hearing the concept of video calling instructions were positive and they expressed many ways that this intervention could help. Most of them believe that video calling instructions could save them time and energy because sometimes they really feel bad due to their disease, and is really uncomfortable to move.
‘’I believe that it will be very easy and it would not be difficult to use. That is, I believe that you can save many hours of waiting by simply pressing a button. In any case, I believe that it would help me to have better control of my disease. In the practical part it would also help a lot’’.
Another advantage is that people who are vulnerable could avoid the contact with others. As many patient mention, sometimes they feel vulnerable and prefer to avoid contact with others.
‘’It will help because patients do not come in contact with the outside world which means that they may not suffer and also have the services of a doctor. Also patients are in vulnerable groups so if their contact with other people is limited then they will not be vulnerable to viruses’’.
‘’I would feel much better if I passed her instructions from home because I would not have to bother and get into the process of getting ready and leaving my house. Once I had to go and I was in a bad situation that I did not want to move out of my house. I felt very uncomfortable that others saw me in this situation and of course it was weird. If there was a video call at that moment I think it would save me’’.
Patients: Video Calling Instructions: Negative Perception
On the other hand some patients also expressed their negative perceptions about the video calling instructions. Patient mention that prefers to get the instructions in doctor’s office, because this will make him to better understand and trust the process.
‘’I would feel better in the doctor's office because he can examine me and also gives me more security to be there knowing that I have a problem. This way I could better understand the procedure of use and I would trust my doctor more. I think he will understand my problem better’’
Possible Solution: Video Calling Instructions
The aim of the interviews was to investigate whether the video calling instructions could have a positive impact on the implementation of the inhaler instructions. In conclusion patients and healthcare providers expressed their opinion on the most effective way to implement this intervention. Their possible way is that the instructions should be interactive. This means that the patient will be able to understand his/her error and also to repeat the process in front of the doctor any time that feels insecure, which drives to better diagnose.
Patient: ‘’I think this would help me a lot. It would give me great confidence to know that I can talk to my doctor at any time. More specifically I could show him and he would listen to me to see better if I have something. Also sometimes with some small symptoms I have to go to the doctor while with the camera if the doctor can make a diagnosis, this can be avoided’’.
Patient: ‘’I think it would help me a lot if the instructions were documentary, ie the doctor would show the camera that it is the correct use of the device and then I would do it in front of him. I would feel safer to learn right away what my mistake is’’.
Pulmonologist: ‘’Initially the doctor must have the same device as the patient in order to be able to show him how to do it. If the doctor has already shown the procedure to the patient, then he asks him to use it in front of him and to make the appropriate corrections. Therefore, in order for the video call to be implemented better, the first visit with the doctor should be made and then used so that the doctor can effectively examine his patient, but also the patient can get the best education’’.
On the other hand patients and healthcare providers also mention possible risks for this intervention. Some people may lack of technology knowledge, which will make it harder for them to follow this process.
Clinic Manager: ‘‘there is difficulty in this. It depends on whether the patient will have an experience in the field of technology and understand some basic things, this of course can also depend on his level of education. If he does not have the required knowledge he should visit the doctor's office’’.
Another risk that a manager of the hospital mention that the cost is a major factor for the implementation of this intervention. It is very important to make something that will save time and make life simpler for patient but also it must product profits for doctors.
Clinic Manager: ‘’Of course, a big factor for the application of a new technology is the cost and I can not ignore it, also it should cost less for the patient but also be profitable for the doctor’’.
Adaptation on Cehres Roadmap and Damschroder model Diagnosis of the implementation (Damschroder Model) Context of the implementation
Adaptability
Patients and healthcare providers had very positive perceptions of change through technology. They believe that now is the right time for technology to intervene in the system due to digitalization of the world and also the plenty opportunities that technology could offer.
Trialability
Trialability plays a major role as the online video instructions must be tested and evaluated many times before will be delivered on the patients hands. Healthcare providers must teach the patient how to use the video calling and be sure that he learn it before leave the office. Is easy to confuse the patient if the instructions are not
Complexity
Patients have the opportunity to call daily in specific times the doctor and ask possible questions or repeating the process of inhaler machine in order to receive the doctor’s feedback.
Cost
Healthcare providers agreed that video calling will probably save them more time to focus on other responsibilities in order expand their activities and create more profit in relation with better control of their patients health. On the other hand patients mention that this service will save them a lot of money by avoiding the unnecessary movements.
Inner setting
As mention before one of the main values for the implementation of this intervention is the knowledge of the patient about it. Healthcare providers can only have this service for people who having tablet laptop or phone with camera, which is a limitation, but their responsibility is to teach patients with the required devices to use this service properly and avoiding mistakes, which can result to the worse progress of the patient. Healthcare providers are responsible to control the process and avoid the patient to misunderstand instructions. Based on the results of the interviews, healthcare providers seems very positive on using video calling and most of the agreed that is easy to use and is not going to confuse the patient but it will improve their performance on using the inhaler device.
Outer setting
Patients’ need is to avoid any unnecessary movement but also to have direct communication with the doctors. As healthcare providers mention, video calling is not always applicable and depends from the patient’s current situation. Patients also seem very positive for this intervention and most of them mention that they are already adapted with the technology and the video calling is easy to use for them. Everyone conclude that video calling could have positive impact on their practice.
Content of the implementation
Individuals involved
Important role-plays the knowledge and beliefs about the intervention. Healthcare providers must have the proper technology knowledge to follow this intervention and probably some old doctors will still prefer only the physical contact. Based on the interview data the individuals involved have sufficient knowledge for technology, even the patients with less knowledge are able to use the video calling.
Implementation process
For the implementation process is very important the initial instructions by the healthcare provider to the patient. Healthcare providers are responsible on teach the patient how to use the video calling and use it if needed. In our case it is very important to provide frequent feedback for the improvements of the instruction delivery by both patients and healthcare providers for the best implementation of video calling instructions.
We can conclude that video calling could have a positive impact on the delivery of the inhaler instructions. All the participants agreed that monitoring through the video calling could improve the communication between healthcare provider and patient, the use of the inhaler device and also to avoid the unnecessary movements for the patient and to save some important time for the healthcare providers in relation with the opportunity to improve their own skills on giving the instructions.
Cehres Roadmap
Furthermore, Cehres roadmap will be used to guide an action plan for effectively implementing this technology-enabled innovation in the Greek HC system.
the opportunity to get doctors advices or sometimes diagnoses from home. A week point may be that healthcare providers are not always able to make diagnose through the camera, as they mention it depends from the patient’s situation, and if they have any new symptom they should visit the doctor’s office. In this step all the participants involved must have the required knowledge to follow the video calling intervention.
More specifically healthcare providers must have the appropriate knowledge to guide the patient and explained him in details the process of the new intervention. However if patient does not have the required knowledge, then the healthcare provider must teach the patient how to use the video calling or to choose an alternative approach.
Value specification
The most important values for stakeholders about the video calling instructions is that can be a technological innovation that could improve the patients use of inhalers.
Moreover healthcare providers believe that this intervention could be easily used by most of the people especially young people who already know how to use the technology. More specifically healthcare providers prioritize the correct use of inhalers of the patient first and then agreed that video online instructions could be a tool for improvement. This could also attract younger people or others who may not have time to visit the doctor. In this step the action is that healthcare providers agreed that video-calling intervention could help in the most of the situations but sometimes the physical contact is needed. Healthcare providers point the importance of specific steps that needs to be taken in order to use successfully the video calling. Except of the required technological knowledge, patients sometimes need the physical contact with the doctor in order to feel more secure. Most of the participants agreed that technological knowledge is very important for the implementation of the video calling and everyone was very interested to learn it and practice their skills on that.
Design: Based on the stakeholder’s value mapping
Patients were very positive about this intervention, they believe that this could save them from very bad situations and they are unable to move. It is something that can improve their communication with doctors and also to make their progress more efficient. However some of them mention that the lack of technology knowledge may
be a problem for the implementation of this intervention, which can easily result on confusing the patient. For that reason healthcare providers have the opportunity in the first visit with the patient to explain him how to use the video calling if need it in the future. This can overcome the negative perceptions about this intervention and also make people more adapted with the new era of technology. In this steps stakeholders agreed for the best way to implement this intervention in the Greek healthcare system.
Patients and doctors need the feeling of secure and the idea of the intervention that could probably decrease the physical contact did not help them to feel confident about it. For that reason both patients and healthcare providers agreed that the first action to be taken is that the patient needs to make the first visit in the doctors office in order to make the best diagnose and then to use the video calling as a monitoring tool to improve the patient’s skill on using the device.
Operationalization
Both healthcare providers and patients agreed for the best way to implement this technology intervention. Both agreed that physical contact with the doctor is important because makes the patient to feel more secure and the doctor to gain more trust with the patient. Video calling instructions is an intervention that could easily have positive impact on both sides. The operationalization of this innovation is that patients should make the first visit in doctor’s office and get physically instructions for the inhaler and also to learn how to use the video calling if need it and then the doctor can use the video calling to monitor and control the patients progress. In this phase both Healthcare providers and patients agreed that this intervention could be implement in the Greek healthcare system and based on their needs this could save them energy, time and money. The concept of video calling is easy to use for everyone and even the elderly people seem to have the need to learn more the concept of digitalization. The action for the best implementation is the first visit to be in the doctor’s office and then the monitoring and the feedback could be easily take place
Summative Evaluation
In this study the new health technology will not actually be developed and implemented. Therefore this phase of the model is not applicable for this study.
Discussion
Principle findings
It was clear that most of patients do not use correctly the inhaler device and possible intervention for improvement is needed. Both healthcare providers and patients shown great interest for the impact of the technology for better implementation of inhaler instructions, despite the lack of knowledge that may some people have (elderly, education level). Most of the patient agreed that this intervention could save them time, energy and maybe costs in relation with better communication and instant contact with the doctor. On the other hand healthcare providers in general had positive perception about video calling but they also mention the importance of physical contact. Furthermore, healthcare providers agreed that video calling would be a great tool under the condition that patient should make the first visit for instructions in doctor’s office and then it is possible and efficient to monitor the progress of the patient through video calling. Both agreed that the best way to deliver the instructions is interactive, which means that doctors must show to the patient with the same machine the process and then the patient to repeat the progress. In addition healthcare providers believe that technology and more specifically online video calling would help on implementing better the inhaler instructions but they also point out the importance of costs. They want to be involved in innovation that would make the life of the patient simpler but also to be profitable for the doctor.
Technology could have positive impact in Healthcare
Based on the findings, both healthcare providers and patient believe that technology already helps and it will help the healthcare sector. Healthcare providers point out the importance of technology they mention that already on type and deliver medication (electronic prescribing), and at the level of diagnose and therapies. Health IT tools support diagnostic team members and tasks in the diagnostic process, which means that health IT has the potential to improve diagnosis and reduce diagnostic errors (El-
Kareh et al., 2013). Furthermore, e-prescribing can transmitting orders accurately among prescribers, pharmacies, and health plans, and more advanced e-prescribing systems could help physicians avoid prescribing errors, adhere to treatment guidelines, and monitor patients’ responses to treatment (Bell et al. 2004). Both examples shown the positive impact that technology already has in healthcare.
Patients also believe that technology could be a great tool for their health control.
Most of them mention that technology could provide them with better knowledge about their disease and health in general, and also could offer them better communication with the doctor in relation with less cost. An important advantage technology is that patients are able to get in contact with health care providers quickly and easily. They do not have to wait in the office have physical contact with the doctor or to travel to the. Technology could give them access to Internet, which is a useful to provide the patients with information about diseases and treatments (Eland‐
de Kok et al. 2011).
Patient’s thoughts about their training
It is mentioned that some doctors do not give too much attention on giving instructions for the inhaler to the patient, which result on the bad progress of the patient. One of the most important aspects to be taken into account when evaluating the progress of disease treatment among individuals with COPD, and guidelines emphasize the importance of assessing inhalation technique to improve the efficiency of drug delivery is the correct use of the inhaler (Pothirat et al. 2015). In general patients who were involved in my research mention that they receive sufficient training by the doctor and they are happy with it. They explained that doctor was persistent and showed many times the use of the inhaler before the patient leave the office.
On the other hand one patient mention that he never received instruction from the doctor and learn the process through the Internet. Studies have identified that a variety of healthcare professionals often have poor knowledge on the optimal use of
Our findings show different views on this topic. Patients most of the times state that feel better to know that they can get advises from both pharmacists and doctors. Two patients state that they feel more secure knowing that only one person is responsible for the instructions, more specifically the pulmonologist. On the other hand some doctors state that pharmacists sometimes gave different order from them, which can easily result on worse medication progress for the patient. Another doctor’s view is that anyone who has the knowledge to deliver those instructions must be responsible to help the patients.
Looking on the literature most studies propose the pharmacists to be responsible for giving the instructions because they are the last healthcare provider that has contact with the patient before asthma or COPD medication and also they have more frequent contacts with the patient (Giraud et al. 2010). The most effective way is every health provider, which is involved in the patient’s progress to participate on the repeating inhaler training for the patient. In Greece will be applicable if both can have the right to give instructions but also to create a communication network to build strong relationship and to discuss any issue before contact the patient. Some studies mention that poor communication between doctors and pharmacists is a major cause of medical errors and the effective collaboration between them can significantly improve patient care (Gallagher et al 2010).
Video calling instructions
Poor inhaler technique could lead to increased symptoms and the progress of the patient to get worse. This study proposes video calling instructions with the aim to be efficient for both patients and healthcare providers. Based on our findings, healthcare providers will have the opportunity to monitor any time and also to save time for other responsibilities that may have. On the other hand patients could feel more secure knowing that they can communicate with the doctor any time and ask questions if need it. Most important is that people who may belong to vulnerable groups can stay home and get advices from the doctor, without moving outside.
There are also some negative thoughts about this intervention. The manager of the hospital mention that video calling may be difficult for elderly people due to lack of knowledge but also difficulties will face some people with low education level (Pothirat et al. 2015). Previous study showed that videos are not adequate substitutes for face-to-face training, for that reason we propose that video calling will be
effective after the first visit with the healthcare provider. That will give the opportunity to the doctor to give sufficient instructions at the beginning physically and then to monitor the progress of the patient through video call if need it. If the patient need help or feel insecure about the use of the device then he can call the doctor and repeat the use process in front of the doctor, then the doctor will give interactive instructions if need it. The basics of effective inhaler training and consequently effective treatment are simplification, demonstration, and repetition.
Another aspect of video calling is that formal training and demonstration shown that can help both patients and healthcare providers to improve their inhalation technique (Pothirat et al. 2015).
Cost effectiveness
Video calling it is an e-health intervention that could not product profit instantly for the healthcare providers, but indirectly. However, it can help them to save time, building better relationship and be able to make diagnose or assist the patient.
E-health increases the efficiency in healthcare sector, which drives on decreasing costs. Possible way to reduce cost is by avoiding therapeutic interventions or unnecessary diagnostic through enhanced communication possibilities between health care establishments, and through patient involvement (Eysenbach 2001).
Barriers to Patient video calling use
If you discover the Greek healthcare system you can realize that technology has no impact at the moment, especially on the patients contact with the doctor. Patients prefer to visit doctor to get advices and have physical contact, which means that the adaptation of video calling would probably take more time. Most of the patients mention that video calling would probably make their life easier but also point out the importance of physical contact with the doctor. On the other hand healthcare providers state that touch and more specifically the first visit is very important to take place in doctor’s office, to see and hear the patient to touch him and to diagnose him
