Integrated Remote Primary Care Infrastructure: A Framework for Adoption and Scaling of Remote Patient Management Tools and Systems

Abstract

Digital health technologies have for number years now been expected to reduce the skyrocketing health related costs as well as the care burden on traditional healthcare systems. However, their adoption and scaling have consistently been unsatisfactory and sometimes, outright disappointing. Scholars have offered several valuable, insightful, and pertinent contributions to address the above challenge. However, these contributions are in most cases atomistic, transitory, non-spatial, and dispersed. The above state of affairs has left practitioners in limbo as to where and when to apply which insights to what type of digital health intervention and in which context. In this article, a new holistic and integrated theoretical framework, specifically focusing on remote patients’ health management tools and systems (RPMTSs) used to engage patients and potential patients at distance or away from healthcare facilities is proposed and introduced to address the above existing fragmentation and gaps. The new framework demonstrates how a clear and holistic understanding of “adoption” and “scaling” processes in the context of a given type and nature of digital health intervention along with an adaptive complex, processual and systems thinking approach can help confront the complexity of the healthcare apparatus while at the same time responding to its constantly evolving, dynamic nature with “agents” who may sometimes act irrationally or behave in unpredictable ways. In the process, a new framework is added to the knowledge base to guide and support the adoption and scaling of RPMTSs.

Appendices

Appendix 1: Topology for Theorizing RPMTS’s Development Populated with 35 Potential Theories

Appendix 2: Theory Selection Details and Suitability Assessment for CR

	Selected theory/framework	Explaining the match/link to the stage or stage-gate	Main author (and outcome)	h-index (publications)	5 year impact factor of major journal
	Pervasive theory
1	Diffusion of Innovations	The entire adoption process essentially aims at understanding how the new RPMTS intervention will spread over time. Designers and developers, therefore, seek to predict and respond to the needs of the present adopter segment on the diffusion curve. Rogers’ diffusion of innovation theory was thus included as a pervasive theory not only to help designers and developers to take a long term view of any new RPMTS intervention but to also deliberately track its diffusion over time at critical stage-gates. This ability to track an intervention’s diffusion over time, would allow developers and implementers to take appropriate action, at the right time to evolve the intervention to meet the needs of successive segments identified by the theory and overcome barriers to the adoption and scaling of RPMTSs as and when they arise	Everett M. Rogers (included)	40 (172)	4.498 (2019-Communication Research)
Assessment/dissemination theory
2	Sociotechnical Imaginaries	Assessment and dissemination theories are aimed at both evaluating collectively held views around the proposed RPMTS intervention as well as the current state and infrastructure of primary healthcare services and at the same time, informing target potential adopters of a new intervention in the pipeline. The main activities and tasks here include the assessment of mobile device penetrations, level of technology literacy and skills (mobile device use), identifying opinion leaders and innovators as well as attitudes and opinions about current access to and quality of primary healthcare services and the proposed new intervention, its benefits, main features and perceived risks. Of the four theories listed, “sociotechnical imaginaries” was selected because it is future oriented and seeks to assess collectively held views rather than individual opinions to be aggregated	Sheila Jasanoff (included)	23 (61)	2.366 (2019-Minerva); 1.705 (2019-Science as Culture)
Attitudes, behaviour and perceptions shaping theory
3	Community-Based Participatory Research	After evaluating collectively held views; attitudes, behaviour and perceptions shaping theories seek to influence potential adopters towards a favourable position in relation to the proposed intervention. While the technology itself may be designed in a such way that it accomplishes this objective, the researchers primarily believe that meaningful involvement of concerned users in solving their specific challenges is the most appropriate approach and thus selected “community-based participatory research (CBPR)” from among the listed theories as the most suitable framework for systematically involving users in solving their own problems	Barbara A. Israel (excluded and replaced)	1 (1)	2.818 (2019-Journal of Urban health)
Readiness and uptake prediction framework
4	Fit between Individual, Task and Technology	To conclude the preconception stage, we proposed the use of readiness and uptake prediction theories to assess the level of preparedness of the adopting context to take up the use of the new intervention. Activities here include measuring attitudinal changes around the proposed new intervention, its benefits, main features, and perceived risks; soliciting inputs from innovators and opinion leaders within the target adopter segment; projecting the new RPMTS intervention's uptake and spread based on the diffusion of innovation theory and assessing improvements in technology literacy and skills (assuming sufficient time has passed since the initial assessment [e.g., 2 years]). Among the listed theories here, it was thought that the FITT framework was the most appropriate because of its focus on how the individual uses the technology to accomplish a specific task or collection of tasks	D. Goodhue (Included)	33 (79)	2.410 (2020-Decision Sciences); 8.180 (2020-MIS quarterly)
Implementation model
5	Behavioural Model of Health Service Utilisation	The uptake/acquisition stage begins with implementation theories aimed primarily at planning for implementation and initial uptake or use of a given, new RPMTS intervention. Activities here go beyond mere project management tasks aimed at rolling out the new RMPTS intervention (which like design, ought to be informed by contextual realities) but also include understanding what would move target adopters to start using the new intervention and on what occasions. Therefore, to be able to subsequently measure improvements in access to and quality of healthcare services as a result of the new RPMTS intervention, it was felt that “the behavioural model of health service utilisation (BM-HSU)” might offer insights beyond project management activities related to implementation and chosen	Ronald Max Andersen (included)	88 (256)	3.675 (2019-Journal of Health and Social Behavior)
Uptake contextualising model
6	Fogg's Behaviour Model	Next, we propose the use of uptake contextualising theories to focus on the actual setting in which the initial decision to try out the new intervention is anticipated to take place and seek to bring together all the elements necessary to kick start the initial use of the new intervention from the target adopters’ perspective. Fogg behaviour model (FBM) was specifically selected for its simplicity and insights on role of “triggers” in inducing desired behaviour (uptake) in contexts where motivation and ability are pre-existing	B. J. Fogg (Included)	33 (63)	2.449 (2019-Research Technology Management Journal)
Uptake assessment model
7	P ractical, Robust Implementation and sustainability model	To end the uptake stage, we make use of uptake assessment theories to evaluate how the deployment of the new intervention in its context of use, may be impacting its uptake and sustainability thereafter. Now that the intervention is already being used at least by some in the target adopting population, we focus on evaluating the perspectives of adopters and non-adopters alike, on the deployed intervention as well as characteristics or attributes of each of these groups to understand how either the intervention or its implementation may be improved to subsequently increase uptake. For these tasks, “the practical, robust implementation and sustainability model (PRISM)” was thought to be the most fitting framework when compared to other listed theories at this stage-gate	Adrianne C. Feldstein (included)	29 (66)	6.084 (2019-BMJ Quality & Safety)
Diffusion assessment framework
8	Reach, Effectiveness, Adoption, Implementation and Maintenance	We started “the adaptation/acceptance” stage with diffusion assessment theories to primarily measure the achieved level of adoption so far, to determine whether the intervention has reached the critical mass (reach) required to now begin embedding its use in the habits and routines of its target users. At this stage-gate, we found that RE-AIM framework not only combines the concepts of reach and adoption that we are seeking to evaluate while at the same time being well integrated with the PRISM framework but also enables us to double up on the evaluation of implementation and effectiveness of the newly deployed intervention along with the evaluation of maintenance. RE-AIM was, therefore, thought to be the best framework for the job at this stage-gate	Russell E. Glasgow (included)	108 (482)	4.210 (2020-American Journal of Public Health)
Routinisation and internalisation theory
9	Domestication theory	If it is established that the critical (diffusion) mass for the newly deployed intervention has been reached based on the RE-AIM framework, we suggest the use of routinisation and internalisation theories to embed the seamless use of the new intervention in the habits and routines of its users as well as to ensure that it is part of their lives and lifestyles. For the above purpose, domestication theory proved to be the most appropriate because of its clarity, simplicity, and seamless integration with adaptation stage of the adoption process	Roger Silverstone (included)	16 (46)	1.929 (2019-Media, Society and Culture)
Learning and knowledge management theory
10	Socialisation, Externalisation, Combination and Internalisation model	Finally, we proposed that the adoption process as a whole be completed with learning and knowledge management theories to draw and document lessons from the adoption process and to potentially create new knowledge about the process for scaling the intervention. While knowledge management theories and practices such as “case-based reasoning” could have done the job, the socialisation, externalisation, combination, and internalisation (SECI) model was found to be most appropriate framework for offering formal mechanisms for creating new knowledge as opposed to merely learning from experience	Ikujiro Nonaka (included)	30 (65)	13.21 (2019-Harvard Business Review)

Appendix 3: A Framework for Adoption and Scaling of Remote Patient Management Tools and Systems