By Helen Lionarons MSc., Consultant Clinical Psychologist and Clinical Director at Oh My Mood UK Ltd, Dr. Andrew Jones, Institute of Psychology, Health and Society, University of Liverpool and Pauline Post MSc., Health Psychologist and Co-Founder at Oh My Mood UK Ltd
Technology is viewed an essential component to substantially improve health care services. It offers great opportunities to address some of the biggest challenges that the mental health sector is currently facing. Despite the many initiatives to improve access to health care, currently only about 40% of people with mental health conditions are receiving proper treatment. According to the Health Foundation and Institute for Fiscal Studies (IFS), financial resources need to more than double to reach 70% of the people who need mental health care. Increasing demands and limited resources necessitate to search for more efficient ways to provide mental health care, i.e. making better use of health technologies. However, despite widespread political agreement about the importance of eHealth, the realization of its benefits has been slow, mostly due to difficulties with adoption and implementation by the sector. In this article we will take a closer look at what we, from both a practical and a scientific point of view, consider one of the most important pitfalls in the adoption of IT by clinical staff.
Technical vs Adaptive change
It was Harvard professor Ronald Heifetz who made clear the distinction between technical versus adaptive change. When dealing with technical change, expertise rules. Problems may be complicated, and require collaboration across disciplines; yet the resolution of the problem is clear and straightforward: follow a series of steps and things go well. For the most part, when we face technical challenges, we focus on improving processes, providing training to improve skills, and doing the right things right. In other words, we know the answer; it is more a matter of careful implementation. Following a recipe is a technical change; so is downloading and then using most apps for your smartphone.
How different things are with adaptive change. Adaptive change requires more than simply sharpening our processes and skills. Instead, adaptive change challenges our beliefs and ways of thinking. It requires that we change our mindset, our mental models of how things should be done. But since our mental models provide internal stability in a world of continuous change, we are often resistant to change. As Heifetz and colleagues stated: Adaptive challenges can only be addressed through changes in people’s priorities, beliefs, habits and loyalties. Making progress requires going beyond any authoritative expertise to mobilize discovery, shedding certain entrenched ways, tolerating losses and generating the new capacity to thrive anew.
Implementing technology in clinical practice
One of the challenges of implementing eHealth in clinical practice is that it gives the impression of being a technical change, while the complexity, nuance, and decision making under uncertainty that characterizes clinical work makes it an adaptive change of the highest order. Implementing eHealth into clinical practice not only asks for changes in the system, at the bottom line it asks for changes in clinicians’ beliefs, habits and loyalties.
Clinical staff will undoubtedly have put blood, sweat, and tears into their traditional clinical practice. Asking them to break with old habits, especially for those who have successful methods, can be difficult; an inappropriate proposal to change high held values about the doctor-patient relationship, or more down-to-earth, a way to change roles within health care for the benefit of other parties. But as we all know, beliefs, ideas, images, and opinions that we have consciously or unconsciously formed from our experiences, when formed become representations of a perceived reality and predispose us to behave in certain ways. Although meant to provide internal stability in a world of continuous change, our mental models also blind us to facts and ideas that challenge or defy our deeply held beliefs, and guide our thoughts and actions within narrow channels.
Change of focus of eHealth implementation
Until this moment, much focus of eHealth funding has been directed to the clinical effectiveness of eHealth, while research on the adoption and implementation of eHealth has not yet received the funding that is necessary for eHealth to successfully become a part of health care. For eHealth to be successfully implemented, leaders in the field must also understand the difference between what is technical and what is adaptive. Technical solutions are so much quicker and easier to explain and implement, but they only work for technical problems. Adaptive change asks for changes in clinicians’ mental models that cannot be resolved through the application of authoritative expertise and through organizational structures, procedures and habitual ways of doing things. Therefore, when implementing our innovative health care pathways, we always carefully take these factors into consideration. The adaptive challenges can only be addressed through changes in clinicians’ priorities, beliefs, habits and loyalties.
Making progress requires going beyond any authoritative expertise to mobilize discovery, shedding certain entrenched ways, tolerating losses and generating the new capacity to thrive anew.
Encouraging the implementation of eHealth
Since the adoption of new models of care can be disruptive to daily practice, especially for those in the front line, it is necessary to take a careful look at why and how clinicians adopt eHealth. Various studies have identified barriers to e-health implementation; including financial, structural, cultural and technical. For a successful adaptive change multiple levels within an organization should be actively involved in the change process. From our experience we notice that only with the support on various levels within an organization the road for the clinicians can be paved and facilitated to adopt eHealth solutions. Without the right motivation or incentives the implementation of eHealth will be limited to a few techie doctors, whereas the aim is that the majority of clinicians will embrace it.
One way of encouraging the implementation of eHealth is by linking its technology with a clinical content clinicians are used to work with. Therefore, new health care pathways should be developed that combine evidence-based therapeutic interventions with the latest digital solutions. Such new models of blended care can seamlessly integrate eHealth with care as usual, and avoids the deployment of eHealth products as an add on only. Such blended health care concepts do not only increase health care capacity, reduce waiting lists and increase the quality of care. It also reduces the pressure on clinicians immensely and creates freedom in their work routines.
An often heard fear of clinicians in the adoption of eHealth is that it would make treatment less personal. However, eHealth has been developed to facilitate psychotherapy without losing the personal attention for the patient. When applied in an intelligent way, technology can contribute to an even more personalized mental healthcare, in which treatment can be more easily adapted to the idiosyncratic characteristics of the patient. To really profit from all technology has to offer, it is important to develop and test new health care pathways in which technology is ruled by the clinician and adaptive challenges (changes in beliefs, habits and loyalties) are monitored by action learning, reflection and investigation in order to understand the gains from adapting technology in clinical practice.
Recent systematic reviews have identified other factors which may further improve the uptake of e-health through adaptive change, including cognitive participation, in which enthusiastic health professionals act as ‘local champions’ and support enrollment and commitment to e-health amongst colleagues. Furthermore, overcoming more practical barriers such as organizational issues (policy and administrative support, resource allocation) and issues around confidence and accountability may require small amounts of effort but lead to large shifts in attitudes towards e-health and its many benefits.
Oh My Mood develops innovative and widely applicable health care pathways for improving care processes within mental health care.
References
Heifetz R, Grashow A & Linsky M. The Practice of Adaptive Leadership (2009).
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Mair FS, May C, O’Donnell C, Finch T, Sullivan F, Murray E. Factors that promote or inhibit the implementation of e-health sysemts: an explanatory systematic review. Bulletin of the World Health Organisation.