What makes a successful telehealth implementation toolkit: A qualitative study exploring the usability and perceived value of the “Ready, Steady Go” Telehealth Toolkit

Academic Report 2015

Project Team Lauren A Powell, University of Sheffield, [email protected] Tim Ellis, NHS Sheffield Clinical Commissioning Group Susan Mawson, NIHR CLAHRC Yorkshire and Humber

Contents Abstract................................................................................................................................. 3 Chapter 1: Introduction.......................................................................................................... 4 Chapter 2: Methods............................................................................................................... 6 Sampling Frame: ............................................................................................................... 6 Chapter 3: Results ................................................................................................................ 7 Time and staff work load.................................................................................................... 8 Layout and format.............................................................................................................. 8 Learning ............................................................................................................................ 9 Pragmatic focus............................................................................................................... 10 Expectations .................................................................................................................... 10 Expectations exceeded ................................................................................................... 11 Chapter 4: Discussion ......................................................................................................... 12 References ......................................................................................................................... 14 Acknowledgements ............................................................................................................. 15 Useful Links ........................................................................................................................ 15

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Abstract Objectives Telehealth implementation toolkits are documents that outline a series of steps or activities that can assist in starting up or modifying a telehealth service. Currently, telehealth technology implementation is frequently not sustained after a pilot phase and there is no “gold standard” to “benchmark” against, with a limited information base regarding what makes telehealth implementation toolkits successful. This study consists of two phases; phase one aims to assess and explore the qualities that comprise a successful telehealth implementation toolkit and phase two aims to assess the usability of the current version of the Ready, Steady Go Telehealth Implementation Toolkit.

Method A two phase study encompassing qualitative semi structured interviews and a focus group. Participants were telehealth experts from academia, the NHS, industry and a local authority from the UK and Europe. Phase one explores key factors of a successful telehealth implementation toolkit and phase two focuses on areas of improvement and ease of use of the Ready, Steady Go Telehealth Implementation Toolkit.

Results The results drew attention to the importance of considering time required to use the toolkit and how to balance this with staff workload. The layout of toolkits, the importance of including external documents others can learn from (e.g. case studies) as well as toolkits having a pragmatic focus were all highlighted. In addition, phase two participants identified the importance of services being “Ready” before actively trying to implement telehealth. This has implications for project sponsors who should only sign-off project launch once certain baseline conditions have been met.

Conclusions The findings of the study have highlighted the essential requirements of a telehealth toolkit and will be used to develop a second version of the “Ready, Steady, Go” Telehealth Implementation toolkit (Brownsell & Ellis, 2012) developed by the NIHR Collaboration for Leadership on Applied Research and Health Care for South Yorkshire into a web-based tool.

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Chapter 1: Introduction The global challenges of an ageing population1 and the consequential increase in long term 2 conditions (LTC) together with increasing public expectation of health and social care are making 3 healthcare in the UK, as it stands, unaffordable. Over the past decade, there has been an increase in 4 secondary care expenditure and A&E admissions with 55% of all GP and 68% of all outpatient and A&E appointments in the UK being by patients with LTC.5,6 These problems, alongside the financial crisis are driving the need to develop new ways to deliver healthcare. Telehealth has the potential to be integrated into care pathways, educating patients and providing support in a paradigm shift 7 towards increasing self-management in healthcare. A report by the House of Lords Public Service and Demographic Changes Committee in 2013 suggested that the use of telecoaching, telecare, telemedicine and mHealth (medical and public health work centred on mobile devises) are potential ways of reducing pressure on the UK health and social care systems. 8

Following the publication of a White paper in 2006 by the Department of Health on health and social care for people with LTC, three initiatives were launched in the UK to test whether telehealth and telecare could be used to redesign health systems. The Whole Systems Demonstrator (WSD) trial was initiated in 2008. The WSD results suggested that telehealth can help reduce hospital admissions, length of stay and 45% reduction in deaths for telehealth patients (4.6% mortality) 9 compared with standard care (8.3%) . The second was the Assisted Living Innovation Platform run by the Technology Strategy Board a key part of which being Dallas (delivering assisted living lifestyles at scale). Initiated in 2012 this is a large scale demonstration of telehealth and telecare services evidence which will begin to be reported in 2015. The final initiative was the ‘3 million lives’ campaign which aimed to work in partnership with industry to promote telehealth and telecare uptake. Subsequently this has evolved into ‘Technology Enabled Care Services (TECS)’ with a commissioners guide to TECS to be published by NHS England in early 2015 to describe how TECS can help establish a more integrated care approach for management of LTCs. However, the results of the telehealth economic evaluation published in March 2013 found that telehealth was not cost effective at the scale implemented in the trial. This suggests that the WSD results should not be viewed as unequivocal although it might be suggested that the use of a Randomised Controlled Trial may have contributed to the inconsistent findings with the trial recruitment process potentially 10 increasing hospital use by control patients the trial itself identifying previously unmet need. 11 A report by the health think tank 2020 health in 2012 highlighted a number of key lessons for the NHS from the Veterans Health Administration (VHA) experiences these included:

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targeted patient selection

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strong clinical evidence base

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integration of telehealth into a co-ordinated health and social care system

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scaling-up telehealth to achieve staffing and logistical efficiencies seen in the VHA programme

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national oversight of the design of the system and over commissioning, procuring and funding services

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patient and staff training.

In a drive towards achieving greater adoption and spread of telehealth the VHA and the UK’s National Health Service (NHS) agreed to an “Exchange Programme” for three years starting in 2013. The aim is to improve clinical engagement and leadership with the overall aim of embedding digital health into 11 the everyday use of patients with LTC. www.clahrc-yh.nihr.ac.uk

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In 2011 ‘Innovation for Health and Wealth’ paper was published by the Department of Health, setting out an architecture, the Academic Health Science Networks (AHSN), the sole purpose of which being to ensure the adoption and spread of evidence based innovations thereby not only improving the health but also the wealth of the nation through engagement with industry. Furthermore the AHSN were charged with the remit to realise the benefits of six high impact innovations one being ‘3 million 12 lives’ and another ‘digital first’. With the UK and USA evidence base and policy drivers dictating the need to scale up telehealth, it is important to ensure the implementation process of telehealth services run smoothly. However, 13 telehealth services are rare, often small scale and frequently fail. A recent systematic review of barriers and facilitators for successful Telehealth Implementation identified 19 themes with the most prominent being the need for reliable and effective ICT infrastructures to support deployment and the 14 need for organisational and individual readiness to embrace change. . In 2008 the NIHR funded the Collaboration for Leadership in Health Research and Care (CLAHRC) in South Yorkshire with the remit to undertake NHS embedded applied research and implementation of evidence based practise. One programme of work within the Collaboration, with a track record in the field, was the Telehealth and Care Technologies theme (TaCT). In order to support the overarching objectives of the CLAHRC and partnership working with the Yorkshire and Humber AHSN, the “Ready, Steady Go” (RSG) telehealth implementation toolkit was developed by Brownsell and Ellis (2012) http://clahrc-sy.nihr.ac.uk/toolkit-form.html the purpose being to assist all telehealth stakeholders within the region in the implementation process of sustainable telehealth services. The work was jointly funded by the European Commissions’ RICHARD ‘Regions of Knowledge’ project and the first version of the toolkit was launched nationally in September 2012 and in Brussels in October 2013. The RSG, unlike its predecessors, is structured around the analogy of preparation for, undertaking and reviewing a race with emphasis on the preparation required before telehealth services can be successfully implemented. RSG is a living document and strives to continuously adapt over time. The anticipation being the development within the new NIHR Y&H CLAHRC of an electronic second version based on the findings of this study. This study consisted of two phases. The aim of phase one was to assess and explore the qualities that comprise a successful telehealth implementation toolkit, with phase two aiming to assess the usability of the current RSG in order to inform the development of a web-based second version.

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Chapter 2: Methods Ethical approval was gained from the appropriate ethical board (University of Sheffield Ethics Reference 0617) and NHS Research and Development approval was gained from NHS Trusts where necessary. A sampling frame (see below) of telehealth experts, all fluent in English, was developed to include all potential users and readers of the RSG as well as a broad range of telehealth experts to address the phase one objectives. Recruitment comprised of a convenience sample based on the sampling frame. Inclusion criteria for both phases were the same, participants should have telehealth expertise, and with phase two participants also required to have read or used all or part of the RSG. Snowball sampling via current contacts and participants was also adopted. Recruitment continued until data saturation was achieved. Participants took part in a qualitative semi-structured telephone interview (phase one and two) or focus group (phase two only) in 2013/14 and were from rural or urban areas. All interviews and the focus group were conducted in the English language. Potential participants were invited to take part via email. Phase one interviews were semi-structured and questions covered participant backgrounds, telehealth experience, experience with implementation toolkits and other related services or technologies. Questions included; “If you have used an implementation toolkit in the past, what were your main expectations?” and “Toolkits can be used a lot in other types of services. Could you explain if you have used toolkits for other purposes in the past? If so, could you briefly explain what you have used them for and your experiences of using them.” Phase two interviews were semi-structured beginning with asking participants about their background, their experience with RSG, telehealth and other related services or technologies. Respondents were asked questions about the RSG covering areas of improvement and ease of use. Questions included; “What were your main expectations of RSG?”, “how did the RSG meet/not meet your expectations?”, “what do you believe to be the key positive and negative aspects of RSG?” Participants are referred to as pseudonyms, each starting with P1 (phase 1 participants) or P2 (phase 2 participants), UK or EU, followed by where the participant is based; H (healthcare), I (industry) or A (academia). The focus group and interviews were audio recorded and transcribed verbatim. A 15 was adopted to ensure analysis reliability; this analysis began with framework analysis familiarisation with the data by reading the transcripts to obtain an overview of the material. A thematic framework was then identified, drawing on a) ideas that were explored in the interview question schedule and b) new themes emerging from the respondents. The data were then systematically coded (indexed) and mapped against the thematic framework to achieve an overall 16 interpretation and synthesis of the findings . A random sample of transcripts were also analysed using the same method by a second researcher. Quotes were selected and used to support emerging 16 themes. In line with the Data Protection Act all data was stored confidentially and participant data was anonymised.

Sampling Frame:         

Telehealth coordinator – NHS Associate Professor Managing Director – Industry Head of Business and Development Investment – NHS Project Manager Business Development Support Manager – NHS Evaluation Lead Lecturer/Head of Department Policy Lead

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Chapter 3: Results Despite an extensive recruitment programme, 8 semi-structured qualitative interviews (phase 1), a focus group (n=10) and 5 semi-structured qualitative interviews (phase 2) were conducted in 2013 by a University of Sheffield Researcher. The sample size reflects the paucity of live telehealth implementations in the region at the time of major NHS reform. Participant demographics are described in table 1. Participant’s telehealth expertise enabled them to critically comment on the RSG and factors that would make a successful telehealth implementation toolkit. Participants were asked about what they believed defined telehealth, telecare and telemedicine, what they believed would make a successful telehealth implementation toolkit and their expectations of them both before and after they came across them for the first time. In addition, phase two participants were asked about their expectations of the RSG and if they were met, past experiences of using telehealth toolkits and how these experiences compared with the RSG. Respondents were also asked what they felt worked well with the RSG and what additional information they felt the RSG could benefit from. All participants were given the opportunity to add additional comments where they felt it was necessary. Results demonstrated the importance participants placed on considering staff work load, accessible toolkit layout (e.g. the chapters entitled “Are you Fit Enough?”, “Ready”, “Steady”, and “G0”), the option to learn from other people and how toolkits should have a pragmatic focus. Phase one themes were mapped onto phase two data, with an additional theme (“Expectations exceeded”) emerging during the framework analysis. Overall, six themes emerged from the data and are outlined in table 2 and discussed below. Tables Pseudonym

Gender

Background

P1NHS1

F F F F F F M M F M M M F M F M M M M F M M

NHS NHS NHS Academia NHS NHS/Academia Industry NHS/LA* NHS Industry Industry Industry NHS Industry NHS Academia Academia Industry Industry Healthcare Industry NHS

P1NHS2 P1NHS3 P1A1 P1NHS4 P1NHSA1 P1I1 P1NHSLA1 P2UKH1 P2EUI1 P2UKI1 P2UKI2 P2UKH2 P2EUI2 P2UKH3 P2UKA1 P2UKA2 P2EUI3 P2EUI4 P2EUH1 P2UKI2 P2UKH4

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Telehealth experience (months) 24 42 24 18 30 156 60 84 42 60 84 60 18 48 6 122 75 24 12 60 60 72

Interview/ Focus Group

Read/ Using RSG

Interview Interview Interview Interview Interview Interview Interview Interview Interview Interview Focus Group Focus Group Focus Group Focus Group Focus Group Focus Group Focus Group Focus Group Focus Group Focus Group Interview Interview

N/A N/A N/A N/A N/A N/A N/A N/A Read Using Using Read Read Using Read Read Read Read Read Read Using Using Page 7 of 15

P2UKH5

M

NHS

24

Interview

Read

Table 1. Phase 1 and 2 participant demographics. Please note some participants work for more than one company e.g. NHSLA1 worked for the NHS and a Local Authority. *Local Authority

Themes Time and staff work load

Summary Toolkits should be short, precise and easy to navigate to required information.

Layout and format

Toolkits should be visually attractive and available in multiple formats. Different chapters within toolkits should also be aimed at different stakeholders. Toolkits should be up to date, elicit critical thinking and should recommend a wealth of relevant information resources. Toolkits should be chronologically structured. The RSG elicits critical thinking.

Learning

Pragmatic focus

Evidence “Short, precise and to the point not too long…. anything to keep the document as short as possible to save valuable time.” (P1UKNHS3) “I like the colours it (RSG) flows well, I like the tables at the end of each section ...I love the layout of it.” (P2UKH2) “…we learnt a lot from looking at other Trusts… and other countries evaluations” (P1UKNHS2)

"I think this document is going to prompt people to think of things that they wouldn’t otherwise have done… a very good trigger…" (P2UKI2) Expectations “…it’s really got to start with this is Participants sought clarity on target what this is trying to do so you audiences, aims, objectives and also stated that the term “toolkit” can lead to don’t have to have false expectations” (P1UKNHSA1) unrealistic expectations. Expectations “…I think they should stress that I Participants were impressed by the exceeded think that the first step (“Are you Fit RSG’s emphasis on being “Ready” Enough”, “Ready”) is the most prior to implementation activities. important which comes before all ready.” (P2EUI1) Table 2. Illustrating a summary of the themes that emerged from phase one and two interview data. For further details, please see the results section.

Time and staff work load It was made clear that toolkits should be as short as possible including only necessary information. Seven of the participants (phase one) believed people won’t have time to read a lengthily toolkit. It was also agreed that the RSG contained a wealth of relevant information but in some, not all, cases was considered too lengthy, “Short, precise and to the point not too long. Clinicians don’t have time to read large documents…anything to keep the document as short as possible to save valuable time.” (P1UKNHS3) “…exec summary to me that was long enough to read if you said that whole toolkit was sort of a lot bigger than that… the whole toolkit was probably too lengthily” (P2UKH5) “…sets out the journey …guide you in the right direction and keeps you on track erm so you don’t waste time looking at areas you shouldn’t be…” (P1UKNHS2)

Layout and format Emphasis was placed on toolkit design and that toolkits (including the RSG) should be user friendly (e.g. brief) and available in multiple formats to accommodate different working styles. Four phase one www.clahrc-yh.nihr.ac.uk

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participants said they would have preferred interactive web-based toolkits. Some NHS staff in particular preferred information to be represented in flowcharts, “I would like an exact replica of this one as a PowerPoint that I can translate and make my own amendments and have a lightweight form print in PDF, …make it available in as many formats as possible because then we can make full use of it.” (P2UKA1) “I would expect it to have a flow chart of… the process really of you know, set up, teach where the readings go, what you know etc what would happen if there’s a fault…” (P1UKNHS4) It was also suggested that toolkits should have different sections aimed at different stakeholders e.g. clinicians, senior management, project management, informatics etc. One participant gave the analogy of manuals for cars, “…I can see a suite of kind of (car) manual type toolkits that are for different circumstances or different types of implementation because I think implementing telehealth for people say monitoring their own… for an example people monitoring their own asthma or COPD it’s a very different kind of thing to implement than me using technology for speech and language therapy rehabilitation. Way different and so a toolkit that is trying to help people implement both of those I think is setting itself up to fail… But they could come in a series!” (P1UKNHSA1) Emphasis was placed on maintaining the RSG’s current visual image, “I like the colours it (RSG) flows well, I like the tables at the end of each section ...I love the layout of it.” (P2UKH2)

Learning One of the key motivations for accessing a telehealth implementation toolkit was to learn about how to conduct a successful and sustainable telehealth service implementation. People were keen to learn from each other, from theory and relevant examples of best practice via links to policy and case studies, “…we learnt a lot from looking at other Trusts… and other countries evaluations” (P1UKNHS2) “You need to reference the fact that this is current thinking and that this is something we should be doing… thinking nationally so I think it is helpful to reference those things.” (P1UKNHSLA1) Phase one participants noted the importance of business plan development and their confusion regarding procurement, “…industry will tell you something different to what Department of Health tell us and our procurement people so it’s a bit of a mind field for us” (P1UKNHS2) “…the biggest thing is the business plan and evidencing financial savings unfortunately it the only thing our commissioners are interested in.” (P1UKNHS2) Discussion around training was two-fold; it was suggested that RSG users would require training and those who lack project management experience would struggle to use the document, “…err some people feel that it’s …too laborious I think it’s… as an effect of less training in project development…” (P2EUI1) “It’s also important to have training activities of all the colleagues so they are more or less on the same track in developing or delivering care” (P2EUI1)

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These comments reflect that it is still unfortunately common within the NHS for complex service change to being undertaken without appropriate regard for the use of supportive project and change management resource.

Pragmatic focus Many phase one and two, not all, believed that toolkits should be adaptable and highlight a step by step, chronological process. Being able to tailor the toolkit to your local (changing) environment was emphasised, “…it needs to be of chronological structure” (P1UKNHS1) “I think one of the things I learnt using (a) model… actually the chronological order of how you implement things the steps in which you implement things might be different in different institutions as well so… you have to bear that in mind” (P1UKNHSA1) One participant pointed out that it would be helpful to include information regarding staff management, “…people who will be adopting the system may not be in your direct supervisory control and therefore they can advocate from the project by just saying I don’t want to do it and to use the American expression ‘you are not the boss of me’ so I’m not gona do it and therefore you have to find some other way in which you can capture the enthusiasm the interest of the people who are going to adopt a system so that’s one part of it” (P1UKI1) RSG encourages users to make considerations they wouldn’t have made alone, "I think this document is going to prompt people to think of things that they wouldn’t otherwise have done… a very good trigger…" (P2UKI2)

Expectations The interviews revealed how toolkit expectations change from when individuals first approach a toolkit to the present day. People expected toolkits to tell them exactly what to do during a telehealth implementation, which they later learned, isn’t the case, “That it would tell me exactly how to do my job! [laughs]… so my expectation was everything I would need to know about implementation would be in there.” (P1UKNHS2) This is at odds with the request that the toolkit be brief and perhaps points to a multi-layer toolkit which can be implemented more easily when using web technology. There was a feeling that toolkits should state who the audience is and what the aims and objectives are, “…it’s really got to start with this is what this is trying to do so you don’t have to have false expectations of what” (P1UKNHSA1) “Is it the NHS or is it the EU wide toolset, you have to, we have to define the (RSG) scope what are we aiming at?” (P2UKA1) The toolkit was developed based on experience gleaned from the NHS but was intended to be relevant to all telehealth implementations whether NHS or otherwise. Perhaps this was too broad an audience. One phase one participant felt that referring to models rather than toolkits is easier due to less expectation that a model will provide specific answers to your area of expertise. They felt models were less specific than toolkits but easier to apply and take in due to their brevity, www.clahrc-yh.nihr.ac.uk

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“…there could be an awful lot of information in a toolkit to read… a model is quicker to read and think okay so these are the steps I need to go through I think” (P1UKNHSA1) In some cases people thought the RSG required more information about the intervention itself and its definitions. It was also suggested that information regarding medical device regulations was missing from the RSG, “…I think you need much, much, much more about the intervention itself so you need much more about what is meant by telehealth” (P2UKA2) “…I think there’s a whole load about medical device regulation that is completely missing from it..” (P2UKI1)

Expectations exceeded In addition, phase two participants appreciated the RSG’s emphasis on making sure a service is “Ready” prior to implementation activities, “…I think they should stress that I think that the first step (“Are you Fit Enough”, “Ready”) is the most important which comes before all ready.” (P2EUI1)

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Chapter 4: Discussion Phase one results presented the importance participants placed on considering time and staff work load, toolkit layout, the option to learn from other people and how toolkits should have a pragmatic focus. These findings informed phase two. It was discovered that the majority of participants felt the RSG was too lengthy but contained a lot of useful information. The layout was commended by participants however there was a feeling that more case studies and examples of best practice would be beneficial. Participants felt the RSG was a very pragmatic document that exceeded many people’s expectations, especially with the unique emphasis on the importance of a service being “Fit Enough” and “Ready” before the implementation process begins. Whilst few participants were required to achieve data saturation, time and staff work load was more prevalent in NHS respondents. The following suggestions were made for a web based RSG V2.0: • • • • • • • • • • •

The RSG should be as short as possible, only including information that is absolutely necessary, due to time constraints on busy professionals. They should set out a chronological journey from project inception through to final evaluation which could potentially save time. The RSG should be available in multiple formats, present information in different, visually attractive, ways such as tables and flowcharts. Different sections within the RSG should be aimed at different stakeholders. To facilitate learning, the RSG should provide further content such as links to case studies, relevant policies, business plans and information about procurement. The RSG should be updated regularly to avoid becoming out dated. The RSG should clarify its aims, objectives and audience. To keep the current analogy of preparing for and undertaking a race and continue using the vibrant colours To provide clarity on the intervention itself (this reflects the confused terminology in this sector with multiple service definitions being attributed to telehealth by different user communities) To provide training in the use of the toolkit for people who request it to ensure everybody using the RSG share the same understandings To continue to emphasise the importance of the “Are you fit enough” and the “Ready” phases

The recommendations from this study will be taken forward in the development and design of a second web-based version of the RSG telehealth implementation toolkit developed by Brownsell and 7 Ellis the purpose being to assist all telehealth stakeholders in the implementation process of sustainable telehealth services. The development of the toolkit was jointly funded by the European Commissions’ RICHARD ‘Regions of Knowledge’ project and the first version of the toolkit was launched nationally in September 2012 and in Brussels in October 2013. Whilst a valuable document the authors of this paper feel it needs developing as a web based multimedia tool with wider relevance to stakeholders. It is anticipated that version two will also include information about medical device regulations, new relevant policy, benefits and portfolio management and incorporate the recommendations from this study. The results of this study are by no means unequivocal; the authors faced recruitment challenges both in terms of people agreeing to take part and finding people who considered themselves to have enough telehealth “expertise”, which is presumably due to telehealth being a relatively new area. Despite these difficulties, this research has drawn attention to a topical, yet under investigated area. It has highlighted the gaps in knowledge that are required to implement sustainable telehealth services. The identification of useful qualities that telehealth implementation toolkits should contain, according to this study’s participants, can help inform the next web-based V2.0 of the RSG as well as others wishing to write telehealth implementation toolkits in the future. To ensure successful evolution of this www.clahrc-yh.nihr.ac.uk

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relatively under-researched field, academics should report not just on the results of their work, but provide more context on the environment in which the research was carried out. This could support the identification of implementation challenges and increase the maturity of the field as the intervention is never just about telehealth equipment but always includes how the service is introduced.

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References 1. United Nations. World population prospects: The 2010 revision. Report, New York, 2011. 2. Department of Health. Long Term Conditions Compendium of Information: Third Edition. Report, May 2012. 3. Digital First. High Impact Innovations Home, http://digital.innovation.nhs.uk/pg/dashboard (2012, Accessed on 28th March, 2014) 4. Audit Commission. More for less? Are productivity and efficiency improving in the NHS? Report, Audit Commission, December, 2010. 5. Blunt I, Bardsley M, Dixon J. Trends in emergency admissions in England 2004-2009. Report, Nuffield Trust, 2010. 6. Parliamentary Office of Science and technology. Telehealth and telecare. 2014; 456: 1-4 www.parliament.uk/post 7. Wootton, R. Twenty years of telemedicine in chronic disease management - an evidence synthesis. Journal or Telemedicine and Telecare 2012; 18: 211-20. 8. Department of Health. Our Health, Our Care, Our Say: a new direction for community services. Report, January 2006. 9. Department of Health. The Whole System Demonstrator Programme. Report, November, 2015. 10. Steventon, A., Bardsley, M., Billings, J, et al. Effect of Telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. British Medical Journal 2012; 344:e3874 11. Cruickshank, J., Harding, J., Paxman, J. et al. Making Connections. A translantic exchange to support the adoption of digital health between the USVHA and England’s NHS. Report, March 2013. 12. Nicholson, D. Innovation for Health and Wealth. Department of Health 2011. https://www.gov.uk/government/uploads/system/.../dh_131785.pdf 13. World Health Organisation. Telemedicine: Opportunities and developments in member states, report on the second global survey on health Report, 2010 14. Brownsell et. al., Identification of the Barriers and Facilitators for Successful Telehealth Implementation: A Systematic Review. 2014. submitted for publication 15. Ritchie, J., & Spencer, L. Qualitative data analysis for applied policy research. In: A. Bayman & R.G. Burgess, (eds.), Analysing Qualitative Data, London, Routledge, 1994 pp. 173-194. 16. Data Protection Act. http://www.legislation.gov.uk/ukpga/1998/29/contents (1998 Accessed 28th March, 2014).

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Acknowledgements This report was produced in collaboration with NHS CCG as part of the Telehealth and Care Technology Theme of the NIHR CLAHRC YH. This report presents independent research by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber (NIHR CLAHRC YH). www.clahrc-yh.nir.ac.uk. The views and opinions expressed are those of the authors, and not necessarily those of the NHS, the NIHR or the Department of Health.

Useful Links     

NIHR CLAHRC Yorkshire and Humber NIHR CLAHRC for South Yorkshire TACT Theme Ready Steady Go Toolkit Rehabilitation and Assistive Technology Research NIHR CLAHRC YH E-repository

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