**2. Challenges in the design and implementation of technology in health care**

#### **2.1. Human-centered design of assistive technology**

In order to ensure an optimal match between the technological product or service and the person who will use it (or is otherwise affected by the technology), it is important that all stakeholders are involved in the whole process of design, development and implementation. Over the last decades involving users and other stakeholders already in the design of new products and services has become standard and is commonly denoted as human-centered design [5, 6], participatory design [7], or co-design [8, 9].

Central in any human-centered design approach are the following aspects: empathy, collaboration and experimentation [5, 6]. *Empathy* is our ability to see the world through the eyes of someone else, to see what they see, feel what they feel and experience things the way they do [10]. The ability to be empathic is vital in order to not project one's own preconceived ideas to the design of new products and services, but really incorporate the (sometimes latent) needs and wishes of the people designed for. Empathizing with the users, understanding them and bringing them along in the design process are essential basic principles of any human-centered design process.

*Collaboration.* The challenges in our current society (also for the design of new assistive technology) are so complex that they cannot be solved by a single designer. Instead, they require a design team consisting of specialists with different backgrounds, not only interaction designers or industrial designers, but also psychologists, engineers, business people, care professionals and the intended users.

*Experimentation.* When solving complex issues it is unlikely that the design team will come up with the optimal solution at the first guess. Therefore, experimentation is central in the humancentered design process. The process entails multiple cycles of ideation, refining and improving the design, allowing the design team to have multiple ideas, to try out various approaches, to be creative and to arrive at successful solutions more quickly. Very early in the design process a first prototype of the design is built and tested. Watching users interact with the prototype and asking them what they think and experience while using it, provides relevant feedback on the basis of which improvements can be made to the design. This learning-by-doing approach to design allows new ideas to be tried out without running too much risk. It ensures that the design optimally matches the wishes and needs of the users.

Human-centered design will lead to products and services that better match the needs and wishes of the users, and thus will be purchased easier and create more impact. Moreover, involving patients and care professionals as well as other stakeholders in the development process, also creates more support among them for the product or service. When they play a role in the development process, they will be more inclined to act as ambassadors and to stimulate others to use the product.

In the human-centered design process three main phases can be distinguished: the *inspiration phase*, the *ideation phase* and the *implementation phase* [6]. Each human-centered design process will go through each of these three phases at least once. However, the process is not always sequential, rather it may consist of several iterations of going back and forth through the different phases while rethinking and refining the design, based on feedback of the people designed for.

The *Inspiration phase* is about empathizing with the people designed for, getting to know them and trying to understand what they feel, think and experience. In this phase the design team will be talking to people and observing them in their own context.

In the *Ideation phase* creative solutions are generated for the design opportunity that has been identified in the inspiration phase. Still early on in the design process, one or two of the most promising ideas will be concretized into a prototype. The prototypes are tested and feedback is collected from users, which will be the basis for another iteration of refining the idea, prototyping and testing.

In the *Implementation phase* the end product or service is developed and put to use with real users. In this phase the product or service is also evaluated: does the product do what it is supposed to do, is it effective? In the implementation phase it becomes apparent whether the technology is accepted by the users or not.

#### **2.2. General models explaining the use of technology**

which industry and health service readiness are main themes [3]. The focus of this chapter is on technology adoption at the third level, that is, the micro level, which is the level of the actual user. Assistive technology has two main user groups, i.e., healthcare professionals and patients/clients. Therefore, we will discuss issues around technology adoption in general *and* with specific focus on healthcare professionals, as they are usually facilitators for the uptake of technology in care practices. In Section 2, we will first discuss challenges in the design and implementation of assistive technology, including the vision of human-centered design, followed by theories on technology acceptance *in general,* and the readiness of technology uptake of healthcare professionals. In Section 3, we will present some examples of recent practice based research to illustrate the presented theories and elaborate on the perspectives of different stakeholders and their mutual relationships in the use of technology in health care.

**2. Challenges in the design and implementation of technology in** 

In order to ensure an optimal match between the technological product or service and the person who will use it (or is otherwise affected by the technology), it is important that all stakeholders are involved in the whole process of design, development and implementation. Over the last decades involving users and other stakeholders already in the design of new products and services has become standard and is commonly denoted as human-centered

Central in any human-centered design approach are the following aspects: empathy, collaboration and experimentation [5, 6]. *Empathy* is our ability to see the world through the eyes of someone else, to see what they see, feel what they feel and experience things the way they do [10]. The ability to be empathic is vital in order to not project one's own preconceived ideas to the design of new products and services, but really incorporate the (sometimes latent) needs and wishes of the people designed for. Empathizing with the users, understanding them and bringing them along in the design process are essential basic principles of any human-centered

*Collaboration.* The challenges in our current society (also for the design of new assistive technology) are so complex that they cannot be solved by a single designer. Instead, they require a design team consisting of specialists with different backgrounds, not only interaction designers or industrial designers, but also psychologists, engineers, business people, care profes-

*Experimentation.* When solving complex issues it is unlikely that the design team will come up with the optimal solution at the first guess. Therefore, experimentation is central in the humancentered design process. The process entails multiple cycles of ideation, refining and improving the design, allowing the design team to have multiple ideas, to try out various approaches, to be creative and to arrive at successful solutions more quickly. Very early in the design process a first prototype of the design is built and tested. Watching users interact with the prototype and asking them what they think and experience while using it, provides relevant feedback on

**2.1. Human-centered design of assistive technology**

design [5, 6], participatory design [7], or co-design [8, 9].

**health care**

94 Assistive Technologies in Smart Cities

design process.

sionals and the intended users.

In this section *general* models that explain factors and circumstances influencing the use of technology, are presented. Although mostly developed within general workplace situations, they can also help to understand acceptance of assistive technologies in specific contexts, e.g., within healthcare situations.

With the exponential growth of the use of technology in several domains, specific models have been developed to explain technology use. The most important and well known models are the Technology Acceptance Model (TAM) [11] and the Unified Theory of Acceptance and Use of Technology (UTAUT) [12]. The core of the TAM is the perceived *usefulness* and *ease of use* of the to be used technology. In several domains, up to 40% of the variance of the intention to use technology in several domains, including health care, is explained by the TAM [13].

In UTAUT [12, 14], the TAM was further refined into a model that could explain up to 70% of the variance of the acceptance and use of technology. The UTAUT not only includes ease of use (redefined as 'effort expectancy') and usefulness (redefined as 'performance expectancy') as explanatory factors, but also social influence. These three factors influence behavioral intention and thus, indirectly, use behavior. Apart from that, facilitating conditions are defined, which directly influence use. Finally, a set of five moderating factors are distinguished, being gender, age, experience (with technology) and voluntariness of the use of the technology (**Figure 1**) [12].

*2.3.1. Acceptance by individual healthcare professionals*

to rely on technology and prefer face-to face contact [21].

'human-centered design', we will elaborate on this topic.

such as interoperability, installation issues, and user friendliness [22].

call center [19].

*theory*

Many healthcare professionals working in healthcare practice nowadays, do not consider technology routinely as an important solution for health problems [17]. Several factors can explain this often problematic adoption of technology [18]. One main factor is the fear that technology interferes with the relationship with the patient [18]. Care professionals worry about, e.g., the quality of the contact with patients through eHealth. Professionals who are familiar with this form of caregiving, are far more positive, although they approve contact with a 'well-known' professional in a blended construction over purely digital relationships, e.g., exclusively via a

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Another important barrier for the uptake of technology in healthcare practice is the change in work processes that it requires. In practice, new technologies are often introduced as pilot projects [18]. These projects are in most cases temporary, and therefore they are not integrated into daily routine. As a consequence, professionals perceive these new technologies as something extra on top of their work, thus mainly increasing their work load. EHealth technology is also considered to cause additional responsibilities rather than provide an opportunity to do the care work in a more efficient manner. For instance, the introduction of telemonitoring in the care practice for patients with chronic heart failure poses the question of responsibility between patients and professionals: who is responsible for which data and how and when should one react [20]? The reconsideration of patient-professional relationships is another barrier, closely related to the issues concerning changed work processes and responsibility. The use of self-monitoring technology leads to a shift towards patients' self-management, which leaves professionals worried about patient safety. Especially with vulnerable patients, professionals are hesitant

Finally, technical issues interfere with the uptake of technology by healthcare professionals,

There are also factors that facilitate the implementation of technology by healthcare professionals. Facilitators of technology uptake are the so called 'clinical champions', enthusiastic ambassadors and leaders of innovations within an organizations [18, 23]. Apart from leadership, also training and support of professionals are important, in order to develop confidence in the technology and the accompanying changes in work process and role [22, 24]. Finally, involving relevant stakeholders in the *design* of technology, especially patients or citizens and healthcare professionals, improves the adoption of technology and facilitates the process of implementation and transformation into self-management by patients [18, 22]. In Section 3,

*2.3.2. Implementation of technology within healthcare organizations: normalization process* 

As described in Section 2.3.1, there are many factors influencing the intention to use and the actual use of assistive technologies by care professionals. In this section, we will describe the dynamics of technology use in health care explained by a sociological theory, the Normalization

Of these factors, *performance expectancy*, is the strongest predictor. Performance expectancy refers to the degree in which a person expects technology to be helpful for doing a job. *Effort expectancy* indicates how easy a person thinks that the technology is in its use. *Social influence* refers to the degree in which an individual thinks important others think he or she should use the technology [12]. *Facilitating conditions* are supportive infrastructures (both organizational and technical) that facilitate the use of the technology.

#### **2.3. Technology acceptance and implementation in healthcare organizations**

In the adoption of assistive technology, the views of many stakeholders influence the ultimate successful implementation of technology and the delivery of technology at scale. In this section, we will describe the perspective of healthcare professionals (Section 2.3.1) and we will describe the Normalization Process Theory as the theoretical framework to explain how individual professionals within healthcare organizations understand and integrate new technologies into their own daily practice (Section 2.3.2) [15, 16].

**Figure 1.** The Unified Theory of Acceptance and Use of Technology (UTAUT) [12].

### *2.3.1. Acceptance by individual healthcare professionals*

as explanatory factors, but also social influence. These three factors influence behavioral intention and thus, indirectly, use behavior. Apart from that, facilitating conditions are defined, which directly influence use. Finally, a set of five moderating factors are distinguished, being gender, age, experience (with technology) and voluntariness of the use of the technology

Of these factors, *performance expectancy*, is the strongest predictor. Performance expectancy refers to the degree in which a person expects technology to be helpful for doing a job. *Effort expectancy* indicates how easy a person thinks that the technology is in its use. *Social influence* refers to the degree in which an individual thinks important others think he or she should use the technology [12]. *Facilitating conditions* are supportive infrastructures (both organizational

In the adoption of assistive technology, the views of many stakeholders influence the ultimate successful implementation of technology and the delivery of technology at scale. In this section, we will describe the perspective of healthcare professionals (Section 2.3.1) and we will describe the Normalization Process Theory as the theoretical framework to explain how individual professionals within healthcare organizations understand and integrate new technologies into

**2.3. Technology acceptance and implementation in healthcare organizations**

and technical) that facilitate the use of the technology.

their own daily practice (Section 2.3.2) [15, 16].

**Figure 1.** The Unified Theory of Acceptance and Use of Technology (UTAUT) [12].

(**Figure 1**) [12].

96 Assistive Technologies in Smart Cities

Many healthcare professionals working in healthcare practice nowadays, do not consider technology routinely as an important solution for health problems [17]. Several factors can explain this often problematic adoption of technology [18]. One main factor is the fear that technology interferes with the relationship with the patient [18]. Care professionals worry about, e.g., the quality of the contact with patients through eHealth. Professionals who are familiar with this form of caregiving, are far more positive, although they approve contact with a 'well-known' professional in a blended construction over purely digital relationships, e.g., exclusively via a call center [19].

Another important barrier for the uptake of technology in healthcare practice is the change in work processes that it requires. In practice, new technologies are often introduced as pilot projects [18]. These projects are in most cases temporary, and therefore they are not integrated into daily routine. As a consequence, professionals perceive these new technologies as something extra on top of their work, thus mainly increasing their work load. EHealth technology is also considered to cause additional responsibilities rather than provide an opportunity to do the care work in a more efficient manner. For instance, the introduction of telemonitoring in the care practice for patients with chronic heart failure poses the question of responsibility between patients and professionals: who is responsible for which data and how and when should one react [20]?

The reconsideration of patient-professional relationships is another barrier, closely related to the issues concerning changed work processes and responsibility. The use of self-monitoring technology leads to a shift towards patients' self-management, which leaves professionals worried about patient safety. Especially with vulnerable patients, professionals are hesitant to rely on technology and prefer face-to face contact [21].

Finally, technical issues interfere with the uptake of technology by healthcare professionals, such as interoperability, installation issues, and user friendliness [22].

There are also factors that facilitate the implementation of technology by healthcare professionals. Facilitators of technology uptake are the so called 'clinical champions', enthusiastic ambassadors and leaders of innovations within an organizations [18, 23]. Apart from leadership, also training and support of professionals are important, in order to develop confidence in the technology and the accompanying changes in work process and role [22, 24]. Finally, involving relevant stakeholders in the *design* of technology, especially patients or citizens and healthcare professionals, improves the adoption of technology and facilitates the process of implementation and transformation into self-management by patients [18, 22]. In Section 3, 'human-centered design', we will elaborate on this topic.

## *2.3.2. Implementation of technology within healthcare organizations: normalization process theory*

As described in Section 2.3.1, there are many factors influencing the intention to use and the actual use of assistive technologies by care professionals. In this section, we will describe the dynamics of technology use in health care explained by a sociological theory, the Normalization Process Theory (NPT) [25], in which these, partly interdependent factors, can be summarized into a framework.

and care recipients and their loved ones [17, 27]. These changes can create opportunities for new and meaningful connections between them, but they also pose moral questions that may

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**1.** How does the introduction of new technology change relationships between healthcare

**2.** What values and beliefs do healthcare professionals, service users and significant others

**3.** What kind of dilemmas arise when using technology, for instance when technology inter-

Nine studies focusing on the implementation phase were carried out, aiming to expand our knowledge on the impact of technology in care and wellbeing and how it contributes to the relationships between different stakeholders. We collected evidence, in and from practice, related to the personal perspectives of healthcare professionals and primary service users (patients, citizens, clients) as well as significant others (managers, next of kin), with regard to the use of assistive technology. Three different applications of eHealth were involved: telec-

A qualitative design, using interviews, as well as focus groups, was used. This enables revealing subtle changes in relationships and is helpful in exploring beliefs and values of healthcare professionals and service users. In each study data from interviews and focus groups were audio recorded and transcribed verbatim, with the interviewer keeping additional field notes. Member check was carried out by means of summaries to assess the researchers' understanding and interpretation of the input of the participants. Data were analyzed using thematic analysis by Braun and Clark [28]. In order to generate initial codes, in each project two researchers coded the transcripts independently. One of the researchers had not collected data and acted as peer reviewer to warrant trustworthiness. Once all data had been initially coded, the different codes were sorted into potential themes. After construction of concept themes, the themes were refined based on the criteria that all data within themes should cohere, while there should be clear and identifiable distinctions between themes [28]. In the last phase themes were defined by describing the meaning, the scope and content in a couple of sentences.

Five qualitative studies focused on the beliefs and values about, and experiences with telecare

Telecare in these studies involved real-time contact between a home-dwelling service user and a healthcare professional using a display screen with an audio-visual connection (see **Figure 2**). The service offered practical support, such as medication intake, or cues for day structure, exercises, reminders for toileting or food intake, as well as emotional support with

interfere with successful implementation of technology in practice.

professionals, service users and significant others?

are, telemonitoring and the use of surveillance technology.

for, mostly elderly, people who live independently at home.

Research questions formulated were:

have, related to technology?

feres with certain values?

**3.2. Methods**

**3.3. Telecare**

NPT describes what actually happens in practice, not the behavioral intention for using a (technological) innovation. The NPT comprises four constructs, being: *Coherence, Cognitive participation, Collective action* and *Reflexive monitoring* [15, 26].

*Coherence* is the extent to which professionals working together with the technology attribute the same meaning or importance to the system; do they have the same values or ideas about the (new) system and are they aware of changes in their individual work processes?

*Cognitive participation* refers to the work that is done to enhance the engagement and involvement of all relevant stakeholders and their motivation to stay involved. This means that great effort has to be taken, especially at the start of a program, to invest in good leadership and ambassadors, and the continuous involvement of everybody.

*Collective action* means what is actually done in practice while working with the technology, to facilitate the use of it. Several factors play a role here, e.g., financial support or time investment and sufficient management support. Also a workable system, a good help-desk and other technical support, as well as training, is crucial. And, most importantly, transparency on responsibilities of all involved professionals.

*Reflexive monitoring* is the final construct of the NPT, which in practice is often forgotten or neglected. It refers to the evaluation after implementation of the technology: has it brought what was expected for all stakeholders, what are elements that need improvement, are all stakeholders still involved?
