Virtual reality technology for surgical learning: qualitative outcomes of the first virtual reality training course for emergency and essential surgery delivered by a UK-Uganda partnership.

INTRODUCTION: The extensive resources needed to train surgeons and maintain skill levels in low-income and middle-income countries (LMICs) are limited and confined to urban settings. Surgical education of remote/rural doctors is, therefore, paramount. Virtual reality (VR) has the potential to disseminate surgical knowledge and skill development at low costs. This study presents the outcomes of the first VR-enhanced surgical training course, 'Global Virtual Reality in Medicine and Surgery', developed through UK-Ugandan collaborations. METHODS: A mixed-method approach (survey and semistructured interviews) evaluated the clinical impact and barriers of VR-enhanced training. Course content focused on essential skills relevant to Uganda (general surgery, obstetrics, trauma); delivered through: (1) hands-on cadaveric training in Brighton (scholarships for LMIC doctors) filmed in 360°; (2) virtual training in Kampala (live-stream via low-cost headsets combined with smartphones) and (3) remote virtual training (live-stream via smartphone/laptop/headset). RESULTS: High numbers of scholarship applicants (n=130); registrants (Kampala n=80; remote n=1680); and attendees (Kampala n=79; remote n=556, 25 countries), demonstrates widespread appetite for VR-enhanced surgical education. Qualitative analysis identified three key themes: clinical education and skill development limitations in East Africa; the potential of VR to address some of these via 360° visualisation enabling a 'knowing as seeing' mechanism; unresolved challenges regarding accessibility and acceptability. CONCLUSION: Outcomes from our first global VR-enhanced essential surgical training course demonstrating dissemination of surgical skills resources in an LMIC context where such opportunities are scarce. The benefits identified included environmental improvements, cross-cultural knowledge sharing, scalability and connectivity. Our process of programme design demonstrates that collaboration across high-income and LMICs is vital to provide locally relevant training. Our data add to growing evidence of extended reality technologies transforming surgery, although several barriers remain. We have successfully demonstrated that VR can be used to upscale postgraduate surgical education, affirming its potential in healthcare capacity building throughout Africa, Europe and beyond.

From 'making up' professionals to epistemic colonialism: Digital health platforms in the Global South.

Platforms have been studied in terms of their impact on knowledge production and generation of social value. Little however is known about the significance of the knowledge they transfer to the recipient communities-often in faraway countries of the Global South-or its potential perceived colonizing effects. Our study explores the question around digital epistemic colonialism in the context of health platforms involved in knowledge transfer. Using a Foucauldian lens, we study digital colonialism as a phenomenon that emerges from platforms' underpinning power/knowledge relations. Drawing upon a longitudinal study of MedicineAfrica-a nonprofit platform intended to offer clinical education to healthcare workers and medical students in Somaliland-we discuss interview findings from two phases: (a) with Somaliland-based medical students who studied MedicineAfrica as part of their medical studies, and (b) with medical professionals who attended a MedicineAfrica Continuing Professional Development (CPD) course on Covid-19 treatment/prevention. Our study shows how the platform 'makes up' healthcare professionals by offering opportunities for learning and skill development whilst instilling work values and ethos resembling Western medical identities. The platform was also perceived to produce subtle colonizing effects as its content embodies knowledge that (a) presupposes medical infrastructures that are absent in the recipient country; (b) is presented in English instead of participants' mother tongue; and (c) neglects the idiosyncrasies of the local context. The platform sets its tutees in a colonial condition in which they cannot fully practice what they learn; they cannot entirely engage with the subject they learn, taught as it is in a different language, and they do not necessarily learn about the medical conditions and the patients they encounter. This alienation from their local context, embraced by the platform's underpinning power/knowledge relations, is at the heart of digital epistemic colonialism and comes together with the social value the platform generates.

The Cultivation of Digital Health Citizenship.

Contemporary health policy discourse renders individuals responsible for managing their health by means of digital technology. Seeing the digital as productive of citizenship, rather than facilitative of it, this paper unpacks the contested role of technology in acts of digital health citizenship. Drawing on longitudinal data collected in the English healthcare context, this article shows that digital health citizenship is produced through patients' involvement in the generation of health knowledge, including 'big' health data, digital artefacts, experiential knowledge and service feedback. The paper adds to existing literature by disaggregating the contested role of technology in displays of digital health citizenship, showing that digital health technology can give rise to expressions of altruism, belonging, and demands for recognition and change in healthcare, whilst responsibilising citizens for the care of themselves and others. The discussion shows how, rather than merely facilitating the actions of a free and autonomous subject, this citizenship often becomes algorithmically produced (e.g. through nudges) and remains isolated to separate instances of engagement without a long-term orientation. Our study enriches the growing sociological literature on health citizenship by exploring how digital technology produces health citizenship at the intersection of biosociality and technosociality.

Between empowerment and self-discipline: Governing patients' conduct through technological self-care.

Recent health policy renders patients increasingly responsible for managing their health via digital technology such as health apps and online patient platforms. This paper discusses underlying tensions between empowerment and self-discipline embodied in discourses of technological self-care. It presents findings from documentary analysis and interviews with key players in the English digital health context including policy makers, health designers and patient organisations. We show how discourses ascribe to patients an enterprising identity, which is inculcated with economic interests and engenders self-discipline. However, this reading does not capture all implications of technological self-care. A governmentality lens also shows that technological self-care opens up the potential for a de-centring of medical knowledge and its subsequent communalization. The paper contributes to Foucauldian healthcare scholarship by showing how technology could engender agential actions that operate at the margins of an enterprising discourse.

Hybridity as a process of technology's 'translation': customizing a national Electronic Patient Record.

This paper explores how national Electronic Patient Record (EPR) systems are customized in local settings and, in particular, how the context of their origin plays out with the context of their use. It shows how representations of healthcare organizations and of local clinical practice are built into EPR systems within a complex context whereby different stakeholder groups negotiate to produce an EPR package that aims to meet both local and generic needs. The paper draws from research into the implementation of the National Care Record Service, a part of the National Programme for Information Technology (NPfIT), in the English National Health Service (NHS). The paper makes two arguments. First, customization of national EPR is a distributed process that involves cycles of 'translation', which span across geographical, cultural and professional boundaries. Second, 'translation' is an inherently political process during which hybrid technology gets consolidated. The paper concludes, that hybrid technology opens up possibilities for standardization of healthcare.

Technological affordances of risk and blame: the case of the electronic prescription service in England.

Information and communication technology (ICT) is often presented by health policymakers and software designers as a means for reducing clinical risk, leading to safer clinical practice. Studies have challenged this view, showing how technology can produce new or unanticipated risks. Although research seeks to objectively identify these risks, we recognise that technological risks are socially constructed through the interaction of technology and practice. The aim of this article is to explore how technology affords opportunities for the social construction and control of risk in health care settings. Drawing upon a study of the electronic prescription service introduced in the National Health Service in England, we make three arguments. Firstly, as technology interacts with social practice (for example, through policy and the design and use of ICT) it affords opportunities for the construction of risk through its interpretive flexibility, transformative capacity and materiality. Secondly, social actors interpret these risks within and across professional boundaries and cultures. Thirdly, the social construction of risk affords certain implications to policymakers, designers and users of health ICT, specifically a reordering of power and responsibility and a recasting of questions of blame. These, in turn, raise questions concerning the boundaries and bearers of responsibility.

Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems.

BACKGROUND: A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments' healthcare reform strategies. The resulting politically-initiated large-scale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money. METHODS: Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England's National Health Service's Care Records Service (NHS CRS). RESULTS/DISCUSSION: We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations → intervention → changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions. SUMMARY: New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.

The possibilities of technology in shaping healthcare professionals: (re/de-)professionalisation of pharmacists in England.

The paper discusses the possibilities technology provides for (re-)shaping healthcare professionals. Drawing upon critical studies of technology and the sociology of professionals, we present findings from a longitudinal study into the introduction of the Electronic Prescription Service (EPS) in Community Pharmacies in England conducted between June 2009 and July 2011. Our case illustrates the conditions that allow technology to shape healthcare professionals and the potential consequences of such shaping. The data collected, which consisted of qualitative interviews and document analysis, and their analysis rests on predictions of future directions and developments of the pharmacy profession through EPS. Specifically, we show that technology has the potential to shape fundamental aspects of pharmacy work such as its nature and values, professional roles, the degree of power professionals can exercise, their jurisdictions and professional boundaries. Drawing upon these changes and on their implications, we argue that the introduction of technology in a healthcare setting does not determine consequences but opens up a field in which processes of de-professionalisation and re-professionalisation occur simultaneously. Their implications for healthcare professionals in the future, remains an open, yet worth exploring, question for the present.

Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals.

OBJECTIVES: To evaluate the implementation and adoption of the NHS detailed care records service in "early adopter" hospitals in England. DESIGN: Theoretically informed, longitudinal qualitative evaluation based on case studies. SETTING: 12 "early adopter" NHS acute hospitals and specialist care settings studied over two and a half years. DATA SOURCES: Data were collected through in depth interviews, observations, and relevant documents relating directly to case study sites and to wider national developments that were perceived to impact on the implementation strategy. Data were thematically analysed, initially within and then across cases. The dataset consisted of 431 semistructured interviews with key stakeholders, including hospital staff, developers, and governmental stakeholders; 590 hours of observations of strategic meetings and use of the software in context; 334 sets of notes from observations, researchers' field notes, and notes from national conferences; 809 NHS documents; and 58 regional and national documents. RESULTS: Implementation has proceeded more slowly, with a narrower scope and substantially less clinical functionality than was originally planned. The national strategy had considerable local consequences (summarised under five key themes), and wider national developments impacted heavily on implementation and adoption. More specifically, delays related to unrealistic expectations about the capabilities of systems; the time needed to build, configure, and customise the software; the work needed to ensure that systems were supporting provision of care; and the needs of end users for training and support. Other factors hampering progress included the changing milieu of NHS policy and priorities; repeatedly renegotiated national contracts; different stages of development of diverse NHS care records service systems; and a complex communication process between different stakeholders, along with contractual arrangements that largely excluded NHS providers. There was early evidence that deploying systems resulted in important learning within and between organisations and the development of relevant competencies within NHS hospitals. CONCLUSIONS: Implementation of the NHS Care Records Service in "early adopter" sites proved time consuming and challenging, with as yet limited discernible benefits for clinicians and no clear advantages for patients. Although our results might not be directly transferable to later adopting sites because the functionalities we evaluated were new and untried in the English context, they shed light on the processes involved in implementing major new systems. The move to increased local decision making that we advocated based on our interim analysis has been pursued and welcomed by the NHS, but it is important that policymakers do not lose sight of the overall goal of an integrated interoperable solution.

Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation.

OBJECTIVES: To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service. DESIGN: A mixed methods, longitudinal, multisite, socio-technical case study. SETTING: Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete. Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data. Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the top-down, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a "middle-out" approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities. CONCLUSIONS: Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations' perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.

Sociotechnical changing in healthcare.

This paper discusses a conceptual approach to the study of the implementation of ICTs in healthcare organizations. The paper uses some fundamental concepts from sociotechnical studies to address the complex process of change--the changing--that accompanies ICT innovations. The paper argues for the importance of the perspective of changing as a way to account for the dynamics as technology and people, organizations and institutions co-constitutively work-out their future together.