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Health Cascade researcher Qingfan An (ESR 13) located at Umeå University, are focusing on co-creation of eHealth tools in a hospital context. Three sessions were held: a co-conception session, a co-envision session, and a co-design session to address the wicked problem of early discharge in COPD care in Sweden. The co-conception session was held on 7^th Dec 2022, through the problem mapping process, reasons and consequences for early discharge inn COPD care were identified collaboratively by stakeholders (physicians, physiotherapists, occupational therapists, nurses, dietitians, family members of patients, people with COPD). In the co-envision session held on 10^th Jan 2023, co-creators used a card deck adapted from Situation Lab’s “The Things From The Future” to explore the lifestyle-based future scenarios desired by all stakeholders. On 24^th Jan 2023, co-design session was held using the method of Provotype to provoke and engage co-creators to imagine possible intervention points. If you’re interested, please keep an eye out for the following planned sessions. For more information feel free to contact qingfan.an@umu.se 

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Qingfan will use co-creation to adapt an eHealth tool for patients hospitalised with Chronic Obstructive Pulmonary Disease (COPD). To advise her approach, Qingfan has been reviewing the eHealth literature. It soon became apparent that there are a number of considerations when developing eHealth tools in a hospital context. In this blog, she argues that a system level perspective can shed more insight into the levers that drive change, and is needed to build sustainable eHealth tools. 

Over the last decade, the use of eHealth has expanded, and it appears to be on the rise, with significant potential to enhance patients’ health and dramatically change the way healthcare is delivered. The World Health Organization (WHO) defines eHealth as: 

“the cost-effective and secure use of information and communications technologies (ICT) in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research.”   

The increases in accessibility and sophistication of ICT have prompted researchers to study interventions in telemedicine, mHealth, and telehealth. Millions of eHealth tools have been developed, and new eHealth tools are released every day. However, many eHealth tools fail to get implemented or are short lived in practice even if they have proven usability in previous research studies. So we ask ourselves, “Are we focusing research too much on the technology, rather than the service delivery from the user’s perspective?” 

Co-creation, when applied to eHealth, includes ‘end-users’ in the research and development of the intervention. Including end users can increase the value derived from the technology, drive innovation, improve clinical outcomes and lower costs.  But, co-creation of eHealth tools is generally being approached with a narrow lens. It is more focused on specific difficulties with the target demographic that they set out to serve. There is limited work on sustainable eHealth development. According to Bashshur, sustainable eHealth development relies on 1) Improved access, 2) Enhanced quality and 3) Cost containment, none of which may be solved by focusing on a specific population.  

In order to address the issues of access, quality and cost, we’ve got take a step back; and appreciate the broader context of the technology being tested and the target group we are serving. Understanding how eHealth tools are used, based on social and cultural norms, as well as the power structures that govern its use are important in informing its design and implementation. However, this has been relatively unexplored thus far. Instead of taking this holistic view, many one-off co-creation practices are frequently developed to address concerns within the system. However, this disparate approach is not ideal as it may contribute to work being duplicated, and waste time and resources. A system wide perspective can identify the levers that can drive sustainable eHealth development for a broad range of target groups. The leverage points for effective interventions are not always where we want them to be. By linking our work together, we can create a more complete picture of eHealth; identifying the common barriers and the touch points for driving sustainable change.  

A co-creation strategy might help in putting the pieces of the puzzle together. That is, a co-creation strategy at the system level can inform individual projects, whilst considering the project’s contribution to the bigger picture. A co-creation strategy for sustainable eHealth development would first need to appreciate the scale and complexity of the challenge, before tackling it. Developing eHealth tools in a sustainable manner is one of the biggest challenges facing us and is a sound example of a wicked problem. Rittel used the terms wicked and tame to group problems that varied in complexity. Sustainable development of eHealth tools is considered wicked since 

1. there are complex systems in play within ICT and healthcare 
2. the dimensions of the problem are continuously changing as technology advances, health care improves and policy changes 
3. there is no single solution 
4. we cannot describe a solution as “right” or “wrong”. Different co-creators will attach different value judgements (“good” or “bad”) to the solution based on their needs. 
5. issues in one part of the system might be a symptom of problems at a different level of the system 

Transition Design (TD) was proposed by Irwin to tackle system-level wicked problems. It aids in “facilitating stakeholders in the co-creation of visions of desirable futures and identifying leverage points in the large problem system in which to situate design interventions”. Transition Design encourages a transformative view; calls for healthcare infrastructure to be reimagined to support sustainable eHealth development. TD calls for an iterative approach, to reach the desired future state, through the following three phases:  

• re-framing the present and future: looking at the problem from different perspectives and exploring how we might transition from our present to our ideal future state  
• designing interventions: developing interventions to address the problems and facilitate our transition to the ideal future state  
• wait and observing: observe and reflect on the impact that the interventions have had at the system level  

It may be even more important to apply transition design thinking in the context of eHealth development than simply healthcare or ICT, since it incorporates both ICT and healthcare principles. 

The development of eHealth tools is a wicked problem, within complex systems of ICT and healthcare, and requires a level of coordination between co-creation initiatives to identify the levers and increase the chances that tools will be implemented and sustained. When only one or two groups are used to frame the problem, their needs and concerns will be prioritized over others. To put it another way, when problems arise in a specific population or group, the most effective intervention points may be located outside of that population or group.  There are leverage points situated in a system, where small changes can have a big impact.  Thus, when confronted with wicked problems, it’s critical to try to adopt a system-level mindset. We propose that stakeholders involved in co-creating sustainable eHealth tools do not begin by servicing a specific group or concern. Instead, stakeholders should begin by gaining a shared understanding of the system, then look for leverage points for system-level change. In this case, methodologies and tools within transition design thinking have a high potential to handle those difficulties. 

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