Date/Time: Friday, 17th March 2017 12:00-13:00

Venue: Open Lab, Floor 3, 89 Sandyford Road, Newcastle upon Tyne

Introduction: This presentation explains user experience of innovative healthcare technologies through the lens of marketing theoretical perspectives. It discusses findings from a qualitative study of 27 patients with complex chronic comorbidities in their homes to understand their experiences of an NHS telehealth service.

Background: Telehealth is an umbrella term for the application of information and computing technology to enable remote patient monitoring. It was originally developed integrating communications, computing and telemetry for space exploration and battlefield contexts to provide non-medics with access to medical expertise. Early civilian applications enabled between-medic remote communications in low population density and rural contexts, and are now being mainstreamed by healthcare services to share patient data for decision-support between a heterogeneous group of users including patients. Healthcare policy responding to rising incidence and prevalence of chronic disease suggests telehealth can help to manage unsustainable demand for scarce resources by introducing self-service healthcare channels.

Turn to the user: In Science and Technology Studies (STS) there has been a shift away from considering the designer as solely configuring both the technology and consequently the user through interface design (Pinch and Oudshoorn, 2003). As user studies reveal deviations from original design intentions (Schot and de la Bruheze, 2003; Schwartz Cowan, 1985, 2012), this suggests users commonly exploit technological affordances to reconfigure designs through use (Sharples et al., 2012). Similarly, Marketing studies have moved beyond ideas from the 1950s depicting customers as passive dupes manipulated by marketing tools and techniques through evidencing consumer resistance to marketing strategies. One example is consumers subverting brands to reflect their own values (Martin et al., 2006). Therefore, consumption acts (including technology use) can be understood to involve transformative co-production processes.

Use vs experience: Consumption practices are often framed in terms of goal seeking, e.g. to experience hedonic or eudemonic well-being. This means the assessment of products and services are frequently framed in terms of value, i.e. benefits to the consumer, in exchange for value to the provider (e.g. economic, co-production, promotion, feedback, etc.). Studies informed by health economist techniques tend to assess telehealth use in terms of value-in-use, which relates to economic utility, and rational means-ends goal achievement (Woodruff, 1997), where value is argued to be objective and calculable. For instance, avoiding transportation costs, and unnecessary appointments is value that is aligned with provider perspectives of costs and benefits. Similar approaches to framing value is evident in technology adoption studies focusing upon usability, convenience and perceived benefits (Liljander et al., 2006). An alternative conceptualisation of value focuses upon the subjective nature of value co-creation during pre-consumption experiences, consumption behaviour and post-consumption evaluation stages. This concept of value-in-context (Chandler and Vargo, 2011) describes the value sought, generated and even imagined as future value by consumers as a result of their accumulated consumption experiences (Helkkula et al., 2013; Helkkula and Kelleher, 2011). Therefore, rather than tightly focusing on interactions with the user interface to understand economic value-in-use with rationally designed routes to pre-specified goal attainment, service marketing perspectives allow for objects and their use to be valued as a result of their embeddedness in a wider cultural context wherein value is always subjectively determined by consumers (Akaka et al., 2013; Chandler and Vargo, 2011).

Methods: Using a multiple case study within a single case study design (Eisenhardt, 1989; Yin, 2014) enabled use of rich ethnographic data. A heterogeneous sample of 27 adults (40-90 years old) with complex chronic comorbidities and experienced using an NHS telehealth service were interviewed and observed demonstrating use of telehealth equipment. Transcripts were thematically analysed using a constant comparative method within case and cross-case (Miles and Huberman, 1994). Themes were then analysed using a narrative strategy for process analysis (Langley, 1999) to identify links between user-perceived inputs, usage, and outputs from telehealth.

Findings: Patients with chronic comorbidities are observed to experience loss of control in their interactions with familiar social and physical environments, including during healthcare service interactions. Compensatory use of technology to supplement depleted personal resources (e.g. mobility, social interaction, physical well-being) results in high levels of technology consumption used by patients to mitigate risk from harm when losing control over their bodies (e.g. stairlifts, hand rails, walking sticks, ramps, etc.). Patient homes, therefore, feature overlapping health-related technologies. The personal combination of technologies to suit their changing needs suggests patients are highly adept technology consumers.

Supposedly ‘easy to use’ telehealth machines are experienced as effortful due to heterogeneous physical, social, cognitive, and emotional needs. The experience of problems in use, suggesting unsuitability, leads to the introduction of customisation and deviation from designed use rather than withdrawal or avoidance. Such customisations are rationalised by patients through home spun theories of causality, or personalised health literacy. Therefore, despite perceived reliability and service design issues reducing subjectively perceived usability and convenience, these resource constrained patients are observed to persist with their use of telehealth by integrating their own cognitive, physical and emotional resources to continue using telehealth services. Narrative analysis suggests this is because their extensive experience as healthcare service users provides them with memorable instances of negative service experiences, providing an impetus motivating them to integrate scarce resources to avoid unnecessary hospital admission. This manifests in improved self-care and use of remote self-service healthcare channels like telehealth and the reduced demand for face-to-face service.

Implications: Although telehealth equipment and service designs are often inappropriate for the complex needs of resource-constrained patients, reducing their perceived usability and convenience, they are experienced as valuable in the context of being able to maintain access to healthcare services while keeping it at arms’ length. Hence satisfaction with telehealth is related to its paradoxical use by patients to keep themselves at a safe distance from incidental harm through negative in-hospital experiences, where they feel the loss of control over their bodies acutely. Self-service selection is motivated by avoidance of full-service.