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Health and care information technologies can improve service delivery, but unfortunately many fail to realise their potential. This is because tools fail to effectively integrate with user and organisational practices. We here draw on two decades and an extensive body of practical and theoretical experience of conducting formative evaluations in health service settings to extract seven essential principles for planning and developing digital tools. Firstly, it is important to determine if digitalisation is the right approach for the desired change and to view these tools as complex interventions needing careful planning. The development process should embrace varying levels of co-creation and adapt to different needs and contexts. Ensuring that tools integrate well with existing information infrastructures and striking a balance between being widely applicable and locally relevant is essential. Furthermore, planning for how these interventions will fit into broader health and care pathways is vital. By considering these factors, decision-makers can significantly improve the chances of successful implementation, adoption and scaling of health and care technologies., Competing Interests: Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Remote monitoring can strengthen postoperative care in the community and minimise the burden of complications. However, implementation requires a clear understanding of how to sustainably integrate such complex interventions into existing care pathways. This study aimed to explore perceptions of potential facilitators and barriers to the implementation of digital remote postoperative monitoring from key stakeholders and derive recommendations for an implementable service., Methods: A qualitative implementation study was conducted of digital remote postoperative wound monitoring across two UK tertiary care hospitals. All enrolled patients undergoing general surgery, and all staff involved in postoperative care were eligible. Criterion-based purposeful sampling was used to select stakeholders for semi-structured interviews on their perspectives and experiences of digital remote postoperative monitoring. A theory-informed deductive-inductive qualitative analysis was conducted; drawing on normalisation process theory (NPT) to determine facilitators for and barriers to implementation within routine care., Results: There were 28 semi-structured interviews conducted with patients (n = 14) and healthcare professionals (n = 14). Remote postoperative monitoring was perceived to fulfil an unmet need in facilitating the diagnosis and treatment of postoperative complications. Participants perceived clear benefit to both the delivery of health services, and patient outcomes and experience, but some were concerned that this may not be equally shared due to potential issues with accessibility. The COVID-19 pandemic demonstrated telemedicine services are feasible to deliver and acceptable to participants, with examples of nurse-led remote postoperative monitoring currently supported within local care pathways. However, there was a discrepancy between patients' expectations regarding digital health to provide more personalised care, and the capacity of healthcare staff to deliver on these. Without further investment into IT infrastructure and allocation of staff, healthcare staff felt remote postoperative monitoring should be prioritised only for patients at the highest risk of complications., Conclusion: The COVID-19 pandemic has sparked the digital transformation of international health systems, yet the potential of digital health interventions has yet to be realised. The benefits to stakeholders are clear, and if health systems seek to meet governmental policy and patient expectations, there needs to be greater organisational strategy and investment to ensure appropriate deployment and adoption into routine care., Trial Registration: NCT05069103., (© 2024. The Author(s).)

Background: Antibiotic resistant infections cause over 700,000 deaths worldwide annually. As antimicrobial stewardship (AMS) helps minimise the emergence of antibiotic resistance resulting from inappropriate use of antibiotics in healthcare, we developed ePAMS+ (ePrescribing-based Anti-Microbial Stewardship), an ePrescribing and Medicines Administration (EPMA) system decision-support tool complemented by educational, behavioural and organisational elements., Methods: We conducted a non-randomised before-and-after feasibility trial, implementing ePAMS+ in two English hospitals using the Cerner Millennium EPMA system. Wards of several specialties were included. Patient participants were blinded to whether ePAMS+ was in use; prescribers were not. A mixed-methods evaluation aimed to establish: acceptability and usability of ePAMS+ and trial processes; feasibility of ePAMS+ implementation and quantitative outcome recording; and a Fidelity Index measuring the extent to which ePAMS+ was delivered as intended. Longitudinal semi-structured interviews of doctors, nurses and pharmacists, alongside non-participant observations, gathered qualitative data; we extracted quantitative prescribing data from the EPMA system. Normal linear modelling of the defined daily dose (DDD) of antibiotic per admission quantified its variability, to inform sample size calculations for a future trial of ePAMS+ effectiveness., Results: The research took place during the SARS-CoV-2 pandemic, from April 2021 to November 2022. 60 qualitative interviews were conducted (33 before ePAMS+ implementation, 27 after). 1,958 admissions (1,358 before ePAMS+ implementation; 600 after) included 24,884 antibiotic orders. Qualitative interviews confirmed that some aspects of ePAMS+ , its implementation and training were acceptable, while other features (e.g. enabling combinations of antibiotics to be prescribed) required further development. ePAMS+ uptake was low (28 antibiotic review records from 600 admissions; 0.047 records per admission), preventing full development of a Fidelity Index. Normal linear modelling of antibiotic DDD per admission showed a residual variance of 1.086 (log-transformed scale). Unavailability of indication data prevented measurement of some outcomes (e.g. number of antibiotic courses per indication)., Conclusions: This feasibility trial encountered unforeseen circumstances due to contextual factors and a global pandemic, highlighting the need for careful adaptation of complex intervention implementations to the local setting. We identified key refinements to ePAMS+ to support its wider adoption in clinical practice, requiring further piloting before a confirmatory effectiveness trial., Trial Registration: ISRCTN Registry ISRCTN13429325, 24 March 2022., (© 2024. The Author(s).)

Given the requirement to minimize the risks and maximize the benefits of technology applications in health care provision, there is an urgent need to incorporate theory-informed health IT (HIT) evaluation frameworks into existing and emerging guidelines for the evaluation of artificial intelligence (AI). Such frameworks can help developers, implementers, and strategic decision makers to build on experience and the existing empirical evidence base. We provide a pragmatic conceptual overview of selected concrete examples of how existing theory-informed HIT evaluation frameworks may be used to inform the safe development and implementation of AI in health care settings. The list is not exhaustive and is intended to illustrate applications in line with various stakeholder requirements. Existing HIT evaluation frameworks can help to inform AI-based development and implementation by supporting developers and strategic decision makers in considering relevant technology, user, and organizational dimensions. This can facilitate the design of technologies, their implementation in user and organizational settings, and the sustainability and scalability of technologies., (©Kathrin Cresswell, Nicolette de Keizer, Farah Magrabi, Robin Williams, Michael Rigby, Mirela Prgomet, Polina Kukhareva, Zoie Shui-Yee Wong, Philip Scott, Catherine K Craven, Andrew Georgiou, Stephanie Medlock, Jytte Brender McNair, Elske Ammenwerth. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 07.08.2024.)

Background: Antimicrobial resistance (AMR) represents a growing concern for public health., Objective: We sought to explore the challenges associated with development and implementation of a complex intervention designed to improve AMS in hospitals., Methods: We conducted a qualitative evaluation of a complex AMS intervention with educational, behavioral, and technological components in 5 wards of an English hospital. At 2 weeks and 7 weeks after initiating the intervention, we interviewed 25 users of the intervention, including senior and junior prescribers, a senior nurse, a pharmacist, and a microbiologist. Topics discussed included perceived impacts of different elements of the intervention and facilitators and barriers to effective use. Interviews were supplemented by 2 observations of ward rounds to gain insights into AMS practices. Data were audio-recorded, transcribed, and inductively and deductively analyzed thematically using NVivo12., Results: Tracing the adoption and impact of the various components of the intervention was difficult, as it had been introduced into a setting with competing pressures. These particularly affected behavioral and educational components (eg, training, awareness-building activities), which were often delivered ad hoc. We found that the participatory intervention design had addressed typical use cases but had not catered for edge cases that only became visible when the intervention was delivered in real-world settings (eg, variations in prescribing workflows across different specialties and conditions)., Conclusions: Effective user-focused design of complex interventions to promote AMS can support acceptance and use. However, not all requirements and potential barriers to use can be fully anticipated or tested in advance of full implementation in real-world settings., (©Kathrin Cresswell, Susan Hinder, Aziz Sheikh, Neil Watson, David Price, Andrew Heed, Sarah Katie Pontefract, Jamie Coleman, Jillian Beggs, Antony Chuter, Ann Slee, Robin Williams. Originally published in JMIR Formative Research (https://formative.jmir.org), 26.07.2024.)

Objectives: Adverse childhood experiences (ACEs) can affect individuals' resilience to stressors and their vulnerability to mental, physical and social harms. This study explored associations between ACEs, financial coping during the cost-of-living crisis and perceived impacts on health and well-being., Design: National cross-sectional face-to-face survey. Recruitment used a random quota sample of households stratified by health region and deprivation quintile., Setting: Households in Wales, UK., Participants: 1880 Welsh residents aged ≥18 years., Measures: Outcome variables were perceived inability to cope financially during the cost-of-living crisis; rising costs of living causing substantial distress and anxiety; and self-reported negative impact of rising costs of living on mental health, physical health, family relationships, local levels of antisocial behaviour and violence, and community support. Nine ACEs were measured retrospectively. Socioeconomic and demographic variables included low household income, economic inactivity, residential deprivation and activity limitation., Results: The prevalence of all outcomes increased strongly with ACE count. Perceived inability to cope financially during the cost-of-living crisis increased from 14.0% with 0 ACEs to 51.5% with 4+ ACEs. Relationships with ACEs remained after controlling for socioeconomic and demographic factors. Those with 4+ ACEs (vs 0 ACEs) were over three times more likely to perceive they would be unable to cope financially and, correspondingly, almost three times more likely to report substantial distress and anxiety and over three times more likely to report negative impacts on mental health, physical health and family relationships., Conclusions: Socioeconomically deprived populations are recognised to be disproportionately impacted by rising costs of living. Our study identifies a history of ACEs as an additional vulnerability that can affect all socioeconomic groups. Definitions of vulnerability during crises and communications with services on who is most likely to be impacted should consider childhood adversity and history of trauma., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: With an increasing focus on the digitalization of health and care settings, there is significant scope to learn from international approaches to promote concerted adoption of electronic health records., Materials and Methods: We review three large-scale initiatives from Australia, Canada, and England, and extract common lessons for future health and social care transformation strategy., Results: We discuss how, despite differences in contexts, concerted adoption enables sharing of experience and learning to streamline the digital transformation of health and care., Discussion and Conclusion: Concerted adoption can be accelerated through building communities of expertise and partnerships promoting knowledge transfer and circulation of expertise; commonalities in geographical and cultural contexts; and commonalities in technological systems., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)