Factors Impacting Clinicians’ Adoption of a Clinical Photo Documentation App and its Implications for Clinical Workflows and Quality of Care: Qualitative Case Study

Introduction

Background

Mobile health (mHealth) tools are gaining importance in health care as they show promise in several capacities, ranging from efficiencies and time-saving [1,2] to decreasing clinicians’ workload and enhancing access to care [3,4]. The use of health apps has also contributed to tackling patients’ information needs and making them feel more empowered [5]. The data generated by such tools also help clinicians adapt and customize treatment plans accordingly [6], improving patients’ quality of care via personalized treatments [5,6]. Although research shows that clinicians have an overall positive attitude toward mHealth, some barriers to adoption persist [7,8].

In clinical photo documentation and dermatology, research has shown the potential of mHealth tools in managing and preventing skin issues [9-11] and that clinicians and patients recognize their value and are generally willing to use them [12-14].

The Global Observatory of eHealth in the World Health Organization defines mHealth as “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices” [15]. mHealth solutions differ from other information and communication technology apps in the sense that they are typically user-driven, accessible, and affordable [16]; consequently, it is very important to understand better the factors affecting user adoption and the respective implications for workflow and quality of care.

Therefore, this research focuses on understanding the factors affecting clinicians’ adoption of mHealth and its implications for clinical practice through a case study of a clinical photo and wound documentation app called imitoCam and its adoption by clinicians in Switzerland and Germany.

Founded in 2016 in Switzerland, imito AG is a clinical photo and wound documentation start-up offering the imitoCam app for medical photo and video documentation and wound measurement. It also supports system interoperability and electronic medical record (EMR) integration. Visuals from the app are presented in Multimedia Appendix 1. The app’s key features are explained in Multimedia Appendix 2 and include secure photo documentation; direct patient identification via barcode; measurement of the area (and length, width, and circumference) of wounds and specimens; patient timelines to better understand the case progression; categorization of images to enable photo search; and team collaboration via a chat function, for example, second opinions. The visual in Multimedia Appendix 3 demonstrates seamless integration between the app and existing hospital systems. The wide adoption of the app in 15 hospitals and clinics across Switzerland and Germany at the time of writing this paper made it an ideal candidate to explore mHealth usage and its implications for clinical workflow and quality of patient care.

Objective

This work is a part of a larger study focusing on understanding clinicians’ adoption of mHealth; a previous study published earlier presented a more detailed account of our theoretical approach [2]. In this paper, we employ a sociotechnical framework [17] to build a comprehensive analysis of the factors affecting clinicians’ adoption of mHealth and its implications for workflow and clinical practice following these 3 main steps:

• Investigating the material aspects of technology and their limitations by identifying the utility and limitations of the app as perceived by the users
• Connecting the material aspects of technology to the tasks it enables and facilitates by highlighting the real constraints to its potential as seen by the user
• Identifying the processes resulting from these affordances and determining the resulting interactions taking place in the organization by identifying the implications for clinical practice and quality of care

The following section explains the research method and how the interview questions and subsequently, the analysis, stemmed from these 3 steps.

Methods

A qualitative paradigm was implemented as it gives priority to “the voices of participants” and the individual and unique “reflexivity of the researcher” [18] and for the rich insights it provides, which can help understand clinicians’ individual perceptions in different ways, which cannot be achieved by quantitative methods [19,20].

Data Collection

Data were collected via in-depth, semistructured interviews that were conducted via Skype, Google Hangout, or telecon. Physical artifacts such as screenshots of the app, the devices it can be used on, and examples of user feedback were collected to develop a broader assessment of the studied app [21]. Data collection took place from July 2019 to January 2020, and a total of 20 interviews were conducted with 18 participants working in 8 clinics and hospitals across Switzerland and Germany (2 interviews were preparatory alignment interviews about the tool’s features and capabilities). The interviews were conducted via telecon and lasted between 17 min and 90 min, with a median of 35 min. A total of 4 participants sent their responses electronically via email as they did not have the time for a live call. Interviews were conducted and recorded by the first author (CJ) in English. The interview topic guide is available in Multimedia Appendix 4. The research themes and questions were developed in line with the Methodological Guidelines for the Study of Materiality and Affordances by Leonardi to crystallize the focus on the data collected in the interviews [17]. Accordingly, the themes in the interview guide were clustered into 3 categories, starting with an understanding of the tool’s utilities and limitations, followed by investigating the technical and social factors affecting adoption and a discussion about organizational and policy factors and implications. The data collection phase continued until an acceptable level of saturation was reached, which was when new data did not generate new insights anymore [20].

Sampling Techniques and Participant Profiles

We used a purposive sample where participants were chosen based on their ability to specify rich and in-depth information about the app and its usage [18,19]. Key informants in imito AG were contacted, and snowball sampling was consequently used to identify suitable participants in partner hospitals and clinics. The key selection criteria were that participants must be clinicians or medical informatics experts in one of the partner hospitals or clinics using the app and must have experienced the app for at least several months. The medical informatics experts had a very good overview of the app and its features, given their access to usage statistics, user feedback, and their constant engagement with clinicians to ensure its successful implementation and sustainability. To minimize the risk of selection bias that might result from the key informants selectively picking users with a positive predisposition toward the app, it was decided that the participants would be asked if they could, in turn, suggest other colleagues who used the app and were willing to participate.

The participants worked in 8 hospitals and clinics across Switzerland and Germany, and the sample consisted of 9 clinicians (one of them was also an imito AG team member), 5 medical informatics experts, and 4 other members from the imito AG team, as shown in Table 1.

Data Analysis and Ethical Considerations

Thematic analysis was used to identify and extract the relevant themes and interpret their potential meaning and interrelationships among [19,22]. Computer-assisted qualitative data analysis software, QSR’s NVivo was used for data coding. Excerpts were chosen to create an account that expressed the narrative of each theme in a way that helped the reader better understand the analysis. The first author (CJ) conducted the interviews and performed the initial analysis and coding; she is a digital strategist with more than 18 years of experience and has contributed to the creation and realization of several digital tools in health care. The second author (ASV) reviewed the coding; any cases of disagreement were discussed in conjunction with the last author (CI) and mutually agreed upon. The phases of the thematic analysis are clarified in detail in Multimedia Appendix 5 [22].

Our themes were mostly influenced by sociotechnical theory and Leonardi’s methodological guidance [17] looking into the technical, social, and organizational factors interacting with shape technology adoption. We also took into account the emerging themes in the most used frameworks for studying mHealth adoption based on a systematic review that we had published earlier [23]. Accordingly, our themes were also influenced by other prominent frameworks such as the Technology Acceptance Model [24], the Diffusion of Innovation theory [25], different forms of extensions of the Unified Theory of Acceptance and Use of Technology [26-29], and the Consolidated Framework for Implementation Research [30,31]. Multimedia Appendix 6 clarifies in detail how each of our themes was influenced by one or more of the existing frameworks and the themes that emerged from the data.

Ethical approval was obtained from the faculty research ethics panel under the terms of Anglia Ruskin University’s Research Ethics Policy. All participants were briefed about the research background and signed a consent form agreeing to participate.

Results

Accounting for the Materials: Utility and Limitations

As a first step, we investigated the app’s utility and limitations by exploring the most used features, the perceived added value, and the potential limitations or ideas for improvement. Figure 1 shows the themes in these 3 categories and their respective subthemes, reflecting the frequency of each theme (frequencies reflect the number of participants that mentioned that specific theme).

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Participants were first asked to name the app features that they used the most to better understand the technological artifacts that they found most useful. Photo and wound documentation (n=16) was the most used feature, followed by EMR integration (n=13), which enables clinicians to link the photos to the right patient in the hospital information system. This was followed by patient progress management (n=9), which gives them visibility of each patient’s development over time; wound measurement (n=7) using the imito calibration markers (quick response [QR] codes) for image calibration; and the possibility of obtaining a second opinion (n=7) through the chat function. Participants equally valued the categorization and classification feature (n=7) that enables them to tag the photos and easily find them later. Finally, they also appreciated the privacy and security (n=4) that the app offers as it ensures compliance with the General Data Protection Regulation (GDPR).

Participants were then asked to explain how the app helped them and their patients daily to better understand imito’s utility from their perspective. Saving time and efficacy (n=15) was clearly an added value for most of the participants. They also saw an improvement in patient safety and quality of care (n=14) as well as data security and validation (n=9) and explained that the mobility of the app improves data accessibility through the compact overview that it offers (n=6).

To complete the picture, the participants were asked about any limitations they faced or features they would like to add to the app. Limitations mentioned by the participants included the absence of a patient interface, lack of offline functionality, data quality of the user-defined hashtags (eg, typos in user-defined hashtags can limit their searchability), possibility of accessing the imito data from the EMR but not the other way around (eg, the user cannot see the patient data stored in the EMR from the imito tool on their mobile device unless they were captured using the app), the necessity of using physical calibration markers (QR codes) for the measurement function can be cumbersome when the users do not have them on hand, and that the app can only be used inside the hospital as it requires connection to the hospital’s system. Participants also expressed their desire for some additional features such as a patient interface (n=3), 3-dimensional measurement (n=3), export of information from the app via email (n=2), multitagging of body parts or regions to cover injuries involving different body parts (n=2), a search function for diagnoses (n=1), enhancement of the slow-motion video function (n=1), and a better connection with radiology devices (n=1).

The key themes and subthemes, their frequencies, and some sample quotes about utility and limitations are summarized in Table 2 for clarity.

Accounting for Materiality: Constraints and Affordances

We then examined the app’s materiality by looking into the constraints and affordances affecting the tool’s adoption from technical and social perspectives. Figure 2 shows the themes in these 2 categories and their respective subthemes, reflecting the frequency of each of them.

Technical and material factors evolved around 5 key themes: usefulness, information technology (IT) capability and compatibility, data-related factors, ease of use, and monetary factors. Usefulness is clearly crucial for adoption; most participants explained that the efficacy of the app and the time saved encouraged adoption (n=14), improvements in the quality of patient care also resulted in more usage of the app (n=8), its usefulness in general was valuable (n=5), and the role that it could play in generating scientific evidence via better documentation was also considered (n=2).

The IT capability and integration factors were focused on the app’s interoperability (n=13), showing how important it was for the users that the chosen app could integrate effectively with the hospital’s local information system, so as to avoid double work and documentation errors, aside from technical issues (n=6) such as poor connectivity, log-in difficulties, or short battery life that are mostly perceived as barriers to adoption. Although data-related factors mostly focused on privacy, security, and data liability issues related to the use of mHealth tools and sharing patient data (n=13), such issues can be overcome with secure and GDPR-compliant tools such as the studied app as it ensures patient data security and privacy; and the challenges related to data management (n=3), especially with the myriad of data generated by such tools which makes the resulting amount of data hard to manage.

Ease of use (n=13) was mostly perceived as a facilitator in the case of imito, with several users mentioning that an easy-to-use tool was central to adoption. Furthermore, monetary factors such as the cost entailed by these tools (n=6) may play a role, not only with regard to the apps’ licensing costs but also the related system integration and infrastructure costs. These key technical factors and subthemes, their frequencies, and some sample participant quotes about each of them are summarized in Table 3 for clarity.

Factors affecting adoption went beyond the technical aspects to also cover some social and cultural elements. The users’ personal characteristics such as previous experience and habits (n=4), attitude toward technology and change (n=4), and their awareness of the value of such tools (n=3) may also play a role in their decision to adopt such an app. In addition, cultural factors (n=3), such as other people’s views and perceptions of using mobile devices at the workplace, may also play a role in the adoption decision. These key social factors and subthemes, their frequencies, and some key participant quotes about each of them are summarized in Table 4.

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Accounting for Materialization: Organizational Factors and Their Implications

The organizational factors and their implications for clinical workflow and quality of care were then discussed in detail. Figure 3 shows the themes in this category and their respective subthemes, reflecting the frequency of each theme.

Organizational and policy factors revolved around 5 key themes: workflow-related themes, organization’s specific inner setting, patient-related factors, user engagement, and policy and regulations. Workflow-related themes were mostly focused on workflow fit and location flexibility (n=12), showing that the app’s fit with clinicians’ existing work practices encouraged its adoption. Improvements in collaboration and transparency may also increase usage (n=12), whereas traditional clinical practices and infrastructure, such as the lack of use of mobile devices in hospitals, could pose a challenge (n=8). Users naturally favor apps that make their daily work easier (n=6), although existing high workload or lack of resources could sometimes be a barrier (n=5). Some participants explained that the data availability and accessibility facilitated by the app empowered them on the job (n=3). However, apps could also alter some existing roles and responsibilities (n=1). Apps such as imitoCam, for example, have the potential to reduce or even eliminate the role of a professional photographer at the hospital.

Factors related to the organizational inner setting include the complex nature of the decision-making process in hospitals (n=14). Slow decision making can slow down the adoption decision or even prevent it. Participants also pinpointed as to how mHealth tools are replacing traditional tools such as digital cameras in the case of imito (n=10). The importance of training and education to facilitate usage was also highlighted (n=4). The organization’s propensity for innovation and appetite for change may also play a role in the adoption decision (n=3), for example, when the organization desires to be perceived as innovative to better compete with other hospitals and clinics. The possibility of trying and piloting the new tool may also facilitate adoption as it minimizes the risk of a full rollout until users have tried the app (n=2).

Patient-related factors were also central and focused mainly on how the app might impact patient engagement and safety (n=11) and enhance access to care (n=2). Many participants also emphasized the significance of user engagement in the development process (n=8), and several imito team members acknowledged the importance of this factor in the success of the tool, explaining that they realized the importance of onboarding their app into the hospital’s system and workflows, rather than the other way around.

Policy and regulations in general (n=3), and reimbursement and funding (n=4) in particular, were equally perceived as essential factors for adoption. These key organizational and policy factors, their subthemes, frequencies, and some representative participant quotes are summarized in Table 5.

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Discussion

Understanding the App’s Utilities and Limitations

Participants found the app generally useful, with most users using all the key features and the main utility being efficacy and time-saving as taking clinical photos and documenting them using the app is much quicker and easier. This matches the findings from previous studies that suggested that anticipated improved efficacy enhances the intention to use [2,32-38]. Another utility is the improved patient safety and quality of care by structurally showing each case’s progression and enabling the care team to optimize the treatment accordingly; this too validates previous findings that showed mHealth may enable early detection and documentation, resulting in greater safety for patients [39-48].

Clinicians and medical informatics experts were very appreciative of the security and validation aspects of the app, stressing the importance of GDPR compliance and patient data privacy. This utility is of great importance given the typical medicolegal concerns related to confidentiality, inappropriate use, and anonymity of health data [12,45,49-72]. The accessibility and compact overview were clearly an added value of the app as they facilitated timeliness and collaboration, which were also reported in other studies that highlighted how the portability of mHealth tools enabled the care teams to easily access information and flexibly perform tasks anytime and anywhere [1,2,73-76].

Several limitations mentioned by the participants were also reported in previous studies about clinicians’ adoption of mHealth, such as potential data quality and management issues [77,78], potential information overload [79-81], and challenges related to data integration and exchange [82-85]. As for the features that the participants wanted added to the app, it was noteworthy to see that some current features such as integration with radiology devices and the offline functionality were on the wish list, revealing that users were not always aware of all available functionalities and underlining the vital role of training and education. Some of the other requested features such as the patient interface are already under consideration by the imito team but are sometimes stalled because of their high development cost.

Understanding Constraints and Affordances

When exploring the factors affecting adoption, users reported several constraints and affordances because of not only technical functionality but also app utility in relation to the particular social and individual context of use. Usefulness was the most prominent technical factor relating to the app’s features. In alignment with previous research, perceived usefulness was closely related to time-saving and efficacy resulting from the usage of the app [2,47,48,86], its positive impact on the quality of patient care [66,72,87,88], and the potential benefit for research and scientific evidence because of better data availability [42,89]. Perceived ease of use is an equally important facilitator that has been widely reported in similar studies [2,90-93].

Participants also emphasized the importance of IT factors such as the interoperability and integration of the app with the local system in the hospital or clinic, as this would help them avoid the extra work of having to enter the same data again in the system and what it might entail from documentation errors. This has been perceived as a strong advantage of imito. Interoperability is a known challenge for mHealth and has been reported in many other studies [58,59,94-97]. These are system-level integration issues requiring that the app function properly in relation to existing systems and not just within the bounds of a given mobile device, in addition to other technical issues such as log-in or poor connectivity, which may hinder adoption [64,98-101].

Given the highly regulated nature of health care, factors such as patient data privacy and security are vital for adoption. In the case of imitoCam, this factor was perceived as a facilitator, as the app offers a secure solution for clinical photo documentation, whereas other studies reported this as a barrier if data privacy and security could not be guaranteed [53,59,66,68,82,85,102]. Security requirements thus boost the adoptability of apps that can meet stringent requirements in this regard. Another common challenge relating to data is their management and interpretation, especially when the ease of use of such apps increases the data captured and generated significantly, as discussed in other studies [40,77,78,81,84].

Of course, the cost and cost-benefit play a key role. These may be perceived as facilitators when the app helps in saving costs by creating efficiencies as narrated in similar studies [67,83,103,104]; however, they may also be a barrier [56,105,106] considering the tool’s direct costs and the indirect costs related to creating a suitable infrastructure, such as providing handheld devices across the clinic or hospital to support the app’s usage.

The findings also revealed that adoption decisions rely not only on the technical and material factors such as app features and the available infrastructure but also embrace some important social and cultural aspects. For instance, the users’ individual characteristics such as their previous experience with technology generally, and mHealth specifically, may influence their decision to adopt, as reported by other researchers [1,58,101,107,108]. Their attitudes (eg, resistance to change, risk aversion) may also hinder adoption, and comparable findings were described in earlier studies [39,40,82,109,110]. Even though mHealth is no longer a new concept, cultural views on the use of mobile devices at work may be a barrier [2,111-113]; this is slowly changing and people are accepting these tools more as per our study participants.

Understanding How Technology Materializes in the Organizing Process

The organizational and policy implications of the app’s usage were quite prominent, showing that the interaction between the users and the technology creates the adoption patterns that we observe and influences the way people organize their work when using these new tools.

The app’s introduction created workflow advantages by offering location flexibility and a better workflow fit as data could be accessed at the point of care and easily embedded in the patient’s treatment process—a finding that is aligned with the findings of other studies that a good workflow fit encourages adoption [33,68,91]. Making daily work easier and improving collaboration and transparency were additional workflow advantages described by many participants, as they observed that the app made interdisciplinary teamwork easier and provided more transparency as a direct result of better documentation, which is also in line with the findings of other studies regarding the impact of mHealth on cooperation [12,33,40,67,69,91,103] and streamlining clinical work [114-116]. Empowerment resulting from data availability is another advantage as the app instantly equips clinicians with all the information they need, helping them make more informed decisions, as reported in similar studies [2,100]. Conversely, some other studies stated that mHealth might be perceived as a threat to clinicians’ autonomy [43,80,117,118]. We did not find this to be a concern among the participants of this study.

However, workflow disadvantages were apparent around workload and resources. Most clinical staff are already overstretched and the lack of resources may consequently be a barrier to adoption, which has been similarly described in other studies [12,39,92,119,120]. In addition, as one of the participants explained, the greater efficiencies resulting from an app such as imitoCam may also result in a higher workload that could be perceived as an additional burden for clinical staff. The implementation of these new tools may also result in changes in the roles and responsibilities of staff members as reported in other research [45,97,121,122], such as decreasing or eliminating the role of professional photographers as the app replaces their role. Furthermore, the lack of preexisting use of mobile devices in traditional clinical practice is also a challenge as it requires not only workflow adaptations but also infrastructure changes on the part of the hospital.

The nature of the organization of the hospital or clinical setting is also vital for the successful adoption and implementation of mHealth. Factors such as an ambiguous or complicated decision-making process may delay the adoption decision or even prevent it. Other researchers have also shed light on this issue [62,81,92,123], and many participants pinpointed that it is not always easy to identify the people that should be involved in deciding about a new mHealth tool in their organization, and even when they are identified, the process can be quite challenging as the decision involves an interdisciplinary team spanning IT, medical informatics, finance, and medical staff. Given this complexity in decision making, factors such as the trialability of the app and the possibility of piloting it may encourage adoption as it enables decision makers to try a new tool without risking the failure of a broad rollout [48].

Training is another vital aspect of app adoption. This is especially important when the turnover of personnel is high. This point confirms other research that has highlighted the importance of training and education [94,95,124-126]. The organization’s desire to be perceived as innovative may also facilitate the adoption of new health apps, a finding that is aligned with those of other studies showing that institutional innovation and openness to change may play a role in the adoption decision [48,127,128].

Patient-related factors reflecting the implications of app usage on quality of care also have an impact on clinicians’ adoption of mHealth. Apps that enhance patient engagement and safety, such as imito, have better chances of being adopted. This has also been described in other studies [89,102,129,130]. Similarly, there is a higher acceptance of apps that improve patient access to care [39,67,103]. Furthermore, the external context of the organization, including policy and regulations, may impact adoption. Participants explained that more clarity and simplification of the relevant regulation may facilitate adoption. Specific regulations regarding reimbursement and funding are of special importance for mHealth adoption [52,66,67,84,94,105,131]. The lack or ambiguity of such regulations may hinder the compensation of clinical activities performed via mHealth and may accordingly discourage adoption.

User engagement in the development and implementation of the app is vital for its success [48,54,69,71,99,132-134], and our findings show that this is a mutual responsibility of the health care organization and the mHealth provider. imito offers a best practice example of embedding the partners on the hospital or clinic’s side in the development and implementation processes. In this case, they constantly work together with the partner organization (hospital or clinic) in a one-team approach to ensure that the app fits into the technical infrastructure (interoperability and integration) and clinical workflow, taking into account optimization of the clinicians’ daily work through the app. This was emphasized in the functionalities implemented to ensure integration with the hospital’s systems and processes such as using patient barcodes to identify patients, directly documenting photos in the EMR, and enabling clinicians to log on to the app using the personal code on their hospital badge.

Incorporating user feedback and input in the continuous development and testing of the app is not without challenges, especially when the tool is completely embedded in the hospital’s mostly closed system, which results in blocking the visibility of usability statistics from the tool provider. However, imito has established various feedback channels where they get the opinions of the users as well as the inputs of the medical informatics experts that run the tool on the hospital’s side to ensure that their app remains relevant and useful.

Limitations and Recommendations for Future Research

This qualitative case study has some limitations that we would like to outline. Our study is limited to a particular mHealth tool and 2 countries in a specific timeframe, and generalization to other settings that might have different characteristics, such as a different regulatory landscape, is not possible. Moreover, the relatively small sample size and the dynamic nature of mHealth necessitate a constant update of the findings to cope with the changes. The sample also excluded nonusers as their recruitment proved to be very challenging, and there is a possible favorable bias in the subgroup of participants who work for the technology provider. Future research may address some of the cited limitations by covering other apps in other countries, timeframes, and settings.

Conclusions

This study demonstrates the utility of the studied app for clinical photo and wound documentation. The app’s adoption resulted in several benefits from the participants’ perspective, such as time-saving and efficacy, better patient safety and quality of care, data security and validation, and better accessibility. Technical and material factors affecting adoption are usefulness, ease of use, interoperability, cost, and security of the app, whereas social and cultural factors include personal experience, awareness, and attitudes.

Workflow advantages resulting from the app’s adoption include better collaboration and transparency, streamlined daily work, clinician empowerment, and improved quality of patient care. Although workflow disadvantages are associated with the available clinical practice infrastructure, workload and resources, the complexity of decision making in hospitals, the need for continuous training, and the lack or ambiguity of regulations, active user engagement in the development and implementation process may help overcome some of the workflow challenges.

A deeper look into the factors that afford or constrain user acceptance helps us understand materiality at the intersection of social and technical aspects, as the findings show that mHealth adoption is affected not only by the technical features of the app itself but also other social and organizational factors that come into play. These relationships among the technical, social, and organizational factors demonstrate that a successful acceptance and implementation of medical apps not only relies on the tool itself but also necessitates a close collaboration among the tools’ providers, clinicians, and decision makers, so that they can address the barriers and harness the potential of these new tools in advancing health care.