Patient experience of telehealth for the self-management of chronic disease: applying a value co-creation framework

This thesis is a study of patient experience of telehealth services for self-management of chronic disease. It investigates the use of technology-based services to address the social and managerial problem of unsustainable demand for scarce resources by focusing on the understudied patient perspective. Chronic disease care is a ‘wicked problem’ affected by complex interdependencies that are difficult to change, such as rising demand from ageing populations, unhealthy lifestyles, spiralling healthcare costs and economic contraction weakening the financial foundations of healthcare systems. Studies suggest that using technology-based services installed in patient homes can play a part in safely reducing demand for in-clinic appointments and emergency hospitalisations. Conceptualising the research problem involved unpacking extant patient experience concepts. The thesis applies marketing theoretical perspectives to explicitly question the assumptions in the healthcare literature relating to patient experience and argues for application of a service-dominant logic (S-DL) (Vargo & Lusch 2004; 2008; 2016) to address provider-led biases. The perspectival shift enables patient experience to assume patients participate in service experiences as social actors rather than objects. In committing to marketing perspectives, the thesis draws on explanations of consumers agentically experiencing service interactions through resource integration aimed at deriving value from their consumption experiences (Arnould et al. 2006). It also conceptualises telehealth as a self-service technology (SST) (Dabholkar 1996) within a multi-interface, multichannel service context. Using an S-DL approach grounds the study of patient experience in their interactions with various aspects of services based on patient goals and interests. This is consistent with the S-DL’s explanation of value emergence by advocating attention to structure and agency in order to account for value as it is subjectively determined by the patient in context. Applying the S-DL perspective is consistent with the critical realist (Bhaskar 1978) standpoint adopted in the thesis (Löbler 2011; Peters et al. 2013). Critical realism is capable of maintaining consistency between the ontology of patient perspectives of service experiences while accounting for the influence of provider-led social structures. As a philosophical background, critical realism also provides epistemological tools for investigating the interaction of agency and socio-technical structures of healthcare services to explain social change. Its theory of morphogenetic social action (Archer 1995) provides a methodological route to logical conjecture about the generative mechanisms that explain the structure of interactions between patients and providers implicit in service structures even if the actors involved are unaware of them. Therefore, the conceptual framework is philosophically equipped to engage with debates between epistemological approaches in the healthcare literature about the role of individual agency and deterministic service structures. Critical realism also provides analytical tools useful for adducing the potential of telehealth services to disrupt ingrained attitudes and behaviours. The theoretical stance adopted in the thesis suggests that identification of generative mechanisms at the micro level of telehealth service experience can be used to theorise about changes introduced by patient use of telehealth to trigger meso-level structural change, toward transformation of wider healthcare service interactions in different service channels. Transformation is argued to be signalled by the selection of alternatives that challenge the relationship dynamics sustaining ingrained interdependencies that contribute to the problem of unsustainable demand for chronic disease care. An in-depth case study of an NHS telehealth service informed by multiple case studies of experienced telehealth users provides rich empirical data. Employing interviews and participant observations with a heterogeneous sample of 27 complex chronic comorbid adults, data collection took place in patient homes in a large English city over an 18-month study. The findings show telehealth to involve effortful experiences challenging the prevailing view that telehealth is convenient, easy to use, cost-saving for patients, and that it extends the ‘objective’ clinical lens on the patient condition in non-clinical settings. The thesis highlights the relationship between telehealth and wider healthcare service relationships by showing that the outcomes from telehealth use are valued by patients as they compensate for inappropriate functional outcomes and poor relational outcomes that result from full-service interactions. Telehealth is a resource that enables patients to manage service relationships with healthcare services. Patients are shown to regain control over what happens to them through customising clinical decision-making processes. Patient participation in decisions about access to further healthcare resources is argued to be transformative because it makes healthcare interactions patient-led. The core contributions of the thesis are a patient-centred framework improving the construct validity of patient experience and patient value research. By studying disadvantaged and vulnerable consumer experience of SST in a highly institutionalised healthcare service context, it contributes to the SST literature by moving beyond psychology-based focus upon ‘use’ and applying a S-DL to consider the role of ‘experience’. It contributes to the S-DL literature on consumer-provider value misalignment by showing the importance of service channel affordances as opportunities for patients to co-create subjective value. The findings contribute insights into debates about patient choice and autonomy and evidences strategic value from loosely integrated multichannel services in order to counteract effects of misaligned provider and patient value systems. Practical implications include support for continuing telehealth provision, and acknowledgement of non-economic costs of use for patients by ensuring availability of full-service options to provide much-needed support and feedback in response to changing needs. Additional resources are needed to guide users to learn more about clinical measurement and interpretation of vital signs to develop their practical self-management skills. This could improve patients’ ability to derive improved value from their healthcare service interactions. Managers should understand that telehealth is valued by patients because it increases patient autonomy which is missing from full-service experiences. Customisation is an important part of the value that patients derive from using telehealth, enabled by provision of multichannel services. Work is needed to transform organisational culture and values currently focused on clinical outcomes at the expense of the functional and relational outcomes valued by patients