Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
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Journal of medical Internet research
Evolution of Regional Information Infrastructures Integrating Health and Social Care in Scotland: Qualitative Study
BACKGROUND: Expectations of integrating health and social care providers have driven the development of digital solutions aimed at overcoming interoperability challenges and ensuring access to information needed for integrated care across fragmented services. However, challenges persist in aligning diverse coding practices, heterogeneous data-sharing mechanisms, and stakeholder needs. OBJECTIVE: We examine how expectations of interoperability and integrated care have shaped the growth of regional information infrastructures in Scotland, using the Key Information Summary (KIS), a summary record that shares key patient information from general practitioner records with out-of-hour services, ambulance services, hospitals, social workers, and caregivers across multiple care settings, as a case study. METHODS: This qualitative study examined the development, implementation, and adoption of KIS in Lothian, Scotland, across health and care settings, where it has been in use for 13 years. Multisited ethnography was used to understand how technology design, implementation, and adoption were shaped by social, organizational, cultural, and political factors. Data were collected through interviews with users, vendors, and implementers; observations of technology use and multidisciplinary team meetings; and documentary analysis of policies, user guides, and internal reports. A hybrid analytical approach was applied: the Technology, People, Organization, and Macroenvironment framework guided initial coding, while the sociology of expectations and information infrastructure theory were used inductively to trace evolving visions of integration, and the long-term development of regional information infrastructure. RESULTS: Data included 54 qualitative interviews, 20 hours of observation, and 59 documents collected between April 2024 and March 2025. Findings illustrate how information infrastructures for integrating health and care providers evolved through successive concerted efforts, conceptualized as waves. Three waves were identified, each characterized by attempts to interlink disparate information systems used by various health and care providers. The first wave focused on linking health care providers by developing networks and architectures required for sharing clinical information, which later supported the development and sharing of KIS. Subsequent waves sought to interlink information systems used by health care providers with those used by local authorities and social care providers. In the absence of shared data standards across these sectors, interoperability was achieved by extending the existing health care-centric infrastructure to different social care settings through workarounds such as providing proxy access to hospital systems and secure emailing networks. CONCLUSIONS: This work illustrates how regional information infrastructures for integrated care evolve through orchestrated waves of change. Some expectations for change required coordinated, system-level action, such as setting up standards, networks, and architecture, while others were realized through local adaptations. Integrating health and care providers through digitalization is a long-term process requiring sustained coordination, with progress often occurring through incremental, local extensions. Policies must support adaptive, long-term coordination, balancing system-level initiatives with local adaptations to achieve meaningful integration.
12 July 2026
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Development of Virtual Mental Health Stepped Care Service for a Heart Failure Remote Management Program: Qualitative Descriptive Study
BACKGROUND: Depression is highly prevalent yet undertreated among people living with heart failure, indicating barriers to mental health services. Although various digital mental health interventions have been developed to detect, treat, and manage depression in this population, these interventions have seen limited integration into clinical care and a lack of implementation research. Stepped care is a service innovation that may promote the implementation of these technologies into clinical settings, but few studies have examined how these services are designed in clinical settings. OBJECTIVE: This study aimed to identify strategies to address health system barriers to accessing mental health care from the perspective of people living with heart failure, clinicians, and researchers, and to incorporate these strategies into the design of a virtual mental health stepped care service within a heart failure remote management program. METHODS: A qualitative description study was conducted using purposive recruitment of people living with heart failure, clinicians, and researchers from a heart failure remote patient management program. As part of a service design approach, semistructured interviews explored potential strategies to address barriers to accessing mental health services. Two researchers coded the data descriptively and constructed themes to guide the development of a virtual stepped care service. RESULTS: A total of 22 participants were interviewed, comprising 13 people living with heart failure and 9 clinicians and researchers. Six themes were identified, comprising 4 requirements and 2 foundational principles. The requirements were to (1) adopt a collective approach to identify distress across methods, people, and time points; (2) maintain a referral-based approach; (3) rely on existing mental health human resources; and (4) offer patient choice among various mental health care options. These requirements were supported by two principles: (1) building on organizational strengths and (2) reducing treatment burden. Based on these findings, a virtual stepped care service was developed, incorporating a depression screening module, referral-based workflows, and, where clinically appropriate, patient choice in treatment selection. CONCLUSIONS: The stakeholder-informed design of this virtual stepped care service contributes to the limited literature on stepped care service design and demonstrates how such models can be tailored to their intended contexts. Although each component was designed to address health system barriers to mental health care for people living with heart failure, resource limitations may constrain the balance between feasibility and quality of care. Future research should evaluate the acceptability of this model among people living with heart failure and clinicians.
16 Apr 2026
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