Beyond adoption: A new framework for theorising and evaluating Non-adoption, Abandonment and challenges to Scale-up, Spread and Sustainability (NASSS) of health and care technologies

Background: Many promising technological innovations in health and social care are characterized by nonadoption or
abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the
organization or system level.
Objective: Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and
evaluate the success of a technology-supported health or social care program.
Methods: The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains,
and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6
technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment,
pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management
via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data
were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level
(national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual,
organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other
technology-supported health or care programs and refined in response to feedback.
Results: The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic
systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of
ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up,
spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the
value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider
(institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical
case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few
components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated
into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those
characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise
when applied (both prospectively and retrospectively) to other programs.