Aim: To explore dietitians' perspectives on the eHealth readiness of Australian dietitians, and to identify strategies to improve eHealth readiness of the profession. Methods: Dietitians who met the criteria for nutrition informatics experts participated in semi‐structured interviews between June 2016 and March 2017. The interviews were recorded and transcribed verbatim. Thematic analysis using coding was undertaken until consensus was reached by the researchers regarding key themes, topics and exemplar quotes. Results: Interviews with 10 nutrition informatics experts revealed 25 discussion topics grouped into four main themes: benefits of eHealth for dietitians; risks of dietitians not being involved in eHealth; dietitians are not ready for eHealth; and strategies to improve eHealth readiness. The strategies identified for improving eHealth readiness included: collaboration and representation, education, offering of incentives and mentoring, as well as development of a national strategy, organisational leaders, nutrition informatics champions and a supportive environment. Conclusions: These findings suggest that dietitians may not be ready for eHealth. Strategic leadership and the actioning of other identified strategies will be imperative to preparing dietitians for eHealth to ensure the profession can practice effectively in the digital age, optimise nutrition care and support research for eHealth. If dietitians do not engage in eHealth, others may take their place, or dietitians may be forced to use eHealth in ways that are not the most effective for practice or maximising patient outcomes.
Keywords: dietitian; eHealth; health information technology; nutrition informatics
The complexity of modern health care, combined with the growing legislative requirements of healthcare organisations and the increasing demands of client expectations, make the delivery of health services to patients difficult without the support of technology.[[
Realising the benefits of eHealth, however, is complex and requires professional readiness to successfully guide the development, selection and implementation of eHealth solutions.[[
Nutrition informatics, as a subsection of eHealth, is defined as 'The effective retrieval, organisation, storage and optimum use of information, data and knowledge for food and nutrition‐related problem solving and decision‐making. Informatics is supported by the use of information standards, processes and technology'.[
In order to investigate eHealth readiness of dietitians, our team has used a mixed‐methods approach across three phases, investigating from several perspectives. The first phase involved the development of a framework for assessing eHealth readiness through a systematic literature review and semi‐structured interviews (using both a quantitative and qualitative approach).[
The first phase revealed that there were no guiding theories or frameworks to determine the eHealth readiness of dietitians within the literature. Therefore we utilised an inductive approach to develop a Framework for eHealth Readiness of Dietitians (FeRD), which encompasses five key eHealth readiness dimensions: access, standards, attitude, aptitude and advocacy.[
The national surveys, forming the second phase, provided baseline data and an indicative trend of dietitian eHealth readiness. The findings demonstrated a moderate level of eHealth readiness by Australian dietitians, with minimal improvement between 2013 and 2016 (survey periods).[[
Given the limited improvements in eHealth readiness of dietitians, we endeavoured to investigate the perspectives of dietitians to determine if they could provide specific direction on strategies to assist further progression. Specifically, this research (phase 3), aimed to explore the areas identified for improvement in the national surveys. We used in‐depth interviews to investigate nutrition informatics experts' perspectives of eHealth and eHealth readiness, and identify strategies to strengthen the capacity of all dietitians to lead eHealth initiatives and effectively drive successful nutrition‐related eHealth implementations.
A post‐positivist approach was adopted for this qualitative study to elaborate on the key areas for development identified in the national surveys,[[
The interview questions were developed based on the gaps identified in the surveys. Namely, to specifically address the lack of awareness of the broader eHealth benefits, low levels of experience, and minimal involvement in eHealth initiatives by dietitians, in order to generate practical strategies to improve dietitian eHealth readiness. Ten questions were developed relating to the nutrition informatics expert's perceptions on the benefits of eHealth; risks of not being involved; dietitian eHealth readiness; reasons for lack of dietetic engagement in eHealth projects; the impact dietitian involvement has on eHealth projects; and ways dietitian engagement could be improved. The questions were piloted with two dietitians, with some minor modifications made to reduce duplication in responses.
Initial coding of the data was performed with the assistance of QSR NVivo 11 Pro (v11.0.0.317) qualitative analysis software. The transcripts were read and reread to gain a comprehensive overview of the opinions and perceptions expressed by the participants. Thematic analysis[
Ten dietitians who met the criteria of a nutrition informatics expert participated in the present study. Practice areas represented included: hospital (management, clinical and foodservices) (n = 5), university or research (n = 2), government (n = 1), private practice (n = 1) and industry (n = 1). Females represented 80% (n = 8) of the respondents and is reflective of the gender ratios within the profession.[
The data analysis identified 25 topics which formed four key themes, namely: benefits of eHealth for dietitians; risks of dietitians not being involved in eHealth; dietitians are not ready for eHealth; and improving eHealth readiness strategies (Table). Exemplar quotes were identified for each of the topics (Table).
Key themes, topics and exemplar quotes for the interview transcripts
Themes Topics Quotes (interviewee, practice area/setting) 1. Benefits of eHealth to dietitians Access to information 'So eHealth makes it easy to access information that is going to help you inform your care plan. The benefit of that is you have more co‐ordinated integrated care for the patient which would drive better patient outcomes' (Interview 6, Hospital). Accuracy and safety 'I think there is a lot of potential for safety built into it in a much more effective way than what happens in a paper record for example' (Interview 3, University/Research). Consumer access to healthcare 'Keeping up‐to‐date with what consumers are accessing and what patients (our consumers) are accessing, and providing services to patients in different forms other than traditional face‐to‐face form to enable a broader reach and I guess meeting patients and consumer needs and ultimately satisfaction' (Interview 4, Hospital). Data analytics 'It can help us target our service because it can provide information that will change your service delivery as a result of analysing larger pieces of data' (Interview 1, Hospital). Efficiency 'The immediacy of access, so not just the waiting time, but no matter where you are you can find them, access them, many people can be using it at the same time' (Interview 3, University/Research). 2. Risks of dietitians not being involved in eHealth Clinical risk 'I think you can have some clinical risks and you know we have seen that in some of our hospitals' (Interview 8, Hospital). Lose professional domain 'I think dietitians risk being left behind, becoming out of touch, and being seen as redundant. A rise in other nutrition professionals, or professionals claiming to have nutrition qualifications and training, and being better at using certain aspects of eHealth and promoting themselves' (Interview 9, Private Practice). Miss the benefits 'Well, as a profession we won't get the benefits, we won't get the initiatives, we won't get innovation. We would possibly be lost and swamped by a multiple other professions who will ultimately leverage off that data and leverage off the opportunities to change and grow and capture that patient interest in the sense of healthcare...' (Interview 1, Hospital). Systems not suited to professions' requirements 'I think that's the biggest risk, decisions are going to be made without them, systems are going to be built that don't require a dietitian, and some EMRs [electronic medical records] can be completely setup to not require dietitian involvement' (Interview 2, Industry). 3. Dietitians are not ready for eHealth Disconnect between IT and clinical departments 'So, I think that lack of a link, or lack of communication with IT departments, or lack of connection, has resulted in dietitians being very disengaged from the process' (Interview 9, Private Practice). Focused on role and not seeing the bigger picture 'And that may be for any number of reasons, we are all busy people and we are focused on patient care and we don't see the immediate benefit of our time and effort' (Interview 6, Hospital). Frustration 'I feel there is a huge amount of frustration that we were unable to move things forward and have real meaningful headway into getting and attracting interest within the profession, even though as an industry health informatics has not stopped, in fact it has escalated exponentially, but as a profession our interest has not followed that vein' (Interview 1, Hospital). Generational 'The younger generation has grown up with technology; they expect it to be in their daily lives, so when you suggest ideas that involve electronic systems they are much more ready to use that' (Interview 2, Industry). Lack of enthusiasm or interest 'I do think that because there is very little current interest in the dietetics field about nutrition informatics or not so much current interest, but certainly a lack of enthusiasm' (Interview 1, Hospital). Lack of informatics expertise 'Part of the frustration is, that once this thing has been designed is that you can't go back and redesign, and there are all sorts of rules and barriers. We've had a very frustrating time going back and asking can we start again, and they say sure you can start again, but they aren't making the changes we put forward' (Interview 6, Hospital). Lack of knowledge, awareness and confidence 'I think the fear, lack of understanding, so there is a lot out there; it's not just one thing.' (Interview 7, University/Research) Lack of progress 'I feel we are a pretty passive workforce, that we will adopt technology when it is given to us, or we will critique it when it's handed to us. But on a whole I don't think we are well engaged as a profession in this sort of stuff' (Interview 6, Hospital). 4. Improving eHealth readiness strategies Collaboration and representation 'I think that if we got involved in some of those key organisations that are involved in nutrition informatics or health informatics that it puts us on the map, it creates a skill level for us that keeps the conversation going. It probably embeds us as a profession within that whole health network, and if we don't do it we'll miss the opportunity altogether or someone will come in and provide it for us, but it will be with their perspective of dietetics which may not be within our profession' (Interview 1, Hospital). Education 'I think that we need to provide more education about what eHealth is; that it's more than just the EHR [electronic health record], which is how eHealth is widely seen by clinical dietitians in hospitals. We need to provide education about existing systems and how they fit in, how they are existing eHealth systems I guess, and also future possibilities' (Interview 9, Private Practice). Offer incentives 'I do think that because there is very little current interest in the dietetics field about nutrition informatics or not so much not current interest, but certainly a lack of enthusiasm that perhaps we might need some sort of impetus to get us over the hurdle to help bring an awareness or create a profile or create a structure for us as a profession to move forward' (Interview 1, Hospital). Mentoring 'So I suppose it's a matter of supporting, encouraging, mentoring and building confidence from a professional perspective about a field that was not our primary area of study' (Interview 1, Hospital). National strategy 'I think DAA [Dietitians Association of Australia] have a role to play here to actually educate, promote and assist dietitians to become better informed about eHealth, what eHealth is, how it impacts us and what the risks are of not embracing it as a profession' (Interview 9, Private Practice). Organisational leaders 'Obviously for individual dietitians it is very difficult for them to change a whole system or whole approach, but those in positions of leadership are the ones who can help guide, help reassure, help put stepping stones in place to have it all happen' (Interview 3, University/Research). Nutrition informatics champions 'I do think you need big picture people, holistic people, visionary people in place to get some of the big overarching stepping stones in place, and we need the right people in the right place at the right time'(Interview 3, University/Research). Supportive environment
Theme 1: Benefits of eHealth for dietitians: The benefits of eHealth to dietitians were clearly articulated. The responses identified the same topics outlined in the eHealth readiness survey relating to the benefits of eHealth for dietitians, including access to information, accuracy and safety, consumer access to health care, data analytics and efficiency.[[
Theme 2: Risks of dietitians not being involved in eHealth: The risks to dietitians not being involved in eHealth extend beyond just missing the benefits. The topics identified during the interviews also outlined the potential for clinical risk, which is a possibility if solutions for dietitians are developed by those without the nutrition expertise. The management of diet restrictions and allergies in hospital patients, for example, need to be accurately linked to the corresponding codes in order for hospital interfaces to be safe and reliable (Interview 9, Private Practice setting). A similar topic identified was systems not suited to the professions' requirements, meaning if dietitians are not involved in the development of an eHealth solution, it may not end up including the key fields and processes required to support dietetic practice, and consequently will not be adopted by dietitians. The ultimate risk, however, is dietitians 'will become obsolete' (Interview 5, Government setting), with others claiming authority in the nutrition space.
Theme 3: Dietitians are not ready for eHealth: Dietitians are not ready for eHealth was a consistent theme arising from the interviews with eight topics revealed contributing to this belief. The topics identify barriers to dietitian eHealth readiness, including dietitians' lack of knowledge, awareness, confidence and informatics expertise in relation to eHealth that was most often discussed. It was identified that eHealth projects are often challenging and difficult to engage in, with the terminology and processes foreign to a dietitian, so they are 'getting dragged along with what the organisation is doing' (Interview 4, Hospital setting) because of their lack of informatics expertise, rather than confidently driving clear nutrition‐related solutions. In addition, the importance of a fine balance was highlighted, 'balance between collecting data for research purposes and having a system that promotes good workflow and good communication... because it's very easy to create for example a progress note that is a blank page and that's the electronic equivalent to the patient paper note, but that does not give you any of the added benefit that eHealth provides' (Interview 6, Hospital setting). This quote provides a clear example supporting the need for someone with informatics skills and experience.
There was frustration with the current lack of progress across the profession, passive engagement and lack of national support and strategy for moving the profession forward. A quote from one of the participants: 'We need to move forward as a group and we need to move forward with I guess a united idea of what this concept is and clearly that's not happening' (Interview 7, University/Research setting).
Theme 4: Improving eHealth readiness strategies: Eight strategies were identified to improve eHealth readiness: collaboration, incentives, education, mentoring, national strategy, leaders, champions and supportive environment. Many of these strategies were related to leadership: collaboration and representation; organisational leaders and nutrition informatics champions. Collaboration and representation recommendations were reported on a multitude of levels, starting from individual organisations, to state‐wide, to national and international opportunities, whereas the other two topics related more to individual leadership attributes. For the strategy of organisational leadership, it was suggested that this could be fulfilled by those already in a position of leadership, or alternatively it may require a dedicated position. 'It may need a dedicated project type role, where it would be a key strategy of the organisation to further develop and once that interest is created I suspect a higher uptake of interested parties can then have a snowball effect and move the profession forward' (Interview 1, Hospital setting). Supporting the suggestion of nutrition informatics champions were the following quotes: 'Have some sort of group or a group that can show leadership and start to drive the process and upskill people and start to really inspire people who don't necessarily don't want to lead, but who are interested in the area and that tiny bit of interest is all we need to start the ball rolling and get others on board' (Interview 7, University/Research setting). 'I do think champions are helpful, the thing I think are helpful about champions is almost a pure sales approach if I can say, so the champions themselves have been upskilled, but after a couple of years need a rest, but I think they can be a buddy or guide to the next generation of champions. So if any one of them could then be a support for several other newer people coming on board, then 10 becomes 100 becomes 1000 in no time at all if we use that type of approach. I think that supportive model could be very strong and very valuable' (Interview 3, University/Research setting).
Education and mentoring were highlighted in regard to creating opportunities for eHealth awareness raising and exposure. The need for a national strategy with 'simple messages, and consistent hammering of those key areas' (Interview 5, Government setting) to members, and an action plan to 'influence at a national commonwealth level' (Interview 5, Government setting) eHealth standards and policies. Also raised was the need to create an 'impetus to get over the hurdle for the profession to move forward' (Interview 1, Hospital setting), and an 'incentive' (Interview 8, Hospital setting) for individuals to get involved. A supportive or enabling environment to enable the coordination of the effort required for the profession in this space, 'with everyone working together to achieve these goals' (Interview 3, University/Research setting).
The participants suggested many strategies for improving eHealth readiness. However, when prompted they found it difficult to identify who, and how these strategies could be coordinated and actioned. Primarily, the Dietitians Association of Australia (DAA) and universities were identified as having key roles in assisting with providing education to increase awareness of eHealth, to provide incentives, develop a national strategy, and to provide a supportive environment. To quote: 'I think that Universities certainly have a role for the future graduates – talk about eHealth, what it is, how it fits in, and it's more than just EMR or nutrition support software that you might use in your workplace. I think DAA have a role to play here to actually educate, promote and assist dietitians to become better informed about eHealth, what eHealth is, how it impacts us and what the risks are of not embracing it as a profession' (Interview 9, Private Practice setting).
This research explored the perceived eHealth readiness of dietitians through interviews with nutrition informatics expert. Twenty‐five topics were identified, forming four key themes, with similar responses and perspectives being reported by all the participants. There was agreement that there were benefits to dietitians in using eHealth, as well as risks of dietitians not being involved. However, there was frustration with the current lack of progress across the profession, and overwhelming consensus that dietitians were not yet ready for eHealth. This supports the findings of the eHealth readiness study.[[
The benefits identified during the interviews were comprehensive and reflect commonly reported key eHealth benefits, all of which contribute to the ultimate goal of eHealth: to improve the quality of health‐care delivery.[[
The risks of dietitians not being involved in eHealth became the second theme, which like benefits, are an important part of this discussion.[
There were strong opinions relating to the theme that dietitians are not ready for eHealth, and several potential barriers for this identified. These reasons should be taken into consideration and targeted when developing the strategies to address dietitian eHealth readiness. For example, how can we leverage the younger generations' knowledge and confidence with technology to improve the professions interest and enthusiasm for eHealth? Dietitians are not aware of the benefits of these solutions, the risks of not being involved,[[
The fourth and final theme encompassed the strategies for improving eHealth readiness amongst the profession. This area is challenging, with no previous framework to guide the profession and insufficient investment in reflecting on our limited experiences, to identify how we can do better moving forward.[
The importance of greater collaboration and engagement by dietitians as part of the development and implementation process of eHealth solutions has also been identified in research studies, and in particular in several with nutrition focus.[[
Some topics related to strategies that did not arise in the interviews included competency standards for dietitians and health (or specifically nutrition) informatics certifications. Ayres et al. in 2012 from the Academy of Nutrition and Dietetics identified that whilst other professions had addressed informatics competencies at different levels of practice, the dietetics profession had not.[
As with any semi‐structured interviews, a limitation is the risk that participants may not reveal all of their true opinions as they may wish to please the interviewer. This method was specifically chosen over focus groups, for example, as there is the risk that the responses may be influenced by a dominant view, and alternate views may be less accepted or possibly not externalised.[
When the three phases of this research were considered as a whole using triangulation methodology, a significant finding was the complexity of eHealth readiness, and the lack of understanding of what readiness entails by the profession. This may be the key issue and the first place for the profession to focus eHealth awareness efforts. It appears that understanding of readiness is limited to personal experience (and unfortunately dietetic experience in eHealth is very low), and therefore is often assumed to be made up only of attitude and aptitude. Dietitians' high confidence and experience in using computers may be creating their belief that they are ready for eHealth, when in fact they are not (when all FeRD dimensions of readiness are assessed).[
There is an opportunity to embrace this knowledge, and for dietitians to demonstrate they are the clinical leaders for nutrition, and ensure they are driving the eHealth solutions for nutrition care, rather than financiers or technologists. Whilst achieving the benefits of eHealth will be complex, collaboration across the profession is key, with a number of strategies imperative to prepare dietitians for eHealth and ensure the profession can practice effectively in the digital age, optimise nutrition care and support research for eHealth. These strategies include developing a national strategic plan; enhancing university training and graduate competency; engaging and collaborating with external organisations to ensure inclusion and interoperability (incorporated into standards and policy); utilising the skills and expertise across the practice areas to identify champions and leaders; embracing those with experience; and drawing on the varying expertise demonstrated by the different generations.
The authors declare that no funding was received for the present study.
KM acknowledges the nonfinancial support of her employer The CBORD Group. MF, Director of Dietitian Connection, receives sponsorship from The CBORD Group.
KM determined the key concepts for the paper, prepared the interview questions, conducted and transcribed the interviews, conducted thematic analysis and drafted the manuscript. KW assisted in the interview questions, conducted thematic analysis and assisted in the development of the manuscript. PW assisted in the interview questions and in the development of the manuscript. MF assisted in the interview questions and in the development of the manuscript. EB assisted in the interview questions and in the development of the manuscript. All authors approved of the final version of the manuscript.
By Kirsty Maunder; Karen Walton; Peter Williams; Maree Ferguson and Eleanor Beck
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