Power, paradox and pessimism: On the unintended consequences of digital health technologies in primary care

We consider what might be learned from the unintended, apparently unanticipated, consequences of the use of digital health (including alternatives to face to face consultations, electronic medical records, use of apps and online monitoring) in primary care. We chose a conceptual literature review method, to seek a higher order understanding of the nuanced patterning of unintended consequences of digital health technologies (for people, relationships, organisations and ways of working) which are rarely simply positive or negative. The approach is informed by realist review, which recognises that experiences and outcomes of interventions work (or fail) in different ways in particular contexts.

We present three higher order themes to illuminate underpinning mechanisms for unintended consequences in digital health technologies in primary care. These themes are illustrated by case examples, with particular focus on those that have been little discussed in the literature. Following Merton’s (1936) differentiation between consequences for the actor(s) and others, which are mediated through the culture and social structure, we discuss consequences that i) disrupt power relations between patients and health professionals or between different groups of health professions, ii) contribute to paradoxical outcomes and iii) result in a potentially corrosive sub-culture of pessimism about digital health.

We conclude that when implementing or evaluating digital technologies in primary care, it is wise to consider the ‘dark logic’ of the intervention (Bonell et al., 2015). Attention to issues of power relations, the potential for paradoxical outcomes, and impacts on the expectations of staff in relation to digital innovation are particularly salient in relation to the dramatic changes in primary care delivery initiated during the Covid-19 pandemic. Fostering a sense of ownership and interest in monitoring the effects that matter to the organisation will likely help counter pessimism and renew interest in deploying those digital innovations that show promise.