DIGITAL INNOVATION

IN DANISH HEALTHCARE AND ELDERCARE

EVIDENCE FROM A LARGE-SCALE TELEMEDICINE

PROGRAM

BY JEPPE AGGER NIELSEN, PROFESSOR (MSO), AALBORG UNIVERSITY,

DEPARTMENT OF POLITICAL SCIENCE, CENTER FOR IS MANAGEMENT

RESEARCH INTERESTS

Digital innovation

• Diffusion, adoption, implementation, and use

Elderly care and Healthcare (eHealth)

• Telemedicine, robotics, and mobile technology

Management concepts

• Leadership Pipeline, Lean, IT PPM

Current research project (2018 – 2021)

• Welfare Technology Implementation: From Vision to Value • WP1: Scaling-up WT innovation

• WP2: WT and value creation

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AGENDA

(1) The Danish welfare system

(2) Digital innovation in healthcare and eldercare: The case of Welfare technology

• Strategies, practices, and challenges

(3) Evidence from a large-scale telemedicine program in Denmark

• From pilot project to large-scale: Effective scaling in an interorganizational context

• From vision to value: Mixed results

(4) Lessons learned and conclusion

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THE DANISH WELFARE SYSTEM

• 5.4 mio. inhibitants

• The basic principle of the Danish welfare system, often referred to as the

Scandinavian welfare model, is that all citizens have equal rights to social

security

• A number of services are available to citizens, free of charge. This means

that for instance the Danish healthcare, eldercare, and educational systems

are free of charge.

• Key components of the Danish welfare model

• Denmark has one of the highest rates of taxes in the world

• Like many other countries, Denmark is faced with the challenge of an

ageing population

TECHNOLOGY USE IN HEALTH SYSTEMS ACROSS EU CONTRIES

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ORGANIZING HEALTHCARE AND ELDERCARE IN DENMARK

Danish health care system: a public and politically led system that is primarily

financed by taxes.

The Danish health care system is divided into three administrative and political

levels: the state, 5 regions, and 98 municipalities.

• The state takes care of overall financing and regulation.

• The hospitals are owned and administered by the 5 regions.

• The 98 municipalities finance and administer home care and nursing homes.

• 3,500 general practitioners (family doctors) act as gatekeepers of specialist

hospital care.

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WELFARE TECHNOLOGY IN USE: EXAMPLES FROM DK

Social

robots

The robotic seal

'Paro' for dementia.

Sensors and

wearables

GPS-tracking, e.g.

to track people with

dementia.

Service

robots

The 'Melvin' robot is

used to help elder

and disabled people

get clothes on and

off in the bathroom.

Apps

How’R’You-app,

daily journal, and

follow-up during

the course of an

illness.

VR-

technology

VR-training, e.g. for

rehabilitation of

brain-damaged

patients.

Relocation

lifts

Multi-Tower Robot

for relocation of

patients.

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WELFARE TECHNOLOGY

Welfare technology (WT) – “technology capable of assisting citizens in their daily lives, reduce costs, and provide a better work environment for health care professionals” (Hofmann 2013) – offers a potentially radical solution to innovate and transform healthcare and eldercare services

The promise of welfare technology (a term coined in the Nordic countries) manifests itself in many Western countries’ IT policies and strategies, and a variety of emerging technologies, such as VR, robots and telemedicine, are increasingly being adopted by contemporary healthcare and eldercare organizations

Denmark is a frontrunner (Östlund et al. 2015), thereby providing a unique case for exploring the WT phenomenon

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THE PROBLEM OF UP-SCALING

The transformative power of WTs is widely recognized but many projects tend to fail.

It is notoriously difficult to realize the expected benefits;

The long-term co-operation of multiple actors is hard to sustain.

Despite promising results from various WT pilots throughout the world, scaling up WT pilot

projects often fails (Bartel & Garud, 2009; Dougherty & Hardy, 1996).

Even when WT innovations demonstrate viability in initial pilot testing, it is not a given that they

survive beyond the pilot phase and become implemented at a wider scale (Garud et al. 2013).

Especially not when funding runs out!

Focusing on the early phase of innovation diffusion that I label “scale-up” draws attention to the

critical transformation of new ideas and practices from a small-scale setting to a more complex

setting with a larger population.

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EVIDENCE FROM TELEMEDICINE IN DENMARK

Pilot project:

TELEKAT

Large-scale program:

TeleCare North

Health

care

actors

2 hospitals

2 municipalities

4 GP´s

4 hospitals

11 municipalities

225 GP´s

Patients 111 1225

Budget $1,6 million $10 million

Period 2008-2010 2012-2015

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THE DANISH TELEMEDICINE INITIATIVE

• Telemedicine technologies facilitate delivery of health

care services at a distance.

• The Danish telemedicine service is characterized by

remote home monitoring of COPD patients. Health

care service is installed directly in the homes of the

patients.

• COPD = Chronic Obstructive Pulmonary Disease,

including people with chronic bronchitis. Usually

caused by smoking (and air pollution) and symptoms

include shortness of breath.

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THE DANISH TELEMEDICINE INITIATIVE

• COPD is a common and cost-intensive disease that constitutes 10% of the overall healthcare budget for citizens above the age of 40 in Denmark.

• COPD patients measure their oxygen levels,

blood pressure, pulse, and weight themselves.

These measurements are sent to a database that is

monitored by GPs and healthcare professionals from

municipalities and hospitals.

• Expected benefits: Prevention of hospitalization (save money), empowerment of patients, and decrease in demand for eldercare services.

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FROM PILOT PROJECT TO LARGE-SCALE PROGRAM

From pilot project to large-scale program

Pilot (2008-2010) Transformation (2011-2012) Large-scale (2013-)

Main activity User-driven

development and

experimentation

Backstage activities, decision-

making, planning, and building

the project organization

Launch and top-down

implementation

Change actors Researchers Managers and project

secretariat

Health care professionals and

patients

Main translation

activities

Translating

telemedicine ideas

into practice

prototypes

Translating the pilot findings into

a business case, work

instructions, and plans of action

for the large-scale program

Re-translation of the objectives

and practices developed in

phase 1 and 2 to a workable

large-scale solution

FINDINGS [1]: SCALING AS A POLITICAL PROCESS

Scaling up the telemedicine pilot project was a difficult task.

The period after the end of TELEKAT (pilot) was a critical period without funding or

visible project management. A period of silence followed, which involved waiting time,

back-stage activities, and networking.

Tensions between the interests of municipalities and hospitals were a recurring issue in

the transformation from pilot to large-scale, since it was “difficult for the participants to

think out of their own silos” (project manager). Actors from hospitals were guided by a

“medical logic,” emphasizing telemedicine as a treatment tool, whereas actors from the

municipalities were guided by a “care logic”, focusing on telemedicine as a rehabilitation

tool.

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FINDINGS [1]: SCALING AS A POLITICAL PROCESS

Although the case represents a successful example of upscaling, the process

was loaded with different motivations for participation, disagreements about

who should perform telemedicine tasks, different professional standards for

treatment, and protection of own interests.

Political behavior at the local and institutional level

• Region (hospitals) vs. municipalities

• Region (hospitals) vs. general practitioners

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FINDINGS [2]: HANDLING POLITICAL DYNAMICS

Observation of how the transformation into a large-scale program was facilitated by intensive efforts of

a group of managers. They used their social capital to mobilize resources and their alliances to

support the large-scale vision.

(1) Re-mobilizing networks

• Establish new constellations of actors

• “Behind the scenes” management

(2) Aligning interests

• Negotiate feasible compromises

• Create a flexible vision

3) Connecting to the field-level (national strategies and networks)

• Handle cross-level interdependencies

• Navigate field-level battles

Re-mobilizing network

When I left the closing conference on

TELEKAT, it was obvious that we had

achieved excellent results in the pilot.

However, if we were to be able to use them

for anything, we had to go large scale. Our

municipality couldn’t do such a project on our

own. It would have to include more parties.

Together with a regional top manager, we

started deliberating how we could realize a

large-scale project (Municipal top manager).

“Behind the scene” management

The work prior to the official project initiation

is invisible to others. However, it takes an

extreme amount of time and effort to mobilize

a network that supports a large-scale

telemedicine program. This work is not so

much about telemedicine – it relates to all

kinds of other things, for instance,

communication, networking, and the ability to

organize and think strategically. (Regional top

manager).

Negotiate feasible compromises

It was crucial to make a separate organization

the project secretary who is anchored at

neutral place. It is not the municipalities’ or

the hospitals’ organization. Instead, the

project secretary is our shared organization.

Create a flexible vision

Drafting a BC and highlight market potential,

efficiency gains and empowerment of

patients, thereby legitimating telemedicine as

a win-win situation for involved actors,

including financial and non-financial reasoning

Handle cross level interdependencies

The regional manager has put a lot of effort

into promoting our project in national

networks. So has the manager of the project

secretary. Thanks to their effort we became

visible outside of our region.

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Source: Christensen, Nielsen, Gustafson Seemann, forthcoming

LARGE-SCALE

Expected economic benefits difficult to realize. Economic benefits only realized for the group with ”severe COPD.” (not mild and moderate). The goal of significantly fewer hospitalizations was not achieved (Udsen, 2016)

*The benefits realization of WT is dependent on the technology being targeted at those citizens who get the most use out of it (in this case people with severe COPD)

In a survey about COPD patient experience, 88% of participants expressed that telemedicine is easy to use, while 72% experienced an increased feeling of safety and 62% felt more in control over their disease by using the technology. Half of the respondents experienced greater attention paid to their COPD symptoms, while 16% experienced more freedom during the course of their illness (Lilholt et al. 2015)

TeleCare North has launched by Danish Government as a model for nationwide telemedicine in Denmark

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FINAL REMARKS

• Zoomed-in on the critical phase of upscaling WT innovation, which is a notoriously difficult task that often results in failure

• Revealed how upscaling WT is not merely about enlarging a pilot project but rather about transformation, legitimacy building, and handling political dynamics to make the pilot eligible for a large-scale context

• Leadership support and professional acceptance key factors in facilitating the upscaling of telemedicine services. This case also show the importance of understanding and handling political dynamics (re-mobilizing networks, aligning interests and connecting to national strategies) in the scale-up process

• Scaling up WT innovations in health care settings is a political process and managers must master the politicized context to succeed

• Expected (economic) benefits difficult to realize

THANK YOU

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