New E-Service Development in the Home Care Sector: Beyond Implementing a Radical Technology

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i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 7 ( 2 0 0 8 ) 679688

j o u r n a l h o m e p a g e : w w w . i n t l . e l s e v i e r h e a l t h . c o m / j o u r n a l s / i j m i

New e-service development in the homecare sector: Beyond

implementing a radical technology

Anna Essen a,, Moya Conrick b,1

a School of Business, University of Stockholm, Stockholm, Swedenb School of Nursing, Griffith University, Nathan, Brisbane 4111, Australia

a r t i c l e i n f o

Article history:

Received 4 September 2007

Received in revised form

22 February 2008

Accepted 27 February 2008

Keywords:

Elderly homecare services

Technology

Organizational innovation

Telemedicine

Smart home technology

Aged care

a b s t r a c t

Purpose: This paper explores the constituents of and challenges related to the innovation of

technology-based services in the long-term homecare sector.

Methods: This research used purposeful extreme case sampling, a mixed methods approach

to research that included focus groups and interviews, to learn from the experiences of

an innovative telehomecare project. The paper uses a framework that integrates service

management; information systems innovation and medical informatics theory.

Results: Thefindingsindicatethatthe claimed andthe ratherabstractbenefitsof thetechnol-

ogy espoused by information technology vendors were difficult to transform into a service

concept. The organization studied is still struggling with conflicts between technological

possibilities on the one hand, and the prevailing service delivery systems and user prefer-

ences on theother. Decisionsabout theextent to whichthe service needs to be reengineered,

what non-technology resources are required, what should be the role of the consumer in

the new care process and identifying who is actually the primary beneficiary and user of

the new service remain.

Conclusions:A comprehensive development model and mindfulness is necessary for radical

service innovation in the long-term homecare sector. Creating new services that exploit

the capability of radical technical innovations requires organizational development and the

use of many non-technology innovations and resources. To understand what combinations

of technological and non-technological resources can provide sustainable benefit, all key

internal and external stakeholders must be involved from the beginning of the project.

2008 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Numerous international reports emphasize the need to

develop new models of care service delivery to deal with

the escalating demands and massive increase in costs in the

healthcare sector [1,2]. The potential for new information and

communications technology (ICT) to underpin these mod-

els has been mooted, especially in the long-term homecare

Corresponding author. Tel.: +46 8 16 11 83; fax: +46 8 674 74 40.E-mail address: [email protected] (A. Essen).

URLs: http://www.annaessen.blogspot.com/ (A. Essen), http://members.optusnet.com.au/conrick/index.html (M. Conrick).1 Moya Conrick passed away in January 2008. She was a very special person and an excellent co-author. This paper is dedicated to her.

setting [35]. While there is a growing body of technology-

oriented literature discussing telehomecare or smart home

technologies for seniors [6], less attention has been paid to

organizational perspectives in this context. That is, research

has focused on the technical accuracy of specific telehome-

care applications rather than highlighting more general issues

related to how organizations can develop effective ways of

using such technologies in their everyday work [3,6].

1386-5056/$ see front matter 2008 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijmedinf.2008.02.001


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680 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 7 ( 2 0 0 8 ) 6 7 9 6 8 8

This paper seeks to redress this imbalance particularly in

the telehomecare area, by shifting the focus from technology

to the innovation of new care services. It highlights the issues

involved in the process of integrating telehomecare technol-

ogy in the daily delivery of long-term elderly care services.

The paper is organized into five sections. These present: theresearch background and the frameworks used; data genera-

tion and analysis methods; empirical findings; discussion and

conclusions.

1.1. Background

This research was undertaken in Sweden where community

care providers are responsible for serving the broad group of

seniors who need general help with managing their everyday

life at home, as opposed to providing hospital care to patients

who have medical needs. It was triggered by a group of man-

agers in a community care organization who envisioned that

information technology (IT) could enable them to use theirscarce resources more effectively.

They decided to invest in an in-home monitoring system

that continuously monitors the activity level of seniors. This

system is sensor-based and would not require any active input

from the senior (and computer illiterate) beneficiaries of care.

The managers identified that this area of information tech-

nology may hold some of the answers to their resourcing

challenges, they had no explicit strategy concerning how to

use it or how to develop new IT-based services on basis of it.

This paper is based on a case study that focused on how this

new telehomecare technology was introduced in the organi-

zation. It elicits the elements and challenges associated with

this process in the public elderly care context.

1.2. Frameworks

Research on the use of remote and sensor-based telemoni-

toring to enhance long-term elderly homecare is scarce in

the medical informatics literature [5]. However research about

implementations of healthcare information systems (HIS)

more generally provides insights that are relevant to this con-

text. This literature has increasingly broadened its focus from

the technical to the socio-technical dimensions of information

systems suggesting that the success of IT implementations

not only depend on the quality of hard- and software used

[79,39]. The literature also argues that organizational fac-tors are also the key to success [1012]. Several organizational

prerequisites for successful IT implementations are iden-

tified by a number of authors and these include financial

and structural support, mobilizing champions during imple-

mentation, involving, educating and motivating users, and

dealing with confidentiality, standardization and legal-related

issues [7,10,11,1319]. In general, the importance of embed-

ding thetechnology in practice is underlined andthis involves

a mutual adjustment of both technology and care practices

[7,13,16,17,20,21]. These are crucial insights that inform the

current research. However, while claims about the impor-

tance of introducing the technology with consideration to the

organizational context abound, there are still uncertainties as

regards how this can be achieved in actual work settings [10].

This is particularly the case as regards the use of telehealth in

the care of frail elderly living in their ordinary homes. Indeed,

there is a lack of studies that outline the issues involvedin the

organization of telehealth technologies into long-term elderly

carepractice and the wider public careservicedelivery [10]. We

argue thatthis is a questionof e-service innovation and believe

that the service management and information systems liter-ature provide insights helpful in this context. Theories from

this body of literature were drawn on to create a functional

framework for the present study.

At the heart of new e-service development is innovation.

This is broadly defined as an idea, artifact, or behavior that is

new to the organization adopting it [22,23,38]. Edvardsson and

Olsson [24] suggested that at general level, service innovation

includes the development of: (1) the service concept (consumers

needs and how these are to be satisfied); (2) the service sys-

tem (static resources required, the organizational, physical and

technical environment); and (3) the service process (the chain

of activities that must occur for the service to function). As

regards to how these dimensions should be innovated studieson new product/service development proposed a number of

success factors. These include engaging in internal communi-

cation, in particular involving front-line employees [2528] and

engaging in external communication with consumers, suppli-

ers, competitors and other stakeholders in all stages of the

innovation process. It has been argued that this leads to more

comprehensive and varied information and thus to a higher

performing development process [2934].

While the service management literature provides insights

about the issues involved in service innovation, it says little

about the specificity of using a new technology that may con-

stitute a radical innovation. However,the information systems

(ISs) literature is helpful in this context. What emerges fromthis literature resonates with argument in the medical infor-

matics literature, namely that introducing new ICT systems

in an organization often entails changes in work process and

the organizational structure as well as in the ICT system itself

[35,36]. Swanson andRamiller [37] identify the issues involved

in this process. In their model, an organizations interest in

new technology is often sparked by an organizing vision,

which is describedas the decontextualizedand general advan-

tages of a new technology and often espoused by groups such

as technology vendors, consultants and academics. The orga-

nizing vision typically defines the IT system in broad strokes,

which helps to legitimize it [36,37]. A mindful organization

is not seduced by the organizing vision but will objectivelyevaluate a systems suitability for their needs. This is what

Swanson and Ramiller [37] refer to as comprehension. Ifadoption

is entertained, a deeper consideration of the system follows.

Here a context-adjusted supportive rationale is developed by

paying attention to issues specific to the organization. The

implementation phase involves a myriad of considerations,

choices, and actions (p. 557). The mindful enterprise will

make adaptations during implementation in either the sys-

tem or organization to address unanticipated problems or

realize unforeseen potential. A reliance on expertise over for-

mal authority and a readiness to relax formal structure is

important in this stage. Assimilation commences as the IT sys-

tem is absorbed into the organizations work practices and its

usefulness is demonstrated. In time, the innovation becomes

infused and routine [37].


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Fig. 1 An ideal framing of the process of innovating technology-based services.

Combining insights from Swanson and Ramillers [37] ideal

model of IS innovation and Edvardsson and Olssons [24]

model of new service development, the framework in Fig. 1

was created. This depicts an ideal innovation process and

has been inspired by the service management, information

systems innovation and medical informatics literature. This

framework has been used in the generation and analysis of

empirical data in this study.

2. Method

This study forms part of a larger research program on tech-

nology in elderly care. It is based on empirical data collected

over several years (20032006) during a Smart Home Devel-

opment project in a small municipal care organization in

Sweden. It uses purposeful extreme case sampling; satisfy-

ing the requirements for this method by selecting a case that

was information rich andspecial in some way [40,41].Acase

study approach allowed the researcher to follow the service

innovation process over time and to use a variety of informa-

tion sources [42].

Participants in the study included the Home-help man-

agers and Home-helpers involved in the development projectfrom its inception. The primary researcher (and author) gath-

ered data using e-mail, phone and large numbers of formal

andinformal meetings (31meetings) over a 3-yearperiod. This

was followed by 10 semi-structured, face-to-face interviews

with operational and management personnel in the organiza-

tion who hadbeen directly involved in making theinvestment

decision and/or using the technology. Except for one section

manager, there wasno turnover of personnel during the study

period. The researcher used an interview schedule that con-

tained both open and closed ended questions (see Appendix

A). One hour long non-participant observation of employees

using the new technology was also performed at five occa-

sions.

Data were analyzed, using a combined inductive and

deductive approach [43,44]. The authors departed from the

theoretical framework at an overall level while attempting to

inductively infer andbe attentive to themes emerging fromthe

empirical material. In all, the analysis process went through

three iterative rounds of culling the interviews, consulting

the tentative framework, adjusting the analysis and refining

conclusions as required by the research approach [45]. The

findings presented here represent broader sets of empirical

data; the quotes chosen are typical for the interviews and

observation. The names of respondents are excluded for pur-

poses of confidentiality and the study fully complied with

ethical standards for this type of research and was approvedby the Regional Research Ethics Committee of Stockholm.

It should be noted that in this paper the term The Man-

ager is used for the person making the corporate decisions

and interviewed separately while the term managers refers

to the group of section managers in the organization.

3. Results

The results of this study must be considered in light of the

municipal care organization managers lack of an explicit

strategy concerning how to develop newIT-based services and

their scant knowledgeabout the technologies available. In thisenvironment, it is not surprising that this study found the

development process used by the organization deviated from

the ideal framework presented in Fig. 1. In thecurrentclimate

this is probably not a unique circumstance.

3.1. Comprehension and adoption

The managers scanned the market for potential healthcare

technologies and in doing so uncovered a vast number of

radical technologies in the market. They rejected many prod-

ucts because they focused on providing new medical services

to certain groups of chronic patients at home, as a way of

reducing hospital admissions. Few products were promoted

as providing benefits for either the senior consumers mar-

ket or personnel in this non-medical, long-term care context.


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The managers finally selected an activity monitoring system,

which they thought would bring benefits to the broad group

of homebound seniors in general and independent of their

medical diagnosis. Twenty-three units were purchased. These

units replaced the pendant safety alarms that were currently

in use.The system included monitoring units worn on the wrist,

in similar fashion to traditional alarms. They offered sim-

ilar functionality to traditional alarms with a button that

seniors press in an emergency situation. The new units also

included sensors that continuously monitored non-critical

activity level, which indicated the sleep/wake rhythm of the

seniors. These sensors detect and send automatic alarms to

healthcare personnel if significant changes in activity level

are detected for example, if a person is inactive due to a fall.

The systems could provide both non-emergency and emer-

gency information, something that the managers found very

appealing. Because data could be continuously gathered by

remote sensing and subsequently presented in graphical formfor analysis either in real time or retrospectively, they believed

that the technology represented a radical new way of under-

standing the health-state and needs of their consumers.

3.1.1. Translating the organizing vision into concrete

benefits

Thetechnologywas adopted after thevendor assurance that it

could enhance the organizations capacity to ensure the safety

of seniors and act as a preventive measure. The Manager

was convinced that seniors would feel safe in their homes,

knowing that they were monitored and that the information

collected by the technology would enable the organization

to know their seniors and their needs better. Initially, TheManager saw the potential for the information provided by

the system to be used in developing customized care ser-

vice processes. For example, if the client had a disturbed

night Home-helpers could let this senior sleep a bit longer

in the morning and prepare the breakfast one hour later than

usual. . . [The Manager, Group meeting, 2005]. Beyond this, the

benefit was unclear; The Manager reported that they found it

difficult to predict. . . At this stage, the implicit understanding

was that the detailed advantage of the monitoring technology

would emerge along with the personnel starting to use it. . .

[Interview 8, 2006].

3.2. Implementation

The managers were involved in the purchase of the new

technology. However, they werenot engaged in the implemen-

tation phase, which involved many decisions related to the

configuration of the technology as well as decisions related to

the adjustment of the organization.

3.2.1. Adjusting the technological infrastructure

The system included many features that could be applied and

customized to each individual, or they could be kept latent.

It was possible to configure the technology so that various

alarms were triggered for example, if the senior leaves the

apartment. The decision on what software features to activate

was delegated to the front-line employees; the home-health

aids and their group leader. Their decision was to use only the

most basic functions and to send alarms to the home-health

aids on duty in the same manner as the traditional alarm this

new system was replacing.

Only the home-health aids were given access to the

information showing seniors longitudinal activity patterns

although this non-emergency activity information could bemade available to others like. The seniors general practi-

tioner and family. As these external parties were not involved,

their potential needs and roles are not discussed. Ideally,

organizational issues should have been dealt with before the

implementation of the system, as the reconfiguration of the

system is a way of implementing these roles [24]. In this

researchknowledge of allthe internal andexternal actorswho

were to use the system was extraneous and therefore a model

of usage and workflow was not mapped.

3.2.2. Adjusting the organizational infrastructure

The managers were not engaged in developing an organiza-

tional infrastructure supporting the use of the newmonitoringtechnology. . . .Tasks need to be performed, butwe neverreally

decided who should do what, and we never really allocated

resources to this. . . [The Manager, Interview 5, 2006].

Hence, the myriad of choices related to how to use the new

technology and who should use it were delegated to opera-

tional personnel. Thispresentedthis group of personnel witha

number of challenges. For one, they did not possess the power

to provide resources for the new service system: The Group

Leader explained: . . .I cannot employ new personnel. . .I have

been able to spend time on themonitoringsystem byspending

less time on other tasks. . . [Interview 2, 2006]. It was decided

informally thatthe Group Leader should install themonitoring

units in the senior households and no maintenance routineswere developed to cover for when this person was away.

There were four automatic alarms sent by the equipment

during the study period and in all of these cases healthcare

personnel responded in exactly the same way as for the old

system; that is, two Home-helpers immediately drove to the

seniors residence to check on them. In none of these cases,

there was a real emergency. Alarms were rather caused by

various more subtle reasons such as seniors being unusually

weak. The seniors were happy to be paid a visit at these occa-

sions. There was no routine for examining the longitudinal

non-emergency information gathered by the system. Conse-

quently a Home-helper [Interview 3, 2006] reported, . . .I look

now and then, when I have a free moment. . .

. The GroupLeader was the most frequent user of the data devoting a few

minutes to analyze them every third day.

The Group Leader reported findings of abnormal activity

patterns or seniors not wearing their alarm to the Home-

helpers on duty. The system was effective in identifying these

anomalies but work process remained the same. That was,

during their next scheduled visit the seniors not consistently

wearing their monitor were reminded to do so. Additional vis-

its were not activated based on the activity information. This

was partially due to the Home-helpers being time poor and

unable to providenew or extended serviceswithin theirtight

schedules. These workers lack the authority to change or add

to the services they deliver. Social workers make these deci-

sions and their budget is provided by government and funds

predefined needs with pre-determined services. Maintaining


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a normal activity pattern among seniors is notseen as a part

of this. A home-health aid talked about her limited possibil-

ities to attend to activity or sleeping disorders illustrated by

the activity curves:

. . .

There is not much one can do though. I may ask thesenior how he has been sleeping lately and may ask if he

has sleeping medication etc during my scheduled visit. Of

course, there is much more that one would like to do. For

example activate those seniors who are too often inactive

during the day this would most likely make them sleep

better during night. . .but there is no time for that. . .I can

onlyprovide services thatare formally granted by the social

workers. . .

[Home-helper, informal meeting, 2005]

In some cases the personnelalso had difficulty interpreting

the problems detected by the system and deciding how to

respond to them.

. . . how long is it normal to have a low activity level?

Some seniors may need a lot of rest while in other cases

low activity level can be a signal that something is wrong

health-wise. . .a sign of depression. . . something that could

get worse if we do nothing about it. . .but we dont want to

turnthe seniors intohypochondriacs. . . preventive services

are not easy. . .

[Home-helper, Interview 6, 2006].

Home-helpers werehesitant to intervene in the non-urgent

reports. They describe notknowinghow to approachthe client

without sounding as if they were watching them in a nega-

tive big brother sense and without alarming the senior. This

applied to activity information as well as to information about

those not wearing their alarms.

. . .If an activity curve indicate that something is not OK,

you feel like asking the senior about this. . . But we cannot

say to a senior that We have seen on the curves that you

are very inactive during the days. This might make the

seniors feel watchedin a negative sense. . .howdoyouaska

senior about her activity level without sounding strange? It

is easy to make seniors worried. . .we found it very difficult

to define a routine for this. . .

[Group Leader, Informal meeting, 2006]

. . .

I saw that Anton neverwears hisalarmduring thenight.I told one of the girls to remind him to wear his alarm dur-

ingher regular visit, butshe didnot really know what to say

to him. She didnt want to say that we can see if he wears

it or not. However she managed to tell him in a nice way

and now wesee on the curves that he is always wearing his

alarm. . .

[Group Leader, Personal communication, 2006]

The seniors were informed about the new service via letter

and phone. The personnel had not given much thought to fur-

ther educating the seniors, fearing that this would make the

seniors worried and confused [Group Leader, Project meeting,

2005]. They implicitly assumed that the monitoring technol-

ogy was passive and did not require any input from the user.

As a result, a few of the seniors described being unclear as to

what to expect from the new service or how they should use

it. Some began to over rely on the technology, believing that

it could detect any change in their health status. For example

one Home-helper reported that:

. . .

Jim told me he had felt really bad before my visit. Buthe didnt call for help, or press the alarm button, as he

thought the technology would notice this. You could see

this on the computer, couldnt you he said. . .but of course

we couldnt. . .

[Interview 1, 2006].

In this case, the Home-helper tried to make clear to the

seniors the limits of the new technologywithout eroding

the seniors faith in the new technology completely. A true

challenge.

3.3. Assimilation

The general claims that inspired the managers adoption of

themonitoring technology were not shared by the operational

employees. They generated their own ideas about the benefits

that could flow from using the technology. Some of these were

expected while others were unforeseen.

Not surprisingly, the operational employees believed that

the new automatic inactivity emergency alarm function could

increasetheir responsiveness in certain emergency situations,

particularly if the person was physically unable to manually

call for help. This would mean shorter delays that, according

to the Group Leader, could produce qualitative and economicbenefits by reducing the likelihood of permanent functional

impairments among seniors. . . [Interview 4, 2006].

Less expected was the fact that seniors were more likely

to wear their monitor, because, they realize that staff could

tell if they were not, unlike with the previous untraceable

alarms. According to the Home-helpers, the seniors them-

selves appreciated this function as they are aware of their

tendency to forget to wear their alarmsand thereducedsafety

this implies in cases of incidents such as fall accidents. This

function also reassured both staff and relatives and was seen

as economically important for the service because usually

the relatives apply for nursing home placements. . . [Group

Leader, Meeting, 2006]. Interviewees also reported the abil-ity for early client interventions and congruent with The

Managers initial visionto provide new customized services

that could lead to an improved general health status of the

seniors. However, not all section managers shared this vision

considering the provision of such services economically unvi-

able. One of them remarked: . . .we do not have capacity to

address all seniors sleeping and activity disorders. . . This is

beyond our commitment. . . we will suffer increased produc-

tion costs. . .without being reimbursed for this. . . [Manager 2,

Interview 10, 2006].

Hence, during the study period Home-helpers responded

immediately to emergency callsbut were hesitantto intervene

in the non-urgent reports. They had ideas about how to act on

the non-urgency activity data but found it difficult to realize

such ideas.


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Fig. 2 The major issues in radical ICT services development.

4. Discussion

Thisresearch illustrates thatinnovatingservicesbased on new

radical technology is a complex and multidimensional under-taking. Not all of the issues that arose were expected and

participants in this research dealt with them in a variety of

ways. Some of the issues emerged because of lack of through

decision-making and planning by management and otherper-

sonal. The major issues are presented in Fig. 2 in which the

stages are depicted in the observed rather than an ideal order.

The project studied began with comprehension and

adoption [37] as the managers took the essential first step

when learning about the new available technologies. The

lack of involvement of the front-line home-help employees

in this phase was unfortunate and ultimately damaging to

the project, as they could have provided crucial insights into

operational specifics of the organization. The elderly clientsand their family were similarly excluded from the decision-

making in the comprehension and adoption phase, contrary to

recommendations in the literature [30,31,47,48]. Instead, the

managers selected andadopteda new technology on thebasis

of the vendor-claimed benefits. They assumed that benefits

would emerge in use.

The managers did not participate in the implementation

although this phase involves many crucial decisions. Indeed,

although the managers selected an intelligent technology,

which included many automated functions, providing the

monitoring service required the execution of several human

tasks. Someone needed to design the human service elements,

that is, they needed to formulate the complete service pro-cess with routines for how to use the technology and so forth.

This instead was delegated to the operational personnel, who

developed some new informal routines (or service elements).

This implied incremental rather than radical change in the

existing service processes. Further, these changes were not

transformed into routines and assimilated.

These results need to be understood in light of how theproject commenced. As the elderly care recipients were not

involved in the first phase, their needs and possible user roles

were overlooked in the selection of the system. It is impor-

tant to recognize that another technology would perhaps have

been selected had the seniors and their family been involved

in the first place. In general, the needs of the consumer were

not central and did not guide the project studied. There was

only a diffuse managerial wish to improve the effectiveness of

care. As a result, there was a lack of direction and the target

group for whom the service was being developed was unclear.

It is also important to question why considering that the

monitoring technology was installed only modest service

changes were achieved in this study. This answer to this liesin the failure to reengineer the organization to accommodate

for the possibilities inherent in the newtechnology. In general,

there were several conflicts between the action made possible

by the technology on the one hand, and the activity allowed

by prevailing systems on the other. For example, the technol-

ogy enabled the provision of customized services based on

real time data about the consumer. To realize this potential,

front-line employee must possess the power to continuously

adjust the services they provide. In the care setting studied,

this would require giving the Home-helpers the authority to

change theirschedule and the content of the servicesthey pro-

vide on basis of thelatest consumerdataavailable. This is far

from todays situation in the Swedish National Health System,where the Home-helperscannot make anychangesin situ, but

have to defer to the social workers decisions about what ser-


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vices are to be provided to what seniors. These conditions are

contingent on the prevailing hierarchical system of author-

ity and the financial reimbursement system. There is nothing

a regional care manager can change in this. Hence, issues

related to the national health system impeded the effective

integration of the new technology in existing practice. Thepresence of structures served as a barrier to radical service

innovation in this context [10].

Not only the presence but also the absence of systems

impeded a constructive development of new services in the

setting studied. Guidelines and criteria for the use of the

monitoring system were not developed and quality assurance

systems were not in place. Important in this context is defin-

ingwho should be made accountableif themonitoring system

is deliberately misused, or leads to negative effects in unpre-

dictable ways.

The findings in this study illustrate that the lack of infor-

mation provided to consumers about their user role could

threaten their safety. To manage risk effectively, accountabil-ity for such unintended but negative consequences must be

established; is it the responsibility of front-line employees,

the managers or the technology vendor? Further, to ensure

fairness in public service delivery it is important to define the

criteria that should be used by the social workers when deter-

mining which seniors are eligible for the new service. Such

criteria were not developed during the study period. This is

related to the fact that theneedto whichthe new monitoring

service actually responds was not clear.

There were further conflicts between the technological

possibilities and the needs and preferences of the senior con-

sumers. More specifically, the workers struggled with bridging

the gap between

whatthe technology could monitor andthe seniorsconcern

about privacy,

the possibilities for preventive careand earlystage response

to health changes and the risk of exaggerating the impor-

tance of such changes leading to seniors excessively

worrying about their health and

the actual capability of the technology and seniors inappro-

priate expectations of the technology.

The development process studied began with the man-

agers making a new technical resource available to their

personnel. This approach may have its merits as it enablesexperiential learning and enhances the chances of the orga-

nization staying open to the unforeseen potential of the

new resource [22]. Indeed, unexpected possibilities emerged.

However, the managers in this case failed to recognize that

selecting and implementing a radical new technology is not

the same as producing a radically new service innovation.

Hence, the operational employees had to bridge the gap

between the new technology and the new service. This is not

necessarily negative; involving the operational personnel in

the service process innovation is in line with the literature

[24,3234,5154].

However, contrary to the literature, in this study (and the

Swedish National Health System overall) the operational per-

sonnel were not given the power necessary to enforcechanges.

In general, there were no rewards or other incentives for oper-

ational employees to innovate new services into their setting.

Home-helpers were not encouraged to be creative and explore

new models of care delivery partly due to a fear for harm-

ing the consumers and possible legal consequences. In short,

there was no climate for innovation as described in the litera-

ture [3234]. These factors are very likely to have affected thedevelopment process performance.

This study lends support to other work that has argued

that in practice telehealthcare systems are highly problematic

and demand that the organization of care work is radically

re-engineered [10]. Other scholars have also underlined the

need for adjusting technology to existing ways of organizing

care work, andvice versa, andpointed to the practical difficul-

ties that it poses for care personnel [10,17,21,49,50,55]. In the

project studied the need to make various design choices were

brought to the fore, to operational personnel as well as man-

agers(see Fig. 2). Much work remains to effectivelymake these

decisions. Hence, the development project can be describedas

a learning process andit is difficult to categorize the project asa success or failure atthisstage. InZoe Stavri and Ash [56] par-

ticipantsdefine successful IT implementations as those where

the system is accepted and remains operational. According

to this modest definition, the project discussed here was not

a failure. The organization continues to work with the new

technology and as a result valuable learning for the sector

has resulted. Their perseverance will see this continue in the

future.

5. Conclusion

This study explores the constituents of and issues involvedin the development of new technology-based care services in

the long-term elderly care setting. The framework developed

for this project and inspired by insights from the normative

medical informatics, service management and information

systems literature quickly demonstratedthat the project stud-

ied deviated from the ideal model in several ways. This

had vast implications on what new service processes could

be developed. Although a technology enabling quite radical

changes was used, only incremental changes in care work

were realized.

This paper identifies several reasons for such deviance and

modest result. The presence of national hierarchical deci-

sion systems and rigid financial reimbursement systems areimportant here. As is the absence of quality assurance and

accountability systems related to theuse of IT in service deliv-

ery. Most importantly, the paper highlights that there is no

innovation friendly climate in the public long-term elderly

care setting in Sweden. What dominates the care managers

agenda is rather an ambition to survive financially.

The managers appeared to have little knowledge about

change management and further, there was no research and

development department who had the financial resources,

competence and authority to formulate a service concept.

Therefore no one undertookto identify latent consumerneeds

or to develop a technology-based solution that satisfies these

needs. Indeed, while the community care providers may have

been aware of the problems, they possessed little knowledge

about how technology could be used to solve them.


9/11



In these kinds of projects, it might be expected that

development process start with care providers learning from

technology providers and trialing existing technologies. Yet,

it is important to recognize that this leads to a technology-

oriented rather than user-needs driven approach. In order

for truly innovative and effective IT-based care services todevelop, operational employees and clients need a much

more salient role in development projects. Further, opera-

tional employees need to be empowered. This in turn requires

political decisions about changes in the National Health Ser-

vice delivery structure and new kinds of competences.

5.1. Study limitations and research suggestions

This study illustrates the innovation process observed in one

case with a particular technology used in the particular set-

ting and so the findings reported here cannot be generalized.

Theorganizationstudiedfaced challenges related to thepublic

reimbursement system, and the centralized decision hierar-

chy characterizing the Swedish public care system. Private

firms obviously operate under completely different condi-

tions. The development of preventive care services added to

the challenges in the situation studied here. As did the use of

a radical technology in the community care setting, which is

far from computerized.

While this study does not offer definitive answers related

to the innovation of technology-based services, it doesprovide

insights, an in-depth account of the organizations struggles to

implement a high technology solution into a low technology

setting and this experience may no doubt resonate with expe-

riences in other settings. Most importantly though it reports

the learning and knowledge gained during this challenging

process. The lessons learned here will be valuable for other

care providers if they are to avoid the pitfalls experienced by

theactors in this study. It will also improve thechancesfor the

successful deployment of innovative information technology

into new models of service delivery.

This study may further inspire othersto investigatethe rel-

evance of the model presented as Fig. 2 in contexts other than

the public care setting studied in this paper. This is needed in

order to advance and further validate the model to prove its

suitability to underpin the use of technology into the home-

care sector. This is fundamental to successful Smart Home

innovations and deployments wherever they take place. With-

out a workable model it seems that these innovations will

fail.

What emerge from this study are several other questions

that need to be answered by further research.

From the organizational perspective:

How can public healthcare organizations become more

innovation oriented?

What does an innovation-friendly climate imply in the

public care setting?

And concerning the preferences and possible role of con-

sumers:

Is there necessarily a trade-off between the consumersperceived privacy and safety when developing new care

services on basis of new digital consumer data?

Summary points

What was known before the study?

The interest in Telehomecare and Smart Home

technology is increasing as Governments world-wide plan for the future healthcare needs of the

elderly.

New telehomecare technology in terms of hardware

and software is continuously emerging and gaining

attention as promising.

Studies have focused on demonstrating the technical

feasibility of specific applications rather than high-

lighting the role of telehomecare in care organizations

that is, the total picture is missing.

The medical informatics literature underlines the

importance of integrating technology into the organi-

zation but offers little guidance as regards how elderly

care providers can exploit technological advance-ments to provide new care services.

What has the study added to the body of knowledge?

As Telehomecare applications can be used in sev-

eral different ways, understanding the technological

possibilities inherent in a telehomecare application

and installing new hardware and software are only

the first steps in the process of new care service

innovation.

Service innovation involves developing a sustainable

service concept, service process and service system.

Generally, if telehomecare technology complementrather than supplement existing services, short-term

production costs will rise. Public care providers may

not be reimbursed for such increases in production

cost.

Hierarchical management structure where front-line

employees do not possess the authority to make

changes in the service content impedes the effective

use of real-time patient data generated by many mon-

itoring technologies.

Defining the user-role related to the care consumer

is necessary even in passive technologies, for example

sensor-based monitoring technologies still assumes

certain consumer behavior that needs to be clarified. Personnel play an important role in using the technol-

ogy in ways that do not intrude on consumers privacy.

How can consumers be involved in the development of

new technology-based services?

How can the role of consumer in service settings, where

passive technologies with completely automated func-

tions are used, be mapped?

Finally, it is crucial that further research examines the thorny

issues related to the use of technology in long-term elderlycare in order to understand the promises and perils of these

new technologies.


10/11



Acknowledgements

This work was partly supported by a grant from the Swedish

Kinnander foundation. The authors are further grateful for

constructive advice made by the editor and three anonymousreviewers at the International Journal of Medical Informatics

Journal.

A.E. initiated and designed the study, formulated the theo-

retical framework and collected the data in Sweden. A.E. and

M.C. were involved in the data analysis phase, as well as in the

drafting and revision of the paper.

Appendix A. Interview guide

To managers:

How did you decide to invest in this particular technology?Who did you engage in the decision phase?

Why?

What was problematic in this first stage?

What wasyourintention at this stage?Vision?(whatbenefits

did you foresee at this stage)

How did the project proceed?

Has your vision been realized?

What have you learned?

If it would be up to you to decide, would you recommend a

continued use of the technology?

Why?

How would you explain the results at this stage?

To Home-helpers:

What do you think of the new technology?

How many times per week have you used it, and for how

long?

How have you used it?

Why have you used it in this way?

Has it been difficult?

Did you use all functions/features possible in the applica-

tion?

Why did you not use certain features?

If it would be up to you to decide, would you recommend a

continued use of the technology?Why?

What benefits can the technology produce from your view-

point?

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Documents

New E-Service Development in the Home Care Sector: Beyond Implementing a Radical Technology