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journal homepage: www.intl.elsevierhealth.com/journals/ijmi

New e-service development in the homecare sector: Beyond


implementing a radical technology

Anna Essén a,∗ , Moya Conrick b,1


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

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This paper explores the constituents of and challenges related to the innovation of
Received 4 September 2007 technology-based services in the long-term homecare sector.
Received in revised form Methods: This research used purposeful extreme case sampling, a mixed methods approach
22 February 2008 to research that included focus groups and interviews, to learn from the experiences of
Accepted 27 February 2008 an innovative telehomecare project. The paper uses a framework that integrates service
management; information systems innovation and medical informatics theory.
Results: The findings indicate that the claimed and the rather abstract benefits of the technol-
Keywords: ogy espoused by information technology vendors were difficult to transform into a service
Elderly homecare services concept. The organization studied is still struggling with conflicts between technological
Technology possibilities on the one hand, and the prevailing service delivery systems and user prefer-
Organizational innovation ences on the other. Decisions about the extent to which the service needs to be reengineered,
Telemedicine what non-technology resources are required, what should be the role of the consumer in
Smart home technology the new care process and identifying who is actually the primary beneficiary and user of
Aged care 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 setting [3–5]. While there is a growing body of technology-


oriented literature discussing telehomecare or smart home
Numerous international reports emphasize the need to technologies for seniors [6], less attention has been paid to
develop new models of care service delivery to deal with organizational perspectives in this context. That is, research
the escalating demands and massive increase in costs in the has focused on the technical accuracy of specific telehome-
healthcare sector [1,2]. The potential for new information and care applications rather than highlighting more general issues
communications technology (ICT) to underpin these mod- related to how organizations can develop effective ways of
els has been mooted, especially in the long-term homecare using such technologies in their everyday work [3,6].

Corresponding author. Tel.: +46 8 16 11 83; fax: +46 8 674 74 40.


E-mail address: aes@fek.su.se (A. Essén).


URLs: http://www.annaessen.blogspot.com/ (A. Essén), 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.
1386-5056/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijmedinf.2008.02.001
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This paper seeks to redress this imbalance particularly in the care of frail elderly living in their ordinary homes. Indeed,
the telehomecare area, by shifting the focus from technology there is a lack of studies that outline the issues involved in the
to the innovation of new care services. It highlights the issues organization of telehealth technologies into long-term elderly
involved in the process of integrating telehomecare technol- care practice and the wider public care service delivery [10]. We
ogy in the daily delivery of long-term elderly care services. argue that this is a question of e-service innovation and believe
The paper is organized into five sections. These present: the that the service management and information systems liter-
research background and the frameworks used; data genera- ature provide insights helpful in this context. Theories from
tion and analysis methods; empirical findings; discussion and this body of literature were drawn on to create a functional
conclusions. framework for the present study.
At the heart of new e-service development is innovation.
1.1. Background This is broadly defined as an idea, artifact, or behavior that is
new to the organization adopting it [22,23,38]. Edvardsson and
This research was undertaken in Sweden where community Olsson [24] suggested that at general level, service innovation
care providers are responsible for serving the broad group of includes the development of: (1) the service concept (consumers’
seniors who need general help with managing their everyday needs and how these are to be satisfied); (2) the service sys-
life at home, as opposed to providing hospital care to patients tem (static resources required, the organizational, physical and
who have medical needs. It was triggered by a group of man- technical environment); and (3) the service process (the chain
agers in a community care organization who envisioned that of activities that must occur for the service to function). As
information technology (IT) could enable them to use their regards to how these dimensions should be innovated studies
scarce resources more effectively. on new product/service development proposed a number of
They decided to invest in an in-home monitoring system success factors. These include engaging in internal communi-
that continuously monitors the activity level of seniors. This cation, in particular involving front-line employees [25–28] and
system is sensor-based and would not require any active input engaging in external communication with consumers, suppli-
from the senior (and computer illiterate) beneficiaries of care. ers, competitors and other stakeholders in all stages of the
The managers identified that this area of information tech- innovation process. It has been argued that this leads to more
nology may hold some of the answers to their resourcing comprehensive and varied information and thus to a higher
challenges, they had no explicit strategy concerning how to performing development process [29–34].
use it or how to develop new IT-based services on basis of it. While the service management literature provides insights
This paper is based on a case study that focused on how this about the issues involved in service innovation, it says little
new telehomecare technology was introduced in the organi- about the specificity of using a new technology that may con-
zation. It elicits the elements and challenges associated with stitute a radical innovation. However, the information systems
this process in the public elderly care context. (ISs) literature is helpful in this context. What emerges from
this literature resonates with argument in the medical infor-
1.2. Frameworks matics literature, namely that introducing new ICT systems
in an organization often entails changes in work process and
Research on the use of remote and sensor-based telemoni- the organizational structure as well as in the ICT system itself
toring to enhance long-term elderly homecare is scarce in [35,36]. Swanson and Ramiller [37] identify the issues involved
the medical informatics literature [5]. However research about in this process. In their model, an organization’s interest in
implementations of healthcare information systems (HIS) new technology is often sparked by an “organizing vision”,
more generally provides insights that are relevant to this con- which is described as the decontextualized and general advan-
text. This literature has increasingly broadened its focus from tages of a new technology and often espoused by groups such
the technical to the socio-technical dimensions of information as technology vendors, consultants and academics. The orga-
systems suggesting that the success of IT implementations nizing vision typically defines the IT system in broad strokes,
not only depend on the quality of hard- and software used which helps to legitimize it [36,37]. A ‘mindful’ organization
[7–9,39]. The literature also argues that organizational fac- is not seduced by the organizing vision but will objectively
tors are also the key to success [10–12]. Several organizational evaluate a system’s suitability for their needs. This is what
prerequisites for ‘successful’ IT implementations are iden- Swanson and Ramiller [37] refer to as comprehension. If adoption
tified by a number of authors and these include financial is entertained, a deeper consideration of the system follows.
and structural support, mobilizing ‘champions’ during imple- Here a context-adjusted supportive rationale is developed by
mentation, involving, educating and motivating users, and paying attention to issues specific to the organization. The
dealing with confidentiality, standardization and legal-related implementation phase involves a “myriad of considerations,
issues [7,10,11,13–19]. In general, the importance of embed- choices, and actions” (p. 557). The ‘mindful’ enterprise will
ding the technology in practice is underlined and this involves make adaptations during implementation in either the sys-
a mutual adjustment of both technology and care practices tem or organization to address unanticipated problems or
[7,13,16,17,20,21]. These are crucial insights that inform the realize unforeseen potential. A reliance on expertise over for-
current research. However, while claims about the impor- mal authority and a readiness to relax formal structure is
tance of introducing the technology with consideration to the important in this stage. Assimilation commences as the IT sys-
organizational context abound, there are still uncertainties as tem is absorbed into the organization’s work practices and its
regards how this can be achieved in actual work settings [10]. usefulness is demonstrated. In time, the innovation becomes
This is particularly the case as regards the use of telehealth in 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 Ramiller’s [37] ideal theoretical framework at an overall level while attempting to
model of IS innovation and Edvardsson and Olsson’s [24] inductively infer and be attentive to themes emerging from the
model of new service development, the framework in Fig. 1 empirical material. In all, the analysis process went through
was created. This depicts an “ideal” innovation process and three iterative rounds of culling the interviews, consulting
has been inspired by the service management, information the tentative framework, adjusting the analysis and refining
systems innovation and medical informatics literature. This conclusions as required by the research approach [45]. The
framework has been used in the generation and analysis of findings presented here represent broader sets of empirical
empirical data in this study. 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
2. Method ethical standards for this type of research and was approved
by the Regional Research Ethics Committee of Stockholm.
This study forms part of a larger research program on tech- It should be noted that in this paper the term The Man-
nology in elderly care. It is based on empirical data collected ager is used for the person making the corporate decisions
over several years (2003–2006) during a Smart Home Devel- and interviewed separately while the term ‘managers’ refers
opment project in a small municipal care organization in to the group of section managers in the organization.
Sweden. It uses purposeful extreme case sampling; satisfy-
ing the requirements for this method by selecting a case that
was “information rich and special in some way” [40,41]. A case 3. Results
study approach allowed the researcher to follow the service
innovation process over time and to use a variety of informa- The results of this study must be considered in light of the
tion sources [42]. municipal care organization managers’ lack of an explicit
Participants in the study included the Home-help man- strategy concerning how to develop new IT-based services and
agers and Home-helpers involved in the development project their scant knowledge about the technologies available. In this
from its inception. The primary researcher (and author) gath- environment, it is not surprising that this study found the
ered data using e-mail, phone and large numbers of formal development process used by the organization deviated from
and informal meetings (31 meetings) over a 3-year period. This the ‘ideal’ framework presented in Fig. 1. In the current climate
was followed by 10 semi-structured, face-to-face interviews this is probably not a unique circumstance.
with operational and management personnel in the organiza-
tion who had been directly involved in making the investment 3.1. Comprehension and adoption
decision and/or using the technology. Except for one section
manager, there was no turnover of personnel during the study The managers scanned the market for potential healthcare
period. The researcher used an interview schedule that con- technologies and in doing so uncovered a vast number of
tained both open and closed ended questions (see Appendix radical technologies in the market. They rejected many prod-
A). One hour long non-participant observation of employees ucts because they focused on providing new medical services
using the new technology was also performed at five occa- to certain groups of chronic patients at home, as a way of
sions. reducing hospital admissions. Few products were promoted
Data were analyzed, using a combined inductive and as providing benefits for either the senior consumers mar-
deductive approach [43,44]. The authors departed from the ket or personnel in this non-medical, long-term care context.
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The managers finally selected an activity monitoring system, most basic functions and to send alarms to the home-health
which they thought would bring benefits to the broad group aids on duty in the same manner as the traditional alarm this
of homebound seniors “in general” and independent of their new system was replacing.
medical diagnosis. Twenty-three units were purchased. These Only the home-health aids were given access to the
units replaced the pendant safety alarms that were currently information showing seniors’ longitudinal activity patterns
in use. although this non-emergency activity information could be
The system included monitoring units worn on the wrist, made available to others like. The senior’s general practi-
in similar fashion to traditional alarms. They offered sim- tioner and family. As these external parties were not involved,
ilar functionality to traditional alarms with a button that their potential needs and roles are not discussed. Ideally,
seniors press in an emergency situation. The new units also organizational issues should have been dealt with before the
included sensors that continuously monitored non-critical implementation of the system, as the reconfiguration of the
activity level, which indicated the sleep/wake rhythm of the system is a way of implementing these roles [24]. In this
seniors. These sensors detect and send automatic alarms to research knowledge of all the internal and external actors who
healthcare personnel if significant changes in activity level were to use the system was extraneous and therefore a model
are detected for example, if a person is inactive due to a fall. of usage and workflow was not mapped.
The systems could provide both non-emergency and emer-
gency information, something that the managers found very 3.2.2. Adjusting the organizational infrastructure
appealing. Because data could be continuously gathered by The managers were not engaged in developing an organiza-
remote sensing and subsequently presented in graphical form tional infrastructure supporting the use of the new monitoring
for analysis either in real time or retrospectively, they believed technology. “. . .Tasks need to be performed, but we never really
that the technology represented a radical new way of under- decided who should do what, and we never really allocated
standing the health-state and needs of their consumers. resources to this. . .” [The Manager, Interview 5, 2006].
Hence, the myriad of choices related to how to use the new
3.1.1. Translating the organizing vision into concrete technology and who should use it were delegated to opera-
benefits tional personnel. This presented this group of personnel with a
The technology was adopted after the vendor assurance that it number of challenges. For one, they did not possess the power
could enhance the organization’s capacity to ensure the safety to provide resources for the new service system: The Group
of seniors and act as a preventive measure. The Manager Leader explained: “. . .I cannot employ new personnel. . .I have
was convinced that seniors would feel safe in their homes, been able to spend time on the monitoring system by spending
knowing that they were monitored and that the information less time on other tasks. . .” [Interview 2, 2006]. It was decided
collected by the technology would enable the organization informally that the Group Leader should install the monitoring
to know their seniors and their needs better. Initially, The units in the senior households and no maintenance routines
Manager saw the potential for the information provided by were developed to cover for when this person was away.
the system to be used in developing customized care ser- There were four automatic alarms sent by the equipment
vice processes. For example, if the client had a disturbed during the study period and in all of these cases healthcare
night Home-helpers “could let this senior sleep a bit longer personnel responded in exactly the same way as for the old
in the morning and prepare the breakfast one hour later than system; that is, two Home-helpers immediately drove to the
usual. . .” [The Manager, Group meeting, 2005]. Beyond this, the senior’s residence to check on them. In none of these cases,
benefit was unclear; The Manager reported that they “found it there was a real emergency. Alarms were rather caused by
difficult to predict. . . At this stage, the implicit understanding various more subtle reasons such as seniors being unusually
was that the detailed advantage of the monitoring technology weak. The seniors were happy to be paid a visit at these occa-
would emerge along with the personnel starting to use it. . .” sions. There was no routine for examining the longitudinal
[Interview 8, 2006]. non-emergency information gathered by the system. Conse-
quently a Home-helper [Interview 3, 2006] reported, “. . .I look
3.2. Implementation now and then, when I have a free moment. . .”. The Group
Leader was the most frequent user of the data devoting a few
The managers were involved in the purchase of the new minutes to analyze them every third day.
technology. However, they were not engaged in the implemen- The Group Leader reported findings of abnormal activity
tation phase, which involved many decisions related to the patterns or seniors not wearing their alarm to the Home-
configuration of the technology as well as decisions related to helpers on duty. The system was effective in identifying these
the adjustment of the organization. anomalies but work process remained the same. That was,
during their next scheduled visit the seniors not consistently
3.2.1. Adjusting the technological infrastructure wearing their monitor were reminded to do so. Additional vis-
The system included many features that could be applied and its were not activated based on the activity information. This
customized to each individual, or they could be kept latent. was partially due to the Home-helpers being time poor and
It was possible to configure the technology so that various unable to provide “new” or extended services within their tight
alarms were triggered for example, if the senior leaves the schedules. These workers lack the authority to change or add
apartment. The decision on what software features to activate to the services they deliver. Social workers make these deci-
was delegated to the front-line employees; the home-health sions and their budget is provided by government and funds
aids and their group leader. Their decision was to use only the predefined needs with pre-determined services. Maintaining
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a “normal” activity pattern among seniors is not seen as a part it. Some began to over rely on the technology, believing that
of this. A home-health aid talked about her limited possibil- it could detect any change in their health status. For example
ities to attend to activity or sleeping disorders illustrated by one Home-helper reported that:
the activity curves:

“. . .There is not much one can do though. I may ask the “. . .Jim told me he had felt really bad before my visit. But
senior how he has been sleeping lately and may ask if he he didn’t call for help, or press the alarm button, as he
has sleeping medication etc during my scheduled visit. Of thought the technology would notice this. ‘You could see
course, there is much more that one would like to do. For this on the computer, couldn’t you’ he said. . .but of course
example activate those seniors who are too often inactive we couldn’t. . .”
during the day – this would most likely make them sleep [Interview 1, 2006].
better during night. . .but there is no time for that. . .I can
only provide services that are formally granted by the social
workers. . .” In this case, the Home-helper tried to make clear to the
[Home-helper, informal meeting, 2005] seniors the limits of the new technology—without eroding
the seniors’ faith in the new technology completely. A true
In some cases the personnel also had difficulty interpreting
challenge.
the ‘problems’ detected by the system and deciding how to
respond to them.

“. . . how long is it normal to have a ‘low activity’ level? 3.3. Assimilation


Some seniors may need a lot of rest while in other cases
low activity level can be a signal that something is wrong The general claims that inspired the managers’ adoption of
health-wise. . .a sign of depression. . . something that could the monitoring technology were not shared by the operational
get worse if we do nothing about it. . .but we don’t want to employees. They generated their own ideas about the benefits
turn the seniors into hypochondriacs. . . preventive services that could flow from using the technology. Some of these were
are not easy. . .” expected while others were unforeseen.
[Home-helper, Interview 6, 2006]. Not surprisingly, the operational employees believed that
Home-helpers were hesitant to intervene in the non-urgent the new automatic inactivity emergency alarm function could
reports. They describe not knowing how to approach the client increase their responsiveness in certain emergency situations,
without sounding as if they were “watching” them in a nega- particularly if the person was physically unable to manually
tive “big brother” sense and without alarming the senior. This call for help. This would mean shorter delays that, according
applied to activity information as well as to information about to the Group Leader, could produce qualitative and economic
those not wearing their alarms. benefits by “reducing the likelihood of permanent functional
impairments among seniors. . .” [Interview 4, 2006].
“. . .If an activity curve indicate that something is not OK, Less expected was the fact that seniors were more likely
you feel like asking the senior about this. . . But we cannot to wear their monitor, because, they realize that staff could
say to a senior that ‘We have seen on the curves that you tell if they were not, unlike with the previous untraceable
are very inactive during the days’. This might make the alarms. According to the Home-helpers, the seniors them-
seniors feel watched in a negative sense. . .how do you ask a selves appreciated this function as they are aware of their
senior about her activity level without sounding strange? It tendency to forget to wear their alarms and the reduced safety
is easy to make seniors worried. . .we found it very difficult this implies in cases of incidents such as fall accidents. This
to define a routine for this. . .” function also reassured both staff and relatives and was seen
[Group Leader, Informal meeting, 2006] as “economically important for the service because usually
the relatives apply for nursing home placements. . .” [Group
“. . .I saw that Anton never wears his alarm during the night.
Leader, Meeting, 2006]. Interviewees also reported the abil-
I told one of the girls to remind him to wear his alarm dur-
ity for early client interventions and congruent with The
ing her regular visit, but she did not really know what to say
Manager’s initial vision—to provide new customized services
to him. She didn’t want to say that we “can see” if he wears
that could lead to an improved general health status of the
it or not. However she managed to tell him in a nice way
seniors. However, not all section managers shared this vision
and now we see on the curves that he is always wearing his
considering the provision of such services economically unvi-
alarm. . .”
able. One of them remarked: “. . .we do not have capacity to
[Group Leader, Personal communication, 2006]
address all seniors’ sleeping and activity disorders. . . This is
The seniors were informed about the new service via letter beyond our commitment. . . we will suffer increased produc-
and phone. The personnel had not given much thought to fur- tion costs. . .without being reimbursed for this. . .” [Manager 2,
ther educating the seniors, fearing that “this would make the Interview 10, 2006].
seniors worried and confused” [Group Leader, Project meeting, Hence, during the study period Home-helpers responded
2005]. They implicitly assumed that the monitoring technol- immediately to emergency calls but were hesitant to intervene
ogy was ‘passive” and did not require any input from the user. in the non-urgent reports. They had ideas about how to act on
As a result, a few of the seniors described being unclear as to the non-urgency activity data but found it difficult to realize
what to expect from the new service or how they should use such ideas.
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Fig. 2 – The major issues in radical ICT services development.

developed some new informal routines (or service elements).


4. Discussion This implied incremental rather than radical change in the
existing service processes. Further, these changes were not
This research illustrates that innovating services based on new transformed into routines and assimilated.
radical technology is a complex and multidimensional under- These results need to be understood in light of how the
taking. Not all of the issues that arose were expected and project commenced. As the elderly care recipients were not
participants in this research dealt with them in a variety of involved in the first phase, their needs and possible user roles
ways. Some of the issues emerged because of lack of through were overlooked in the selection of the system. It is impor-
decision-making and planning by management and other per- tant to recognize that another technology would perhaps have
sonal. The major issues are presented in Fig. 2 in which the been selected had the seniors and their family been involved
stages are depicted in the observed rather than an ideal order. in the first place. In general, the needs of the consumer were
The project studied began with ‘comprehension’ and not central and did not guide the project studied. There was
‘adoption’ [37] as the managers took the essential first step only a diffuse managerial wish to improve the effectiveness of
when learning about the new available technologies. The care. As a result, there was a lack of direction and the target
lack of involvement of the front-line home-help employees group for whom the service was being developed was unclear.
in this phase was unfortunate and ultimately damaging to It is also important to question why considering that the
the project, as they could have provided crucial insights into monitoring technology was installed only modest service
operational specifics of the organization. The elderly clients changes were achieved in this study. This answer to this lies
and their family were similarly excluded from the decision- in the failure to reengineer the organization to accommodate
making in the comprehension and adoption phase, contrary to for the possibilities inherent in the new technology. In general,
recommendations in the literature [30,31,47,48]. Instead, the there were several conflicts between the action made possible
managers selected and adopted a new technology on the basis by the technology on the one hand, and the activity ‘allowed’
of the vendor-claimed benefits. They assumed that benefits by prevailing systems on the other. For example, the technol-
would emerge in use. ogy enabled the provision of customized services based on
The managers did not participate in the implementation real time data about the consumer. To realize this potential,
although this phase involves many crucial decisions. Indeed, front-line employee must possess the power to continuously
although the managers selected an intelligent technology, adjust the services they provide. In the care setting studied,
which included many automated functions, providing the this would require giving the Home-helpers the authority to
monitoring service required the execution of several human change their schedule and the content of the services they pro-
tasks. Someone needed to design the human service elements, vide on basis of the “latest consumer data available”. This is far
that is, they needed to formulate the complete service pro- from today’s situation in the Swedish National Health System,
cess with routines for how to use the technology and so forth. where the Home-helpers cannot make any changes in situ, but
This instead was delegated to the operational personnel, who 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 ational employees to innovate new services into their setting.
contingent on the prevailing hierarchical system of author- Home-helpers were not encouraged to be creative and explore
ity and the financial reimbursement system. There is nothing new models of care delivery partly due to a fear for harm-
a regional care manager can change in this. Hence, issues ing the consumers and possible legal consequences. In short,
related to the national health system impeded the effective there was no climate for innovation as described in the litera-
integration of the new technology in existing practice. The ture [32–34]. These factors are very likely to have affected the
presence of structures served as a barrier to radical service development process performance.
innovation in this context [10]. This study lends support to other work that has argued
Not only the presence but also the absence of systems that in practice telehealthcare systems are highly problematic
impeded a constructive development of new services in the and demand that the organization of care work is radically
setting studied. Guidelines and criteria for the use of the re-engineered [10]. Other scholars have also underlined the
monitoring system were not developed and quality assurance need for adjusting technology to existing ways of organizing
systems were not in place. Important in this context is defin- care work, and vice versa, and pointed to the practical difficul-
ing who should be made accountable if the monitoring system ties that it poses for care personnel [10,17,21,49,50,55]. In the
is deliberately misused, or leads to negative effects in unpre- project studied the need to make various design choices were
dictable ways. brought to the fore, to operational personnel as well as man-
The findings in this study illustrate that the lack of infor- agers (see Fig. 2). Much work remains to effectively make these
mation provided to consumers about their user role could decisions. Hence, the development project can be described as
threaten their safety. To manage risk effectively, accountabil- a learning process and it is difficult to categorize the project as
ity for such unintended but negative consequences must be a success or failure at this stage. In Zoë Stavri and Ash [56] par-
established; is it the responsibility of front-line employees, ticipants define successful IT implementations as those where
the managers or the technology vendor? Further, to ensure the system is accepted and remains operational. According
fairness in public service delivery it is important to define the to this modest definition, the project discussed here was not
criteria that should be used by the social workers when deter- a failure. The organization continues to work with the new
mining which seniors are eligible for the new service. Such technology and as a result valuable learning for the sector
criteria were not developed during the study period. This is has resulted. Their perseverance will see this continue in the
related to the fact that the “need” to which the new monitoring future.
service actually responds was not clear.
There were further conflicts between the technological
possibilities and the needs and preferences of the senior con- 5. Conclusion
sumers. More specifically, the workers struggled with bridging
the gap between This study explores the constituents of and issues involved
in the development of new technology-based care services in
• what the technology could monitor and the seniors’ concern the long-term elderly care setting. The framework developed
about privacy, for this project and inspired by insights from the normative
• the possibilities for preventive care and early stage response medical informatics, service management and information
to health changes and the risk of exaggerating the impor- systems literature quickly demonstrated that the project stud-
tance of such changes leading to seniors excessively ied deviated from the ideal model in several ways. This
worrying about their health and had vast implications on what new service processes could
• the actual capability of the technology and seniors inappro- be developed. Although a technology enabling quite radical
priate expectations of the technology. changes was used, only incremental changes in care work
were realized.
The development process studied began with the man- This paper identifies several reasons for such deviance and
agers making a new technical resource available to their modest result. The presence of national hierarchical deci-
personnel. This approach may have its merits as it enables sion systems and rigid financial reimbursement systems are
experiential learning and enhances the chances of the orga- important here. As is the absence of quality assurance and
nization staying open to the unforeseen potential of the accountability systems related to the use of IT in service deliv-
new resource [22]. Indeed, unexpected possibilities emerged. ery. Most importantly, the paper highlights that there is no
However, the managers in this case failed to recognize that innovation friendly climate in the public long-term elderly
selecting and implementing a radical new technology is not care setting in Sweden. What dominates the care managers’
the same as producing a radically new service innovation. agenda is rather an ambition to survive financially.
Hence, the operational employees had to bridge the gap The managers appeared to have little knowledge about
between the new technology and the new service. This is not change management and further, there was no research and
necessarily negative; involving the operational personnel in development department who had the financial resources,
the service process innovation is in line with the literature competence and authority to formulate a service concept.
[24,32–34,51–54]. Therefore no one undertook to identify latent consumer needs
However, contrary to the literature, in this study (and the or to develop a technology-based solution that satisfies these
Swedish National Health System overall) the operational per- needs. Indeed, while the community care providers may have
sonnel were not given the power necessary to enforce changes. been aware of the problems, they possessed little knowledge
In general, there were no rewards or other incentives for oper- about how technology could be used to solve them.
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In these kinds of projects, it might be expected that


Summary points
development process start with care providers learning from
What was known before the study?
technology providers and trialing existing technologies. Yet,
it is important to recognize that this leads to a technology-
• The interest in Telehomecare and Smart Home
oriented rather than user-needs driven approach. In order
technology is increasing as Governments world-
for truly innovative and effective IT-based care services to
wide plan for the future healthcare needs of the
develop, operational employees and clients need a much
elderly.
more salient role in development projects. Further, opera-
• New telehomecare technology in terms of hardware
tional employees need to be empowered. This in turn requires
and software is continuously emerging and gaining
political decisions about changes in the National Health Ser-
attention as “promising”.
vice delivery structure and new kinds of competences.
• Studies have focused on demonstrating the technical
feasibility of specific applications rather than high-
5.1. Study limitations and research suggestions lighting the role of telehomecare in care organizations
that is, the total picture is missing.
This study illustrates the innovation process observed in one • The medical informatics literature underlines the
case with a particular technology used in the particular set- importance of integrating technology into the organi-
ting and so the findings reported here cannot be generalized. zation but offers little guidance as regards how elderly
The organization studied faced challenges related to the public care providers can exploit technological advance-
reimbursement system, and the centralized decision hierar- ments to provide new care services.
chy characterizing the Swedish public care system. Private
firms obviously operate under completely different condi- What has the study added to the body of knowledge?
tions. The development of preventive care services added to
the challenges in the situation studied here. As did the use of • As Telehomecare applications can be used in sev-
a radical technology in the community care setting, which is eral different ways, understanding the technological
far from computerized. possibilities inherent in a telehomecare application
While this study does not offer definitive answers related and installing new hardware and software are only
to the innovation of technology-based services, it does provide the first steps in the process of new care service
insights, an in-depth account of the organizations struggles to innovation.
implement a high technology solution into a low technology • Service innovation involves developing a sustainable
setting and this experience may no doubt resonate with expe- service concept, service process and service system.
riences in other settings. Most importantly though it reports Generally, if telehomecare technology complement
the learning and knowledge gained during this challenging rather than supplement existing services, short-term
process. The lessons learned here will be valuable for other production costs will rise. Public care providers may
care providers if they are to avoid the pitfalls experienced by not be reimbursed for such increases in production
the actors in this study. It will also improve the chances for the cost.
successful deployment of innovative information technology • Hierarchical management structure where front-line
into new models of service delivery. employees do not possess the authority to make
This study may further inspire others to investigate the rel- changes in the service content impedes the effective
evance of the model presented as Fig. 2 in contexts other than use of real-time patient data generated by many mon-
the public care setting studied in this paper. This is needed in itoring technologies.
order to advance and further validate the model to prove its • Defining the “user-role” related to the care consumer
suitability to underpin the use of technology into the home- is necessary even in passive technologies, for example
care sector. This is fundamental to successful ‘Smart Home’ sensor-based monitoring technologies still assumes
innovations and deployments wherever they take place. With- certain consumer behavior that needs to be clarified.
out a workable model it seems that these innovations will • Personnel play an important role in using the technol-
fail. ogy in ways that do not intrude on consumers’ privacy.
What emerge from this study are several other questions
that need to be answered by further research.

From the organizational perspective: • How can consumers be involved in the development of
• How can public healthcare organizations become more new technology-based services?
innovation oriented? • How can the role of consumer in service settings, where
• What does an innovation-friendly climate imply in the passive technologies with completely automated func-
public care setting? tions are used, be mapped?
And concerning the preferences and possible role of con-
sumers: Finally, it is crucial that further research examines the “thorny
• Is there necessarily a trade-off between the consumers’ issues” related to the use of technology in long-term elderly
perceived privacy and safety when developing new care care in order to understand the promises and perils of these
services on basis of new digital consumer data? new technologies.
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