Key factors influencing the implementation success of a home telecare application.

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jo u r n al h o m e p a g e :w w w . i j m i j o u r n a l . c o m

Key

factors

inﬂuencing

the

implementation

success

of

a

home

telecare

application

T.R.F.

Postema

a,∗

_,

_J.M.

_Peeters

b

_,

_R.D.

_Friele

b,c

a_Department_of_Operations,_Organization_&_Human_Resources,_University_of_Twente,_Enschede,_The_Netherlands b_NIVEL,_Netherlands_Institute_for_Health_Services_Research,_P.O._Box_1568,₃₅₀₀_BN_Utrecht,_The_Netherlands c_Tilburg_University,_Faculty_of_Social_and_Behavioural_Sciences,_Tilburg,_The_Netherlands

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received10March2011 Receivedinrevisedform 2December2011 Accepted3December2011 Keywords: Innovation Adoption Hometelecare Implementation Homecareorganization

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b

s

t

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Rationale:Theintroductionofhometelecareinhealthcareorganizationshasshownmixed resultsinpractice.Theaimofthisstudyistoarriveatasetofkeyfactorsthatcanbeused infurtherimplementationofvideocommunication.Wearguethatkeyfactorsaremainly foundintheorganizationalclimateforhometelecareimplementation,thecharacteristics oftheimplementationstrategyandtheavailabletechnology.

Methods:Interviewswereconductedinthreecareorganizationswith27respondentsof dif-ferentlevelswithinandoutsidetheorganization.Implementationdeterminants,basedon earlierresearch,wereusedasacategorizationframeworkfortheinterviews.

Results:Wefoundthatmostprominentfactorsinﬂuencingimplementationoutcomesrelate tothestabilityofthetechnicalandtheexternalenvironmentandthealignmentof organi-zation,goalsandimplementationstrategy.

Conclusion: Becauseoftheexperimentalnature ofimplementingvideo communication, attentiontotelecareinﬂuencershasbeeninconsistentanddisorganizedbutitisbecoming increasinglyimportant.Accordingtotherespondents,achampion-ledroll-outisimperative forimplementationinordertoadvancetothenextstageinhometelecareandtoorganize servicesforsubstitutionofcare.

1. Introduction

Theagingpopulationandthepushformoreefﬁcient deliv-eryofhospitalserviceshavefueledtheincreasingdemandfor homecareservices[9].Hometelecareisconsideredoneway toanswerthisincreasingdemandbyprovidingcost-effective carethroughtheuseofinformationtechnology.

In a recent systematic review, the main beneﬁts of hometelecarewere discussed[24].Mostimportantbeneﬁts relateto(1)reducedclienthospitalutilization;(2)improved clientcompliancewithtreatmentplans;(3)improvedclient

∗ _{Corresponding}_author._Tel.:₊₃₁_654761029.

E-mailaddresses:t.r.f.postema@utwente.nl,tim.postema@gmail.com(T.R.F.Postema),j.peeters@nivel.nl(J.M.Peeters),r.d.friele@uvt.nl (R.D.Friele).

satisfactionwithhealthservices;and(4)improvedqualityof life.Hometelecarealsoimprovedcognitivestatus,cognition andself-ratedhealthstatus[23].

By theterm hometelecare,werefertothedeﬁnitionof Dansky,wherehometelecareisdescribedas“Thetransmission ofdigital,audioandvideodataduringliveinteractivehealthcare encountersbetweenparticipantsindifferentlocations[8]”.

Hometelecare isaninnovationthat isbeing considered byhomecareorganizationstomanagecostsandtoenable inde-pendenceforclientswantingtostayathome[24].Anumber of home telecare services, for instance video communica-tion, can beprovided inorder to achieve these goals.The

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complexity and speciﬁcally the cost-effectiveness of these kindsofimplementationsare thesubjectofalargevariety ofresearchstudies[2–4,7–10,13,15,16].

Inthisarticle,weconsiderhometelecareimplementation tobeasuccesswhenthereishighgoal-performance congru-enceandadherenceaccordingtothehealthcareorganization implementingthe technology.Avarietyofpreviousstudies hasdiscussedthedeterminantsofimplementationsuccess ofcomparablehealthcareinnovations[3,4,6,12,14,17,20,26,27]. Thesestudiesmainlybuildonknowninnovationdiffusionand innovationadoptionresearch[11,22].

Fewstudieshowevercontainempiricalresearchdatathat conﬁrmorevaluatethesedeterminantsforspeciﬁc innova-tions incaresettings like hometelecare. Even fewerfocus ontheimplementationofhometelecareapplicationsandthe associatedimplementationstrategies.

Theaim of our study is to determine which factors inﬂu-encethesuccessoftheimplementationofvideocommunicationas ahometelecareapplicationfromanorganizationalperspective. Insightsintothesefactorsmayaidthedevelopmentof match-ingimplementationstrategiestopresetgoals.Thesestrategies canbeusedforthefurtherimplementationof(other)home telecareapplicationsandmaycontributetotherelevantbody ofliteratureinthisspeciﬁcdomain.

Inthisstudy,wefocusontheimplementationofone appli-cationofhometelecareinTheNetherlands;theuseofvideo communicationinhomecareorganizations.Throughthepresence ofatouchscreenathomeorthrougharegularTVset,clients areabletocontactthehomecareorganizationnurseviaacall centertochatoraskadviceconcerninghealthproblems;or theycanengageinvideocommunicationwiththeirrelatives, etc.

Implementationsuccesscanbeseenasacrucial prerequi-siteinordertoattainintendedinnovationbeneﬁts[18].

2. Methods

2.1. Animplementationevaluationframework

Inordertoevaluatekeyinﬂuencersofhometelecare imple-mentationsuccess,weconstructedanevaluationframework suitablefortheevaluationofhometelecareimplementations. AsindicatedbyFleureninherextensiveliteraturereview, ﬁve factors should be considered in evaluating healthcare implementationsuccessingeneral:(1)innovation character-istics,(2)thesocio-politicalcontext,(3)thecharacteristicsof theadoptingpersons,(4)thecharacteristicsofthe organiza-tionand(5)theimplementationstrategy[14].Togetherthese factorsfacilitateorimpedeimplementationsuccess.Wewill usetheabovecategorizationasthebasisforourevaluation frameworkforhometelecare. Inaddition, Barlowproposed moredetaileddimensionsfortheevaluationofhometelecare successinparticular,suchastheavailabilityofalocalsupport frameworkandtopmanagementsupport[4].

InTable1,asummaryofthesefactorsandbarriersis pre-sentedaswellastheintegrationofthetwodifferentmodels indomains forourresearchframework.Weuse the frame-workasabasistoclassifyandstructureourﬁndingsandto

answerourresearchquestion,relatingtothedetermination ofkeyinﬂuencersinthevideocommunicationdomain.

Centraltoinnovationimplementationisthe implementa-tion strategy; the waypeopleare involvedand when– the so-calledstakeholderinvolvement–ispartofthis implemen-tation strategy.Differentgoalsrequiredifferent approaches and strategies; each goal and strategy for implementation adherencerequiresitsownconﬁgurationoftechnology, stake-holderinvolvementandstructure[27].

Asillustrated byHaileyandCrowe,the degreetowhich allstakeholdersareinvolvedandcooperate,andthestability ofmanagementstructuresarefundamentaltothesuccessful introductionofinnovations[15].

2.2. Amultiplecasestudy

Sincewe aimto researchimplementationsuccessfrom an organizationalperspective,weanalyzedavarietyofdifferent organizationswithdifferentcompositionsofthestakeholder environment.InTheNetherlands,around10homecare orga-nizationsareinvolvedinvideocommunicationapplications.

Afterinvitingalargesampleofinvolvedcareorganizations, threeorganizationswerewillingtoparticipateinthestudy. Theselectedorganizationshadlargedifferencesinown per-ceived successoftheorganizations’ implementationofthe videocommunicationapplication.

Oneorganizationwasoneoftheﬁrsttoimplementhome telecare inThe Netherlands(A); another organization that started implementing videocommunication systems afew yearsago(B);andthethirdwasoneoftheﬁrstorganizations tostartahometelecareimplementationprojectbutrecently haltedtheproject(C).

2.2.1. Datacollectionandanalysis

In order to evaluatekey inﬂuencers, we aimedto conduct in-depth interviews with key stakeholders involved in the implementationofvideocommunication.

We used the results of our desktopresearch, including management reportsof the organization in question, plus evaluationreportsandarticlesonhometelecare implementa-tioningeneralthatwerepubliclyavailable,todevelopalistof themostimportantstakeholdersconcernedwiththeproject andtocompileasemi-structuredtopiclistfortheinterviews (AppendixA).Topicswerebasedontheevaluationframework andincludedtheinitiationoftheimplementationproject,the choiceoftechnologyandtheprocess,strategyand organiza-tionoftheimplementation.Wedevelopedinterviewquestions accordingtothespecificfunctionoftherespondents identi-fied.Theprojectmanagerinchargeofeachprojectapproved thefinalsetofintervieweesandsuppliedthecontactdetails. OnlyonerespondentoforganizationBandoneoforganization Crefusedtoparticipate.

Between July and December 2010, atotal of 27 respon-dents were interviewed. These were (1) stakeholders from differentlevelsoftheorganization,suchasboardmembers, managers,front-ofﬁcenurses,caregivers,clients,caretakers intheassistedlivinghomeand(2)stakeholderssuchas tech-nology providers,healthinsurersandhousingassociations. Thedomaincategorizationinourevaluationframeworkwas discussedwiththerespondents.Wedidnotexplicitlyasked

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Table1–TheintegrationofFleuren’sbarriersandbarlow’sbarriersinourframeworkdomains.

Combinedinﬂuencedomains Fleuren’sfactors Barlow’sbarriers Encompasses...

Technology Characteristicsofthe innovation

Evidenceofeffectiveness Theproducthard-andsoftware deploymentandoperationneeded fortheapplicationtofunction properlyandasintended.

e.g.touchscreens,network,and webbasedapplication.

Externalcontext Characteristicsof socio-politicalcontext

Localframeworkforsupport Theenvironmentoutsideofthe organization,potentially inﬂuencingtheclimatefor innovation.

e.g.ﬁnancialrestrictions,laws,and supplierdemands.

Organizationalclimate Characteristicsofthe organization

Organizationalcontextandcultures Localframeworkforsupport

Theimplementation organization’savailabilityof operationalprotocolsand structures,thedecisionmaking infrastructure,attentionto sense-makingand(in)formal knowledgespreadand(top) managementsupport[2].

e.g.managementsupport,procedures andreimbursementforextraactivities employed.

Usercontext Characteristicsofthe adoptingperson

Userneedsanddemands Projectcomplexity

Theinnovation-valuesﬁtofthe innovation;theextenttowhich targetedusersperceivethatthe useoftheinnovationwillfoster thefulﬁllmentoftheirvalues[11].

e.g.privacyconcerns,professional values,andethicalconcerns.

Implementationstrategy Characteristicsof innovationstrategy

Projectcomplexity

Localframeworkforsupport

Thewaytheintroductionofnew technologyisorchestrated.

e.g.top-down/bottom-up,planning andgoals,embeddednessin organization.

respondentstoagreewiththebarriersofBarlow,sinceitmay inﬂuenceinterviewresults[4].Theinterviewswereguidedby asemi-structuredtopiclistandwererecorded,literally tran-scribedandpreparedforuseinMAXQDA(www.maxqda.com). Relevantthemesintheinterviewswereextrapolatedbymeans ofqualitativedataanalysis.Thiswasdonebytworesearchers. Interviewfragmentswere labeledaccordingtothe detailed

factors described earlier. There were only minimal state-mentsmadethatdidnotﬁtoneoftheevaluationframework domains.Allotherdomainswerecovered,ascanbeseenin theresultssection.

Categorizationswerecomparedandsynthesized.Here,the above-mentioned innovationimplementation determinants were used asa categorizationforthe interview fragments.

Table2–Generalorganizationandimplementationcharacteristicsofourstudysites.

A B C

Generalorganizationalcharacteristics

Employees(FTE) 416 3020 1500

Region Urban Urban Mainlyrural

Implementationcharacteristics

Location Clusteredhousingblocks ownedbyorganization

Clients/clientsconnected(2010) 407/153(intramural) 2712/75(extramural)(787 clientsintramural)

5000/335(2009)(extramural) Technologystrategy Co-developedwithsupplier Jointventurewithothercare

organizations

Jointventureinsurerand telecommunicationsprovider Implementation Centralroll-outhousingblock Decentralroll-outatclient’s

house(localteams)

Decentralroll-outatclient’s house

Technologyhard-/software Touchscreens,TVset-top boxes

Touchscreens/multi-platform software

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Finally,wediscussedtheresultswiththerespectiveproject managersbymeansofanevaluationreport.

3. Results

InTable2,relevantgeneralandimplementationspeciﬁc char-acteristicsoftheresearchedstudysitesarepresented.

Severalspecificreasons weregivenduringtheinterview sessions,relatingtowhytheorganizationsembarkedonthe projectusingvideocommunicationtechnology.Thesereasons included:havinghighexpectationsofvideocommunication forcontributingtoareductionincostsand improving effi-ciencyofcaredelivery;improvingqualityofcare;andseeking toestablishaprofileasatechnologyleaderinthefieldaswell astobecomeinvolvedinexperimentation(A).

Whencomparingthedifferentorganizations,adifference ingoalfocuscanbeobserved.WhilebothorganizationsAand Bfocusedonimprovingqualityofcare(‘tofacilitateclients toliveathomeforaslongaspossible’)bytheadditional ser-vicesdelivered,organizationCmainlyfocusedonareduction ofcarecostsbymeansofsubstitutionservices.

Notsurprisingly,themostadvancedhomecare organiza-tionincludedinthestudy(A)wasmorewillingtoparticipate inthecasestudythantheorganizationthathaltedtheproject (C).Notallemployeesapproachedwerewillingtoparticipate intheinterviewsessions(n=3)foravarietyofreasons.These includedunfamiliaritywiththeinnovationornegative feed-backfromclientswithrespecttothetechnologyorservices provided.

3.1. Technologicalcontext

3.1.1. Inﬂuencer1:stabilityandreliabilityofthe technology

Withregardtothetechnologyusedinourcareorganizations, wemay conclude that atthetime ofthe described imple-mentation,thetechnologywasimmatureintermsofsoftware andhardware[21].Evidently,thestabilityandreliabilityofthe technology,however,iscrucialinservicedeliveryand adop-tionofthetechnology.Atpresenthowever,nomajorproblems areexperiencedorindicatedbytheorganizationsinrespect ofthetechnology(AandB).

“...technical disruptionshave gradually become fewand far between...”(ProjectmanagerA)

3.1.2. Influencer2:experienceofthetechnologypartner Themannerinwhichthetechnologywasdeveloped,installed andprovidedtotheclientsdifferedbetweentheorganizations inquestion.OrganizationAcollaborated withatechnology partnerthatwasnewinthefield.Thisresultedinavarietyof technicaldifficultiesduringtheinitialphasesof implementa-tion,likenon-functioningtouchscreensorinterfaceglitches: “...Atthebeginning,therewasalackofattentiontouser require-mentsandoperationalimpact...”(BoardofDirectors,A). OrganizationAimplementedthetechnologyinahousing complexcontaininglong-termcareapartments.

OrganizationBjoinedanalreadyexistingandsuccessfully operatingjointventureofbothtechnologyandcareproviders.

Content groups and templateswere already available.The joint venture focused on a platform-independent software solution. This saved time and effort for organization B in terms ofservicedevelopment.OrganizationBimplemented the technologyin clients’ own homes, which meant there wasnoguaranteethatasolidorreliableinfrastructurewas inplace.

Organization C worked in collaboration with a large telecommunicationsproviderinTheNetherlands,providing theinfrastructuralsupport.ThetechnologywasTVbasedand wasonlyinitiatedbyclientsfromtheirownhome.

Inourinterviews,itwasfrequentlymentionedthat expe-riencedsupplierswereexpectedtobebetterabletodeliver reliablesupportandtechnology,leadingtohigheracceptance duringtheimplementationstagesforhometelecarenurses andclientsinparticular.

3.1.3. Inﬂuencer3:levelofcontent–goalalignment

Furthermore, the contentprovided throughthe technology infrastructuremustmatch thegoalsofthehomecare orga-nization andthe hometelecare servicesitaimstoprovide, asalreadyconcludedbyVanOffenbeek[27].Wecallthisthe importanceofcontent–goalalignment.Asstatedduringoneof theinterviewsbyanurse:

“...Ittookussometimetorealizethatitisoflittleuse think-ingintermsofillnessesortreatmentcharacteristicsindeﬁning appropriatecontent.Instead,weevaluateddifferentsetsofneeds independent ofclient characteristicsand matched appropriate servicesthatcouldbesuppliedusingthevideocommunication application.Then,weevaluatedanddiscussedtheneedswith eachclient...”(ProjectManager,C)

3.2. Externalcontext

Asemergedintheinterviews,financingisconsideredamajor influenceinrelationtohometelecare.Other external influ-encersmentioned includethe waycollaborationhas taken shapeandtheroleoflegislation.

3.2.1. Inﬂuencer4:thestabilityofinfrastructuraland operationalﬁnancing

Bytheendof2012,itisprojectedthatallDutchgovernment grantsrelatingtothefinancingofservicesdeliveredbyvideo communicationinhomecarewillceasetobeprovidedintheir existing format. This implies that organizations must find waystofundtheseservicesthemselvesorfindandorganize partnershipstopayforthecostsoftheservicesprovided.

Althoughhometelecareandspecificallyvideo communi-cation,mayleadtoimprovedefficiencyofcare,thefinancing systemwhichisbasedonhoursofcareprovidedmeansthat hometelecaremayresultinlowerincomeforthecare organi-zationcomparedtotheincomefromregularcare.Asindicated intheinterviewsbyafinancialmanageroforganizationB:

“... Thefutureofourservicesisablur;wereallydon’tknowwhat isgoingto happenwith thefunds wearecurrently receiving. Atthisstage,however,wearenotabletoﬁnanceitsolelyby ourselves...”(FinancialManager,B)

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Thestageofmaturityofthetechnologyincreasesthe com-plexityofﬁnancingtheinvestment,sinceconsiderablecosts areinvolvedduringthedesignandimplementationperiod, notall ofwhich are coveredbythe supplier.Inthe future, thesedevelopmentcostsareconsideredbytherespondentto belessofaproblem,sincethetechnologyislikelytobecome morecost-effectiveasthedesignofthetechnologymatures, asalsonotedbySicotteandLoane[19,25].

3.2.2. Inﬂuencer5:thelevelandstructureofservice collaboration

Collaborationwithotherpartiesisperceivedasamajor fac-torinspeedinguptheimplementation,especiallysincethe effectsofhometelecareserviceslikevideocommunication, arenotlimitedtothecareprovidedbythehomecare organi-zation.Financialconsiderationsarealsoinvolved:

“...Wedonotreceiveproperreimbursementforcostreductionby preventingphysicianvisitsbyclientsthroughvideo communica-tion.Thisisaconsequenceofalackofcollaborationbetweenthe differentcarepartnersinvolvedinaclient’scare...”(Financial ManagerB)

Allthreeorganizationswereengagedinsomesortof collab-orativeventurewithboththesupplierofthetechnologyand thehousingcorporationsinvolved.Importantly,thedegreeof contributiontocontentvariedamongstthedifferentjoint ven-tures.WithrespecttoorganizationA,forexample,thecontent wasdevelopedtogetherwiththetechnologysupplier.Since the development ofservices can be somewhat haphazard, collaboration with others in content groups seems beneﬁ-cial,fromtheperspectiveoflearningfromothersandsharing experiences.Thissavedconsiderabletimeandeffortfor orga-nizationB.

Collaborationswithothercarepartnerswereonlypresent onsmallscaleatorganizationsBandC.Thismainlyinvolved thecollaborationwithGP’sforregularteleconsultationofthe homecareinstitutionclients,e.g.regardingdiabetesfollow-up orwoundcare.

3.3. Usercontext:innovation-valueﬁt

3.3.1. Influencer6:thevirtual–physicalcarealignment Traditionally,care professionalsgreatly appreciate the per-sonalcontactwith clients. Thiswas identified asa source ofresistancetowardvideocommunicationtechnologyinthe interviewsconducted.Atthesametime,thebenefitsofvirtual carewerebetterappreciatedbycarersoperatinginruralareas (institutionC):

“...Notallclientcontactscanbesubstitutedwithvirtual assis-tance.Therewillalwaysbethenecessityforphysicalactivities.At thesametime,becauseofthetechnologywearenowabletohave morecontactmomentswithdistantclientsthatishighly appreci-atedandcontributestothereductionoffeelingsofloneliness...” (Nurse,A)

Inthe interviewsitwasindicatedthatit isimportantto positionservicesnotasareplacementofphysicalcare,butas anenhancementofqualityofcare.Insteadofoneactualvisit, threevirtualvisitscantakeplace.

3.3.2. Inﬂuencer7:continuousassessmentofthe(in)direct effectsofvirtualservicedeliveryonallusergroups

Theinnovationmustalsoﬁtwiththeclients’changingdaily activitiesandneedsorthoseoftheprimarycaregivers.This ﬁtcanbeestablishedbyclosely,continuouslyinvolvingthe variousstakeholdersinthedevelopmentofnewservicesas partoftraditionalcareprograms.

Reasonsforresistancecanbefoundinalackofconviction thatthetechnologycanactuallyimprovethequalityofcareor indeedthatitcouldprovidecareservicesatall.Itwasfeltthat virtualservicedeliverymustbeofaddedvaluetoallclients, employeesandprimarycaregivers(e.g.partner,sonor daugh-ter)involved,andthatclearlyformulatingandcommunicating thesebeneﬁtsenhancesthesuccessofimplementation.This includesforexample,family andthe effectshometelecare mayhaveontheircontactandinvolvementwiththeclient.

3.4. Organizationalclimate

3.4.1. Inﬂuencer8:theavailabilityofacomprehensive frameworkforsupport,withsufﬁcienttopmanagement supportandabasicsetofprocedures

Inallcases,theprojectseemedtobeinitiatedbytop manage-mentwhobelievedinvideocommunicationtechnologyand the addedvalueofthe services.Thecollaborationbetween avarietyofpartnersatinitiation,allenthusiasticaboutthe proposedservices, alsofacilitatedthestart-upoftheactual project.

Furthermore,duringthestartupandimplementationtop management was closely involved and afﬁliated with the project. Theprojectswere prominentlymentionedin strat-egyandpolicyplans.Themanagementoftheprojectstrongly believesinthebeneﬁtsoftheservices,althoughtheresults mayonlybevisibleafteraverylongperiod.

Withrespecttooperationalprotocols,thesewerepresent inallthreeorganizations,almostdirectlyfromthe start.In bothorganizationsAandB,theseoperationalprotocolswere developed from the bottomup. However,not all protocols and procedureswere adheredtoinpracticeduringthe use oftelecare,whichsometimesledtomisunderstandingsand impromptudecisionmaking.WithrespecttoorganizationB, whererolloutwasdesignedonalocallevel,thissometimesled toadifferenceinserviceprovisionacrossteams,complicating thecentralorchestrationoftheimplementation.

3.5. Implementationstrategy

Asstatedbefore,theimplementationstrategyshouldmatch theoperationalgoalsoftheimplementation.

3.5.1. Inﬂuencer9:thelevelofinvolvement–goal alignment

Amismatchbetweengoalsandstrategyleadstopoor perfor-mancebytheinnovation.Thisimplicatesproperinvolvement ofbothclientsandcarepersonnel.Equallyimportantishow servicesaredevelopedandimplemented:bottom-upor top-down.ThiscanbeseeninorganizationC,wheretherewere highexpectationsofsubstitutioncare,onlytobefollowedby disappointmentfromafailuretoidentifysuitablecontacts.

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WithinorganizationA,inparticular,alotofattentionwas devoted tomeaningfulcommunication,involving clientsat multiplestagesduringthedesignphase.

Organization B depended heavily on decentralized care unitstointroducethetechnologyandservices:

“...Ourcareteamshavethechoicethemselvestointroduceand promotetheservicetotheirownclients;theyarenotobligedto doso...”(ProgramManager,B)

Mixedeffectscanbeobserved;someteamsembracedthe technology, took ownership and actively sought clients to connectwith,whileotherteams didnotuseor attemptto introducethe technologyat all.Thisseems mainly due to individualchampionswithinthedifferentteams.

There was considerable homogeneity in the way home telecare was introduced. In all three organizations the introduction ofthetechnologystarted top-down. Next,the projectwasorchestratedcentrally.Contentwasdiscussedand decidedontop-downandcloselydiscussedwithbothclients andnurses.Theactualinstallationintheclients’homes dif-fered amongst the organizations. Organization A centrally introducedbothhard-andsoftware,whileorganizationB del-egatedthe‘marketing’and installationtothedecentralized careteams,whoknewtherespectiveclientspersonally.

InorganizationA,thecontentoftheserviceswasfurther shapedbyemployeesthemselves(bottom-updevelopment). ThisdiffersfromorganizationBwherecontentwasmainly decidedoninthe jointventure contentgroups. All organi-zationsstronglyfocusoneliminatingclientconcerns,e.g.by reimbursingelectricitycosts.

AscanbeconcludedfromtheinterviewsatorganizationB, adecentralizedroll-outshouldbeperformedinphases, start-ingwithenthusiasticteamsandusingtheseasshowcasesto convincetherest.

3.5.2. Inﬂuencer10:orchestrationofachampion-led roll-out

Asindicatedinthevariousinterviews,thebestwayto over-cometheresistanceexperiencedistocontinuouslypromote theservicesthroughenthusiasticambassadors:

“...Withoutourcaretaker,theimplementationwouldnothave gonethissmoothly;heknowseveryoneinthebuildingandcan acttheminuteproblemsoccur...”(ProjectManager,A) Ideally,theseambassadorshavethetrustoftheclientand primarycaregiver(partner,sonordaughter)andaretherefore ofgreatvaluetocareprofessionalsindirectcontactwiththe client.

Duringthedesignstageofthetechnology,theclientsand the technology supplier were the partners. During imple-mentation,thekeystakeholderwasstatedtobetheonein closephysical contactwith the client (primarycaregivers); thischampioningroleappearedtobecrucialinconvincingthe userstoactuallyutilizethetechnologyandinremovingany reservations.

Theseﬁndingsareinteresting,sinceotherstudiesofhome telecare in The Netherlands showed that the care coordi-natorsandcaregiversdidnotautomaticallyﬁndit tobein theirinteresttostimulatethesubstitutionofhomevisitsby hometelecare[1].Consequently,clientsdidnotactivelyuse

thesystem.Wemayconclude,particularlyonaccountofthe (decentralized) implementation oforganization C, that the localcareteam’sattitudecanbeseenasadecisivesuccess factorduringtheﬁnalstagesofimplementation[27].

4. Conclusion

Theaimofourresearchwastoidentifykeyfactorsthat inﬂu-ence the implementation successofhometelecare incare organizationsinTheNetherlands.Accordingtothe stakehold-ersincluded inourstudy,anumberofinﬂuencersneedto betakenintoaccountwhenimplementinghometelecare ser-vices.

Intheopinionofthemajorityofparticipants,thesuccess ofhometelecareapplicationsand videocommunicationin specific, is critically dependent on enthusiastic champions alongtheimplementationtrajectory,onstrategic,tacticaland operationallevels oftheorganization. Fromamanagement perspective, theproperorganizationofthelocalframework forsupportandfindingwaystoensurelongtermfinancing arefoundtobecritical.

Inevaluatingandinterpretingtheresultsshown,wefound that a major theme underlying the indicated inﬂuencers seemstobestakeholdermanagementasatoppriorityduring implementationofvideocommunication.Bothinternal stake-holdermanagement;whotoinvolvewhen,aswellasexternal stakeholder management;managingpartnersfor collabora-tion(bothinthetechnologyandcaredomain).

Thisseemsinconnectionwiththeevolutionofhealth insti-tutions,frombeinganationalinstitute,tobecomingamore commercialandcompetitivecarepartner.

Theresultsofthestudyshowthatexperimentationatthis stageofthedevelopmentofhometelecareinTheNetherlands isappropriateandtendstohavehighersuccessratesthan try-ingtosubstitutecare,eventhoughsubstitutionisfrequently expected(C).ThisechoestheconclusionsofBayeretal.who cautionagainstoveroptimisticexpectationsoftheimpactof telecareintheshorttermandwarnthatthebeneﬁtsof imple-mentationwillonlybecomefullyeffectivewithasigniﬁcant delay[5].

5. Discussion

Oneofthemainstrengthsofourresearchliesinitsin-depth evaluationofmultiplecases.Thisyieldsareasonably thor-ough insightintorelevantfactorsand processesrelatingto hometelecare.Theframeworkused,asacombinationof exist-ingmodels,provedvaluablefortheclassiﬁcationofthefound inﬂuencersandthestructuringoftheinterviews.

Thecomparisonoforganizationswithdifferent implemen-tationapproachesand outcomesprovidedvaluableinsights intospecifichometelecareinfluencers.Theresearchapproach used,interviewingthespectrumofdirectandindirect stake-holders ofhome telecare lead to a set of influencers, not foundassuchinpreviousliterature.Existingliteratureoften stateshighlevelevaluationsthatoftenproveimpracticalin home careimplementation projects. The influencers men-tionedherecanbeusedtoshapeimplementationprograms

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relatingtovideocommunicationofhometelecareservicesin general.

Theinfluencersfoundinthisstudyarecloselyrelatedtothe specificdomainofvideocommunicationinhomecare,with itsowndistinctserviceandclientcharacteristics.For exam-ple,thestabilityoffinancingoftechnologyinthehomecare domainisa specificinfluencerwithevenmorecomplexity thaninforexamplehospitalcare.

Therelativelysmallnumberofparticipants,however,may reducethe generalizability oftheinﬂuencers foundinthis study. The differences in services, technology and client case-mixbetweenorganizationsandthefocusonvideo com-municationmayalsoinﬂuencethegeneralapplicabilityofthe factorscited.

Ourgoalwastoidentifyfactorsinﬂuencing implementa-tion successaccording tothe stakeholdersinvolved. These factorsmaypointtowardanagendafororganizationsstarting orstrugglingwithhometelecareimplementation.

Theinﬂuencersasmentionedbytherespondentsare gen-eralopinionsasexpressedbyaselectionfromthe relevant stakeholderenvironments.Furtherresearchexploringtowhat extenttheinﬂuencersindeedrelatetoimplementation suc-cesswouldbeofgreatvalue.

Eventhoughindicatedaskeytosuccess,inthecases stud-ied,limitedattentionwasgiventoadetailedservice-to-user match.Thismighthelptoidentifythekindofserviceelements eligibleforvideocommunicationsubstitution(e.g.medication follow-up,woundexamination,etc.).Onemustbeawareof secondaryeffectsintermsofincreasedcareburdenfor fam-ilyorsecondarycaregiversandtheshiftinresponsibilitiesas aresultoftransferringcareactivities.Littleevidenceofthis awarenesswasfoundduringthisstudy.

Asstatedearlier,weareapproachinganeweraofhome telecareservicesandanysubsequentbenefits.Inparticular, best practice research in this area concerning service and content provisioncan contributetothe field. Furthermore, additionalempiricalresearchisneeded-specificallyaimed atmeasuringandfollowingtheprogressofservice(or con-tact)substitutionbyhometelecare,thestrategiestopromote theadoptionofhometelecareanditseffectsonre-alignment oftheinfluencersdescribed here. Inthis sense, the earlier mentionedeffectofthetimedimensionandsubsequentlag incost-effectivenesseffectsrequirefurtherstudy.Specifically, the increasingmaturityof the hometelecare environment mayleadtothealignmentofgoalswithanimplementation strategyencompassingadifferentsetofinfluencers.

Authors’

contributions

TPandJPdesignedandconductedthestudy.TPcarriedout thedatacollection,performedtheanalysesanddraftedthe manuscript.JPandRFcriticallyreviewedthemanuscript.All authorsreadandapprovedtheﬁnalmanuscript.

Competing

interest

Theauthorsdeclarethattheyhavenocompetinginterests.

Acknowledgments

Theauthorsareverygratefulforallthesupportandworkfrom StefanieBolder,aMaster’sstudentwhowasdoingher the-sisaspartofthisresearchatNIVEL.Sheassistedduringthe interviewsandinanalyzingthedata.

Appendix

A. Topic

list

template

1.Introductionofresearch

-Researchtheme

-Approvalofprojectmanagement -Outlineofquestions

-Approvalofrecordingtheinterview

2.Initiationofhometelecareengagement

-Whatwasandisyourrolewithrespecttohometelecare implementationininstitutionX?

-Wouldyoucaretoelaborateonthetriggertoparticipate andengageinthisimplementation?

-Whoinitiatedtheproject?Canyouelaborateonthestart oftheproject?

-Couldyouelaborateontheinitialgoalsandtargetstobe achievedatthebeginningoftheproject?

-Howdoesthesegoalsﬁtwiththeinstitutionalstrategy? -Whendidtheprojectstart?Whatstakeholderswere involvedintheprojectstart-up?

-Whatinﬂuencewasexpressedbythesestakeholders duringstartup,accordingtoyou?

3.Technology

-Wereyouinvolvedinthetechnologyselection?What wereyourmainconcernsandperceivedbeneﬁts?

-Couldyouelaborateonthechoiceprocess? -Howdidstakeholdersreactontheeventualchoice? -Didthereactionsleadtoanalterationofchangeinthe technology?

4.Implementation

-Couldyoudescribethemainmilestonesprojectedand achievedduringimplementation?

-Whatwasyouropinionabouttheimplementation organizationandstrategy?

-Couldyouelaborateontheplanningoftheproject? -Didtheinitial,presetgoalsandtargetschangeduringthe implementationprocess?

-Whatactivitiesdidyouundertakeduringthe implementationprocess?

-Whatactivitieswereemployedbyotherstakeholders? -Couldyouelaborateonthestructureofthebusinesscase fortheimplementation?

-Whatinvolvedstakeholdershadthemostinﬂuenceon thecourseandoutcomeoftheimplementationprocess, accordingtoyouropinion?

-Didstakeholderrolesandinﬂuencechangeoverthe courseoftheimplementation?Couldyousupplyexamples?

-Couldyouelaborateonthestakeholdermanagementby theprojectteamandtopmanagementduring

(8)

-Whatconﬂictsorbottleneckscanbeidentiﬁedin dealingwithotherstakeholders?

5.Inﬂuencers

-Howwouldyouratethelevelofinﬂuenceofthe technologyonthesuccessoftheproject?

-Howwouldyouratethelevelofinﬂuenceofthe environment(legal,ﬁnancial)onthesuccessofthe project?

-Ifyouhadtosupplyalistof5mostinﬂuencingfactors onhometelecaresuccess,howwouldthislistlooklike?

6.Conclusions

-Ifyouhadtostart-upcomparableprojectsagain,what wouldyoudodifferently?

-Areyousatisﬁedwiththe(preliminary)results? -Doyoulookatother,comparableprojectsinThe Netherlands?

-Whatdoyouexpectinthe(near)futuretochangeor contributetohometelecare?

Appendix

B. Implemented

services

at

study

sites

InTable3,theservice characteristicsofthestudy sitesare presented.

Table3–Overviewofdifferencesinservicesavailableat thecasestudysites.

Category Hometelecareservices A B C

Contactand participation services -Goodmorning, goodevening services(more informalcontact moments) -Socialintermediary (connectingpeople) X X X Entertainment andcomfort services -WideInternet accessprovisionto clients,speciﬁcally categorizedfor seniors -Information requests -Dooropening systems X X

Safetyservices -Personaldistress alarm(connection betweenvideo communication systemandalarm center) -Dooropening systems X (Medical)care services -Monitoring appointments (‘visits’previouslyin person) Summarypoints Alreadyknown:

• Hometelecareimplementationhasproventoleadto mixedresultsintermsofprolongedadoption. • Amultitudeofdomainsinﬂuencehometelecare

adop-tionandimplementations.

• Cost-effectivenesshasnotbeenprovenunequivocally, hinderingthediffusionofhometelecare.

Addedvalue:

• Insightsinmulti-stakeholderperceptionsabout cru-cialhometelecareimplementationfactorssupportthe understandingoftheuseandimplementationofvideo communicationapplications.

• Itseemsthatthestabilityofthetechnicalandﬁnancial environmentiskeyinthedomainofhometelecarefor successfulimplementationatpresenttime.

• Thewaystakeholdersareengaged,frominitiationto implementationofhometelecare,playsacrucialrole; champion-wiserolloutsseemimperativeconnecting totheorganizationalcharacteristicsofhomecare.

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