Author Jurjen Julianus

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STAKEHOLDER OBJECTIVES, POSITIONS AND INFLUENCES IN EHEALTH PORTAL IMPLEMENTATION

The PAZIO case

Author Jurjen Julianus

Student number s1571524

Institute Rijksuniversiteit Groningen

Faculty Economics and Business

Degree program MSc Business Administration Specialization Business & ICT

Version Definitive

04-03-2012

Faculty supervision

Supervisor Prof. dr. ir. J.C. Wortmann Co-supervisors Prof. dr. A. Boonstra

Drs. J.B. van Meurs

External supervision VitaValley

Supervisor W.C.J. Schuttelaar MSc

VitaValley Foundation UMC Utrecht University of Groningen Zonneoordlaan 17 Heidelberglaan 100 Nettelbosje 2

6718 TK Ede 3584 CX Utrecht 9747 AE Groningen

The Netherlands The Netherlands The Netherlands

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ACKNOWLEDGEMENTS

This thesis was written as graduation assignment for my master’s degree in Business Administration, specialization Business & ICT, at the University of Groningen. The research was conducted during an internship at the University Medical Center Utrecht and the VitaValley foundation in Ede. These organizations are responsible for the PAZIO health portal programme.

Although the fact that I am author of this thesis, I could not have achieved this without the received support. Therefore, some people deserve a word of thanks for their support during this research. First of all, special thanks to my supervisor from VitaValley, Wilco Schuttelaar. Wilco, thank you for answering my questions, reviewing my chapters and helping me with my activities in the PAZIO programme. Also I would like to thank André Dekker and Mark de Lange for providing me the opportunity of this internship at the UMC Utrecht and the VitaValley foundation.

Furthermore, I would like to thank the faculty supervisor, prof. dr. ir. Wortmann, for introducing me in the topic, and for providing me with constructive feedback during the research process. Also thanks to prof. Boonstra, for contributing as co-assessor.

Looking back, I really enjoyed this internship since it enabled me to explore the dynamic field of healthcare and ICT. In addition, writing this thesis enabled me to improve my scientific research skills.

Last but certainly not least, I would like to thank my parents, and my girlfriend for their major support during my study.

Jurjen Julianus

Utrecht, 04-03-2012

IV

MANAGEMENT SUMMARY

Demographic pressure in The Netherlands is increasing. People will demand more care in the future. In order to be able to fulfill the care demands in the future, measures have to be taken. eHealth (Healthcare & ICT) initiatives are developed in response to this trend.

However, a high extent of fragmentation can be recognized among eHealth initiatives.

PAZIO is a health portal which is a ‘socket’ for healthcare information systems. PAZIO acts as a platform for other portal solutions, which enables healthcare providers to provide online services from different software suppliers with only one login (Single Sign On).

Currently, PAZIO is implemented at primary healthcare center Leidsche Rijn Julius Gezondheidscentra in Utrecht, The Netherlands.

Insight in the current implementation process is gained, for the purpose of improving health portal implementation in the future. In order to gain insight in the implementation of the PAZIO portal, this study describes and analyzes the PAZIO implementation at Leidsche Rijn Gezondheidscentra from a stakeholder perspective. The following implementation stakeholder groups are identified: board of managers, general practitioners, doctor’s assistants, platform supplier, project management, application supplier, HIS supplier and patients. The stakeholders are categorized according to the stakeholder salience theory (Mitchell et al., 1997). This resulted in the following categorization (figure A):

Figure A – Categorization stakeholders PAZIO implementation LRJG

Figure B – Categorization stakeholders MGn implementation GCM

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For the purpose of comparison, the MijnGezondheid.net portal implementation at Gezondheidscentrum Maarssenbroek, The Netherlands, has been analyzed in the same way. The following implementation stakeholders are identified in the implementation at Gezondheidscentrum Maarssenbroek: Board of managers, general practitioners, doctor’s assistants, project management, software supplier and patients. Figure B shows the categorization of the stakeholders.

A qualitative cross-case analysis was conducted. Remarkable is the dynamic position of the board of managers and the patients in both implementations. Furthermore, the cross case analysis pointed out that the healthcare centers started with a different product, and attached different objectives to the implementation. In addition, their communication approach differed. The implementations in Leidsche Rijn and Maarssenbroek followed a different route, and consisted of a different field of stakeholders.

Practical implications for the project management

Per stakeholder group, practical implications are distilled. Discretionary stakeholders have little salience from the project management, their claims do not need immediate attention. Dominant stakeholders expect to receive more attention from the project management; however, they do not deserve much attention. Dangerous stakeholders should only be identified without acknowledging them. This requires some tactic from the project management. Dependent stakeholders need to exercise governed power, by means of other stakeholders. Implication for the project management with regard to definitive stakeholders is that claims of these stakeholders should have priority against claims from other stakeholders. The project management should pay specific attention to the dynamic position of stakeholders, in order to be able to act adequately to the shifts in position.

Management focus areas for future health portal implementations

The analysis of both implementation processes resulted into six management focus areas.

These areas deserve specific attention from the project management for health portal

implementations in the future. The following management focus areas are identified by

this research:

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First management focus area is the area of stakeholder relationships. Stakeholders are interrelated in a health portal implementation. These relations should be managed carefully by the project management. It may for example be more beneficial for the project to let a software developer be supplier instead of being partner.

Second area is dedication; dedication of stakeholders is a key enabler of success. A non- committal attitude of one or more stakeholders seems lethal for the success of

implementation.

Vision and leadership is the third management focus area. The project management should execute future implementations within primary healthcare centers that have an internal project leader with leadership and vision. This causes all employees in the healthcare center to face the same direction.

Fourth management focus area is confidence of care providers. If care providers have a lack of confidence in the software or working with the software, they may attempt to delay implementation. The project management should thus invest in stable software and education for care providers.

Next management focus area is knowledge of key people. An internal project leader is considered to be a key person in implementation. If this person has a certain amount of business knowledge this may increase the chances of implementation success.

Last and perhaps most fundamental focus area for management is the area of usage by patients. A health portal is supposed to be a communication means between care providers and patients. However, if patients are not willing to use the portal, for any reason, successful implementation cannot be achieved. Implementation will then stagnate, because routinization among employees in the healthcare center can never be achieved.

The six management focus areas can be generalized to future PAZIO implementations, as

well as to other health portal implementations in primary healthcare centers.

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LIST OF FIGURES AND TABLES

Figures

Figure 1 | Demographic pressure in The Netherlands (van Duin & Garssens, 2010) ... 1

Figure 2 | PAZIO Concept (modified from http://www.pazio.nl/concept , 2011) ... 3

Figure 3 | Innovation stages - adopted from Deloitte (2010) ... 8

Figure 4 | Distribution of interviews ... 11

Figure 5 | Visual representation of research strategy ... 13

Figure 6 | Current PAZIO runtime architecture ... 16

Figure 7 | Aligned elements of IT innovation (Boonstra, 2011) ... 22

Figure 8 | Visual representation of stakeholder typology (Mitchell et al., 1997) ... 26

Figure 9 | Project governance framework (Young, 2005)... 27

Figure 10 | Organizations involved in PAZIO project ... 31

Figure 11 | PAZIO Time line ... 33

Figure 12 | Aligned elements of the PAZIO implementation at LRJG ... 43

Figure 13 | Stakeholders involved in PAZIO implementation at LRJG based on Mitchell et al. (1997) ... 47

Figure 14 | Aligned elements of implementation at GCM ... 52

Figure 15 | Stakeholders involved in MijnGezondheid.net implementation at GCM based on Mitchell et al. (1997) ... 55

Tables

Table 2 | Aspects of Terms of Reference (Boddy et al., 2009) ... 20

Table 3 | IT implementation stages – Cooper & Zmud (1990) ... 21

Table 4 | Stakeholder typology (Mitchell et al., 1997) ... 26

Table 5 | Six inter-related project governance activities (Young, 2005)... 28

Table 6 | Software suppliers at pilot locations ... 31

Table 7 | Perceived problems of PAZIO implementation stakeholders at LRJG ... 51

VIII

TABLE OF CONTENTS

1 Introduction ... 1

1.1 Case description ... 2

1.2 Research objective ... 5

1.3 Research questions ... 5

Background – eHealth ... 7

2 Methodology ... 8

2.1 Focus of the research ... 8

2.2 Data collection methods ... 9

2.3 Data analysis ... 11

3 Health Portals ... 14

3.1 Portals defined ... 14

3.2 Health portals ... 14

3.3 Relation to other systems ... 15

3.3.1 Health Information Systems ... 17

3.3.2 Electronic Health Record... 18

4 Portal Implementation ... 20

4.1 Implementation methods ... 20

4.2 Stakeholder analysis theory ... 24

4.2.1 Characterization of stakeholders ... 25

4.3 Project governance ... 27

Background – Short description of organizations ... 29

IX

5 Implementation of PAZIO ... 32

5.1 Leidsche Rijn Julius Gezondheidscentra ... 32

5.2 Gezondheidscentrum Maarssenbroek ... 38

6 Stakeholder analysis of PAZIO implementation ... 42

6.1 Leidsche Rijn Julius Gezondheidscentra ... 42

6.1.1 Identification of stakeholders ... 42

6.1.2 Stakeholder analysis ... 44

6.1.3 Problems and lessons learned ... 47

6.2 Gezondheidscentrum Maarssenbroek ... 52

6.2.1 Identification of stakeholders ... 52

6.2.2 Stakeholder analysis ... 53

6.2.3 Problems and lessons learned ... 55

7 Cross-case analysis and Practical implications ... 57

7.1 Cross-case analysis ... 57

7.1.1 Product and objective ... 57

7.1.2 Implementation stages ... 57

7.1.3 Communication approach ... 58

7.1.4 Range of stakeholders ... 58

7.2 Practical implications for stakeholder management ... 59

7.2.1 Discretionary stakeholders ... 59

7.2.2 Dominant stakeholders ... 59

7.2.3 Dangerous stakeholders ... 60

7.2.4 Dependent stakeholders ... 60

7.2.5 Definitive stakeholders ... 60

8 Important implementation issues ... 62

8.1 Management focus areas for future implementations ... 62

8.1.1 Relationships of stakeholders ... 62

8.1.2 Dedication ... 62

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8.1.3 Vision and leadership ... 63

8.1.4 Confidence of care provider ... 63

8.1.5 Knowledge and or experience of key people... 63

8.1.6 Usage by patients ... 64

9 Conclusion and Discussion ... 65

9.1 Conclusion ... 65

9.1.1 Definitions ... 65

9.1.2 Leidsche Rijn Julius Gezondheidscentra ... 65

9.1.3 Gezondheidscentrum Maarssenbroek ... 67

9.1.4 Management focus areas for future health portal implementations .... 69

9.1.5 Implications for theory ... 69

9.2 Discussion ... 69

9.2.1 Limitations of the research ... 69

9.2.2 Recommendations for further research... 70

Bibliography ... 71

List of abbreviations ... 76

Appendices ... 77

Appendix A: Interview questions... 77

Appendix B: Full stakeholder analysis LRJG – PAZIO implementation ... 78

Appendix C: Full stakeholder analysis GCM – MGn implementation ... 83

Appendix D: PAZIO & MGn Screenshots... 86

Appendix E: Interviewees ... 88

Appendix F: Keywords project group meetings ... 127

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1 INTRODUCTION

Demographic pressure in The Netherlands is increasing. Figure 1 shows the Dutch labor force opposed to the group of ageing people. By 2040 the group of elderly people will be larger than the Dutch labor force. As people in The Netherlands will have a longer life span, they will demand for more care. In addition, there will be more people with a chronic disease. However, there is less labor force to provide the care demands in the future.

Figure 1 | Demographic pressure in The Netherlands (van Duin & Garssens, 2010)

In order to be able to fulfill the care demands in the future, measures have to be taken.

One measure mentioned in the Dutch state budget is reengineering of care processes (Skipr, 2011). Such reengineering projects may be well supported or enabled by

innovations in the care sector. Process innovations in the care sector are highly reliant to

the usage of information and telecommunication technology (ICT). Initiatives which

combine healthcare with ICT are called eHealth initiatives. A high extent of fragmentation

among eHealth initiatives can be recognized in The Netherlands. For example, recent

research by the NICTIZ (National IT Institute for Healthcare in the Netherlands) pointed

out that there are over 40 patient portals in The Netherlands by the end of 2010. These

portals all have different functionalities and are intended for different client organizations

(Heldoorn & Veereschild, 2011). The challenge with eHealth lies in integration of those

initiatives.

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In The Netherlands there are 4 large companies that possess more than 80% of the general practitioners information system (HIS) market (Table 1). Such a market concentration brings opportunities for one integrated portal. Despite these opportunities, there are over 40 health portals in The Netherlands. Only few of them have integration with a HIS.

Among and within Dutch hospitals there is an even higher extent of fragmentation of information systems and online services. Innovators of the VitaValley foundation and the UMC Utrecht have identified the trend of portal fragmentation, and brought up the idea of a platform that integrates the information systems of healthcare providers into one clear online portal for the care consumer.

HIS FTE General Practitioners Market share

Medicom (PharmaPartners) 2200 33%

Promedico 1450 22%

MicroHIS 1100 17%

Omnihis 835 12%

Mira 450 7%

HetHis 250 4%

Zorgdossier 250 4%

TetraHis 40 1%

CITO 25 0%

Total 6600 100

Table 1 | Market share HIS in The Netherlands (estimation by PharmaPartners, 2011)

1.1 C

PAZIO is an online healthcare portal which can be seen as a ‘socket’ for healthcare organizations and eHealth providers to plug-in their existing information system. The PAZIO platform offers integration between the information system of the healthcare organization and its online services. In other words, it connects the healthcare provider to the patient via the internet channel.

PAZIO consists of a limited customizable user interface and an ‘app-store’.

Customization is offered, because PAZIO is offered as a white label product. Thus,

healthcare providers are enabled to change certain colors, logos and texts. They can even

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decide to choose an own name for the portal, which can help to increase the amount of trust of care consumers. Within the app-store, software suppliers can offer their own eHealth app. Obviously, apps have to comply with PAZIO infrastructure standards because of single sign on requirements. Single sign on (SSO) means that all applications can be accessed with only one login. eConsult, eAppointment and Disease Management are available in the app-store at this moment. Other applications, such as eMentalHealth (for patients with depressions), ePrescription (for pharmacists) and Self-Management (applications for prevention) are in the development stage. The pre-competitive approach for applications on the platform seems unique; not only does it open up the market for smaller software suppliers, it also assures an integrated approach for eHealth applications.

The portal enables care consumers to arrange their care needs online. For instance, scheduling an appointment or requesting a consultation online. In addition to the functionality itself, PAZIO services are offered via a single sign on. Entrance for the PAZIO portal is often a login button on the healthcare center’s website. The sign on is secured by the Dutch DigiD (Digital Identity) system, which enables citizens to login to a number of services provided by Dutch government agencies. DigiD has two levels of authentication; the regular login with username and password, and the more secure method which sends a text-message verification code to the user’s mobile phone.

Especially the latter of the two authentication levels is suitable for securing access to medical related data. It has to be noted that PAZIO is not a government service.

Another distinctive feature of PAZIO is the possibility for researchers to conduct research within the project.

One of the parts of the PAZIO project is the

Figure 2 | PAZIO Concept (modified from http://www.pazio.nl/concept , 2011)

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development of a Center of Excellence (CoE). The CoE aims to identify, document and distribute the knowledge that comes available during such an innovation process.

Scientific researchers are invited to conduct their research; in addition, best practices will be documented by members of the project team. Distribution of the knowledge is

facilitated by a symposium which will be organized by the project team.

Introduction of a ‘new’ means for communication with a healthcare center may involve changes in behavior and or habits of both patients and the employees of a healthcare center. First of all, care consumers are used to grab the telephone in case they want to consult their general practitioner; they are not accustomed to use the internet for this purpose. Second, employees within a healthcare center are equally used to this

communication method. Moreover, for them, implementation of a patient portal causes a certain change in their work processes. Therefore, implementation consultants are employed to streamline this process.

The PAZIO team is now working on the scalability of the product. Information systems provider Imtech, responsible for the PAZIO infrastructure, indicates that the technological infrastructure is all set for national deployment. The challenge lies in making the

implementation of the portal scalable. Since the product is in development, links with the different underlying information systems are not yet finished. In addition, implementation consultants are necessary to streamline processes within the healthcare centers. Currently, the PAZIO team provides all services concerning an implementation of the portal. They fulfill all roles in the implementation process: they are seller, coordinator of the software part, implementation support provider and developer of the product. For the future, a decision has to be made which role suits the PAZIO team best. In other words, what is their core business? For each of the roles mentioned above, there is a make or buy decision. This implies that there is a make or buy decision for implementation as well.

However, before an external consultancy firm is able to implement PAZIO,

implementation guidelines have to be created. The identification of management focus

areas for future implementations of PAZIO may be the first step in creating such

implementation guidelines.

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1.2 R

The aim of this research is to obtain insight in the implementation process of a health portal. Furthermore, that insight should be translated into management focus areas for future health portal implementations within primary healthcare centers. These insights should be rooted in existing academic knowledge on ICT implementation processes, and if possible contribute to this body of knowledge.

A primary healthcare center in the Netherlands consists of a group of general

practitioners, practices nurses and sometimes physiotherapists and pharmacists which operate together under a joint name. Such a multidisciplinary organization enables these groups to spread their overhead costs (administration, the premises etc.), and to offer more complete primary care.

1.3 R

In order to obtain insight in the implementation process of PAZIO, an implementation analysis has to be conducted. This research chooses to analyze from a stakeholder’s perspective both a PAZIO implementation, and another health portal implementation.

Outcomes of this analysis will serve as foundation for identification of management focus areas for primary care providers in implementing portals. The following question will serve as the main research question of this research.

What are the stakeholder’s objectives, positions and influences within a portal

implementation in a primary healthcare organization? And which management focus areas for future PAZIO (and other health portal) implementations can be derived from these findings?

The main question immediately raises a number of questions. First, what is a health

portal? Second, what is an implementation? And what does this mean in the context of a

health portal? In addition, the main research question calls for a stakeholder analysis of a

PAZIO implementation and an implementation of another health portal within a primary

healthcare center. These questions have been translated into the following sub research

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questions. Sub research questions 1, 2 and 7 are generalizable, while sub questions 3, 4, 5 and 6 are case specific questions.

Sub RQ1:

What is a (health) portal?

Sub RQ2:

What is IT implementation?

Sub RQ3:

Which stakeholders are involved in implementation?

Sub RQ4:

How can the objectives of the different stakeholders be characterized?

Sub RQ5:

How can the positions of the different stakeholders be characterized?

Sub RQ6:

How do the objectives and positions of the stakeholders influence the implementation?

Sub RQ7:

Which management focus areas for future implementations can be distilled from the

stakeholder analysis?

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BACKGROUND – EHEALTH

There exists some confusion about the definition of eHealth. Moreover, there are several definitions for the application of ICT in the healthcare sector; eHealth, telehealth, telecare, telemedicine. These terms are all used to indicate care, support and monitoring of a patient’s health from a distance (Frankwatching, 2011). For the purpose of this research we will follow the eHealth definition of the Dutch Association of eHealth (NVEH):

Innovative application of ICT, especially internet, to support and improve health and the healthcare sector.

Several issues around the implementation of eHealth can be identified. The following issues are identified by the researcher and are considered particularly of relevance for this research.

From fragmentation to integration

Within the world of eHealth, a high level of fragmentation can be identified. Lots of separate initiatives are started (Website KNMG, 2010). For example, UMC Utrecht already uses 14 standalone patient portals at this moment. General practitioners have their own information system, and most of time, they have their own website as well. Although the websites often come with eConsult and eAppointment functionality, there is no integration with the underlying information system. Within healthcare, integration seems to be the keyword for the success of eHealth initiatives.

Changing work processes

General practitioners and doctor’s assistants are often used to work in a certain way (Medical rationality; Heeks, 2006). The introduction of eHealth applications such as eConsult and eAppointment may cause a shift in their work processes. Organizational change often raises resistance among the subjects of change (Waddell et al., 2004). Initially, it will cost them a lot of effort to comprehend the applications which may cause resistance implementation.

Education

Currently, there is too little attention for eHealth topics in educations for doctor’s assistants and

general practitioners. A suggestion may be to make eHealth part of today’s medicine studies

(Programme manager PAZIO, interview, December 1

2011). Moreover, it may increase the

efficiency in which eHealth initiatives are implemented in the future.

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2 METHODOLOGY

2.1 F

Objective of the research is gaining insight in the implementation process of PAZIO, and in the implementation process of another health portal. Subsequently, this insight should be translated into management focus areas for future health portal implementations in primary healthcare centers. This objective is translated into an analytical question which can be answered by doing literature and empirical research. A cross case study seems to be the most appropriate research method, because the outcomes of the analysis have to be dedicated and useful for future health portal implementations. Case study is a powerful research methodology that combines interviews, analysis of relevant records and (participative) observation (Cooper et al., 2003).

PAZIO is an innovative programme, which is still being tested and improved during implementation. It is therefore meaningful to address the current status of the PAZIO programme, viewed from an innovation perspective. Furthermore, it has to be noted that the research focuses on the implementation process.

Figure 3 | Innovation stages - adopted from Deloitte (2010)

The PAZIO programme can now be placed in the green area; business plans are created, and they are being aligned with the strategies of the different stakeholders. At this moment in time, a pilot is running, and an implementation plan is available. Despite the promises stated in the plan, this implementation can be characterized as ‘learning by doing’. This implementation, obviously, covers organization and change management

Visioning, sensitization and

ideation

Operational

excellence Go2 Market strategy and implementation Create business plan

Align innovation and R&D strategy

Governance & KPI’s

Financial modeling

Implement processes and tools

Organization and change management

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issues. Governance, KPI’s and financial modeling are issues which are to be discussed by the PAZIO programme team.

Approach for fulfillment of the research objective is a stakeholder analysis of both a PAZIO implementation, and an implementation of MijnGezondheid.net in two primary healthcare centers. Stakeholder analysis is chosen because earlier research pointed out that it is important to obtain insight into the interpretations and power relations of stakeholders in order to develop a proper understanding of a project (Boonstra & De Vries, 2005, 2008). Such insights enable the researcher to identify supporters and resisters of the innovation. Effective implementation strategies can be developed based on these insights.

Boonstra & Govers (2009) call this process “IT stakeholder management”.

2.2 D

The research uses a (cross) case study approach. Literature research is conducted to obtain a clear image of the main concepts of the research; health portals, IT implementation and stakeholder theory. Furthermore, qualitative methods are used to answer the research question.

Literature research

The main question of the research consists of three aspects; portals, IT implementation and stakeholders. For the purpose of understanding these terms, a literature research has been conducted. Moreover, the literature is used as a guideline for the case description.

First, non-scientific literature and websites concerning health portals have been consulted in order to define the terms ‘portal’ and ‘health portal’. In addition, information systems that may have integration with a health portal are addressed to obtain a clear image of the complex architectural environment of an integrated health portal as PAZIO. Second, IT implementation literature has been consulted. It is important to know, what an

implementation is; where does it start? Where does it end? And what is in between. Third, stakeholder theory has been consulted. A definition of stakeholder is part of this section.

Furthermore, this literature serves as a foundation for mapping the stakeholders who are

identified during the stakeholder analysis. Moreover, it helps to translate the stakeholder

analysis into IT stakeholder management implications.

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Sources for the scientific literature research have been: Business Source Premier, Google Scholar. Terms that were used to search in these scientific databases include: web portal, portal, health portal, patient gateway, IT implementation (model, stages, phases), IT implementation in healthcare, IT implementation stakeholder management, Stakeholder analysis, Stakeholder salience, Health information systems, Patient care information systems. Furthermore, the snowball technique was utilized to obtain more relevant

literature. Books and literature provided during the lectures of the course ICT: Human and Organizational Issues have been used as foundation for the literature research as well.

Knowledge and experiences in practice have been utilized to obtain background

information, besides that, presentation slides of an eHealth master class have been used to obtain relevant background information concerning the eHealth topic.

Literature is selected based on the extent of support it provides for the understanding of the concepts in the case. It has been utilized to provide definitions of various terms and to obtain knowledge about analysis methods. The goal was and not to provide an exhaustive image of the available literature in the field of healthcare and IT implementation.

Empirical data

The case description and stakeholder analysis have been conducted based on data

obtained from both interviews and participative observation. In order to ensure construct validity, both interviews and participative observation have been utilized for data

gathering (Cooper et al., 2003). Participative observation is realized by the fact that the

researcher is providing support tasks the project team in this case, in addition to the

research tasks. Observations have been documented by means of keywords, during

meetings with internal project groups at the healthcare centers and during meetings with

the PAZIO project team. Advantage of such close involvement is the in-depth access to

people, issues and data (Walsham, 2006). Downside of close involvement includes the

danger that the field researcher who is closely involved, becomes socialized to the views

of people in the field. The benefit of a fresh look is then lost (Walsham, 2006). Figure 5

provides an overview of the interviews that were conducted with stakeholders of both the

PAZIO implementation and the other portal implementation.

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Figure 4 | Distribution of interviews

Patients are important in the implementation process of a health portal, because they are able to make or break the success of implementation. In other words, a health portal implementation may have limited success if patients are not willing to use it. In order to gain insight in the objectives, positions and influences of members in this group, two interviews have been conducted with patients from LRJG. The patients interviewed for this research were asked different interview questions than the other stakeholders. This is because of the fact that they have no knowledge about which other stakeholders are involved in implementation in addition to the employees of their healthcare center.

Furthermore, the patients were selected at random. More in-depth research regarding patient behavior and attitudes in the PAZIO case will be performed by Nicol Nijland PhD (Twente University) and Michiel van Well MSc (Maastricht University). Particularly the research that will be conducted by Nicol Nijland focuses on the role of the patient.

Moreover, the overall effectiveness of the PAZIO portal will be reviewed in that particular research based on user experiences.

In addition to the use of interviews, secondary data has been consulted to underpin the findings in the interviews. Presentations, project plans, implementation plans, e-mails and other documents have been consulted.

2.3 D

Data has been gathered by means of three channels. Participative observation, semi-

structured interviews and secondary data have been utilized to cover the empirical part of

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this research. Data from the sessions in which the researcher exercised participative observation, was aggregated on to a time-line. Thereafter, the data was placed into the context of the implementation stages (Cooper & Zmud, 1990) and the structuration model (Boonstra, 2011) by means of interpretations of the researcher. Finally, the observation data was used to strengthen the findings of the stakeholder analysis.

The interviews are digitally taped by the researcher, the associated audio files have been translated into summaries of the relevant information. Afterwards, the audio files have been deleted. A confirmation email with the summary of their interview has been sent to each interviewee, interviewees were thus enabled to give their comments on the summary of their own interview. These comments have been processed. Subsequently, the

interviews are analyzed by means of interpretation. Collected data has been arranged according to the implementation stages (Cooper & Zmud, 1990) and the structuration model (Boonstra, 2011). This enables the researcher to explain and characterize the actual implementation process using a theoretical perspective. In addition, the data is used to map the stakeholders based on the stakeholder salience theory (Mitchell et al., 1997). The latter theory will be used to formulate implications concerning a future PAZIO

implementation process within a primary healthcare center based on the outcome of the analyses. This outcome consists of a characterization of the different interest groups in both implementations. Based on these characterizations, management focus areas for future PAZIO implementation will be formulated for the project management.

Secondary data has been utilized to provide support for the findings regarding the description of the actual implementation process.

Figure 6 provides a visual representation of the research strategy.

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Figure 5 | Visual representation of research strategy

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3 HEALTH PORTALS

In order to answer the first sub question of the research, this chapter covers the part regarding web portals. The chapter starts with defining web portals in general, and will narrow scope towards health portals. It is necessary to obtain a clearer image of the terminology around portals, in order to better understand the subsequent sections. In addition, it is relevant to have insight in the systems which are or can be linked to a portal.

3.1 P

Synonyms for portal are web portal, links page and gateway. These terms all have a similar meaning. Various definitions of portals can be identified. Some only define it as a starting point for internet activities (Emazing, 2010; Broadband TV Nieuws, 2007).

Wikipedia (2011) defines web portals more broad, and adds that it presents information of diverse sources in a unified way.

In addition to general or horizontal portals, like for example iGoogle or MSN, there exist field specific portals. Such ‘vertical’ portals are also called ‘vortals’ (Zoeken-en-

vinden.nl, 2011). Although a health portal can be called a vortal, we prefer to use the term ‘portal’ because the addition of ‘health’ indicates that we discuss a vertical portal in this paper. A vertical portal can also refer to a personal portal. Personal portals usually have a secured area which requires login, it renders applications specifically for the user that is logged in. For this paper we will follow the personal portal definition provided by Wikipedia (2011):

“A site on the World Wide Web that typically provides personalized capabilities to its visitors, providing a pathway to other content.”

3.2 H

While portal is the equivalent of gateway, health portal is that of patient gateway or

patient portal. In practice, we can distinguish two types of health portals; generic health

portals, which consist of hyperlinks to healthcare websites or services, and secured

personal health portals. Personal health portals allow patients to login in a secured

environment and enable them to update their contact information, request appointments,

request consults online, and offers reliable licensed health information (Schnipper et al.,

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2008). Kittler et al. (2004), add patient access to parts of their health records to that. For this research we will follow the health portal definition of Schnipper et al. (2008):

“A site that allows patients to login in a secured environment and enables them to update their contact information, request appointments, request consults online, and offers reliable licensed health information.”

The reasons for introduction of a health portal

Particularly secured personal health portals are interesting for healthcare organizations, since they are able to configure the portal to their preferences. Research conducted by Bergman et al. (2008) pointed out that secured personal patient portals have the promise of enhanced communication between patient and provider, increased overall satisfaction with care, increased identification and management of chronic conditions, increased access to health information, and improved disease management for conditions such as diabetes. However, introduction of a portal with online appointment and online consulting functionality requires a redefinition of existing work processes within these organizations.

Currently, healthcare centers are already using information systems for scheduling and for maintaining personal health records. In the future, secured personal health portals should be able provide access to parts of medical records online. At the moment, a secured personal health portal only enables patients to schedule an appointment or request an eConsult. This requires the portal to be integrated with the information system of the corresponding healthcare center. The following section describes the systems to which a health portal may have a connection.

3.3 R

A secure personal health portal has limited functionality if it is not integrated with other

systems in the healthcare IT architecture. Thus, portals should be placed in the wider

context of the healthcare IT architecture. First a description of the relation of a secured

personal health portal with other systems is presented. Thereafter, functionality and

definitions of these systems will be provided.

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The example of PAZIO will be used to illustrate to which other systems a portal may relate. Figure 7 is a conceptual representation of the current PAZIO architecture. The figure indicates the relationship of PAZIO with other information systems in healthcare.

PAZIO is a software as a service (SaaS) application, that does not need hardware

installation at the healthcare centers. Different healthcare centers may use the same SaaS application, and customize it to their demands (Lankhorst, 2010). Currently, there is connection with the Health Information Systems (HIS) of only a couple of primary healthcare centers. PAZIO enables app suppliers (yellow squares) to connect to a HIS. It is imaginable that one of the software suppliers develops an application for patients to gain access to their medical files (EHR). Therefore, these systems should be taken into consideration when implementing a portal. It is important to know how such systems can be defined, and what their functionalities are. In addition to applications that have

integration with the care provider’s HIS (eConsult

, eAppointment

), apps without this integration are offered as well (eMentalHealth

for example).

Figure 6 | Current PAZIO runtime architecture

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3.3.1 Health Information Systems

Health Information Systems is an umbrella term for information systems used within the care sector. It refers to both information systems used by hospitals (Littlejohns et al., 2003), but also to information systems used by general practitioners. According to (Berg, 2003a) the term Health Information Systems (HIS) is one of many Patient Care

Information Systems (PCIS). Ash et al. (2004) define such systems broadly as

applications that support healthcare processes by allowing healthcare professionals direct access to the system. The aim of HIS is to contribute to a high-quality and more efficient patient care. This aim is primarily patient-driven (Haux, 2006). In reality, however, we observe that HIS are not developed to work for patients. Besides, they are particularly used as a means for management and administrative support including invoicing. Berg (1999) discerns two modest yet powerful roles in healthcare work. Professionals and organizations are enabled to accumulate data-elements into meaningful information and these systems help to coordinate complex processes of interaction and collaboration.

Information systems offer the opportunity to span network over a larger number of entities. Larger numbers of data can be collected and used by the same professional.

Moreover, “even events in distinct spaces and times can be brought together.” (Berg, 1999; Berg, 2003b). As a result, higher level of process complexity can be achieved. In later research Berg (2003b) refers to the above HIS’s qualities as electronic information handling and electronic coordination.

Health information systems are considered highly relevant for the achievement of high quality care. Imagine for instance a healthcare professional, who does not have access to necessary information, this can have fatal consequences for the patient (Haux, 2006). In addition, Ash et al. (2004), state that it is obvious that HIS will ultimately be necessary for high quality care delivery. This is confirmed by Boonstra et al. (2011), who argue that HIS are the means towards higher quality care. We define HIS as follows for the purpose of this research:

“Applications that support administrative and healthcare processes by allowing healthcare professionals and their assistants direct access to patient information.”

In addition to the achievement of higher quality care, information system services for

healthcare purposes are increasingly established as ways to achieve more efficiency and

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lower costs (Ash et al., 2004; Boonstra et al., 2011). However, research conducted in the United States, The Netherlands and Austria pointed out that there are many instances in which the HIS seems to foster errors instead of reducing their likelihood. Ash et al. (2004) divide these errors in two broad categories: errors in the process of entering and retrieving information and errors in the communication and coordination process. The system of people, technologies and organizational routines then seems to be weakened as opposed to the intended strengthening of the HIS applications (Ash et al., 2004). HIS applications have the best results when they automate routine work, however, healthcare processes are often complex rather than routine. The researchers state that “many of these errors are the result of highly specific failures in HIS design and/or implementation.” They, however, focused their research on errors that occurred from a mismatch between the functioning of the HIS and the demands of the healthcare work. Only when implementers of HIS give thoughtful consideration to design and implementation issues, then HIS will be able to fulfill their promise (Ash et al., 2004). As mentioned, healthcare work is rather complex in nature. Due to the complexity, healthcare work does not come in logically structured flowcharts. Patient trajectories are rather uncertain, a lot of contingencies exist. This insight should be heeded; else the information system will embed its mechanistic properties into the contingent and complex environment of healthcare work (Berg, 2003b).

3.3.2 Electronic Health Record

Electronic Health Records are defined by the International Organization for Standards (ISO). According to their definition, EHR is a repository of patient data in digital form, stored and exchanged securely, and accessible by multiple authorized users. This research follows the EHR definition posed by ISO (2004):

“The EHR consists of retrospective, concurrent and prospective information, which has the purpose to support the continuation of efficient and quality integrated healthcare.”

EHRs are used within primary, secondary and tertiary care institutions. Primary care is

provided by a general practice, secondary care involves medical specialists and tertiary

care is provided by a team of specialists in a major hospital (Häyrinen et al., 2008).

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Electronic Health Record in the Netherlands

On May 20

of 2008, the Dutch government created a bill for modification of the law on the Dutch Social Security Number. The national electronic health record (EHR) was supposed to be linked with the social security number. The bill was accepted by the Chamber of Deputies, and it obligated healthcare providers to comply their data and security measures according to LSP (Landelijk Schakel Punt) standards. Moreover, the LSP promised to enhance data integration among different healthcare professionals.

However, in 2011, despite of the concessions that had to be done, the proposal was rejected by the senate (Website Senate, 2011). Reasons for rejection are primarily issues concerning security of data and privacy. Rejection of the bill has caused healthcare organizations and Dutch politicians to think different about eHealth applications for the future. Recent research conducted by the NIVEL (Dutch Institute for research in

healthcare) and Academic Medical Center Amsterdam pointed out that healthcare providers find it important to have control over patient data when it is transferred electronically. Therefore, they prefer to roll-out electronic patient filing on a regional level. On a smaller scale more control is offered, which in turn nurtures the degree of trust (Ploem et al., 2011).

In this chapter, portals, health portals and related systems have been discussed and

defined. Furthermore, it can be concluded that a health portal has limited functionality if it

is not integrated with the underlying HIS. Literature also indicates that HIS do not always

align with the needs of the healthcare organization, and that thoughtful consideration

should be given to alignment. The following section continues with describing the

literature regarding IT implementation.

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4 PORTAL IMPLEMENTATION

It is important to define what the characteristics of IT implementation are. First, IT implementation in general will be discussed to understand which phases can be distinguished and which facets are involved. Second, stakeholder analysis theory and theory regarding project governance will be discussed.

4.1 I

Implementation of Information Technology (IT) in organizations is more than only implementing hardware and software. Implementation of IT involves organizational changes. Therefore, it is arguable to assume that IT implementation in essence is a form of managing change. This is acknowledged by Cooper & Zmud, (1990) who theorized IT implementation stages based on the most basic model of change by Lewin (1951).

Technology has impact on an organization, simultaneously, the organization determines the use of the technology. Therefore, it is a reciprocal relationship in which the variables are interdependent (Boonstra et al., 2011; Boonstra, 2011). In other words, there is interaction between the system and its stakeholders.

Before implementation

First of all, there has to be focus on understanding what powerful stakeholders expect from the implementation. Production of a Terms of Reference document is a critical step in the period leading up to implementation (Boddy, Boonstra, & Kennedy, 2009). This document should include:

Aspect Content

What is to be done Intended activities and desired outcomes. Including CSFs, indicators for a successful implementation.

Who is to be involved Names, roles and responsibilities of the main project team, and others whose support is required.

How will it be done Which approach to use, which resources, costs incurred.

When it will be done A main schedule of activities at a high level

Table 2 | Aspects of Terms of Reference (Boddy et al., 2009)

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Implementation

According to (Cooper & Zmud, 1990) implementation, viewed from a diffusion perspective can be defined as “an organizational effort directed toward diffusing appropriate information technology within a user community”.

A fundamental IT implementation stage model is proposed by Kwon & Zmud (1987; cited in Cooper & Zmud, 1990), which has its foundation in the three basic stages of

organizational change: Unfreeze – Change – Refreeze (Lewin, 1951).

The following stages for IT implementations have been identified by Kwon & Zmud (1987; cited in Cooper & Zmud, 1990). The stages consist of a process description and a specific end point.

Stage Process Product

Initiation Scanning of organizational problems or opportunities. Pressure for change evolves from either organizational need (pull), technical innovation (push) or both.

A match between the IT application and its application in the organization.

Adoption Get organizational backing for implementation through rational and political negotiations

Decision to invest resources necessary to accommodate implementation effort.

Adaption IT application is developed, installed and maintained. Processes are revised and users are trained in new procedures and in the IT

application.

IT application is available for use in the organization.

Acceptance Members in the organization are induced to use the IT application

The application is employed in organizational work Routinization Usage of the application is encouraged as a

normal activity

the IT application is no longer perceived as something out of the ordinary

Infusion Increased organizational effectiveness is obtained. Application integrates in more complex work processes

Application is used to its fullest potential

Table 3 | IT implementation stages – Cooper & Zmud (1990)

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Taking a closer look to the stages proposed by Cooper & Zmud (1990) we see that during the stages, there is continuous interaction between the IT application, the organization and the members of the organization. The effectiveness of any technology driven change process relies on the interdependence between the technology, the organizational context, and the change model used to manage the change (Orlikowski & Hofman, 1997; cited in Legris et al., 2003).

These elements are represented in a structurational model. In such a model, IT

implementation is modeled as a complex and dynamic socio-technical system (Boonstra

& Van Offenbeek, 2010; Boonstra, 2011). Interaction takes place between the IT

application, the organizational context and the stakeholders during the innovation process.

Figure 8 illustrates the aligned elements of IT innovation. The figure consists of the following elements: The innovation process, the IT innovation, stakeholders, context and their interaction (marked by the arrows). The solid lines represent the scope of the

research, the dotted lines are beyond this research’s scope.

Figure 7 | Aligned elements of IT innovation (Boonstra, 2011)

Interaction in structuration theory (Giddens, 1984,1993; cited in Boonstra, 2011) is based on the ‘duality of structure’, which means that “characteristics of the IT innovation are both the means for and the outcome of human interaction.” (Boonstra, 2011). Two concepts that have their fundament in ‘duality of structure’ are technology appropriation

Time

IT innovation

Organizational contexts

Stakeholders

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and social multidimensionality (Boonstra & Van Offenbeek, 2010). As said, technology appropriation is based on the two-way interaction of the IT innovation and the user. On the one hand, this soft-deterministic view does acknowledge that technology influences human behavior. On the other hand, users of technology have interpretive flexibility, which means that users build up their own motivations for their actions (Boonstra & Van Offenbeek, 2010). People, thereby, reproduce the structural properties of technology because they can either adapt their methods to the technology or adjust the technology to their methods (Boonstra & Van Offenbeek, 2010; Boonstra, 2011; Orlikowski, 2008).

Social multidimensionality refers to the notion that technology appropriation takes place within a certain organizational context which has its own structural properties (Boonstra

& Van Offenbeek, 2010). The institutional context of the stakeholders determines cognitions, norms and values where they can draw upon. Since the context of different stakeholders may overlap or differ considerable, tensions between the stakeholders can arise (Boonstra & Van Offenbeek, 2010). Therefore, social multidimensionality seems crucial in eHealth implementation research. Different views and interpretations of stakeholders will cause some people to support the innovation, and others to exert resistance (Boonstra & Broekhuis, 2010). It seems obvious that people do not choose a side in isolation. Coalitions are formed as a result of people influencing each other regarding the IT innovation implementation (Walsham, 1997; cited in Boonstra, 2011).

Taking the IT implementation literature into consideration, it is safe to conclude that the stakeholder is perceived important. Stakeholders often have different expectations of an innovation. They interpret the innovation from their own perspective, and might attach different meanings to it. In order to develop a meaningful understanding of IT

innovations, insight should be gained into interpretations and power relations of

stakeholders (Boonstra & de Vries, 2005). “Managers must be willing to intervene in the political systems surrounding IT innovation” (Boonstra, 2011). In other words, it is important to exercise stakeholder management. However, before stakeholder management can be exercised, stakeholders have to be identified first. Thereafter, a stakeholder

analysis needs to be conducted.

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The next section introduces the concept of stakeholder analysis, which will be applied to two portal implementations later on in the research.

4.2 S

The previous sections described information technology implementations within organizations. We have seen that stakeholders are at least as important as the IT innovation and the organizational context where the innovation fits in. IT

implementations are not only famous for their large number of stakeholders (Boonstra &

Govers, 2009), but also for the interaction between the stakeholders, the IT innovation and the organizational context (Boonstra, 2011). Since interaction is important for the

description of implementation, it is equally important to identify the different stakeholders of an implementation as well as their relationships. For this research we follow the classic definition of stakeholders by Freeman (1984),

“A stakeholder is any group or individual who can affect or is affected by the achievement of the organizations objectives”.

For the purpose of this research we will replace ‘the organizations objectives’ with ‘the project’s objectives’.

Boonstra & Govers (2009) state that within healthcare, such implementations often involve large numbers of stakeholders which have different degrees of autonomy and expertise. They argue that particularly for healthcare organizations, misfits in expectations and established features of the organization may lead to resistance of the stakeholders.

The different degrees of autonomy and expertise among the stakeholders may bring the problem of colliding rationalities. Heeks (2006) has identified three archetypes of rationalities which exist within IT implementation in healthcare. Technical rationality is the technical worldview of IT professionals and IT suppliers. Managers within healthcare often operate from legal, financial and control perspectives, the managerial rationality.

Medical rationality refers to the wish of medical professionals to put patients at the center

of the system (Heeks, 2006). These rationalities may collide and may then easily lead to

implementation and usage failure. The incentive for conducting a stakeholder analysis

thus seems evident. According to Goodpaster (1991), a stakeholder analysis consists of

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two elements: perception and analysis. Perception is fact gathering about options available and about short- and long term implications. Stakeholder analysis is the analysis of these implications. Specific attention should be paid to affected parties and the goals,

objectives, values and responsibilities of decision makers.

4.2.1 Characterization of stakeholders

For the purpose of characterizing the stakeholders we will follow the stakeholder salience theory (Mitchell et al., 1997). In this theory, stakeholders have power, legitimacy and urgency. “The theory identifies that stakeholders possess one or more of three relationship attributes” (Boonstra, 2006). These attributes find their origin in the actions of the

different stakeholders towards each other. Power equals the extent to which a group can exert its coercive, utilitarian or normative means to force its will in a relationship.

Coercive power is based on physical resources of force or violence, for instance, the use of a gun. Utilitarian power finds its basis in material or financial resources. Normative power is based on symbolic resources such as esteem, love or acceptance. Legitimacy is defined as “the general perception that the actions of an entity are desirable, proper or appropriate within some socially constructed system of norms, values, beliefs and definitions”, it also refers to claims that have a legal foundation. Urgency refers to the extent to which a stakeholder claim calls for immediate attention, delay in attending to the claim is unacceptable to the stakeholder (Mitchell et al., 1997). Characterization of

stakeholders according to this theory acts as fundament for managerial implications of an implementation. Moreover, the model contributes to the potential effectiveness of

managers in a multi stakeholder environment.

Combination of the relationship attributes power, legitimacy and urgency leads to the following seven stakeholder types (table 4).

Stakeholder type Characteristics

1. Dormant stakeholder Have the power to impose their will, they however, have no legitimacy or urgency to use the power.

2. Discretionary stakeholder

Possesses legitimacy but has no influential power.

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3. Demanding stakeholder Has urgent claims but has no power or legitimacy to influence the project.

4. Dominant stakeholder Have both power and legitimacy. Their influence in the project is assured since they are able to form dominant coalitions.

5. Dependent stakeholder Have a lack of power, and thus rely on other to fulfill their legitimate and urgent claims.

6. Dangerous stakeholder Possesses power and urgency. Without legitimacy, this is a combination that can be considered as dangerous for a project.

7. Definitive stakeholder Has the possession over all three relationship attributes.

8. Nonstakeholder

Table 4 | Stakeholder typology (Mitchell et al., 1997)

Figure 8 | Visual representation of stakeholder typology (Mitchell et al., 1997)

Mitchell et al. (1997) predict that the salience of a stakeholder to the project management is low if one of the relation attributes is present, moderate if two attributes are present and high if all three attributes are present. Mitchell et al. (1997) define salience as:

1 Dormant

stakeholder 2

Discretionary stakeholder

3 Demanding stakeholder

4 Dominant stakeholder

5 Dangerous stakeholder

6 Dependent stakeholder 7

Definitive stakeholder

POWER

LEGITIMACY

URGENCY

8 Nonstakeholder

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“The degree to which managers give priority to competing stakeholder claims”

In other words, it means identification of whom or what really counts.

As organizational change projects are dynamic in nature, relationships can evolve. A stakeholder’s relationship attributes can thus change over time as well. Moreover, stakeholders can even acquire missing attributes themselves.

4.3 P

Since a PAZIO implementation can be characterized as a project for the stakeholders who are involved, it is important to address the project governance. According to Young (2005), projects can only be effectively governed if the most fundamental concepts are considered by the management of the organization subject to the particular project:

 Projects are undertaken to realize benefits

 Benefits are seldom realized during the implementation process

 Benefits tend to be enabled by IT projects; however, they can only be realized by complementary organizational change.

Young (2005) distinguishes between hard dimensions of governance, for instance steering committees or governance processes, and soft dimensions of governance, for instance will to change, and communication / influential skills of the top management. The latter was considered more important in achieving a successful project.

Figure 9 | Project governance framework (Young, 2005)

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The framework by Young (2005) shows that projects are undertaken to achieve benefits.

In addition, it imposes that the board of managers has a clear overview over the business processes and over the project which should change those business processes. The model identifies six inter-related project governance activities that should be undertaken by the board of managers.

Governance activity What is involved?

Initiate / Evaluate An evaluation of the potential benefits and risks should be conducted. A business case should be prepared, and eventually approved.

Support – motivation How much organizational change is necessary?

Furthermore, a project sponsor needs to be found. Such a sponsor needs passion, ability and skills to ‘make it happen’.

Underlying issue here is how to motivate the stakeholders of the project.

Support – structure

Monitor – project A mechanism must be found by the board to monitor the sponsor of the project, because it would be a conflict of interest if the sponsor monitored themselves.

Monitoring has to occur on both organizational level and project level.

Monitor - benefits

Table 5 | Six inter-related project governance activities (Young, 2005)

The previous chapter has shown that implementation of IT is seldom possible without

taking the people involved into account. Moreover, some authors argue that it is

conditional to manage stakeholders in IT implementation properly. The subsequent

section describes the actual implementation process of two different health portals in two

healthcare centers based on the implementation theory provided in this chapter.