Integrating service providers in the
healthcare chain;
The accessibility case
“A roadmap for supporting an alternative solution to centralize the patient”
C.A. Bosma S1499211
Master of Science in Technology Management Faculty of Economics and Business
The accessibility case
December 2007
Author : C.A. Bosma
Student Number : S1499211
Email : Rien.Bosma@gmail.com
Date : 13-12-2007
Version : 1.0
Organisation : LogicaCMG
Project Leader : René Tuinhout
Architect : Drs.A. van der Heide
Educational Institute : University of Groningen
Study : MSc Technology Management
Coordinator : Drs. J.H. van Uitert
Acknowledgements
This thesis is the final part of the master program “Technology Management” at the University of Groningen. The motivation to perform a diagnostic research in a practical setting is a well considered one. The past five months I completed the internship at LogicaCMG Groningen, starting 16 July. Therefore, I want to thank LogicaCMG for giving me the opportunity to complete my research in an exiting and interesting environment.
Writing such a thesis would not be successful without the help of others. In particular, I would like to thank René Tuinhout, Anja van der Heide, Wico Mulder and Laurens Lapré from LogicaCMG for their encouraging feedback, support and supervision. Furthermore, I would like to state my appreciation towards my supervisor drs. J.H. van Uitert from the University of Groningen for supporting me with the research setting and the conceptual model. In addition, I want to thank drs. J.B. van Meurs also from the University of Groningen for his feedback and second opinion. Last but not least, I want to thank my parents and friends from whom I always could expect support when needed.
During my internship, I shared a room with students who all participated in the Working Tomorrow program. This program provides students for completing their thesis. Because of the variety of students and table soccer during pauses, I experienced my time at LogicaCMG most pleasant.
Rien Bosma,
Management summary
Centralizing the patient is the governments’ wish. However, current practices such as the electronic patient dossier (EPD) show that the fulfillment of this desire lack a structured collaborative approach. In this thesis, a guided transformation is shown for the accessibility problems that occur for in-home services. This study shows that the current key-management is complex due to a number of factors, such as problems with logistics, privacy and safety issues, financial aspects and legal elusiveness. This research categorizes different accessibility solutions and concludes that there is not a common answer for technical entry. However, this is not a problem, but considered a business opportunity.
The research conducted recognizes the current demand driven healthcare is not suitable for accessibility issues. The need for studying patient driven alternatives and centralizing the patient is the aim of this research. This transformation from a demand driven solution (push perspective) towards a patient oriented solution (pull perspective) needs guidance. For the guidance of the transformation, Collaborative Network Solutions (CNS) is used. For the accessibility case, a new model is proposed. In this model, a Virtual Organization (VO) and a Virtual organization Breeding Environment (VBE) are created. By using a Virtual Organization, the patient becomes really centralized. The argumentation using this model is the broker role a patient could play. This is critical for the patients’ safety and autonomy perception. Using such a model creates a number of benefits for both the patient and the different service providers.
First, the patient is able to request his own services, in the role of a broker. The patient stays in control, due to selecting services he needs. The breeding environment stimulates the trustworthiness of various service providers. Secondly, the patient receives faster healthcare in case of unplanned care, due to the proposed alternative solutions. In order to enter the breeding environment, the service providers need to verify their cooperation, common infrastructure and patient-oriented policy.
quickly to the wishes of the patient. This agility is supported by the common protocols and ICT infrastructure.
Table of content
1 Introduction... 6 1.1 Research setting... 6 1.2 Relevance... 7 2 Preliminary analysis... 9 3 Methodology... 19 3.1 Research objective... 19 3.2 Conceptual model... 19 3.3 Definitions... 20 3.4 Research question... 21 3.5 Research constraints... 22 3.6 Data collection... 234 Current situation in healthcare chain... 24
4.1 Insight in healthcare stages... 24
4.2 Path towards key management... 26
5 Performance criteria... 32
5.1 Safety... 32
5.1.1 Technical... 33
5.1.2 Psychological safety and privacy... 34
5.2 Flexibility... 38
6 Solution types and consequences... 42
7 Transformation... 47 7.1 Politics... 51 8 Organizational integration... 52 8.1 Collaboration... 52 8.2 Culture... 61 9 Business integration... 63 9.1 Application... 68 9.2 Infrastructure... 68 9.3 Broader perspective... 70 10 Conclusions... 71 11 Further research... 76
12 Reflection and limitations... 79
13 References... 80
1 INTRODUCTION
1.1 Research setting
This research assignment is conducted at LogicaCMG Groningen, at the business unit Energy, Utilities and Telecom (EUT). LogicaCMG plc. originated on 30 December 2002 from formerly Logica plc. and formerly CMG plc. Both ICT service providers are originally English, however CMG was bigger in the Netherlands than its business in England. Since January 2006, the French Unilog was taken over. This created a third domestic market. In October 2006, WM Data was taken over. WM Data operates in Scandinavia and the Baltic States and this created the fourth domestic market.
LogicaCMG is an international ICT service provider and has nearly 40.000 employees in 42 countries. It belongs to the international top 20 of ICT service providers. The turnover is mostly realized in Europe and Australia.
LogicaCMG delivers various services, such as management and ICT consultancy, system development and integration and it can manage customers’ complete business processes. The company develops and implements solutions for customers all around the world. It makes use of advanced technologies that directly affect business results. LogicaCMG expresses this in her mission statement: “To help leading organizations worldwide achieve their business objectives
through the innovative delivery of information technology and business process solutions.”
This assignment is carried out at the Working Tomorrow-program. This program is started up within LogicaCMG and holds about 120 students. This program supports students throughout various locations for their graduate thesis. Those theses should be innovative regarding technology, concept or methodology. The Working Tomorrow program aims at four goals:
• Delivery of internships
• Stimulating innovation that could increase business results
• Researching social relevant subjects
1.2 Relevance
The ever-increasing computational power and pressure from the government to lower the healthcare cost make domotics feasible in healthcare. According to Rialle, Duchene, Noury, Bajolle, Demongeot (2002) three drivers support the smart homes or domotics in relation to healthcare. First, the economic trend towards the healthcare cost. As is widely known, demographics are changing and people tend to live longer. When the life expectancy increases, healthcare cost for this group will rise. Staying longer at home could temper this increasing cost, thus reducing the number and length of expensive hospital admissions. The second driver is a mounting wish of patients to stay longer at home. This also coincides with the government encouraging citizens to participate longer in society and live longer at their homes. The third driver is the progression of technology that can meet the economic and social needs, such as ICT and domotics sensors.
In accordance with the first and second driver named by Rialle et al (2002), there is a tendency to discharge the patients as soon as possible from a hospital. When patients need further care, they are sent to their home for homecare or to a nursing home1. This fits the patients’ desire to live longer and be treated at their homes. In the Netherlands, approximately 500.000 people get some sort of home care2. In this situation of homecare, different parties are needed to provide some services, such as the homecare organization, general practitioner, paramedics and others.
In case a patient is not able to provide access to healthcare service providers, a problem situation could emerge. This could be problematic specifically when the patient is single, which is according to CBS becoming a trend3. A survey among homecare organizations done by de Bruin, Quak and van Beekum (2005) showed that between 10.000 till 25.000 people for this reason give their key to a homecare organization. This current key-management, by collecting keys and managing them is time consuming and could cause several problems. Sometimes, employees forget returning the key to the headquarters, which causes problems for the next shift. This could create a problem situation and therefore this needs further investigation. In interviews with healthcare consultants at LogicaCMG, a problem situation is defined. The problem situation is the key-management in the sequenced health care. Numerous problems from different perspectives exist. These will be among others elements examined in the preliminary study.
1
http://www.umcg.nl/azg/nl/patienten/opname/5078/
2
Checklist sleutelbeheer: Sleutelen aan een toegankelijke toekomst!, TNO 2005
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2 PRELIMINARY ANALYSIS
The goal of the preliminary research is to recognize a relevant, feasible and useful direction for the central research. For the preliminary investigation, it is wise to use a methodology. In order to choose the right methodology the Systems of Systems methodology (SoSM) by Jackson (2000) could be used. This framework unifies different methodologies and system approaches, in order to advice its users, which approach to use for tackling problems. Therefore, SoSM provides a bigger picture. There are two dimensions in this model, complexity of the system and social relations between the participants. The problem situation here is perceived as complex, due to variety of stakeholders who all have their own interest and their dynamic relationships between them. The system is also considered open to the environment, because of the interactions with privacy laws and health care insurance policies. The stakeholders in this project have different objectives and values, but assumed is that they have enough objectives (such as better key-management) in common to cooperate in this situation. Therefore, it is argued that a pluralistic view is relevant here.
S y s te m s c o m p le x it y
Figure 1 The System of Systems Methodologies (Jackson, 2000)
Soft systems methodology (SSM) consists of seven stages, which is called the learning cycle. SSM does not speak of a problem, but rather of an opportunity or problem situation. The first three steps are relevant here, because these steps create insight in the problem situation. The first stage is called the problem situation unstructured. This is basic research, where the problem situation is explored. The second stage is expressing this problem situation using a rich picture. The third stage is selecting the perspective, a viewpoint to look at the problem situation. The goal of these three stages is to get insight in the current problem situation. Step four is the creation of a conceptual model, which will be discussed in the next chapter.
There is not yet a common definition of ‘the situation’, but there is a common understanding that the situation is open for improvement. The core question here is what improvement for this system is. The goal remains learning to deal with unclear situations, hence the learning cycle.
The problem unstructured
In this paragraph, the unstructured problem situation is investigated. At this point LogicaCMG thinks there might be a problem or room for improvement in the area of key-management. Therefore, an analysis is initiated. The guiding questions here are:
1. Who are the involved stakeholders?
2. What are the current problems in the processes for the stakeholders who play a role in the key management issues?
Home Care Organisation Hospital Physiotherapist Accessibility in healtcare chain Care Instution General Practioner Patient Housing Corporation Secondary Service providers Voluntarily Caregiver
Figure 2 Stakeholder map
Among the stakeholders, interviews have been held by the researcher to gain knowledge about their problems and views. These interviews are carried out in a semi-structured way.
The patient is the central stakeholder, because this stakeholder needs in-home services of some degree. This could be the case after he is discharged from a healthcare institution and needs further care at home. Another scenario emerges when the patient lives at his own home and is becoming less mobile. The patient becomes bedridden (temporarily or chronically) or psychologically not able to open the front door (e.g. demented). The role of the patient in this accessibility situation is to provide access to healthcare providers of some sort, because the patient needs care. It is however not always clear who is the problem owner for key-management. According to home care organizations some patients are not comfortable with giving keys to healthcare providers. (Source: interview patient and homecare organization). However, it is uncertain at this point whether this holds for the whole group of patients. The introduction of the new care insurance law4 has made the position of the patient stronger. The patient needs to be active towards his own ailment, in coordination with patient organizations. The patient is able to choose the desired healthcare, within certain boundaries. With this new law, the patient can hold caregivers and care insurance organization responsible for the right healthcare.5
4
http://www.minvws.nl/dossiers/zorgverzekering/default.asp
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The home care organization as a specific healthcare provider is another very important stakeholder. The homecare organization is able to give three types of services; medical care, domestic care and accompaniment. It needs to comply with the Kwaliteitswet Zorginstellingen,6 which contains global quality demands. For delivering effective and patient oriented care, different standards, protocols and guidelines are set up. In the case of key-management, they are the problem owners, because they feel responsible for care giving (source: interview homecare organizations). They are the ones that provide care for bedridden patients and therefore need access to the residence. This stakeholder primarily deals with the key management problems. A number of issues arose from interview with the home care organizations ThuisZorg Groningen and WoonzorgGroep. Those interviews were conducted by using a checklist made by TNO 2 and asking open questions about the healthcare chain. The problems that surfaced could be categorized into four areas; (a) logistical, (b) financial, (c) privacy and safety, (d) and legal.
a) Logistical problems relate to administration and transportation of the keys. A lot of time is lost with the current management of keys. This is especially true with unplanned care, when keys need to be collected at support-locations. Key registering takes relatively much administration time. In addition, errors in administration occur when keys are not properly returned. Therefore, the current key-management is not always time-efficient and effective. b) Homecare organization WoonzorgGroep is having discussions with different parties in the healthcare chain to create insight in financing this key-management. The patient could pay for a certain solution, like a key-box at the home. However, the homecare organization benefits most, for managing keys is ‘outsourced’ to the patient. Another option for financing is the healthcare insurer. This unclear sense of problem ownership could prevent an implementation of an alternative solution.
c) The privacy and safety problems relate to the feeling of the patients and employees. The employee carries many keys and could be the target of criminals. However, this problem is probably stronger in urban areas then the rural Northern Netherlands. (source: interview
Woonzorg)
d) Safety and privacy feeling decrease when different people have access to the residence. Another problem regarding safety and privacy is the social effect of stigmatizing. Clients feel stigmatized, which decreases their perceived safety feeling, according to the interviewee. For legal problems, its not always clear who is responsible for burglary in case of missing keys. Some homecare organizations have written protocols or formularies that cover liability. At another homecare organization, there is little awareness about such an issue.
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In addition, a general practitioner was interviewed. The government regards the general practitioner as a gatekeeper in the healthcare, which people first consult. The interviewed general practitioner is not having problems with accessibility issues and is not involved in key-management. The general practitioner agrees with the patient upon how and when to enter the residence. The responsibility for accessing the residence lies at the client, according to the general practitioner.
The housing corporation is also important in the accessibility problems. Housing corporations regularly provide extra services regarding easy access to front door and porch entrances, like removing doorsteps. The government is expecting more achievements on care and living, e.g. easy accessible housing from the housing corporations. These expectations are made clear by the addition of living and care section to the BBSH (Besluit Beheer Sociale Huursector), made by the department of VROM (Department of Living, Spatial Constrution and Environment). The BBSH is a protocol with rules to which housing corporations should comply. An interview with a housing corporation however, showed that the corporation is not obliged to provide easy and quick access to healthcare providers. The BBSH relates more to the inhabitants and not to service providers. Therefore, they do not see themselves as problem owner for this accessibility issue.
Care insurer is the organization that is responsible for financial administration and insurance for
the patient. System wide reduction of cost could be a goal to encourage system integration. According to the new insurance law, the care insurer negotiates with the healthcare providers about the price, purpose and the organization of care. The position of the care insurer is stronger than before this new insurance law, because they can choose to contract only the best healthcare providers. Another effect of the change in the insurance law is that insurance organizations can compete with each other on price.
The specialized care organization, e.g. a hospital, is also a stakeholder in the healthcare chain. This organization gives the patient specialized treatment and discharges the patient as soon as medically possible. The patient is transferred to his home or care institution for further care.
The municipality is since the introduction of the Wmo (Wet maatschappelijke ondersteuning)7 the director of providing in-home services to citizens. This law comprises several elements: domestic care, supporting activities and daycare. The government has made the municipality responsible for the implementation of the care providing, because they are positioned closer to citizens. The goal of the Wmo is to create a link between care, living and well-being. The municipality is responsible for financing, executing and policy of the Wmo. The municipality in Groningen is acting as a director
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in the healthcare. Uniting different stakeholders and come to terms into a covenant accomplishes this.
Another stakeholder in the healthcare process is the Centrum Indicatiestelling Zorg (CIZ), an institution that gives an indication about ones need for professional care, e.g. homecare or living in a nursing home. This type of care is paid from the AWBZ (Algemene Wet Bijzondere Ziektekosten), which is a social peoples insurance that covers heavy health risk, e.g. long-term home care due to sickness. The AWBZ is only available after the indication.
Nurse practitioner is the one who among other things coordinates the post hospital care. The nurse
practitioner is seen as a liaison between nursing and medical personnel. The nurse practitioner could give consults to elderly people in care institutions, instead of the general practitioner. According to Thuiszorg Groningen, the nurse practitioner is responsible for collecting integrated nursing and medical anamneses, coordinating healthcare processes around the patient, consulting patients and family, etcetera. However due to the newness of this function, it is not integrated in hospitals in the whole of the Netherlands. Several nurse practitioners work from the Universitair Medische Centrum
Groningen (UMCG).
The paramedics provide also some services (e.g. check-ups, exercises with patients) when the patient is treated at home. These parties need also access to the home, however usually not on a daily basis.
Secondary service providers are e.g. meal-service, pedicure service, hairdresser, etc. These
stakeholders visit the patient irregular, except the meal-service.
Voluntarily caregiver is someone who is usually a relative, which gives intensive care for a long
Problem situation expressed
In this step of SSM, the problem situation is expressed. This is where a rich picture could be helpful to gain an understanding of a situation where the various stakeholders feel a degree of unease (Jackson, 2000). It provides a representation of how we can think about the system. It can be refined as our understanding of the system becomes clearer. The rich picture (figure 3) becomes ‘rich’ by interviewing stakeholders about their issues and worldview about the problem situation.
This rich picture shows a number of issues, e.g. the complex key-management and the desire of healthcare providers to get an easy and flexible access to the residence of the patient. The patient is his home is waiting for care, planned or unplanned. When the patient is not able to give access, the short-term solution is to give away his key. However, this leads to a lower safety perception for the patient, because the patient could sense a loss of control and privacy could be at stake. The nurse practitioner is acting as a liaison between medic personnel and nursing personnel for some types of patients. Also depicted is homecare nurse with many keys and the potential danger of losing or theft of those keys. In line with this key collecting, there is the complex administration of those keys (bottom left). Furthermore, there is a need for other service providers to access the home of the patient, perhaps on a less frequent base. Furthermore, the financing-routes are briefly depicted. In addition, there is the question who finances for the accessibility of the service providers, namely the patient, the service providers, or even the housing corporation. The general path from discharge from a hospital towards acquiring homecare is presented in the top left of figure 3.
Research Direction
There are different systems in this rich picture to be named as described above. The core of SSM is that tackling all the issues in the rich picture would be too complex. To gain some clearness a single perspective is treated independently, also because this research project time constraints. The direction of this research relates to the problems with key-management for the homecare organization. From held interviews with homecare organizations, some key-management conditions emerged. From the patients’ perspective the key-management should be safe, as well as for the service providers. Interviews with consultants at LogicaCMG gave rise that other service providers should also get access to the patients’ residence. Therefore, flexibility is also a condition. These choices for the research direction are partly based on interviews held with different stakeholders and partly based on interviews with healthcare consultants at LogicaCMG. There exists a need to change the current way of handling key-management. This research direction is agreed by healthcare consultants at LogicaCMG and is being judged as relevant by the homecare organization. Therefore the Weltanschauung (Worldview) used here, is the perspective of the healthcare service providers. This choice is made due the fact that these stakeholders are considered as the problem owners.
owner and the environment. By using CATWOE, it will be easier to model the system. The activity safely and flexibly accessing the home of the patient will be used for the system to be modeled. For this activity, the CATWOE will be used.
Customers: Healthcare service providers and patients.
Actors are the healthcare service providers, in particular the homecare organization and perhaps
housing corporations.
Transformation: This starts with inflexible and unsafe way of accessing residences and ends with a
flexible and safe way of accessing homes seen from the perspective of the homecare organization.
Weltanschauung; Easy and safe access for healthcare providers and the patient leads to less
complex key-management and an increased safety feeling of patient (as well as for the employee of the homecare organization).
Owner of the system is the homecare organization.
Environment exists of privacy laws, financing issues (e.g. allowance policies) and innovations
issues.
Together with CATWOE and the transformations, a root definition is formed. This could look like a mission statement, a common understanding of a certain activity. According to Checkland and Scholes (1999, p36) a ‘full’ root definition’s core transformation should be ‘a system to do X by Y in
order to achieve Z’. In this case, the root definition could be defined as:
“Giving the healthcare service providers a safe and flexible access by using ICT / domotics (without reducing the safety perception of the patient) in order to make the process of accessing homes of patients more time-efficient”.
Healthcare chain
Accessibility issues
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Ou t o f s co pe Level 1 Level 2 Level 3 Level 4Figure 4 Demarcation funnel
3 METHODOLOGY
Now that the research direction is made clear by conducting the preliminary study, a methodology for the main research is needed. In the preliminary analysis, interviews with healthcare consultants and stakeholders were held and relevant literature and background was studied. This input is used to form the methodology and the focus.
3.1 Research objective
To form the research objective, Verschuren and Doorewaard (2005) is used. Therefore the research objective consists of a “what” and a “how” part. The “what” part specifies the expectations of this thesis. The goal of this research is to give LogicaCMG and different (healthcare) service providers on the one hand insight into how given accessibility criteria validate alternative solutions for accessing patients’ residence and on the other hand give advice on how different service providers can use a solution integrative.
3.2 Conceptual model
Soft systems methodology continues with step 4, the creation of a conceptual model. This symbolizes the researcher’s vision of the situation. This model is based on the problems that surfaced in the preliminary study and on the research objective.
3.3 Definitions
Accessibility
This term relates to the different processes executed by the patient and/or healthcare service provider to give the healthcare provider access to the patient’s house.
Safety
Safety is a state in which or a place where you are safe and not in danger or at risk. Safety in this case could be divided into technological safety, psychological safety and privacy issues.
Flexibility
In the conceptual model, flexibility relates to the ability to change or be changed easily by giving different stakeholders access. In this case, various healthcare service providers should gain access relatively easy. Therefore, the solution needs to contain a generic element, to encapsulate different parties.
Enablers
Enablers are factors that facilitate the implementation of efficient access. These enablers could be divided into 3 elements set by Davenport (1993); Human resource, Organizational and ICT.
Barriers
Barriers are factors that obstruct the implementation of effective access. According to the report ICT
in de Care 2004-2006,8 the barriers relate to unclear financing and the aversion against ICT. These elements affect the implementation of an innovative solution.
Explanation conceptual model
The accessibility solution for healthcare providers needs to comply with a number of criteria. These performance criteria arose from the preliminary study. These criteria are safety and flexibility. The former criterion emerges from requirements of homecare organization and requests of patients. LogicaCMG defines the latter criterion. These performance criteria affect the type of solution and perhaps its implementation. To implement and support a (to some extend generic) solution or service, there are various factors which have a positive (enablers) or negative (barriers) influence realizing this solution. These factors are researched.
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3.4 Research question
What alternative solutions for accessibility exist given the performance criteria and what actions need to be taken in order to support a solution for different healthcare service providers?
To answer this research question, this main question is divided into five sub questions. These questions arise from the conceptual model.
1. How does safety affect an alternative solution for accessing homes?
In order to find the relationship between solution and safety, it is necessary to define and elaborate the term safety in an accessibility context. From this elaboration, solution requirements could be set. Because safety is a wide conception, this is divided into technical safety, psychological safety and privacy.
2. How does flexibility affect an alternative solution for accessing homes?
In order to find the relationship between solution and flexibility, it is necessary to define and elaborate the term flexibility in an accessibility context. From this elaboration, solution requirements could be set.
3. What are possible solutions for entry and what are the consequences?
A literature study is performed to find numerous alternatives and they are categorized in a matrix. These solutions are validated against the performance criteria in sub question 1 and 2.
4. What are the barriers and enablers for implementation an innovative access solution in the healthcare?
A literature study is performed and interviews are held to find barriers and enablers for innovation.
5. In what way could an accessibility solution be supported in a way that different healthcare service providers could benefit?
3.5 Research constraints
The boundary conditions could be divided into two parts. Firstly, the research outcome is an analysis of problems and recommendations regarding the accessibility problems at residents who need home care. This is in the form of an advice report.
Secondly, some boundaries conditions need to be set in the research process. The available time for this research is 16 weeks. The research will aim at the troubles caused by accessing patients’ homes perceived by healthcare providers. The patient has a few specific characteristics. He needs home care of some degree. This patient is physical or mental not capable to give access to his home by opening the door. This could be the case when the patient is bedridden, demented or for instance deaf. There is no exception made regarding demographics, as long as the patient has no one to open the door from the inside.
3.6 Data collection
After the problem situation is made clear in the preliminary research, the research goal is presented. To answer the five sub questions, mentioned in paragraph 3.4, data needs to be collected. This data is collected by interviewing different stakeholders, attending a workshop and a congress and studying relevant scientific literature, policy reports of the government and reports from consulting organizations. This research is of an explorative nature resulting in quantitative data.
These interviews were conducted after an appointment made by telephone and took about 1 hour and 15 minutes. The interviews are semi-structured and contain a number of open questions asked by the researcher, which was used as a guideline. The researcher tries to let the interviewee as free as possible, to extract implicit knowledge and reduce the selection bias. The emphasis during these interviews is placed on key-management related problems. These interviews are elaborated into a digital document and send back to the interviewee for eventual correction. This increases the reliability of these interviews. Conclusions are drawn from these interviews.
4 CURRENT SITUATION IN HEALTHCARE CHAIN
4.1 Insight in healthcare stages
In this chapter some insight is given, to place the accessibility in the healthcare chain context. This research aims at people with a chronic disease as the main target group. However temporarily disabled people should not be excluded as into the target group. Regarding people with chronic disease, according to Van Eijk and de Haan 1998) there are three different stages of chronic disease. The first stage is where the crisis for the patient emerges. In this phase, the patient has some complaints and symptoms and consults the general practitioner. Sometimes the general practitioner can diagnose himself while in other cases the patient is referred to a specialist. After the diagnosis, the patient becomes aware that the chronic disease will influence his/her life. The chronicity phase is from stabilization towards complication. The self-care abilities may not be sufficient anymore. This means that the patient experience complications and needs more care from social network or professional help. In the case of chronic illness, the general practitioner is the main care provider. The terminal phase is the last phase described by van Eijk and de Haan (1998). Heavy dependency is placed upon family and care providers. The general practitioner is guiding the patient and family in this terminal phase. In the chronicity phase, there is usually the opportunity for self-care (van Eijk et al, 1998). The general practitioner and a district nurse play an important role in the home care in the Netherlands (van Eijk et al, 1998). The chronicity phase is most important in this context, where transdisciplinary collaboration is needed. One segment of this collaboration is gaining access to a patient’s house, when self-care is no longer sufficient.
Close collaboration and joint responsibility
In the literature, there are different terms for healthcare chain integration, such as transmural healthcare, multi agency healthcare or healthcare chain. In this thesis, the term healthcare chain will be used. Healthcare chain is defined by the Inspectie voor de Gezondheidszorg (IGZ) as “an interconnected set of care strains by various care providers at one patient who has a certain disease”. The mission of the IGZ is promoting a safe, effective and patient oriented care9. Care chain originates when there are formalized agreements between different types of healthcare providers. The goal of care chain integration has also been subject of a survey executed by the IGZ. Making the care more effective and efficient and increase the patient orientation are main goals of the IGZ. Important in the care chain integration is making a set of agreements to increase efficiency. The IGZ made a few recommendations for developing a (better) care chain.
• Give insights into the consequences for the care chain as whole. This is done so that solutions at the start of the chain exclude problems at the end of the chain.
• Arrange multidisciplinary meetings to create a mutual understanding of tasks and processes.
• Various parties should take their responsibilities to implement a care chain and communicate their protocol explicitly to other partners in the care chain.
• Government should aid the care chain by reducing the financing and law.
• There should be one coordinator in the care chain, like a general practitioner or nurse practitioner, and communicate this through-out the chain.
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4.2 Path towards key management
The need for in-home services starts when the patient feels an unease of mental or physical wellbeing. He could consult the general practitioner. The general practitioner is the first consult point for the patient. The general practitioner is seen as gatekeeper in the healthcare, as stated by the
Landelijke Huisartsen Vereniging (LHV).10 If the patient needs specialized treatment, he is sent to a hospital for treatment and after a while discharged.
When the patient is discharged from a cure organization (e.g. hospital), he/she could need homecare of some degree. The patient can appeal to care paid from the AWBZ. There are four main events distinguished here. (1) An appeal for care, nursing, treatment or stay in nursing home is made by the client. (2) The CIZ (Centrum Indicationstelling Zorg) criticizes the request for remuneration of AWBZ care. (3) This indication ordinance states whether the requested AWBZ care is financed and for what period. If this request is granted the indication is sent to a regional healthcare office. (4) The last main step in this process is the mediation of care by the regional healthcare office accordingly to the indication, e.g. aiding in the choice of a particular homecare organization.
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After acquiring homecare financed by AWBZ, some patients indicate they aren’t able to give access to their home by themselves. A homecare employee is notified, and the key-transfer is initiated. The client delivers the key; both parties sign a key formulary. This formulary is stored at the homecare organization and a copy is given to the client. The key is stored and a coding list is adjusted with the relevant data. The coding list represents a number, which is attached to the key. It is important that the key-number and the personnel data, e.g. address are separated, to secure the safety of the client. The steps in the business processes for accessing are shown in the following figures, starting with figure 6. These steps are represented by using the Actor Activity Diagramming (AAD).11 The grey boxes stand for an activity executed by the corresponding actor. The white boxes represent a delivery of services or goods. The special C and D white boxes respectively stand for à charge and à décharge, meaning start and end point for processes.
Home care organization Key-management
ACTOR ACTIVITY DIAGRAM
Patient Homecare organization Employee Can’t give access to residence itself Notify Access given Allotment to employee Key transfer Sign key-formulary Store formulary
Send copy formulary
Store key
Adjust codinglist
Figure 6 Current key management at homecare
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When homecare is no longer required, the client’s key needs to be returned. The organization administrates this deregistration. The key is returned to the client; both parties sign the key-formulary. This is administrated in the care dossier, as depicted in figure 7.
Home care organisation Cancellation key-management
ACTOR ACTIVITY DIAGRAM
Patient Home care
organization Employee Care is no longer needed Assign employee Process data Collect key
Sign form for received key
Case closed
Object
Process data
Figure 7 Care cancellation relating key-management
The process outlined beneath is the focus of this thesis. This process is executed on a daily basis. There is a difference in the situation of unplanned care giving compared to planned care giving. Therefore, both processes are described. When care is needed, the employee collects the correct key based on the coding list and if necessary signs a checking list.
Home care organization
Care providing with key management (planned care)
ACTOR ACTIVITY DIAGRAM
Patient Employee Homecare
organization Needs care Collect keys Provide care Access residence Administration Administration Care provided Travel to patient Store key Travel to office
The unplanned care occurs in situations where clients are subscribed to an emergency response service. The patient needs unplanned care (outside office hours) and contacts the emergency room. The employee is contacted and collects a key at support location where the key is stored during after-office hours. After some administration, the employee travels to the residence of the patient to provide care. Afterwards the key is returned to the support location, where some administration is conducted.
Home care organization
Care providing with key management (unplanned care)
ACTOR ACTIVITY DIAGRAM
Patient Employee Homecare
organization Emergency room Needs care Collect keys Provide care Access residence Administration Administration Care provided Travel to patient Store key Call employee Collect key at support location Travel to support office
5 PERFORMANCE CRITERIA
To support safe access for the patient and flexible access for healthcare service providers, domotics and the support IT need to fulfill some performance criteria. These criteria are depicted in the conceptual model (figure 5). These performance criteria have a certain influence on an alternative (domotics) solution. Therefore, in this chapter an answer to the first two sub questions will be given, which relate to the performance criteria.
5.1 Safety
As Rialle et al (2002) state, in-home apparatus must suit the patient’s need in order to ensure their safety and privacy. Privacy will be discussed in paragraph 5.3. Safety is a very important criterion, for this criterion heavily affects the patient, but also the reliability of the accessibility. The term safety is too wide to be useful here, therefore safety should be subdivided. The separation is as follows; (1) technical safety of the service/solution (e.g. reliability), (2) psychological safety perceived by the patient and healthcare service provider (e.g. stigmatization, a safe entry for healthcare service provider) and (3) privacy (e.g. who and when someone can enter). This is depicted in figure 13.
5.1.1 Technical
Technical safety can be divided into a number of elements. This could be material requirements, which need to be set by the supplier of the solution, as there are the experts. This choice will be briefly reviewed. An aspect of the technical safety could be measured as the time an intruder needs to break into the house. There are two quality marks, which operationalize the technical safety. First, there is the police quality mark safely living (PKVW)12. This quality mark goes beyond the safety of the front door as a holistic approach is used to safeguard the whole house. The Stichting
Kwaliteit Gevelbouw (SKG) quality mark is the second quality mark. This mark measures
mechanical elements of locks, which should not disintegrate within 3, 5 or 10 minutes13. The material’s choice is taken at the supplier of a certain alternative solution.
Another requirement is the communication between the front door or safety lock containing a key and the key (e.g. mobile phone, electronic card, master key). There are a number of wireless communication protocols, such as IrDA, Bluetooth, RFID or NFC. Infrared Data Association (IrDa) designed a protocol to communicate on a wireless basis through infrared signals, with a short range (< 1.0 meter) and small angle (<15°). Bluetooth is a protocol originally designed to reduce the cabled communication between laptop, PDA’s or mobile phones. This wireless communication has a range which varies between 10 and 100 meters, is isotropic (no specific angle required to connect to another device) and incorporates a build-in security. Radio frequency identification (RFID) is an identification method, using radio waves distinguished by a different frequency. The higher the frequency, the higher the range (between 0.5 until 10.000 meters). There is no standard security present, which need be included explicitly. Privacy becomes an issue, due to the great range and lack of standard security. Near field communication is a specific communication technique which uses RFID’s high frequency (13,56 MHz), which makes the range as short a 4-20 cm. This short range increases safety; however, NFC does not ensure secure communications. However, NFC security protocols has been developed within the Working Tomorrow program (Donker, 2007). A NFC tag is easily implemented into a mobile phone.
Donker (2007) in his research thesis provides us with some directions as he discusses the former four protocols. He concludes RFID and NFC are techniques that are very useful for accessing buildings. IrDA and Bluetooth are less useable due to usability issues, hardware security (specifically for IrDA) and efficiency and response time (specifically for Bluetooth). Response time
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http://www.politiekeurmerk.nl/
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could be become an issue for both the patient and healthcare service provider, however these response times are all within 6 seconds.
Using NFC, with a passive RFID tag within a mobile phone, in accordance with a new protocol called MGMS (Multifunctional Geïntegreerde Mobiel Sleutel) could also preserve privacy and security due to decoded messages and encrypted keys. For further details, see Donker (2007).
5.1.2 Psychological safety and privacy
According to Smorenburg, Kievit, van Everdingen and Wagner (2006) patient safety is “the almost absence of the chance for the patient to be harmed in a physical and/or mental way, emerged by not handling according professional guidelines or shortcomings of the healthcare system”. It is important according to Rialle et al (2002) that domotics and their techniques are not merely seen as reasons that save money and time. Acceptance of these techniques would be difficult. This is especially true when besides domotics for accessibility also tele-monitoring is implemented, as isolation issues come to play. This psychological safety could be alienated for the patient as well as for the healthcare service provider. However, the focus is placed onto the patient, because they are involved most in this case. Different pilot projects throughout the Netherlands implementing domotics, described by NiWZ14, show that elderly inhabitants prefer safety functions such as emergency response or entrance by video above other home automation functions, e.g. automatic/ remote control of opening and closing a curtain.
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Increa ses Decr ease s In c re a s e s
Figure 11 Influential factors for patients’ psychological safety
As depicted in figure 11, this conceptual model tries to give insight of some effect onto the patients’ psychological safety. By autonomy is meant the self-control regarding giving access to a certain healthcare provider. By letting this decision in hands of a mentally capable patient, from logical reasoning the researcher states that this has a positive effect on the patients’ psychological safety. Stigmatization in this situation means that a certain accessibility solution brands the patient as one who needs healthcare and the related decreased mobility. So branding a patient in this way could for instance provoke burglary, which obviously reduces the patients’ feeling of safety. Trust as depicted in figure 11, is seen as the trust in a alternative (domotics) solution and the trust in the healthcare provider. Trust could also be argued to increase the patients’ safety. In the next paragraphs, we will zoom in on these three elements.
could be the case when the patient becomes demented (this could be chronic) or temporarily when the patient has fallen and is not able to grant access. Therefore, it is important to make the difference between mentally disabled and physically disabled. This difference categorization is illustrated in figure 12.
Mentally disabled Physically disabled
Planned care Unplanned care Type 1 solution Type 4 solution Type 3 solution Type 2 solution
Figure 12 Difference matrix
Another factor influencing is the stigmatization effect. Stigmatization means to accuse or condemn or openly or formally brand as disgraceful15. In this context, when the accessibility solution can be seen from the outside world, the patient could be stigmatized as requiring care and having reduced independence. This could provoke theft or burglary. Therefore, it is argued that stigmatization reduces the psychological safety perception. To increase this psychological safety, an option would be to make the accessibility solution non-visible for the outside world.
Trust in figure 11 relates to trust in automation technology and in the healthcare provider. Trust in the technique is among others described by Ho, Kiff, Plocher and Haigh (2005) and Miller, Haigh and Dewing (2002). As the latter states, technology should not lead towards an isolation of the patient. In addition, the patient should trust the technology; however, the reliance should not be too great to become complacent to automation errors. Ho et al (2005) mentions different studies which prove that older users trust automation devices, and furthermore may be expected to not succeed in
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grasping detecting and correcting an error of such a device. (e.g. Lee, Stone, Gore, Colton, McCauley, Kinghorn, Campbell, Finch and Jamieson (1997) and Ho, Wheatley and Scialfa (2005)). Reasons for this trust and reliance towards automation are fivefold according to Ho et al (2005). These will be briefly discussed for guiding a direction; (1) Attention-Allocation, which states that elderly trust automation devices and reroute their attention outside the automation system. As a result, they tend to miss errors. (2) Deficits in Working Memory explain why older users of automation rely more on automation devices. (3) The mental workload is perceived higher for elderly compared to younger users of automation devices and errors exceed the standard workload. (4) Decision-making of elderly is different from their younger counterparts as they use heuristics processing under pressure. In complex situations, this heuristic type of processing leads to a satisfying solution instead of the most appropriate (Simon, 1955). (5) Interpreting Stochastic information relates to the idea that elderly will be less adaptive to “notice or adjust their usage of
automation because they fail to recognize the frequency of faults”.
The direct influence of trust onto patients’ safety is somewhat deserted in the literature, however Entwistle and Quick (2006) try to address this void. They state that trust is not limited to circumstances where no risk is involved. It gets applicable when in this context the patient is potentially susceptible at the hand of others. Such is the case in the accessibility context. A breach in trust towards the healthcare provider could be reduced by pointing out the competence of the healthcare provider (Entwistle and Quick, 2006). A concrete example to increase the patients’ safety perception is providing a kind of certificate that states a proof of good behavior, as is the case at Woonzorg Groep. For the healthcare provider psychological safety is also an issue. Healthcare providers are carrying numerous keys during planned care, which could provoke theft; this is more conceivable in rural areas then the countryside in the Northern Netherlands (source: interview WoonzorgGroep). Choosing the right organization based on prior experience is a manner to increase trust for the patient (Entwistle and Quick, 2006). Another attention point is the trust in the patient itself, which is out of scope here. For further details see Entwistle and Quick (2006).
In this context, privacy relates to unwanted entry of the house (physical) and distribution of personal information supporting accessibility, e.g. medical records (informational). Unwanted entry could be nullified by the earlier mentioned autonomy or self-control to grant access to healthcare providers. 5.2 Flexibility A cc es sing Patient Paramedics Homecare organization General Practitioner A c c e s s in g Acc essi ng Door
Figure 13 Flexibility in the accessibility context
Flexibility is the quality of being adaptable or variable.16 Flexibility in this research context is the adaptability for other (healthcare) service providers to gain access to the patients’ residence. This complexity is modeled in figure 13, where different service providers are presented gaining access with different tools. Flexibility is a precondition set by LogicaCMG to give multiple healthcare service providers flexible access to the patient. Therefore, various partners in the healthcare chain need to cooperate in order to deliver the patient the right service. A scenario, depicted in figure 14
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Patient Meal services Consult general practitioner Providing in-home services Transportation service Voluntary caregivers Nursing home Planned home-care visitation Emergency response Alarm response Shopping delivery services
Services in the accessibility scenario
Hospital Maintenance services
As illustrated in figure 14, numerous parties are incorporated in the healthcare chain, such as homecare, general practitioner, paramedics, meal services and others. A true sequenced health chain focuses their services together to serve the patient. Each of those parties provides their own services towards the patient, which are depicted in figure 14.
To concede to flexibility, different parties should be seen as different modules in the total system. The system here is the gathering of organizations and their interfaces or interrelationships in the accessibility context. To become flexible, the architecture of this system should be modular based. Allen and Carlson-Skalak (1998) define a module as a component or chunk, which has a unique function within the product or solution. When this specific module is removed from the product or solution while the product still functions. Ulrich and Eppinger (1995) ascribe two characteristics to modular architecture. First, a chunk implements one or some functional elements into the whole. Secondly, the interactions between these chunks are clearly defined and contain the primary functions of the product. The advantage of a modular based architecture in this context is the cushiness to incorporate numerous services. Decoupling of tasks is one advantage described by Erixon, Erlandsson, Ostgren, and Von Yxkull (1994) which could be useful in this case. A modular system would be practical, because different instances or organization could be seen as modules, which in turn could be assigned, as a task or service. For example, the general practitioner is seen as a module in the system, which provides a service namely consulting the patient. When removing the general practitioner from the system, the system would not disintegrate.
6 SOLUTION TYPES AND CONSEQUENCES
In the previous chapter, the performance criteria are studied in depth. In this chapter, sub question three is answered. This question is tries to validate different alternative solutions against the performance criteria. In addition, at the end of this chapter a connection is made with the first two questions regarding these criteria. The chosen solution depends on two factors, whishes from the patient and from the healthcare provider. Some patients do not want the outside world to see that they are in need for care. This feeling is called stigmatization, which is described in the former chapter. In addition, there are a number of contextual factors. These will be briefly described. The first relates to the type of housing, privately owned or rented. It is not always possible to change or implement a solution, due to e.g. monumental status of the property or lack of permission from a corporation to alter the front door. Secondly, the type of care has its affect on the solution, whether it is planned vs. unplanned care. Thirdly, the type of disease of the patient is important. This could be a mental or physical disability. The second and third factors are earlier modeled in figure 12, chapter 5.1.
Due to the quickened discharge from hospitals, people receive longer care at home. Therefore, special interest is placed onto the long-term solutions where domotics to some degree are used. The choice for domotics fits in the growing trend to implement domotics as tele-monitoring for elderly care. Short-term solutions, such as a central key closet at the homecare office for key-management are consequently not used for further investigation. Current long-term solutions for key-management are discussed below. In the following solutions, a mobile phone is seen as special entrance device. The assumption is made that a mobile phone is common good and does not need to be returned to or collected from a supporting location. These solutions are a combination of Delville and Knuvers (2007) and the report of TNO17:
• Key locker at client, outside of the house. The front door key is stored inside this locker. This lock is opened with a (magnetic) key. This solution has the advantage to keep the current key and lock. Disadvantage is the stigmatization perception of the client. In addition, the service provider still needs to bring a (magnetic) key and is less suitable for housing complexes.
• Key locker at client, outside the house. The front door key is stored inside this locker. This lock is opened by mobile phone, so no special key needs to be collected and returned. Privacy is more guaranteed and this is suited for unplanned care. A disadvantage could be that this is less suitable for housing complexes and the perceived stigmatization.
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• Key locker inside the door or house with a sort of key dispenser. This locker is opened through a PIN code or by calling an emergency room. The same advantages and disadvantages count as for the former solution, except for the stigmatization effect. The solution is after all not visible. This solution is also less suitable for housing complexes, due to porch entry usually needing another key.
• An electronic lock remotely opened by the client. Advantages are the perceived control of the client, which enhances the privacy feeling. This is however not always possible for mental disabled patients. A disadvantage is the big change made to the door, e.g. electricity measures.
• An electronic lock opened by an emergency room. A service provider guarantees privacy, due to controlling the entry. A service provider calls the emergency room that verifies the authorization. In addition, this solution is not visible for the outside world and suited for unplanned care. A disadvantage is the big change made to the door, e.g. electricity measures.
• Adapted lock opened by a programmed key, such as an RFID tag. Advantages are that the service provider does not need to call an emergency room. Disadvantages are the heavy change made to the door and the collecting and returning of such a tag. This could be tackled by implementing a RFID or NFC tag in a mobile phone.
TNO in their report18 mention a number of existing solutions categorized into short term and long term solutions, whereas solutions mentioned by Delville and Knuvers (2007) could be categorized as depicted in figure 15. There is a clear distinction between adaptation to the front door or lock and a difference in entrance with or without a device, such as a RFID card.
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No adaptation to lock Adaptation to lock Entrance with device Entrance without device
Safe outside house, opened by PIN code
Box inside door/ residence command
post Key exchange lock
by key,masterkey magnetic key or
mobile phone
Access through mobile phone
(client-side) Access given by emergency room (alarmresponse) Access by masterkey Remote access by e.g. RFID,NFC card
Access by transmitter (client-side)
Figure 15 Categorization of solutions for accessing residence
After a literature study was performed for finding alternative solutions for accessing, the researcher created and filled a solution score table as depicted in figure 16. In this figure, alternative solutions are validated against the performance criteria. Besides the earlier mentioned safety and flexibility criteria, adaptation to housing and efficiency is added. Adaptation to the house comprise contextual factors, which also should be accounted for. These contextual factors are mentioned in the beginning of this chapter. Efficiency is used as this is mentioned in the root definition on page 16. Cost is not mentioned here, because this depends on many factors such as new development of housing, number of solutions implemented, etc. Therefore, this is too difficult to give clear insights given the time constraints. Therefore, this scoring table should be used as a guideline. Weighting factors can be added, to set importance to specific criteria. Here is a brief recap of the criteria used:
• Technical safety relates among others to burglary issues.
• Psychological safety relates to self-control or perceived autonomy.
• Flexibility relates to using the system by multiple service providers.
• Adaptation to housing relates to chancing door or locks.
Criteria
Solutions for accessibility Total
Short term
Central key-closet at homecare office 4 3 2 5 1 15
De-central key-closet in care district 3 2 2 5 1 13
Long term
External key locker at client, opened by normal key 2 2 2 4 2 12
External key locker at client, opened by mobile phone 2 2 5 4 5 18
Internal key locker at client open by normal key 4 4 2 3 2 15
Internal key locker at client, opened by mobile phone 4 4 5 3 5 21
Eletronic lock remotely opened by client 5 5 4 2 5 21
Eletronic lock remotely opened by emergency room 5 3 5 2 5 20
Electronic lock remotely opened by employee (e.g. RFID) 5 3 5 2 5 20
Generic key 3 3 3 3 3 15
Score between 1 and 5 Higher is better
T e c h n ic a l s a fe ty A d a p ta ti o n t o h o u s e E ff ic ie n c y ( ti m e w is e ) P s y c h o lo g ic a l s a fe ty F le x ib il it y
Figure 16 Alternative scoring table
An electronic lock remotely opened by the client is ranked as one of the highest. Psychological safety is perceived highest from a patient’s perspective. However, this does not mean that this type of solution is applicable in all situations. As stated earlier contextual factors could prevent a successful implementation. When the patient is mentally disabled, the solution would be sub-optimal due to plausible inability of the patient to use the solution. This solution is better suitable for physical disabled patients with planned or unplanned care.
as rights could be granted to service providers. In addition, this solution is among others still flexible, because of using a mobile phone that could be considered standard gear nowadays.
An electronic lock remotely opened by an emergency room is also a good option. Flexibility is granted because service providers could call the emergency room. Psychological safety is perceived lower, due patient’s autonomy could be less. Reason for this is the remote opening of their door. However, if these trust issues are overcome, this type of solution could be promising.
The last good choice is an electronic lock remotely opened by a service provider. Access could be given by placing a RFID/NFC tag against a receiver that opens the door. The restriction here is that such a RFID or NFC tag must be implemented in a (privately owned) mobile phone. If a tag should be retrieved from a support location, the efficiency benefit disappears.
