EHEALTH INNOVATIONS: GETTING FROM A PILOT TO SCALE UP
Irene Menkveld S2701049
i.menkveld@student.rug.nl
Supervisor: M.L. Hage, PhD Second Assessor: E.I. Metting, PhD Supervisor de Friesland: R. Poel, MSc
22 June 2020
Master Thesis
Faculty of Economics and Business
MSc Business Administration, Specialisation Health University of Groningen
ABSTRACT
eHealth has the potential to address several challenges faced in healthcare, however implementation at a larger scale is challenging. While literature is mature on the adoption and implementation of eHealth, limited research has been conducted on how eHealth innovations reach a scale up. Furthermore, research to date has not yet determined how the wider system influences the scale up of eHealth innovations. This study explores how and why eHealth innovations reach a successful scale up. By providing an empirical analysis of eHealth practices in three healthcare sectors in the Dutch healthcare system, a comparison could be made and the effect of variations in the wider system could be assessed. Important factors that influence scale up are identified. The findings show that to scale up eHealth, it is important to recognize the interaction and to find alignment between the wider system, organisation and technological intervention.
INTRODUCTION
eHealth, the use of health and care information technologies in order to deliver or support healthcare (Eysenbach, 2001), has the potential to address several challenges faced in healthcare (van Gemert-Pijnen et al., 2011). Despite successfully localized implementations of new eHealth innovations, implementation at a bigger scale is often difficult (Greenhalgh et al., 2017).
There is a need for implementing eHealth at a larger scale, as the healthcare system has to cope with several changes. A contemporary challenge is the need for more affordable healthcare systems to handle the rising health expenditure per capita (CBS, 2019; Gopal, Suter-Crazzolara, Toldo, & Eberhardt, 2019). Causes are predominantly an increase of prices, expensive technological developments and an aging population (Aujoulat et al., 2008; Johansen, Loorbach, & Stoopendaal, 2018). The latter results in a growing number of chronic patients and an increased demand for healthcare. Furthermore, the well-being of healthcare professionals needs to be considered, as they often deal with burnout and dissatisfaction, due to an increasing workload, a high administrative burden and a scarcity of staff (Bodenheimer & Sinsky, 2014; Nictiz & Nivel, 2019). Another change in healthcare is the shift from a physician-centred approach to a patient-centred approach. The patient-centred approach is characterized by the patient having a more central role in their treatment (van de Bovenkamp, Trappenburg, & Grit, 2010). They are better informed about their health status and actively participate in the treatment process (Johnson, 2011). The use of eHealth can give patients insight into their health status (Aujoulat et al., 2008). All in all, eHealth has the potential to help overcome the aforementioned challenges, as it facilitates care remotely and it can replace or alter existing routine processes of healthcare professionals to make their work less demanding (Black et al., 2011; Verhoef et al., 2019). Hence, eHealth is seen as crucial in reaching the objective to decrease costs, while facilitating and improving the care delivered and moving towards patient empowerment (Aujoulat et al., 2008; Nictiz & Nivel, 2019).
unsuccessful (Greenhalgh et al., 2017). In sum, eHealth should be scaled up to reap all its benefits, however, attempts to scale up eHealth often fail.
Barriers for scaling up exists at multiple levels of the healthcare delivery, for example in the wider healthcare system, at the organisational level, at the provider team or at the patient level (Damschroder et al., 2009). It could for example be that there are problems in the process prior to implementation, such as technical issues with the technology or finding funding for the new technology. Problems may also arise in the implementation process in the sense that the technology is not adopted by the user community (van Limburg et al., 2011). Healthcare practitioners and patients might for instance be sceptical about using some eHealth innovations. They may think it is not beneficial for them to use the technology (van Limburg et al., 2011). The failure or success of a new eHealth innovation is thus highly dependent on several factors, such as the design of the eHealth innovation itself; the implementation factors; the involvement of the different stakeholders; the organisation; the wider system; and interactions among these in the process (van Gemert-Pijnen et al., 2011). Concluding, there are various factors and perspectives that need to be taken into account in an attempt to scale up eHealth. Theoretical frameworks are useful to plan the scale up (Walters, Scott, & Mars, 2018), as they provide us with the convenience of a systematic way of thinking about scaling up. Frameworks are comprised of multiple factors, differing per framework. Following the change model of Pettigrew and Whipp (1991), these factors can be classified in terms of ‘’content’’, i.e. the eHealth technology, the ‘’internal context’’, referring to where the eHealth needs to be implemented, the ‘’external context’’, referring to the wider system, i.e. the economic, financial, regulatory, legal, political and social context and the ‘’process’’; how the change process will be shaped. There are some frameworks in the current literature concerning the scaling up of health interventions like eHealth, such as the ‘’Consolidated Framework for Implementation Research’’ (Damschroder et al., 2009), or the ‘’Framework for Going to Full scale’’ (Barker et al., 2016) and several others. However, most literature is not published in a peer reviewed paper (Cooley & Kohl, 2006; Cruickshank & Beer, 2010; IBPC, 2007; Jensen et al., 2015; WHO, 2009; WHO, 2015) or lacks empirical investigation (e.g. Damschroder et al., 2009). Furthermore, part of the few scholarly contributions that have been made to this domain are conducted in low to middle income countries (Barker, Reid, & Schall, 2016; Leon, Schneider, & Daviaud, 2012) and their findings may not be generalizable to high income countries. All in all, previous research has investigated the scaling up of health interventions, however, the research field is still limited in scope and empirical evidence.
adequately taken into account. Research to date has not yet determined how these external context factors contribute to the process of scaling up. Concluding, literature is mature on adoption and implementation of eHealth. Scaling up should be planned deliberately: the eHealth innovation and the implementation process needs to be adapted to the specific context to have a chance of succeeding (Lanham et al., 2013). However, literature lacks investigation of complexities in the external context. What are the financial, regulatory, legal and political influences on stakeholders and consequently, on the scale up process? There is a need to deepen the understanding of how processes in the wider healthcare system influence the scalability of new eHealth innovations.
It is important to fill this gap, as complexities in the external context such as financial and regulatory issues and often related conflicting interest and diverse perspectives of stakeholders can have a significant impact on the scalability of eHealth technologies (Greenhalgh et al., 2017; van Limburg, et al., 2015). What are these factors in the Dutch healthcare setting? And how and why do these influence the process to get from a pilot to a scale up? All in all, this study focuses on the following research question: “How and why do eHealth innovations reach a successful scale up in the Dutch healthcare setting?”. Accordingly, this study aims to investigate the scale up of eHealth initiatives in the Dutch healthcare setting by examining the complex external context in which they are embedded. Furthermore, developments in the Dutch healthcare sector which may facilitate eHealth scale up are investigated. Data was collected through an analysis of five empirical case studies by means of qualitative semi-structured interviews.
This study contributes to innovation research by increasing our understanding of how complexities in the external context influence the process of scaling up. Through gathering perspectives on scaling up eHealth from different stakeholders such as healthcare managers, clinicians, insurers and IT suppliers, a comprehensive image could be established. By providing an empirical analysis of three healthcare sectors and eHealth practices in the Dutch healthcare system, a comparison could be made and the effect of variations in the external context could be assessed. It is important to recognize the interaction between the external context, internal context, content and process, as these are co-dependent. To scale up eHealth it is crucial to find alignment between these aspects. This is of practical significance as these insights can help key stakeholders to scale up eHealth. In the end it contributes to the wider spread use of new IT innovations in healthcare, which could contribute to accessible, affordable, valuable and sustainable health services.
LITERATURE REVIEW
eHealth
Eysenbach (2001, p. 1) defines eHealth as ‘’Health services and information that is delivered or enhanced through the internet and related technologies with the goal of improving healthcare by using information and communication technology’’. eHealth is increasingly used to deliver or support healthcare, in order to provide better care (Eysenbach, 2001). It has the potential to diminish costs, while improving the quality and access of care (van Gemert-Pijnen et al., 2011). There are three main areas where eHealth technologies deliver value. These are (1) the storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance (Black et al., 2011). The latter is often referred to as telecare. Its use increases the access to healthcare (Agarwal, Gao, DesRoches, & Jha, 2010), as care can be delivered at the homes of individuals instead of at a healthcare institution (Barlow, Bayer, & Curry, 2006). In terms of patient empowerment, eHealth facilitates self-management by giving patients the opportunity to have insight into one’s own health data, informing them about their condition. This can foster collaboration between healthcare provider and patient, as it gives the patient the ability to make informed choices. It can also foster self-care activities (Alpay, et al, 2010; Aujoulat et al., 2008). eHealth has thus the potential to deliver value in various areas.
Scalability of eHealth: the content, context and process of strategic change
Figure 1: Dimensions of strategic change (Pettigrew & Whipp, 1991).
2013). In addition, there might be barriers in the external context, such as barriers in the socio-political context or financial, regulatory or legal issues. Healthcare providers might for instance be reluctant because of a lack of financial compensation for time spent on the process of implementation (Peeters, Krijgsman, Brabers, De Jong, & Friele, 2016). Lastly, the implementation process might bring difficulties. When there is for example no well-planned process of change in which progress is evaluated regularly, the implementation could fail (Grol, Wensing, Eccles, & Davis, 2013). There are thus multiple content, context and process aspects that can complicate the scale up of eHealth (Simmons et al., 2007). To take all these content, context and process aspects in consideration during an approach to scale up, the use of frameworks can be advantageous (Walters et al., 2018). Frameworks provide us with the convenience of a systematic way of thinking about scaling up. They mostly include a guide for planning and implementation processes on how to approach a scale up. Afterwards, it can often be of use as an evaluation-tool, giving us feedback and informing us about further approaches (Damschroder et al., 2009). Frameworks are often characterized by having multiple components, sub-components or phases. There are frameworks for scaling up health interventions, and moreover, frameworks specifically focused on scaling up technological health interventions, such as care delivered by mobile apps. To gain insight into current theoretical knowledge on scaling up, recent frameworks will be discussed.
Frameworks for scaling up health interventions
(NASSS) of health and care technologies’’, and incorporates different domains that need to be taken into account to predict and evaluate eHealth (Greenhalgh et al., 2017). In sum, this results in twelve identified frameworks that can be used for scaling up eHealth (described in table 1).
Table 1
Identified frameworks
Name of framework Aim or content Methodology
Blueprint for telemedicine (Jensen et al., 2015) 18 critical success factors for telemedicine deployment. Grey source, not published in a peer reviewed paper. Consolidated Framework for Implementation Research
(CFIR; Damschroder et al., 2009)
Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science.
Snowball sampling approach to identify published theories.
Framework for Going to Full Scale (Barker et al., 2016) A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa.
Review of literature, re-examination of work of governmental bodies and a reflection on two national-scale improvement projects in Africa. Framework for Success (Yamey, 2011) Scaling up global health interventions: a proposed framework for success.
Review of relevant literature on scaling up global health interventions in low to middle income countries and interviews with implementation experts.
Implementing best Practices Consortium (IBPC, 2007) Implementing Best Practices Consortium: A guide for fostering change to scale up effective health services. Grey source, not published in a peer reviewed paper.
Management framework (SUM; Cooley & Kohl, 2006) Scaling up - from vision to large-scale change: A management framework for practitioners. Grey source, not published in a peer reviewed paper.
mHealth assessment framework (mHA; Leon et al., 2012) A framework for assessing the health system challenges to scaling up mHealth in South-Africa. Key informant interviews, site visits to local project and document reviews. mHealth toolkit (MAPS; WHO, 2015) The MAPS toolkit mHealth assessment and planning for scale. Grey source, not published in a peer reviewed paper. Multiplicative scale up framework (Masso & Thompson,
2006)
An approach to rapid scale up using HIV/AIDS treatment and care as an example.
Grey source, not published in a peer reviewed paper.
Recommendations for telehealth (Cruickshank & Beer,
2010) To inform the future NHS strategy for telehealth. Grey source, not published in a peer reviewed paper. Scale up framework (WHO, 2009; WHO, 2010; WHO, 2011) Practical guidance for scaling up health service innovations. Grey source, not published in a peer reviewed paper. Theorizing and evaluating nonadoption, abandonment, and
challenges to the scale up, spread and sustainability (NASSS; Greenhalgh et al., 2017)
A framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale up, spread, and sustainability of health and care technologies.
The relevant frameworks and strategic change
In the previous section, identified frameworks that are relevant for scaling up eHealth are described. With the exception of the grey sources, these will be discussed and compared with the change model of Pettigrew & Whipp (1991). Limitations and strengths will be discussed. Finally, a conclusion will be drawn.
Framework for going to full scale (Barker et al., 2016)
The ‘’framework for going to full scale’’ is focused on scaling up health interventions in low to middle income countries but gives a good general overview of what needs to be considered in an attempt to scale up, guided by questions. The first phase (a) is about ‘’Who needs to be involved in scale‐up?’’ and is concerned with setting up an entry to the health system; followed by (b) ‘’What intervention and implementation strategies need to be taken to scale?’’: the phase in which the scalable unit is developed; followed by (c) ‘’How will scale‐up be achieved?’’ where scale up strategies are developed. In these phases, it needs to be considered what contextual factors influence ‘’when scale‐up is or is not successful’’; and (d) go to full scale, where the findings from the phases 1–3 are applied to take the intervention to scale across multiple settings (Barker et al., 2016). The phases are illustrated in figure 2. This provides a general overview of factors that need to be considered to work towards successful scale up, according to Barker, Reid & Schall (2016).
Figure 2. The four phases of the framework of Barker, Reid & Schall (2016).
This framework does however not include the content and context aspect very well. They are mentioned, but the authors did not investigate this thoroughly. Contrary, the CFIR and NASS framework cover these aspects better.
The Framework for success (Yamey, 2011)
thus consider the content, internal and external context and process. However, these success factors remain superficial. The framework does not give us additional insights that are relevant for the scale up of eHealth, as most findings are not generalisable because the framework is developed for scaling up in low to middle income countries. Therefore, the framework will not further be elaborated upon.
The mHA framework (Leon et al., 2012)
The mHA framework is focused on scaling up mHealth in South-Africa (Leon et al., 2012). Four key system dimensions are identified. One dimension is about the ‘’content’’ aspect, namely ‘’the technological system’’ incorporating the use-ability, interoperability and privacy aspects of the technological intervention. The other three dimensions are about the internal and external ‘’context’’, namely ‘’government stewardship’’, which reflects the need for a supportive policy environment, the ‘’financial system’’ and the ‘’organisational system’’. A limitation of the framework is that it does not include a process aspect. Additionally, the framework is based in the context of low to middle income countries and therefore, most findings are not generalisable to the Dutch healthcare setting. The content and context aspects are reflected more in depth by the CFIR and NASS framework, and will therefore not be elaborated upon.
The Consolidated framework for implementation research (Damschroder et al., 2009)
Figure 3: The Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009). NASSS framework (Greenhalgh et al., 2017)
the influences of the wider system. There is a need to deepen the understanding of how processes in the wider healthcare system influence the scalability of new eHealth innovations.
Figure 4: The NASSS framework (Greenhalgh et al., 2017)
Table 2
Summary of the five identified frameworks Framework Focus of scaling up Contains
Co nte nt In te rn al Co nte xt Ex te rn al cont ext Pr oc es s Framework for Going to Full Scale Health interventions in developing countries
Four phases: Set-up, Develop the Scalable Unit,
Test of Scale up, and Go to Full Scale +/- +/- +/- +
Framework for Success Health interventions in developing countries
Success factors in six areas: Attributes of the specific tool or service being scaled up, the implementers, the adopting community, the socio-political context, the chosen delivery strategy, and the research context.
+/- +/- +/- +/-
mHA mHealth in South-Africa Four key system dimensions: Government stewardship and the organisational, technological
and financial systems. + + +/- -
CFIR Health interventions
Five major domains: Intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation of eHealth within a setting
+ + +/- + NASSS Technological innovations in health and social care
Seven domains: The condition or illness, the technology, the value proposition, the adopter system, the organisation(s), the wider system, and the interaction and mutual adaptation between all these domains over time.
+ + +/- -
Concluding, there are several frameworks addressing the scalability of health interventions. However, there appear to be a lot of grey sources which indicate that there is no empirical support. Additionally, most are not contextualized to scaling up eHealth in the Dutch healthcare setting. If the frameworks are compared with the change model of Pettigrew & Whipp (1991), we can conclude that not all frameworks cover these aspects sufficiently. While the CFIR and NASSS framework (Damschroder et al., 2009; Greenhalgh et al., 2017) do inform us about the content and context factors, they vaguely explain how the wider system is of influence on the process of scaling up an eHealth innovation. The framework ‘’going to full scale’’ (Barker et al., 2016) makes an attempt to create a sequential approach, but again, the importance of the wider system is not taken into consideration adequately. If frameworks included a process aspect, this is about the process of implementation of the new intervention. But what about processes happening in the wider system? We need to deepen our understanding of how processes in the wider healthcare system influence the scalability of new eHealth innovations. This is crucial, as scale up often fails due to encountered barriers in the wider context (Greenhalgh et al., 2017). Therefore, the current study aims to explore how complexities in the external context influence the process of scaling up. As the frameworks of Greenhalgh et al. (2017) and Damschroder (2009) are both relevant for the Dutch healthcare setting and their findings are derived through a systematic literature review, these frameworks will be used for analysing the data. Lastly, many terms in literature have been used to refer to ‘the external context’. In this study, terminology of Greenhalgh (2017) will be adopted, and the external context will be referred to as the wider system; including the environment of the organisation and the economic, financial, regulatory, legal, political and social context. The research methods deployed in this study are outlined in the following section.
METHODOLOGY
This section elaborates on the multiple case study research design employed in this study. First, the research design and research setting are described. Subsequently, the cases are introduced. Lastly, the data collection and analysis are described.
Research design
evidence is provided from different sources. This has the advantage that findings are grounded in various empirical evidence, making generalizability higher. Therefore, an embedded multiple case study was conducted to investigate what the co-dependencies between the wider system and the scale up process are, while also taking into account the content and internal context. By doing so, a complete image could be obtained. These cases were conducted at multiple levels and are therefore defined as practices. Practices are relevant at multiple levels: ‘’it allows to conceive and examine the interaction of technology and organisations at interorganisational, organisational, group and individual level of analysis.’’ (Orlikowski, 1992, p.422). Actions link the structural level to the individual level, putting them in relation with each other. These cases are in three healthcare sectors, namely primary care, medical specialist care and mental healthcare (in Dutch: Geestelijke gezondheidszorg, GGZ). This is of added value, as these are all within the Dutch healthcare setting, but have variations in their wider systems that are sector specific. Examples are different policies, laws or regulations. This allows for comparison and analysis of what the effects of variations in the wider system on scale up are.
Next to investigating the ‘’how’’, this study aimed to explore ‘’why’’ eHealth initiatives reach a successful scale-up, which are the mechanisms of why stakeholders act in a certain way in the process. Semi-structured interviews are appropriate to investigate the ‘’why’’ and ‘’how’’ of relationships (Eisenhardt, 1989). Construct validity was assured by conducting semi-structured interviews and having one key informant (employee of health insurer company) review the draft version of this thesis (Yin, 2009, p. 41). In addition to construct validity, internal validity was sought by looking for dominant patterns and pattern matching in interviews. External validity was sought by interviewing multiple stakeholders with similar but different roles, for example insurance employees with different functions; such as purchasers, policy advisors and innovation advisors. Except for one case, at least one healthcare provider, health insurer and technical supplier were interviewed. Next to validity, reliability was sought by clearly and detailed describing the procedures followed, to ensure the research can be repeated. The steps taken in this research were made as transparent as possible. This was done by attaching the interview protocol as appendix, describing how respondents were approached and how the data was analysed. In sum, by applying this research design, the study has validity and reliability (Yin, 2017).
Research setting
The Dutch healthcare system is regulated by the state, care is provided by the voluntary and private sector and care is financed on the societal level (Böhm et al., 2013). For a description of these three dimensions and their variations per healthcare sector, see appendix 2.
Case introductions: eHealth practices studied
eTriage (primary care/GGZ). With eTriage, patients fill in adaptive screening questionnaires online. Efficiency and patient empowerment are increased by preventing mismatch and increasing self-awareness by patient. When eTriage is used, the triage process is improved, which results in a better referral. The patients are referred to the appropriate healthcare organisation and provider, which can shorten waiting lists (Dijksman, 2018).
Digital general practice (primary care). A newly emerging business model where IT related aspects are outsourced, and GP’s pay a certain fee to the delivering organisation. Communication goes through a web application: patients can chat, plan consults with their GP or order chronic medication through this application. Consults can be at distance, for example by telephone. This proposed efficient way of working could contribute to maintaining accessibility care, as it is often difficult to find new GP’s or successors (VWS, 2020).
Self-monitoring applications (medical specialist care). Self-monitoring applications are targeted at facilitating care for chronic diseases (Huygens et al., 2016). In general, these incorporate self-measurements tools, health status monitoring from a distance and often offer the possibility for video consultations with a healthcare provider. If health status is monitored continuously, this can decrease visits to the emergency department, hospitalization, or premature death, as normally deterioration can remain unnoticed (Kauw et al., 2019).
Program structure (medical specialist care). A program structure in a hospital to facilitate the transformation to deliver a certain percentage of care at home instead of in the hospital. Insurer and hospital collaborate in this practice, which could make scale up effective.
Blended and 100% online treatment (GGZ). In blended treatment, patients receive their treatment partly online. This should reduce face to face contact with a therapist. Another possibility is the full provision of online treatment. Assumed advantages are savings in (overhead)costs, easier to deal with geographical peeks in demand/supply and the possibility to appeal the labour market abroad. This would be beneficial, as there is a shortage of post-academic clinicians in the mental healthcare sector and it could possibly shorten the long waiting lists that exist.
Table 3
eHealth practices, healthcare sector and value
eHealth practice Healthcare sector Proposed value
eTriage Primary care / GGZ Better referral, right care at the right place.
Digital general practice Primary care Efficient method of working, tackles shortage of GP’s. Self-monitoring
applications
Medical specialistic care
Patient empowerment, improved quality of care, accessibility, decrease healthcare costs.
Program structure:
delivering care at home Medical specialistic care Effective scale up of interventions aimed at delivering care at home. Blended and 100%
online treatment GGZ
Data collection
Primary data was collected through semi-structured interviews. Stakeholders were contacted directly or reached by means of a ‘snowball recruitment’ approach. The network of health insurance company De Friesland was used to identify these stakeholders. In total, six IT suppliers, eight insurers and fourteen healthcare providers were contacted. This resulted in a total of 20 semi-structured interviews, as some of the approached stakeholders gave no response or indicated having no time available due to COVID-19 pandemic. See table 4 for an overview of the interviews conducted. The interviews lasted approximately between 30 and 90 minutes. These interviews were conducted via telephone (n = 3) and video calling (n = 17). Sometimes this was inconvenient, as a poor connection could disrupt the conversation and nonverbal communication could remain unnoticed. The purpose of the interview was clearly explained and confidentiality was guaranteed. Permission for recording the interview was asked. The interview protocols for the three stakeholder groups can be found in Dutch in Appendix 1. The interview protocols were structured around the content, context and process aspects of Pettigrew and Whipp (1991). During the interviews, the main aim was to explore the influence of the wider system and how this is intertwined with the scale-up process. Data was collected in April and May 2020.
Table 4
Overview of conducted interviews, n = 20
Role n Function Abbreviation
eTriage (Primary care/GGZ)
Healthcare provider 1 Manager chain care (1x) MC
Health insurer 1 Purchaser primary care (1x) INS
Technical supplier 1 CEO (1x) ITS
Digital general practice (Primary care)
Insurer 1 Innovation advisor(1x) INS
Self-monitoring applications (Medical specialist care)
Health care providers1 3 ANIOS (1x), Medical Specialists (2x) P
Health insurers2 4 Purchaser medical specialized care (1x), policy
advisors (2x) Innovation advisor (1x) INS
Technical supplier 1 CEO (1x) ITS
Program structure (Medical specialist care)
Health care provider 1 Project leader (1x) PL
Health insurers 1 Project leader/innovation advisor (1x) INS Blended and 100% online treatment (GGZ)
Health care providers3 4 CEO (3x), digital psychologists (1x) CH, DP
Health insurer 1 Senior care content advisor GGZ (1x) INS
Technical supplier 1 Sales manager (1x) ITS
Data analysis
The conducted interviews were voice recorded, transcribed and coded. The interviews were transcribed verbatim and imported in the software tool ATLAS.ti for analysis. Consecutively, the data was coded through three iterative stages, being open coding, axial coding and selective coding (Wolfswinkel, Furtmueller, & Wilderom, 2013). Data was coded and analysed per medical domain. The data was analysed on three levels: the wider system, the organisation and the eHealth practice. This formed an excellent basis for doing cross case analysis in the discussion. The transcripts were coded using inductive and deductive coding strategies. Deductive codes were based on the domains of Greenhalgh (2017) and categories of Damschroder (2009). In appendix 3 the coding schemes can be found. Based on the transcripts, these were enriched with inductive codes that emerged out of the data. Through this free-response method, new insights could be identified.
Results
The results section of this study is structured as follows. Results will be given per sector, respectively primary care, medical specialist care and mental healthcare. As the literature is short on how the wider system influences scale up, this will be elaborated upon first, followed by the organisation and the eHealth practices. In general, to reimburse health, there needs to be a pay title, meaning that the service is formally approved for funding. If a new eHealth application is developed and there is no similar eHealth application yet, it can be a long procedure to acquire a pay title. However, in the last years various pay titles for eHealth are introduced, making reimbursement possible. A digital consult has the same pay title as a face to face consult, this holds for every sector. The reimbursement is thus the same.
Primary care
must also know a lot about ICT.’’ [INS]. This reduces ease of use. These factors complicate the implementation and sustainability of eHealth innovations. The financial structures however allow innovation, as reimbursement is based on three ways of funding primary care. However, participants are under the perception that GP’s do not respond to financial incentives: ‘’But I think, the average doctor, does not even exactly know how the financing works. It sounds nice a bonus, but over time, a financial bonus is also common. And they will not do anything extra for it.’’ [INS].
An insurer indicated that care groups, regional collaborative care groups of primary care practices, can play a role in the scaling up of eHealth: ‘’We actually think that the care groups are also responsible for innovations. Because if an individual GP has to innovate, then you are very dependent on the person. … So we often want entire regions to work together on an innovation. Then that care group can also actively go to those people and say, if you use this, we take care of the financial settlement. You can limit yourself to using the instrument, and we will take care of the rest.’’ [INS]. However, this is not supported by all respondents. ‘’Personally, I also think that if you are going to make very large regions, there are also disadvantages. You have to find consensus with all your GP’s. … If you are going to cluster and organise large groups of people, you will also get a lot of discussions.’’ [INS]. Thus, care groups can potentially play a role in reaching scale but can also hinder it. The same holds for the Dutch College of General Practitioners, the scientific association of GP’s. ‘’They make the guidelines and things like that. And they are also occupied with eHealth. I think they are the driving force. If they indicate that care can be provided in a certain way, then I think that has authority.’’ [INS]. However, the same respondent also mentions that this is still difficult: ‘’But … you can put everything on paper. You can adjust the NHG guidelines. But then there must be something in the region, …, those GP’s, they have to be addressed. They probably won't do it themselves, except for those few interested people who are already doing it. But the mass must be stimulated anyway.’’ [INS].
The organisation. Due to the implications of the wider system, the general practice has a small scale with limited resources and skills such as time or IT knowledge, leading to a weak implementation climate. For eHealth to have a chance of succeeding in primary care, it should be made attractive, as easy as possible for GP’s and it should require only a limited investment in time. Respondents also put forward the importance of change leaders: ‘’You need a number of leaders in the region. Who embrace something, who go for it, who like it, who are enthusiastic, who want to tell about it.’’ [INS].
Being aware of the limited resources and skills available within GP practices, two care groups in the south of The Netherlands took on a leading role initiating eTriage implementation within their region. Information meetings were organized for the GP’s in this area. They were contacted directly by IT supplier or through the newsletter of the care groups. The meetings were meant for GP’s to get informed about eTriage. To incentivize GP’s to attend the meetings, accreditation was offered, which GP’s have to acquire every year, so no extra time investment was required. Using eTriage requires little time investment of GP’s. They only have to register the patient, as the following process is automated. ‘’Everything is automated and streamlined, so that minimal effort of people is required. To guide this whole process.’’ [ITS].
However, in the last years, usage of eTriage by GP’s declined, but usage by mental healthcare institutions has grown: ‘’after 7 years, we should actually conclude that GP’s themselves do not use this instrument so quickly. … While GGZ is embracing it.’’ [ITS]. Respondents are under the impression that reasons include that GP’s think that patients are not eligible for eTriage, or want to rely on their own judgement, or perceive it as too time consuming to use eTriage and arrange the financial settlement. GGZ institutions do however not get reimbursed the costs of an eTriage consult if the patient is not treated in their institution. Therefore, a new business model was created in collaboration with the dominant insurer in the south of the Netherlands, where a GGZ institution can use eTriage and get financial reimbursement from the CET-arrangement.
Digital general practice. The digital general practice is a start-up started by an innovative GP. This new business model aims to address the main tensions in scaling up eHealth in primary care, namely insufficient time and limited IT skills and knowledge. Based on an agreement, GP’s pay a certain fee to the digital general practice and adopt a new digital working style. In return, IT services are delivered to GP’s. Therefore, they do not need exhaustive IT knowledge. The focus of this digital general practice is on starting GP’s, since they do not have any patients yet. Subsequently, difficulties at the organisational level can be circumvented, such as culture or structural characteristics. Furthermore, patients choose voluntarily for a digital general practice. The same holds for GP’s, they do not have to participate: ‘’Because as we recruit customers, you also get a bit of a coalition of the willing. If you look regionally, there are always people who don't want it. And they block things. While we say: if you don't want to, then you leave. We want to work with people who want to move forward and accelerate.’’ [INS]. If the business model works, this is a gain for participating GP’s in terms of efficiency. In the end, participating GP’s can act as change facilitators, which could lead to a change in knowledge and beliefs about a digital way of working (efficient) of non-participating GP’s.
IT related aspects. eTriage on the contrary seems to induce extra side processes for GP’s and usage declined in the primary care sector.
Figure 5: Main results. A green arrow indicates an enabling (facilitating) force, red a constraining force and black a potential enabling force.
Medical specialist care
stakeholders in this process, as they are often employed by the hospital. Their income is also affected when the hospital revenue is lower. As an insurer stated, this is a complicating factor, as they have a lack of power and knowledge about this issue: ‘’We don't really have much to say about how the hospital finances the medical partnership. That is why this is sometimes also a stumbling block for us, because we do try to introduce incentives, or stimulating financing. But there is also still a negotiation between the hospital and the partnership. I do not know that exactly.’’ [INS]. Concluding, it is necessary to align payment methods with health system priorities.
As there is a regulated market structure, there is little competition. ‘’The existing players have a lot of power. Hospitals ... I mean, you don't build a hospital overnight, … they have little competition. And that's why they're not going to change that much. So I believe, and that is my personal opinion, that the system should be much more open. There should be much more commotion. There must be some kind of Uber in healthcare.’’ [INS]. Through the lack of competition, the pressure to undergo radical change is low.
The government is perceived as regulating and facilitating. The policy is to stimulate eHealth that contributes to the right care at the right place. To support initiatives that contribute to the right care at the right place policy, there are several grants available. One of these are the transformation grants: there is 425 million available for the period 2019-2020, to support the aforementioned transformation the hospital needs to go through. Healthcare providers have to come up with ideas that contribute to the aim, and insurers reimburse the initiatives. These need to meet certain set requirements.
respondents mention that there are price differences among IT suppliers. ‘’Of course, suppliers always want to earn money. And that is okay. But it must be within a normal range. … It shouldn't be that they make huge profits over the back of policyholders.’’ [INS]. In sum, IT related aspects are not a barrier, costs related to the IT are.
Technical suppliers perceive no barriers in the legal and regulatory aspects of patient-facing technology: ‘’So you have all kinds of ISO standards, NEN standards, yes we all comply with those, those are just rules that you must adhere to.’’ [ITS].
The organisation. Due to aspects of the wider system, the tension for change in hospitals is low. However, the policy of the government establishes some sense of urgency and contributes to the vision and strategy of hospitals. ‘’Some hospitals are already very progressive, believe in it, have a vision on digital care, how it should be. They are already working on it. … There you do not have to push at all or put penalties on it so to speak.’’ [INS]. A medical specialist agrees: ‘’It starts with leadership and vision. That you say, guys we are going that way, this is what we are going to do, …, then you have to find innovators who will do it, then it must be proven that it works in practice, yields something for parties.’’ …. ‘’But you will need to have leadership and create a climate in the hospital, where it can be piloted, tried, and then rolled out.’’ [P]. Change leaders that can inspire and motivate others are seen as important by all respondents. All in all, if the hospital does not have a clear vision and strategy on how to make care more efficient, of which eHealth could be one of the methods, eHealth initiatives have a low chance of scaling up.
Furthermore, the financials structures provoke production, not innovation. ‘’Why would you change when your entire waiting room is full? What is the need for that? … If you run a good business, or just perform well. Then innovation is often a threat, not really an opportunity.’’ [INS]. Certain production targets must be met, leading to a high workload and no time to spent on innovation during working hours. Multiple respondents state that for innovation, it is important that medical specialists have sufficient time and space available during working hours. ‘’You have to imagine, as a medical specialist you are busy. You have your hands full with your usual work. You want to change something, that takes time. You do that in your own time. In the evenings, weekends, things like that. But to really do something with it, you have to have extra time. That means that you just have to close 1 or 2 clinics a week to be able to do this.’’ [P]. If there is no time given for innovation during working hours, ‘’then you cannot show that leadership, nor can you show exemplary behaviour’’. [P]
enthusiasm, how do you get that in such an organisation? ICT systems must be adapted, the work processes must be adjusted, the secretary …, the nurse …, [and] the doctor must work differently.’’ … ‘’An organisation like a hospital organisation, is often looking for ways in which you can put forward good ideas that are innovative, so that they are embraced and also embedded in a hospital.’’ [P]. The medical partnerships further complicate the process: ‘’Because that hospital has a board, there are all partnerships under it, you know, before it is completely dripped, and that is why I think that you often see that it is easier in hospitals with salaried physicians than in hospitals with partnerships.’’ [INS]. A medical specialist states that all these parties have different interests: ‘’The security thinks it is not safe. And ICT thinks … that they get an extra system. The nurse thinks oh no, if they measure at home, then I no longer have to come to the hospital, and I have to find other work. So I'm also going to counteract a bit. The doctor thinks, I have to do an extra click, so never mind. Just let that patient drop by.’’ [P]. Additionally, as a physician mentioned the individual stage of change is often low: ‘’health care providers are very much attached to their working methods, their standard working methods, and find it difficult to change that.’’ [P]. In sum, the complex business operations of a hospital, the aforementioned friction costs and all different interests of stakeholders in hospitals complicate the implementation of innovations greatly.
Self-monitoring applications. Self-monitoring applications should be desirable, deliver value and be safe, against reasonable costs. For clinicians the first priority is value for patients. As a medical specialist stated it is important that the technology is safe and desirable for patients: ‘’Doctors are very critical, so you have to look very carefully whether something can and should be allowed in terms of medical content.’’ [P]. Important factors are for example data exchange, privacy, and scientific evidence: ‘’And the more evidence there is, because that's the case with doctors, ..., the easier it is.’’ [P]. That is with good reason, because they are professionals, but as an insurer mentions this also delays innovation: ‘’…innovation in the medical sector also goes slow, because the gold standard is still a RCT that takes several years. … And it just takes a really long time before you can get significant results from it.’’ [INS]. However, physicians also mention that scientific evidence isn’t always necessarily at the start: ‘’Well the question is whether you need that scientific evidence. If you believe in a concept, and if you start, that you indeed have to participate in an observational study to demonstrate that it works.’’ [P]. Furthermore, respondents mention that the intervention source sometimes also play a role. Individuals might have a negative attitude towards eHealth when it is developed at other universities, also called the ‘not invented here syndrome’.
wider system and the implementation in the organisation. If shadow systems are maintained next to the new work practice, there are no savings. ‘’…All visits were maintained. And then telemonitoring is actually a bonus. And then it can never be a positive business case, because then you do it on top of it instead of replacement’’. [INS]. Additionally, it is important to include the right patient group. This is twofold, namely for some patients self-monitoring is not desirable and a solid business case is often only attainable if the severe patient group is included. If the new IT costs are higher than the costs for treating the patient without eHealth, it is not lucrative. Furthermore, economies of scale need to be attained to get the expected savings. If a high scale of operations is reached, cost advantages rise as cost related factors can be scaled down, such as staff. Only then a solid business case is possible. Consequently, the transformation process and its corresponding friction costs are important, enabling the hospital to create economies of scale. However, requiring economies of scale while only a small patient group is suitable for self-monitoring is a paradox. In sum, it is difficult for hospitals to attain a positive business case.
Finally, as a medical specialist put forward, ease of use is important. ‘’…The application must also work really well. Because we are used to applications, like the ING app, the Rabobank app, the Uber app. They are all so nice. They are genuinely tailored to the consumer. A lot of medical apps, or medical EHRs that do not reach that level. And that means that we break off quickly. Because our expectations, both from the care provider and the patient/consumer, the bar is set very high.’’ [P]. Connections with EHR are also important for ease of use.
Figure 6: Main results. A green arrow indicates an enabling force, red a constraining force and black a potential enabling force.
Program structure: delivering care at home. As became clear, there are various (financial) issues to overcome in implementing and scaling up eHealth. Throughout the Netherlands, health insurers take a different role and move towards collaboration with healthcare providers: ‘’Broadly speaking, we are trying to move more towards a situation in which we are a partner in healthcare transformation. You could roughly say that you move from something, say more, financial attitude, to a more substantive role.’’ [INS]. Through contract innovation, incentives are better aligned with health system priorities like the right care at the right place. There are several initiatives in the Netherlands where insurer and hospital collaborate to deliver a percentage of care at home instead of in the hospital. Through multi-year agreements, the hospital gets time for this transition. Both parties then confirm the objective to initiate this transition with a declaration of intent. In sum, by a new constructive way of working, opportunities arise, and value can be created.
much transition grants can be used and when. Through the clear vision and strategy, healthcare providers get more enthusiastic over time: "What you see, when it gets more and more attention, that others will follow, that they also like to participate. Because you [physicians] can just think for yourself how you want to improve your care." [PL]. The intention, need for change is created. When employees work on a specific project, they can invoice the hours they work on the project, so it is not on top of their normal workload. ‘’And you can see that the cooperation of doctors and nurses, department managers, actually everyone, just increases very much. Because they just get it reimbursed.’’ [PL]. Concluding, medical specialists have time during working hours available and the financial incentives are better aligned.
The transformation process within the hospital is characterised by a systematic approach, as a scrum framework is adopted to manage the process. As the project leader stated, new projects are always initiated by physicians, as they can come up with ideas or meetings are organised to discover ideas: ‘’So then, for example, we just organise a meeting with the department, and then we start thinking about it: Which care could we organise differently?’’ [PL]. The ‘product owner’ is always a physician. This is important, as this kind of medical leadership is essential to redesign the care pathway and motivate others, as they have the knowledge. Additionally, subjective opinions from peers are more accessible and convincing. If there is a new project, a scrum master and team members join the product owner.
given its approval, then it means they will all adopt the new work practice.’’ [PL]. In this way, it is ensured the new pathway is used by all medical specialist. Because if the protocols are adjusted, the whole partnership agreed upon it. Finally, in stage four, through built dashboards everything is measured, to see whether the proposed savings are realised.
However, as an insurer stated this agreement is based on a declaration of intent: ‘’But that is still very complicated, if it doesn't work. Who is responsible for that …? Financially speaking. Imagine that we [hospital and insurer] both agree to start a downward trend, and there is no downward trend. Who is going to pay for that difference?’’ [INS].
In figure 7 it is illustrated how and why this program structure has potential to overcome the aforementioned drawbacks.
Figure 7: The green circles indicate important influential aspects of this initiative. A green arrow indicates an enabling force, red a constraining force and black a potential enabling force.
GGZ
savings on overhead costs can be attained when treating 100% online, while others point out that it is necessary to reach a high scale of operations to get these savings, which is not the case yet in the Netherlands.
In case of blended care, eHealth applications without needing therapist time, could possible reduce therapist time and simultaneously contribute to more valuable healthcare services. However, the current system does not incentivize the development of these initiatives. ‘’The usual care that is provided is based on minutes. …. Online treatment is of course something else, that is something the client does at home, and then there are completely different types of costs. You have a program that you have to pay, you have a client platform that you have to pay. … So actually, the minutes structure does not fit well with the online world. We just get paid minutes while we give modules online.’’ [CH]. As a therapist sees their client less because of the use of eHealth, the organisation would earn less. There are developments of new financial structures: the ‘’Zorgprestatie model’’, aiming to start in 2022. This is however still based on minutes. Insurers do provide incentives for online treatment: ‘’in our healthcare purchasing process, we can provide clear incentives to provide more online care.’’ [INS]. More volume is offered to people who meet certain requirements regarding the delivery of online care. The volume-based payment method thus does not incentivize to do things more efficiently, but insurers do provide some financial driven incentives.
Similar as in the medical specialist care, forms of collaboration between healthcare provider and insurer arise in the GGZ as well. The aim is to attain higher efficiency and to improve quality of care: ‘’It originated from years of cooperation, where we look at a different way of contracting than just based on financial parameters. Many insurers have in their contracts mainly a budget ceiling for an average price, well we have agreed for years that we want to get rid of that and want to focus on quality and data. ... A different contract form, a different way of working. As far as we are concerned, healthcare is mainly about quality, and secondly about money.’’ [CH].
The government is perceived as facilitating. Like in medical specialist care, there are similar grants available to support initiatives that contribute to right care at the right place policy.
Technology is in general no obstacle in delivering eHealth. However, caution must be paid to not become dependent on block contracts with an IT supplier. Furthermore, IT suppliers have to fulfil certain law requirements, for example regarding privacy: ‘’…we must be NEN certified, we are also ISO certified. You must have a C1 mark. You have to meet certain legal security requirements, such as two factor authentication, logging file access, those are all requirements that you have to meet. And they are quite clear. And if you comply with that, your system can be used.’’ [ITS]. However, some institutions also use widely available platforms, of which privacy aspects are debatable.
are trained very well in traditional working, with everything face-to-face, but the online component in the education is minimal. We regain GZ-psychologists from that training, who are actually a step back in modernization.’’ [CH].
Organisation. Implementing blended or 100% online is a change process within the organisation. It requires another way of working. As a care-content advisor insurer put forward, this is a transformation process within the healthcare organisation: ‘’In the end the transformation is of course not about the technical part of that online care, but also about the process within a company, and employee behaviour. I think we can say that maybe only 10% is the technical part, so what IT suppliers deliver, and 50% is employee behaviour and 40% is how you set it up in your business processes.’’ [INS]. There can be resistance towards this change due to culture aspects within the organisation, or it might be difficult because bureaucracy may constrain the implementation: ‘’All that ICT, video calling, internet modules, that actually requires a completely different way of working. And if you want to roll that out in an organisation, it is complicated. Because in an organisation you have bureaucracy, culture. There you have, we never do that here, we do it like this.’’ [CH]. To effectively implement eHealth in an organisation, a strong vision and strategy is important. It is important for an organisation to know what they want to achieve by using eHealth. In the mental healthcare sector, there are several organisations that have a strong digital vision and strategy. In these organisations, the implementation of delivery of digital health is well imbedded into business processes: ‘’That is actually a practice that is already well established.’’ [CH]. Organisations want to deliver high quality of care, and eHealth is seen as a tool to support the care delivered or to deliver care that fits better with characteristics of individuals. ‘’My goal is not to provide treatment online as much as possible. My goal is to offer the best treatment. And we also offer online treatment.’’ [CH]. The respondents all mention that working model based and measuring outcomes are important to improve the quality of care delivered. ‘’Everything is based on questionnaires and outcomes. And the client is actually king. Because the client determines whether he or she is doing well or not. And together you recalibrate all the time, what do you need for the next step.’’ [DP]. Concluding, organisations want to deliver high quality of care, and eHealth is seen as a tool to reach this aim.
Blended and 100% online treatment. As waiting lists are a serious problem in the GGZ and complete online treatment is seen as a solution, there are providers that are able to deliver online care within 5 days, as an alternative to waiting for the usual treatment. There is evidence about the effectiveness of using digital methods in the treatment process, so this is not a constraint. However, as a psychologist stated, this might not be appropriate: ‘’People A) do not know what digital is, B) they have just taken a very big step, because they have just started treatment.’’ [DP]. Therefore, their approach is different. In the beginning of the treatment there is an intrinsic screening method, in which the situation of the client is examined, and what the implications for the treatment are. ‘’And if people then opt for the digital treatment method, they have chosen it themselves, without us recommending it. And if they opt for the regular form of treatment, they already have more motivation for it, because they have deliberately chosen to do so.'' [DP]. It is examined whether patients are eligible for eHealth. Furthermore, for therapists, the full provision of online treatment asks for different skills. ‘’I actually see digital treatment as a specialism … If you want to do your treatment online, then you have to be able to embrace that medium well.’’ [DP]. Hence, some organisations train their employees in online treatment.
Because delivering 100% online care imposes a structural change which can result in resistance, some of the GGZ healthcare providers circumvented this by starting a subsidiary organisation that only delivers 100% online treatment: ‘’so after brainstorming, we said to the board: If you want to make it a success, you actually have to build something separate from the organisation from scratch.’’ [CH]. They received all the freedom and the resources of the main organisation. Therefore, they had the time and resources to set their vision, the preconditions and to decide on how to shape care pathways. As an insurer stated, this is successful as the clinicians who work for these subsidiary organisations choose explicitly for this job. ‘’And you see at those organisations, they just choose very specifically for that delivery in their business model. For online delivery. And the people that work there also have consciously chosen to work 100% digital.’’ [INS]. Subsidiary organisations are thus effective in circumventing constraints in scaling up 100% online care that are related to organisational design, structure and culture.
Figure 8: Main results. A green arrow indicates an enabling force, red a constraining force and black a potential enabling force. The arrows that start at the box transformation process indicate that it is a transformation process to implement blended or 100% online treatment.
Discussion
technologies need to be integrated and contextualized within local work processes and roles. Nonetheless, there is a tension between scalability and contextualization. Different use settings may incorporate different stakeholder groups with different needs and preferences (Shaw et al., 2018). Intervention characteristics such as ease of use and evidence strength are enabling forces when they are present. Lastly, a theme that is similar in all settings is the question which patients are eligible for eHealth. The similarities are illustrated in figure 9. Next to similarities, important differences were observed within healthcare sectors. Additionally, in all domains there are newly emerging revenue models that attempt to circumvent constraints to scale up eHealth. These will be discussed in the following sections.
Figure 9: General similarities across the three healthcare sectors. A green arrow indicates an enabling force, red a constraining force and black a potential enabling force.
Limitations
Furthermore, the three interviewed stakeholder groups for the other cases, being healthcare providers, health insurers and technical suppliers, do not represent all stakeholders involved. This response bias can affect the validity of this study. Third, this study was carried out within the Dutch healthcare system. This limits the generalizability of the findings to other healthcare systems. Finally, patients are the primary stakeholders in eHealth practices. This study did not take into account the perspectives of patients, as the focus of this study was mainly on the wider system.
Theoretical contributions and implications
Existing literature lacks the investigation of complexities in the wider system and what the implications are on the scalability of new eHealth innovations. This study is a first step in filling this gap in the literature. From the results it can be derived that factors in the wider system have implications for scaling up of eHealth, which is in line with literature (Damschroder, 2009; Greenhalgh et al., 2017). However, it differs per healthcare sector which factors are present and to which extent these are influential. Research to date has not made this distinction. When scaling up, it is thus crucial to not neglect the specific healthcare sector. Furthermore, it is not just about the presence of the wider system, but more importantly about the need to recognize the dependence between these factors and co-dependence between different stakeholders which are not organisation-bound. While Greenhalgh (2017) addresses this slightly by mentioning that the domains are interacting, other frameworks do not address this at all (i.e. Barker et al., 2016; Damschroder et al., 2009; Leon et al., 2012; Yamey, 2011). To clarify this co-dependence and why it is crucial to recognize this, the healthcare sectors and newly emerging revenue models will be discussed hereafter.
Primary care. As GP’s have a high workload, work at a small scale and in general have little knowledge about eHealth, scaling up eHealth is challenging. Additionally, through the lack of local competition, the pressure for GP’s to undergo radical change is probably, and understandably, low. Although there are financial incentives, respondents are under the impression that GP’s do not respond to these incentives and are not aware of payment structures. Respondents suggest that GP’s are mainly intrinsically motivated.
Medical specialist care. In medical specialist care, all respondents mentioned that finance is one of the most important factors in scaling up eHealth. As the reimbursement system is a fee for service method, there is a clear incentive to produce more volume of services. Compared to primary care, medical specialists seem to be more aware of payment structures than GP’s. Production targets must be met and there is no time during working hours to spent on innovation. Additionally, due to the regulated market mechanisms there is no competitive environment. These wider system factors lead to no initial motive to change. This is in agreement with literature; it is widely acknowledged that for change, a sense of urgency to change has to be established (e.g., Kotter, 1995). Without a sense of urgency, no change is initiated. The governmental policy is, however, a pressure that drives healthcare organisation to adapt a vision and strategy to deliver the right care at the right place by for example using eHealth. Furthermore, health insurers have been given the role by the government to both reduce costs and stimulate providers to improve quality. To achieve this, insurers can use purchasing mechanisms to deliver better care. This often implies engaging in collaboration with hospitals: the distinction between the wider system and organisational level is blurred. There is thus co-dependence between the different stakeholders which are not organisation-bound.
The adopted program structure by the hospital and the collaboration between insurer and hospital demonstrates this co-dependency. Through contract innovation with a multi-year runtime, the hospital is guaranteed of a stable income. The incentive to produce more volume of services is removed as the hospital is offered financial comfort. Additionally, through collaboration, agreements with the insurer are made on how much, and when, transition grants can be used, to cover for friction costs. Hereby, constraining factors induced by the wider system are taken out. From this starting point an initial motive to change can be created. By a clear vision, employees are brought under the perception the current state is undesirable. That a vision and strategy is important to bring about change is in line with prior literature (Battilana, et al., 2010). Management needs to stress the need for change and share their vision of the need for change with employees. In sum, these advancements make it possible to establish a sense of urgency.
accordance with the findings of prior literature (e.g. Kotter, 1995), that acknowledges the role of leadership in successful change implementation. In this program, the projects are initiated by physicians, acting as change leader. Another important aspect of the projects is the formal approval from the whole medical partnership to use a new care pathway. Cawsey, Deszca, & Ingols (2015) agree the need for formal approval for organisational change. As the change leader is a medical specialist, they can inspire and motivate peers, which increases the likelihood of successful scale-up within the hospital. In this way, eHealth is contextualized into local work routines, it is not an extra side process and can yield savings. Finally, monitoring and review practices are developed. It is measured if the assumed savings are attained. Literature acknowledges that measuring and evaluating is indeed important to adapt when necessary and to guarantee sustainability (e.g. Grol et al., 2013; Higgs & Rowland, 2005). In sum, when comparing characteristics of this approach with literature, this approach is associated with successful change implementation.
GGZ. From the results it could be derived that similar as in medical specialist care, the financial reimbursement system is volume based. This implies that to deliver blended care, it should be outweighed by less treatment minutes per treatment. Similar as in the medical specialist care, forms of collaboration between healthcare provider and insurer arise. Again, this illustrates the co-dependence of stakeholders that are not organisation bound. Opportunities to deliver better quality of care arise, as the focus on financial parameters decreases.
