ONLINE HEALTH-PORTALS
“How to develop new services, adding value to health
consumers and network participants.”
Msc Ba Business & ICT
Rijksuniversiteit Groningen
Student: Byron Schuurman
Student number: s1504010
University of Groningen
Faculty of Economics and Business
Landleven 5, P.O. Box 800,
9700 AV Groningen, The Netherlands
1ST Supervisor: Prof. Dr. H.G. Sol
2nd Supervisor: Prof. Dr. Ir. J.C. Wortmann
Company: TNO
Information and Communication Technology
Eemsgolaan 3, 9727 DW Groningen
PREFACE
This master thesis forms the final step for graduating for the specialisation Business and ICT of the Master of Business Administration at the University of Groningen. While orientating for a suitable research topic my interests already lay with healthcare and the rapid technological developments that currently take place. TNO – Information and Communication Technology offered me an internship that challenged me to investigating this topic by examining e-Health in more detail, focussing on health-portals and the development of new services.
E-Health can provide an important contribution for achieving high quality of care, accessibility and cost effective healthcare. According to The Council for Public Health and Health Care (RVZ), the healthcare sector is far behind other sectors when it comes to using internet technology in every day practices. This thesis is written to provide further insight on how to effectively design new e-Health services, and in the end to stimulate an increase in the level of adoption.
First of all, I want to thank Oscar Rietkerk of TNO for providing me with the opportunity to pursue an internship at TNO, and providing me with the necessary supervision, support and all the helpful comments during the research. For this research, the health-portal PAZIO was chosen as the main subject of study. I would like to thank Andre Dekker (project manager) for making it possible for me to conduct research on PAZIO, inviting me to the opening of PAZIO in Utrecht, and bringing me in contact with other project members of PAZIO. I would like to thank Mark de Lange (project manager of the Business Team) and Marianne Dekker (project manager of the Realisation Team) who contributed to the research via in-depth interviews and providing me with the necessary documentation.
I also thank my academic supervisors, Professor Henk Sol and Professor Hans Wortmann, for their suggestions, and valuable feedback.
In conclusion, I sincerely thank my family for their everlasting support.
Byron Schuurman
SUMMARY
The increase of the ageing Dutch population will result in an increase of demand for healthcare and at the same time the provision of healthcare will decline as a result of fewer health workers. This will result in a ever growing gap between demand and supply in healthcare in the near future (i-Zorg Consortium, 2006). Because of this seemingly frightening scenario, policy makers and researchers are finding solutions to fill this gap. One of these possible solutions is through the use of e-Health. The general goal of this research is to contribute to a growing knowledge on a particular domain of e-Health, namely online health-portals, and more specifically how portal initiators can effectively develop new services.
This research has been performed for TNO ICT. TNO is a independent Dutch research organisation with the aim of developing, integrating, and applying scientific knowledge. This research is in line with TNO ICT’s specific areas of study on the barriers of e-Health adoption and scaling and is aimed at determining ‘how new services can be developed that add value to the health consumers and to the
network partners of an online health-portal’, stemming from the problem statement.
In order to assess this problem statement it was first necessary to scope the area of research. This was done by explaining the terms e-Health and health-portals, and determining its relevant actors, based on a literature study. Furthermore, the different needs of health consumers and the specific motives of network partners for participation regarding online health-portals were described.
For this particular research Van de Kar’s (2004) design approach was assessed to provide recommendations on how to develop new services that add value to health consumers and network participants. According to Hernandez and Hodges (2003), the current literature concerning integral design approaches for healthcare related service systems is scarce. However, Van de Kar’s (2004) design approach, which is primarily focussed on mobile information service systems, is an example of such an integral approach. In order to provide recommendations Van de Kar’s (2004) approach needed to be assessed. This was done through a case study research. The online health-portal PAZIO was chosen as the ideal case for assessing Van de Kar’s (2004) approach in practice based on its characteristics and scope.
After having conducted several personal interviews and by analysing relevant project documentation (like e.g. storyboards, user requirements list, architectural study reports and business case reports) recommendations were made. These recommendations are made based on: 1) improvements on Van de Kar’s (2004) APSIT method, and 2) through presenting several design guidelines from assessing trade-offs. Hereby Van de Kar’s (2004) approach can be extended and suffice as a useful approach for effectively developing new services for online health-portals.
1. Improvements on Van de Kar’s (2004) APSIT method
The improvements on Van de Kar’s (2004) APSIT method are aimed at acknowledging the importance of: the client organisation regarding its work processes, and determining distinct and unambiguous value propositions and evaluating them during the different phases of design.
The client organisation and its work processes
In contrast to designing mobile information service systems, the design and implementation of e-Health services requires full attention to current work processes of the customer organisation (Boddy, D. et al. 2009). According to Boddy et al (2009), it takes much time to obtain users' advice on how e-Health technologies and working practices can be jointly redesigned to improve performance. It is therefore critical that the impact of the design activities regarding the service formula on current work processes is assessed throughout every phase and decided how these processes should be redesigned. If this is neglected the possibility exists that projects are delayed and that e-Health services and/or work processes still have to be redesigned in a later phase.
From assessing the APSIT method even further it became clear that it is recommended to make formal agreements with the client organisation. This can be done in the form of a ‘letters of intention’ in the analysis phase of the value network. These ‘letters of intention’ should include e.g. financial consequences if the client organisation neglects to fully participate during the design or implementation. It is a possibility to appoint e.g. an interim manager whose task it is to lead the design and implementation directly at the client organisation.
Determining and evaluating distinct and unambiguous value propositions
2. The assessment of design guidelines based on the trade-offs of Van de Kar (2004)
The design guidelines that result from trade-offs according to Van de Kar (2004) are assessed through determining their relevance and importance based on the PAZIO case. This led to cases where a number of original guidelines were accepted and several improved guidelines were made applicable to pose recommendations for new health-portal initiatives. These design guidelines can be categorised in three different groups, namely: 1) guidelines for developing new services adding value for health consumers, 2) guidelines for developing new services adding value for network participants, and 3) guidelines that pose general recommendations for developing new services.
1) Guidelines for developing new services adding value for health consumers
The original guideline 3, the improved guideline 4, and a number of non-functional requirements by Van de Kar (2004) are presented as recommendations. These design guidelines and requirements are consistent with the problem statement, with regard to developing services that add value to health consumers, and are described below.
Original guideline 3: The targeted user has to be part of the design approach in all phases of the
design process.
Improved guideline 4: The design approach has to start with the investigation of the targeted users’
context, wants and needs only after all the possibilities of the services are fully explained and understood by the users.
The non-functional requirements by Van de Kar (2004) that were assessed and proven applicable for online health-portals based on the PAZIO case, are requirements regarding: reliability, trust and interface design.
2) Guidelines for developing new services adding value for network participants
The original design guidelines 6 and 8 by Van de Kar (2004) are presented as recommendations. These design guidelines are consistent with the problem statement, with regard to developing services that add value to network participants. These guidelines pose recommendations for the creation of value networks and consider potential motives of network partners to participate in a health-portal project.
Original guideline 6: Take into consideration when creating a value network that the purpose of
Original guideline 8: Take into consideration when creating a value network that the value of network
membership in an innovative undertaking is to learn and to achieve a competitive advantage.
3) Guidelines that pose general recommendations
The original design guidelines 1 and 5 by Van de Kar (2004) were improved and made applicable for online health-portals, based on the findings from the PAZIO case.
Improved guideline 1: Actors in the network can only start to design applications when the technical
architecture has the potential to overcome key functional constraints (e.g. interface integration, secure authentication), and complies to industry standards set up by the NICTIZ.
Improved guideline 5: During the course of a project the role list of multidisciplinary teams must be
checked and the composition of these teams evaluated.
TABLE OF CONTENTS
1. INTRODUCTION AND RESEARCH...9
1.1 Introduction...9
1.2 Problem definition...10
1.2.1 Introduction to the problem ...10
1.2.2 Problem statement ...10
1.2.3 The motive for research...11
1.2.4 Research questions and methodology ...11
1.2.5 Structure...12
2. THEORETICAL BACKGROUND...13
2.1 The Concept of e-Health...13
2.1.1 Defining e-Health...13 2.1.2 e-Health services ...14 2.1.3 Interactions...16 2.2 Online Health-Portals ...16 2.2.1 Definition...16 2.2.2 Characteristics...17
2.2.3 Interoperability and standardisation ...17
2.2.4 The healthcare IT network...18
2.3 Analysis of the actors of e-Health ...19
2.3.1 Relevant actors...19
2.4 The Demand and Supply of E-Health ...23
2.4.1 Patients’ needs ...23
2.4.2 Motives of service providers...27
2.5 Summery and conclusion...28
3. CASE STUDY RESEARCH ...30
3.1 Introducing the design approach by Van de Kar (2004) ...30
3.2 Research Approach ...33 3.1.1 Research Design...33 3.1.2 Procedure ...33 3.1.3 Methodology ...34 3.2 Research Setting...34 3.2.1 Introduction...34
3.2.3 The concept of the portal PAZIO...36
3.2.4 The actors of PAZIO ...37
3.3 The assessment of Van de Kar’s (2004) APSIT method...39
3.3.1 The Analysis Phase ...39
3.3.2 The Preparation Phase ...42
3.3.3 The Synthesis Phase ...48
3.3.4 The Implementation and Test phase...51
3.4 Summary and conclusion...53
3.4.1 Improvements on Van de Kar’s (2004) APSIT method...56
3.4.2 Continuation – the assessment of trade-offs by Van de Kar (2004) ...58
4. THE ASSESSMENT OF TRADE-OFFS BY VAN DE KAR (2004) ...59
4.1 The Assessment of the Trade-off: Service Formula - Technology ...59
4.2 The Assessment of the Trade-off: Technology - Value Network...61
4.3 The Assessment of the Trade-off: Value Network - Service Formula...63
4.4 The Assessment of Internal Network Factors...64
5. CONCLUSIONS AND RECOMMENDATIONS ...69
5.1 Conclusions based on research questions ...69
5.2 Recommendations ...70
5.2.1 Recommendations for improving Van de Kar’s (2004) APSIT method...71
5.2.2 Recommendations based on trade-offs and design guidelines of Van de Kar (2004) ...72
5.2.3 Final recommendation ...76
REFERENCES...77
APPENDIX A ...81
1.
INTRODUCTION AND RESEARCH
1.1
Introduction
The Dutch population is ageing. In the next twenty years the amount of elderly people of 65 years and over will be doubled from 14% in 2005 to 21% in 2025. This sharp rise will be accompanied with an increase in the amount of people with chronicle illnesses, an shortage of medical staff, more demanding patients and a subsequent increase of health costs which bring new challenges for the healthcare sector. A possible solution could be to radically optimise the healthcare sector by making it more effective to be able to cope with these challenges. As a result the Dutch government, health insurers, health providers and consumers explore new solutions for adequate health provision.
E-Health, and respectively telemedicine offer a solution for providing effective healthcare. It are collective terms for offering ‘care on a distance’ with the use of information and communication technology. This form of assistance in healthcare can offer a positive contribution in making healthcare more effective in coping with an increase in demand by health consumers and health providers who have to maintain the provision of qualitative care (Vlaskamp, J.M. et al. 2001). There are a lot of promising new e-Health services that are currently made available. These applications are for instance: patient-physician communication tools, electronic and patient-centred health records, administrative or scheduling related services and patient networks (Katz S., Moyer C., 2004, Bos, L., et al 2009). This research will focus on one specific application of e-Health that can incorporate an array of all these different kinds of e-Health services, namely online health-portals.
user acceptance and trust (Luo W., Najdawi M., 2004, Klein R., 2006) and on specific technical design characteristics (Theofanos, M., Mulligan, C., 2004, Kukafka R. 2007, Lu S. et al 2008) of such portals.
1.2
Problem definition
1.2.1 Introduction to the problem
Because healthcare IT has improved in recent years, new models for electronic delivery of healthcare services are now being created (Tan, J., 2005, Kalyanpur, A., et al., 2007). In particular, because of the rapid technological developments of web applications, health-portals face new challenges for incorporating services to facilitate in better healthcare provision. These new advancements in technology give rise to the possibilities of providing healthcare that can fulfil the needs of health consumers, providers and other relevant actors. Complementary, Yang and Hsiao (2009) state that the real challenges associated with the development of new services in the e-Health domain are to provide new, extensive, custom-made, ubiquitous and seamless services to an increased number of patients at any time and at a lower cost.
Today there are a number of health-portal initiatives that are unrolled nationwide, who seek other parties to incorporate their health applications into their system. Because of this these health-portals are confronted with a number of issues about how to be able to provide sufficient value to end-users and at the same time to be able to manage their extending value network of different stakeholders, roles, interactions and activities. In other words, these extending portals must determine how they can still deliver value to their customers and to their network partners.
1.2.2 Problem statement
This research focuses on how online health-portals could develop new services that add value to the health consumers and to the network partners and thus become able to effectively extend their service offering. This will be achieved by acknowledging the technological advances in e-Health, but in particular by focussing on how services could be developed from the perspective of health consumers and the different network partners. These services must comply to the needs of the health consumers, and the different stakeholders must be able to make an effective contribution in their value network.
The introduction above has led to the following problem statement:
1.2.3 The motive for research
This research is initiated by TNO ICT. TNO is a independent Dutch research organisation with the aim of developing, integrating, and applying scientific knowledge. TNO ICT is a unique innovation centre in the Netherlands that brings together ICT and Telecom disciplines of TNO. One of the research areas that TNO ICT investigates are how ICT solutions (respectively e-Health) can play a role in e.g. stimulating self-care by patients, or making healthcare more accessible for health consumers. This research is in line with these current areas of study and the conclusions and recommendations made in this research are in the particular interest of TNO ICT.
The health-portal ‘PAZIO’ (Patientgeoriënteerde Zorg Informatie Omgeving) was chosen by TNO ICT as the main subject of study. The PAZIO project was chosen in the first place because of its generic characteristics of being a platform which offers the possibility for service providers to integrate their distinct e-Health services on to the portal. Secondly, PAZIO was chosen because of its scope, the project will eventually be unrolled nationwide. The Medical Centre of the University of Utrecht has the ambition that PAZIO should become the leading health-portal in the Netherlands. PAZIO allows potential new service providers to join the value network and integrate their distinct e-Health services into its health-portal. Two main subjects must be taken into account:
Newly added services must be designed to add value for the health consumers of PAZIO
(customer value).
The motives of network partners for joining the network must originate from the fact that
joining the network results in added value for them (value for the network participants).
Because of PAZIO’s characteristics and scope the health portal seemed for TNO ICT an unique research opportunity for assessing current knowledge on how to develop new services that can add value to health consumers and network partners. This should contribute to TNO’s general knowledge on e-Health and other related areas that are previously mentioned.
1.2.4 Research questions and methodology
A) What are e-Health and health-portals, and what are their relevant actors?
B) What are the different needs of health consumers and what are the specific motives for
network partners to contribute in the value network of a health-portal?
The goal of this research is to gain insight on how to develop new services that add value to health consumers and contributing partners. In order to gain this insight and to provide possible recommendations, the design approach of Van de Kar (2004) was chosen. According to Hernandez and Hodges (2003), the current literature concerning integral design approaches for healthcare related service systems is scarce. However, Van de Kar’s (2004) design approach, which is primarily focussed on mobile information service systems, is an example of such an integral approach. In order to provide recommendations on how to develop new e-Health services the design approach of Van de Kar (2004) needs to be assessed. The health-portal PAZIO was selected to assess Van de Kar’s (2004) approach in practice through case study research. This has led to the main research question:
“Which recommendations can be made from assessing the design approach of Van de Kar (2004) based on the PAZIO case, for TNO ICT and new health-portal initiators?”
1.2.5 Structure
The structure of the paper is based on the order of the research questions. Chapter 2 describes the literature survey on e-Health and health-portals, different actors, and their needs and motivations. This survey is based on the two preliminary research questions.
Chapter 3 describes the case study of the project PAZIO and gives an detailed overview of the research approach and research setting. Afterwards, Van de Kar’s (2004) APSIT method is assessed through a case study research.
Chapter 4 examines Van de Kar’s (2004) approach even further by assessing the different trade-offs between value network, technology and service formula in order to provide detailed recommendations and improved design guidelines.
2.
THEORETICAL BACKGROUND
2.1
The Concept of e-Health
The average age of the citizens in the Netherlands is rising and the number of years that people need to be treated for their health problems rises too. At the same time the amount of health providers decreases (figure 1). This means that new solutions in healthcare must be developed to ensure high-quality healthcare, which is largely accessible and is still affordable. These new solutions (or respectively; innovations) in healthcare almost all fall in the domain of e-Health.
Figure 1: The gap between supply and demand in the Dutch healthcare sector (i-Zorg Consortium, 2006)
2.1.1 Defining e-Health
“The application of Internet related technologies in the healthcare industry to improve the access, efficiency, effectiveness, and quality of clinical and business processes utilized by healthcare organizations, practitioners, patients, and consumers to improve the health status of patients.”
To provide better focus, some important boundaries around this definition were formulated by Broderick and Smatz (2003):
1. E-health is not a surrogate for the clinician. It does provide the means to extend the reach of the provider beyond a face-to-face patient encounter, with the advantage of expanding the delivery of limited resources and expertise. For instance, using electronic images and pictures, diagnoses may be made from a remote location, either within or outside the facility.
2. E-health provides delivery of useful medical information via the Internet, that may facilitate patient education and provider decision-making.
3. E-health facilitates collaboration between providers and other caregivers through file sharing, email and electronic medical record systems.
4. E-health does not replace existing infrastructure applications. Instead, it facilitates those processes to expedite delivery and improve the quality of the services provided both locally and remotely. It operates within the walls of the health facility and across geographic boundaries.
5. E-health is not another name for e-commerce in the healthcare industry. However, the facilitation of business processes among employers, employees, insurers, suppliers, clinicians, patients, administrators and regulators may include examples of E-health.
6. E-health is not the routing hardware or the networking software, but it uses those to deliver the information needed to achieve the primary goal.
7. E-health uses these means, as well as other telecommunications services, to deliver the information and processes necessary for the ultimate outcome of patient care: improved health status.
2.1.2 e-Health services
Tele-monitoring
Tele-monitoring is based on the surveillance and measurement of the health status of the patient over the internet. The monitorisation of bodily functions falls within the domain of prevention, diagnostics and/or after care by registering, transporting, storing and analyzing data without the presence of health providers, by using medical technology in an advanced manner (Kruijff and Hoevenaars, 1999). Tele-monitoring can be applied intramural as well as extramural. Examples could be of Tele-monitoring blood values, blood pressure, heart beats or respiration.
Tele-care
Tele-care can be regarded as a sub-part of tele-monitoring. Tele-care (or e-treatment) means literally ‘care on a distance’. Strictly speaking, this does not fall under the definition of tele-monitoring. However, it has to do with medical technology that is applied in a home environment. Treatments that were only possible in medical centres can now also been done at home over the internet. Tele-care can be categorised in the support of: physiological functions (like home-respiration, oxygen treatment, home dialyses, vacuum therapy for wound-treatment, external electro-stimulation or traction treatment), administering (like infusion treatment, insulin pump therapy, probe feeding, UV-therapy or nebulisation), and monitoring and diagnosis (Hollestelle, M., et al. 2005).
E-Consult
E-Consult between patient and professional is the consultation of a general practitioner with a patient over the internet. This can be someone’s own practitioner, but that does not always have to be the case. For many less stringent questions that patients might have is a physical meeting during often overcrowded consulting-hours not always necessary. With the use of an e-Consult is it possible that a patient can receive their answers at home so that the practitioner has more time and space to call its attention to more urgent disturbances that require physical examination. E-Consult between professionals themselves is a convenient way to exchange information to each other, which in fact is an inter-fraternal consult over the internet.
E-Therapy (therapy with the use of IT which is often e-mail or internet) and e-Diagnosis (offering diagnosis on a distance) are different forms of e-Consult.
Self-diagnosis by patients
E-Buy
E-Buy refers to the purchase of medicine (through e-Prescription), assisting equipment (like for example incontinence material, second hand wheelchairs and stair lifts). Most of the literature is based on e-Prescription and self-tests. Self-tests are primarily focused on retrieving the presence of an increased risk of getting a specific illness or disorder (Bovendeur, I. et al. 2007). There are different kinds of self-tests, namely: self-tests on bodily material (e.g. the vitro self-test) and monitoring tests (tests for monitoring the illness in the home environment, like blood glucose measurements by diabetic patients). A great number of different tests are being offered on the internet and the results of those tests are often being sent to the patients’ home address.
There are two different forms of purchasing medicine and self-tests on the internet, namely: the receiving medicine or self-tests without the intervention of a health provider and obtaining these products directly over the internet (through a website or specific e-Health application within a health-portal).
2.1.3 Interactions
The use of e-Health services creates possibilities for health providers and patients to interact with one another in ways that were not possible before. The National Patients and Consumers Federation (NPCF) (Baardmans, J., et al, 2009) described in a vision document how the different e-Health services can be classified on the basis of the connections that can be made between different actors in healthcare:
Health provider connected to another health provider (“doctor to doctor”; D2D).
Health provider connected to a patient (“doctor to patient”; D2P or P2D).
Patients connected to other patients (“patient to patient”; P2P).
In this research online health-portals can assist in all three forms of interactions.
The next section will further describe online health-portals by providing a definition, describing its main characteristics and its key benefits for the IT delivery network.
2.2
Online Health-Portals
2.2.1 Definition
online health-portals as the integration of different e-Health services from different domains in one web-based application that possesses all three forms of the previously mentioned interactions (see paragraph 2.1). This research endorses this concept and defines online health-portals as a collection of different e-Health services in one web-based application that can make interaction or, respectively, multidirectional communication between health providers, health consumers and other relevant actors possible.
2.2.2 Characteristics
According to Andry F. et al (2010), the basic characteristics of online health-portals in terms of the reoccurring features found in most portals offerings today, are first of all that portals offer a ‘single point of access’. Portal solutions offer a unified and personalised view for various healthcare professionals (Koufi et al. 2008), and provide real-time access to a selected patients’ clinical information with integrated single sign-on (SSO) authentication capabilities. Secondly, portal administrators have the ability to set permissions by which they can limit specific types of content and services to groups of users based on their roles and profiles. Role-based concepts are included in most portal offerings and offer flexible configuration capabilities for specific targeted sets of user groups. Thirdly, portals offer the possibility for aggregation of data and services from multiple systems in terms of integration which include generic content, knowledge management and collaboration components into visual front-end fragments or portlets. Portlets are user interface software components that are managed and displayed in a web portal. Fourthly, contemporary portals are federative by nature which basically means that they can offer a combination of content from various sources. A fifth characteristic is that health portals enhance its user experience by offering an efficient and consistent user interface (even though the underlying services can come from multiple sources). The sixth and final characteristic is based on the ability for personalisation. Users can choose specific services and tailor the content to their needs. This could mean that they can sometimes even customise the layout and the look and feel of the presentation layer.
2.2.3 Interoperability and standardisation
designed and developed separately and deployed as they are completed. As a result, service providers can quickly develop features and functions as needed by their customers and demanded by the marketplace. A health-portal that is interoperable can easily integrate these new e-Health modules and to deliver them to the relevant actors.
Standardisation on various levels with regard to process, communication and semantics can also help resolving the issue of interoperability. Health portals can benefit from these standards by ensuring reliable and safe means to communicate with the different healthcare systems. Care provider organisations must take up the matter of formulating joint requirements for IT products, so that service suppliers are less confronted with individual requirements. A good example of this is the model for GP information systems from the Dutch Association of General Practitioners (NHG, in Dutch abbreviation). On the level of “harder” technology, it is primarily up to the service providers to resolve the interoperability issue. Cooperation between suppliers within HL7 (global authority on standards) and IHE (global initiative by healthcare professionals and industry) is a good example of this. In areas where international standards already have been developed, such as in radiology, international suppliers are also active in the Dutch market. In other areas, however, it is primarily smaller niche players who are active.
2.2.4 The healthcare IT network
With regard to its architecture and to the specific characteristics of health portals (see previous paragraphs), these portal approaches can benefit the whole healthcare IT delivery network (Andry, F. et al 2010) in contrast with offering individual or separate e-Health services:
Benefits to the end-users: The portal application represents a ‘single point of access’ to
perform important healthcare tasks through a very convenient “dashboard” paradigm. Portal solutions also present a rich user experience by leveraging Web 2.0 technologies (Phifer, Gootzit and Valdes 2008) and specific components (e.g. wikis, blogs, message boards, social networking, maps etc). Portal customisation and personalisation also offers end-users a more personalised experience based on their profiles such as their role in the organisation or user group and preferences (e.g. choice of layout, look and feel, medical content);
Benefits for the development team: This includes a common architecture for the aggregation
of heterogeneous components and services, a clear separation between the presentation layer and the service layer, and the fact that portlets are based on standard technologies (e.g. JSP. JSF, Spring, Hibernate, JSR 168, JSR 286, WSRP, AJAX, Java EE, or even Adobe Flex).
Benefits for the professional service team: Portal technology can save substantial costs to the
A reduction of the Total Cost of Ownership (hereinafter referred to as TCO): For the service providers deploying and maintaining services and applications, the ability to run multiple portal sites, each with a unique domain, on the same portal server reduces the duplication of hardware and image instances. Portlets can be deployed at run-time (hot deployment) reducing down time for the user, facilitating the maintenance of the applications and increasing the overall quality of service (QoS). In addition, specific content, branding, layout and skins can be stored and managed independently of the application in a content management system, saving costs during deployment and maintenance.
2.3
Analysis of the actors of e-Health
The objective of this analysis is to present a comprehensive coverage of the involved problem owners and stakeholders by the development of new services for health-portals. It is important to get an overview of the demand-side of health consumers who want to benefit from a service that are related to their needs and the supply-side of which service providers want to make a contribution to the healthcare sector and are trying to sell their innovative e-Health services. An important remark must be made with respect to the area of demand and supply in healthcare. A product or service related to healthcare is by no means comparable to other products or services that are being developed and traded on the ‘traditional’ consumer market because healthcare products or services are not only an individual goods but also public goods (Leys M. and Potlood, L. 2004). This implies that other actors like health insurers, government agencies and research organisations have a profound influence on the way e-Health services are being developed and received.
First, the different actors related to the development and implementation of e-Health services are discussed. Afterwards the demand and the supply side of e-Health, with regard to the needs of health consumers and the motives of service providers are clarified.
2.3.1 Relevant actors
Health consumers
Health consumers can be national citizens; resident aliens; short-term visitors; and tourists in need of or receiving medical attention, social care, or allied treatments. When healthcare is involved health consumers are called ‘patients’. Health consumers who are involved in social care are regarded as ‘clients’, and in commercial situations they are called ‘customers’. In this research health consumers in general are regarded as the end-users of online health-portals. This can be explained by referring to conventional healthcare services that are developed on the basis of patients’ concerns, safety and well being, in other words services that are patient-centred. E-Health services can be developed to benefit the health provider as well, for example e-consultation (decrease travelling time), scheduling services (decreased workloads). However, care is always provided to the persons who are for example in need of counselling or who are in need of surgery. The same applies to e-Health services.
The NPCF protects the interests of the health consumers in the Netherlands. They want to strengthen the position of patients and health consumers in healthcare. Their basic principle is demand-driven healthcare and they play an active role in ensuring that e-Health initiatives are developed according to demands of health consumers. The NPCF movement counts approximately 350 associations and patient organisations.
Health providers
Health providers can be divided in care practitioners and care providers. Care practitioners in a medical context, include doctors, nurses, and allied care professionals. Doctors would include general practitioners, physicians and surgeons and mental health specialists. Nurses would include hospital, community, and specialised nurses, such as cancer care nurses. Allied care professionals, who usually need formal training and accreditation before they are employed, would include medical assistants, dental hygienists, physio- and occupational therapists, laboratory technicians, medical equipment technicians, radiographers, medical secretaries, medical coders, care assistants, caterers, posters, and drivers. Most of the care practitioners in the Netherlands are connected to The Order of Medical Specialists (OMS). The OMS protects the interests of medical specialists with regard to regional and central interests and material and immaterial interests.
The Dutch Association of Medical Centres (NVZ)1 is an organisation that is primarily focused on collectively serving the health related social and economical concerns of care providers in the Netherlands. The care providers of which the NVZ is serving their interests are: general medical centres and categorical institutions like for instance asthma centres, audiological centres, cancer centres, radio therapy institutions, rehabilitation centres and dialysis centres.
Health providers can also be regarded as the end-users of online health portals only when specific services are made on the basis of the demands (or specifically the needs) of health-providers. These services would typically be “doctor to doctor” services.
Health insurers
All the health insurers in the Netherlands are connected to the association of health insurers (Zorgverzekeraars Nederland). This association covers all the different health insurance funds and private health insurance companies. However, different health insurance companies participate in different health-portal initiatives. For example, Agis Health Insurances participates in Portavita Health Innovations and Delta Lloyd and NUTS verzekeringen participate in the GigaBroCa project.
There are even portals like Medicinfo (www.medicinfo.nl) which are explicitly made available only
for the members and customers of health insurers.
Service providers
The service providers of e-Health service applications in the Netherlands vary from large multinationals like Philips, Siemens and IBM, to much smaller enterprises like Chipsoft, Forcare, NetSourcing, Rogan Delft or Topicus Zorg who develop innovative e-Health services to support in healthcare.
Some specific e-Health services that health providers may want to use and deploy, like for instance EHR-systems, have to meet certain qualifications. Therefore different qualifications are proposed by the standardisation institutes. The reason for this is because of the concerns regarding the privacy and safety of patients when using medical data and during information exchanges. Health providers may only make use EHR software if it meets to the demands of an Adequate Managed Health system (GBZ in Dutch abbreviation). An AMH is a health information system (like for example an online health-portal) by which a health provider can exchange medical information about patients with other health providers.
Service providers must ensure that their applications meet the necessary qualifications. A service provider that wants to deliver a health information system that meets the demands of an AMH must obtain ‘XIS-type’ qualifications from the NICTIZ. The exchange of medical data to other health providers in the Netherlands is managed by the ‘National Switching Point’ (LSP in Dutch
1
abbreviation). Only e-Health services that meet the XIS-type qualifications can exchange information
over the LSP2. Service providers themselves must also be qualified as an official ‘Health Service
Provider’ (ZSP in Dutch abbreviation) by meeting the ZSP-qualifications of the NICTIZ.
Standardisation institutes
For standardisation institutes lies the emphasis on the observance of existing standards and the preparation of upcoming standards. One of their primary objectives is to ensure that different regional standards that are based on local protocols can not originate so that they could interfere with national standards. The rise of regional standards could mean that the implementation of promising e-Health services can be at risk because of the missing interoperability of these services. A lot of former e-Health initiatives show that these projects fail in becoming nationwide successes which can also explain the fragmented market of different e-Health services today.
There are two major institutions that govern and supervise the standards of e-Health services in the Netherlands. The first one is the NICTIZ, which is a national expertise centre that facilitates the development of IT in healthcare. The NICTIZ deliver the possibilities, preconditions and qualifications for electronic data exchange with regard to patients in the Dutch healthcare sector. They want to stimulate the quality level and the effectiveness of healthcare in the Netherlands. Another important standardisation institute is the IHE (Integrating the Healthcare Enterprise). The IHE is an international collaboration between the users and the service providers of IT in healthcare. The IHE promotes the coordinated use of established standards like DICOM and HL7 to fulfil specific clinical needs with regard to optimal patient care. Healthcare systems that are developed according to the norms of the IHE are interoperable with each other, can be easily implemented and make it possible for health providers to use information more effectively.
Government agencies
Government agencies like the ministry of public health, welfare and sport (Volksgezondheid, Welzijn en Sport, VWS) and the ministry of economic affairs (Economische Zaken, EZ) are concerned with the development of innovative e-Health solutions in terms of funding and the observance of adequate health provision. The VWS pursues their policy with regard to the implementation of IT in the healthcare sector. The ministry of housing, spatial planning and environment (Volkshuisvesting, Ruimtelijke Ordening en Milieu, VROM) plays an important role in exploring the possibilities of living longer at home with the use of e-Health services.
2
Research organisations
Research organisations are focused on research, development or utilisation of IT in healthcare. The leading and co-ordinating organisations in this field in the Netherlands are:
The Association of Organisations for IT in healthcare (OIZ) represents since 2001 the
concerns of organisations that participate in the development and provision of IT in healthcare.
Novay (former Telematica Institute) delivers fundamental as well as market-oriented
applications on the area telecommunication. They are working on strategic research for the business community in a network of (inter)national knowledge institutions.
TNO, (an independent research organisation) which delivers a contribution to the competitive
position of organisations, the economy, and the quality of life in general on the basis of their expertise and research efforts. The departments ‘Prevention and Care’ and ‘Information and Communication Technology’ focus their activities, knowledge and experience on medical technology solutions in research settings and in market-oriented fields.
2.4
The Demand and Supply of E-Health
A widely support of health providers and patients plays an important role by the development and implementation of new e-Health services. Underlying this premise lies the belief that involving patients leads to more accessible and acceptable services and improves the health and quality of life of patients (Beresford P, Croft S.,1993, Barker J., et al. 1997). This view is endorsed by government policy, which states that involving patients leads to “more responsive services and better outcomes of care.” (NHS Executive Department of Health, 1999). The general consensus between scholars is to involve health providers and consumers in the decision making process with regard to the introduction of a new healthcare information system. If this will not happen than there is a risk of getting resistance towards the service which will diminish the initial advantages of the new e-Health initiative. The involvement of health consumers implicitly means to list the way the end users would value a new service. The next paragraph will first give an overview of the different needs that patients have with regard to healthcare and how e-Health could help in fulfilling those needs. The different motives of services providers for participating in a health-portal and offering their services, are also addressed.
2.4.1 Patients’ needs
hand, when health consumers are better informed they tend to have higher expectations and so become dissatisfied with care (Wen, K., et al. 2004). The National Health Service (NHS) define the concept of ‘need’ in healthcare as the 'capacity to benefit from health care services'. However, Ansadi-Lari et al. (2004) consider this definition as ‘too restrictive’ in the fact that it limits patients’ needs to only those that are medically necessary and dismisses others. With regard to the increasing number of e-Health services being developed, many of them are not only designed to fulfil the needs of health consumers based on medical necessities. Many services are also designed based on desires and expectations of health consumers regarding e.g. better information provision, or increasing the freedom of choice in health providers or treatments. In this research e-Health services should fit to all the needs, desires and expectations of health consumers.
The NPCF (Heldoorn, M. 2008) have presented an overview of what they regard to as the most common needs, desires and expectations that patients have regarding different e-Health services. This overview is based on extensive research about the future and meaning of e-Health for the Dutch health consumer:
The need for adequate information
Patients want to become optimally informed about their own state of health, the applied treatments and reliable information of particular diseases. The internet has revolutionised access to health information. Lewis et al. (2005) see the volume of internet-based information generally as a source of satisfaction. Studies conducted in the United States and Europe by Harris Interactive and by the Health on the Net Foundation have found that the health information that citizens find on the internet has a significant impact on their interaction with medical professionals (Wilson P. et al 2004).
In an international study which interviewed citizens in the United States, France, and Germany, found that about half of all those seeking health information on the net in France (49%) and Germany (50%) believe that the internet has had a major impact in their understanding of their health problems (Harris Interactive, 2002) (see figure 4).
Figure 4: Impact of health-related internet use (Harris Interactive Volume 2, Issue 12—June 11, 2002)
related questions to physicians, therapists and researchers. These sites are offering these e-consult and e-diagnostic services in response to the increasing needs of patients for adequate advice regarding their health problems.
The need for adequate care provision
In general, there is always the need for a sufficient amount of qualitative care. In this context patients have the need to be able to make choices about the physical location were healthcare is provided and the quality of the provided care. E-Health services must therefore be able to guarantee or even increase their freedom of choice. There are e-Health services that can deliver information to patients about which health provider could provide the most adequate treatment. Patients can also compare different health providers on the basis of a quality assessment to determine for example which medical centre offers the most qualitative care for the treatment of particular condition. There are also e-Health services that provide patients with an overview of current waiting lists, so that they know for example in which medical centre they will be treated first.
The need for adequate access to healthcare
Health consumers long for a twenty-four hour accessibility for submitting their health problems by their health providers. As mentioned previously, they want to be able to ask health related questions, make appointments and request prescriptions. E-Health has the potential to fulfil the need for easily accessible health through services like consultation, appointment scheduling services and e-Prescription. A challenge for e-Health lies in the way health providers could provide the access to these services. There are a few possible approaches:
The most obvious approach is that health providers (for example general practitioners) discuss
during an appointment or by surveying what the specific needs of a patient are and offer the possibility for using certain e-Health services. When patients approve to these alternative ways of health provision the health provider can grant a patient access to these services.
Another option demands a more pro-active approach of the patient itself. Patients can
subscribe themselves to possible e-Health services which they can access freely without the need for a health provider to grant patients access.
A more rigorous approach is by gradually restricting the health provision through e-Health
solutions only. This approach is definitely not recommended for most health consumers, because a great number of (mostly elderly) people are not acquainted and are sometimes even reluctant to usage of IT or internet related applications.
The need for adequate security of personal data
2002). E-Health services that meet the necessary qualifications can present their quality marks to their patients for reassuring privacy and safety.
The need for assistance and advice
Patients must be fully informed before the deployment of e-Health services and the necessary advice must be given about how to use these services. The patient must always be able to request and receive the assistance and advice of an expert.
The need with regard to the technology and design
The e-Health service must be designed in such a way that as many patients as possible can make use of the service. This means that the way of operating the specific e-Health applications must fit to the level of comprehension and the physical possibilities of the target group.
The general need for an online health-portal
The NPCH (National Panel Chronicle and Handicapped patients) held in 2007 a survey among their members to gain insight in the needs and desires of patients with regard to a possible online health-portal (Brink-Muinen, A. 2007). 594 panel members with a chronicle illness were randomly picked and the response rate was 84%. Most of the panel members who make use of the internet point out that they in particularly would want to make use of the medical information on a portal with regard to: choosing a treatment, a medical specialist, a medical centre or a health insurance. The majority of panel member would want to have insight in their medical file and one out of three would register their medical information themselves. Almost half of all the panel members would want to have the access to e-consults or consults per e-mail with their general practitioner. Seven out of ten panel members would value the support and assistance e-Health services for changing their behaviour with regard to issues like smoking, healthy eating, more exercises.
2.4.2 Motives of service providers
Service providers have different motives for developing and offering their e-Health services. The most obvious reason is that they want to sell their services to generate revenue and at the same time to contribute to a better healthcare provision. However, introducing and offering new innovative e-Health services in the Dutch healthcare market is difficult because of a number of reasons:
First of all the healthcare market is highly segmented. At present time there are numerous different parties who are offering their services individually, or as a network of various contributing partners each trying to position themselves in the market with fierce competition.
Secondly, it is essential that large scale projects have enough financial assets and funding for successfully launching an innovative e-Health service. Many government agencies already provide subsidies for these large scale e-Health initiatives of which the government itself often play an active part in the development of it.
Thirdly, like many other (semi-)commercial healthcare services they have to be put under the attention of the general public. This means that service providers have to invest in marketing activities or lobby with different healthcare institutions, health insures or government agencies for acknowledging their added value for the healthcare sector. Christensen et al (2009) points out that in general terms the intent of schemes to influence and regulate upcoming industries like e-Health by government agencies evolves through three stages:
1. Subsidising the foundation of the industry.
2. Stabilising and strengthening the companies involved, ensuring fair and equal access to their products and services, and assuring that their services are safe and effective.
3. Encouraging competition to reduce prices.
It is difficult to say in what exact stage the e-Health industry in the Netherlands can be placed in, however due to growing segmentation and the rising costs of healthcare it would probably be somewhere between stage 2 and 3.
2.5
Summery and conclusion
The previous paragraphs provided a theoretical background, based on two preliminary research questions to scope the area of research. The first question is described below:
A) What are e-Health and health-portals, and what are their relevant actors?
According to Della Mea (2001), e-Health is often used as an umbrella term for the combined use of electronic communication and information technology in the health sector. This research uses the definition by Broderick and Smatz (2003) to define e-Health, emphasizing the use of healthcare practices over the internet: “The application of Internet related technologies in the healthcare industry
to improve the access, efficiency, effectiveness, and quality of clinical and business processes utilized by healthcare organizations, practitioners, patients, and consumers to improve the health status of patients.”
Prismant (a leading service provider in Dutch Healthcare) made a thorough literature study on the field of e-Health and categorise its services based on their characteristics and ways of interaction. This categorisation is used in this thesis because it corresponds with the previous described definition of e-Health by Broderick and Smatz (2003) regarding the emphasis on internet and healthcare practices. These categories are: telmonitoring, telcare, consultation between patient and professional, e-consultation between professionals, self-diagnosis by patients and e-buy.
The literature defines health-portals in different ways. Some scholars define health-portals strictly as health information websites, others as the integration of different e-Health services in one web-based application. This research endorses the latter description and defines online health-portals as a collection of different e-Health services in one web-based application that can make interaction or, respectively, multidirectional communication between health providers, health consumers and other relevant actors possible.
The analysis of the relevant actors of health-portals resulted in a comprehensive coverage of the involved problem owners and stakeholders that are direct and indirectly related to the development of e-Health services and health-portals. These actors fall within the categories of: health consumers, health providers, standardisation institutes, government agencies and research organisations.
B) What are the different needs of health consumers and what are the specific motives for
There seems to be no consensus about the meaning and concept of 'need' in healthcare (Lightfoot, J. 1995, Culyer, A. 1998, Asadi-Lari, M. et al. 2003). In this research e-Health services should fit to all the needs, desires and expectations of health consumers. The NPCF (Heldoorn, M. 2008) have presented an overview of what they regard to as the most common needs, desires and expectations that patients have regarding different e-Health services. These are: the need for adequate information, the need for adequate care provision, the need for adequate access to healthcare, the need for adequate security of personal data, the need for assistance and advice, the need with regard to the technology and design.
3.
CASE STUDY RESEARCH
The previous chapter presented a thorough literature background on e-Health, from the perspective of its domains, services, actors, supply and demand, and the generic concept of health-portals. In this chapter Van de Kar’s (2004) design approach is assessed through a case study research of which the health-portal PAZIO was selected. In the following paragraphs the research design, procedure and methodology is described. Herein, the nature of the research is explained, as well as how the research is carried out and which methods are used. Before these subjects can be described properly, the design approach by Van de Kar (2004) is introduced to describe its basic elements and its relevance for this research.
3.1
Introducing the design approach by Van de Kar (2004)
Design approaches can be expressed as a way of thinking, a way of working, a way of modelling and a way of controlling (Seligmann et al. 1989). This ‘ways of’ framework by Seligmann et al (1989) formed the basis for Van de Kar’s (2004) design approach which Van de Kar used to structure the summarisation of existing design theories that are useful for designing mobile information services. For describing the main elements of Van de Kar’s (2004) approach and its relevance for this research the ‘ways of’ framework is described in the context of designing health-portals.
‘Way of Thinking’
Like the development of mobile service systems, the design of an online health-portal can be seen as the development of a system that consists of a service formula, enabling technology and a value network (as illustrated in figure 6). Health-portals are also designed in a multi-actor setting consisting of a complex value network and of which the different e-Health services are accessible through a distinct and enabling technical architecture. Based on these similarities and on the previous described characteristics of health-portals (see chapter 2, paragraph 2) this research applies the same classification as for mobile service systems.
The elements of Van de Kar’s (2004) service system design model are described below in the context of designing health-portals:
Service formula
The service formula describes the service concept that adds value to customers (Van de Kar, 2004). Developing a service formula is possible through differentiating value propositions that are demanded by its users. This means that before the actual (physical) design of a health-portal can start the different actors have to define a service formula that gives answers to various questions in terms of: ‘Who is the target group?’ ‘Does the portal with its different e-Health services replace other health services and is it really new?’ ‘What is the added value of the portal compared to existing services currently in use?’ ‘How important are the services provided by the portal for the different health consumers and how can it improve the quality of life?’ These questions can lead to a detailed service description. Other elements of a service formula are based on decisions regarding the service quality, price, market communication in terms of privacy and legal aspects. The service formula can be further evaluated during the implementation and test phase.
Enabling technology
The technology is the driving and enabling factor for the development and integration of e-Health services of a health-portal. A portal must provide a service architecture where over the different e-Health services can interact with each other and exchange data between different information systems of healthcare institutions. Before developing a technical architecture different choices have to be made regarding interoperability and standardisation issues (see chapter 2, paragraph 2). It is important that different functional and technical design decisions are made before the actual development activities of programming, scripting, assembling and testing of the architecture can take place.
Value network
A value network can be described as the configuration of activities between organisations and the correlated relationships, revenue models and cost structures (Van de Kar, 2004). The design of an online health-portal requires the collaboration of different actors that have different interests and motives for participation. It also means that business cases must be made and the roles, responsibilities and tasks before, during and after the development of the portal must be agreed upon and adjusted if necessary.
‘Way of Working’
phases. The way of working consists of a combination of iterative as well as incremental working methods. Within the different design activity phases iterations can take place as a result of testing. Incremental steps can occur after e.g. a pilot version is launched and the initiator chooses to undertake incremental improvement of the service.
‘Way of Modelling’
The ‘Way of Modelling’ framework describes the design models that a presented in the literature and previous case studies during Van de Kar’s (2004) research. Design models are helpful tools through which for example the interaction with users are examined and documented. Examples of such models are: storyboards, prototyping, component architecture modelling, use case modelling, context modelling and interface modelling.
Finally, figure 7 illustrates the ‘ways of’ frameworks by Van de Kar (2004).
Figure 7: The ‘ways of’ framework of Van de Kar (2004)3
3
‘Trade-offs’
In each of the pre-described design phases (APSIT) trade-offs can occur between the service formula, technology and value network. These trade-offs can provide insight and deliver specific guidelines for designing services from the perspective of adding value to users and network participants, stemming from the problem statement. Therefore an assessment of trade-offs found in the case study is a critical step in this research. The trade-offs described by Van de Kar (2004) are:
Trade-off between Service Formula and Technology - which concerns the issue of how the
enabling technology can support services that fulfil the demands of the users.
Trade-off between Value Network and Service Formula - which concerns the issue of how to
create a network of actors and coordinate the activities of these different actors to deliver value to the user.
Trade-off between Technology and Value Network - which concerns the issue of how a value
network can be put in place to provide the necessary technology.
Trade-offs between internal network factors - which concerns the issue of what drives and
motivates firms (in particular service providers) to form interorganisational ties?
3.2
Research Approach
3.1.1 Research Design
The nature of this research can be characterised as design-oriented research according to Verschuren and Doorewaard (1999). The result of this research is presented as what can referred to as design knowledge. Design knowledge consists of design models and heuristic statements (Van Aken, J., 2001). According to Van Aken (2001), design models are operational rules applicable in specific domains and heuristic statements are guidelines and principles on how to design in operational settings. This classification corresponds with the outcome of this research in that it provides adjustments on: (1) the current design approach (or respectively ‘model’) of Van de Kar (2004), and provides improvements on and additional new (2) design guidelines (or respectively ‘statements’), based on Van de Kar (2004).
3.1.2 Procedure
added in each of the phases depending on the project’s specific circumstances. However, the triad ‘value network, technology, and service formula’ must always be taken into account.
First the activities are described that can take place during each phase of design. Afterwards, the results are presented on how the actual development of PAZIO took place compared with the design activities by Van de Kar (2004). A summary of this assessment on Van de Kar’s (2004) APSIT method is described in subsection 3.4. This led to a number of recommendations for improving Van de Kar’s (2004) initial APSIT method by making it more applicable for online health-portals.
In chapter 4 the case study continues by examining Van de Kar’s (2004) approach even further. Here the different trade-offs between value network, technology and service formula are assessed resulting in design guidelines that pose more detailed recommendations for developing new services.
3.1.3 Methodology
For assessing the design approach of Van de Kar (2004) and to provide recommendations for TNO ICT and potential new health-portal initiators, qualitative case study research is used. As mentioned previously, the choice was made to assess Van de Kar’s (2004) design approach in practice using the PAZIO case. This was possible after having conducted a number of personal interviews and by gathering and analysing relevant project documentation (like e.g. storyboards, user requirements list, architectural study reports and business case reports). The interviews were held with all the members that were direct responsible for carrying out the project. These members were: the program manager, the managers of the realisation team and of the business team, and the main service providers.
The greatest disadvantage of personal interviewing is that it is costly in terms of the time that is spent on processing and analysing the results, and in terms of time and money for the researched organisation (Cooper, D., and Schindler, P., 2006). Based on this disadvantage and the degree of in-depth research necessary for fully analysing the relevant areas of development (service formula, technology and value network) during the different phases of design, only one specific case study was chosen.
3.2
Research Setting
This paragraph provides detailed information about the project of the health-portal PAZIO with regard to its objective, its actors and its current planning. Furthermore, the concept of the health-portal is been described, as well as its basic functionalities.
3.2.1 Introduction
