How does the change towards smart
pacemakers affect the social system of
cardiologists and what are the changes for
their work design?:
A Qualitative Research On How Smart Pacemakers Have
Impacted The Social System and Work Design of
Cardiologists.
By:
Tom Stammes
Master Thesis
MSc BA – Change Management
University of Groningen
Faculty of Economics and Business
Date: 15-03-2019
Supervisor: A.J. Boonstra
Co-Assessor: O.P. Roemeling
Tom Stammes
t.stammes@student.rug.nl
Student number: s2348233
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Abstract
As devices and technologies grow smarter in healthcare organizations, the effects of these changes and their consequences have yet to be unraveled. This study explores how cardiologists are affected by the move towards smart pacemakers, in their work design and in their social system. Through an explorative lens, 11 interviews were conducted with cardiologists, pacemaker technicians and other related professionals. In order to discover how the social system of cardiologists is affected, this study uses the lens of the socio-technical system, provided by Leonardi (2012).
The results show that the cardiologist’s job has become more complex, needs more specific knowledge and leans more on the pacemaker technician. He can deliver higher quality care, but issues have come up in the form of data overload and extra time necessary for new tasks without the right remuneration, leading to frustrations.
3 Table of contents Abstract ... 2 Introduction ... 4 Literature Review ... 7 Internet of Things ... 7 Socio-Technical Systems ... 9 Work design ... 12 Methodology ... 14 Research design ... 14 Selection of participants ... 15 Data collection ... 18 Data analysis ... 18 Research quality ... 19 Findings ... 20
Evolution of pacemakers & ICD’s ... 20
Consequences in work ... 23 Discussion ... 31 Socio-Technical System ... 31 Work design ... 35 Theoretical contribution ... 38 Managerial implications ... 38 Limitations ... 39
Future research avenues ... 40
Conclusion ... 40
References ... 42
Appendix ... 46
A – Interview protocol ... 46
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Introduction
In a world where technology intermingles with our lives and continuously increases its significance on the planet and in the way we live our lives, technology will be here to stay and influence us in ways we would have never imagined 100 years ago. Technology is booming and devices keep getting smarter, find new linkages, ways to connect, collect and share information. We are currently in a trend of moving towards a ‘hyper-connected’ world (Shin, 2014). A significant contribution of this trend comes from the rise of the so-called ‘Internet of Things’ (IoT). This phenomenon is conceptualized as: “A network of entities that are connected
through any form of sensor, enabling these entities, which we term as Internet-connected constituents, to be located, identified, and even operated upon” (Ng & Wakenshaw, 2017, p.4).
This phenomenon creates interconnectedness of everyday objects with the use of information technology. It is colliding the internet, or digital world, with the physical world (Ng & Wakenshaw, 2017).
Through the Internet of Things, smart systems are created, which are able to sense, control and actuate on the situation, and act in a smart manner (Gubbi, Buyya, Marusic, & Palaniswami, 2013; Miorandi, Sicari, De Pellegrini, & Chlamtac, 2012). As the Gartner Hype Cycle of Emerging Technologies predicts that IoT will reach mainstream adoption in two to five years, smart systems are slowly but surely making their entrance in important industry sectors, including the healthcare industry (Gartner Inc., 2017).
In the healthcare industry, IoT is already implemented in the following ways: sensors in patients rooms to continuously check the patients’ body temperature or blood pressure; geolocational devices to monitor the location of, for example, wandered off Alzheimer patients; RFID tags in appliances to track the location, monitoring of equipment that needs to be refilled (Laplante & Laplante, 2016). These are just some examples of the numerous ways of how IoT is implemented within healthcare. However, a vast amount of previous academic research shows that when technologies and smart systems are adopted, potential problems arise, and businesses have to adapt to the characteristics of these new technologies (e.g. Chua & Lam, 2005; Dutton, 2014; Laplante & Laplante, 2016; Lyytinen & Newman, 2008; Soh & Sia, 2005).
5 Therefore, further research is necessary. From a practical standpoint, research can shed some light on this uncertain future, elaborate on what changes are to be expected and show how organizations change because of the implementation of smart systems. For example, data handling will only rise in importance, the healthcare professionals have to organize their jobs in different ways, roles and processes have to change, new jobs have to come up due to the rate of innovation and knowledge necessary to comprehend the complex systems. These are just some examples of the numerous changes that might take place in organizations due to smart systems implementation. Research can help organizations in their implementation and make arrangements for the transition.
From an academic standpoint, it is interesting to find out how the implementation of the Internet of Things is taking place, and how these systems affect the organizations. How are healthcare organizations changing by IoT and what are the consequences for healthcare professionals?
This research paper addresses this question by focusing on one specific example of a smart system in healthcare, namely the smart pacemaker.
The artificial, implantable pacemaker exists since 1958, and has been further developed since then. Since about a decade, the pacemaker and the implantable cardioverter defibrillator (ICD) have started to become ‘smart’. This started with the introduction of telemonitoring, which means that patients could remotely be monitored (Klein & Inama, 2010). This has further evolved to the point that nowadays, the functionality of the wires, the battery life, and the hearth rhythm is continuously monitored and any discrepancy is directly notified to the cardiologist or pacemaker/ICD technician. As a consequence, patients have to visit their cardiologist only quarterly to yearly, with an increased rate when the device approaches its end of service, or in case of emergencies. This is not only more convenient for the patient itself, but also changes the way cardiologists have to work, paving the way for more efficient and effective care (Ricci, Morichelli, & Varma, 2014).
These are just some of the functionalities that are now possible with the newest forms of pacemakers and ICD’s, made possible through the evolution of the Internet of Things and smart systems.
6 consequence their entire work design and related work processes undergoes changes. Furthermore, their social interrelationships are affected. These interrelationships between persons within an organization is conceptualized as the social system, which in turn affects how the technology is put to use. (Leonardi, 2012; Orlikowski & Gash, 1994).
Following these arguments, this paper examines the following research question:
How does the change towards smart pacemakers affect the social system of cardiologists and what are the changes for their work design?
In order to address the research question, this study will draw on 11 expert interviews with multiple cardiologists, pacemaker technicians and other relevant healthcare professionals. This is combined with extant literature on the Internet of Things, Socio-Technical Systems and work design. The objective of this paper is to contribute to the literature on the Internet of Things, Socio-Technical Systems and work design, specifically in the context of healthcare. From a practitioner standpoint, this paper will demonstrate how organizations in healthcare can expect changes in the work of cardiologists from the implementation of smart systems. Next, it posits that when implementing and adopting technology, an holistic view of both the social and technological system is of vital importance, as this will prevent flaws, misappropriation and other negative outcomes.
The results show that the social system of cardiologists is affected by the move towards smart pacemakers in the form of more specific knowledge that is necessary to handle these devices, leading to new and more important roles, new tasks that turn into a fixed part of the job, different communication networks and the process of gaining trust in the devices (by having both positive and negative experiences). Moreover, the intention in which cardiologists approach these devices is influenced by these experiences. Negative experiences and unintended outcomes which negatively influenced their work are attempted to be prevented, by not always using the full potential of these devices.
Furthermore, the work design of the cardiologist is altered, as changes have taken place in task variety, job complexity, autonomy, specialization, information processing and quality of work. Not all these alterations have improved the quality of his job, but they definitely have improved the quality of healthcare; which in turn improves job satisfaction of cardiologists, as their true intention is to help a patient in the best way.
7 and explained, followed by the results and insights of the expert interviews and the discussion. At the end of the discussion, the contributions on both managerial and theoretical level, are highlighted. Furthermore, the limitations and propositions for future avenues of research are discussed. The paper closes with a conclusion.
Literature Review
This chapter encompasses the literature that has been written around the core concepts of this paper.
It will portray what previous academic literature has shown in order to create a common understanding of the topics and the prior research evolving around these topics. The topics that this literature review will focus on, are: the Internet of Things, Socio-Technical Systems theory and Work Design.
Internet of Things
The term ‘Internet of Things’ was first introduced by Kevin Ashton in 1999, as a matter of description of how everyday objects could turn into an internet of things, by adding radio-frequency identification and other sensors to these objects (Ashton, 2009). Now, the term has evolved to a description of the IoT that is:
“A network of entities that are connected through any form of sensor, enabling these entities, which we term as Internet-connected constituents, to be located, identified, and even operated upon” (Ng & Wakenshaw, 2017, p.4).
In the time since 1999, the Internet of Things has seen an explosion in popularity and in applications. The amount of things connected to the internet is 12,5 billion in 2010, and is estimated to grow to the staggering number of 50 billion in 2020 (Ellen MacArthur Foundation, 2013).
8 urine. Then this data can be used to check for the person’s wellbeing (Ng & Wakenshaw, 2017). This process is called the ‘liquification of information’ (Lusch & Nambisan, 2015; Normann, 2001).
Secondly, the IoT can be used as digital materiality. Where physical materiality is about what a physical object can do, digital materiality is conceptualized by Yoo, Boland, Lyytinen, & Majchrzak (2012) as how the software embedded in the physical object can manipulate this object. New functionalities can be achieved by embedding sensors, RFID and software in physical objects (Guinard, Trifa, Mattern, & Wilde, 2011). Yoo, Henfridsson, & Lyytinen (2010) specify that digital materiality can be described in seven properties, enabling tracing objects, communicating with them, store information, adding new instructions and modifying the behavior, and, finally, gather information on its environment. These seven properties are conceptualized as: senseability, addresseability, traceability, associability, communicability, programmability and memorability (Yoo et al., 2010).
Thirdly, the IoT reshapes products by serving as an assemblage or service system, which consists of a network of products that interact together (DeLanda, 2006; Hoffman & Novak, 2015). In an assemblage system, the whole is more than the sum of its parts, as together they create functions that were not possible if the products functioned on their own (Hoffman & Novak, 2015).
Furthermore, due to the amount of data that is collected through IoT, companies can change their offerings (Wortmann & Flüchter, 2015). Product design, production and consumption starts to become fluid and come closer together, leading to a focus on affordances instead of forms and functions (Withagen, de Poel, Araújo, & Pepping, 2012). Affordance focuses on the action-ability of the products (Ng & Wakenshaw, 2017).
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Socio-Technical Systems
The social and technical subsystem were first mentioned in 1951, by Trist & Bamford. They showed in a coal mining company, how the technical and social subsystem related to each other and how these two aspects influence each other (Trist & Bamforth, 1951). In this mining company, the system of extracting coal changed, due to technological advancements. With this implementation of new machinery and a new extracting system, the way the tasks were divided among employees also changed, causing the technical subsystem to change (Trist & Bamforth, 1951). Further, they showed that also the social subsystem changed, as communication patterns, hierarchies and power relations shuffled and changed (Trist & Bamforth, 1951). With their paper, Trist & Bamford were the first ones to underline that both people and technology have to be considered in organizations, as change in one aspect can trigger both intentional and unintentional changes in the other aspect as a consequence.
In time, this study led to the development of socio-technical systems theory (van Eijnatten, 1997). In this theory, organizations are complex systems, where all parts are interdependent. In order to reach effectiveness of a change in this system, possible effects of this change in other parts of the system have to be considered, even as early as in the design phase (Hendrick, 1997). Thus, a holistic view on organizational system components, comprising of both the social and the technical subsystem, and change is necessary to increase effectiveness.
Most importantly, the socio-technical systems theory has successfully contributed to improving the design of new technologies and technology-led change (Baxter & Sommerville, 2011). For example, it has helped guiding designers on how users can be of value regarding the use of new technology and how this integrates and interacts with the existing social system (Mumford, 1983; Klein, 2005).
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Figure 1: The Socio-Technical system model (Leonardi, 2012).
The social subsystem consists of interrelationships between people in an organization. Every organization has its own social subsystem. These interrelations consist of social formulations, evolving around the aspects of power/hierarchy, beliefs and norms, communication, roles, status, knowledge, habits, abilities, experiences with and expectations about technology and its affordances (simply said, what can be done with it, that couldn’t be done without it) and constraints (Leonardi, 2012; Orlikowski & Gash, 1994). These aspects of the social subsystem relate to the technical subsystem, as these social formulations influence how people intend to use technologies and really use it (Orlikowski, 2000).
11 agency stands for the ability to form and realize one’s goals (Emirbayer & Mische, 1998; Giddens, 1984). In this model specifically, human agency consists of the goals that people form as they use the artifact, given its materiality. Moreover, if more human agencies are coordinated, it can be considered social agency (Leonardi, 2012).
An important notion, showing the interconnectedness of the social and technical subsystem, is that the intentionality is continuously formed by the social formulations in the social subsystem. Leonardi and Orlikowski & Gash explain that the social subsystem forms ideas for people on how to use technology, what they can do with it and what they can’t do with it. Through ongoing interaction with others and with the technology, this opinion and knowledge continuously is in motion and keeps updating, potentially changing the way the technology is put into action (Leonardi, 2012; Orlikowski & Gash, 1994).
As there is human agency, there is also material agency. Material agency stands for the capacity of the artifact to act, even without human intervention. Technologies exercise their agency through performativity, so through the things they do that users cannot completely control (Constant & Pickering, 1997; Leonardi, 2011). In Leonardi’s model specifically, it refers to how the artifact acts when it is put to use by the person. Thus, given the materiality of the artifact, the person uses this artifact to accomplish his/her goals (Leonardi, 2012).
What the artifact is, does not change across space and time, but what it does can and often changes. Thus, materiality is stable at one point in time and consequently relatively stable (how a hammer physically looks like is rather stable), but material agency is continuously in motion. This depends, partially, on the materiality, but also on the person’s perception of how this materiality affords the ability to achieve the goals or places constraints towards those goals (Leonardi, 2012).
Lastly, Leonardi includes imbrication in his model. Imbrication represents how social and material agencies become intertwined and entangled (Leonardi, 2011). In other words, imbrication leads to infrastructure (Taylor, Groleau, Heaton, & Van Every, 2007). Imbrication happens when the technology is put to use, or how Leonardi states it: “The agencies become
imbricated in the space of practice” (Leonardi, 2012, p.22). Imbrications produce routines and
12 After this explanation of Leonardi’s model and its components, sub-research questions can be introduced. These evolve around Leonardi’s model and thus needed explanation before introduction. The sub-research questions are:
How is the social subsystem of cardiologists affected by the move towards smart pacemakers? How is a cardiologist’s intentionality towards smart pacemakers affected by changes in the social subsystem?
How is a smart pacemaker’s materiality affected by changes in the social subsystem?
Work design
Work design theory came up in the beginning of the 20th century, when Gilbreth (1911) and Taylor (1911) started to focus on specialization and simplification of tasks to improve work efficiency. However, reaching maximum work efficiency tended to result in work dissatisfaction, increased absenteeism and turnover (Hackman & Lawler, 1971).
As a reaction, researchers developed theories that focused on the motivational aspect of work (e.g. Hackman & Oldham, 1976; Herzberg, Mausner, & Snyderman, 1959). Hackman & Oldham (1976) rooted for five work characteristics which would make jobs more interesting for workers: autonomy, skill variety (variety of skills necessary for the tasks), task identity (whether they could finish the task by themselves), task significance and feedback from the job. Improvements on these factors would mean a higher job satisfaction, higher performance and less absenteeism. These five work characteristics would reach these outcomes through three psychological states: experienced meaningfulness (degree to which an employee feels value and importance in the job), experienced responsibility (degree to feeling liable and accountable for job results) and knowledge of results (awareness of level of performance) (Hackman & Oldham, 1976).
13 Hackman & Oldham (1976) discussed autonomy as a one-dimensional construct, while later scholars described it as a multi-faceted construct. This resulted in the constructs of work-scheduling autonomy (freedom to control work-scheduling and timing of work), work methods autonomy (freedom to control which methods are used) and decision-making autonomy (e.g. Houtman, Karasek, Amick, & Bongers, 1998; Jackson, Wall, Martin, & Davids, 1973).
Next to motivational characteristics, social characteristics impact the employee in its work. On this notion, Trist & Bamforth (1951) were among the first to recognize the importance of the social environment. Two social characteristics were found: dealing with others and friendship opportunities, but it took until the 2000’s for social characteristics to come back into the picture, partially due to an increased importance of team work in organizations (Hackman & Lawler, 1971; Humphrey et al., 2007). As an example, it has been established that relationships between workers are one of the most important determinants of well-being and ideas of meaningful work (Gersick, Bartunek, & Dutton, 2000; Myers, 2003). These characteristics would reduce job stress, increase motivation, prosocial work behavior, promote security and a positive frame of mind on the job (Adler & Kwon, 2002; Grant, 2007; Karasek, 1979).
From a vast amount of research, four characteristics are identified by scholars to be the most important regarding social characteristics: interdependence, feedback from others, social support and interaction outside the organization.
Additionally, next to social characteristics and motivational characteristics, work context characteristics are well established in work design theory. Here, ergonomics, physical demands and work conditions are most important (Humphrey et al., 2007).
Concludingly, all these characteristics together, will lead to positive behavioral and attitudinal outcomes, in the form of higher performance, less turnover and absenteeism and higher satisfaction and job involvement (Humphrey et al., 2007). When organizations are changing work processes and tasks, it is important to take into account how it will affect employees in their work, both behaviorally and attitudinally.
Following this explanation, another sub-research question can be introduced:
How does the change towards smart pacemakers affect the work design of cardiologists?
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Methodology
The purpose of this research is to enrich the scientific field by investigating how the introduction of smart pacemakers has affected the social system of cardiologists and their work design. Therefore, this research is focused on the explanatory paradigm (Van Aken, Berends, & Van der Bij, 2012). The introduction and literature review demonstrate that researchers have shown the technological relevance of IoT, but little has been written about its social impact in organizations, specifically in the healthcare sector. Hence, a theory development approach is appropriate (Van Aken et al., 2012; Yin, 2013). Interviews with experts have been used to collect empirical evidence on this phenomenon.
This chapter illustrates the research methodology, including the choice of research design, data collection, data analysis and research quality.
Research design
As this study focuses on theory development, it focuses on the first part of the empirical cycle, since the phenomenon can be seen as more general than a business problem in a specific company (Van Aken et al., 2012; Eisenhardt, 1989). The first step in the empirical cycle is the trigger. A business phenomenon which is not yet (well) explained in the academic literature (Eisenhardt, 1989). In this case, this is how the introduction of smart pacemakers has impacted the social system of cardiologists and their work design. The second step is to study the phenomenon more closely, via case studies. The insights gathered out of these cases lead to the development of explanations that can be compared with the existing literature in the scientific field (Eisenhardt, 1989). The result of the analysis of the new results with existing literature leads to propositions. These can be either changes in existing propositions or additions to the existing literature (Van Aken et al., 2012).
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Selection of participants
This research focuses on the implementation of smart systems in the healthcare industry. Thus, an example of these smart systems had to be chosen for the research focus, as investigating all devices would be too broad. Therefore, the example of smart systems in hospitals that is discussed in this research is the pacemaker. This device keeps getting more complex and collects more data about the carrier. It is smarter than before in the sense that it is collecting more data, has better algorithms, can communicate data wireless through telemonitoring and can alert hospitals in real-time. It has developed into a smart system compared through the older versions.
Since this research design consists of expert interviews, persons had to be identified and selected as experts to fit the research scope. Experts in this case are identified as healthcare professionals that are working with pacemakers or ICD’s, or have worked with these appliances and are now still closely active in the field. Preferably, experts should either be a cardiologist or pacemaker technician, as these professionals are in close contact with pacemakers and ICD’s in their daily work. However, the range of experts was broadened to other practices that are closely related and still are closely linked to pacemakers and ICD’s.
Multiple approaches were followed to recruit experts. First, the researcher used his own network and acquaintances to see whether any persons that would fit the requirements could be found and willing to be interviewed. Secondly, hospitals in the Netherlands were contacted by phone and mail, in order to reach the cardiology department. And thirdly, specific filters, such as Cardiologist, Pacemaker Technician, Cardiology, were used on professional service platforms to identify experts, after which they were contacted through that platform.
One interviewee provided the researcher with extra data beyond the interview. An extra online document was provided, consisting of an interview from 5 years ago, discussing cardiology and the surplus of trained cardiologists in the field.
Eventually, a total of 11 experts could be recruited. Table 1 presents a list of all respondents (R), including the organization they work for, the type of organization, their role within this organization and the country in which they work and were interviewed. All experts are working with pacemakers and ICD’s or closely see these devices in the field. Following Bogner & Menz (2009), the experts are relevant people working in the field, possessing specialized knowledge that is not available to the researcher.
16 between a cardiologist and a pacemaker technician. Furthermore, 2 of the cardiologists are also active in another role, 1 as medical specialist and founder of a private clinic, and 1 who works as a social insurance consultant.
Table 1: List of Expert Interview Respondents
R Organization Type of Organization Position Country
1 Cavari Clinics
Independent Treatment Center /
Private Clinic Founder, Cardiologist The Netherlands
2 AMC Amsterdam Academic Hospital Senior Pacemaker & ICD Technician The Netherlands
3 Diakonessenhuis General Hospital Cardio Technician / Pacemaker Technician The Netherlands
4 Noordwest Ziekenhuisgroep Alkmaar Regional Hospital Device Cardiologist The Netherlands
5 UMCU Utrecht Academic Hospital Physician Assistant Device Therapy / Electrophysiology The Netherlands
6 UMCG Groningen Academic Hospital Head of Cardiology The Netherlands
7 UMCG Groningen Academic Hospital Pacemaker & Bio Technician The Netherlands
8 UMCG Groningen Academic Hospital Cardiologist & Electrophysiologist The Netherlands
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Medisch Centrum Leeuwarden / Ludwig MD
General Hospital /
Insurance Agency Cardiologist & Social Insurance Consultant The Netherlands
10 Martini Ziekenhuis General Hospital Cardiologist The Netherlands
Data collection
Observing the phenomenon is carried out solely with the use of primary data, in the form of in-depth interviews.
Interviews (primary data collection)
In-depth semi-structured interviews were used as a primary data source in this research. The interviewees are all people falling into the categories of the sample. A total of 11 interviews were conducted. The preferred setting for the interviews was face-to-face, but due to filled agendas or geographical distance, some interviews were conducted through telephone or Skype. During the interviews, field notes were taken to capture nuances in tone, attitude and body language. All interviewees are working and geographically located in the Netherlands. The interviews were conducted in the interviewees’ mother tongue, to allow for greater accuracy. The length of the interviews varies between 40 minutes and 1 hours and 15 minutes, depending on the answers of the interviewees and the amount of sidesteps taken during the interview. This was possible, as a flexible interview protocol was set up (See Appendix A), allowing for interesting sidesteps, further clarification and letting the informants lead the investigation of the research question (Gioia, Corley, & Hamilton, 2013). The interview protocol was revised as the research progressed and taken as a guideline, in order to have the interviews in a semi-structured setting. The interviews were recorded, with permission of the interviewees, so that they could be transcribed.
Data analysis
As the research progressed, there was some overlap of data analysis and data collection. Some interviews were already being coded while new interviews still needed to be conducted. This generated new questions and insights during the interviews, as they could be compared to previous findings in other interviews (Eisenhardt, 1989).
The data is analyzed according to the described method by Eisenhardt (1989). Each interview is recorded, transcribed, analyzed and codified for separate interpretation. A coding scheme was developed to analyze the transcripts. This coding scheme used 2nd order and 1st order
19 first step in this was open or initial coding (Charmaz, 2008). First the transcripts were read without assigning codes, after which relevant parts were coded and grouped together in Atlas TI, to create an overview of the frequency (Charmaz, 2008). The groups were adherent to informant terms (Gioia et al., 2013). The second step was selective or focused coding, where prominent and interesting code groups were focused on and used for the results (Charmaz, 2008). Due to the length of the research and narrow focus, some codes are not used for the results.
Research quality
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Findings
This chapter includes the results from the analysis. First, it is discussed how pacemakers and ICD’s have become smarter and what these devices can do, with an overview of the improvements. After that, the consequences in the work of cardiologists, both positive, negative and neutral changes are handled and changes in social aspects and tasks and processes. This will display how the changes in the devices have led to challenges and improvements in cardiologist’s work and the organization. Quotes are used for further explanation and clarification on how the results are drawn from the data.
Evolution of pacemakers & ICD’s
From the primary data it is observed that pacemakers and ICD’s are definitely not the same as five or ten years ago. Since then they have seen an increasing pace of innovation, leading to many new possibilities. The rate of innovation in these appliances is increasing. With the years,
the developments and innovations have increased at a fast pace’ (Physician assistant, R5).
This increasing rate of innovation leads to improvements in devices. These come in the form of
new algorithms and improvements on existing algorithms, leading to better diagnostics in
the device. ‘Algorithms have been improved’ (Pacemaker technician, R2). All innovations and improvements come from the production companies, sometimes inspired by medical specialists in the field, through feedback loops.
The devices can through these improved algorithms provide better, more refined and detailed results on the measurements, using less battery power.
‘The devices used to tell us only how much power it needed, now we get all kinds of data about other aspects of the patient’ (Cardiologist, R8).
‘Besides the main functions, pacemakers are nowadays complete diagnostical centers’
(Pacemaker technician, R3).
The devices are measuring more than just the basic needs now. From the interviews it came forward that nowadays the devices can measure for fluid retention, arrhythmia, quality of sleep, patient activity, detection of fluid in the lungs, etcetera. Over the years these extra functionalities have come up and not all of these are directly of added value to the medical specialists, but are valuable indirectly through a combination of parameters or in other departments of healthcare. Not all of these functionalities are useful for every patient, but they enable more specific care.
21 Next, the devices are equipped with wireless receivers, to enable wireless communication with a programmer (device that connects with the pacemaker or ICD in the hospital and gathers the data). This provides more comfort to the patient, as the patient can lie down or sit up straight and do something else whilst the device is being checked. Older devices and older versions of wireless connections are known to be faltering and losing the connection once in a while.
‘With patients with older devices I sometimes have wireless connectivity issues, even though I’m only one meter away. With the newer devices, this does not happen anymore. The connection is much more trustworthy, causing less frustration and higher patient comfort’
(Pacemaker technician, R3).
Another way in which wireless communication has become more important and is improved, is through the upcoming of telemonitoring. Here, patients receive a home monitor, which is connected to their implanted device, measuring whether the device works well and if any problems arise at the patient; so that the healthcare professionals keep up to date about the well-being of the patient. The home monitor connects with the implanted device a few times a day, when the device is in close enough proximity.
‘Telemonitoring is about seeing a patient virtually, instead of at the policlinic’ (Pacemaker
technician, R2).
‘The home monitor device sends an alarm to the hospital if a value of a patient falls outside of preset parameters’ (Cardiologist, R4).
Also telemonitoring has seen technological advancements. In the beginning, about 10 years ago, the patient needed a landline and a lot of technical hassle to get telemonitoring to work on their implanted device. Now all data is send via GPS and all you need is an outlet to make the home monitor work (it already connected with the implanted device once at the hospital).
‘It used to be much more complicated to set up home monitoring. As not everyone is very technical, it is definitely an improvement that only an outlet is necessary now’ (Cardiologist,
R8).
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‘Telemonitoring causes us to receive data sooner than before. Not only once every six months, but much more often’ (Head of cardiology, R6).
As there is some ambiguity among patients and the general public on what the implantable devices can do as they grow smarter, it is important to get some myths and rumors out of the way.
First of all, pacemakers and ICD’s do not have a built in artificial intelligence. These devices cannot make decisions on their own, they act on preset parameters and most importantly, aid the vital heart functions of the patient when necessary.
‘A pacemaker functions in the way you set it up, it is nothing more than a computer, it does not have artificial intelligence’ (Cardiologist, R4).
Secondly, the home monitors are not watching the patients’ moves and conditions 24/7. It only checks the patients a few times or once per day. Therefore, it does not replace emergency services in case of a critical event.
‘We are not real-time checking the patients device, we can’t facilitate that’ (Cardiologist, R4). ‘Every night the home monitor checks whether the device is running smoothly and if there are any irregularities’ (Pacemaker technician, R3).
‘Patients should not think that home monitoring replaces the ambulance, as we do not look at the data at any given moment’ (Head of cardiology, R6).
Thirdly, there is ambiguity about whether it is possible to remotely change settings of implanted devices. Remotely here means outside of the hospital, without the use of a programmer. All interviewees noted that technically it is possible, but due to legal, privacy and safety issues, a safety measure is built in to prevent this possibility. This prevents unnecessary risks for the patient, as there is no crash team in proximity if something might go wrong. Furthermore, the connection might get lost, with all possible consequences. Changing settings that might have a direct impact on the patient is a risky business, thus having the patient in the hospital, at close proximity, provides the patient with a feeling of safety and trust. This is something that cannot yet be given remotely. Therefore, through legal reasons, remote changes are impossible thus far. Remote contact with a pacemaker is only possible on the level of data transferring. Therefore, there is no real threat in the hackability of the devices. A hacker would only be able to gather data and not change any vital settings.
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of safety. If you can change settings remotely, it will also be possible to hack the device and inflict potential harm on the patient’ (Cardiologist, R8).
Consequences in work
As the implantable devices grow smarter and innovations take place at a fast pace, this has notable consequences in the work of healthcare professionals that work with these appliances. From the data analysis it came forward that these organizational and work changes improved the quality of healthcare, but in the jobs there are both improvements and impairments, and some neutral changes. First, the improvements will be handled. After that, the impairments and neutral changes are discussed one by one.
To create an overview, the identified aspects of improvements are briefly presented in Table 2. These improvements in the table and results are randomly ordered.
Table 2: Work improvements through smarter devices
Aspect Description
Task variety
The extent to which the healthcare professional has to carry out different tasks
Interdepartmental cooperation
The extent to which one department can cooperate with other departments within the same organization
Tasks taken over by device
The extent to which employee tasks are taken over by a device
Time organization The extent to which the healthcare professional can organize his own time
Performance of tasks
The degree of quality that the healthcare professional delivers through the individual tasks
Specialization
The extent to which a job involves the performance of tasks requiring specific knowledge and skill; depth of knowledge and skill necessary for the job
Task variety. It is observed from the interviews that through telemonitoring, the tasks of
cardiologists and pacemaker technicians has changed. They have to see patients virtually, go through data, check for possible alarms, act on irregularities, consult during surgeries and if one of their patients is at a different department, consult between themselves, et cetera. It has made their jobs more versatile than before. ‘I like my job for the better now, it has become much more
versatile’ (Pacemaker technician, R7).
Interdepartmental cooperation. One firm created software in their pacemakers to gather data
24 This means that if a patient needs an implantable device and his dossier shows that it is assumed that he has sleep apnea, choosing this particular device will be helpful for both the cardiologist and the ear, nose & throat specialist or lung doctor. Furthermore, a cardiologist can better advice general practitioners on their shared patients, as more data is measured, linking conditions, treatment and medication, ensuring the patient will not have any discomfort in his lifestyle. Thus, the new algorithms and improved diagnostics lead to further interdepartmental cooperation, either within hospital, but also outside of it.
‘A pacemaker technician can advise the general practitioner and patient about his condition and medication in a better way, in order to find the right combination and provide comfort to
the patient’ (Head of cardiology, R6).
Tasks taken over by device. The improved diagnostics and extra features in the implanted
devices ensure that the device checkups are of higher quality than before. It takes over measurements that normally the pacemaker technician had to carry out. Hence, instead of doing these measurements himself, the pacemaker technician can now just copy some measurements and carry out the rest by himself.
‘If I’m now controlling the pacemaker, more than half of all measurements, sometimes even all, are already carried out by the device itself. Then I’m simply copying the data and spend more time on other tasks’ (Pacemaker technician, R3).
Time organization. As the device is taking over tasks of the cardiologist and pacemaker
technician, they have more time for other tasks. Besides that, also telemonitoring provides the cardiologist with more autonomy in time organization. A virtual patient does not have to be checked and seen directly, like a patient at a policlinic, who has to be seen at the made appointment time. This means that the task of seeing patients virtually can be done at any moment in time, which enables new autonomy regarding the work schedule of cardiologists and pacemaker technicians.
‘The addition of seeing a virtual patient through telemonitoring is that he is not physically present at the policlinic, which means I can check his values and measurements at any given moment, it has no punctual time in which it has to be done. Through telemonitoring the time organization of my job is now different than before’ (Pacemaker technician, R3).
Performance of tasks. As discussed in the improvements in the devices, there are new and
25 taken. This has positively influenced their job in that sense. ‘The more extensive and detailed
the information we receive from the devices, the better we can inform the cardiologist about what we saw and provide advice on potential follow-up actions’ (Pacemaker technician, R7).
Specialization. As the devices grow more complex, more knowledge is necessary to grasp the
affordances of these devices. This causes that within the field of cardiology, more specialization is taking place. Device cardiology has become a small part of the spectrum within the field, with medical specialists belonging to this part having specialized knowledge of the devices, troubleshooting, medication and other tasks related to this field. In order to keep up with the technological advancements, specialization is necessary. The field of practice gets more fractioned, while the depth of knowledge per fraction increases. As a result, also the education of cardiologists has changed, with specialization in the curriculum, replacing general cardiologists.
‘We carry out very specialized work. We are a small part within cardiology in general nowadays, only the technicians and device cardiologists possess this knowledge. In that sense, our position is unique, as we are necessary’ (Pacemaker technician, R2).
‘Nowadays you see much more device-cardiologists. These are cardiologists who are specialized in ICD’s and CRT’s, but also pacemakers. There used to be more general cardiologists, but now you see more specialized cardiologists.’ (Cardiologist, R10).
‘I am one of the last cardiologists to be educated in a general way. Then you had to be able to do it all, also implanting pacemakers. The cardiologists that are educated now are having a specialization year, where they choose a specific direction, a part of the spectrum.’
(Cardiologist, R9).
For example, the profession of pacemaker technician is relatively new and unique in the Netherlands, as it does not exist in many other countries. It is created to relieve some pressure from the cardiologists and to ensure that the technical knowledge of the implantable devices remains up to date. ‘The Netherlands is quite unique in the sense of having a pacemaker
technician. There are countries where that profession does not exist and the cardiologist also has to check the implanted devices’ (Pacemaker technician, R2).
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‘I am medically trained to have the competence of a medical specialist, but I’m not a cardiologist. That job is much more diverse, dealing with much more complex care. I’m concerned with lower complex care, which is more protocolized’ (Physician assistant, R5).
Lastly, in order to provide the best care for the patient and set up the device in the most efficient and effective manner, occasionally a representative of the company that created the device is present at the surgery. As the devices have grown more complex and not all types of pacemakers and ICD’s are implanted frequently, having a representative apparent is of added value. He can adjust the settings in the right manner and provide useful feedback and directions where necessary. ‘We keep close contact with the device firms, regarding feedback on the new
features, and sometimes they are present at the surgery’ (Head of cardiology, R6).
Naturally, not all consequences of the devices growing smarter are positive for the medical specialists. An overview of the work impairments is given in Table 3 and are randomly ordered and ranked.
Table 3: Work impairments through smarter devices
Aspect Description
Job complexity The extent to which the job is multifaceted and difficult to perform
Data increase The extent to which the job involves dealing with data
Data issues The extent to which the job faces issues from dealing with data
Informing patients
The extent to which the healthcare professional has to provide information to patients
Job complexity. As discussed in the work improvements, the devices have grown more
complex, leading to more specialization. Moreover, there are more types of devices, that all have distinct features and differ slightly from each other. For pacemakers and ICD’s, there are five big brands, of which each brand has about ten different devices in their product lines. The downside in this specialization, growing complexity of devices and more product ranges is that it is harder for the cardiologist and pacemaker technician to keep up with the developments. Supplementary training for the extra features in the devices is given by the production companies, but the more innovations, the more supplementary training is necessary. However, this is no longer enough to remain an expert on all aspects of the devices. ‘It is impossible for
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implantable devices, but also for patient care and implantation of these devices. I cannot remain an expert in all aspects. It goes faster than I can keep up’ (Cardiologist, R4).
Data increase. Through the rise of telemonitoring and the improvements and additions in
algorithms in the devices, a significant increase in data has to be handled by both the cardiologist and the pacemaker technician. The features that are not of added value for all patients cause extra work in the sense that it has to be turned on in the beginning, and after close examination of gathered data on this parameter and the patient’s feeling, it can be adjusted or not. ’There is definitely a population of patients that reacts well on this feature, but I don’t
know which patients that will be upfront. This means that I have to turn on the feature for all patients and only afterwards find out whether it is of an addition or not, and thus adjust or not’
(Physician assistant, R5).
‘A lot of the extra data that comes from the device is not (yet) proven to be useful. It might even cause overtreatment, with higher costs, more work and unnecessary risks… The extra data is so far hardly used, but does cost extra battery power’ (Cardiologist, R8).
Furthermore, the home monitor device sends a lot of data to the medical specialists, and patients are able to manually send test data when they think something is wrong or they felt a discomfort. This led to a huge increase in data, send both automatically by the home monitor and manually by the patients. Processing this data and handling the administrative part costs the medical specialists significantly more work than before, for some this requires even more time than available. ‘Telemonitoring costs us a lot of time. Where patients before only came in twice a
year for manual checkups, now they’re able to manually send us data every day, through their home monitor and implanted device. For every palpitation, they get scared and unnecessarily send data manually to the hospital, leaving us with enormous amounts of data’ (Pacemaker
technician, R3). ‘I need 1,5 FTE (Full-Time Equivalent) for the processing of telemonitor data
alone… There are clinics that can’t handle the stream of data and are forced to look at other ways to try to keep up. But they can’t go back anymore, stopping with telemonitoring is no longer an option’ (Physician assistant, R5).
In order to tackle this issue, most hospitals are hiring extra people, especially pacemaker & ICD technicians. These people are able to check patients virtually and thus check the telemonitoring data, next to their normal tasks. Furthermore, hospitals are changing the daily schedules of pacemaker technicians, but more about that will be explained in the last section of the findings.
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for 3 days a week, we are now open 7 days a week, at all times. We have become more important’. (Pacemaker Technician, R11).
Frustrating for the medical specialists is that even though telemonitoring is starting to become more important and the number of patients with a home monitor are increasing, there is so far not a well-designed remuneration system, by insurance agencies for seeing a patient virtually, leading to frustrations among the specialists. ‘We are looking at a challenge, as on the one hand
we want to move more towards telemonitoring, taking over polyclinical care. But on the other hand we are so far not financially rewarded for that. It costs me 1,5 FTE a year, but I’m not paid for it’ (Physician assistant, R5).
Data issues. It came forward from the interviews that through telemonitoring, the medical
specialists receive tons of notions and data about the device functionality, whether it still works perfectly or not. Even when the device works properly, it sends data about its functionality. While for the specialists it is particularly important to know when the device is not functioning according to plan. Thus, this data created extra challenges in how to filter the necessary information on devices that have functionality issues, plus challenges in ensuring that patients send only manually data when it is necessary. ‘The unnecessary manual data sending from the
patients challenged us in finding a way to manage these patients to only manually send data when it is necessary’ (Pacemaker technician, R3). ‘What we know now, also from the literature, is that 80 to 90% of the data from a home monitor is merely a confirmation that the device is functioning properly, which is not relevant for the hospital. For the patient it is relevant, as he wants to know whether the device works perfectly. This means that we don’t have to see 80 to 90% of the data. I only want to be able to act on devices that are not working properly’
(Physician assistant, R5). ‘We set up the devices in such a way that we only get alerted when
there is a potential life-threatening situation. We were swarming in data, which didn’t yield significantly positive results’ (Cardiologist, R4).
Moreover, the data alone does not tell the full story. Most of the time the medical professional has to contact the patient in order to find out what was happening and if there was a logical explanation for a palpitation or alarm. They need to add context to the data to determine what really happened and if further actions are necessary. ‘Whenever there is a malfunction, it can
29 A possible solution for this issue is to make a useful combination between telemonitoring, ICD & pacemaker systems, and the online patient portal. Then the patient can send a message to the medical professional through the patient portal, to add context to the data of the telemonitoring.
‘When you retrieve the data from the ICD, it doesn’t state how the patient feels. I expect a lot from ICD systems and patient portals. Then a patient can leave a message for his cardiologist there. This way the data is better understood. It saves an unnecessary phone call with the patient. This is a redundant act, which can be prevented.’ (Cardiologist, R1).
From the interviews, part of the negativity around telemonitoring and its consequences is stated to be a generational issue. Many of the older generation of cardiologists want to keep seeing their patients face-to-face instead of virtually, and are not used to putting trust in technology and the accompanied data. ‘I think it’s a huge step, going from being face-to-face with the
patient towards an electronic connection. Especially the older generation has lots of troubles with that.’ (Cardiologist, R9). One interviewee that has not started long ago as a cardiologist,
explained that she’s used to telemonitoring, grew up with it, and is trained and educated for it.
‘I grew up with telemonitoring and dealt with it frequently during my education. For me it’s normal.’ (Cardiologist, R10).
But it’s not only the medical specialists that deal with a bit of a generation issue, the same is to be said of the patients. The younger generation of patients are used to put their trust in technology and are used to work with complex technological systems. Hence, there are less issues with informing them about how telemonitoring works and how they are expected to perform certain tasks themselves. Further, the longer telemonitoring is around, the more experienced people become in using it and dealing with it. ‘As years go by, people become more
used to the system. Now, the younger the people are that receive a home monitor, the more used they are to the technology. Over the years a lot more people are working with the technology, and start to deal with it in an easier manner.’ (Pacemaker technician, R11).
On the level of privacy and security, the changing privacy and security regulations cause challenges for the hospital and the medical specialists. Patients have to sign a consent form regarding telemonitoring, informing them what data is collected and what is done with it. It is connected with how patients are informed.
Informing patients. Since telemonitoring has come up and more data is being measured,
30 patients have to be well aware of when they can manually send data, to prevent unnecessary data from flooding in. Specifically educating the patient regarding this matter causes huge improvements, leading to less frustration for the medical specialists. ‘When I started, we had
90 patients with a home monitor, manually sending us data 170 times a month. Now we have 1.000 patients, with 4.500 manual data transfers per year… Through better and more extensive awareness we’re trying to minimize the manual data transfers’ (Physician assistant, R5). ‘Patients have to sign that they are aware that they are not checked in real-time by the telemonitor, and that it can take a day before we spot anomalies, if the patient doesn’t perform a manual data transfer.’ (Pacemaker technician, R11).
Other changes in the work of cardiologists and pacemaker technicians comes in the form of
redefined roles, interdependence and daily schedule.
Redefined roles. As discussed in the specialization aspect, the fact that more specific
knowledge was necessary to keep up with the growing complexity of the devices, created new positions in the form of pacemaker technicians and physician assistants. Besides the fact that pacemaker technician is a relatively new profession, it has grown in importance in the spectrum of cardiology. The tasks regarding telemonitoring, virtually checking the patients, has moved more towards the pacemaker technician. The responsibility for making technical changes in the device, without necessary permission of the cardiologist, lies with the technician now.
‘When the pacemaker doesn’t function properly and needs an adaptation, we don’t need permission from the cardiologist. That’s our responsibility. But when an intervention is necessary in the form of changes in medication or surgery, we are not qualified. That’s when a cardiologist comes in’ (Pacemaker technician, R2).
Thus, the pacemaker technician has gained more interdependence. The pacemaker technician is allowed to perform most actions on the pacemaker independently, without the supervision of the cardiologist. Their responsibility has increased. ‘We have much more responsibility then
back in the days. We measure and adjust where necessary. Only when we’re programming on zones with resuscitation functions, we have to consult a cardiologist. But most of the time that is just to see whether they agree on our ideas’. (Pacemaker technician, R11).
31 However, not all technicians think this trend is positive. From one interview it came forward that receiving legitimacy of knowledge is a positive thing, but now cardiologists presume too easily that what the technician advices is true. Instead of having a meaningful discussion about whether the advice is best for the patient or not, it is assumed the technician is right.
Lastly, some hospitals have changed the daily schedule of pacemaker technicians in order to keep up with the increasing scale of telemonitoring. Besides hiring extra people, hospitals alter schedules to be able to virtually see all the patients that are having a telemonitor. They do this in multiple ways. For example, one hospital is no longer seeing patients physically between 08.00 and 09.00 on the cardiology policlinic. Instead, they use this timeslot to check their patients with a home monitor, checking all automatic send data, plus manually send data and alarms. ‘We ensured that between 8 and 9 in the morning we don’t have patients in the
policlinic, in order to go through the telemonitoring data. I start my day with it’. (Pacemaker
technician, R11). Another hospital organized it in such a way that the pacemaker technicians should check all telemonitoring data before 12.00. They have to check it in between patients.
‘The rule is that we have to see all virtual patients before 12.00. That counts for all days, even in weekends’. (Pacemaker technician, R7).
Discussion
This chapter relates the results to the literature review and shows the derived propositions. The research questions are handled one by one, showing propositions for every question. With handling the sub research questions one by one, consequently the main research question will be answered. The main research question here is: How does the change towards smart
pacemakers affect the social system of cardiologists and what are the changes for their work design?
Socio-Technical System
From the results can be drawn that there are definitely some aspects of the social subsystem affected by the move towards smart pacemakers. Almost all aspects of the social subsystem are altered and affected.
32 The cardiologist needs more complex knowledge to deal with the devices, and needs to keep up by training himself. If he wants to remain relevant and be an expert in all aspects of his wide job, without leaning on other specialists, he needs to keep up (Bresnahan, Brynjolfsson, & Hitt, 2002). Through this ever-increasing pace of innovation in the devices, more specialization was necessary, leading to a more fractionized field of practice, but with an increased depth of knowledge. This relates to Garicano & Hubbard (2004), as field-specialization leads to an increased depth of knowledge.
The introduction of telemonitoring has created new habits, in that it has totally worked its way into the normal schedule and tasks of the cardiologist. He either sees patients physically at the policlinic, or virtually through telemonitoring.
Proposition 1a: The move towards smart pacemakers has created a need for more specific
knowledge, leading towards new, more important roles.
Proposition 1b: The move towards smart pacemakers has led to new tasks, turning into habits.
Next, communication networks have altered. Pacemaker technician-cardiologist interaction is increased, discussing more about the devices, observations regarding telemonitoring and advice on follow-up actions. Moreover, the cardiologist is more in contact with the patient, both directly and indirectly through the device. This is in line with existing literature, that shows how communication patterns can decrease and alter as smarter systems get introduced (Han et al., 2005).
Proposition 2: The move towards smart pacemakers has created new and stronger
communication networks.
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Negative experiences come in the form of having to deal with massive amounts of data, which
cardiologists have not seen before at such a scale (Dutton, 2014). Furthermore, they are dealing with an ever increasing amount of administrative work accessory to seeing a patient virtually and found the need to educate and inform the patient in a better way, as the ability of sending data manually has gained his role more importance, as also discussed in Boyne & Vrijhoef (2013). However, the balance between these experiences falls over to the positive side, as the increase in quality is of vital importance to both medical specialists and the patient.
Lastly, the affordances and constraints of the devices. These are constantly in motion, as new possibilities and improvements come up with every innovation. Through a process of learning, the cardiologists find out what the device can do and what it cannot do. As such, the devices has significantly more capabilities and functionalities than 5 or 10 years ago.
Proposition 3a: The move towards smart pacemakers has, both through experience in use and
through positive experiences, led to a higher amount of trust in the device and quality of care.
Proposition 3b: The negative consequences and experiences with smart pacemakers weaken
the satisfaction about the improvements.
How is a cardiologist’s intentionality towards smart pacemakers affected by changes in the social subsystem?
The cardiologist’s intentionality is not directly affected by the move towards smart pacemakers, but indirectly through the changes in the social subsystem. Regarding the intentionality towards smart pacemakers, the desired outcome has not changed. Still, the desired outcome is to deliver the best care and comfort for the patient. But some extra desired outcomes have come into the picture. Besides delivering the patient the best care by finding the right device with the right settings, the medical specialists desire to have a minimum amount of manually send data. The results show that through better educating patients and finding the right settings, white noise and unnecessary data can be prevented. This is also found in the study carried out by Tempels, van der Bijl, Nagtegaal, Groener, & Jansen (2014). Thus, the new abilities in the devices and revised role of the patient lead to undesired outcomes in the use of the device, enhanced by the negative experiences.
Proposition 4: The move towards smart pacemakers has impacted the intentionality through
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How is a smart pacemaker’s materiality affected by changes in the social subsystem?
The physical properties of the implanted devices has not changed through innovations and growing complexity. The devices have essentially changed in their digital properties and capabilities (Yoo et al., 2010; Yoo et al., 2012). For example, the new functionalities that are not useful for all patients, ensure that the medical specialists can turn features on and off, depending on the patient’s specific needs. Furthermore, through all the data, there are risks of overtreatment, as also discussed in the paper of Hanley, Pinnock, Paterson, & McKinstry (2018). From that same paper is drawn that workloads increase through the significant increase of data, as is the case here. This created challenges and changes in some hospitals on how they handled the data. For example, one hospital started to act only on events, and did not check all data, as it was no longer feasible. Therefore, they do no longer use all the digital properties of the device. It is observed to be impossible to quit telemonitoring, even though it leads to some unintended consequences. This can be lead back to the level of sunk costs already put into the implementation (Keil, Truex, & Mixon, 1995) and the fact that it has proven to improve the quality of healthcare.
Proposition 5: Changes in the social subsystem leads to changes in digital materiality of smart
pacemakers, depending on the experiences.
Concludingly, all these propositions lead to the following adjustments to Leonardi’s model (2012), found in Figure 2:
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Figure 2: The adjusted Socio-Technical system model. Work design
Drawing from the results, the design of cardiologists work has seen its adjustments through the innovations in the devices. This comes forward in multiple characteristics in work design. First of all, the cardiologist has to perform a multitude of new tasks that emerged from device innovations, specifically telemonitoring. Now he has to see patients virtually, check the manual data transfers and provide more consultations, to both patients and other departments. This leads to more versatility in the work of a cardiologist, leading to a positive effect on job satisfaction, as proposed by Humphrey et al. (2007).
Through the additional functions in the pacemaker and ICD, the potential cooperation between
a cardiologist and other departments has reached new levels. They are able to measure data
