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Upscaling eHealth: Why do organizations fail?
A Systems Approach Perspective on Upscaling Telemonitoring at a Dutch
University Medical Center
Master Thesis
MSc Change Management
Faculty of Economics and Business
University of Groningen
Name: Jesper Koen Luca
Student Number: S3843912
Supervisor: Dr. N. Renting
Second assessor: Prof. dr. ir. D.J. Langley
Date: 22-07-2020
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Abstract
Context. New innovations are changing the healthcare industry. Different types of eHealth change the
work practices of healthcare professionals and the way healthcare is delivered to patients. Telemonitoring facilitates monitoring of patients from a distance. Many innovations have been proposed, studied and tested in healthcare settings and most of the outcomes are positive regarding patient experience, health outcomes and controlling or reducing costs. Nonetheless, the success of actual implementations on large scale as part of regular healthcare services remains limited. Service design is a relatively new perspective in implementation science that could potentially facilitate or promote the success rates of eHealth tools.
Objectives. The objective of this study is to research stakeholder perspectives towards eHealth,
routines and the way service is currently delivered to identify the ecosystem of digital healthcare innovations within a university medical center (UMC). With the aid of these perspectives an explanation is given for how upscaling success can be achieved. Next to that, the objective is to contribute to literature on the systems perspective of eHealth.
Methods. I conducted a case study at a large Dutch university medical center. I reviewed existing
relevant literature streams on the topic and conducted interviews with stakeholders of digital innovations in healthcare, which represents the collected data for this study. The socio-technical lens provided a focus on the link between stakeholder background and perspectives and technology.
Results. The results surprisingly show that each stakeholder as an individual has a positive attitude
towards telemonitoring, but still many upscaling initiatives fail. The issues in the case show that the complexity of the environment, internal structure and culture and technology play an important role in upscaling success. The theoretical model provides a more in depth insight into the interaction between eHealth domains, their interactions and the influence on upscaling success and therewith contributes to the systems approach literature on eHealth.
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1. Introduction
The COVID-19 outbreak rushed many healthcare organizations into a state of crisis and a requirement of fast adaptations to the novel situation, in which innovations play an important role. When it becomes a threat to visit a hospital, physical contact is unsafe and a healthcare organization’s resources are tested, innovations that enable healthcare practices from a distance, such as telehealth and telemedicine, can play an important role in managing the outbreak and creating more efficiency in healthcare organizations (Gong et al., 2020; Keshvardoost et al., 2020; Ohannessian et al., 2020).
This growing role of IT innovations in tackling the great challenges and problems the sector faces, by improving efficiency and effectiveness of healthcare pathways, is also described by the term eHealth (Campanella et al., 2016). eHealth is an umbrella term to describe the realm of technologies that provide access to healthcare providers, care management and education (Ahmed et al., 2014). One very promising eHealth technology is telemonitoring, which enables healthcare professionals to remotely monitor patients and involves the transmission of health-related data from patient to healthcare institution with the aim of providing care and clinical feedback (Hernandez-Quiles, 2020). The use of telemonitoring and other eHealth innovations has the potential for better management of “The Triple Aim”; healthcare quality and delivery, enhance patient experience and to control or reduce healthcare costs (Shaw et al., 2018; Weber-Jahnke, Peyton, & Topaloglou, 2012).
However, many healthcare organizations fail to achieve upscaled eHealth systems and fail to make these innovations part of regular healthcare (Williams, 2016). Therefore many of these innovations seem to have limited impact. Moreover, their impact in terms of effectiveness and efficiency varies per healthcare setting (Shaw et al., 2018; Kellermann & Jones, 2013). Most of the implementation literature surrounding this issue seems to focus on barriers and facilitators as separate factors of implementation success, overlooking the importance of the dynamic interaction between these factors (Greenhalgh et al., 2017). A systems approach towards eHealth upscaling initiatives might provide new insights as it searches to identify eHealth domains and their dynamic interactions that make up a complex system. However, this approach towards eHealth is relatively new and is lacking evidence from local case studies (Greenhalgh et al., 2017; Shaw et al., 2018).
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Shaw et al. (2018) propose an approach to this problem when offering a “service design” perspective towards implementation science in healthcare. This approach focuses on the link between product innovation and service innovation and has the aim of reinventing healthcare service processes to achieve greater benefit and promote the successful deployment of digital health innovations in healthcare settings. However, Shaw et al. (2018) mainly focus on the individual and group level. Greenhalgh et al. (2017) focus on organizational level by proposing the NASSS framework, which also tries to identify the interactions between different domains of eHealth and assess the environment complexity. However, this theory does not describe an actual approach. Both frameworks are lacking evidence from locally implemented case studies to validate their theories.
This research tries to add evidence to the systems approach literature and add value to eHealth upscaling success literature, by using the system approach to research upscaling success within an UMC. The proposed research question for this paper is: “How do dynamic interactions within the eHealth ecosystem affect the upscaling success of an eHealth monitoring system?”
This study searches to identify the dynamic interactions between eHealth ecosystem domains, which have implications for upscaling of eHealth innovations and to identify possible changes in the service design as a solution to the successful upscaling of eHealth tools. Stakeholders are important here as the systems approach takes a holistic view and searches to identify the interactions between different components and individuals, instead of technology barriers and enablers only (Gubin et al., 2017). It requires insights in the interactions between different stakeholders at different levels of the organization to identify how these interactions form the system (Støtropp et al., 2019).
The topic of this research is interesting, because it provides new insights into implementation science in the fast-changing healthcare environment. By taking a systems perspective, it could provide a more thorough understanding of why many eHealth initiatives fail, even after development and demonstration phases (Mendel et al., 2008), resulting in less alignment between IT and the organization and high and unnecessary investments that could have been prevented (Kreps & Richardson, 2007). With more attention taken towards system approaches in healthcare, it will possibly result into more models and methods that provide evidence for the effectiveness of service design approaches and it could offer an opening to alternative process design strategies for hospitals seeking for future digitalization efforts.
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findings of the literature and case study are discussed and followed up by a conclusion, which includes limitations, implications and recommendations for further research.
2. Literature review
The aim of this research is to explore different stakeholder perspectives towards telemonitoring in order to identify key domains and their interactions that affect upscaling success of telemonitoring and therewith, make an effort to find answers to the proposed challenges of implementing eHealth innovations in a healthcare setting. According to Aarts (2013), understanding information systems demands a focus on the interrelation between technology and its social environment. Because IT is largely influenced by the healthcare context it is implemented in and IT and technology are intertwined with the political, legal and social systems in that specific context (Saleem et al., 2015; Grisot & Vassilakopoulou, 2017). This research focuses on the effects of people on technology and vice versa and will therefore adopt a socio-technical lens when reviewing the existing literature.
Existing streams of literature concerning eHealth, healthcare service contexts and the existing implementation science connecting the technologies with the healthcare contexts are being reviewed, with a specific focus on the systems approach. Furthermore, a specific part of the literature will focus on telemonitoring, which is the eHealth innovation used in the case of this research.
2.1 eHealth
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One type eHealth that could possibly address all these three domains is telemonitoring, indicating that eHealth innovations are not necessarily linked to one domain specifically.
2.2 Telemonitoring
Paré et al., (2007) define telemonitoring as the use of audio, video or other telecommunication technologies that monitor patient status at a certain distance. However, they do add that this definition is somewhat outdated and highlight that telemonitoring is much more about automatically transmitted healthcare data from a patient to the responsible healthcare setting. Some topics that include telemonitoring have been thoroughly researched in academic literature. For example, many studies focus on the effectiveness of telemonitoring on patients with certain chronic diseases, such as chronic obstructive pulmonary disease (COPD) (Cruz et al., 2014; Fairbrother et al., 2012; Bolton et al., 2011; Jordan et al., 2013), diabetes (Jaana & Paré, 2007; Istepanian et al., 2009) and cardiac diseases (Oudshoorn, 2008; Piotrowicz et al., 2010). These are illnesses that often require expensive readmissions in hospitals, that telemonitoring might help prevent.
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2.3 eHealth Implementations
The literature concerning eHealth implementations is quite broad. Existing literature describes many causes of failed implementations and risks that occur when implementing eHealth. For example, implementations of eHealth tools in professional healthcare settings require large financial investments, clinical engagement and often have consequences for the quality of healthcare (Ingebrigtsen et al., 2014; Campanella et al., 2016; Ossebaard & Van Gemert-Pijnen, 2016). Furthermore, eHealth innovations might not be accepted, used or the usage declines over time (Van’t Riet et al., 2010; Ossebaard & Van Gemert-Pijnen, 2016) or eHealth implementations fail due to reimbursement issues and a lack of a standardized payment methods for these kind of tools. Another mentioned challenge is the integration with other information systems in healthcare settings (Istepanian et al., 2004; Weber-Jahnke, Peyton and Topaloglou, 2012) and information privacy and security (Islam et al., 2015)
Hence, it is difficult to move eHealth applications beyond its initial phases of demonstrations and funding (Mendel et al., 2008). Mendel et al. (2008) describe a gap between research and practice, which is the issue of implementing evidence-based eHealth innovations in practical contexts, meaning that evidence-based interventions that work in small research settings, often fail to proof efficiency when attempts to upscale are initiated or their effectiveness diminishes over time. This is in line with what Greenhalgh et al. (2017) claimed when talking about how managers are often struggling to preserve scientifically justified components. When translating evidence-based interventions to other settings (Mendel et al., 2008), Greenhalgh et al. (2017) clarifies this by explaining the lack of dynamic interactions in the healthcare environment most studies fail to disclose and propose a systems approach perspective.
2.4 Systems approach
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Figure 1: NASSS Framework (Greenhalgh et al., 2017)
The aim of this framework is to identify and address key domains of eHealth and interactions and thereby predict the complexity of the situation. These key domains are: the condition, the technology, the value proposition, the adopter system, the health or care organization(s) and the wider societal context. A seventh domain consists of the interactions and adaptations over time. This framework could be useful in the case analysis, because it considers interactions of domains that have not been elaborated on extensively in existing literature, for example the roles of organizational context, wider context and adaptation of systems over time. However, it remains very theoretical and merely provides an indication of the complexity of a healthcare context. Moreover, it is a very broad theory, focusing on evaluation of complexity rather than a prescription of how successful upscaling of eHealth innovations can be achieved. Therefore, the domains can only be used as useful tools to consider all domains, their interactions and their complexity in this research.
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successful deployment of a technology that advances the achievement of the Triple Aim relies on a collection of people seeing value in the new technology and as a result building meaningful changes into their everyday work routines” (Shaw et al., 2018, p. 3). Moreover, they mention that a new technology requires more than just implementation, it also causes a new service to establish itself through the interactions between a new tool, a team of healthcare providers and other stakeholders and new routines of service delivery. Therefore, they established the heuristic [Team+Tool+Routine] (figure 2).
Figure 2 Team+Tool+Routine Heuristic (Shaw et al., 2018)
It starts with identifying the values of the people involved, the way routines will change and the adaptability of the tool and the interactions between these three factors that, in an iterative process creates a way of service delivery (Shaw et al., 2018). Shaw et al.’s tool is useful to consider the possibility of adaptation over time and the interactions between all three components. However, the tool remains at an individual or group level and does not consider other important domains on organizational or environmental levels that could also possibly interfere the configuration of clinical service.
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This systems approach towards eHealth seems very novel and limited evidence in the existing literature exists to support these approaches. Moreover, Greenhalgh et al. (2018) call for more local case studies applying this approach. Therefore, it is interesting to contribute to this new stream of literature through a case study, using a relatively new technology (telemonitoring) and researching the interaction within the context it will be implemented in, using the NASSS framework as guiding framework to explain the results.
3. Methods
3.1 research method
The research approach that I have chosen for this study, is a qualitative approach, which is necessary to identify interactions between different domains of the healthcare environment. Some of these interactions might be easily identifiable, but others might be deeply rooted within the setting and harder to identify, qualitative research methods usually provide more in-depth data that is not visible on the service or can be retrieved with quantitative research methods. Moreover, case study research methods are suitable here, because the systems approach is in need of evidence from local studies and examples.
3.2 Setting and participants
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concerning the interviews. Their names and other related personal information have been anonymized and the respondents will be referred to by their assigned codes.
Table 1.: Respondents information
Interview nr. Code Role Date Duration
1. IC01 Innovation Consultant 30-3-2020 01:06:56
2. CH01 Oncology Surgeon 1-4-2020 00:48:48
3. OE01 Researcher eHealth 6-4-2020 00:48:41
4. OE02 Researcher eHealth 13-4-2020 01:08:50
5. CH02 Researcher Surgical Oncology 7-4-2020 01:04:47
6. UU01 Program Manager eHealth 8-4-2020 00:52:00
7. SO01 Strategic Development Advisor 10-4-2020 00:48:14
8. CH03 Technical Physician 25-4-2020 01:07:27
9. NU01 Nurse (leading role) 29-4-2020 00:54:01
10. PA01 Patient 15-5-2020 00:48:29
11. PA02 Patient 15-5-2020 00:49:28
12. PA03 Patient 15-5-2020 01:28:54
13. PA04 Patient 18-5-2020 00:39:08
14. PA05 Patient 18-5-2020 01:06:02
15. NU02 Nurse (leading role) 20-5-2020 00:49:24
16. CM01 Change Manager 25-5-2020 01:28:21
17. IT01 Enterprise Architect 27-5-2020 01:15:15
3.3 Data collection and analysis
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telemonitoring, ideas about changes in service design of telemonitoring and upscaling/implementation approaches. These themes slightly differed dependent on the interviewee. The analytical strategy applied to analyze the obtained data has been both inductive and deductive coding. The first step was to transcribe all the interviews. Thereafter, the transcripts were analyzed using coding software (ATLAS.TI). The reviewed literature helped identifying important concepts, which could be used as codes during the analysis of the data. First, during open coding I read through the data several times and highlighted important concepts or things that stood out and labelled them. Thereafter, axial coding was the process of categorizing different codes and explaining their relationships, whilst creating main categories. The third step was selective coding, in which the relations between the categories were elaborated on to identify the dynamic interactions between different organizational parts. A detailed codebook can be found in appendix 2.
4. Results
The data resulting from the interviews proved to be very versatile. Among the different stakeholder perspectives towards telemonitoring and how it should be upscaled, there were many parts where these perspectives coincided, whereas in other parts, the different roles and backgrounds of the stakeholders resulted in different perspectives. The results will be presented guided NASSS framework by Greenhalgh et al. (2017), the most remarkable results were identified within the Wider system, organization and technology when compared to upscaling success. Therefore, the results section will focus on these domains only. This does not mean the other domains are not important, however the findings seem to largely coincide with these other domains of the NASSS framework and thus, provide less new insights.
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4.1 The Wider System
First, corresponding with the NASSS-framework, the case data showed an important role of the wider system influences on system complexity. These were external forces that pushed the academic medical center into the direction of innovation, but also caused serious challenges that highly impact the upscaling possibilities of telemonitoring. The different forces that were grouped as demographic, economic, environmental, legal and technological external forces. Although these external forces have been grouped, some external forces can belong to more than one group and what is essentially a legal external influence, could have economic implications for the UMC. One example of a demographic external force that was mentioned by interviewee OE01: “Eventually it will be that people do want to take more ownership over their health. That they will use digital devices more and that… also as healthcare providers ehm… you are more responsive in an earlier phase to start the conversation and that people can address that ‘I need this or I need that, I am curious what these kind of systems can mean to me.’ And all those
experiences can definitely help.”
This person mentions a demographic change that describes the emerging need for people to be the owner of their healthcare data, which technical developments also do enable. Another important example of an external force is given by interviewee IC01: “You can perform the best healthcare in the best place, if the doctor doesn’t get paid for such a mode, it probably won’t take off, because the interest to still get patiënts to the hospital is still too high. So incentives are important, if the funding has not been taken care of… or at least doesn’t seem to be taken care of in the future, it is probably better to not do it at all.” This quote indicates the funding issues for telemonitoring. Due to external Dutch legislations, funding for new tools is provided based on a diagnosis and then treatment you will receive for it. Telemonitoring can still be part of a diagnosis, however, the monitoring process cannot be defined as a single treatment, as it is often ongoing and takes place outside the hospital doors. Because this has not yet been considered an opportunity for external parties such as healthcare insurers, it will become very hard to fund telemonitoring initiatives, which will enhance the force of sticking with old habits and routines.
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conditions), it will take many years and consequently high costs to obtain the CE certification. Another example of an external factor that has been mentioned is the COVID-19 outbreak. The outbreak pushed the UMC into a situation of crisis in which scarce resources needed to stay available for the infected persons, while also being able to provide healthcare to other patients from a distance. A broader elaboration on this event and how the UMC dealt with the crisis can be found later on.
The NASSS Framework shows the other eHealth dimensions as coëxisting within this wider system and thus every domain interacts with these external forces. This is also visible from the case data. The first quote demonstrated the effect of changing patient needs and expectations on hospital service design and the communication between adopters, the second quote shows how external financial issues influences organizational decisionmaking and the third quote provides a major external barrier on technology design.
4.2 The Organization
The findings provide useful insights on three organizational domains; organizational strategy, organizational structure and organizational culture, which are all interconnected and all provide insights into how the UMC responds to the external forces in the wider system, how well UMC is able to pursue their strategies and eventually their change capacity.
4.2.1 Organizational Strategy
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As the previous quotes suggested, patient needs are very important, the interviewee’s recognize that patients value a more patient-centered approach and this requires the reallocation of care as is explained by interviewee UU01: “You have to work towards shaping the personalization of healthcare, thus the right care at the right place and for the right person.” This might indicate that regular healthcare paths need to be adjusted to provide a more individually oriented healthcare trajectory. This need is also confirmed by several patients that were interviewed, for example patient PA05: “ I have symptoms that do not fit anywhere or do not fit into a box and this is why I eventually cannot get a suitable treatment.” This persons mentions his or her complex symptoms that cannot be assigned to a specific clinical picture, while the organizational structure of this UMC is largely based on doctors and other experts which have expertise on certain illnesses or parts of the human body. However, this interviewee, among others, do mention that they would value a different type of approach in which the individual is assessed as a whole and gets treatments based on individual circumstances, instead of being assigned to certain “boxes.” This reallocation of healthcare and adjustment of the healthcare path is also a means to provide more sustainable healthcare, as is explained by interviewee IC01: It is essentially about the relocation of healthcare to make sure that healthcare is sustainably available for all citizens in a good way in the Netherlands.” This indicates that there are challenges of healthcare availability that need to be addressed by providing more efficient and sustainable healthcare.
Several interviewees also recognize a possible role of technology in performing this change of more personalized and sustainable healthcare. One example is given by IC01: “What I do see is that technology makes it possible to arrange the responsibility and the processes in a certain way, but how exactly…” However, for this person it is unclear what role this is. Interviewee UU01 provides an example of how technology might facilitate this change of more patient-centered healthcare: “We think that it can improve by using algorithms that take care of some items […] algorithms or machine-learning clinical decision tools that provide support, because otherwise it will not operate well.” This person indicates that patient-centered healthcare can be achieved with the use of data and data-analytics, implemented in clinical decision tools based on data from individuals. This change would also imply a change in the healthcare path of patients and routines and processes within the UMC.
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4.2.2 Organizational Structure
The organizational structure is, as mentioned in the section above, largely based on certain expertise fields when it comes to illnesses and/or body parts. This is also explained by interviewee CM01: “we have eighteen thousand employees which are all split up within columns. Actually, it is pretty old-school how we established the [UMC name], very hierarchical.” This indicates that the organization consists of many levels with a high degree of hierarchy, which is often found in older organizational models. This might also indicate that this structure has been used for a long time already. Interviewee IT01 Mentions: “That is typically [UMC name], different little groups with thick walls around them.” This indicates that the different columns within the UMC mainly focus on their own column or department, the thick walls could refer to a lack of communication and interaction between different columns or departments.
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This quote points out the political and competitive interaction between different parts of the organization and could potentially be a barrier to upscaling eHealth innovations such as telemonitoring.
Moreover, CM01 has seen many eHealth projects fail due to budget shortages: “The most initiatives strand due to a shortage of budget. That is eighty per cent and also approved applications, for which there was supposedly sufficient budget, those are eventually being repelled, along the process investments have been made, because the budget is gone.” This indicates that innovation implementations fail due to budget shortages and the strict budgeting policy of the UMC does not grant extra budget when this might be necessary.
Other interviewees specifically mention that the current structure does not support the upscaling capability of telemonitoring, an explanation is given by IC01: “Across the border of the [UMC name], but that requires such a different way of operating, that we think that we can easily do it, but I believe that our whole system is not equipped for this […]. Technically we can make it happen, but we are the stakeholders, the bigger parties are not equipped to change the processes and the system to transmural care.” Thus, eHealth innovations as telemonitoring change caretaking from within the hospital walls to the home environment of patients. This person indicates that the UMC is currently not ready to change their organizational model to facilitate this type of healthcare. OE02 seems to agree with this and provides an explanation: “The use of telemonitoring actually changes the whole care path of the patient […] these types of innovations are less applicable in the classical scientific model that has been applied […]. However, you have to say that it might be good that we protect the population from not yet sufficiently validated systems to apply in regular healthcare on a large scale.” This person explains that telemonitoring would not fit the classical organizational forms, however there is no other scientifically validated organizational models, which means that it would be risky to change.
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4.2.3 Organizational culture
The organizational structure section already provided some insight into how the organizational structure also determines partly the behavior of individuals. CM01 provides more evidence about how organizational structure influences cultural features:
“That means that each sector or each department or each discipline has its own people to regulate these things, thus their own change coach and their own decision-making… […] that is what I mean with fragmentation, they are not on the same page, there is not one vision, there is not one policy […] there are just many ego’s and that is not a very negative word. There are many individuals that draw their own path. IT01 adds to this: “All self-interest things. I belief that it is not just [UMC name], I think that it’s the healthcare industry in general and scientific research surrounding healthcare.”
Thus, the way the UMC is structured leads to fragmentation between different departments and individuals with their own visions and ideas. This might also be common in the healthcare industry. This also means that, in order to upscale certain eHealth technologies, it requires change support from many individuals, as is explained by CM01:
“I think the [UMC name] is a very big organization where things sometimes […] take a long time. It is a pretty inert organization, in order for the plan to pass everyone and to get everyone to agree, it takes a long time, through which adaptation is sometimes quite late… if you want to be progressive. This indicates that the fragmentation leads to much bureaucracy within the organization, possibly causing inertia. Hence it could be a barrier when talking about upscaling eHealth innovations.
On the other hand, the organizational culture can also be a facilitator of upscaling innovations. An example is given by SO01 when talking about the role of the head of department: “That person can also push things through, he can ring the bell when things go too slow or ehm… start a functional fight, all those things belong there. The power these heads of departments thus also are a tool for successful implementation in certain departments. CM01 has a comment that adds to this vision and how these tools can be used in upscaling initiatives as well:
“If only enough people of the higher management say ‘I don’t care what it takes, I want it to be taken care of,’ then everybody feels free to look beyond their own… to look beyond their own little tunnel and they make sure that it will be done with everybody involved and everybody understands that it needs to be done together and the situation is not ‘us against them’ anymore.”
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upscaling initiative with a different software supplier ready for over two years. This shows the significant role of bureaucracy and organizational politics at this UMC, which has been a major barrier, but can also function as a tool to successfully upscale telemonitoring.
The fragmented culture of this UMC also leads issues concerning decision-making, taking responsibility and communication. CM01 provides an explanation:
“No decisions are made and that is indeed something you would expect at a higher level at a certain moment, hè, that there is someone that stands up and says ‘stop it, we are now taking a decision.’ Ehm… there is a lot of ‘ping ponging,’ which is also a consequence of the fragmentation hè […] the compartmentalization is just not contributory.”
The different departments have a lot of autonomy and one department cannot make any decision for another department. This means that there is no head of all departments or something similar that makes certain decisions about innovations except for the board of directors. Nobody within the UMC seems to be willing to take the responsibility. Moreover, due to this fragmented structure and culture, communication lines are unclear, as is explained by IT01: “[…] Where do you start? Hè, there is not a place to start, well there is, but you have to know where it is. Like ‘I have a new eHealth application, how do I implement it in the [UMC name]?’ well no idea, where do you start? You know someone within the [UMC name] and that is the person you will go to and dependent on who you’ll talk to you will go through a certain trajectory for example.’ This also indicates the fragmentation of the organization and the lack of communication beyond departments or columns. People do not know where to go with their innovative proposals and therefore depend on the people they know. This could also be a reason why there are many different initiatives and proposals running simultaneously which have similar goals, as was explained earlier.
4.3 Technology
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value to the supply side, in this case the hospital. It should be able to fit in the IT architecture and the information it provides should be integrated with the Electronic Health Records system that is in place, as is explained by IC01: “It needs to integrate well with the existing workflows. So if you have a plaster of Phillips that cannot easily share its data with for example the Electronic Health Records System of the [UMC name]. yes… and it is replaced by a separate system, or something like that. So it needs to, let me think, fit into the workflows of the doctors.” The case data also indicates an important link between technology and external forces. Within the first section of the results the Medical Device Regulation has been mentioned as an example. These types of legal external influences often change, as is explained by IT01: “the legislation also changes, new legislations are being made and then you have to start all over again.” This interviewee points out that the legislations around technologies and data are changing, which means that constant flexibility and adaptation of the organization is necessary in order to keep up with these legal forces. Another mentioned external influence on technology is the standardization of data to which the UMC needs to adapt in order to increase interoperability of healthcare data, which is a subsidized program by the government.
Thus external forces influence the development of eHealth technologies, because developers of eHealth tools need to comply with legislation and constantly adapt in order to prevent future issues. Therefore, it can be concluded that external forces both influence technology development and the organization. The types of available technology then again require adaptation by the organization in order to facilitate the technology and integrate it within its own structure and processes. On the other hand, an organization can also decide to develop a certain technology themselves to fit within their processes.
4.4 Upscaling success
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telemonitoring. Thus, change readiness seems to be there on individual level and less on organizational level.
The organizational structure and culture are also quite inflexible, as is explained by CM01: “The client needs to take a different stance, a different attitude to make it right. But what I do think is that we stick very much to ‘this is what we agreed upon, this is what we’ll do’.” With client this person means the organization. IC01 Also indicates that the complexity of the process of upscaling telemonitoring might be underestimated: “It is a complex problem, which we might treat like… what is it? Complicated, what was it? Like a jigsaw, but it is a very complex problem, what I believe is being treated as a complicated problem.”
These issues have several consequences. One of them is inertia, which is explained by NU02: “I think that the [UMC name] is a very big organization where things sometimes… […] sometimes take long. […] it takes such a long time, which is why you sometimes are too late in joining… ehm… if you want to be innovative.”
4.5 Theoretical model
The domains and explained connections between these different domains based on the case data are summarized in the theoretical model in Figure 3.
This theoretical model summarizes the most interesting and notable outcomes. This means that these domains provide an explanation of the important interactions between domains applicable to this specific case and that for other research contexts, different domains might be more applicable.
First, the influences of the wider system on every domain have been mentioned multiple times. Demographic, technologic and environmental changes require adaptation of the organization. The wider system also provides the context which determines whether upscaling success can be achieved
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and the environmental complexity. The wider system also influences technology development. Examples are legislation and patient needs.
Secondly, the UMC in this case seems to use external forces in defining their strategies of sustainable care, care reallocation and patient-centered healthcare. However, several issues in the organizational structure and culture of the UMC have been mentioned that are current barriers that block the successful upscaling of telemonitoring. These are: the fragmentation of the organization, interdepartmental competition, budgeting policy, strong hierarchy, organizational politics, lack of interdepartmental communication and collaboration, responsibility and decision making and the service design itself all seem to contribute to the low success rate and slow process of upscaling eHealth in this UMC.
Thirdly, the technology influences upscaling success through its degree of value to both the demand and supply side. Through external influences, telemonitoring technologies need to be developed that comply with legislation and quality certificates. This means that the organization needs to have the right structures and processes in place in order to integrate these technologies. On the other hand, the organization can also built or change telemonitoring technologies that both fit their organization and complies with external rules and regulations.
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5. Discussion & conclusion
This section includes an explanation of the results in relation to existent research, a conclusion, theoretical and managerial implications, limitations and recommendations for further research.
5.1 Results related to existent literature.
Comparing the results with the reviewed literature, the results seem mostly to be in line with existing literature using the systems approach in explaining eHealth. The results indeed show that it might be too simple to research the link between single barriers or facilitators and upscaling success. This research shows the dynamic interactions at play between different domains and how these domains are part of an ecosystem. This research is largely guided by the NASSS Framework of Greenhalgh et al. (2017), this is visible in the theoretical model as well. Similarly to the NASSS framework, the theoretical model considers technology and organization as interactive domains within a wider environment of external forces. However, where the NASSS framework focuses more on value proposition and evaluation of environmental complexity, this theoretical model assesses interactions between domains in terms of upscaling success. Hence, where the NASSS framework talks about change capacity and change readiness, this theoretical framework tries to go further into detail by explaining key organizational domains that determine their change capacity in the light of upscaling success.
Wentzel et al. (2014) mentioned that eHealth innovations require a fit of the technology between user needs and the clinical context in which it is implemented. This research also confirms the need for this fit, but also addresses the importance of external forces that have a major role in eHealth success rate. These external forces can determine conditions or norms for the technology and the clinical context, which was the case in this research.
When comparing the results of this research to the heuristic provided by Shaw et al. (2018), it does seem to disagree in some points. Shaw et al. (2018) mention how the interaction between team, tool and routine and constant adaptation create service design. This research shows that next to this, organizational factors such as structure and external influences also play a major role in how healthcare service is provided. Therefore, the Team+Tool+Routine heuristic might be too simple to explain the concept of service design.
5.2 Conclusion
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system?” The case research provides evidence that external influences in the wider system, the organization and technology and the dynamic interactions between these domains affect the success rate of upscaling initiatives. The case provided an example of misalignment between the organization wider environmental forces and internal structure and culture, resulting in a low change capacity and consequently a high degree of failed eHealth implementations and upscaling initiatives. The theoretical model that has been conducted contributes to the systems approach literature, as it provides a more thorough understanding with case data how the domains technology, organization and wider system interact.
5.3 Theoretical and managerial implications
The research contributes to existing research in the field of systems approach to eHealth. It extends the NASSS framework by providing a more in-depth explanation of the interaction between different organizational domains with the eHealth ecosystem. The importance of organizational strategy, structure and culture have not been mentioned much in systems approach literature and this research gives useful insights in how these domains interact and what their role is in upscaling success. Moreover, this research answers to the request of more local case evidence for system approach theory by Greenhalgh et al. (2017), which delivers new insights and a possible start for further research on this topic.
25
5.4 Limitations and recommendations for further research
There are several limitations that can be identified from this research. Firstly, the research is based on a single UMC located in the Netherlands. Although most University Medical Centers focus on providing care to patients, research and education, other UMC’s might be organized differently within a different environmental context creating different circumstances. Therefore, it is hard to generalize the outcomes of this research. However, it might be interesting to compare the theoretical model in this research to other UMC’s with different organizational models and in different environmental contexts to evaluate the theoretical model or propose further extension of the model based on different circumstances. It might also be interesting to compare this research performed at a UMC with general hospitals to spot how these two healthcare institutions resemble and differ from each other to get a broader understanding of the upscaling eHealth in general.
Secondly, the interviews have been performed within a population of which most interviewees already had experience with eHealth. For example, of the patients that were interviewed, three out of five already participated in earlier research concerning eHealth
implementations, which might have resulted in a bias in favor of eHealth innovations, because most interviewees had a positive view on eHealth innovations and telemonitoring in specific. Other research designs (for example quantitative research methods) might be recommended to get a more reliable view of the opinions and attitudes of people towards eHealth or telemonitoring innovations. Thirdly, the research elaborates on influences from the wider system. However, the research was performed mostly within the organizational environment and thus includes an internal
26
References
Aarts, J. (2013). A sociotechnical perspective of health information technology. International Journal of Medical Informatics, 82(12), 1133-5. doi:10.1016/j.ijmedinf.2013.10.007
Abbing, H. D. (2010). Social justice and healthcare systems in europe. European Journal of Health Law, 17(3), 217-22. Retrieved from https://rug.on.worldcat.org/oclc/672353366
Aken, J. E. v., Berends, J. J., & Bij, J. D. van der. (2012). Problem solving in organizations : A methodological handbook for business and management students (2nd edition. ed.). Cambridge: Cambridge University Press. Retrieved from https://rug.on.worldcat.org/oclc/795326812
Avgar, A. C., Litwin, A. S., & Pronovost, P. J. (2012). Drivers and barriers in health IT adoption: A proposed framework. Applied Clinical Informatics, 3(4), 488-500. doi:10.4338/ACI-2012-07-R-0029
Bachiri, M., Idri, A., Fernández-Alemán, J. L., & Toval, A. (2018). Evaluating the privacy policies of mobile personal health records for pregnancy monitoring. Journal of Medical Systems, 42(8), 1-14. doi:10.1007/s10916-018-1002-x
Bolton, C. E., Waters, C. S., Peirce, S., & Elwyn, G. (2011). Insufficient evidence of benefit: A systematic review of home telemonitoring for COPD, Wiley Online Library.
Boogerd, E. A., Arts, T., Engelen, L. J., & van de Belt, T H. (2015). "What is eHealth": Time for an update? JMIR Research Protocols, 4(1), e29. doi:10.2196/resprot.4065
Campanella, P., Lovato, E., Marone, C., Fallacara, L., Mancuso, A., Ricciardi, W., & Specchia, M. L. (2016). The impact of electronic health records on healthcare quality: A systematic review and meta-analysis. European Journal of Public Health, 26(1), 60-64. doi:10.1093/eurpub/ckv122
27
Carlos Hernandez-Quiles, Máximo Bernabeu-Wittel, Maria del Rocio Garcia-Serrano, Salvador Vergara-Lopez, Jose Antonio Perez-de-Leon, Alberto Ruiz-Cantero, . . . Manuel Ollero-Baturone. (2020). A multicenter randomized clinical trial to evaluate the efficacy of
telemonitoring in patients with advanced heart and lung chronic failure. study protocol for the ATLAN_TIC project. Contemporary Clinical Trials
Communications, 17 doi:10.1016/j.conctc.2019.100512
Cruz, J., Brooks, D., & Marques, A. (2014). Home telemonitoring effectiveness in COPD: A systematic review, Wiley Online Library.
Fairbrother, P., Pinnock, H., Hanley, J., McCloughan, L., Sheikh, A., Pagliari, C., & McKinstry, B. (2012). Continuity, but at what cost? the impact of telemonitoring COPD on continuities of care: A qualitative study, Nature Publishing Group.
Gong, K., Xu, Z., Cai, Z., Chen, Y., & Wang, Z. (2020). Internet hospitals help prevent and control the epidemic of COVID-19 in china: Multicenter user profiling study. Journal of Medical Internet Research, 22(4), e18908. doi:10.2196/18908
Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A'Court, C., . . . Shaw, S. (2017). Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. Journal of Medical Internet Research, 19(11), e367. doi:10.2196/jmir.8775
Greenhalgh, T., & Papoutsi, C. (2018). No title. Studying Complexity in Health Services Research: Desperately Seeking an Overdue Paradigm Shift.
Grisot, M., & Vassilakopoulou, P. (2017). Re-infrastructuring for eHealth: Dealing with turns in infrastructure development doi:10.1007/s10606-017-9264-2
28
Harrison, J. P., & Lee, A. (2006). The role of E-health in the changing health care environment. Nursing Economic$., 24(6), 283-289. Retrieved
from https://rug.on.worldcat.org/oclc/108105612
Ingebrigtsen, T., Georgiou, A., Clay-Williams, R., Magrabi, F., Hordern, A., Prgomet, M., . . . Braithwaite, J. (2014). The impact of clinical leadership on health information technology adoption: Systematic review. International Journal of Medical Informatics, 83(6), 393-405. doi:10.1016/j.ijmedinf.2014.02.005
Islam, S. R., Kwak, D., Kabir, M. H., & Kwak, K. S. (2015). The internet of things for health care: A comprehensive survey. IEEE Access, 3, 678-708.
Istepanian, R. S. H., Jovanov, E., & Zhang, Y. T. (2004). Guest editorial introduction to the special section on M-health: Beyond seamless mobility and global wireless health-care
connectivity. IEEE Transactions on Information Technology in Biomedicine, 8(4), 405-414. doi:10.1109/TITB.2004.840019
Jaana, M., & Paré, G. (2007). Home telemonitoring of patients with diabetes: A systematic assessment of observed effects Wiley Online Library.
Jordan, R., Adab, P., & Jolly, K. (2013). Telemonitoring for patients with COPD. Bmj, 347(oct17 3), f5932. doi:10.1136/bmj.f5932
Kellermann, A. L., & Jones, S. S. (2013). What it will take to achieve the as-yet-unfulfilled promises of health information technology. doi:10.1377/hlthaff.2012.0693
Keshvardoost, S., Bahaadinbeigy, K., & Fatehi, F. (2020). Role of telehealth in the management of COVID-19: Lessons learned from previous SARS, MERS, and ebola outbreaks. Telemedicine Journal and E-Health : The Official Journal of the American Telemedicine
Association, doi:10.1089/tmj.2020.0105
29
Levina, N., & Vaast, E. (2005). The emergence of boundary spanning competence in practice:
Implications for implementation and use of information systems. MIS Quarterly, 29(2), 335-363. Retrieved from https://rug.on.worldcat.org/oclc/7781119461
Marshall, M. N. (1996). Sampling for qualitative research. Family Practice, 13(6), 522-526.
Mendel, P., Meredith, L. S., Schoenbaum, M., Sherbourne, C. D., & Wells, K. B. (2008). Interventions in organizational and community context: A framework for building evidence on dissemination and implementation in health services research. Administration and Policy in Mental Health and Mental Health Services Research, 35(1-2), 21-37. doi:10.1007/s10488-007-0144-9
Moyo, M., Goodyear-Smith, F. A., Weller, J., Robb, G., & Shulruf, B. (2016). Healthcare
practitioners' personal and professional values. Advances in Health Sciences Education : Theory and Practice, 21(2), 257-86. doi:10.1007/s10459-015-9626-9
Oh, H., Rizo, C., Enkin, M., & Jadad, A. (2005). What is eHealth (3): A systematic review of published definitions. Journal of Medical Internet Research, 7(1), e1. Retrieved
from https://rug.on.worldcat.org/oclc/111676001
Ohannessian, R., Duong, T. A., & Odone, A. (2020). Global telemedicine implementation and
integration within health systems to fight the COVID-19 pandemic: A call to action. JMIR Public Health and Surveillance, 6(2), e18810. doi:10.2196/18810
Ossebaard, H. C., & van Gemert-Pijnen, Julia E. W. C. (2016). eHealth and quality in health care: Implementation time. International Journal for Quality in Health Care, 28(3), 415-419. Retrieved from https://rug.on.worldcat.org/oclc/7079811431
Oudshoorn, N. (2008). Diagnosis at a distance: The invisible work of patients and healthcare professionals in cardiac telemonitoring technology Wiley Online Library.
30
Pinnock, H., Hanley, J., McCloughan, L., Todd, A., Krishan, A., Lewis, S., . . . McKinstry, B. (2013). Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: Researcher blind, multicentre,
randomised controlled trial. Bmj, 347(oct17 3), f6070. doi:10.1136/bmj.f6070
Piotrowicz, E., Baranowski, R., Bilinska, M., Stepnowska, M., Piotrowska, M., Wójcik, A., . . . Klopotowski, M. (2010). A new model of home‐ based telemonitored cardiac rehabilitation in patients with heart failure: Effectiveness, quality of life, and adherence Wiley Online Library.
Saleem, J. J., Plew, W. R., Speir, R. C., Herout, J., Wilck, N. R., Ryan, D. M., . . . Phillips, T. (2015). Understanding barriers and facilitators to the use of clinical information systems for intensive care units and anesthesia record keeping: A rapid ethnography Elsevier Ireland Ltd.
Shaw, J., Agarwal, P., Desveaux, L., Palma, D. C., Stamenova, V., Jamieson, T., . . . Bhattacharyya, O. (2018). Beyond “implementation”: Digital health innovation and service design. Npj Digital Medicine, 1(1) doi:10.1038/s41746-018-0059-8
Shaw, J., Rudzicz, F., Jamieson, T., & Goldfarb, A. (2019). Artificial intelligence and the implementation challenge. Journal of Medical Internet Research, 21(7), e13659.
Shaw, T., McGregor, D., Brunner, M., Keep, M., Janssen, A., & Barnet, S. (2017). What is eHealth (6)? development of a conceptual model for eHealth: Qualitative study with key
informants doi:10.2196/jmir.8106
Star, S. L., & Griesemer, J. R. (1989). Institutional ecology, 'translations' and boundary objects: Amateurs and professionals in berkeley's museum of vertebrate zoology, 1907-39. Social Studies of Science, 19(3), 387-420. Retrieved from https://rug.on.worldcat.org/oclc/5548970333
31
Tanvir Ahmed, Henry Lucas, Azfar Sadun Khan, Rubana Islam, Abbas Bhuiya, & Mohammad Iqbal. (2014). eHealth and mHealth initiatives in bangladesh: A scoping study. BMC Health Services Research, 14(1), 260. doi:10.1186/1472-6963-14-260
van't Riet, J., Crutzen, R., & De Vries, H. (2010). Investigating predictors of visiting, using, and revisiting an online health-communication program: A longitudinal study. Journal of Medical Internet Research, 12(3) Retrieved from https://rug.on.worldcat.org/oclc/7079707727
Weber-Jahnke, J., Peyton, L., & Topaloglou, T. (2012). eHealth system interoperability. Information Systems Frontiers : A Journal of Research and Innovation, 14(1), 1-3. doi:10.1007/s10796-011-9319-8
Wentzel, J., van Velsen, L., van Limburg, M., de Jong, N., Karreman, J., Hendrix, R., & van Gemert-Pijnen, J. E. (2014). Participatory eHealth development to support nurses in antimicrobial stewardship. BMC Medical Informatics and Decision Making, 14, 45. doi:10.1186/1472-6947-14-45
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Appendix
Appendix 1: Interview schemes
INTERVIEW SCHEME 1 - GENERAL
Introductie
Ten eerste wil ik u hartelijk bedanken voor de tijd die u voor mij heeft vrijgemaakt om dit interview met u af te nemen. U bent hierover van tevoren geïnformeerd, maar ik zal nog even een korte toelichting geven voor dit interview. Dit interview vindt plaats als onderdeel van het onderzoek dat gedaan wordt voor Citrien 2 eHealth en is tevens mijn afstudeerproject. Dit onderzoek heeft het doel de visie van verschillende eHealth stakeholders te identificeren in het opschalen van telemonitoring tools. De resultaten worden volgens de richtlijnen van de Medisch Ethische Toetsingscommissie (METc) van het [UMC NAME] verwerkt, wat betekent dat uw data veilig en anoniem verwerkt zullen worden. Voordat we beginnen, heeft u misschien vragen?
Introductievragen
1. Hoe zou u uw rol omschrijven binnen het ziekenhuis? eHealth
eHealth is een verzamelnaam voor gebruik van informatie en communicatietechnologie (ICT) ter ondersteuning van zorg. Technologieën zoals het elektronisch patiëntendossier maken het delen van gegevens mogelijk, waardoor zorg efficiënter, veiliger en overzichtelijker geleverd kan worden.
2. Bent u betrokken bij eHealth initiatieven in uw dagelijks werk?
I. Hoe bent u hier precies bij betrokken?
3. Wat is uw ervaring met eHealth?
I. Kunt u hier een voorbeeld geven?
Telemonitoring tool
Eén van de nieuwste ontwikkelingen op het gebied van eHealth is telemonitoring. Dit kan een technologie zijn die het mogelijk maakt om patiënten op aftand (thuis of verpleegafdeling) te monitoren, bijvoorbeeld doormiddel van applicaties, sensors of andere meetapparatuur.
4. Voor welke doelen zou telemonitoring volgens u effectief kunnen worden ingezet?
I. Hoe zou deze gebruikt moeten worden?
II. Kunt u een voorbeeld geven van een situatie waarin deze gebruikt zou kunnen worden?
III. Wanneer is telemonitoring juist niet handig?
5. Voor wat voor ziektebeelden of voor welke patiënten zou de tool gebruikt kunnen worden?
6. Wat voor functies zou een telemonitoring tool moeten hebben?
I. Waarom?
Gebruik van de tool
7. Wat voor informatie zou een telemonitoring tool aan moeten leveren?
33 II. Op welke manier?
8. Welke partijen zouden volgens u de tool moeten kunnen gebruiken?
9. Welke partij zou de verantwoordelijkheid moeten dragen voor de zorg van de patiënt met invoering van de tool?
Citrien 2 Project – Wireless vitals tool
Telemonitoring is ook een belangrijk onderdeel van het landelijke Citrienfonds eHealth programma. Hierin ligt de focus op applicaties die vitale functies van het lichaam opmeten in de periode na een operatie om zo eerder achteruitgang van de patiënt te kunnen constateren en dus vermijdbare complicaties te voorkomen. Voorbeeld van een applicatie is een “digitale pleister” die vitale functies opmeet en de waardes gelijk door kan sturen.
Stel, een patiënt krijgt een “digitale pleister” na een operatie met als doel de vitale functies te monitoren.
10. Waar zou het gebruik van de pleister voor het eerst moeten worden toegepast? 11. Wie zou de patiënt informatie moeten geven over het gebruik van de tool en waarom? 12. Op welke manier zou deze persoon de informatie moeten krijgen?
13. Waar zou deze persoon terecht moeten kunnen met vragen over deze “digitale pleister?” 14. Wanneer kan het monitoren van de patiënt worden stopgezet en hoe wordt dat bepaald? Implementatie Telemonitoring
15. Veel zorgorganisaties overwegen om telemonitoring op bredere schaal in te zetten, wat vindt u daarvan?
16. Waar verwacht u dat telemonitoring waarde toe kan voegen aan de huidige zorg? 17. Wat zou er volgens u nodig zijn om telemonitoring op grotere schaal te kunnen
implementeren?
18. Hoe denkt u dat telemonitoring het best ingepast kan worden in het bestaande pakket van informatietechnologie waar het [UMC NAME] al gebruik van maakt?
19. Wat voor barrières voorziet u bij het breder implementeren van telemonitoring? Stel, u mag de implementatie van telemonitoring in het [UMC NAME] begeleiden.
20. Wat zou volgens u de eerste stap in de implementatie van de tool moeten zijn? 21. Hoe zou u de tool verder implementeren?
22. Wie zouden er volgens u betrokken moeten zijn bij de implementatie van de tool en in welke mate?
Afsluitende vraag
34 I. Voor wie zou deze tool bestemd zijn?
Afsluiting
Dan zijn we aan het einde beland van mijn vragenlijst. Heeft u nog vragen?
35
INTERVIEW SCHEME 2 - NURSE
Introductie
Ten eerste wil ik u hartelijk bedanken voor de tijd die u voor mij heeft vrijgemaakt om dit interview met u af te nemen. U bent hierover van tevoren geïnformeerd, maar ik zal nog even een korte toelichting geven voor dit interview. Dit interview vindt plaats als onderdeel van het onderzoek dat gedaan wordt voor Citrien 2 eHealth en is tevens mijn afstudeerproject. Dit onderzoek heeft het doel de visie van verschillende eHealth stakeholders te identificeren in het opschalen van telemonitoring tools. De resultaten worden volgens de richtlijnen van de Medisch Ethische Toetsingscommissie (METc) van het [UMC NAME] verwerkt, wat betekent dat uw data veilig en anoniem verwerkt zullen worden. Voordat we beginnen, heeft u misschien vragen?
Introductievragen
1. Hoe zou u uw rol omschrijven binnen het ziekenhuis? eHealth
eHealth is een verzamelnaam voor gebruik van informatie en communicatietechnologie (ICT) ter ondersteuning van zorg. Technologieën zoals het elektronisch patiëntendossier maken het delen van gegevens mogelijk, waardoor zorg efficiënter, veiliger en overzichtelijker geleverd kan worden.
2. Bent u betrokken bij eHealth initiatieven in uw dagelijks werk?
I. Hoe bent u hier precies bij betrokken?
3. Wat is uw ervaring met eHealth?
I. Kunt u hier een voorbeeld geven?
Telemonitoring tool
Eén van de nieuwste ontwikkelingen op het gebied van eHealth is telemonitoring. Dit kan een technologie zijn die het mogelijk maakt om patiënten op aftand (thuis of verpleegafdeling) te monitoren, bijvoorbeeld doormiddel van applicaties, sensors of andere meetapparatuur.
4. U heeft meegelopen met een onderzoek naar telemonitoring, kunt u vertellen wat voor onderzoek dit was?
5. Wat was uw rol binnen dit onderzoek? 6. Hoe heeft u dit ervaren?
7. Wat is u opgevallen tijdens het onderzoek?
8. Hoe beïnvloedde telemonitoring uw manier van werken? 9. Wat is uw mening over telemonitoring?
I. Waarom?
10. Voor welke doelen zou telemonitoring volgens u nog meer kunnen worden ingezet?
I. Kunt u een voorbeeld geven van een situatie waarin deze gebruikt zou kunnen worden?
36
12. Voor wat voor ziektebeelden of voor welke patiënten zou de tool gebruikt kunnen worden?
13. Wat voor functies zou een telemonitoring tool moeten hebben?
I. Waarom?
Gebruik van de tool
Als we het voorbeeld nemen van de telemonitoring tool die u gebruikt heeft tijdens het onderzoek
14. Wat voor informatie leverde te tool aan?
I. Aan wie?
II. Op welke manier?
15. Welke partijen zouden volgens u de tool moeten kunnen gebruiken?
16. Welke partij zou de verantwoordelijkheid moeten dragen voor de zorg van de patiënt met invoering van de tool?
Stel, een patiënt krijgt een digitale pleister na een operatie met als doel de vitale functies te monitoren.
17. Waar zou het gebruik van de pleister voor het eerst moeten worden toegepast? 18. Wie zou de patiënt informatie moeten geven over het gebruik van de tool en waarom? 19. Op welke manier zou deze persoon de informatie moeten krijgen?
20. Waar zou deze persoon terecht moeten kunnen met vragen over deze “digitale pleister?” 21. Wanneer kan het monitoren van de patiënt worden stopgezet en hoe wordt dat bepaald? Implementatie Telemonitoring
22. Veel zorgorganisaties overwegen om telemonitoring op bredere schaal in te zetten, wat vindt u daarvan?
23. Waar verwacht u dat telemonitoring waarde toe kan voegen aan de huidige zorg? 24. Wat zou er volgens u nodig zijn om telemonitoring op grotere schaal te kunnen
implementeren?
25. Hoe denkt u dat telemonitoring het best ingepast kan worden in het bestaande pakket van informatietechnologie waar het [UMC NAME] al gebruik van maakt?
26. Wat voor barrières voorziet u bij het breder implementeren van telemonitoring? Stel, u mag de implementatie van telemonitoring in het [UMC NAME] begeleiden.
37
29. Wie zouden er volgens u betrokken moeten zijn bij de implementatie van de tool en in welke mate?
Afsluitende vraag
30. Hoe zou de ideale telemonitoring tool er volgens u uit zien?
a. Voor wie zou deze tool bestemd zijn?
Afsluiting
Dan zijn we aan het einde beland van mijn vragenlijst. Heeft u nog vragen?
38
INTERVIEW SCHEME 3 - PATIENT
Introductie
Ten eerste wil ik u hartelijk bedanken voor de tijd die u voor mij heeft vrijgemaakt om dit interview met u af te nemen. U bent hierover van tevoren geïnformeerd, maar ik zal nog even een korte toelichting geven voor dit interview. Dit interview vindt plaats als onderdeel van het onderzoek dat gedaan wordt voor Citrien 2 eHealthprogramma, dat is een programma dat is ontstaan vanuit meerdere UMC’s in Nederland en is tevens mijn afstudeerproject. De resultaten worden volgens de richtlijnen van de Medisch Ethische Toetsingscommissie (METc) van het [UMC NAME] verwerkt, wat betekent dat uw data veilig en anoniem verwerkt zullen worden. Voordat we beginnen, heeft u misschien vragen?
Introductievragen
1. Waarvoor heeft u het afgelopen jaar het [UMC NAME] bezocht?
I. Waarom?
II. Hoe zag het zorgproces er toen precies uit? III. Wat vond u goed aan hoe dit proces verliep? IV. Wat zijn verbeterpunten?
2. Wat vindt u van de huidige manier waarop zorgverlening wordt toegepast in uw situatie?
I. Wat vindt u hierin belangrijk? II. Wat vindt u dat hierin anders kan?
3. Wat vindt u van de groeiende rol van technologie binnen de zorg?
I. Waarin zou technologie u in uw situatie kunnen helpen?
Telemonitoring
Eén van de nieuwste ontwikkelingen op het gebied van technologie in de zorg is telemonitoring. Dit kan een technologie zijn die het mogelijk maakt om patiënten op aftand (thuis of verpleegafdeling) in de gaten te kunnen houden, bijvoorbeeld doormiddel van apps, sensors of andere meetapparatuur die data over de gezondheid doorsturen naar het ziekenhuis. Dit kan verschillende doelen hebben.
4. Wat vindt u hiervan?
I. Waarom?
5. Zou het voor u meerwaarde hebben om in uw situatie gebruik te maken van deze technologie?
I. Kunt u een voorbeeldsituatie noemen waarin dit meerwaarde heeft? II. Waarom?
III. Op wat voor manier?
Stel, u moet een operatie ondergaan en gaat na een aantal dagen hersteltijd weer naar huis. U krijgt een telemonitoring middel mee vanuit het ziekenhuis die uw herstel in de gaten houdt.
6. Wat zou u hiervan vinden?
I. Waarom?
7. Wat zou u van tevoren graag willen weten?
I. Waarom?
II. Hoe zou u hier het liefst informatie over willen krijgen?
8. Op wat voor manier zou het liefst in de gaten gehouden worden?
39
9. Door wie zou u het liefst in de gaten worden gehouden?
I. Waarom?
10. Wat zou u belangrijk vinden dat er in de gaten wordt gehouden?
I. Waarom?
11. Hoe zou u het liefst met de zorginstantie in contact zijn tijdens deze periode van telemonitoring?
12. In hoeverre zou u zelf inzicht willen hebben in de data die wordt opgenomen?
I. Waar zou u precies inzicht in willen krijgen? II. Waarom (niet)?
