Managing the implementation of eHealth within a large hospital
Freekje Huisman
Rijksuniversiteit Groningen
MSc BA: Change management
Supervisor: I. Maris
Co-assessor: C. Reezigt
S2029790
22-06-‘15
Abstract
Due to rising healthcare costs, hospitals try to find ways to deliver high quality care while diminishing costs. The rapid technological breakthroughs are emphasizing the use of eHealth to empower the patients and therefore increase organizational effectiveness. However, the implementation of eHealth
is not something to “just do”. Managing such a large project is very hard and issues arise. The implementation of an integrated electronic medical record (EMR) is studied in this research. Different perspectives are addressed regarding the expectations of key users of the system. A qualitative study is conducted to gain better insight in the implementation of an integrated EMR within a large hospital. Adaptation of medical specialists is influenced by the fact that different perspectives on management
are causing issues. Features of the system itself also influence adaptation of specialists. Finally, according to medical specialist and hospital management, stakeholders expect that patients’ adaptation
is influenced by the specialists’ adaptation.
Introduction
In the last decades, the Dutch healthcare sector changed rapidly. Improvements over the years, by knowledge sharing and technology development, created opportunities for the healthcare to develop. The government made money available for improvements in the healthcare sector (Taskforce beheersing zorguitgaven, 2012), however controlling the expenses within this sector were hard and soon costs were running high. In effect of these growing costs, the costs of health insurances increased as well, for example in 2014 the costs increased with 3% (Badir, 2014).
To put a hold on the rising costs, and prevent the healthcare from becoming unaffordable, the healthcare needs to be changed. Technological possibilities help to improve the healthcare and technology might be the solution towards the upcoming healthcare costs (Nictiz, 2013; Mevius, 2014; Barker, 2011; Silber, 2005).
According to van der Graaf et al. (2014), everything that has to do with technology and healthcare could be defined as eHealth. With the help of eHealth major projects are invented to cut the costs. One of these projects is moving the workload from a medical specialist towards a general practitioner and eventually towards self-management (Miljoenennota, 2014). Using eHealth makes it possible for patients to be more accountable of their own health. Innovations within this area contribute to the growing responsibilities of patients; it facilitates patient empowerment (Horstman, 2014; Schrijven, 2014). In general, patient empowerment shows a decrease in demand for direct care, which will lead to decreasing healthcare costs. However due to socio-economic and demographic differences of the patient population; there is no sufficient evidence for a positive effect on healthcare costs (Blanson Henkemans et al., 2010; Westerink & Hutten, 2014; Mevius, 2014; Van der Graaf et al., 2014).
Furthermore, the influence of patient empowerment in combination with the performance of a medical specialist is a challenge to the classical models of medical care (Hardey, 2002). The specialists’ role will shift from old professionalism, where the specialist had the knowledge and the patient is the ‘passive’ recipient, towards new professionalism in which they take a more facilitating role to enhance the knowledge of patients (Taylor and Hawley, 2010). In order to keep a fit between the external environment and the internal structure to facilitate organizational effectiveness (Nadler and Tushman, 1989), healthcare organizations need to change.
Healthcare organisations are mostly large, complex and slow in changes. This is mainly due to the fact that the change process involves multiple stakeholders, who all have different interest and urgencies (Fitzgerald et al., 2008). Stakeholders are those who can affect change or are affected by the change, basically the key individuals influencing the change (Cawsey et al., 2012). In order to
As for the hospital management, it is important to deal with changes implied by external forces (e.g. rising healthcare costs, laws and regulations, technology development) to keep a fit with the internal structure. Successful management of change is crucial to any organisation in order to survive and succeed in the present highly competitive and continuously evolving business environment (Todnem, 2005; Luecke, 2003; Okumus and Hemmington, 1998).
The implementation of eHealth is facing multiple difficulties. EHealth is not easy to implement, process innovation is hard, benefits are different for specific stakeholders and possible users are not always known with the possibilities of eHealth (Krijgsman et al., 2014).
To gain better insight in the difficulties experienced in practice a qualitative study is done. This research is done in a large Hospital in the east of the Netherlands. They are currently implementing ‘EPIC’ which is an information system used to implement an integrated Electronic medical record (EMR). According to the company itself is EPIC software quick to implement, easy to use and highly interoperable through industry standards (www.epic.com, 2014). Information is sent securely.
However, there are examples in which this was not the case. One of the main reasons why EPIC is implemented is the possibility of adding a patient portal that facilitates patient empowerment. Patients can schedule appointments, get test results and print growth charts. The focus during this research will be on the implementation of the information system called ‘EPIC’ as a form of eHealth to stimulate patient empowerment.
The aim of this paper is to understand what makes the implementation of eHealth successful. This paper contributes to the existing literature by looking at the issues of the implementation of a large change project within a hospital. So, the goal of this study is to discover the dimensions that influence the implementation of eHealth. It focuses on the analysis of success and failure of adaptation of key users to technology from the perspective of different stakeholders as a way of gaining greater understanding of the complexity of the process. This paper focuses on specialists as key users of the EPIC system.
One objective of the study is to find out what is in the way or what is successful to stimulate organizational effectiveness regarding the management of the implementation. The following question will be the central topic during this research:
How is the implementation of eHealth managed within a large hospital to stimulate organizational effectiveness?
With the reduced healthcare costs as result of using eHealth as a tool for patient empowerment in mind, organizational effectiveness will increase when patient empowerment is stimulated (Krijgsman et al., 2013). However, the implementation cannot be successful without the adaptation of key users (Krijgsman et al., 2014) and therefore organizational effectiveness will be influenced by the adaptation of key users to eHealth. Therefore, another objective of this study is to understand the relationships between technology-specialist-patient. Adaptation of technology by specialists can be defined as the degree to which the specialist is willing and able to engage into new ways of working, by the use of technology. The following sub question is formulated:
What is influencing specialists’ adaptation to eHealth?
Patient adaptation towards empowerment can be defined as the degree to which the patient is willing and able to make use of technology to stimulate self-management. In order to see what the expectations are regarding the influence of specialists’ adaptation on patients’ adaptation, the third objective of this study, the following sub question is addressed:
What is the expectation of the influence of the specialists’ adaptation on the patients’ adaptation to eHealth?
The literature gap addressed in this research is the lack of literature about the implementation of information systems in hospitals. There is research done about managing implementations of
information systems in organizations. However, the complexity of healthcare and its networks of many stakeholders (Rouse, 2008) are of such a specific type that literature might not be applicable within a hospital. There is not much information available about the role of issues and stakeholders during IS implementation in healthcare and in similar sectors (Boonstra & Govers, 2009). This paper is trying to provide information about successes and failures that are shown in a practical situation. This paper will show how medical specialists and top-managers perceive the way an implementation is managed. Also their perspectives on the expected role of patients is elaborated because this will influence organizational effectiveness as well. Research can clarify how implementations this big within a hospital should be managed.
successes already achieved. Patients can benefit from the success of this implementation as well, due to the expected cost savings en efficiency improvements if the implementation is managed effectively.
The thesis will start with a literature review about the relevant literature highlighted in the introduction. From this literature review specific hypotheses are formed and at the end of this section the conceptual model of this research is displayed. Next will be the method section. Here, the research design, the data collection and the data analysis will be elaborated. Furthermore, the following section is providing the findings of the research. In addition, the discussion section will follow with a
description of the implications for theory and practice. Finally the limitations and directions for further research will be discussed.
Literature Review
Organizational ChangeChange is part of an organisations’ life, which always will be present both at the operational and strategic level (Burnes, 2004). Nowadays there is a high pressure on the aim to be able to identify where the organisation needs to be in the future and how to manage this (Todnem, 2005). According to Graetz (2000) due to the rapid pace of new technology, management today should be focused on the importance of organizational change. Change is extremely hard to predict and to control, because multiple factors are changing at the same time. There is a high magnitude of environmental change and frequent resistance of human systems (Burke and Litwin, 1992). Environmental factors, such as new technologies, are mostly the starting point of organizational change (Cawsey et al., 2012). Therefore, organizational effectiveness stems from a fit between an organisations external environment and internal structure ( Burke and Litwin, 1992; Nadler and Tushman, 1989).
Effectiveness will be defined as increasing organisations’ ability to generate value for those they serve (Cawsey et al., 2012).
Technological change
Change management
Change management is the process of continuous renewed organizational direction, structure and capabilities in order to serve the changing needs of the external and internal customers (Moran and Brightman, 2001). Successful management of change is important in the fluctuating and shifting nature of organizations nowadays. According to Cawsey et al. (2012) organizational fit between different needs, should be managed by change managers by taking a holistic perspective of the change and focus on informing employees about the changes needed (Cawsey et al., 2012).
Senior management needs to be aware of the fact that without the cooperation of employees, an organization is not able to achieve the goals and objectives set (Cawsey et al., 2012). Furthermore, multiple authors acknowledge the importance of communication during organizational change and how it can affect the reactions of recipients. Especially when creating readiness for change, reducing uncertainty and building commitment for change (Armenakis, Harris, & Mossholder, 1993; Klein, 1994).
In the context of change, communication can be seen as a way to inform, involve, and motivate change agents and change recipients to participate in the change process wholeheartedly (Caldwell, 1993). As a result readiness is created and the organization aims to embrace change and the resistance is lowered. According to Senior and Swailes (2010) management is effective if
management puts effort in the following six factors: communication, involvement, trust, time, training, and leadership.
Change recipients
Since the process of change involves going from the known to the unknown, it is reasonable to expect employees to react to change (Bovey & Hede, 2001). The reaction of change recipients towards technology has influence on the success of the implementation. Wittig (2012) provides a definition of employees’ reaction to change in terms of resistance and acceptance.
Offenbeek, Boonstra and Seo (2013) developed a framework to explain users’ reactions to change during IS implementation. Instead of putting resistance and acceptance on the same axe, the authors suggest a distinction between acceptance and support. Therefore, both resistance and acceptance can coexist. Support and resistance amplify the extent to which the recipient is supporting or opposing the change and how this is manifested.
Organizational Change in Hospitals
The healthcare sector is experiencing pressures from inside and outside. Innovations in medicine and technologies are changing the healthcare (Tsiknakis et al., 2009). As for hospitals, due to the external environment, they need to change into flexible organizations that are able to offer higher quality services at lower costs. Increasing governmental focus on reducing healthcare costs and these rapid changes in technology development, make it urgent to change (Tsiknakis et al., 2009). Where hospitals leave years of growth, expansion and deep specialisation behind, they now face a period with focus on specialisation and concentration in order to reduce the healthcare costs. Furthermore,
insurance companies gained more power in the last years, which influence the hospitals as well Patients become more informed and should be more empowered, therefore the healthcare is changing from process-centred care toward more patient-centred care (Tsiknakis et al., 2009). Due to these changes in the external environment the fit between the internal and external forces decreases and therefore organizational effectiveness will be diminished. Integration of information will be the key towards decreasing costs within a hospital (Barker, 2011). However, healthcare organizations lack central control and there is a high diversity of practice and the degree of autonomy can bring problems to the surface (Tsiknakis et al., 2009).
Technological change in hospitals
In its broadest sense everything that has to do with enormous load of the possible technologies used in the healthcare sector is defined as eHealth (de Vries, 2014; Parikh & Huniewicz, 2015). Hospitals may call upon ICT for scheduling logistics, patient administration, laboratory information, radiology, pharmacy, nursing, electronic messaging between the hospital and other healthcare actors for communication of clinical and administrative data, and telemedicine and second opinions, in any specialty (Silber, 2005). According to the e-health monitor, a research conducted by Krijgsman et al. (2013), there are some expectations regarding the positive effects of eHealth: 1) improve self-management and organize the sector more effective, 2) improved continuity because of easier information sharing between instances, 3) Higher patient safety. The use of eHealth can improve the quality of care, reduces costs and facilitate patient empowerment (Mevius, 2014).
This paper focuses on the implementation of an integrated EMR. Healthcare providers are often stuck with incomplete information, while 90% of the diagnosis is said to be reliant on patient history (Tsiknakis et al., 2009). Therefore the importance of an integrated EMR is very important. However, the implementation of such large integrated information systems(IS) is not easy. As Tsiknakis et al., (2009) stated: “Organizations reliant on highly professional workers, such as doctors and nurses, requires an in depth analysis of organizational factors that influence implementation”. Effective technology adoption requires adaptation of work practices, reorientation and organizational change.
cases, change of IS in the domain of healthcare is accompanied by organizational changes, often leading to low user satisfaction. These problems are then often attributed to the IT system, suspecting a low fit between IT and user or between IT and task. However, the amount and type of training as well as the level of leadership and management are predictors of success. Integration of departments is hard due to the degree of autonomy and routines of medical specialists that are difficult to replace. This is due to tension between different interests in uniformity and therefore lack of central control. In large profit organizations IT is uniform and centralized.
Change management in Hospitals
It is the role of the change agent to create readiness for change. According to Naranjo-Gil (2007), the top management facilitates the strategic change within a hospital. A hospital’s strategy and
structure will be influenced by the implementation of eHealth (Burnes, 2004). For example, the work of medical specialists within a hospital has always been interpretative, interactive and pragmatic (Aarts & Berg, 2004). Now, the standardization of work processes, as result of eHealth
implementation, to adapt to these systems is hard to achieve (WHO, 2002).
According to research done by Krijgsman et al. (2014) it is important to strengthen the information exchange between management and medical specialists. Inform them about the
possibilities of eHealth. Also it is important to give medical specialists the opportunity to exchange practices already experienced by other medical specialists.
External factors or deliberate interventions will make it a constant and complex task to manage the whole life cycle of an IT system. Management has most of the time positive views towards the implementation and possibilities. During the implementation they face difficulties that were not foreseen (Greenhalgh et al., 2007; Krijgsman et al., 2014). As Weick (2007) observed, the complexity of contemporary health care, combined with the multiple stakeholders and perspectives in large technology initiatives, means that eHealth programs require considerably more time than has been the case to date. Lack of technical support and problems with the technology itself are major problems (e.g. difficulties with internet, difficulties with using ICT during care) (Norman et al., 2006). Change recipients in hospitals
The implementation of eHealth is not a kind of “plug and play” implementation (Krijgsman et al., 2014). The specialists’ professionalism will change; their education will be affected, as well as their continuing professional development; their use of technology and the mix of task they perform (Barker, 2011). There will be a shift from old professionalism to new professionalism, due to different roles and tasks of medical specialists in order to facilitate patient empowerment (Taylor and Hawley, 2010).
support the change (Fitzgerald, 2008; Krijgsman et al., 2014), therefore it is likely that there will be resistance from medical specialists. Due to a lack of technological skills, specialists are not ready to implement the change and therefore emphasizes should be on training of specialists.
Benefits according to the medical specialists are mainly arising if there is higher comfort for the patient or if it delivers better efficiency. Also, ease of use is very important. Most problems however occur when input (Time, effort) is bigger than the output (better healthcare, ease of use, financial rewards). According to Barker (2011) few doctors can refer positive to eHealth and update them with ease with the patient in front of them, without it distracting them or slowing them down.
Specialists were used to routines to be effective and to improve performance (Luecke, 2003). Nowadays it is important that specialists are able to adapt to continuous change (Burnes, 2004; Rieley and Clarkson, 2001), which in this case implies the focus on patient empowerment. New
professionalism reduces the specialists’ autonomy and undermines their expertise knowledge. According to former research by Fitzgerald et al. (2008) there are several benefits experienced by medical specialist regarding the implementation of eHealth. However there are also barriers
experienced, which can be grouped in three categories; (1) getting used to different ways of working, (2) high need for highly motivated employees (e.g. lack of financial rewards) and (3) fear of missing face-to-face contact. Other research implies four categories; (A) There is no financial reward, (B) they have no time to deepen in the new ways of working, (C) laws and regulations are unclear, (D) safety is not guaranteed within the technology and (E) there is lack of technical support (Krijgsman, 2014; Henkemans et al., 2010).
Patient empowerment
However, medical specialists are not the only important stakeholders with regard to the change. The role of patients will be changed as well (Taylor and Hawley, 2010).
The complexity enhanced by technology, could make it harder to understand and to process medical treatment, especially for people with undeveloped computer skills. There are doubts about the effects of eHealth on specific groups within the Dutch population (Horstman, 2014; Westerink & Hutten, 2014; Blanson Henkemans et al., 2010; Westerink & Hutten, 2014; Mevius, 2014; Van der Graaf et al., 2014). The lack of self-management skills for some patients is addressed by former research (Fitzgerald et al., 2008). Westerink and Hutten (2014) argue that the elderly and people with lower income will find some problems with the adaption to patient empowerment. Motivation and eHealth literacy will play an important role in the support/resistance level of patients (Fitzgerald, 2008; Nijman et al., 2014; Norman et al., 2006).
behaviour. It is important to get insight in user needs and attitudes, emphasize must lay on the psychological process (Young et al., 2014). This psychological process will be defined as motivation (Holzinger et al., 2007). People are forced to take care of some tasks, which were first carried out by medical specialists or by a general practitioner. In that way a patient is able to monitor the cognitive, emotional and behavioural reactions towards a good quality of health (Wagner et al., 2001). It is not just a matter of telling people to take responsibility. Goals need to be set by medical specialists. Information, tools, expertise, resources and incentives need to be available to pursue the patients (Barker, 2011).
Research propositions
The implementation of eHealth is not something to “just do” (Krijgsman et al., 2014). Adaptation of technology of the key users should be facilitated to stimulate higher organizational effectiveness. Support of the stakeholders is achieved if the implementation meets the requirements of the
stakeholders. However, change agents’ perspectives differ from change implementers’ perspectives and from change recipients’ perspectives. Concerns and requests that are addressed by stakeholders and the interpretation and responses of management are defined as stakeholder issues (Mitchell et al., 2011; Freeman, 1984; Rowley, 1997). If issues are not addressed misunderstandings of the purpose, goals and benefits can arise mainly during the early phase of the implementation (Langer, & Thorup, 2006). It is the role of the management to create and maintain a climate that minimizes resistant behaviour and encourages support in order to achieve maximum benefits (van offenbeek et al., 2013). As such the following research proposition to guide the empirical study is put forward:
Stakeholder issues have a negative influence on specialists’ adaptation of technology.
The implementation of an Information System is not only an ‘organizational change
management’ situation. Risks of only looking at effective management of stakeholders might as well result in people not motivated enough, not skilled enough, or not allowed to behave in new ways (Markus, 1983). This can result in incomplete systems. Stakeholders are influenced by the beliefs about whether it serves their interests. According to Fitzgerald and Russo (2005) such user reactions may relate to the system itself and to their wider context. User reactions regarding the system itself are defined as perspective on technology. The following proposition is stated to guide the empirical study:
A positive perspective on technology has a positive influence on the degree of specialists’ adaptation of eHealth.
changes in the one will be likely to influence changes in the other. Therefore, management of the specialists is not only important in order to their adaptation to patient empowerment, but this can have an influence on the adaptation of patients to patient empowerment as well. There needs to be a change in the specialists’ way of working (Taylor and Hawley, 2010). The following research proposition is therefore developed:
The degree of specialists’ adaptation has a positive relationship with patients’ adaptation to patient empowerment.
The conceptual framework following from these propositions is provided in the figure below.
Figure 1: Conceptual framework
Methodology
The aim of this study is to provide an initial understanding of the implementation of eHealth. Former research showed some essential barriers with the implementation of different eHealth systems (Norman et al., 2009), however the literature is showing gaps when looking at the influence of hospital management on the adaptation of medical specialists. Conducted for this research is a single case study. Chosen for a case study is because this paper wants to examine how and why the
implementation goes as it does and what is required to get specialists in the intended direction
A qualitative research approach is used during this study. Qualitative research methods facilitate exploration of a phenomenon within its contemporary context using a variety of data sources
(Eisenhardt, 1989; Yin 1989, 1993, 1994; Baxter and Jack 2008). This study is chosen to reveal different perspectives within the hospital and to be able to get some valuable information. As for the fact that this is a specific case in which a lot is unknown, this research is an exploratory research (Blumberg, 2008). By doing an exploratory case study, according to multiple authors, patterns and logic rise from the inductive development of theories (Darke, Shanks, & Broadbent, 1998; Paré, 2004).
Research Design: Case Study
The research is done in a hospital in the east of the Netherlands. This hospital is chosen due to the fact that at the moment of writing this paper, the hospital was starting to implement eHealth, which is the focus of this study. The goal of the study was to follow the implementation of eHealth within a large hospital and with the information known about this hospital it was perfect for my case study.
Currently there are working about 2000 people within the organization. This organization is implementing a new eHealth tool, which has major effects on the daily work of medical specialists. The eHealth tool that is going to be implemented is an integrated EPD system. This integration means that the whole hospital is affected by the new system and that all departments are influenced by it. Not only the medical specialists need to work with it, but also the nurses and the physician assistants. The interviewees are selected based on snowball sampling and therefore the specialisms are not specifically chosen. However, the snowball sampling was based on the one condition that the research was gaining information from different specialisms and from different stakeholder groups.
The hospital was during the interview at the very first start of the implementation. Within the hospital they are currently working with a digital status system and an electronic medication prescribing system. These systems are not integrated. Implementation of the new software will integrate all different departments. This implementation is facing different stakeholders and this research is focusing on the specialists’ adaptation and on the management of the implementation. A special task force is developed to lead the implementation. This task force consists of members of the board, a few people of the ICT-department and few medical specialists. The medical specialists who are members of the task force have taken initiative for the change. In the future the taskforce will be expanded with nurses, physician assistants and patients. The task forces will select in the near future champions, who need to spread the change to the workplace. These champions have to meet certain requirements advised by the people working at EPIC.
Interviews. In this study the data is collected by a case study analysis, using individual semi-structured open-ended interview. Interviews are useful because the respondents are enabled to express their experiences and views in their own terms, as opposed to choosing between certain responses (Kaplan & Maxwell, 2005). It shows the participants perspective as well as the level of conformation towards insights the researcher already has (Blumberg et al., 2008). The interviews consisted of twelve questions (APPENDIX 1). By using introductory questions the interview started (Blumberg, 2008). As for the fact that the respondents were interviewed during the start of the implementation, their daily work before the implementation was first questioned, afterwards there were questions about the phase during the implementation, and at last there were questions about the expectations for the future regarding further implementation of the tool. The duration of the interviews was about 45 minutes till 90 minutes.
Participants. Participants are selected by the use of snowball sampling (Arksey and Knight, 1999). For this sampling the only condition was to gain perspectives from different types of
specialists. It is important that different specialists are interviewed, due to the fact that difference in a specific specialism, can create difference in adaptation of patient empowerment (Krijgsman et al., 2014).
Also multiple perspectives were important for this research, therefore the goal was to get insight in perspectives of different stakeholders and the relations between them. This resulted in one interview with a member of the board, who is now working at the hospital for about two years. Furthermore, one interview with someone of the ICT department who is experienced in the healthcare sector for about 20 years but is working in this specific hospital for 2 years. Furthermore, there were four interviews with medical specialists who are key persons in this implementation project because they are members of the taskforce. Lastly, interviews were taken at seven medical specialists. These specialists are the change recipients and are not as informed as the task force. The specialisms of the eleven specialists are shown in table 1.
The interviewees were asked to participate by the use of e-mail. All responded within one day and agreed to participate. The interviews were face to face and were recorded. At the beginning of the interview anonymity was guaranteed and it was made clear that the interviews were only for the use of this study.
Data Analysis
The analysis of the data is done by the use of inductive coding. Issues raised by interviewees allowed the research to get the information from the data itself, and to emphasize that relevant concepts are highlighted (Hennink et al., 2011). Directly after the interview, it will be transcribed and coded with open codes. Open coding is identifying concepts and discovers the properties and
dimensions of it (Strauss and Corbin, 1990). Right after the interview, the interview was transcribed and the open coding was started. Based on the aim of this study, the open codes were focused on the specific perspective of the interviewee on how the implementation is managed, and on their
expectations regarding the role of patients. The information that was not important for the research was in this way eliminated and the open codes covered the relevant data. By comparing the transcripts with the open codes included, patterns became clear. This is called the axial coding phase in which relationships between open codes were identified. Moving from the one perspective (transcript) to the other showed what parts of information were repeatedly addressed and therefore important
information. Also parts of individual information were addressed because that specific part could be important as well. Finally, to be able to answer the research question, the last step in the coding is selective coding. During this stage concepts will be linked and integrated (Mortelmans, 2009). The coding scheme (Rowlands, 2005) with the resulting codes can be found in the appendix (APPENDIX 2).
Quality criteria
Controllability, reliability, and validity are the quality criteria that provide the basis for inter- subjective agreement (Swanborn, 1996; van Aken et al., 2012; Yin, 2003). To meet the requirements of quality these concepts are used. To ensure controllability the research is described in detail in order to show what steps are taken and why. Also, an interview guide is included in this research. Following an interview guide raises the reliability. This interview guide is attached in Appendix 1. Defining the questions of the interviews in a precise way increased the internal validity.
Findings
Stakeholder issues concerning the implementation are emphasized. As stated in literature immediate stakeholders inside the hospital are the hospital management (change agent), the IS management (Change implementers) and the doctors (Change recipients) (Boonstra et al., 2008). The IS management within this hospital is further defined as ‘the taskforce’. These issues give insight in how different stakeholders perceive the way the implementation is managed, and how this is influencing the adaptation of the specialists. The following four issues will be elaborated: Communication, Involvement, and Trust.
Communication
In this hospital, for the current implementation issues are observed in different types of communication. Issues arose mainly between different levels of the hierarchy. However, issues between different departments on the same hierarchical level are, as shown by the former implementation, very important as well.
Vertical Communication. Although the stakeholders are aware of the fact that communication is important, as indicated by the top-management “Communication is very important, to bring the project to a success”, only two specialists emphasize clear communication from the management towards them. According to one specialist: “I have the feeling that I am heard. But I know that there are a lot of specialists who don’t feel the same way. So, this I maybe thanks to my own initiative”. Indeed, the majority of the specialist expresses negative feeling about the way of communicating by the management, as one specialist stated: “At our department, we currently don’t have the feeling that the top-management is investing in the ideas of our department”. Other specialists support this as well.
While top-management in his turn is suggesting that they communicate clearly and that their door is always open, they imply that feelings of lack of communication are not only their fault “We do the best we can to facilitate communication. Our job is to listen and to regulate that everybody gets his chance of talking. However not everybody gets and accepts this message”. The perspective of the task force is arguing that they are the ones communicating clearly, but that the other parties are not easy to work with. As stated by one medical specialist of the task force: “We keep saying things to the top-management and they are repeating our words, but the question is ‘do they really hear us? Same for the medical specialists, they pretend to listen but their actions show the opposite”. Clearly, there are communication issues between different parties. Striking is that members of the taskforce consists of medical specialists as well as management people, however these groups have not the same
perspective on communication. Therefore it’s hard to communicate clearly between different layers. This lack of communication is affecting other factors, important for effective management, as well. The top-management as well as the taskforce and the medical specialists are all on the same page about the fact that the implementation of the system needs to be bottom-up. As a top manager put it: “It doesn’t work if I invent the wheel. Specialist should take initiative for change, my task is only to make the goals clear”. All the specialists and taskforce members indicated this as well. Stakeholders of the implementation all see the importance of involving the specialists. Though, top-management is not succeeding in communicating this to the organization. As stated by one of the specialist “If I were the management of a hospital, I would do it bottom-up. Again this is a top-down situation”. The way of the implementation is that bad communicated that specialists of different departments are not aware of the fact that his own colleagues are leading persons of the task force and that they initiated the change instead of the top-management. As one specialist puts it ”Mostly, we are a leading department when it comes to changes. We are missing the train now, so there will be no other specialists on the train right now”.
Horizontal Communication. Communication between different departments is very important for the success of this implementation, because it will affect all the departments of the hospital. By integrating the departments, the goal of more Patient-centred healthcare can be accomplished. The last implementation shows that integration can only be facilitated by standardization of some of the work processes; departments need to start working the same way. Due to the different systems at different departments, every department is currently working in their own way. The one department is happy with the current situation, as one specialist put it: “We have a very good system that works for us”. Other departments are not happy with the situation at all, one specialist calls it even unworkable: “Our department is that chaotic that it is almost not workable anymore”. This situation is supported by most of the specialists and is acknowledged by the management as well as by the taskforce; “ I walked through the departments and I saw some departments way more neglected than others” said one of the members of the taskforce.
The fragmented system shows the hazards of lack of communication. It is dangerous in terms of safety, it is unpractical and it keeps the organization from innovating. New changes, such as the implementation of EPIC, are affected by the implementation of this system. Without communication between different departments, an integrated system will never work. The medical specialists are now aware of the importance of an integrated system, but they also fight for their own interests, according to one of the specialists; “We know an integrated system is better and we are willing to change, but we are not willing to go backwards. Our current system is working very good, so we want a good offer”. The problem with this attitude is that every department now has its own way of working and they think they have the best way of working, as a result nothing is working together, and according to one of the specialists; “ Every department thinks they have the best way of operating, so they want to implement it their way. As a result nothing is working together”.
The top-management is pointing at communication problems between departments; “ When a change program crosses the boarders of a department, it goes wrong. They need to look behind the boarders of their department”. This is also noticed by one part of the taskforce and supported in his saying. If departments are communicating they can find the best way, for their patients, to work. Patient-centred care should be the overarching goal of the change, process, interests of the departments should be less important.
Involvement
The implementation of EPIC is not possible when specialists aren’t involved. Stated by the top-management and supported by the taskforce and the medical specialists is the following “I believe in bottom-up, specialists need to be involved for the implementation to be successful”. Though, due to several reasons specialists feel like they are not involved.
Communication. One of these reasons, as elaborated above is the lack of communication about the implementation. This became clear after one specialist indicated that he sees this as a top-down
situation. It even showed that some departments felt that they were left behind. Clearly this specialist is not aware of the fact that other medical specialists initiate the changes made so far, while three of the specialists spoken to are members of the taskforce and therefore highly involved. These specialists seemed even more informed than the top-management themselves.
Time. The second factor influencing the involvement of medical specialists is time. Taking
initiative, as a medical specialist, regarding the implementation means that it is extra work. There is no time to do it during their daily work, because the primary process will continue. From a statement of one of the specialists it can be concluded that the specialists see the importance, but are held back due to this reason: “ We need to be involved but we have no time”. The specialists are not able to invest time, without the investment of management in giving them more time to be involved. From the perspective of the management there is indeed not much time, but if specialists want to be involved they need to take initiative themselves, as he puts it: “I can imagine that a specialists wants to go home at six o’clock, however if they want the change to be designed their way they need to take the initiative themselves”. According to the task force, it should be a combination of both “Both the hospital, as the medical specialists are benefitting from a successful implementation. Top-management needs to invest to create time for the specialist to be involved, and specialist should see that he is also benefitting and needs to stop wining and start taking action”.
Training. Time is also an issue regarding the training of employees. Without the training of the key users, consequences of the implementation are very bad. Therefore the taskforce takes the factor “time” very seriously, as the ICT member of the taskforce says: “We need to take time to make everything workable. Some specialists have to make 3 days in the week available for training”. However the problem is, these specialists will be not able to work in the primary process of healthcare (red. Patient care). This scares other specialists; they are scared that it will harm the safety of their patients. They think that they are not able to take over the process without that specialist. Of course there should be made extra time or extra manpower available, to give everybody the chance to work efficiently with the system.
be willing to change but not when it takes to much time. Especially, because there are no extrinsic rewards. So everything is now leaning on intrinsic motivation of the specialists.
Concluding, involvement of the specialists is important. Failed IT projects can result in bankruptcy. With this specific implementation specialists as well as the task force are afraid of consequences this big if they are not involved. As one specialist of the taskforce puts it: “If the medical specialists are not going in the lead, our hospital will not survive”. As for the fact that the implementation is going to happen, it is of importance to the medical specialists that it goes smoothly otherwise they loose their job. Not everybody is sharing this perspective, as one specialist puts it: “The hospital wants to change, we are a partnership and thus not the hospital, so they better come with a good offer”. Therefore, if the management wants to involve the employees, they need to facilitate time or they need to motivate the specialists to put extra effort in the implementation. As one specialists stated about time: “If they can assure us extra manpower to keep the primary process going, we are willing to change”. Motivation will not be a problem if specialists have feelings of involvement. A bottom-up approach is the solution according to one of the specialists, motivation will then not be a problem, as he argues: “If they take a bottom-up approach, which is now not the case, the change will work. Then the motivation you get without saying”.
Trust
Within this hospital issues of trust are found between different stakeholders. These trust issues can be assigned to a few striking conditions.
Confidence. First of all, confidence from specialists in the ability of the management and ICT is an issue. The expertise of the medical specialists is that far away from the expertise of the
top-management and ICT department that specialists have a sceptic view towards the top-top-management; “ The management doesn’t understand our way of working, therefore those are management people”. These issues of trust have different outcomes on the specialists. While some specialists show resistance due to mistrust towards the new implementation, as showed by the following words of a specialist; “If this is an idea of the management again, I rest my case. I have feelings of mistrust towards them”, others are taking action to get a grip on the situation and become members of the taskforce. What is special to this is that within the taskforce there are issues of mistrust. As one specialists of the taskforce puts it: “There is no guidance. At one moment they decide this, while at the other moment they decide something else. The actions of the top-management are worrying me”.
However if a manager is not aware of these issues (s)he will not be able to do something about this. From the point of view of the ICT department, issues of trust don’t play any role. In fact, they see this from an opposite point, as stated by one member of the ICT department: “ I feel a lot of
implementation of EPIC is supported by a whole EPIC-team. They know that they get support from experts, however this is not clear to the rest of the organization.
Continuity. Even though the top-management and parts of the ICT people are already replaced, the mistakes in the past are clearly not obviated. In fact, problems with continuity at the top-management and the ICT department deteriorate the situation even more argued by one of the members of the task force: “ If something went wrong in the past, employees will always point finger at everybody taking the new position”. Within this hospital as management it is hard to create feelings of trust among the specialists. Specialists feel like they are the bosses of the hospital. They don’t like to listen to people who are staying for a few years and then listen to the next person who wants to change things. Most of the time the career of a specialists is within the same hospital, while management is changing. Key to successful management, according to the specialists, is to invest in relations with the specialists. As one specialist puts it: “ There is no continuity at the top-management, they are replaced once in the five years and then the next person comes that thinks he/she can change everything”.
View on technology
Adaptation towards technology of the medical specialist is very important. Issues due to different perspectives regarding the implementation are addressed above. However there are also perceived issues regarding the new system itself.
The software of EPIC is not always implemented with the same ease of use as stated by the company itself can be concluded from the stories heard by the specialists within this hospital. As one specialist puts it; “The things I heard about EPIC till now, from former implementations, are not making me enthusiastic to work with it. It is said to be even harder to learn than the system we currently have”. The specialists, who have seen the system in real life, are positive about the usability and possibilities of the system. They have experienced themselves how easy to use the system is, as one member of the implementation team puts it: “We have been to America and experienced the features ourselves, it is a wonderful system that was easy to use”. These people are supporting the change. For the other specialists, the expectations on the system itself are based on others experience.
specialists puts it: “I don’t like to do administrative work, the love for my work is diminished since the digitalizing. EPIC means probably staring even longer at the screen, I don’t like that”.
The younger employees are not afraid for technical changes; this will not be an expected problem for them. However, they focus on problems regarding the time they need to invest in the system. As one specialist puts it: “I am not afraid for technological change, however I am not willing to invest in meetings during my daily work. Because that would mean that I have less time for my patients”.
The implementation of the current system has its influence on the view on EPIC. Many employees saw the former implementation as incomplete. As one specialist puts it: “The current system is that bad, I can’t imagine that people are not willing to change”. Regarding the
incompleteness of the current system, there was not enough time to master the features of the system. Due to this incompleteness, many specialists are facing technical issues at the moment. Efficiency of most of the specialists lowered, as stated by one of the specialist: “I think it is hard to work with the system. Training was facilitated, but that was just one afternoon. We were not able afterwards to use the system effectively”. The implementation was rushed and implemented when the organization was not ready for the change. They are scared that the same issues will arise during the EPIC
implementation.
However there are also specialists that are content with the system they use. According to one of the specialists they feel distrust in the fact that is EPIC has the possibility to replace their working system from the first moment. As a result they are scared that their patient care, which is the most important, is risking dangers. As he puts it: “I have my doubts about the fact that EPIC can replace our system from the moment t=0. This is scaring me, because this can have deadly consequences”. In order to get one integrated system, standardization is needed. As one member of the taskforce puts it “ Due to characteristics within this hospital, our biggest challenge is convincing specialists to accept a certain degree of standardization”. They are used to their own ways of working and they all think they have the best way of working. Specialists are not eager giving in their attitudes and
behaviour; they are all stubborn, but especially the older specialists are stubborn. They are facing efficiency problems by adapting towards technology; therefore they are scared that a new system will make it even more difficult. As one specialists puts it: “I am working with the system my why, that works for me and therefore I finally got some of my efficiency back. Now I have to change again and it will take a lot of time to make the new system my own again”.
Patients’ adaptation
Standardization is not the only change in the way of working. The introduction of EPIC is introducing a patient portal in which patients are able to look in their own medical record. This is elaborated below.
medical specialists will shift towards a more supporting role, as one specialist of the taskforce puts it: “The specialist gets a more advocating role in the healthcare process. We are there to elaborate the possible treatments and to advice, not to decide”. EPIC can stimulate patient empowerment due to its capability of facilitating self-measurement options and the patient portal in which patients keep track of their own electronic health report. As one member of the top-management puts it: “ We are
designing EPIC in a way that in a few years a patient portal is included in the system”. The specialists are mostly supporting the stimulation of patient empowerment by the use of EPIC. They think it is useful for patients to be able to look in their medical record whenever they want, this is illustrated by the following words: “ I think it would be good to empower the patients. When a patient sits in front of me, and he walks out of my room most of them are already forgotten 80% of the information I just shared with them”.
Though there are some issues addressed that need to be further investigated before this patient portal can be successfully implemented.
Most of the specialists show their doubts about the ability of patients. The specialists can have a role in stimulating the patients towards better adaptation of eHealth. For the ability of patients it is important to make things easy and visible: “One way to help the less developed is to make things visual. If we are talking to them during a consult they forget almost everything. By making it visual they will remember it better”. Though, addressed by one of the specialists is the danger of the well developed people who think they understand it, as het puts it: “Even if you are developed, you have not the experience a specialist has”.
Other specialists are focussing on the wishes of patients. They imply that not enough research is done regarding the wishes of patients. This is supported by the top-management. Specialists are therefore a bit reserved regarding enthusiasm about the patient portal, as a specialist stated: “I don’t know about the wishes, so they better first look into that before we are all getting ready to empower the patient”. Though for people who are not motivated to be empowered specialists can have a role to motivate them. By taking a less directive attitude, as a medical specialist, and taking a more
advocating role will improve the efficiency of the healthcare, according to one of the specialists: “If you are directive as a specialist, you won’t stimulate your patient to take initiative. Therefore the specialists should take a very open and transparent role”. Multiple specialists support this.
Discussion
First objective was to find out what is influencing specialists’ adaptation. Previous research showed that issues addressed due to different perspectives of stakeholders during organizational change could influence the success of the change. This research explored the issues addressed by stakeholders within a specific hospital and tried to explain the how these issues are affecting the way management of the implementation is perceived within the organization.
Main issues arising from the different perspectives are communication, involvement, and trust. Findings on communication can be divided in two types of communication 1) vertical communication and 2) horizontal communication. Findings show that those who perceive low communication show more resistance than others. Information about the implementation plan, for example information about the features and about the way of implementing, should be communicated. This is in line with (Cawsey et al., 2012) who argues that informing employees is an important task for change managers. Within this hospital different perspectives of the stakeholders on vertical communication diminishes specialists’ adaptation due to lack of knowledge about the implementation. They don’t know what to expect and therefore are showing resistance.
Furthermore, horizontal communication is also found to be important for implementing an integrated information system. Former implementation shows the hazards of lack of horizontal
communication; fragmented departments. Regarding the responsibilities of horizontal communication, a stakeholder issue can be identified. Management is pointing towards responsibilities of the
departments while the departments are pointing at the management by blaming them for lack of central control. As can be derived from literature Kanter (1983) argues that an integrative culture should be organized by top-management. Also Tsiknakis et al. (2009) is emphasizing the lack of central control as a reason for problems.
The findings are supporting the view on the importance of communication by management elaborated by multiple authors (Senior &Swailes, 2010; Armekanis et al., 1993; Klein, 1994). However the management is not aware of this lack of communication, so they cannot effectively manage the change based on the expectations of the stakeholders. The fact that this is an issue is in line with literature (Langer, & Thorup, 2006).
Perceived involvement is important for the implementation of eHealth. Although everybody in the hospital is aware of that, they all have their own perspective on the degree of involvement. Involvement of specialists within this hospital is influenced by three factors: 1) way of
Within this hospital there is a chronic time deficiency. The specialists are emphasizing the fact that management needs to make time available for them, while the hospital management thinks that specialists should take the initiative themselves. The taskforce is fighting for something in between. Literature is focusing on the importance of time while implementing an information system, as Senior and Swailes (2010) indicated that management should invest in time. The primary process always continues within a hospital. While managers have 100% time to invest and think about the change, the specialists have to take initiative in their spare time. Specialists and management argue that if
specialists are not involved consequences can be very big. This is in line with existing theory (Beckhard and Harris, 1987; Lewin, 1947).
Lastly, training takes a lot of time. Estimated by the management is an investment of 3 days per week for the specialists that need to become the advocates of the system (champions). Problem is that there are no specialists willing or able to invest that much time in the implementation. The fact that the system takes this much time and training is influencing the resistance of specialists. They showed their expectations about the implementation and showed that it worries them and that they are therefore are less enthusiastic. This is in line with the importance Rogers (2003) indicated of triability; ease of practice.
As can be concluded from the findings, if specialists feel not involved they show more resistance towards the change. This is supported by literature (Wittig, 2012). It is important that specialists perceive the way this change is managed as a bottom-up approach. By investing in communication, training and facilitating time specialists will feel more involved, however management should be aware of this. This is in line with Senior and Swailes (2010), who argue that change is effectively managed if effort is put into involvement.
The next stakeholder issue is trust. A few factors are influencing the trust levels between different stakeholders. First, lack of confidence in the ICT department and the management department. This lack of confidence is partly based on the fact that the expertise of medical specialists is very special, and they are scared that management and ICT people will never understand their way of working.
Furthermore, the fact that there is no continuity in the management of a hospital makes is hard for them to become the boss. Mistakes in the past are projected on the management even when they had nothing to do with former implementations and in order to break through this pattern it is important for the top-management to be carried by the workforce, but they need to invest in that.
The main issues addressed by the stakeholders, are indicated in literature as important factors for managing change effectively (Senior and Swailes, 2010). What is striking is that although
management of this hospital is aware of the importance of these factors, but that the ones managing the change are not aware of certain issues. They are clearly not aware how their employees perceive their way of management. Literature is supporting the importance of stakeholder management (Boonstra et al., 2008), and the beliefs about whether change serves stakeholders interest.
The second objective was focusing on the issues regarding the system itself. Stories about the implementation of EPIC in other hospitals made that the specialists doubt the ease of use of the system. The lack of perceived usefulness of the system has a negative influence on the adaptation of the specialist in this hospital, . The importance of perceived usefulness is supported by theory (Venkatresh et al., 2003). Also within this hospital age and experience are moderating the perceived usefulness. Older and more experienced employees are more resistant to the change, as also indicated by the UTAUT model of Venkatresh et al. (2003).
Furthermore, the former implementation has two outcomes on the specialists; 1) the current situation is that bad that people are willing to change. 2) The current situation is good, and the expectations regarding the new system are equal to their current system, so people are less willing to change. These contradicting results are evaluated based on extra literature. The role negative feelings about the new system plays, is supported by Lapointe and Rivard (2005). They suggest that perceived threats have an influence on the behaviour of change recipients. However, according to Machiavelli (Burnes, 2014) adaptation towards technology is bigger if people are dissatisfied with the current situation. They are more willing to consider alternatives. Although that more specialists were willing to change, the degree of resistance the people who were less willing to change was bigger. Problem is that specialist have high power to block changes, so that this is dangerous for the implementation. This view is supported by Taylor and Hawley (2010).
The way of working changes for the specialists, and preparing them for a certain form of
standardization will is indicated at one of the hardest challenge in this hospital. Most of the specialists are not willing to change their way of working, and to give in to other departments. This is also indicated by literature (Fitzgerald, 2008; Krijgsman et al., 2014).
The second objective of this study was to find out how the perceived adaptation of patients to patient empowerment by using eHealth can be influenced by the specialists’ adaptation. The expectations of important stakeholders within this hospital are elaborated below.
care. This is supported by literature (Fitzgerald, 2008; Norman et al., 2006). Specialists expect that they can influence patients’ adaptation by visualizing things. They emphasize the fact that they should not take a directive style of approaching the patient, but more an advocating role. This is in literature indicated as new professionalism (Taylor and Hawley, 2010).
According to the hospital management these issues are too big to be completely solved by medical specialists. They argue the that these issues could be defined as a social problem, so
specialists are not the ones that need to take all responsibility for this. As for this fact, they imply the importance of further research regarding the wishes and abilities. This is supported by literature (Horstman, 2014).
This paper was emphasizing the influence of specialists’ adaptation on the expected patients’ adaptation. However, based on the finding there can be concluded that in addition the expectations about patients’ adaptation is influencing specialists adaptation. This can be declared by the focus on patient-centred care (Tsiknakis, 2009). The fact that the patient will become empowered, it is important that there abilities and there own wishes are addressed. Specialists are there to facilitate quality of care, so their motivation will be influenced by the wishes and abilities of patients.
Limitations And Future Research
Some limitations of this research should be discussed. First of all, the study is done in one particular organization. This organization is at the very first start of the implementation, the specific software was only chosen two weeks before the interviews. It is hard to generalize this study, because it only focuses on one organization. However, the aim of this study was to find out the issues
addressed in a specific hospital.
Second, the interviewees were only interviewed once. Therefore one specific moment within the huge change process is taken. Perspectives of stakeholders could change over time. Future research could focus on addressing the perspectives at different moments during the implementation. This would heighten the completeness of the study.
Third, one researcher only coded the interviews. Therefore a researcher bias cannot be excluded and this could influence the results. When looking at the results this bias should be kept in mind.
Lastly, only the perspective of the specialists and managers is addressed within this research. However, specialists are not the only key users of the system. Nurses will end up using the system, physician assistants are also going to use it and patients are probably also going to use the system. The view of other users involved might be influencing the implementation as well. Including the
Therefore the wishes and abilities of the patient should be further investigated. Interactions between these groups might be interesting as well.
Conclusion
Concluding, this study has found that in order to stimulate organizational effectiveness change agents need to focus on issues, regarding the management of the implementation and regarding features of the system itself. Important is to look at different perspectives of stakeholders. How things are perceived and expected within a hospital are of that importance that lack of managing stakeholder issues have a negative influence on the support for technology by medical specialists. Perceived vertical communication is key in the successful management of the interactions between the people. Also, top-management needs to show central control to facilitate horizontal communication between change recipients and as such facilitate integration.
The change managers are emphasizing the importance of involvement of employees and therefore preferring a bottom-up approach. However, issues arise if employees perceive the project as top-down. Due to lack of time they are not motivated to take initiative of involving themselves and without clear communication they will not be aware of the way this system is going to be implemented. Issues of confidence are keeping the organization from being as effective as it could be, because attitudes are harder to turn positive if there is not much trust from the recipients towards the change agents and the change implementers. There is no trust in the expertise and due to historical events some people feel even mistrust.
If management is not aware of issues addressed by different stakeholders; this can have large negative consequences on organizational effectiveness and as such it is important to focus on how employees perceive the way the implementation is managed.
There are also features of the system itself influencing change recipients reactions towards the implementation of EPIC. Therefore, not only should be looked at the problems at organizational change level, but also pay attention to the technological issues to increase organizational effectiveness.
As for the focus on patient empowerment, from a perspective of the specialists and the
management a lot of research needs to be done regarding the abilities and motivation of specialists. Specialists can influence patients till a certain degree by adapting their attitude and making
References
Aarts, J. & Berg, M. (2004). A tale of two hospitals: a sociotechnical appraisal of the introduction of computerized physician order entry in two Dutch hospitals. Medische Info, 11(2), 999-1002. Armenakis, A. A., Harris, S. G., & Mossholder, K. W. (1993). Creating readiness for organizational
change. Human Relations, 46(6), 681–703
Arksey, H., & Knight, P. T. (1999). Interviewing for social scientists: An introductory resource with examples. Sage.
Badir, M. Grootschalige hervormingen zorgstelsel in 2015.
https://economie.rabobank.com/publicaties/2014/september/grootschalige-hervormingen-zorgstelsel-in-2015/. 2014, 16 Sept.
Barker, R. (2011). 2030 The future of medicine; avoiding a medical meltdown. New York: Oxford university press.
Baxter, P., & Jack, S. (2008). Qualitative case study methodology: Study design and implementation for novice researchers. The qualitative report, 13(4), 544-559.
Beckhard, R., & Harris, R.T. (1987). Organizational transitions, managing change. Reading: Addison-Wesley.
Blanson Henkemans, O. A., Molema, J. J. W., Franck, E. J. H., & Otten, W. (2010). Zelfmanagement als arbeidsbesparende innovatie in de zorg (No. P&Z 2010.017). TNO.
Blumberg, B., Cooper, D.R., & Schindler, P.S. (2008). Business research methods. McGraw-Hill Education: Berkshire.
Boonstra, A., & de Vries, J. (2008). Managing stakeholders around inter-organizational systems: A diagnostic approach. The Journal of Strategic Information Systems, 17(3), 190-201.
Burnes, B. (2004). Managing change: A strategic approach to organisational dynamics. Pearson Education: New York.
Burnes, B. (2014). Managing change (6th ed.). Pearson education: Harlow.
Cawsey, T. F., Deszca, G., & Ingols, C. (2012). Organizational change: An action-oriented toolkit. Sage: London.
Centraal Bureau Statistiek. Gezondheid aandoeningen beperkingen; persoonskenmerken.
http://statline.cbs.nl/StatWeb/publication/?VW=T&DM=SLNL&PA=81173NED&D1=2%2c5-8%2c24-30&D2=0-39&D3=0&D4=l&HD=130129-1618&HDR=G3%2cG2%2cT&STB=G1. 2014, 30 June.
Commision of social determinants of health. (2008). Closing the gap in a generation; Health equity through action on the social determinants of health. World health organization.
Cook, J., & Wall, T. (1980). New work attitude measures of trust, organizational commitment and personal need non-fulfillment. Journal of occupational psychology, 53(1), 39-52.
Darke, P., Shanks, G., & Broadbent, M. (1998). Successfully completing case study research: combining rigour, relevance and pragmatism. Information Systems Journal, 8 (4), 273-289. Davis, F. D. (1989). Perceived usefulness, perceived ease of use, and user acceptance of information
technology. MIS quarterly, 319-340.
DeSanctis, G., & Courtney, J. F. (1983). Toward friendly user MIS implementation. Communications of the ACM, 26(10), 732-738.
EPIC software. www.epic.com. (2014).
Eisenhardt, K. M. (1989). Making fast strategic decisions in high-velocity environments. Academy of Management journal, 32(3), 543-576.
