Innovation and Sustainability in the National Implementations of

e-Health: an International Perspective on the Role of

Stakeholders

Dr. Rasa Rotomskiene Mykolas Romeris University, Vilnius, Lithuania

STS Roundtable, 2-5 October, 2013 Boston

This research was partly funded by the European Social Fund under the Global Grant measure under the Project „Integrated Transformations of eHealth Development: the Perspective of Stakeholder Networks“.

The main statement of this research

Stakeholder engagement does create the conditions under which national programmes for the introduction of ICT in healthcare sector lead to improvement and innovation in patient care and to sustainability of organisational change.

Main research object

The national process of ICT implementation in healthcare sector and the strategies used for related changes to be transferred and embedded within a workplace level (a comparative analysis of the UK (English and Welsh) experience).

Main focus of this research:

• to deliver new insights in relation to the national delivery of eHealth (integrated information systems in the healthcare sector); and

• explaining the conditions under which national programmes for introduction of ICT lead (or fail to lead) to improvement and innovation in patient care and to sustainability of organisational change.

Key findings:• ICT implementation in healthcare is more socio-

organisational process than a technical one;• patient-focused approaches of healthcare delivery require

changes in work organisation and in an overall delivery of healthcare services;

• stakeholder engagement in the process of ICT implementation in healthcare has multi-dimensional effects and can offer the potential to improve change effectiveness and sustainability;

• the way stakeholder engagement is undertaken has an ultimate role for achieving innovation in patient care and sustainability of organisational change.

Relevance of the research (1)

• growing importance of ICT in human life including public policy domains and the delivery of public services.

Relevance of the research (2)

• Nationally integrated eHealth infrastructure and information systems are now viewed as key enablers for safe, efficient, high quality, patient-centred and seamlessly delivered healthcare.

Relevance of the research (3)

• yet high failure rates of complex ICT projects often lead to wasted public finance investments and failed processes in a highly risk-sensitive environment such as healthcare.

Relevance of the research (4)

• practitioners and academics alike still know little about what mechanisms are effective and which factors influence IS process innovations.

Relevance of the research (5)

• this research extends the growing knowledge of the new direction of IS research with its new and empirically grounded insights on the importance that the stakeholders can play in the (national) processes of eHealth developments.

Findings from the case studies: England

The implementation process (key features leading to failure):- A top-down change implementation approach;- A technocratic view towards ICT-led organisational change;- Unbalanced power of large IT suppliers and management consultants and the NHS;- ‘Big bang’ approach / ‘Rip and replace’ strategy; and- Lack of stakeholder engagement.

Key obstacles: England• Delivered IS were difficult or not possible to use;• Resistance to change by the staff in the NHS;• Lack of local change ownership and commitment by the stakeholders;• Lack of real expectations and deadlines;• IT suppliers trying to hide their difficulties;• Hindered conditions to become an ‘intelligent client’;• The process is led by large IT companies rather than the needs of the

NHS;• Disappearing locally accumulated knowledge and skills;• Hindered NHS’ capabilities to innovate;• Service fragmentation instead of cooperation / integration;• IT failures hurting patient care;• No value for money.

Findings from the case studies: Wales

The implementation process (key features leading to success):

•A bottom-up incremental change implementation approach, where the national programme (the national coordinating body) works as a change management organisation providing a platform for stakeholder cooperation;•Multi-level organisational communication with the NHS Wales and stakeholder engagement;•An extensive involvement of end users into the delivery of service improvement projects (path-finder pilot projects).

Findings from Wales: the contribution stakeholder engagement can make:

• stakeholder engagement improves change communication;• improves change receptivity;• increases change ownership / commitment towards change;• improves internal cooperation;• increases trust;• enables crossing organisational boundaries;• creates conditions for organisational learning;• contributes to cooperation / quality of healthcare;• contributes towards sustainability of achieved changes in

healthcare delivery.

Diagram 1. The Conceptual framework of the national eHealth development

Technical deployment of ICTs & Stakeholder engagement

Management of organisational change & Stakeholder engagement

Stakeholder engagement (stakeholder management tool & nature of response; ladder of stakeholder engagement (Friedman & Miles, 2006: 162)

 

12. Stakeholder control

 

11. Delegated power

 

10. Partnership

 

9. Collaboration

 

8. Involvement

 

7. Negotiation

 

6. Consultation

 

5. Placation

 

4. Explaining

 

3. Informing

 

2. Therapy

 

1. Manipulation

Majority representation of stakeholders in decision-making process

Minority representation of stakeholders in decision-making process

Jodint decision-making power over specific projects

Some decision-making power afforded to stakeholders over specific projects

Stakeholders provide conditional support; it conditions are not met support is removed. The organization decides the extent of conformity

Organization has the right to decide. Stakeholders can advice. 

Appease the stakeholder

Stakeholders can hear and be heard, but have no assurance of being heeded by the organization

Educate stakeholders

Educate stakeholders

„Cure“ stakeholders of their ignorance and preconceived beliefs

„Misleading“ stakeholders, attempting to change stakeholder expectations

Multi-way dialogue, e.g. community projects

 

Multi-way dialogue, e.g. board representation

 

Multi-way dialogue, e.g. joint ventures

Multi-way dialogue, e.g. strategic alliance

Multi-way dialogue, e.g. constructive dialogue

Multi-way dialogue, e.g. reactive: bargaining

Two-way dialogue, e.g. questionnaires, interviews, focus groups, task forces, 

advisory panels

Two-way dialogue, e.g. workshops

One-way dialogue, e.g. verified corporate social reports

One-way dialogue, e.g. briefing sessions, leaflets, magazines, newsletters, 

green glossy social corporate reports, or other publications

Theoretical research results (in brief)

The research has identified the link between the stakeholder engagement and innovation and sustainability in patient care and organisational change in relation to the national eHealth development processes and identified the reasons why this happens.

Recommendations for practitioners:• viewing stakeholders (first of all the end user) as a valuable

resource; • involving clinicians and especially the end users’ of planned

health information systems at the outset of the service improvement projects,

• undertake an incremental implementation process with an extensive multi-dimensional stakeholder engagement (taking into account the width and multi-level nature of the institutional context of a national health service) at every stage of agreeing eHealth national implementation strategy and undertaking service improvement projects,

• facilitating stakeholder (user) empowering and organisational learning in overall, but retaining control over the entire implementation process.

Key findings (1):1. As revealed by the theory review and the empirical evidence delivered by this research, there are significant limitations in current IS research:•for a long time there was an over-reliance on the functionalist paradigm in IS research, where social process models of IT-induced change have remained rare in the literature;•in this way this piece of research has provided additional new empirically grounded evidence, which in the scientific discussions support the position of IS research aiming to expose the shortcomings of the yet predominant technical/functionalist paradigm and to offer new alternatives corresponding better to the contemporary needs of the society (evolutionary and organisational change models such as ‘integrated socio-technical’ approaches started to emerge emphasizing ‘social learning’ and ‘orchestrated organisational change’).

Key findings (2)2. This piece of research has brought additional evidence that the involvement of stakeholders within clinical contexts of organisational change might have even greater importance than in other sectors. This happens for a number of reasons:•Firstly, underlying causes of power and influence of healthcare organisations are linked to the specifics of ‘professional bureaucracies’ (Mintzberg, 1979) (medical staff, administrative staff, managers or IT specialists and others; hybrid roles (Fitzgerald et al., 2006);•Secondly, the environment and policy context in which healthcare is operating are very complex and involve many challenges, and where the national implementation of eHealth additionally puts its own requirements. Therefore to achieve effective problem solving, it is necessary to involve in the process as many necessary stakeholders as possible.

Key findings (3)3. From the two in-depth empirical case studies new insights in relation to ICT implementation in healthcare sector were revealed:•Evidence was found that innovations in relation to the national processes of eHealth development were or had the potential to become both disruptive and sustaining, but in both cases an additional complexity was added by the multi-level nature of the national process as such and especially the multiplicity of players, their interests and ability (or inability by some) to influence the process or exercise their own power;•eHealth implementations usually call for major changes in the way healthcare has previously been delivered. ‘Patient at the centre’ and ‘patient centred-care’ require an effective working across organisational and professional boundaries.

Key findings (4)4. Empirically grounded findings have provided additional evidence to support and broaden the position of Davidson (2006), aiming to strengthen the aspect of dynamism of the Technological Frames of Reference concept (TFR) (Orlikowski and Gash, 1994, Orlikowski, 2000) as a theory framework through which ICT development and use in organisations can be analysed:•the findings of this research suggest that stakeholder theory in general and stakeholder engagement in particular has the power to integrate both the IT project management and organisational change perspectives of technology-led change, and deliver new insights regarding innovation and organisational change sustainability in healthcare sector: stakeholder engagement has the potential to contribute to change communication, change receptivity, change ownership and commitment towards change, internal (within the healthcare sector) cooperation and trust, as well as to the ability of crossing organisational and professional boundaries, improve organisational learning.

Key findings (4)• contribute to the capacity to innovate, the quality of healthcare and sustainability in organisational change

– the main aspects that were derived from empirical research as being among the main obstacles in the national deployment of eHealth solutions;

• Moreover, by taking an interpretive rather than a positivist stance towards ICT-led organisational change (Orlikowski and Baroudi, 1991, Orlikowski & Yates, 2006, Davidson, 2004), the research suggests that stakeholder engagement highly contributes towards the interpretive process of organisational change. The main suggestion of this research is that multi-level continuous stakeholder engagement is an effective intervention strategy aimed at overcoming incongruence and has the potential to result in frame alignment and improve organisation outcomes. Moreover it also is able to account for a more dynamic perspective of frame change as an ongoing interpretive process, triggered by variety of organisational circumstances in time (Davidson, 2006, Simmon & Lovegrove, 2005);

Key findings (5)5. At the same time, user / stakeholder engagement as such does not always lead to successful project / process outcomes. Certain conditions on how to involve stakeholders to achieve innovation in patient care and sustainability inorganisational have to be met:•Regarding the levels of stakeholder engagement and management identified by Friedman & Miles (2006: 162), levels 9 (collaboration) – 11 (delegated power) are most suitable in relation to the engagement of end users in the national process of eHealth development. •Several aspects were derived from the empirical data, which contribute to a more effective stakeholder engagement in a national process of eHealth development: - such as viewing stakeholders as a valuable resource, - involving clinicians and especially the end users’ of planned health information systems at the outset of the service improvement projects,

Key findings (5)- undertake an incremental implementation process with an extensive multi-dimensional

stakeholder engagement (taking into account the width and multi-level nature of the institutional context of a national health service) at every stage of agreeing eHealth national implementation strategy and undertaking service improvement projects,

- facilitating stakeholder (user) empowering and organisational learning in overall, but retaining control over the entire implementation process.

• The role of the national coordinating body (such as the national programme) mainly should focus on creating a platform of stakeholder interaction and organisational learning for the entire national health service by facilitating internal cooperation, providing strategic direction, reducing risk and dependency on IT suppliers and breaking professional and organisational boundaries by stakeholder empowering, but at the same time retaining control over the process.

Key findings (5)• Only then stakeholder engagement may result improved change

communication, increased change receptivity, change ownership and commitment towards change, internal cooperation and trust, ability to cross organisational and professional boundaries, stakeholder engagement and organisational learning / innovation / quality of healthcare and sustainability in organisational change that actually contribute to the innovation in patient care and sustainability of organisational change and therefore an overall quality of patient care.

THANK YOU FOR YOUR ATTENTION

Dr. Rasa RotomskieneMykolas Romeris University, Vilnius, Lithuania

E-mail: rjuciute@mruni.euPhone: +370 612 48 391

This research was partly funded by the European Social Fund under the Global Grant measure under the Project „Integrated Transformations of eHealth Development: the Perspective of Stakeholder Networks“.