Elsevier

Technovation

Volume 26, Issue 3, March 2006, Pages 396-406
Technovation

Implementing complex innovations in fluid multi-stakeholder environments: Experiences of ‘telecare’

https://doi.org/10.1016/j.technovation.2005.06.010Get rights and content

Abstract

‘Telecare’ is the use of information and communication technology to facilitate health and social care delivery to individuals in their own homes. Governments around the world are seeking to introduce telecare partly to help address the challenges posed by an ageing society. Telecare is inherently complex to implement and operate because it involves combination of technological and organisational innovation in an environment of diverse stakeholders.

Using research on two telecare schemes in the UK, the paper explores the way project complexity, organisational context and project management approach interacted during the planning and implementation phases. The paper discusses how insights from research in related areas, including medical technology and service sector innovation in general, could help to explain why mainstream telecare delivery has been difficult and draws conclusions on the role of project management in the implementation of innovation.

Introduction

Faced by rising demand for healthcare and health system capacity constraints, governments and care providers are increasingly turning towards information and communications technology (ICT) to help support and enhance existing services. Moves towards ICT enabled care have also been stimulated by innovation in various underpinning technologies—sensors, information processing, user interfaces—and by the falling costs and rising availability of fixed and mobile telecommunications.

The subject of this paper is the implementation of one specific innovation, telecare. We define this in more detail below; briefly, telecare is a form of ICT-assisted care provision. It involves the use of sensors within people's homes or worn on their bodies, connected to a monitoring centre and then to a response service. This both provides an ‘electronic security blanket’ for those at risk of medical or other physical risk and more continuous monitoring to allow the early detection of changes in an individual's condition.

Many countries are seeking to introduce telecare, but while the technology is largely proven, service development is immature. Its potential benefits are recognised in health policy, but there are few examples of sustained, routine service delivery. The numerous small-scale trials and pilot projects have generally failed to move towards more mainstream deployment.

This immaturity makes research into the technology and innovation management processes involved in telecare implementation and service provision challenging. The strategies or business models of potential service providers are either undeveloped or unproven, customer needs are not clearly expressed and there are no ‘brand names.’ Porter (1998: 215) has noted the difficulties in conducting research on strategy formulation in emerging industries where ‘there are no rules of the game.’ There are additional problems in the case of telecare because of the particular challenges in conducting research on innovation in health service delivery, where interventions tend to be ‘diffuse, complex and difficult to define’ (Fulop et al., 2001: 10). This not only makes it more difficult to implement the innovation and evaluate its effects (controlled trials are often unfeasible), but also presents special challenges for the study of the implementation process. The organisational context within which the innovation has been introduced becomes important and has to be considered.

Our discussion on telecare adoption is grounded in existing research on the influences on the implementation of technology-based innovation in services in general and telemedicine and medical technology in particular. The two case studies presented in this paper are therefore exploratory and our approach is largely inductive. By comparing examples of two different project-based telecare interventions, both carried out in the same health authority with some overlap of personnel, we are seeking to shed light on the microprocesses of organisational change (Tsoukas and Chia, 2002).

In Section 2, we define our use of the term ‘telecare’ and distinguish ‘telecare’ from ‘telemedicine’. This distinction allows us to draw attention to some important characteristics of forms of remote health and social care delivery which shape their implementation. We then discuss how insights from studies in related areas—the implementation of telemedicine in particular and service sector innovation more generally—could help to explain why mainstream telecare delivery has been difficult. Section 3 describes the two case studies, their context and their implementation histories. This is followed by a discussion on the extent to which the factors identified in other research can explain the observations in the case studies. Finally, we draw conclusions on the role of project management in the implementation of telecare.

Section snippets

Definition: telecare or telemedicine?

One problem for researchers and practitioners in this field is the loose terminology (Nagendran et al., 2000)—‘telecare’, ‘telehealthcare’, ‘telemonitoring’ and ‘telemedicine’ are all used interchangeably, sometimes within the same document (e.g. EC, 2003 or Fujimoto et al., 2000), and have different meanings to different people. All these terms describe the remote delivery of health and social care using ICT. We define telecare as a set of services bringing care directly to the end-user. It

Barriers to the implementation of innovation in care delivery

Most existing research on technological innovation in healthcare has focused on the adoption of medical devices and associated procedures (e.g. Edmondson et al., 2001) or telemedicine (e.g. Grigsby et al., 2002). There has been very little work on the introduction of telecare. However, pointers from this research can be supplemented from research on innovation in other service industries to identify five key areas which might influence the adoption of telecare into mainstream services.

Research approach

This paper presents two case studies of telecare implementation projects in order to explore the relative significance in each of the factors described above. Each project was implemented in the same local health authority, at the same time and shared some personnel. The target population of each project was different, but the basic telecare model was the same—home monitoring of vulnerable individuals with a response service in the event of a problem.

One scheme (‘Columba’) combined short-term

Case study 1: telecare plus intermediate care

Columba is an intermediate care and telecare scheme developed jointly by a local social services department and health authority in north west Surrey, near London. Its overall aim is to provide an alternative to residential care for frail older people discharged from hospital, by allowing them to remain in their own homes following a period of short-term intensive residential rehabilitation. A key objective is to ensure that patients return home from hospital faster and are not re-admitted

Case study 2: home COPD monitoring and response

The second case study involves a telecare service aimed specifically at supporting patients suffering from COPD. The proposed project was also located in north west Surrey and there was some overlap in personnel with the Columba scheme. The project was designed to allow patients to remain in their home and through regular monitoring4

Discussion

We have outlined above how existing research on telemedicine implementation, on the adoption of medical technologies and on technology-based innovation in service industries has highlighted some possible influences on the implementation telecare. We have also suggested that the complexity of care delivery makes careful project management particularly important during the project conception, design and implementation phases, and later, during the initial stages of operation. We will now discuss

Conclusions

Our case studies of two telecare schemes illustrate how a combination of complexity in local care service delivery and the evolving policy context influenced both the planning and implementation of an innovation. During the implementation phase of each the external environment underwent significant changes: primary care delivery was fundamentally reorganised with the introduction of primary care trusts, the social services department was reorganised and—with particular relevance for the COPD

Acknowledgements

Part of this work was funded by the EPSRC's Integrated Healthcare Technologies programme. We thank colleagues in our project partners and the project advisory group for their help and advice. This paper was written with support from the EPSRC IMRC, based at the Tanaka Business School.

James Barlow holds a Chair in Technology and Innovation Management at the Tanaka Business School, Imperial College. He is deputy director of the Innovation Studies Centre and leads a research group on the impact of technology on healthcare delivery. His research interests include the structural and organisational challenges to the mainstream adoption of innovation, the relationship between policy, evidence and innovation, and the use of simulation modelling to investigate the system-wide

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    James Barlow holds a Chair in Technology and Innovation Management at the Tanaka Business School, Imperial College. He is deputy director of the Innovation Studies Centre and leads a research group on the impact of technology on healthcare delivery. His research interests include the structural and organisational challenges to the mainstream adoption of innovation, the relationship between policy, evidence and innovation, and the use of simulation modelling to investigate the system-wide impacts of innovation.

    Steffen Bayer is a Research Fellow at the Tanaka Business School, Imperial College. He is exploring the impact of technological innovation in healthcare delivery at the organisational and systemic level.

    Richard Curry is an Industrial Fellow at the Tanaka Business School, Imperial College. He is also a telecare advisor to a primary care trust and manager for a Department of Health programme on information and communication technology in healthcare.

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