ELDERLY HEALTHCARE, COLLABORATION AND ICT

Transcription

1 V I N N O V A R E P O R T V R : 0 5 ELDERLY HEALTHCARE, COLLABORATION AND ICT - enabling the Benefits of an enabling Technology Final Report N I L S - G Ö R A N O L V E & V I V I A N V I M A R L U N D - L I N K Ö P I N G U N I V E R S I T Y

2 Title/Titel: Elderly Healthcare, Collaboration and ICT - enabling the Benefits of an enabling Technology Author/Författare: Nils-Göran Olve & Vivian Vimarlund - Linköping University Series/Serie: VINNOVA Report VR 2006:05 ISBN: ISSN: Published/Utgiven: June/Juni 2006 Publisher/ Utgivare: VINNOVA - Swedish Governmental Agency for Innovation Systems / Verket för Innovatonssystem VINNOVA Case No/ Diarienr: About VINNOVA VINNOVA, the Swedish Governmental Agency for Innovation Systems, integrates research and development in technology, transport, communication and working life. VINNOVA s mission is to promote sustainable growth by developing effective innovation systems and funding problem-oriented research. Through its activities in this field, VINNOVA aims to make a significant contribution to Sweden s development into a leading centre of economic growth. The VINNOVA Report series includes external publications and other reports from programmes and projects that have received funding from VINNOVA. Om VINNOVA VINNOVAs uppgift är att främja hållbar tillväxt genom utveckling av effektiva innovationssystem och finansiering av behovsmotiverad forskning. Genom sitt arbete ska VINNOVA tydligt bidra till att Sverige utvecklas till ett ledande tillväxtland. I serien VINNOVA Rapport publiceras externt framtagna rapporter, delrapporter, kunskapssammanställningar, synteser, översikter och strategiskt viktiga arbeten från program och projekt som fått anslag av VINNOVA. Forskning och innovation för hållbar tillväxt. VINNOVA s publications are published at I VINNOVAs publikationsserier redovisar bland andra forskare, utredare och analytiker sina projekt. Publiceringen innebär inte att VINNOVA tar ställning till framförda åsikter, slutsatser och resultat. Undantag är publikationsserien VINNOVA Policy som återger VINNOVAs synpunkter och ställningstaganden. VINNOVAs publikationer finns att beställa, läsa och ladda ner via Tryckta utgåvor av VINNOVA Analys, Forum och Rapport säljs via Fritzes, tel , fax eller order.fritzes@nj.se

3 Elderly healthcare, collaboration and ICT enabling the benefits of an enabling technology Final report, Linköping 2006 Nils-Göran Olve and Vivian Vimarlund This research was made possible through a grant from VINNOVA (Swedish Agency for Innovation Systems). The authors received valuable inspiration from numerous colleagues and practitioners whom we met during our research, all of whom we thank cordially.

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5 Preface This book, Elderly Healthcare, Collaboration and ICT Enabling The Benefits of an Enabling Technology, is mainly the result of a project led by Professor Birger Rapp and supported financially by VINNOVA (Swedish Agency for Innovation systems). The theme is an important research area for the Economic Information Systems Division of the Department of Computer and Information Science at Linköping University. (For further information see Here one question that we consider is how information and communication technology (ICT) may benefit housing, healthcare and social care for the growing elderly population in western countries. This is one of the many challenges addressed in our quest to improve the management of ICT. However, for more than 20 years we at Economic Information Systems have dealt with similar issues in different parts of society, all relating to the role of information systems in enabling organisational change, and the challenge this presents to management in evaluating and implementing new technology and new patterns of behaviour. In this project, the principal authors are Consulting Professor Nils Göran Olve and Associate Professor Vivian Vimarlund. We are also grateful to Professor Fredrik Nilsson and Ph.D student Mattias Persson for their inspiring ideas. In this book we have developed a model for analysis of change when implementing and using ICT to support healthcare services for the elderly population. Any such change will directly and indirectly involve a number of actors, such as healthcare personnel, technology suppliers, owners of commercial apartments or other residences, elderly care centres, and branches of local or central government. Our model provides a framework for identifying organizational preconditions and consequences, and a structure for economic evaluation of the impact of change on key actors. Our model should prove useful in preparations for changes in work and responsibilities in municipalities and regions as well as at housing providers, for example. Without this type of analysis, promising technologies may fail because some actor lacks incentives to make needed investments in competences, technologies, or changed procedures, or does not trust new modes of operation because roles and responsibilities are unclear. With the aid of the model, such potential pitfalls can be recognized earlier and remedied as part of the introduction of new ICT applications. When a new tool is proposed, our model may be used to analyse whether and how it should be introduced. Needed changes in organization, work, and the division of financing and costs should be reviewed and evaluated.

6 So far the ideas presented here have been applied only conceptually and in few cases. Much work remains to be done, and we hope to be able to play an active part in it. Linköping, March 2006 Birger Rapp Professor, Economic Information Systems Computer and Information Science SE Linköping University

7 Contents Purpose... 9 The research This report Home healthcare: challenges and future References Part One: The field of study References Locating ICT s benefits in elderly care Abstract Great expectations Aim and method How ICT is expected to support elderly care: a first-cut analysis Redesign of work processes: a prerequisite for ICT benefits Collaborating requires win-win Improving the likelihood of collaboration Conclusions References Evaluation as multi-actor trade-off a challenge in introducing ICT innovations in the health sector Abstract Introduction and aim Method Optimizing health systems for home healthcare and elderly care An overview of concepts for evaluating IT applications in healthcare Recommended: multi-actor evaluations Illustrations Telemedicine saving travel-related costs Smart cards in the medical sector Decision support systems for physicians Medical monitoring in the home Readiness for catastrophes and telemedicine networks A comparison of the illustrations Concluding thoughts Possible extensions of our analysis Role of the analysis and the analyst References Summary of Part One... 52

8 Part Two: Our proposal Economic analyses for ICT in elderly healthcare questions and challenges Abstract Introduction Method The context Previous economic evaluations An agenda for economic evaluation of ICT in elderly healthcare Issue 1: Specifying what is being evaluated ISSUE 2: Evaluations as input in decision processes ISSUE 3: Analyzing the system ISSUE 4: Combining metrics ISSUE 5: The analyst s role Applying our agenda in practice Conclusions and implications References Designing IT for home healthcare helping social systems achieve their purpose Abstract Introduction and aim Many can pull the brakes but who will initiate motion? Elements of a service system Theoretical approaches Systems theory and principal-agent theory Division of responsibilities and collaboration in networks and imaginary organisations Cost-benefit, cost-utility analysis and decision theory Ethical concerns, critical theory and behavioural/constructionist views of change An overview of the theories Applying the theories Purpose and performance of the system Influencing the system through its preconditions Summary and conclusions References The model step by step Identify the ICT application and the proposal based on it Identify involved actors Specify how major actors will be impacted by the proposal Clarify organisational contingencies Suggested actions Further example of using the model References

9 Part Three: Experiences Information and Communication Technology (ICT) and elderly homecare the Hudiksvall case Abstract Introduction Method The study setting: the Hudiksvall case Results Improving communication through real-time information Work routines, habits and communication patterns The individual level and the importance of being involved Lessons learned Need for multi-stakeholder evaluation Methodological considerations Concluding remarks References An IT tool for healthcare processes: economic effects in managing leg ulcers Abstract Background and aim The VITA Nova Hemma case Multi-actor evaluations Costs and benefits in the Vita Nova case Leg ulcers and the benefits from improved information Identifying benefits Incidence of costs and benefits Separating the impact of new practices from the impact of the process management tool Discussion: performing and using the analysis Specifying what is being evaluated Evaluations as input in decision processes Analyzing the system Combining metrics The analyst s role Conclusions References Summary of Part Three Part Four: Preconditions to move from evolutionary to revolutionary elderly home care

10 Governing ICT-mediated collaboration in elderly care Abstract Background Aim and method The role of ICT in health service collaboration in some countries Collaborating across organisational boundaries: knowledge, trust, institutions and governance Knowledge Trust 143 Institutions Governance ICT and reforms in elderly healthcare Knowledge, trust and institutions in Sweden, Denmark and England Prerequisites for collaboration Institutions and ICT: consequences or drivers? Conclusions References Transforming elderly healthcare through ICT Abstract Changes and challenges in redesigning delivery of elderly care Interaction between social and health care Discharge from hospital Coordination of service activities Changed division of work New investment needs A framework Pre-requisites to move from evolutionary to revolutionary elderly care Evolution: traditional healthcare organisations Gradual revolution: developing healthcare organisations Major revolution: flexible healthcare organizations Integrating healthcare and social care References Summary of Part Four Concluding Remarks Reiterating some main points The role of the analyst

11 Purpose In this report, we propose a model for the analysis of patterns of change when implementing and using Information and Communication Technology (ICT) to support integrated healthcare services for the elderly population. Sometimes healthcare services need to be combined with social care, and often a major part of such integrated care can be carried out at home ( homecare ). We start out from the premise that ICT has a large potential to be useful in such care, much of it still untapped. While hospitals are now often equipped with advanced tools using digitised (computerized) analysis and embedded technology for operations etc., IT based administrative tools used to coordinate activities and communicate knowledge in the area of elderly care have not yet been generalized. However, new technology by itself is not a sufficient condition for changes to take place. The potential benefits from ICT are realized only when organisations adopt new patterns of behaviour, exploiting new possibilities. In an integrated elderly health- and homecare such change will involve a number of direct and indirect actors: healthcare personnel, technology suppliers, owners of residences, elderly care centres, and branches of local or central government. Our model can be used to identify organisational preconditions and consequences of the introduction and use of ICT, and provide a structure for economic evaluation of how change will affect key actors. The aim of this report is to present the model, its background, and our experience so far of applying it. We have not yet been able to do so in any large-scale cases, but we will present our experiences in testing parts of it. Major parts of the model seem to us just a combination of widely accepted evaluation practices and common sense. What we propose can perhaps best be seen as a structure and a sequence of steps, which we do not ourselves regard as original or in need of verification. We have, however, been struck by the lack of similar evaluation discussions concerning elderly care and home healthcare in the literature. Because of this we find it important to present our results so far, as a way of encouraging contributions by other researchers. Our ultimate aim in doing so is of course to speed up the introduction of useful ICT into elderly care. In Sweden a recent report on ICT use in home healthcare claimed that technology is now less important for successful innovations in the sector than organisational aspects such as division of costs and responsibilities, legal concerns and differing professional cultures (Utbult, 2004). Several 9

12 countries including Sweden have found that they need to sort out responsibilities for elderly care and home healthcare by improving collaboration between different levels of government. Typically, the municipality handles everyday service, while medical care is the duty of regional or state providers. Private or tax financing basically does not change the fact that various professions and principals must coordinate their activities, and that the introduction of new ICT tools will have an impact on how to provide an integrate health and home services for the elderly. The model should prove useful when preparing for changes in work and responsibilities in municipalities, regions, housing providers, etc. Without this type of analysis, promising technologies may fail because some actor lacks incentives to make needed investments in competences, technologies, or changed procedures, or does not trust new modes of operation because roles and responsibilities are unclear. Using the model, such potential pitfalls can be recognized earlier and remedied as part of the introduction of new ICT applications. When a new tool is proposed our model may be used to analyse if and how it should be introduced. Needed changes in organisation, work, division of financing and costs should be reviewed and evaluated. To be possible to use for practical purposes, the model is presented as checklists together with supplementary material and advice on how the analysis may be performed. To make it relevant and useful, it was tested conceptually against some reallife cases. Identifying such cases was an important part of the research. The research A major part of our research consisted of reviewing and combining ideas from prior research in a number of areas: systems theory; principal-agent theory; cost-benefit evaluation; virtual (imaginary) organisations; information theory and consumer behaviour. To understand the field into which the resulting analytical model should be introduced, we also conducted extensive discussions with practitioners, attended a major scientific conference, and arranged public seminars (together with Linköping, our local municipality). The resulting analysis was summarized in the articles that form part of the present report. As they became accepted for publication, we were strengthened in our conviction that the ideas we present are indeed useful to the area of elderly and home healthcare. We also had contacts with professional organisations and a government committee working on IT in healthcare. 10

13 As our model was not applied to any major case that we had studied ourselves, we utilized contacts with researchers at Linköping University, Uppsala University and Skövde University College, who very kindly collaborated with us on articles where we described their projects using the ideas set forth in our own research. These articles are also included in the present volume. This report The project has resulted in a number of articles, most of which are collected in this report. They have served to summarize our ideas and enable discussions with other researchers. Most were submitted to journals or presented in conferences. We have included them in this volume without changes, which has led to some arguments being repeated. By providing linking pages and summaries, however, we believe that we have made this report readable not just as a collection of papers but as a coherent investigation of our topic. The report is divided into four parts: The field of study: the interplay between elderly care in western societies at the beginning of the 21 st century; ICT; the multiactor character of such care; and process redesign and new ways of collaborating The proposal: to use multiactor evaluations as part of the investigation when some new ICT tool is proposed, and a model for how this can be done. Some experiences in performing evaluations. These are at a preliminary stage, serving here more to illustrate than to prove the benefits from using our model. Moving from evolutionary to revolutionary elderly homecare reflections on future developments in our field of study. Each part consists of a short introduction, a few articles, and a summary. Home healthcare: challenges and future Collaboration with other members of the healthcare team has always been a critical component of home healthcare. Advances in technology, however, have changed the way in which members of interdisciplinary elderly healthand homecare teams are and will be communicating with each other. The use of IT is becoming a self-evident part of the development and delivery of home healthcare services. In fact, predictions that collaboration and technology would become critical elements of the elderly health- and homecare industry of the future have proven to be true as home healthcare systems 11

14 have grappled with the interdisciplinary challenges of implementing and expanding IT-based services and IS for the support of caregivers. When healthcare migrates to the community and the home, the talents, behaviours and active involvement of residents in a specific household complement the work in healthcare institutions. In taking increasing responsibilities for their own health, laypeople face growing health information management challenges. Their efforts in keeping things under control, knowing which prevention recommendations to follow, deciding which information to attend to, and which health observations must be reported to health care practitioners, tax even the most intelligent person in their personal health information management. Consequently, what was an optional choice by an individual to engage in or eschew becomes an essential responsibility. What laypeople actually do with the health information they search for and retrieve, where they are using these resources, or how they integrate health information and resources in their daily lives are questions not usually addressed in health services or medical informatics research. Elderly healthand homecare design usually includes questions such as access to telehealth, relevant tailored health information, peer-support groups of individuals, communication resources for collaborative care and treatment post-discharge, patient portals to view the personal health records, and/or agencyspecific information as well as health- related websites. The more common used approaches have been socio-cognitive theories to guide the type of context to include, and the manner in which systematic application motivate individuals behaviours to use IT and to achieve health care goals. Approaches to design technology and business process models to emphasize information-flow and afford insights to the role of personal health-information management in healthcare processes have however, to our best knowledge, only been used to explain the role of personal health-information management in the healthcare process. The usefulness of business-process models are restricted to fairly well-understood, repetitive information-processing tasks such as medication renewal and appointment setting. Studies of the household as the context for health-information management have argued that to best illuminate the complex arena of home healthcare it is necessary to use a socio-technical approach that allows taking into consideration the interrelationship between individual, environment, technologies and organisation. However, at the centre of the model is always the individual, the patient her or his knowledge, perceptions, thoughts and life experiences. Currently, the area of home healthcare is facing many new challenges for information as a result of issues such as the need to evaluate prevention activities, improve the quality of life and reduce costs, the necessity to inte- 12

15 grate public data into individual health records, and the need to monitor the impact of community interventions for improving service quality and at the same time to integrate the elderly more active in the process. For all venues of elderly health- and homecare, software developers responded by developing electronic IT systems instead of outdated data-processing/computer system. Their emphasis shifted from task support to providing individuals with both clinical information and data as a strategic resource for community home healthcare. The IT systems in use today allow for the following: Relational databases that facilitate the retrieval of data for multiple purposes without rekeying Manipulation of data to create information and knowledge Point-of-care devices, computerized patient records and/or electronic health records Clinical repositories as a strategic resource for quality and practice Electronic interfacing systems to facilitate the sharing of data From systems primarily designed to collect and process data in order to prepare the documents required by the personnel and stakeholders, there has now evolved many applications such as service delivery, integrated financial functions, scheduling packages, derision-support functions, payroll, personnel management, accounts payable, billing functions, general ledger, financial reporting and statistical reporting capabilities. Both the elderly health- and homecare industry and IT are changing rapidly due to external driving forces including prospective payment, outcome measurement, electronic billing, and /or disease management. The changing market has brought together networked systems products, client/server computing and internet applications. However, activities, strategies and consequences for the personnel that produce and deliver care services, the economic consequences of their work behaviour and organisational pre-requisites that influence the acceptance of new work-routines and the use of IT as complement at work, the consequences for the stakeholders, and the development of tools that allow to inform future development processes, have until today not been discussed. The next decade will offer many exciting challenges to elderly health- and homecare. Home-healthcare personnel may assist in developing new systems. Advanced IT systems promise improved care quality and safety for the elderly, preventing errors, measuring outcomes and controlling costs in healthcare. However, in the past 25 years of implementing IT and IS in healthcare, people, organisations and policies are the dominant forces 90 % of the time and IT is only 10% of the implementation (Saba & McCormick, 13

16 2005). It is therefore rational to argue that it is necessary to continue to pay attention to business processes, reengineering, organisational dynamics, and changing strategy when planning and implementing systems in home healthcare in order to allocate resources optimally. References Utbult, M., 2004, Vård nära Dig. Hemsjukvård med stöd av IT. TELDOK Report 152: Saba V and McCormick, K, 2005, Essentials of Nursing Informatics. McGraw Hill 14

17 Part One: The field of study In Sweden, hospitals which spend huge sums on new medical equipment and use advanced embedded IT, still may use paper, fax machines, telephones and letters to communicate with the local municipality s social care unit. Personnel attending to an elderly person in her or his home often will find it difficult to access complete data about medicine prescriptions or information about recommendations, treatments, and other data related to the patient that is important to deliver a high qualitative service. Many ICT applications to meet their needs have been proposed, but progress is slow, although human and economic benefits would seem easy to identify. Technical difficulties no longer seem valid as explanations for the delay in using ICT-enabled new care models full-scale. Storing and transmitting large volumes of information has become feasible, and hardware such as fibre optic, cables, satellites, ISDN, and safe and secure technologies are available. Residential broadband networks are becoming available to interconnect households in local communities world wide, providing one common gateway for information exchange. However, the diffusion of ICT applications in elderly healthcare is still much more limited than one could expect from the generally hopeful tone in current studies in the area. Recent studies indicate that a major impediment for investments in ICT applications, especially for the elderly, may be a lack of sufficient evidence of their impact. There are parallels from other industries. For a long time there were concerns that IT did not lead to the benefits that were expected for enterprises. Some talked of a productivity paradox (Solow, 1987), meaning the lack of proof that IT investments provided value for money. Only recently has the general consensus become that IT spending, correctly applied, is indeed profitable (Oz, 2005). Most writers now favour two explanations for the delayed proof of IT s profitability. One is the time required to make concomitant changes in processes, organisation and competences. They believe that most of the economic benefits from introducing IT in industry during the past 40 years have in fact derived from reengineering processes: changing tasks and who performs them. This leads to the second explanation. Many IT investments have not been combined with the needed investments in (re)organisation and training, and such investments are not always well timed with the introduction of new systems. 15

18 Faced with increasingly costly elderly health- and homecare, there are hopes for similar effects in healthcare and social care. Using IT support, it should be possible to reconfigure care in ways that allow us to live longer in our private homes, increase self-service, or substitute cheaper manpower for professional medical staff. The division of responsibilities between social care and healthcare will have a strong impact on whether such changes take place. Another way of stating this is that ICT s value is not primarily in simplifying communication and information provision, or reducing their cost. Rather, its contribution is in enabling new ways of working. These, however, often require organisations to reconsider structures, roles, processes, and skill requirements exactly the kind of changes advocated by the proponents of integrated care (see Leichsenring & Alaszewski, 2004). To realize ICT s potential, however, processes and ICT have to be redesigned together, and investments in reorganisation, training and ICT timed to coincide. A complication here is that elderly care is usually the responsibility of many different organisations who have to collaborate. They may also sometimes have different owners or principals. Faced with a complex web of actors, we should not be surprised if ICT changes that involve redesigning responsibilities and tasks simply don t happen. There are two articles in this part of the report. The first, Locating ICT s benefits in elderly care, provides a brief introduction to the ideas of redesigning processes, and the role evaluation can play as a way to encourage iterative joint thinking about different possible redesigns. In the second article, Evaluation as multi-actor trade-off, the argument is made more concrete. We use some specific ICT applications which have been reported in the literature as vignettes, and show how these will look to each of several actors. Following the articles, we summarize some conclusions concerning our field of study. References Leichsenring, K. and Alaszewski, A. (eds.), 2004, Providing Integrated Health and Social Care for Older Persons. Issued by the European Centre, Vienna. Ashgate Oz, E., 2005, Information technology productivity: in search of a definitive observation. Information and management 42, Solow, R. M., 1987, We d Better Watch Out. New York Times Book Review, July 12,

19 Locating ICT s benefits in elderly care Nils- Göran Olve and Vivian Vimarlund Medical Informatics and the Internet in Medicine, Taylor & Francis, Volume 30, Number 4, December 2005, pages Abstract The impact of information and communication technology (ICT) is indirect and depends on redesign of practices and structures also outside health care as such. Improvements will only be realized if all parties involved can coordinate their efforts to take advantage of new technology. A package of changed work practices and structures extending across organisational boundaries needs to be designed and implemented. This is very different from the common conception of introducing some new ICT tools. Calls for evaluation of benefits before new ICT systems are introduced need to recognize this complexity. This article investigates how analysis and economic evaluations can be used to improve decision-making when new applications are proposed. This is done through drawing parallels with experiences from other industries. We conclude that the entire change package should be analysed for its consequences on the well-being of care recipients, and the requirements it presents for capital investments and changed labour inputs, in particular changed competence needs. Some concepts and structures are suggested for such evaluations. Keywords: Information and communication technology, elderly healthcare, process redesign, economic evaluation, virtual organisation, integrated care. Great expectations The Netherlands has launched a three-year home care pilot program that connects patients at their homes with health workers through a television and phone line The program's $6 million cost will be split between the government and health care providers Amicon and Sensire. The service will be free of charge for patients during the trial, and it is not known how much it will cost once the trial ends. Sensire hopes to offer the service for less than $24 a month. (San José Mercury News, May 11, 2004) In an evaluation of the business case for such an exchange [of national health information in US], a CHCF report found that the largest annual cost savings of such networks resulted in 17

20 large communities (with 10 major hospitals) with a high participation rate among local stakeholders, Karp said. For smaller communities (one major hospital) with health information exchanges, the report forecast a net annual loss. It remains unclear how smaller communities, which have no financial incentive to invest in exchange projects, will ever reach the level of connectivity that larger communities have. (ihealthbeat article by Patrick Wachter, July 23, 2004) Searches [for missing persons] using the technology on average last 30 minutes and cost approximately $150, about 10 times less than the national average. According to one police official, searches prior to the technology soaked up precious time and resources, and sometimes could not locate patients within 24 hours, when they are more likely to be alive and uninjured. (Transcript of CNN story, April 6, 2004) These stories culled from the website ihealthbeat during a few months in 2004 illustrate the great expectations currently associated with increased use of ICT in the health sector. During the launch of the US government's 10-year National Health Information Infrastructure programme, the health sector was described as underdeveloped compared to other sectors of society. We believe the economic benefits may be especially large in the care of the elderly part of the population, for several reasons: Costs in this segment are high and growing, as the proportion of old people is increasing in all western countries Opportunities for increased efficiency should be larger where the processes concerned extend outside care institutions, and the time frame is long enough to justify investments in new equipment and routines. ICT-supported services are expected to make it possible for care recipients to remain in their homes, rather than have to move into institutions. In addition to the benefits from improved ICT in all health care, mainly arising from better access to information for health professionals, in elderly care there will be other potential quality improvements and cost savings. The stories above provide some examples. The Dutch case shows how both government and health care providers stand to gain, immediately raising the important question of how costs and benefits should be shared. The US case indicates that there may even be net costs for some actors, whose cooperation is necessary for the entire system to function. The missing persons story, finally, shows that quite simple uses of ICT, here a wristband with a locator, may lead to important savings even outside the health sector. 18

21 This points to two important conclusions. First, ICT projects in the health sector need careful analysis concerning what redesign of processes and work practices should be undertaken in order to realize their potential to contribute to improved care; second, as the incidence of costs and benefits may be uneven, situations are likely to arise where desirable projects get stuck because of uncertainties concerning who should pay, and justifiable demands for compensation. A Swedish study [1] places this factor on top of a list of counter forces that delay development. The other such forces are legal uncertainties concerning access to information and issues concerning separate work cultures, some related to perceived status. According to the study, these together have led to separate isles of IT applications, rather than systems that will be easily merged. However, the new forms of interaction between the different agents in the knowledge economy are not only about lower transaction costs or improving assets. They are also about advantages obtained from a major integration of different health-care institutions in different parts of the world. Aim and method This article starts from the premise that ICT is underutilized in elderly care. Judging from other industries, redesign of processes is necessary for ICT s potential to be realized. Incentives are needed which make such changes attractive for everyone involved. How can analysis and economic evaluations be used to improve decision-making when new applications are proposed, such as those in the vignettes above? We will answer this question by using concepts from the field of management studies to build a simplified model of how ICT can impact elderly care. This article belongs to a series of articles investigating the scope of economic analysis of effects and impacts of ICT for elderly homecare. In the first article of this series entitled Economic analyses for ICT in elderly healthcare questions and challenges [2], we searched journals and databases for scientific publications in this area and discussed the questions and challenges economic analysis has to overcome. In the present article we discuss prerequisites to take into consideration to analyze the real value and contribution of ICT for elderly homecare, and we develop a model to support our argument. Our argument is based on the findings in our previous article [2], including some widely accepted ideas in the management of IT in industry, and informal discussions with a large number of practitioners in elderly care. These were relatively unstructured and only documented in informal notes shared within the research team, but the experience enriched our understanding of the constraints economic, legal, organisational, technical and 19

22 human and helped us to develop a more realistic model for analysis and presentation of our ideas. In total we have met about a dozen individuals representing the following professional categories: physicians, nurses, managers, researchers and representatives of professional organisations. We also presented our views in a regional conference attended by representatives from the local county council, hospital, politicians and elderly care organisations, with the aim to validate and adjust the propositions presented. Hultberg et al. [3] identify factors on different levels that enable or hinder interprofessional collaboration (see Figure 1). ICT needs to be recognized as one more force that impacts collaboration. Our argument is that it does not do this by itself: most of the other forces in Figure 1 need to reflect the new possibilities. Our aim is to assist this understanding through some simple proposals concerning how they can be analysed and evaluated. Figure 1 Framework used in the project of Hultberg et al. [3] Professional culture Geographical distance Political decision Regulation Economic incentives Organisational structure Interprofessional collaboration with common goals Effects on patients Values in society Patient s expectations How ICT is expected to support elderly care: a first-cut analysis Healthcare services are usually provided in collaboration between hospitals and primary healthcare. In elderly care there are, in addition to these two main actors, a number of other organisations that need to collaborate: municipal or private home care operators; providers of housing and daily services, including relatives; and, when new ICT is introduced, technology suppliers and perhaps support functions such as help-desks. Traditionally, many knowledge transactions take place informally, when the elderly care personnel talk or leave messages on paper to one another [4]. With increasing number of collaborators, the difficulties inherent in the informality 20

23 of this are likely to increase, as people continually need to keep in communication to update themselves. A major disadvantage of these local systems is that the communication channels often are only partially documented [5]. They are thus not available to all individuals who need the knowledge and not in the situations where they are needed. This gives rise to both asymmetry of knowledge and an insufficient interorganisational integration [6]. (For an overview of the situation in various European countries also see [7]. Like other countries Sweden faces major challenges in meeting increasing demands for healthcare services with limited resources. Proposals for developing the elderly care of the future have therefore focused on empowering care recipients and their relatives, using ICT to provide proactive and prospective health services and strategic flexibility [8]. A possibly utopian ideal is to introduce personalized self-service, which will give a new generation of computer-savvy elderly people instant and extensive solutions for all needs that do not require physical interaction. A more limited ambition is to provide the care personnel with ICT tools. Most non-profit elderly healthcare centre, at least in Sweden, has introduced some kind of administrative systems, such as computer-based patient records. However, their implementation has shown un-expected effects for the organisation s work processes due to a low level of informatics knowledge and skills, non-optimal design of human-computer interaction, and absence of complete patient data in computerized form [9]. Also the majority so far are limited to intra-organisational use, while those involving care recipients are only at an experimental stage. Figure 2 Stages of the elderly care, choices and alternatives 1 HEALTH COMPLAINT INVESTIGATION TREATMENT INVESTIGATION HISTORY TREATMENT COMPLETION, TREATMENT HISTORY DIAGNOSIS TREATMENT EXAMINATION DIAGNOSIS PLAN DECISIONS COMPLETION EXAMINATION TESTS PLAN & ON RESOLUTION FUTURE TESTS HEALTH CARE Sporadic contacts CARE RECIPIENTS Continuous contacts HOME CARE CHANGED CHANGED HOUSING, HOUSING, HOME HOME SERVICES? SERVICES? NEW TECHNOLOGY 6 In imagining different ways ICT could contribute we will use Figure 2, which provides a highly simplified description of some stages of elderly care: 21

24 1. An elderly patient and a physician are brought together as a result of a patient complaint. 2. The physician performs an investigation of the elderly patient s condition. This may require physical examination, tests and on some occasions further specialist consultations. 3. The physician diagnoses the condition 4. A treatment plan is designed in collaboration with the patient. Depending on the patient s health, further healthcare personnel are involved in the process. 5. The treatment is carried to completion, the patient s condition returns to normal, and the interaction between physician and patient concludes. 6. The elderly person moves back into her (or his) home. In some situations, and depending on her health condition, changes in living patterns and supporting services are required. In the case of elderly patients who require continued attention, for instance from municipal homecare, there may be a formal transfer of responsibilities between healthcare personnel from healthcare centre of hospital to homecare personnel, through a meeting and/or the exchange of documentation with patient information and his/her treatment. If specialized support or services are necessary the person may move into some form of elderly homecare. Available technologies influence the solutions chosen. 7. The frequency and extent of subsequent contacts between the home care and health care institutions will vary, and may include both pre-scheduled interactions and episodes of acute assistance, depending on the health status of the patient. This phase will extend until some new health complaint or an irreversible deterioration of the health condition occurs. 8. A new cycle may be initiated by the elderly person herself or himself, or by carers such as relatives or healthcare personnel responsible for the health status. ICT can contribute to this cycle in various ways. The administrative healthcare IT systems now discussed in many countries primarily deal with the upper part of Figure 2, i.e. ICT as an intra-organisational support system. Although important, this is not the main focus of the present article. Instead, we are interested in the lower part, starting with the decision (see point 6) about the next stable phase. Can ICT enable the elderly patient to return to her home, if some support is installed (for instance an alarm, or a device for monitoring a heart condition), rather than move to some institution for persons with her condition? Can the stable phase be prolonged safely, if minor complaints can be diagnosed at a distance and correctly identified as unproblematic? Whether this will be possible is influenced by: 22

25 Previous decisions to invest in the appropriate technology and support infrastructure, i.e. how the patient s existing home and alternative residences are equipped and may be linked to care institutions through communication devices Organisational solutions for the cooperation (see point 7 above) during the next few months or years, including training of care recipients and their relatives to utilize available technologies Economic considerations an evaluation has to be made both in principle, to support technology investment decisions, and for each particular case. Obviously, the other forces identified in Figure 1 will also be important here (professional culture; geographical distance, etc.). ICT thus has its effect in combination with appropriate changes in processes, work practices, and organisation. From a societal viewpoint their greatest impact will be on three types of resources: 1) Housing or residency, enabling care recipients to remain at home it will save cost and have benefits for health and general well-being; 2) Healthcare capacity, leading to a more effective utilization of hospital beds and acute intakes, as patients and the people who support them feel comfortable with alternative contact points with health care; and 3) Competences or knowledge capital when new technology for interaction with specialists demands different skills. The key to all these changes is the new technology, as it enables new work procedures. But they will not come about by themselves, and may occur after considerable time delays, as society needs to adapt to the new possibilities. Compare the views of Brynjolfsson [10], one of the leading researchers in the field of IT s effects on productivity and profitability: The same is true in every industry: IT is only the tip of a much larger iceberg of complementary investments that are the real drivers of productivity growth. In fact, our research found that for every dollar of IT hardware capital that a company owns, there are up to $9 of IT-related intangible assets, such as human capital the capitalized value of training and organisational capital the capitalized value of investments in new businessprocess and other organisational practices. [10, p. 21] It is not in the daily routines in elderly care that the potential benefits of ICT are largest, but in enabling a reconsideration of how society structures the processes that require residences, health care institutions, and competences. This evolves through the interaction between many actors: governments at different levels, private and public providers of housing and health care, technology providers, the patients themselves and their relatives, etc. 23

26 We highlight these three issues because they summarize the areas for cost savings, or improved benefits from the same level of cost. ICT s contribution is to enable improved ways of operating. What ultimately limits the quality of care which can be provided in a society (or bought, if patients finance directly themselves) will be the skilled labour and the utilization of specialized capital investments available. Focusing on the need for and utilization of residency, care capacity and competences when comparing different models for elderly care helps to identify how alternatives differ in terms of costs and well-being during the stable phases at the bottom of Figure 1. They will also have an impact on how the need for a new reappraisal is triggered, or can be avoided it if not necessary (points 7 and 8 in Figure 1). Redesign of work processes: a prerequisite for ICT benefits Care capacity such as hospitals, residences such as homes for the elderly (or normal dwellings), and competences such as ability to handle ICT systems all require investments in material and immaterial capital. These normally are meaningful only if they are to be used for several years. Labour from different types of competences will be the main ongoing cost of any care arrangements. Figure 3 A combination of technology and process redesign is needed to realize the potential benefits Redesigning: ICT together with Processes and organization (Further Redesign) ICT Increased well-being Reduced costs for individuals and society (labour, capital) Possible to: Relieve Enable Figure 3 highlights the need to design ICT, processes and organisation together. The terms relieve and enable, proposed by Normann and Ramirez [11], suggest that any purchase can be viewed as motivated by a desire to 24

27 avoid some burden, or by a desire to get access to some pleasure. In designing elderly care an example may be that an elderly person does not have to travel for health check-ups, if they can be performed in the home using ICT [12]. This relieves the person and society of the cost and strain of travelling and may enable the person to live safely in her or his own home. When we move from relieve to enabling, the benefits are no longer static. Relieve involves mostly rationalization of existing procedures, while enable invites us to explore the new ways of organising which become available through new technology. As indicated in Figure 3, a reconsideration of how society structures the processes in elderly care that require residences, healthcare institutions, and competences will be an interactive process. It will not happen through government dictates, but evolves through the interaction between many actors: governments at different levels, private and public providers of housing and health care, technology providers, the patients themselves and their relatives, etc. The result may be something like Table 1, below. Table 1 Examples of possible benefits, costs, and investment needs for a redesigned elderly care, enabled through ICT Residency Health-care capacity Competences Benefits Relieve If some enforced changes of residence can be avoided, it may benefit the emotional state of some elderly. Better information should make it possible to avoid unneeded visits to doctors or care centres, avoiding costs and discomfort. Active use of ICT for consultations lead to release time and/or more effective planing of professional activities of healthcare personnel. Benefits Enable Many will appreciate being able to remain in their familiar surroundings. If health is remotely monitored more or less continuously, it should be possible to improve treatments and discover emerging health problems earlier. New proactive ways of working.may be developed, and more efficient division of labour. Effects on Costs Less need for expensive, specialized residence solutions for the elderly, but more support from homecare in included. If health care can be used more effectively, less will be needed. Either this can be changed to treating other patients, or reduced. Changed skills and division of labour will both increase and decrease salary costs for different personnel cathegories. Investment needs New ICT networks are needed, but there will be a decreased need to invest in oldage homes. Health centres must develop systems for distance monitoring of patients, and reacting on finds. Home-care personnel will have to acquire new skills in handling ICT and noticiing needs to involve health-care specialists Table 1 shows possible benefits, costs, and investment needs in elderly healthcare. Any evaluation of ICT should identify its best use in terms of redesigned processes, the impact these will have on residency, care capacity, and competences, and the consequent economic impacts. Obviously, this will be an interactive process. 25