STAKEHOLDER OBJECTIVES, POSITIONS AND INFLUENCES IN EHEALTH PORTAL IMPLEMENTATION

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2 STAKEHOLDER OBJECTIVES, POSITIONS AND INFLUENCES IN EHEALTH PORTAL IMPLEMENTATION The PAZIO case Author Student number Jurjen Julianus s Institute Faculty Degree program Specialization Rijksuniversiteit Groningen Economics and Business MSc Business Administration Business & ICT Version Definitive Faculty supervision Supervisor Co-supervisors Prof. dr. ir. J.C. Wortmann Prof. dr. A. Boonstra Drs. J.B. van Meurs External supervision VitaValley Supervisor W.C.J. Schuttelaar MSc VitaValley Foundation UMC Utrecht University of Groningen Zonneoordlaan 17 Heidelberglaan 100 Nettelbosje TK Ede 3584 CX Utrecht 9747 AE Groningen The Netherlands The Netherlands The Netherlands II

3 ACKNOWLEDGEMENTS This thesis was written as graduation assignment for my master s degree in Business Administration, specialization Business & ICT, at the University of Groningen. The research was conducted during an internship at the University Medical Center Utrecht and the VitaValley foundation in Ede. These organizations are responsible for the PAZIO health portal programme. Although the fact that I am author of this thesis, I could not have achieved this without the received support. Therefore, some people deserve a word of thanks for their support during this research. First of all, special thanks to my supervisor from VitaValley, Wilco Schuttelaar. Wilco, thank you for answering my questions, reviewing my chapters and helping me with my activities in the PAZIO programme. Also I would like to thank André Dekker and Mark de Lange for providing me the opportunity of this internship at the UMC Utrecht and the VitaValley foundation. Furthermore, I would like to thank the faculty supervisor, prof. dr. ir. Wortmann, for introducing me in the topic, and for providing me with constructive feedback during the research process. Also thanks to prof. Boonstra, for contributing as co-assessor. Looking back, I really enjoyed this internship since it enabled me to explore the dynamic field of healthcare and ICT. In addition, writing this thesis enabled me to improve my scientific research skills. Last but certainly not least, I would like to thank my parents, and my girlfriend for their major support during my study. Jurjen Julianus Utrecht, III

4 MANAGEMENT SUMMARY Demographic pressure in The Netherlands is increasing. People will demand more care in the future. In order to be able to fulfill the care demands in the future, measures have to be taken. ehealth (Healthcare & ICT) initiatives are developed in response to this trend. However, a high extent of fragmentation can be recognized among ehealth initiatives. PAZIO is a health portal which is a socket for healthcare information systems. PAZIO acts as a platform for other portal solutions, which enables healthcare providers to provide online services from different software suppliers with only one login (Single Sign On). Currently, PAZIO is implemented at primary healthcare center Leidsche Rijn Julius Gezondheidscentra in Utrecht, The Netherlands. Insight in the current implementation process is gained, for the purpose of improving health portal implementation in the future. In order to gain insight in the implementation of the PAZIO portal, this study describes and analyzes the PAZIO implementation at Leidsche Rijn Gezondheidscentra from a stakeholder perspective. The following implementation stakeholder groups are identified: board of managers, general practitioners, doctor s assistants, platform supplier, project management, application supplier, HIS supplier and patients. The stakeholders are categorized according to the stakeholder salience theory (Mitchell et al., 1997). This resulted in the following categorization (figure A): Figure A Categorization stakeholders PAZIO implementation LRJG Figure B Categorization stakeholders MGn implementation GCM IV

5 For the purpose of comparison, the MijnGezondheid.net portal implementation at Gezondheidscentrum Maarssenbroek, The Netherlands, has been analyzed in the same way. The following implementation stakeholders are identified in the implementation at Gezondheidscentrum Maarssenbroek: Board of managers, general practitioners, doctor s assistants, project management, software supplier and patients. Figure B shows the categorization of the stakeholders. A qualitative cross-case analysis was conducted. Remarkable is the dynamic position of the board of managers and the patients in both implementations. Furthermore, the cross case analysis pointed out that the healthcare centers started with a different product, and attached different objectives to the implementation. In addition, their communication approach differed. The implementations in Leidsche Rijn and Maarssenbroek followed a different route, and consisted of a different field of stakeholders. Practical implications for the project management Per stakeholder group, practical implications are distilled. Discretionary stakeholders have little salience from the project management, their claims do not need immediate attention. Dominant stakeholders expect to receive more attention from the project management; however, they do not deserve much attention. Dangerous stakeholders should only be identified without acknowledging them. This requires some tactic from the project management. Dependent stakeholders need to exercise governed power, by means of other stakeholders. Implication for the project management with regard to definitive stakeholders is that claims of these stakeholders should have priority against claims from other stakeholders. The project management should pay specific attention to the dynamic position of stakeholders, in order to be able to act adequately to the shifts in position. Management focus areas for future health portal implementations The analysis of both implementation processes resulted into six management focus areas. These areas deserve specific attention from the project management for health portal implementations in the future. The following management focus areas are identified by this research: V

6 First management focus area is the area of stakeholder relationships. Stakeholders are interrelated in a health portal implementation. These relations should be managed carefully by the project management. It may for example be more beneficial for the project to let a software developer be supplier instead of being partner. Second area is dedication; dedication of stakeholders is a key enabler of success. A noncommittal attitude of one or more stakeholders seems lethal for the success of implementation. Vision and leadership is the third management focus area. The project management should execute future implementations within primary healthcare centers that have an internal project leader with leadership and vision. This causes all employees in the healthcare center to face the same direction. Fourth management focus area is confidence of care providers. If care providers have a lack of confidence in the software or working with the software, they may attempt to delay implementation. The project management should thus invest in stable software and education for care providers. Next management focus area is knowledge of key people. An internal project leader is considered to be a key person in implementation. If this person has a certain amount of business knowledge this may increase the chances of implementation success. Last and perhaps most fundamental focus area for management is the area of usage by patients. A health portal is supposed to be a communication means between care providers and patients. However, if patients are not willing to use the portal, for any reason, successful implementation cannot be achieved. Implementation will then stagnate, because routinization among employees in the healthcare center can never be achieved. The six management focus areas can be generalized to future PAZIO implementations, as well as to other health portal implementations in primary healthcare centers. VI

7 LIST OF FIGURES AND TABLES Figures Figure 1 Demographic pressure in The Netherlands (van Duin & Garssens, 2010)... 1 Figure 2 PAZIO Concept (modified from )... 3 Figure 3 Innovation stages - adopted from Deloitte (2010)... 8 Figure 4 Distribution of interviews Figure 5 Visual representation of research strategy Figure 6 Current PAZIO runtime architecture Figure 7 Aligned elements of IT innovation (Boonstra, 2011) Figure 8 Visual representation of stakeholder typology (Mitchell et al., 1997) Figure 9 Project governance framework (Young, 2005) Figure 10 Organizations involved in PAZIO project Figure 11 PAZIO Time line Figure 12 Aligned elements of the PAZIO implementation at LRJG Figure 13 Stakeholders involved in PAZIO implementation at LRJG based on Mitchell et al. (1997) Figure 14 Aligned elements of implementation at GCM Figure 15 Stakeholders involved in MijnGezondheid.net implementation at GCM based on Mitchell et al. (1997) Tables Table 1 Market share HIS in The Netherlands (estimation by PharmaPartners, 2011)... 2 Table 2 Aspects of Terms of Reference (Boddy et al., 2009) Table 3 IT implementation stages Cooper & Zmud (1990) Table 4 Stakeholder typology (Mitchell et al., 1997) Table 5 Six inter-related project governance activities (Young, 2005) Table 6 Software suppliers at pilot locations Table 7 Perceived problems of PAZIO implementation stakeholders at LRJG VII

8 TABLE OF CONTENTS 1 Introduction Case description Research objective Research questions... 5 Background ehealth Methodology Focus of the research Data collection methods Data analysis Health Portals Portals defined Health portals Relation to other systems Health Information Systems Electronic Health Record Portal Implementation Implementation methods Stakeholder analysis theory Characterization of stakeholders Project governance Background Short description of organizations VIII

9 5 Implementation of PAZIO Leidsche Rijn Julius Gezondheidscentra Gezondheidscentrum Maarssenbroek Stakeholder analysis of PAZIO implementation Leidsche Rijn Julius Gezondheidscentra Identification of stakeholders Stakeholder analysis Problems and lessons learned Gezondheidscentrum Maarssenbroek Identification of stakeholders Stakeholder analysis Problems and lessons learned Cross-case analysis and Practical implications Cross-case analysis Product and objective Implementation stages Communication approach Range of stakeholders Practical implications for stakeholder management Discretionary stakeholders Dominant stakeholders Dangerous stakeholders Dependent stakeholders Definitive stakeholders Important implementation issues Management focus areas for future implementations Relationships of stakeholders Dedication IX

10 8.1.3 Vision and leadership Confidence of care provider Knowledge and or experience of key people Usage by patients Conclusion and Discussion Conclusion Definitions Leidsche Rijn Julius Gezondheidscentra Gezondheidscentrum Maarssenbroek Management focus areas for future health portal implementations Implications for theory Discussion Limitations of the research Recommendations for further research Bibliography List of abbreviations Appendices Appendix A: Interview questions Appendix B: Full stakeholder analysis LRJG PAZIO implementation Appendix C: Full stakeholder analysis GCM MGn implementation Appendix C: PAZIO & MGn Screenshots Appendix D: Interview transcripts Appendix E: Keyword project group meetings X

11 1 INTRODUCTION Demographic pressure in The Netherlands is increasing. Figure 1 shows the Dutch labor force opposed to the group of ageing people. By 2040 the group of elderly people will be larger than the Dutch labor force. As people in The Netherlands will have a longer life span, they will demand for more care. In addition, there will be more people with a chronic disease. However, there is less labor force to provide the care demands in the future. Figure 1 Demographic pressure in The Netherlands (van Duin & Garssens, 2010) In order to be able to fulfill the care demands in the future, measures have to be taken. One measure mentioned in the Dutch state budget is reengineering of care processes (Skipr, 2011). Such reengineering projects may be well supported or enabled by innovations in the care sector. Process innovations in the care sector are highly reliant to the usage of information and telecommunication technology (ICT). Initiatives which combine healthcare with ICT are called ehealth initiatives. A high extent of fragmentation among ehealth initiatives can be recognized in The Netherlands. For example, recent research by the NICTIZ (National IT Institute for Healthcare in the Netherlands) pointed out that there are over 40 patient portals in The Netherlands by the end of These portals all have different functionalities and are intended for different client organizations (Heldoorn & Veereschild, 2011). The challenge with ehealth lies in integration of those initiatives. Jurjen Julianus 1

12 In The Netherlands there are 4 large companies that possess more than 80% of the general practitioners information system (HIS) market (Table 1). Such a market concentration brings opportunities for one integrated portal. Despite these opportunities, there are over 40 health portals in The Netherlands. Only few of them have integration with a HIS. Among and within Dutch hospitals there is an even higher extent of fragmentation of information systems and online services. Innovators of the VitaValley foundation and the UMC Utrecht have identified the trend of portal fragmentation, and brought up the idea of a platform that integrates the information systems of healthcare providers into one clear online portal for the care consumer. HIS FTE General Practitioners Market share Medicom (PharmaPartners) % Promedico % MicroHIS % Omnihis % Mira 450 7% HetHis 250 4% Zorgdossier 250 4% TetraHis 40 1% CITO 25 0% Total Table 1 Market share HIS in The Netherlands (estimation by PharmaPartners, 2011) 1.1 CASE DESCRIPTION PAZIO is an online healthcare portal which can be seen as a socket for healthcare organizations and ehealth providers to plug-in their existing information system. The PAZIO platform offers integration between the information system of the healthcare organization and its online services. In other words, it connects the healthcare provider to the patient via the internet channel. PAZIO consists of a limited customizable user interface and an app-store. Customization is offered, because PAZIO is offered as a white label product. Thus, healthcare providers are enabled to change certain colors, logos and texts. They can even Jurjen Julianus 2

13 decide to choose an own name for the portal, which can help to increase the amount of trust of care consumers. Within the app-store, software suppliers can offer their own ehealth app. Obviously, apps have to comply with PAZIO infrastructure standards because of single sign on requirements. Single sign on (SSO) means that all applications can be accessed with only one login. econsult, eappointment and Disease Management are available in the app-store at this moment. Other applications, such as ementalhealth (for patients with depressions), eprescription (for pharmacists) and Self-Management (applications for prevention) are in the development stage. The pre-competitive approach for applications on the platform seems unique; not only does it open up the market for smaller software suppliers, it also assures an integrated approach for ehealth applications. The portal enables care consumers to arrange their care needs online. For instance, scheduling an appointment or requesting a consultation online. In addition to the functionality itself, PAZIO services are offered via a single sign on. Entrance for the PAZIO portal is often a login button on the healthcare center s website. The sign on is secured by the Dutch DigiD (Digital Identity) system, which enables citizens to login to a number of services provided by Dutch government agencies. DigiD has two levels of authentication; the regular login with username and password, and the more secure method which sends a text-message verification code to the user s mobile phone. Especially the latter of the two authentication levels is suitable for securing access to medical related data. It has to be noted that PAZIO is not a government service. Another distinctive feature of PAZIO is the possibility for researchers to conduct research within the project. One of the parts of the PAZIO project is the Jurjen Julianus 3 Figure 2 PAZIO Concept (modified from )

14 development of a Center of Excellence (CoE). The CoE aims to identify, document and distribute the knowledge that comes available during such an innovation process. Scientific researchers are invited to conduct their research; in addition, best practices will be documented by members of the project team. Distribution of the knowledge is facilitated by a symposium which will be organized by the project team. Introduction of a new means for communication with a healthcare center may involve changes in behavior and or habits of both patients and the employees of a healthcare center. First of all, care consumers are used to grab the telephone in case they want to consult their general practitioner; they are not accustomed to use the internet for this purpose. Second, employees within a healthcare center are equally used to this communication method. Moreover, for them, implementation of a patient portal causes a certain change in their work processes. Therefore, implementation consultants are employed to streamline this process. The PAZIO team is now working on the scalability of the product. Information systems provider Imtech, responsible for the PAZIO infrastructure, indicates that the technological infrastructure is all set for national deployment. The challenge lies in making the implementation of the portal scalable. Since the product is in development, links with the different underlying information systems are not yet finished. In addition, implementation consultants are necessary to streamline processes within the healthcare centers. Currently, the PAZIO team provides all services concerning an implementation of the portal. They fulfill all roles in the implementation process: they are seller, coordinator of the software part, implementation support provider and developer of the product. For the future, a decision has to be made which role suits the PAZIO team best. In other words, what is their core business? For each of the roles mentioned above, there is a make or buy decision. This implies that there is a make or buy decision for implementation as well. However, before an external consultancy firm is able to implement PAZIO, implementation guidelines have to be created. The identification of management focus areas for future implementations of PAZIO may be the first step in creating such implementation guidelines. Jurjen Julianus 4

15 1.2 RESEARCH OBJECTIVE The aim of this research is to obtain insight in the implementation process of a health portal. Furthermore, that insight should be translated into management focus areas for future health portal implementations within primary healthcare centers. These insights should be rooted in existing academic knowledge on ICT implementation processes, and if possible contribute to this body of knowledge. A primary healthcare center in the Netherlands consists of a group of general practitioners, practices nurses and sometimes physiotherapists and pharmacists which operate together under a joint name. Such a multidisciplinary organization enables these groups to spread their overhead costs (administration, the premises etc.), and to offer more complete primary care. 1.3 RESEARCH QUESTIONS In order to obtain insight in the implementation process of PAZIO, an implementation analysis has to be conducted. This research chooses to analyze from a stakeholder s perspective both a PAZIO implementation, and another health portal implementation. Outcomes of this analysis will serve as foundation for identification of management focus areas for primary care providers in implementing portals. The following question will serve as the main research question of this research. What are the stakeholder s objectives, positions and influences within a portal implementation in a primary healthcare organization? And which management focus areas for future PAZIO (and other health portal) implementations can be derived from these findings? The main question immediately raises a number of questions. First, what is a health portal? Second, what is an implementation? And what does this mean in the context of a health portal? In addition, the main research question calls for a stakeholder analysis of a PAZIO implementation and an implementation of another health portal within a primary healthcare center. These questions have been translated into the following sub research Jurjen Julianus 5

16 questions. Sub research questions 1, 2 and 7 are generalizable, while sub questions 3, 4, 5 and 6 are case specific questions. Sub RQ1: What is a (health) portal? Sub RQ2: What is IT implementation? Sub RQ3: Which stakeholders are involved in implementation? Sub RQ4: How can the objectives of the different stakeholders be characterized? Sub RQ5: How can the positions of the different stakeholders be characterized? Sub RQ6: How do the objectives and positions of the stakeholders influence the implementation? Sub RQ7: Which management focus areas for future implementations can be distilled from the stakeholder analysis? Jurjen Julianus 6

17 BACKGROUND EHEALTH There exists some confusion about the definition of ehealth. Moreover, there are several definitions for the application of ICT in the healthcare sector; ehealth, telehealth, telecare, telemedicine. These terms are all used to indicate care, support and monitoring of a patient s health from a distance (Frankwatching, 2011). For the purpose of this research we will follow the ehealth definition of the Dutch Association of ehealth (NVEH): Innovative application of ICT, especially internet, to support and improve health and the healthcare sector. Several issues around the implementation of ehealth can be identified. The following issues are identified by the researcher and are considered particularly of relevance for this research. From fragmentation to integration Within the world of ehealth, a high level of fragmentation can be identified. Lots of separate initiatives are started (Website KNMG, 2010). For example, UMC Utrecht already uses 14 standalone patient portals at this moment. General practitioners have their own information system, and most of time, they have their own website as well. Although the websites often come with econsult and eappointment functionality, there is no integration with the underlying information system. Within healthcare, integration seems to be the keyword for the success of ehealth initiatives. Changing work processes General practitioners and doctor s assistants are often used to work in a certain way (Medical rationality; Heeks, 2006). The introduction of ehealth applications such as econsult and eappointment may cause a shift in their work processes. Organizational change often raises resistance among the subjects of change (Waddell et al., 2004). Initially, it will cost them a lot of effort to comprehend the applications which may cause resistance implementation. Education Currently, there is too little attention for ehealth topics in educations for doctor s assistants and general practitioners. A suggestion may be to make ehealth part of today s medicine studies (Programme manager PAZIO, interview, December 1 st 2011). Moreover, it may increase the efficiency in which ehealth initiatives are implemented in the future. Jurjen Julianus 7

18 2 METHODOLOGY 2.1 FOCUS OF THE RESEARCH Objective of the research is gaining insight in the implementation process of PAZIO, and in the implementation process of another health portal. Subsequently, this insight should be translated into management focus areas for future health portal implementations in primary healthcare centers. This objective is translated into an analytical question which can be answered by doing literature and empirical research. A cross case study seems to be the most appropriate research method, because the outcomes of the analysis have to be dedicated and useful for future health portal implementations. Case study is a powerful research methodology that combines interviews, analysis of relevant records and (participative) observation (Cooper et al., 2003). PAZIO is an innovative programme, which is still being tested and improved during implementation. It is therefore meaningful to address the current status of the PAZIO programme, viewed from an innovation perspective. Furthermore, it has to be noted that the research focuses on the implementation process. Figure 3 Innovation stages - adopted from Deloitte (2010) The PAZIO programme can now be placed in the green area; business plans are created, and they are being aligned with the strategies of the different stakeholders. At this moment in time, a pilot is running, and an implementation plan is available. Despite the promises stated in the plan, this implementation can be characterized as learning by doing. This implementation, obviously, covers organization and change management Jurjen Julianus 8

19 issues. Governance, KPI s and financial modeling are issues which are to be discussed by the PAZIO programme team. Approach for fulfillment of the research objective is a stakeholder analysis of both a PAZIO implementation, and an implementation of MijnGezondheid.net in two primary healthcare centers. Stakeholder analysis is chosen because earlier research pointed out that it is important to obtain insight into the interpretations and power relations of stakeholders in order to develop a proper understanding of a project (Boonstra & De Vries, 2005, 2008). Such insights enable the researcher to identify supporters and resisters of the innovation. Effective implementation strategies can be developed based on these insights. Boonstra & Govers (2009) call this process IT stakeholder management. 2.2 DATA COLLECTION METHODS The research uses a (cross) case study approach. Literature research is conducted to obtain a clear image of the main concepts of the research; health portals, IT implementation and stakeholder theory. Furthermore, qualitative methods are used to answer the research question. Literature research The main question of the research consists of three aspects; portals, IT implementation and stakeholders. For the purpose of understanding these terms, a literature research has been conducted. Moreover, the literature is used as a guideline for the case description. First, non-scientific literature and websites concerning health portals have been consulted in order to define the terms portal and health portal. In addition, information systems that may have integration with a health portal are addressed to obtain a clear image of the complex architectural environment of an integrated health portal as PAZIO. Second, IT implementation literature has been consulted. It is important to know, what an implementation is; where does it start? Where does it end? And what is in between. Third, stakeholder theory has been consulted. A definition of stakeholder is part of this section. Furthermore, this literature serves as a foundation for mapping the stakeholders who are identified during the stakeholder analysis. Moreover, it helps to translate the stakeholder analysis into IT stakeholder management implications. Jurjen Julianus 9

20 Sources for the scientific literature research have been: Business Source Premier, Google Scholar. Terms that were used to search in these scientific databases include: web portal, portal, health portal, patient gateway, IT implementation (model, stages, phases), IT implementation in healthcare, IT implementation stakeholder management, Stakeholder analysis, Stakeholder salience, Health information systems, Patient care information systems. Furthermore, the snowball technique was utilized to obtain more relevant literature. Books and literature provided during the lectures of the course ICT: Human and Organizational Issues have been used as foundation for the literature research as well. Knowledge and experiences in practice have been utilized to obtain background information, besides that, presentation slides of an ehealth master class have been used to obtain relevant background information concerning the ehealth topic. Literature is selected based on the extent of support it provides for the understanding of the concepts in the case. It has been utilized to provide definitions of various terms and to obtain knowledge about analysis methods. The goal was and not to provide an exhaustive image of the available literature in the field of healthcare and IT implementation. Empirical data The case description and stakeholder analysis have been conducted based on data obtained from both interviews and participative observation. In order to ensure construct validity, both interviews and participative observation have been utilized for data gathering (Cooper et al., 2003). Participative observation is realized by the fact that the researcher is providing support tasks the project team in this case, in addition to the research tasks. Observations have been documented by means of keywords, during meetings with internal project groups at the healthcare centers and during meetings with the PAZIO project team. Advantage of such close involvement is the in-depth access to people, issues and data (Walsham, 2006). Downside of close involvement includes the danger that the field researcher who is closely involved, becomes socialized to the views of people in the field. The benefit of a fresh look is then lost (Walsham, 2006). Figure 5 provides an overview of the interviews that were conducted with stakeholders of both the PAZIO implementation and the other portal implementation. Jurjen Julianus 10

21 Figure 4 Distribution of interviews Patients are important in the implementation process of a health portal, because they are able to make or break the success of implementation. In other words, a health portal implementation may have limited success if patients are not willing to use it. In order to gain insight in the objectives, positions and influences of members in this group, two interviews have been conducted with patients from LRJG. The patients interviewed for this research were asked different interview questions than the other stakeholders. This is because of the fact that they have no knowledge about which other stakeholders are involved in implementation in addition to the employees of their healthcare center. Furthermore, the patients were selected at random. More in-depth research regarding patient behavior and attitudes in the PAZIO case will be performed by Nicol Nijland PhD (Twente University) and Michiel van Well MSc (Maastricht University). Particularly the research that will be conducted by Nicol Nijland focuses on the role of the patient. Moreover, the overall effectiveness of the PAZIO portal will be reviewed in that particular research based on user experiences. In addition to the use of interviews, secondary data has been consulted to underpin the findings in the interviews. Presentations, project plans, implementation plans, s and other documents have been consulted. 2.3 DATA ANALYSIS Data has been gathered by means of three channels. Participative observation, semistructured interviews and secondary data have been utilized to cover the empirical part of Jurjen Julianus 11

22 this research. Data from the sessions in which the researcher exercised participative observation, was aggregated on to a time-line. Thereafter, the data was placed into the context of the implementation stages (Cooper & Zmud, 1990) and the structuration model (Boonstra, 2011) by means of interpretations of the researcher. Finally, the observation data was used to strengthen the findings of the stakeholder analysis. The interviews are digitally taped by the researcher, the associated audio files have been translated into summaries of the relevant information. Afterwards, the audio files have been deleted. A confirmation with the summary of their interview has been sent to each interviewee, interviewees were thus enabled to give their comments on the summary of their own interview. These comments have been processed. Subsequently, the interviews are analyzed by means of interpretation. Collected data has been arranged according to the implementation stages (Cooper & Zmud, 1990) and the structuration model (Boonstra, 2011). This enables the researcher to explain and characterize the actual implementation process using a theoretical perspective. In addition, the data is used to map the stakeholders based on the stakeholder salience theory (Mitchell et al., 1997). The latter theory will be used to formulate implications concerning a future PAZIO implementation process within a primary healthcare center based on the outcome of the analyses. This outcome consists of a characterization of the different interest groups in both implementations. Based on these characterizations, management focus areas for future PAZIO implementation will be formulated for the project management. Secondary data has been utilized to provide support for the findings regarding the description of the actual implementation process. Figure 6 provides a visual representation of the research strategy. Jurjen Julianus 12

23 Figure 5 Visual representation of research strategy Jurjen Julianus 13

24 3 HEALTH PORTALS In order to answer the first sub question of the research, this chapter covers the part regarding web portals. The chapter starts with defining web portals in general, and will narrow scope towards health portals. It is necessary to obtain a clearer image of the terminology around portals, in order to better understand the subsequent sections. In addition, it is relevant to have insight in the systems which are or can be linked to a portal. 3.1 PORTALS DEFINED Synonyms for portal are web portal, links page and gateway. These terms all have a similar meaning. Various definitions of portals can be identified. Some only define it as a starting point for internet activities (Emazing, 2010; Broadband TV Nieuws, 2007). Wikipedia (2011) defines web portals more broad, and adds that it presents information of diverse sources in a unified way. In addition to general or horizontal portals, like for example igoogle or MSN, there exist field specific portals. Such vertical portals are also called vortals (Zoeken-envinden.nl, 2011). Although a health portal can be called a vortal, we prefer to use the term portal because the addition of health indicates that we discuss a vertical portal in this paper. A vertical portal can also refer to a personal portal. Personal portals usually have a secured area which requires login, it renders applications specifically for the user that is logged in. For this paper we will follow the personal portal definition provided by Wikipedia (2011): A site on the World Wide Web that typically provides personalized capabilities to its visitors, providing a pathway to other content. 3.2 HEALTH PORTALS While portal is the equivalent of gateway, health portal is that of patient gateway or patient portal. In practice, we can distinguish two types of health portals; generic health portals, which consist of hyperlinks to healthcare websites or services, and secured personal health portals. Personal health portals allow patients to login in a secured environment and enable them to update their contact information, request appointments, request consults online, and offers reliable licensed health information (Schnipper et al., Jurjen Julianus 14

25 2008). Kittler et al. (2004), add patient access to parts of their health records to that. For this research we will follow the health portal definition of Schnipper et al. (2008): A site that allows patients to login in a secured environment and enables them to update their contact information, request appointments, request consults online, and offers reliable licensed health information. The reasons for introduction of a health portal Particularly secured personal health portals are interesting for healthcare organizations, since they are able to configure the portal to their preferences. Research conducted by Bergman et al. (2008) pointed out that secured personal patient portals have the promise of enhanced communication between patient and provider, increased overall satisfaction with care, increased identification and management of chronic conditions, increased access to health information, and improved disease management for conditions such as diabetes. However, introduction of a portal with online appointment and online consulting functionality requires a redefinition of existing work processes within these organizations. Currently, healthcare centers are already using information systems for scheduling and for maintaining personal health records. In the future, secured personal health portals should be able provide access to parts of medical records online. At the moment, a secured personal health portal only enables patients to schedule an appointment or request an econsult. This requires the portal to be integrated with the information system of the corresponding healthcare center. The following section describes the systems to which a health portal may have a connection. 3.3 RELATION TO OTHER SYSTEMS A secure personal health portal has limited functionality if it is not integrated with other systems in the healthcare IT architecture. Thus, portals should be placed in the wider context of the healthcare IT architecture. First a description of the relation of a secured personal health portal with other systems is presented. Thereafter, functionality and definitions of these systems will be provided. Jurjen Julianus 15

26 The example of PAZIO will be used to illustrate to which other systems a portal may relate. Figure 7 is a conceptual representation of the current PAZIO architecture. The figure indicates the relationship of PAZIO with other information systems in healthcare. PAZIO is a software as a service (SaaS) application, that does not need hardware installation at the healthcare centers. Different healthcare centers may use the same SaaS application, and customize it to their demands (Lankhorst, 2010). Currently, there is connection with the Health Information Systems (HIS) of only a couple of primary healthcare centers. PAZIO enables app suppliers (yellow squares) to connect to a HIS. It is imaginable that one of the software suppliers develops an application for patients to gain access to their medical files (EHR). Therefore, these systems should be taken into consideration when implementing a portal. It is important to know how such systems can be defined, and what their functionalities are. In addition to applications that have integration with the care provider s HIS (econsult (ec), eappointment (ea)), apps without this integration are offered as well (ementalhealth (emh) for example). Figure 6 Current PAZIO runtime architecture Jurjen Julianus 16

27 3.3.1 Health Information Systems Health Information Systems is an umbrella term for information systems used within the care sector. It refers to both information systems used by hospitals (Littlejohns et al., 2003), but also to information systems used by general practitioners. According to (Berg, 2003a) the term Health Information Systems (HIS) is one of many Patient Care Information Systems (PCIS). Ash et al. (2004) define such systems broadly as applications that support healthcare processes by allowing healthcare professionals direct access to the system. The aim of HIS is to contribute to a high-quality and more efficient patient care. This aim is primarily patient-driven (Haux, 2006). In reality, however, we observe that HIS are not developed to work for patients. Besides, they are particularly used as a means for management and administrative support including invoicing. Berg (1999) discerns two modest yet powerful roles in healthcare work. Professionals and organizations are enabled to accumulate data-elements into meaningful information and these systems help to coordinate complex processes of interaction and collaboration. Information systems offer the opportunity to span network over a larger number of entities. Larger numbers of data can be collected and used by the same professional. Moreover, even events in distinct spaces and times can be brought together. (Berg, 1999; Berg, 2003b). As a result, higher level of process complexity can be achieved. In later research Berg (2003b) refers to the above HIS s qualities as electronic information handling and electronic coordination. Health information systems are considered highly relevant for the achievement of high quality care. Imagine for instance a healthcare professional, who does not have access to necessary information, this can have fatal consequences for the patient (Haux, 2006). In addition, Ash et al. (2004), state that it is obvious that HIS will ultimately be necessary for high quality care delivery. This is confirmed by Boonstra et al. (2011), who argue that HIS are the means towards higher quality care. We define HIS as follows for the purpose of this research: Applications that support administrative and healthcare processes by allowing healthcare professionals and their assistants direct access to patient information. In addition to the achievement of higher quality care, information system services for healthcare purposes are increasingly established as ways to achieve more efficiency and Jurjen Julianus 17

28 lower costs (Ash et al., 2004; Boonstra et al., 2011). However, research conducted in the United States, The Netherlands and Austria pointed out that there are many instances in which the HIS seems to foster errors instead of reducing their likelihood. Ash et al. (2004) divide these errors in two broad categories: errors in the process of entering and retrieving information and errors in the communication and coordination process. The system of people, technologies and organizational routines then seems to be weakened as opposed to the intended strengthening of the HIS applications (Ash et al., 2004). HIS applications have the best results when they automate routine work, however, healthcare processes are often complex rather than routine. The researchers state that many of these errors are the result of highly specific failures in HIS design and/or implementation. They, however, focused their research on errors that occurred from a mismatch between the functioning of the HIS and the demands of the healthcare work. Only when implementers of HIS give thoughtful consideration to design and implementation issues, then HIS will be able to fulfill their promise (Ash et al., 2004). As mentioned, healthcare work is rather complex in nature. Due to the complexity, healthcare work does not come in logically structured flowcharts. Patient trajectories are rather uncertain, a lot of contingencies exist. This insight should be heeded; else the information system will embed its mechanistic properties into the contingent and complex environment of healthcare work (Berg, 2003b) Electronic Health Record Electronic Health Records are defined by the International Organization for Standards (ISO). According to their definition, EHR is a repository of patient data in digital form, stored and exchanged securely, and accessible by multiple authorized users. This research follows the EHR definition posed by ISO (2004): The EHR consists of retrospective, concurrent and prospective information, which has the purpose to support the continuation of efficient and quality integrated healthcare. EHRs are used within primary, secondary and tertiary care institutions. Primary care is provided by a general practice, secondary care involves medical specialists and tertiary care is provided by a team of specialists in a major hospital (Häyrinen et al., 2008). Jurjen Julianus 18

29 Electronic Health Record in the Netherlands On May 20 th of 2008, the Dutch government created a bill for modification of the law on the Dutch Social Security Number. The national electronic health record (EHR) was supposed to be linked with the social security number. The bill was accepted by the Chamber of Deputies, and it obligated healthcare providers to comply their data and security measures according to LSP (Landelijk Schakel Punt) standards. Moreover, the LSP promised to enhance data integration among different healthcare professionals. However, in 2011, despite of the concessions that had to be done, the proposal was rejected by the senate (Website Senate, 2011). Reasons for rejection are primarily issues concerning security of data and privacy. Rejection of the bill has caused healthcare organizations and Dutch politicians to think different about ehealth applications for the future. Recent research conducted by the NIVEL (Dutch Institute for research in healthcare) and Academic Medical Center Amsterdam pointed out that healthcare providers find it important to have control over patient data when it is transferred electronically. Therefore, they prefer to roll-out electronic patient filing on a regional level. On a smaller scale more control is offered, which in turn nurtures the degree of trust (Ploem et al., 2011). In this chapter, portals, health portals and related systems have been discussed and defined. Furthermore, it can be concluded that a health portal has limited functionality if it is not integrated with the underlying HIS. Literature also indicates that HIS do not always align with the needs of the healthcare organization, and that thoughtful consideration should be given to alignment. The following section continues with describing the literature regarding IT implementation. Jurjen Julianus 19

30 4 PORTAL IMPLEMENTATION It is important to define what the characteristics of IT implementation are. First, IT implementation in general will be discussed to understand which phases can be distinguished and which facets are involved. Second, stakeholder analysis theory and theory regarding project governance will be discussed. 4.1 IMPLEMENTATION METHODS Implementation of Information Technology (IT) in organizations is more than only implementing hardware and software. Implementation of IT involves organizational changes. Therefore, it is arguable to assume that IT implementation in essence is a form of managing change. This is acknowledged by Cooper & Zmud, (1990) who theorized IT implementation stages based on the most basic model of change by Lewin (1951). Technology has impact on an organization, simultaneously, the organization determines the use of the technology. Therefore, it is a reciprocal relationship in which the variables are interdependent (Boonstra et al., 2011; Boonstra, 2011). In other words, there is interaction between the system and its stakeholders. Before implementation First of all, there has to be focus on understanding what powerful stakeholders expect from the implementation. Production of a Terms of Reference document is a critical step in the period leading up to implementation (Boddy, Boonstra, & Kennedy, 2009). This document should include: Aspect What is to be done Who is to be involved How will it be done When it will be done Content Intended activities and desired outcomes. Including CSFs, indicators for a successful implementation. Names, roles and responsibilities of the main project team, and others whose support is required. Which approach to use, which resources, costs incurred. A main schedule of activities at a high level Table 2 Aspects of Terms of Reference (Boddy et al., 2009) Jurjen Julianus 20

31 Implementation According to (Cooper & Zmud, 1990) implementation, viewed from a diffusion perspective can be defined as an organizational effort directed toward diffusing appropriate information technology within a user community. A fundamental IT implementation stage model is proposed by Kwon & Zmud (1987; cited in Cooper & Zmud, 1990), which has its foundation in the three basic stages of organizational change: Unfreeze Change Refreeze (Lewin, 1951). The following stages for IT implementations have been identified by Kwon & Zmud (1987; cited in Cooper & Zmud, 1990). The stages consist of a process description and a specific end point. Stage Process Product Initiation Adoption Adaption Acceptance Routinization Infusion Scanning of organizational problems or opportunities. Pressure for change evolves from either organizational need (pull), technical innovation (push) or both. Get organizational backing for implementation through rational and political negotiations IT application is developed, installed and maintained. Processes are revised and users are trained in new procedures and in the IT application. Members in the organization are induced to use the IT application Usage of the application is encouraged as a normal activity Increased organizational effectiveness is obtained. Application integrates in more complex work processes Table 3 IT implementation stages Cooper & Zmud (1990) A match between the IT application and its application in the organization. Decision to invest resources necessary to accommodate implementation effort. IT application is available for use in the organization. The application is employed in organizational work the IT application is no longer perceived as something out of the ordinary Application is used to its fullest potential Jurjen Julianus 21

32 Taking a closer look to the stages proposed by Cooper & Zmud (1990) we see that during the stages, there is continuous interaction between the IT application, the organization and the members of the organization. The effectiveness of any technology driven change process relies on the interdependence between the technology, the organizational context, and the change model used to manage the change (Orlikowski & Hofman, 1997; cited in Legris et al., 2003). These elements are represented in a structurational model. In such a model, IT implementation is modeled as a complex and dynamic socio-technical system (Boonstra & Van Offenbeek, 2010; Boonstra, 2011). Interaction takes place between the IT application, the organizational context and the stakeholders during the innovation process. Figure 8 illustrates the aligned elements of IT innovation. The figure consists of the following elements: The innovation process, the IT innovation, stakeholders, context and their interaction (marked by the arrows). The solid lines represent the scope of the research, the dotted lines are beyond this research s scope. Figure 7 Aligned elements of IT innovation (Boonstra, 2011) Interaction in structuration theory (Giddens, 1984,1993; cited in Boonstra, 2011) is based on the duality of structure, which means that characteristics of the IT innovation are both the means for and the outcome of human interaction. (Boonstra, 2011). Two concepts that have their fundament in duality of structure are technology appropriation Jurjen Julianus 22

33 and social multidimensionality (Boonstra & Van Offenbeek, 2010). As said, technology appropriation is based on the two-way interaction of the IT innovation and the user. On the one hand, this soft-deterministic view does acknowledge that technology influences human behavior. On the other hand, users of technology have interpretive flexibility, which means that users build up their own motivations for their actions (Boonstra & Van Offenbeek, 2010). People, thereby, reproduce the structural properties of technology because they can either adapt their methods to the technology or adjust the technology to their methods (Boonstra & Van Offenbeek, 2010; Boonstra, 2011; Orlikowski, 2008). Social multidimensionality refers to the notion that technology appropriation takes place within a certain organizational context which has its own structural properties (Boonstra & Van Offenbeek, 2010). The institutional context of the stakeholders determines cognitions, norms and values where they can draw upon. Since the context of different stakeholders may overlap or differ considerable, tensions between the stakeholders can arise (Boonstra & Van Offenbeek, 2010). Therefore, social multidimensionality seems crucial in ehealth implementation research. Different views and interpretations of stakeholders will cause some people to support the innovation, and others to exert resistance (Boonstra & Broekhuis, 2010). It seems obvious that people do not choose a side in isolation. Coalitions are formed as a result of people influencing each other regarding the IT innovation implementation (Walsham, 1997; cited in Boonstra, 2011). Taking the IT implementation literature into consideration, it is safe to conclude that the stakeholder is perceived important. Stakeholders often have different expectations of an innovation. They interpret the innovation from their own perspective, and might attach different meanings to it. In order to develop a meaningful understanding of IT innovations, insight should be gained into interpretations and power relations of stakeholders (Boonstra & de Vries, 2005). Managers must be willing to intervene in the political systems surrounding IT innovation (Boonstra, 2011). In other words, it is important to exercise stakeholder management. However, before stakeholder management can be exercised, stakeholders have to be identified first. Thereafter, a stakeholder analysis needs to be conducted. Jurjen Julianus 23

34 The next section introduces the concept of stakeholder analysis, which will be applied to two portal implementations later on in the research. 4.2 STAKEHOLDER ANALYSIS THEORY The previous sections described information technology implementations within organizations. We have seen that stakeholders are at least as important as the IT innovation and the organizational context where the innovation fits in. IT implementations are not only famous for their large number of stakeholders (Boonstra & Govers, 2009), but also for the interaction between the stakeholders, the IT innovation and the organizational context (Boonstra, 2011). Since interaction is important for the description of implementation, it is equally important to identify the different stakeholders of an implementation as well as their relationships. For this research we follow the classic definition of stakeholders by Freeman (1984), A stakeholder is any group or individual who can affect or is affected by the achievement of the organizations objectives. For the purpose of this research we will replace the organizations objectives with the project s objectives. Boonstra & Govers (2009) state that within healthcare, such implementations often involve large numbers of stakeholders which have different degrees of autonomy and expertise. They argue that particularly for healthcare organizations, misfits in expectations and established features of the organization may lead to resistance of the stakeholders. The different degrees of autonomy and expertise among the stakeholders may bring the problem of colliding rationalities. Heeks (2006) has identified three archetypes of rationalities which exist within IT implementation in healthcare. Technical rationality is the technical worldview of IT professionals and IT suppliers. Managers within healthcare often operate from legal, financial and control perspectives, the managerial rationality. Medical rationality refers to the wish of medical professionals to put patients at the center of the system (Heeks, 2006). These rationalities may collide and may then easily lead to implementation and usage failure. The incentive for conducting a stakeholder analysis thus seems evident. According to Goodpaster (1991), a stakeholder analysis consists of Jurjen Julianus 24

35 two elements: perception and analysis. Perception is fact gathering about options available and about short- and long term implications. Stakeholder analysis is the analysis of these implications. Specific attention should be paid to affected parties and the goals, objectives, values and responsibilities of decision makers Characterization of stakeholders For the purpose of characterizing the stakeholders we will follow the stakeholder salience theory (Mitchell et al., 1997). In this theory, stakeholders have power, legitimacy and urgency. The theory identifies that stakeholders possess one or more of three relationship attributes (Boonstra, 2006). These attributes find their origin in the actions of the different stakeholders towards each other. Power equals the extent to which a group can exert its coercive, utilitarian or normative means to force its will in a relationship. Coercive power is based on physical resources of force or violence, for instance, the use of a gun. Utilitarian power finds its basis in material or financial resources. Normative power is based on symbolic resources such as esteem, love or acceptance. Legitimacy is defined as the general perception that the actions of an entity are desirable, proper or appropriate within some socially constructed system of norms, values, beliefs and definitions, it also refers to claims that have a legal foundation. Urgency refers to the extent to which a stakeholder claim calls for immediate attention, delay in attending to the claim is unacceptable to the stakeholder (Mitchell et al., 1997). Characterization of stakeholders according to this theory acts as fundament for managerial implications of an implementation. Moreover, the model contributes to the potential effectiveness of managers in a multi stakeholder environment. Combination of the relationship attributes power, legitimacy and urgency leads to the following seven stakeholder types (table 4). Stakeholder type Characteristics 1. Dormant stakeholder Have the power to impose their will, they however, have no legitimacy or urgency to use the power. 2. Discretionary stakeholder Possesses legitimacy but has no influential power. Jurjen Julianus 25

36 3. Demanding stakeholder Has urgent claims but has no power or legitimacy to influence the project. 4. Dominant stakeholder Have both power and legitimacy. Their influence in the project is assured since they are able to form dominant coalitions. 5. Dependent stakeholder Have a lack of power, and thus rely on other to fulfill their legitimate and urgent claims. 6. Dangerous stakeholder Possesses power and urgency. Without legitimacy, this is a combination that can be considered as dangerous for a project. 7. Definitive stakeholder Has the possession over all three relationship attributes. 8. Nonstakeholder Table 4 Stakeholder typology (Mitchell et al., 1997) Figure 8 Visual representation of stakeholder typology (Mitchell et al., 1997) Mitchell et al. (1997) predict that the salience of a stakeholder to the project management is low if one of the relation attributes is present, moderate if two attributes are present and high if all three attributes are present. Mitchell et al. (1997) define salience as: Jurjen Julianus 26

37 The degree to which managers give priority to competing stakeholder claims In other words, it means identification of whom or what really counts. As organizational change projects are dynamic in nature, relationships can evolve. A stakeholder s relationship attributes can thus change over time as well. Moreover, stakeholders can even acquire missing attributes themselves. 4.3 PROJECT GOVERNANCE Since a PAZIO implementation can be characterized as a project for the stakeholders who are involved, it is important to address the project governance. According to Young (2005), projects can only be effectively governed if the most fundamental concepts are considered by the management of the organization subject to the particular project: Projects are undertaken to realize benefits Benefits are seldom realized during the implementation process Benefits tend to be enabled by IT projects; however, they can only be realized by complementary organizational change. Young (2005) distinguishes between hard dimensions of governance, for instance steering committees or governance processes, and soft dimensions of governance, for instance will to change, and communication / influential skills of the top management. The latter was considered more important in achieving a successful project. Figure 9 Project governance framework (Young, 2005) Jurjen Julianus 27

38 The framework by Young (2005) shows that projects are undertaken to achieve benefits. In addition, it imposes that the board of managers has a clear overview over the business processes and over the project which should change those business processes. The model identifies six inter-related project governance activities that should be undertaken by the board of managers. Governance activity Initiate / Evaluate What is involved? An evaluation of the potential benefits and risks should be conducted. A business case should be prepared, and eventually approved. Support motivation Support structure How much organizational change is necessary? Furthermore, a project sponsor needs to be found. Such a sponsor needs passion, ability and skills to make it happen. Underlying issue here is how to motivate the stakeholders of the project. Monitor project Monitor - benefits A mechanism must be found by the board to monitor the sponsor of the project, because it would be a conflict of interest if the sponsor monitored themselves. Monitoring has to occur on both organizational level and project level. Table 5 Six inter-related project governance activities (Young, 2005) The previous chapter has shown that implementation of IT is seldom possible without taking the people involved into account. Moreover, some authors argue that it is conditional to manage stakeholders in IT implementation properly. The subsequent section describes the actual implementation process of two different health portals in two healthcare centers based on the implementation theory provided in this chapter. Jurjen Julianus 28

39 BACKGROUND SHORT DESCRIPTION OF ORGANIZATIONS UMC Utrecht The University Medical Center Utrecht is one of the largest public healthcare institutes in The Netherlands. The organization consists of more than 10,000 employees. Their mission is stated as follows: The UMC Utrecht is a prominent, international university medical centre where knowledge about health, disease and care, for patient and society is created, tested, shared and applied. (Website UMC Utrecht, 2011) The UMC Utrecht is main sponsor of the PAZIO project, and they provide (human) resources to the project. VitaValley foundation VitaValley is an innovation network in the care sector. Together with partners VitaValley initiates, supports and implements innovations in the Dutch care sector. Their objective is to achieve social impact with innovations. The partner model is chosen, because VitaValley believes that only cooperation between different partners will lead to successful implementations of innovations. VitaValley provides (human) resources for the PAZIO project. Imtech Imtech N.V. is an international supplier of integrated software solutions. With over 27,000 employees in Europe, they aim to provide total solutions that lead to better business processes and higher revenues. Responsibility for the PAZIO project lies at the Imtech ICT Integrated Solutions division. They have built the PAZIO platform, and are now still involved in the further development. Imtech is also part of the PAZIO consortium. Pharmeon Pharmeon is a Dutch software company specialized in web services for healthcare. They offer healthcare providers an own website, and provide the additional support. Pharmeon is one of the first suppliers of applications for the PAZIO platform. They have developed econsult and eappointment with a single sign on for the PAZIO platform. Jurjen Julianus 29

40 PharmaPartners PharmaPartners is with a market share of 33% the market leader HIS supplier in The Netherlands. PharmaPartners offers its own health portal (MijnGezondheid.net) to their customers. They can, however, be characterized as partner of PAZIO, since they integrate their health portal with the PAZIO platform. Leidsche Rijn Julius Gezondheidscentra The Leidsche Rijn Julius Healthcare center is a primary care center which consists of four locations, and is part of the PAZIO consortium. Within the Leidsche Rijn Julius Gezondheidscentra 24 general practitioners are employed. They have strong relationship with the UMC Utrecht, in a sense that they are often subject to piloting innovative project for primary care purposes. Gezondheidscentrum Maarssenbroek Gezondheidscentrum Maarssenbroek is a primary healthcare center, which has two locations. This center is the second pilot location of PAZIO. They, however, chose to implement the portal solution MijnGezondheid.net of PharmaPartners first, with the option to embed it in the PAZIO platform. The healthcare center employs 11 general practitioners. Jurjen Julianus 30

41 Figure 10 Organizations involved in PAZIO project Pilot location HIS supplier Portal supplier App supplier LRJG PharmaPartners Imtech (PAZIO) Pharmeon GCM PharmaPartners PharmaPartners (MGn) PharmaPartners (MGn) Table 6 Software suppliers at pilot locations Jurjen Julianus 31

42 5 IMPLEMENTATION OF PAZIO The healthcare sector differs from other industry sectors. Boonstra & Govers (2009) summarize the differences of the care sector with regular industry based on a hospital. First, the objectives of hospitals are very diverse, they aim at care and cure for patients as well as training and education of new employees. Furthermore, they have an economic objective because of the fact that their costs have to be covered as well. Second, processes in hospitals are different because of their higher complexity than processes in other industries. Third, the workforce in hospitals can be considered as very diverse in power, expertise and autonomy (Boonstra & Govers, 2009). The following section describes the actual implementation process of PAZIO within Leidsche Rijn Julius Gezondheidscentra and the actual implementation process of MijnGezondheid.net in Gezondheidscentrum Maarssenbroek. Afterwards, we are able to indicate whether the aspects mentioned by Boonstra & Govers (2009), are equally applicable in smaller healthcare organizations than hospitals. Moreover, an image can be drawn about the parallels and differences between theory and practice. 5.1 LEIDSCHE RIJN JULIUS GEZONDHEIDSCENTRA IT implementation literature indicates that it is important to create a terms of reference document prior to the actual implementation. Such a document should help to gain insight in what powerful stakeholders expect from the implementation. In addition, it should provide guidelines for the implementation process. Within the case of the PAZIO implementation in the Leidsche Rijn Julius Gezondheidscentra (LRJG) such a document was constructed by the project team (Rietveld & Dekker, 2009). The document can be regarded as an implementation approach -plan, it aims to describe the implementation and to inform all parties involved about what is expected from them. The document defines the project, what product to deliver, responsibilities, risks involved, global planning schedules and budget plans. Referring to the perspective of Boddy et al. (2009) (see 4.1), the document meets the requirements for three of the four aspects. The what, who and when questions have been answered, however, the how question remains unresolved in the document. Separate plans have been constructed in order to deal with the how part. Jurjen Julianus 32

43 Figure 11 PAZIO Time line Jurjen Julianus 33

44 According to literature available in the IT implementation field, implementations can be separated in phases or stages. The following section describes the implementation process at LRJG based on the IT implementation stages identified by Cooper & Zmud (1987). Originally, the PAZIO project has its foundation in the identification of fragmentation with regard to online services for patients. Worth mentioning is that LRJG is partner of the UMC Utrecht in providing an academic setting for primary healthcare. There are two major reasons for initiation of this project. First, LRJG is an innovative healthcare center that was eager to start with online services for their patients. Another incentive for the center to start with online services is the competition they are in with other healthcare centers in the neighborhood. There already were online services available in the market; however, these services were not yet integrated with each other, or with a HIS. Second, since LRJG is the academic primary healthcare setting of the UMC Utrecht, lots of research is conducted together. Earlier, a digital environment was already created to be able to obtain data from patients more easily. The problem for the patient was recognized, different systems with different logins. As a result, both UMC Utrecht and LRJG agreed to create a portal for both patients and researchers which should integrate with the HIS. This idea arose in the first months of the year 2006; however, it took more than a year to allocate sufficient partners to start. Mid-2007 the first official PAZIO meeting was arranged. By that time, VitaValley and VitalHealth software were involved, because they were occupied with the development of a similar concept (Product manager PAZIO, interview, November 28 th 2011). Furthermore, Imtech was involved as software builder. Involvement of Imtech was not surprising, since they are partner at VitaValley s advisory board. At this stage, a consortium was formed, and each partner made an investment in the project. In addition, the partners elaborated on the concept. A PAZIO project team, with members from UMC Utrecht, VitaValley and an external marketing professional was formed to enhance the process of development and to support the future implementation processes. In this case, the pressure for change evolved from organizational need in LRJG. Particularly their competitive drive points in this direction. It seems clear, that at the end of this stage, organizational needs, and functional needs of the IT application were Jurjen Julianus 34

45 aligned. From this point forward, the functional demands were translated into actual software. During the adoption stage, the realization of PAZIO (v1.0) for LRJG started. Imtech started building the portal in the beginning of The approach for building this portal did not yet include architecture possibilities for scaling up to other healthcare centers. A pilot had to be started to be able to show results. In other words, the concept needed to be proven in a live environment (Product manager PAZIO, interview, November 28 th 2011). Meanwhile, grant applications were prepared by the PAZIO team, in order to obtain funds for the development of a more fundamental PAZIO platform. Furthermore, employees in LRJG Parkwijk were informed by the implementation manager, that soon the portal would be introduced. Resources were allocated for supporting the portal implementation, and responsibilities were made clear. Moreover, top management support during the implementation was assured. Then, Early-2009, financial problems arose within LRJG. For this reason, the management team was replaced by an interim management that was supposed to solve the financial problems (Product manager PAZIO, interview, November 28 th, 2011) (Programme manager PAZIO, interview, December 1 st 2011) (Minutes Consortium Meeting, January 5 th 2009). This resulted in a short-term focus of the interim management towards improving the financial situation, which in turn resulted in a lack of commitment for the portal implementation (Minutes Consortium Meeting, April 22 nd 2009). On October 1 st of 2009, the interim management was replaced by a new board of managers. The first pilot started in December 15 th 2009 at location Parkwijk (Minutes Consortium Meeting, November 9 th 2009). The implementation project started earlier. PAZIO was developed; it was installed, and ready for use. It included econsult 1, Research Online and Self-management for diabetics 2. The product that arose was now in use by employees of LRJG Parkwijk, however, according to their colleagues at Vleuterweide, this system was not sufficient user-friendly 1 Pharmeon BV 2 VitalHealth Software Jurjen Julianus 35

46 to work with. Furthermore, they thought that insufficient attention was paid to their opinions in the development phase (General practitioner LRJG, interview, September 6 th 2011). While this standalone solution implementation proceeded in LRJG, grant applications for PAZIO were approved in October 2009 by the municipality of Utrecht, the province of Utrecht and the Dutch Ministry of Economic Affairs. These grant applications included plans for a more fundamental approach, as opposed to the approach that was chosen to realize the portal only for LRJG. From this point in time forward, the PAZIO project team committed themselves to develop a platform, to which more applications could be added by third party application developers. Perhaps more important was the functional demand that it should be easy to connect more healthcare centers to the platform. The platform was redeveloped, in a sense that the architecture of the platform was adjusted in such a way that it enabled multiple healthcare centers to connect to it. Parallel to the modification to the platform, an application supplier 3 was asked to develop an application for eappointments and to extend their current econsult application for PAZIO. By the time these modifications were finished, the interim management within LRJG was replaced by a new management team. Meanwhile, the pilot in Parkwijk continued, but the PAZIO project team decided to phase out this pilot. A second adoption stage arose, because a second implementation project was started in June of The pilot location was changed from Parkwijk to Vleuterweide. This decision was made because of the high personnel turnover rates in Parkwijk. Employees of location Vleuterweide were informed by the new management and the implementation manager, and a project group (or support structure; Young, 2005) consisting of a general practitioner, the senior doctor s assistant, the internal IT specialist and the implementation manager was formed. The general practitioner was appointed the responsibility for successful implementation and the senior doctor s assistant was made responsible for the operational tasks regarding the portal. The project group conducted a meeting once per two weeks. 3 Pharmeon BV Jurjen Julianus 36

47 Once the new PAZIO (v2.0, recall from figure 11) platform was developed, LRJG Vleuterweide started to use it. As mentioned earlier, only econsult and eappointment functionality were in use at this moment, and integration with the HIS was not yet arranged. User manuals were created, and employees were trained in using the portal. Initially, the employees within the center were uncertain in using the system. They were not quite satisfied with the functionality of the system, and used their demands for additional functionality to delay the actual kick-off of it. The implementation manager intervened by setting August 15 th 2011 as the date for kick-off (Implementation Manager PAZIO, interview, November 21 st 2011). From that date forward, patients were encouraged to use the online services in three ways: first, they were told the advantages of the portal during physical consultations. Second, a letter with information was sent to all patients. Third, door-to-door flyers were spread in the neighborhood in order to create awareness (Project group meeting LRJG, September 6 th 2011 & October 1 st 2011). One of the interviewed patients did only receive the letter; the other interviewee received the and took a flyer home from the healthcare center. Both patients found the communication means used fine for the purpose of promoting the health portal (Patient X, interview, January 18 th 2012) (Patient Y, interview, January 18 th 2012). It turned out that the concern of the employees in the center was not without reason. The software was in fact not sufficiently solid, and problems arose (Project group meeting LRJG, September 6 th 2011). The majority of these issues were issues in the care providers part of the portal. As a result, the second adaption phase can be characterized as a development phase as well. With input from the responsible general practitioner, the senior doctor s assistant and the implementation manager, the econsult and eappointment modules are improved incrementally by the application supplier. Furthermore, patients did notice these problems as well; one of the interviewees indicates that he had lots of problems with scheduling an appointment by means of the portal. This eventually resulted in calling the doctor s assistant for an appointment (Patient Y, interview, January 18 th 2012). Jurjen Julianus 37

48 Despite the effort of using multiple channels to encourage the usage of the online services, the number of users is 3% of LRJG Vleuterweide s population (DigiD export users LRJG, November 7 th 2011). Therefore, the project team decided to send an electronic mailing to all patients of the center. This mailing was sent on the 29 th of November As mentioned, the usage of the online services among patients is too low to adjust work processes in favor of the portal (Number of online scheduled appointments and econsults requested, September 2011 November 2011). The internal Project leader is enthusiastic about the implementation process, she is proud that LRJG is able to offer such a service to their patients. However, due to the lack of integration of the portal with the underlying HIS, the doctor s assistants have to do redundant work, they are forced to leave certain time slots open because of possible eappointments (Senior assistant LRJG, interview, September 6 th 2011). According to the senior assistant at LRJG (interview, September 6 th 2011) this interim solution should not take too long, because she expects that other assistants will then throw the towel. However, the assistants do attempt to motivate each other in working with innovative applications such as PAZIO. Patient Y (interview, January 18 th 2012) indicates that he expects more time slots to be available in the eappointment application, before it can be of added value. Due to the limited HIS integration, the availability of time frames is still limited as well. Mid-December 2011, 7% of LRJG Vleuterweide s patient population is PAZIO user (DigiD export users LRJG, December 13 th 2011). Despite all the good intentions, this implementation process is not near its end. For the majority of the employees, working with the system is not yet part of their routine. Therefore, it is safe to conclude that the implementation has not yet reached the stage of routinization. Due to this conclusion, we are not able to describe the infusion stage based on this case. 5.2 GEZONDHEIDSCENTRUM MAARSSENBROEK Healthcare center Maarssenbroek (GCM) is a multidisciplinary healthcare center and has the ambition to utilize the online channel to communicate with their patients by means of multiple applications. By the end Jurjen Julianus 38

49 of 2010 the management of GCM initiated cooperation with PAZIO (CEO GCM, interview, December 8 th 2011), because they believe in the opportunity that PAZIO may be able to become the unified portal for their communication to patients. Conversations with the PAZIO team were arranged, and soon both PAZIO and GCM came to the agreement to roll out the second PAZIO pilot in Maarssenbroek (January 2011). Meanwhile, an implementation document was constructed by the PAZIO team (van Well, 2010). Initially, the document focused on implementing PAZIO with econsult, eprescription and eappointment functionality. However, at that point in time, econsult and eappointment were still in development. Moreover, the development of eprescription did not even start yet. The document, furthermore, consists of a product definition (what is to be implemented), a project definition (goals, approach, scope and results), project activity planning, project risks, and responsibilities/accountabilities for people involved. This indicates that the document complies with the guidelines set by Boddy et al. (2009), who argue that such a plan should include answers to the what, who, when and how questions of an implementation. Despite the completeness of the implementation plan, the implementation did not take place. The econsult and eappointment software for the PAZIO platform was still in development, which delayed the start of implementation at GCM. As a result of the delay, the management of GCM decided to start conversations regarding a health portal with their HIS supplier PharmaPartners (General practitioner GCM, interview, December 20 th 2011). PharmaPartners has its own portal solution, which is perfectly aligned with their HIS. In addition, PharmaPartners portal has electronic health record functionality as well as econsult and eappointment functionality. In March 2011 a second initiation process is started by the management of GCM, and agreements with PharmaPartners were made. Although this solution may seem as a replacement for the PAZIO portal, this is not the case. PharmaPartners portal is a solution which is only available for the HIS of a general practitioner; it does therefore not comply with the needs of GCM. This is why the management of GCM decides to initiate two routes from that point in time forward. First, the implementation of PharmaPartners portal MijnGezondheid.net was started. Second, the management wants MijnGezondheid.net to integrate with the PAZIO platform in the future; therefore, triangle conversations with PAZIO, GCM and PharmaPartners jointly were facilitated (General practitioner GCM, interview, December 20 th 2011). Jurjen Julianus 39

50 PharmaPartners was asked to make some modifications to their portal, which are necessary because of the future integration with PAZIO. In addition, GCM wanted MijnGezondheid.net to be white-label, in order to create a familiar online environment for their patients. An ehealth steering committee was already established in order to ensure integration between the different ehealth initiatives and the current ICT practices at GCM (General practitioner GCM, interview, December 20 th 2011). A strategy of initially addressing only a small number of patients was chosen. This was the result from feedback meetings that were arranged between March 2011 and September 2011 by the steering committee of GCM. The internal project leader also noticed that his colleagues wanted to retain some extent of control. Particularly, opening up parts of the health record caused this perceived need for control among general practitioners. Therefore, GCM invested in extra sessions to make the portal functionality familiar for the employees (General practitioner GCM, interview, December 20 th 2011). The work processes are changed in consultation with the general practitioners and doctor s assistants. Familiar structures in the organization were left as they were. For instance, the senior assistant traditionally has a coordinating role, she now coordinates the subscription procedure and the econsult distribution. Furthermore, there was a kick-off meeting on September 29 th 2011, in order to let all employees know that the portal was operational. Initially, patients were invited to make use of the portal, these patients were pre-selected by the general practitioners. By November 2011, this number of patients was extended to 170 patients, due to the limited amount of traffic that was generated by the initial group (General practitioner GCM, interview, December 20 th 2011). In addition, the portal is now open for new subscriptions from other patients. According to the project leader (General practitioner GCM, interview, December 20 th 2011), the other general practitioners are becoming more flexible in opening up the health record of their patients. Reason for this is the eagerness they have developed to work with the portal functionality. Employees at GCM now start to realize that the only way toward routinization is generating traffic. Jurjen Julianus 40

51 They were, however, disappointed in the eagerness of their patients to use the portal (General practitioner GCM, interview, December 20 th 2011). In their pursuit toward routinization, GCM will attempt to increase the usage of the portal among their patients. The next couple of weeks will be marked for marketing campaigns in order to create the same eagerness among patients. It is not possible to describe the infusion stage, since the routinization stage has not been fulfilled yet. Jurjen Julianus 41

52 6 STAKEHOLDER ANALYSIS OF PAZIO IMPLEMENTATION This chapter covers the identification and analysis of stakeholders in the PAZIO implementations at LRJG and the MijnGezondheid.net implementation at GCM. The descriptions of the actual implementation processes (chapter 5) are used to identify the stakeholders. Furthermore, the objective, actions and influences of the stakeholders in each implementation will be analyzed in order to obtain a clearer image of the implementation process. Finally, the outcomes of the two analyses are compared and a more general image of portal implementation in a primary healthcare center is constructed. The description of the actual implementation processes within LRJG and GCM indicate that a PAZIO implementation always consists of two major components. First, a hard component, implementation of online software and second, a soft component; process change. For both the hard and the soft side of the implementation yields: people are necessary to fulfill and support the process. In order to make an implementation successful, the different groups of people in an implementation need to be orchestrated. Congruence of objectives and interests needs to be achieved. This can be achieved by exercising stakeholder management. First a stakeholder analysis of the PAZIO implementation at LRJG is provided; second a stakeholder analysis of the MijnGezondheid.net implementation at GCM is discussed. 6.1 LEIDSCHE RIJN JULIUS GEZONDHEIDSCENTRA Before stakeholders can be subject to an analysis, they have to be identified first. Outcome of the stakeholder analysis will be used as input for stakeholder management implications Identification of stakeholders Hard component The software platform for PAZIO is delivered by Imtech NV, an international supplier of integrated ICT solutions. Imtech provides the app store concept, and also provides the Jurjen Julianus 42

53 maintenance for the user interface. They are stakeholder in implementation because they are required by the PAZIO project team to facilitate the initial set-up of the platform for a particular healthcare center. From now on we will refer to platform supplier. Applications within the PAZIO platform app store are developed by other software companies, so called app suppliers. One of them is Pharmeon BV, they have built software modules for econsult and eappointments. PAZIO has the ambition to be able to mobilize multiple suppliers per type of application. Healthcare centers are then enabled to choose the applications that align with their needs. Perhaps the most challenging of this particular PAZIO implementation, is the integration of applications within the PAZIO platform with the underlying Health Information System (HIS). Thus, cooperation of the HIS supplier is in principle necessary for successful implementation. This implies that some form of cooperation is required between the HIS supplier and the app supplier. Figure 12 Aligned elements of the PAZIO implementation at LRJG Soft component Within LRJG, there are two groups of people that actually have to work with the portal: the general practitioners and the doctor s assistants. Center managers do not have to work with the portal; however, they may have demands and influences concerning implementation. Therefore, center managers are stakeholders as well. Different or even Jurjen Julianus 43

54 colliding interests among stakeholders seem inevitable. Therefore, implementation consultants are hired for the streamlining of the process. Of course, they are supported and coordinated by the PAZIO project team. The PAZIO project team consists of employees from both VitaValley and UMC Utrecht, they are occupied with development and implementation of PAZIO. Last but, certainly not least are the patients in the implementation process. Since a health portal s initial target is to be a communication channel for patients to their care provider, the group of patients can be considered as stakeholder as well. Figure 13 summarizes the elements that are involved in the PAZIO implementation at LRJG Stakeholder analysis The stakeholder analysis addresses sub questions four, five and six. It aims to describe the interests and relationships of the stakeholders and subsequently how their positions and actions influence the implementation process. All stakeholders are separately discussed. This section consists of the essential findings during analysis. The entire analysis can be found in the appendix B. Board of managers The original board of managers think that a health portal is an important link between the care supply and the patient, in a sense that substitution of work should occur with regard to logistical processes. Because they felt that PAZIO would increase efficiency, and therefore higher care quality could be achieved, it can be concluded that they had a patent interest in successful implementation. The original board of managers can therefore be characterized as definitive stakeholder. by March 2009 the original board of managers was replaced by an interim management team. Due to this change, focus shifted from PAZIO to other aspects in the healthcare center. From that point in time, the board of managers became dangerous stakeholder. In October 2009 the interim management was replaced by a new board. The new board was determined to revitalize the project, and delegated the responsibility for the PAZIO project to a general practitioner in Vleuterweide. The board is then dormant stakeholder. Jurjen Julianus 44

55 General practitioners Interest in implementation of the general practitioners is especially provision of an additional means for patients to communicate with their general practitioner, which should result in an increase in satisfaction of the patient. They are the ones who actually have to work with the portal, and have the legitimacy to demand certain functionality. However, they lack power and urgency because they are forced by the management to be involved in the implementation; therefore they act as discretionary stakeholders. Doctor s assistants Objective of implementation in this group is increasing accessibility of the center by decreasing pressure on the telephone. Although the fact that doctor s assistants actually use the system and their claims therefore can be characterized as legitimate, they do not have the power to fulfill these claims. Furthermore, the doctor s assistants lack the attribute of urgency, since their claims are not accepted as being important. For this reason, the doctor s assistants are discretionary stakeholder in implementation. Platform supplier The platform supplier is partner in the project consortium, and has the objective to obtain knowledge in the healthcare-ict domain. The platform supplier can be characterized as a dominant stakeholder. They have power, because they are the organization that has delivered a customized and (possibly) unique platform. Legitimacy is acquired by the fact that they are part of the project consortium. Application supplier The application supplier has the objective to provide solid applications for the platform, which can be distributed to other healthcare centers later on. An application supplier of econsult or eappointment can relatively easy be replaced by another supplier, therefore they have limited power. They however, do have legitimacy, because they are involved in the development process as well. This makes the application supplier in the LRJG case a discretionary stakeholder. Jurjen Julianus 45

56 HIS supplier The HIS supplier has the objective to offer an integral ICT solution for their customers (the healthcare centers). As they are the only party that is able to open up their own HIS for portal integration, they can be characterized as quite powerful. This form of power has a utilitarian basis. They have a commercial interest in the ehealth market, therefore their claims are not completely legitimate. There is, however, some extent of interdependence between the PAZIO project team and the HIS supplier, they need each other for the creation of an integral solution. For this reason, the HIS supplier in this implementation can be characterized as a dangerous stakeholder. Project management Their objective is to achieve a successful implementation which enables them to obtain knowledge for PAZIO implementations in other healthcare centers. The PAZIO project team is dependent on all other stakeholders during the implementation, they do not have the power to force their claims to other stakeholders. Furthermore, the project management possesses legitimacy because of the fact that they are the party that connects the other stakeholders in order to create a sustainable health innovation. Urgency is acquired by the fact that claims of the project team can be considered as important, their interdependence with the other stakeholders strengthens their urgency. The project team can thus be characterized as a dependent stakeholder. Patients Last stakeholder in this implementation is patient population of LRJG. Objective of this group is difficult to catch in a unified formulation, because of the mutual diversity. Therefore, this research does not attempt to formulate such a unified objective. During the first three stages of implementation (Cooper & Zmud, 1990) patients are not involved. In these stages of implementation they can be characterized as non-stakeholder. The implementation stages of routinization and infusion (Cooper & Zmud, 1990) cannot be reached without regular usage of the portal by patients. This provides patients the attribute of power, because they can choose whether to use the portal or not. Furthermore their claims can be considered as legitimate since they are customer of the healthcare center, Jurjen Julianus 46

57 which means that it concerns their healthcare. Because patients are customer of the healthcare center, they possess the attribute of urgency as well. So later on in the project (from the acceptance stage to the infusion stage; Cooper & Zmud, 1990), the patient population of LRJG can be characterized as definitive stakeholder in this implementation. Figure 13 summarizes the categorization of stakeholders according to the stakeholder salience model of Mitchell et al. (1997). Figure 13 Stakeholders involved in PAZIO implementation at LRJG based on Mitchell et al. (1997) Problems and lessons learned Perceived problems Different problems were perceived by the stakeholders of this implementation. One of the general practitioners indicated that there were issues with the software: In the beginning there were lots of problems with logging in to the system, referring to the start of the implementation in June-July The senior doctor s assistant adds that she does not mind such problems, as long as their patients do not notice them. Furthermore, she thinks that the lack of integration of the current portal software with the HIS causes the work they do to be inefficient. Due to the lack of integration, the system now forces us to work less efficient than before. (Senior assistant LRJG, interview, September 6 th 2011). The Jurjen Julianus 47

58 medical manager of LRJG confirms this by stating: Every time, we see that the technical hick-ups cause the largest bumps in the road during such implementation processes. He, however, thinks that the portal software is easy to work with for their employees (Medical manager LRJG, interview, September 6 th 2011). Furthermore, he adds: We don t want the general practitioner to login to PAZIO, because the basic functionalities should be made available by means of the HIS. The implementation manager states that PAZIO is a product which is in development during implementation. Therefore, issues in the software seem inevitable. However, he is still surprised by the fact that the software hick ups cause such a large amount of delay (Implementation manager PAZIO, interview, November 21 st 2011). Moreover, product manager of PAZIO (interview, November 28 th 2011) argues that the software that is delivered at this moment is below level. Interesting is the view of the application supplier, he finds the implementation expectations at the healthcare center Vleuterweide not well managed. Moreover, he thinks that frustrations of employees at the healthcare center regarding the software could be anticipated by the project team (App supplier representative, interview, December 14 th 2011). The business consultant of the platform supplier acknowledges some technical drawbacks in the development process. He argues such drawbacks to be inevitable in an innovative setting. In addition, he admits that they had too little domain knowledge concerning the care sector: [ ], what is the care sector slow as opposed to the regular businesses. This is acknowledged by the implementation manager and the product manager of PAZIO 4. Based on this analysis we can conclude that each of the stakeholders acknowledge there were problems in the software-category. Another category of problems that can be recognized is the category of organizational problems. Replacement of the management, and anxiety among general practitioners and doctor s assistants to actually start working with the portal caused serious delay in the implementation process. Furthermore, observations during implementation in September 2011 have pointed out that doctor s assistants in Vleuterweide find it hard to work with the portal software, because of the many login passwords (which cannot be changed into passwords that can be remembered more easily), and the many actions that have to be undertaken to be able to schedule an appointment or to answer an econsult. This stands 4 Oral statements Implementation manager PAZIO / Product manager PAZIO Jurjen Julianus 48

59 juxtaposed to the view of their manager who indicates: I do not see any problems in the implementation of changed work processes. (N. de Wit, interview, September 6 th 2011). This also stands in contrast with the view of the sales manager of the HIS supplier in this case: Implementation goes far, in a sense that a lot of energy has to be dedicated to redesign the processes based on the new tools. (HIS supplier representative, interview, December 14 th 2011). What is more is that according to the product manager, an unrealistic implementation approach has been chosen for the second pilot (Early-2011). General practitioners and doctor s assistants were forced to deal with a double login, which resulted in resistance. Furthermore, the implementation manager indicates that he noticed a certain extent of fear for the unknown among the employees in the healthcare center. This resulted in partly withdrawal of employees when the portal was ready for usage. The implementation manager convinced the employees to start using the portal by stating: I am available all week for the purpose of solving problems during the time of the launch. (Implementation manager PAZIO, interview, November 21 st 2011) Afterwards it became clear that actual presence of the implementation manager was not even necessary. A third category of problems is communication. The interviewed general practitioner indicates that there is inertia in the communication process between the different stakeholders. This is confirmed by the manager of LRJG (interview, September 6 th 2011) and the platform supplier, who argues that it is hard to speak each other s language (Platform supplier representative, interview, December 1 st 2011). In other words, they sometimes do not understand each other s business. The analysis of perceived problems confirms that organizational contexts of the stakeholders sometimes may collide. Particularly this is the case for PAZIO, where the organizational contexts vary from healthcare to ICT. Analysis of the different organizational contexts, and how these contexts influence the IT innovation, is beyond this paper s range. Lessons learned Most of the stakeholders acknowledge that they have underestimated the implementation process. When asking the interviewees about the lessons they have learned from the implementation process, most of them indicate responsibility delegation and having a champion -general practitioner as critical for a successful implementation. This Jurjen Julianus 49

60 consistent with the theory of Young (2005) who argues that the sponsor needs the skills to make it happen. Furthermore, literature indicates that IT implementation is in essence a form of managing change. Delegation of responsibilities is an important aspect of managing change. It must, however, be noted that this is not only a process of implementation but also a process of development. Noteworthy is the fact that the project management, represented by the project leader and the product manager both indicate that it should have been better to start implementation in a different center than LRJG, because of the financial problems that arose. The financial problems caused a lack of focus toward the implementation of the portal. If the implementation was performed by the stages of Cooper & Zmud (1990), the project management could have known this was coming, since the initiation phase requires an indication of the organizational problems and opportunities. The representative of the HIS supplier continues by stating that In this stage, implementations should take place at those healthcare centers, where the employees feel a sense of urgency. The so-called early adopters. The business consultant of the platform supplier adds that A lot of patience is needed in order to succeed. Literature does not explicitly indicate that healthcare centers participating in a portal implementation should all be early adopters. However, it does indicate that managers must be willing to intervene in existing organizational systems, while new IT is implemented (Boonstra, 2011). Remarkable is, that only one of the interviewees states that the HIS integration should have been arranged earlier, for a higher chance of success. To sum up, lessons learned by the stakeholders in the implementation at LRJG are: 1) Delegation of responsibilities, 2) Having a champion general practitioner and 3) Having the right focus for implementation. Jurjen Julianus 50

61 General Doctor s Manager HIS supplier Platform Application Project Patient practitioner assistant LRJG supplier supplier management Software In the beginning there were lots of problems with logging in to the systems. Some of the patients are not able to schedule an appointment online due to technical issues. Every time, we see that the technical hick-ups causes the largest bumps in the road during such implementation processes. There were some technical drawbacks; however, that is part of the innovative characteristics of PAZIO. Frustrations found their origin in software problems or delays in updates. The quality of the delivered software is below level. Organizational Communication A weakness is the inertia in the processes of communication between the different stakeholders. Due to the lack of integration, the system now forces us to work less efficient than before. Problems partly have their foundation in communication alignment. Table 7 Perceived problems of PAZIO implementation stakeholders at LRJG Implementation goes far, in a sense that a lot of energy has to be dedicated to redesign the processes based on the new tools. And it took us quite a while to learn the language of the care sector. Resistance arose when the senior assistant of the healthcare center had a six week leave. The communication with the initial implementation manager of PAZIO was laborious, because our way of communication was not aligned. Problem was the lack of management involvement. I find the number of time slots too limited, which implies that the portal is only used for incidental complaints that can wait for a couple of days Jurjen Julianus 51

62 6.2 GEZONDHEIDSCENTRUM MAARSSENBROEK Identification of stakeholders Hard component For GCM, the portal software (branded as MijnGezondheid.net) is delivered by PharmaPartners. PharmaPartners is the supplier of the HIS in GCM as well. They deliver a portal solution that fits onto their HIS, which enables them to integrate both solutions seamlessly. Appointments that are scheduled by means of the portal are placed directly in the agenda of the HIS. The same integration is arranged for econsults, which are placed directly into the HIS of the general practitioner as well. Figure 14 Aligned elements of implementation at GCM Soft component Within GCM three groups of people are able to influence the implementation in their center. First, the management, which make the initial decision whether to start with such ehealth initiatives, and may demand certain behaviors of their general practitioners and doctor s assistants. Second, the general practitioners, they are more or less obliged to adapt their way of working because of the portal introduction. Particularly, since the medical record of patients is partly opened up in this case. Third, doctor s assistants may influence the implementation process, because they actually have to work with the system as well. An external stakeholder group that can be identified is the group of patients. Jurjen Julianus 52

63 Furthermore, implementation of a portal encompasses changes in organizational processes. Therefore, both PharmaPartners and PAZIO deliver an implementation consultant to streamline the implementation process. Figure 15 summarizes the stakeholders of the portal implementation in GCM Stakeholder analysis All stakeholders are separately discussed. This section consists of the essential findings during analysis. The entire analysis can be found in the appendix C. Board of managers The board of managers at GCM wants to become frontrunner in the field of ehealth for primary healthcare centers. GCM wants to have one front door for their online services toward the patient. Initially, they are definitive stakeholder. As the project becomes more defined, and actual implementation starts in July 2011, the management hands over the responsibility for the project to their project leader and the external project team. As a result, they became dormant stakeholder from that point in time. General pracitioners The objective of creating one front door for all online services toward the patient, and therefore becoming frontrunner in the field of ehealth for primary healthcare centers was shared by the general practitioners. They are those who actually have to change their work processes in favor of the portal so their claims are legitimate, moreover, they also have the power to veto the portal implementation. Furthermore, the general practitioners have urgency because they are customer, this relationship with the supplier provides them with urgency. For this reason, general practitioners can be considered as definitive stakeholder in this implementation. Doctor s assistants Doctor s assistants at GCM objective concerning implementation has its foundation in the innovative character, they aim to be ahead of other healthcare centers. In this implementation process, the doctor s assistants can be characterized as discretionary stakeholder. First, they are obliged to work with the portal. Second, they do not possess urgency, since they are not consulted in the preparation process. Third, doctor s assistants Jurjen Julianus 53

64 claims can be considered legitimate, because they actually experience how a portal implementation changes their work process. Software supplier The HIS and the portal software in GCM are both provided by PharmaPartners. PharmaPartners has the objective to offer an integrated ICT solution for their customers. In this implementation, PharmaPartners has a powerful position, in a sense that they already were HIS supplier of this particular healthcare center, which cause a vendor lockin effect (Liebowitz & Margolis,1995). Vendor lock-in entails that it is virtually unthinkable for a customer to switch from supplier because of the switching costs incurred (Liebowitz & Margolis,1995). In addition, they now provide the portal as well. They also possess the attribute of urgency, since they have an interdependent relationship with their customers and with the project team. In this particular implementation, PharmaPartners claims are legitimate as well, because for them this is the first pilot location for their cooperation with PAZIO. It can thus be stated that PharmaPartners is a definitive stakeholder in this implementation. Project management The external project management in this situation consists of an implementation manager from PharmaPartners and an implementation manager provided by PAZIO. The implementation manager provided by PAZIO had a patent interest in successful implementation of PharmaPartners portal, because this would be the first step towards integration with PAZIO. The PAZIO implementation manager is not able to force the other stakeholders to cooperate. Furthermore, his claim can be considered urgent as he has the exact knowledge about what is happening in implementation. In addition, legitimacy is acquired by the fact that the implementation manager has a clear interest in successful implementation. This combination of relationship attributes leads to the classification of dependent stakeholder. Patients It is dangerous to formulate a unified objective for all patients of GCM, therefore we will not attempt to express a unified objective. Patients within Gezondheidscentrum Maarssenbroek have the same position as those at LRJG. They are not involved in the Jurjen Julianus 54

65 initiation, adoption and adaption stage (Cooper & Zmud, 1990) of implementation. For this reason, initially they are non-stakeholder. Usage of the portal by patients is essential for reaching the final stages of implementation. Therefore, the patient is definitive stakeholder in from the acceptance to the infusion stage (Cooper & Zmud, 1990). Figure 15 summarizes the categorization of stakeholders according to the stakeholder salience model of Mitchell et al. (1997). Figure 15 Stakeholders involved in MijnGezondheid.net implementation at GCM based on Mitchell et al. (1997) Problems and lessons learned Perceived problems In this particular implementation, different problems were mentioned. The general tendency of problems mentioned by employees within the healthcare center is based on the expected eagerness of their patients. Their own eagerness stands juxtaposed to the eagerness of their patients to work with the portal. I have misjudged the change in behavior that is necessary for our patients. is the eloquent statement of the internal project leader (General practitioner GCM, interview, December 20 th 2011). Overall, he is, however, quite satisfied with the chosen implementation strategy. The senior assistant argues that the processes are not yet correctly designed in favor of the portal. She, therefore, opts for explicit process guidelines regarding the opening up of a patient s health record and guidelines for doctor s assistants and general practitioners on the frequency of checking their inbox (Senior assistant GCM, interview, November 29 th Jurjen Julianus 55

66 2011). The portal supplier acknowledges that they spent way more energy than expected for implementation of their portal (HIS/Portal supplier representative, interview, December 14 th 2011). Lessons learned The internal project leader argues that it is dangerous to start implementation in organizations which do not have an innovative drive (General practitioner GCM, interview, December 20 th 2011). This is confirmed by the representative of the portal supplier who indicates that they have equal experiences (HIS/Portal supplier representative, interview, December 14 th 2011). This is however not explicitly mentioned in the consulted literature. Possible reason for that may be the differences between the healthcare sector and other more commercial sectors. Portal implementations are quite innovative for the healthcare sector, while other sectors already have experience with such IT implementations. Furthermore, the general manager indicates that evaluations during implementation are necessary to eventually achieve a successful implementation (CEO GCM, interview, December 8 th 2011). Cooper & Zmud (1990) do not address the importance of evaluation in their IT implementation stages theory. A suggestion may be to add moments of evaluation in the IT implementation stages model. In addition, both the general manager and the internal project leader argue that the chosen implementation strategy was a good decision, because it enabled the general practitioners to retain their control. This is consistent with literature, which indicates that it may be beneficial to let the subjects participate in the process of implementation. In this case, the general practitioners were asked to think along with the internal project management regarding the implementation strategy, which provided them with a feeling of control. Literature does not provide guidelines for a specific implementation strategy in terms of scale. All in all, the lessons learned thus include: 1) The subject healthcare center needs to have an innovative drive. 2) Evaluation during implementation supports success of the implementation. 3) Start small, and scale up later to retain control. Jurjen Julianus 56

67 7 CROSS-CASE ANALYSIS AND PRACTICAL IMPLICATIONS While the description of the implementation processes identified that both health portal implementation processes were different, the reasons for these differences were made clear by the two stakeholder analyses. The analyses confirm implementation literature, which argues that stakeholders may have different objectives regarding implementation. This chapter provides a cross-case analysis of the implementations. Next chapter elaborates on the management focus areas for a future PAZIO implementation. 7.1 CROSS-CASE ANALYSIS The descriptions of the two implementation processes have shown that implementation of a health portal may differ in different healthcare centers. The field of stakeholders may be different, as well as the decisions, actions and expectations of those stakeholders. In addition, the descriptions of the implementation processes indicate that it is difficult to capture the processes in models presented in literature. Reason for this may be premature status of the products and thus the innovative nature of these particular implementations. The description of the implementation processes in Leidsche Rijn Julius Gezondheidscentra (LRJG) and Gezondheidscentrum Maarssenbroek (GCM) result in the following observations: Product and objective Both centers decided to start with a different product, because they had a different objective. LRJG had the ambition to be innovative by establishing another link between the patient and care supply, while GCM aimed for an integrated solution in the first place. They had the objective to solve their bottlenecks. As a result, LRJG decided to start with an interim portal solution that was not fully integrated with their HIS, while GCM started to do business with a different software supplier for their portal. This software developer was the supplier of their HIS as well, which caused them to have less software problems than LRJG had Implementation stages The implementation at LRJG followed a different route than the implementation at GCM. Due to the change of management, the decision to start a new pilot in another center at Jurjen Julianus 57

68 LRJG and due to the fact that PAZIO was still in development during implementation, the implementation at LRJG did not pass the implementation stages (Cooper & Zmud, 1990) chronologically. Although the implementation of MijnGezondheid.net at GCM passed the implementation stages chronologically, both implementations are now still stuck between the acceptance stage and the routinization stage. The stakeholders that can change this status, is the group of patients. They now have to use the portal on a regular basis, before it can become part of the care providers regular work process Communication approach Different approaches were chosen by both centers to communicate with patients regarding the newly available portal. While LRJG addressed all of their patients by means of personal letter, flyers and a mailing, GCM started with a small amount of patients. Neither of the approaches did live up to the expectations of the employees in the healthcare centers. The care providers did expect more eagerness from their patients to use the portal. For this reason, work processes could not yet be changed in favor of the portal. In other words, the routinization stage could not yet be reached by both centers due to the limited usage by patients Range of stakeholders Both implementations have a board of managers, general practitioners, doctor s assistants and their patients as stakeholders. Furthermore, both implementations have the same HIS supplier as stakeholder, and they both have a project team. Differences in the range of stakeholders occur from the choice of software supplier for the portal. While the LRJG case implicitly demanded cooperation between the platform supplier, the HIS supplier and the application supplier, GCM started with only their HIS supplier which provided their own portal. The number of stakeholders was thus different in both implementations, particularly at the software side of implementation. Observations indicate that less communication issues and software issues arose during the implementation at GCM. The analyses pointed out that the general practitioners are definitive stakeholder in the implementation at GCM. In the implementation at LRJG the general practitioners can be characterized as discretionary stakeholders. Remarkable is the fact that the HIS/portal supplier is definitive stakeholder in the GCM case, this is because they are in control of Jurjen Julianus 58

69 the majority of attributes that are conditional for a successful implementation. Furthermore, the board of managers changes from definitive to dormant stakeholder in both implementations. Doctor s assistants are discretionary stakeholder in both implementations. Last stakeholder that has been identified in both implementations is the group of patients. In both implementations the group of patient makes the same shift from non-stakeholder to definitive stakeholder half-way implementation. Patients are not involved until the acceptance stage of implementation, this is where the portal usually has its kick-off. 7.2 PRACTICAL IMPLICATIONS FOR STAKEHOLDER MANAGEMENT In this section, the observations from the cross case (stakeholder) analysis are linked to practical implications provided by Mitchell et al. (1997) Discretionary stakeholders The cross-case analysis pointed out that in both implementations the doctor s assistants are discretionary stakeholders. Furthermore, in the implementation at LRJG the general practitioners can be characterized as discretionary stakeholders. Discretionary stakeholders possess only the relationship attribute of legitimacy. In the implementation at LRJG, the application supplier is considered to have only this attribute as well. Implication is that there is no need to engage in an active relationship with them. However, project managers may choose to do different. Discretionary stakeholders have limited salience from the project management, because they only possess one relationship attribute. In other words, it is not necessary for the project management to fulfill claims of these stakeholders immediately Dominant stakeholders Furthermore, the platform supplier in the PAZIO implementation at LRJG can be characterized as a dominant stakeholder, which means that this stakeholder matters to the project management (Mitchell et al., 1997). Moreover, they expect to get this attention from the project management as well. However, it is by no means the stakeholder group that deserves most of the project management s attention. Furthermore, it is a common Jurjen Julianus 59

70 occurrence that a dominant stakeholder moves to the definitive category by acquiring the attribute of urgency Dangerous stakeholders The HIS supplier in the implementation of PAZIO at LRJG can be characterized as dangerous stakeholder. Because of a lock-in effect (Liebowitz & Margolis,1995) they obtained power and urgency. According to Mitchell et al. (1997) dangerous stakeholders should only be identified without acknowledging them. Some form of tactic by the project management is needed to not let stakeholders know that they are actually characterized as dangerous. In other words, they should not be enabled to exploit their position Dependent stakeholders In both implementations the project management is considered to be a dependent stakeholder, they have both legitimacy and urgency, but need other stakeholders to exercise power. Currently, the project management already uses such a form of governed power. For example, the project management uses the power of the general practitioners to force software suppliers to cooperate with them and with each other. General practitioners are able to use power towards software suppliers, because they are in a customer-supplier relationship Definitive stakeholders In the implementation at GCM, the software supplier provides both the HIS and the portal. Therefore this stakeholder is classified as definitive stakeholder. Furthermore, the general practitioners are considered to be definitive stakeholders in the MijnGezondheid.net implementation at GCM. Implication is that claims of these stakeholders should have priority against claims from other stakeholders (Mitchell et al. 1997). These stakeholders can be considered as the most important for a successful implementation. Last important implication for the project management concerns the dynamic position of the board of managers of the healthcare center in both implementations. For instance, during the implementation at LRJG the board of managers shifted from definitive stakeholder to dangerous stakeholder to dormant stakeholder. It is important for the Jurjen Julianus 60

71 project management to identify this shift, because it enables them to act adequately to the board s claims. Claims of a board that is definitive stakeholder should be answered immediately, while claims of a dormant stakeholder do not require an immediate answer. Indicators for such a shift are the handing over of responsibilities by the board, and their extent of interference in the implementation process. Jurjen Julianus 61

72 8 IMPORTANT IMPLEMENTATION ISSUES The previously described cross-case analysis and practical implications provided by theory act as a fundament for the identification of management focus areas for future implementation of health portals. Furthermore, lessons learned mentioned by the stakeholders are used. In the following section, personal observations and opinions regarding both implementations are expressed. This leads to six management focus areas for future implementation of a health portal. 8.1 MANAGEMENT FOCUS AREAS FOR FUTURE IMPLEMENTATIONS Relationships of stakeholders The first management focus area that can be appointed is the area of relationships of stakeholders. These relationships should be managed carefully by the project team. Relationships of stakeholders range from customer-supplier relationships to consortium partner relationships. The stakeholder analysis pointed out that it is sometimes difficult for the project management to increase pressure on a consortium partner. Observations have indicated that software suppliers often possess power because of their knowledge of the platform. They may and sometimes do use their powerful position to make delivery delays acceptable. If the software suppliers are part of the consortium, it is difficult to put pressure on them. Particularly in relationships with a software developer, it may thus be preferable to have a customer-supplier relationship. Delay in delivery can then be penalized more easily. Furthermore, it may be a suggestion for future health portal implementations in primary healthcare centers to use a bonus-malus arrangement in the contract with software suppliers. Such an arrangement may induce software developers to be more dedicated to the project Dedication Second management focus area is the area of dedication. Dedication of stakeholders in an implementation seems to be a key enabler of success. Analysis of the implementation process at LRJG has shown that a lack of focus on implementation delays the process. Dedication of the board of managers and the general practitioners at the healthcare centers, and software suppliers may help to reduce implementation delays. Moreover, a non-committal attitude of one of the software suppliers seems lethal for a successful Jurjen Julianus 62

73 integration of different ICT systems in a healthcare organization and thus for a successful health portal implementation. Dedication of stakeholders is an important area of focus for project managers in healthcare ICT implementations Vision and leadership Third area of consideration for future implementations of PAZIO is the area of vision and leadership. Observations at the MijnGezondheid.net implementation at GCM have shown that presence of a clear vision regarding ehealth may encourage stakeholders to adapt their behavior in favor of that vision. As a result, stakeholders have aligned interests and objectives. In other words, they are all facing in the same direction during implementation in order to achieve an idealized image, which in turn may increase the probability of implementation success Confidence of care provider Confidence of care providers in implementation should be nurtured by the implementation manager. The analysis of the portal implementation at LRJG pointed out that general practitioners may attempt to delay the date of kick-off, because of their lack of confidence. On the one hand, this may have its origin in the software that is below level. On the other hand, it may also have its origin in their lack of knowledge and experience regarding ICT systems and the organizational change processes that are entailed with implementation of the portal. For future health portal implementations it is important to let the care providers feel confident with the software. Training and repeated education may nurture the confidence of the care provider Knowledge and or experience of key people The observations at the MijnGezondheid.net implementation in GCM suggest that a general practitioner (who is project leader) with (business) knowledge and affinity with organizational change processes may eventually contribute towards a more successful implementation. Moreover, the attribute of knowledge seems to foster salience of stakeholders. Knowledge may foster the attribute of power ( knowledge is power ) and it may enable stakeholders to acquire the attribute of urgency. This management focus area is generalizable to future health portal implementations. Jurjen Julianus 63

74 8.1.6 Usage by patients Sixth and last management focus area is usage by patients. This area consists of usage by patients of the healthcare center. A health portal is supposed to be a communication means between care providers and patients. However, if patients are not willing to use the portal, for any reason, successful implementation cannot be achieved. In other words, care providers will then never be encouraged to use the portal, which causes the implementation to get stuck between the acceptance stage and the routinization stage (Cooper & Zmud, 1990). The analysis of the PAZIO implementation at LRJG has shown that implementation cannot be called successful if the number of users remains low. A suggestion may be to involve patients in an earlier stage of implementation in order to stimulate familiarity with the portal. Decisions during implementation should be aimed at maximization of usage by patients. An well thought marketing campaign may also help to achieve this. Last management focus area is only generalizable to other healthcare ICT implementations which encompass communication between care providers and their patients. Jurjen Julianus 64

75 9 CONCLUSION AND DISCUSSION 9.1 CONCLUSION The objective of this research is to identify objectives, positions and influences of stakeholders in a PAZIO portal implementation. Furthermore, management focus areas for future PAZIO implementations should be derived from these findings. In order to achieve this objective, this research is structured as follows: First, literature research regarding (health) portals, IT implementations and stakeholder theory has been consulted for the purpose of understanding these terms, and for a solid theoretical foundation for describing the implementation processes of the cases. Second, the portal implementations of both Leidsche Rijn Julius Gezondheidscentra (LRJG) and Gezondheidscentrum Maarssenbroek (GCM) have been described based on the IT implementation stages model of Cooper & Zmud (1990). Subsequently, a stakeholder analysis of both implementations has been conducted based on the stakeholder salience theory (Mitchell et al., 1997). Third, the two implementation descriptions and stakeholder analyses have been compared in a cross-case analysis. The cross-case analysis results in practical implications for the project management and is used as foundation for formulation of management focus areas for future PAZIO implementations Definitions The research used the definition of Schnipper et al. (2008) who pointed out that a health portal is a site that allows patients to login in a secured environment and enables them to update their contact information, request appointments, request consults online, and offers reliable licensed health information. Furthermore, IT implementation has been defined in terms of the six implementation stages of Cooper & Zmud (1990): initiation, adoption, adaption, acceptance, routinization and infusion Leidsche Rijn Julius Gezondheidscentra Within the implementation at LRJG, the board of managers has the objective to increase efficiency in the logistical processes around the care processes, which in turn should lead to a higher care quality. At that moment, their position in the field of stakeholder can be Jurjen Julianus 65

76 characterized as definitive stakeholder. Because they were actively involved in the development process of PAZIO, they were concerned with implementation in the first pilot location as well. However, their objective was put on hold, since they were replaced by an interim board because of financial problems. Due to the fact that the interim management was only occupied with solving the financial problems, their position moved to dangerous stakeholder. According to the project management, this led to delays in development and implementation. When the financial problems were over, the interim management was replaced by a new board, which was more innovation minded. With help of the approved grant of the consortium, the board decided to start a second pilot. Responsibilities for the implementation were delegated to a general practitioner in the relevant healthcare center. Therefore they became dormant stakeholder from that point in time. From this moment, the board only used its power to demand functionality from the project team, which delayed the implementation process. The general practitioners objective in implementation is to provide an additional means of communication for their patients, which may increase patient satisfaction. Furthermore, they have the ambition to be innovative in the field. In this implementation their position can be characterized as discretionary stakeholder. Because of their uncertainty with new ICT applications, they tried to delay the implementation process. In order to achieve this they used the governed power of the board of managers to demand (added) functionality. The doctor s assistants at LRJG have decreasing the telephone pressure as implementation objective. In this implementation they are discretionary stakeholder. The senior assistant at LRJG was involved from the start of the implementation, therefore she acts as motivator for the other assistants in the center. However, the other doctor s assistants are less motivated to adapt their work processes. This influences the implementation process in a sense that they need to be motivated repeatedly by the senior assistant and the implementation manager. Objective of the project management is to fulfill a successful pilot, and to learn from mistakes. They are dependent stakeholder in this implementation. Their influence in implementation comes with aligning the different stakeholders that are involved. They Jurjen Julianus 66

77 exert pressure to the software suppliers by means of governed power of the board of managers of LRJG in order to achieve alignment. The platform supplier of PAZIO has the objective to obtain knowledge in the healthcare domain and can be characterized as dominant stakeholder in this implementation. They indicate that delays in delivery of software are due to the fact that they do not have enough domain knowledge in healthcare. They indicate that it is hard to speak each other s language. The objective of the application supplier in this is to deliver a solid application for the PAZIO platform during the pilot phase, which can be marketed to other healthcare centers (with or without PAZIO). In the PAZIO implementation at LRJG they act as discretionary stakeholder. The software they deliver is below level according to the PAZIO product manager. Unreliable software causes the employees in the healthcare center to have less confidence in the portal. Such a lowered degree of confidence in the portal results in delay for implementation, because it delays reaching the stages of routinization and infusion. It is dangerous to formulate a uniform objective regarding the portal for the group of patients within LRJG, because they may have very diverse objectives. Their position in implementation shifts from non-stakeholder to definitive stakeholder as the implementation proceeds. They may influence the implementation process by (not) using the portal, and their feedback regarding the functionality that the portal offers. Last is the HIS supplier, who has the objective to develop an integral IT solution for a healthcare center. In this implementation the HIS supplier can be characterized as dangerous stakeholder. Although they are the only party that can open up their own HIS, and have their own portal solution as well, they are willing to cooperate with PAZIO. This cooperation enables them to gain a higher market share in both the HIS-market and the portal market, and it enables them to pursue their objective Gezondheidscentrum Maarssenbroek Analysis pointed out that the board of managers within GCM has the objective to have one front door for all of their online services, which is part of their policy vision. During Jurjen Julianus 67

78 the start of the implementation they were definitive stakeholder. They actively engaged in the decision making process, and demanded functionality from the project team. In a later stage, they became dormant stakeholder. Their influence in implementation was reduced, they did not interfere with the implementation process anymore. Objective of having one front door for all of their online services was shared by the general practitioners at GCM. In this implementation they are the definitive stakeholder. Their attitude towards the portal was skeptical, which resulted in a slight delay in implementation. Actually, they demanded more training sessions, which eventually triggered their eagerness. Furthermore, the doctor s assistants objective with the portal implementation is to be frontrunner. In this implementation they are discretionary stakeholder. Their influence on the implementation is minimal. The software supplier s objective is to offer an integral ICT solution. They possess all three relationship attributes in this implementation, therefore they are definitive stakeholder. They have a powerful position in this implementation, however, they do not fully exploit this position. This is because of their interdependent relation with the board of managers and the general practitioners. Last stakeholder in this implementation is the project team. In this implementation they are dependent stakeholder and have the objective to achieve a successful implementation of MijnGezondheid.net. They have influenced this implementation by means of governed power of the board and the general practitioners. They advised the internal project leader when necessary, on how to deal with implementation. For the same reason as in the LRJG implementation, it is dangerous to formulate a uniform objective concerning the portal for the group of patients within GCM. Initially they have no stake in implementation, for this reason they are non-stakeholder. However, as the implementation comes to the acceptance stage, the group of patients becomes important. Therefore, later on in implementation they are considered to be definitive stakeholder. Their influence in implementation comes from (lack of) using the portal and their feedback on the functionality. Jurjen Julianus 68

79 9.1.4 Management focus areas for future health portal implementations The research questions have been answered, and an image is constructed of the different objectives, positions and influences of the stakeholders in both portal implementation projects. Comparison and analysis of these findings have led to the following six management focus areas for future PAZIO implementations: relationships of stakeholders, dedication, vision and leadership, confidence of care provider, knowledge and experience of key people and usage of patients. These six areas should be taken in consideration by the project management when starting implementation of a health portal Implications for theory The lessons learned mentioned by the stakeholders are compared with the consulted literature. Lessons learned by the stakeholders in the implementation at LRJG are delegation of responsibilities, having a champion general practitioner and having the right focus for implementation. These lessons are all confirmed by the consulted literature. Lessons learned mentioned by the stakeholders in the implementation at GCM include have an innovative drive, evaluation during implementation supports success of the implementation, and start small, to scale up later to retain control. Literature confirms that having an innovative drive increases the chances of implementation success. However, evaluation during the implementation process is not mentioned in the literature consulted. It may thus be a suggestion to add interim evaluation to the IT implementation stages of Cooper & Zmud (1990). Furthermore it can be concluded that it is difficult to capture the implementation dynamics of an innovative programme into the models provided by literature. 9.2 DISCUSSION Limitations of the research Limitations of the research include the fact that from each stakeholder group in the implementation only one person is consulted. This is, however, partly covered by the consultation of secondary data and the participative observations conducted by the researcher. In addition, this research is interpretative in nature. Interviews conducted, observations and secondary data have been interpreted by the researcher, and may thus be Jurjen Julianus 69

80 subject to some form of researcher bias. Furthermore, the research is based on the casestudy method, which may cause that the outcomes cannot be generalized to other IT implementation project other than PAZIO Recommendations for further research This research is primarily focused on portal implementation for primary healthcare centers. For this reason, implementation in secondary healthcare organizations and academic hospitals is beyond this paper s scope. Further research on this topic is recommended, since this field is quite unknown until now. Furthermore, with regard to the ambition to create an integrated ICT solution for care providers and care consumers, it is recommended to conduct further research regarding the forces that may or may not determine standardization guidelines within the healthcare-ict sector. Jurjen Julianus 70

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83 Ploem, M. C., Zwaanswijk, M., Wiesman, F. J., Verheij, R. A., Friele, R. D., & Gevers, J. K. M. (2011). Vertrouwen van zorgverleners in elektronische informatie-uitwisseling en het landelijk EPD. AMC / NIVEL, Schnipper, J. L., Gandhi, T. K., Wald, J. S., Grant, R. W., Poon, E. G., Volk, L. A., et al. (2008). Design and implementation of a web-based patient portal linked to an electronic health record designed to improve medication safety: the Patient Gateway medications module. Informatics in Primary Care, 16(2), Waddell, DM., Cummings, TG., and Worley, C. (2004). Organisation development and change. Thomson, Southbank, Victoria. Walsham, G. (2006). Doing interpretive research. European Journal of Information Systems, 15(3), Young, R 2005, Explaining Senior Management Support Through IT Project Governance, in MGSM, Macquarie University, Sydney. Electronic articles Deloitte (2010) Deloitte Innovation implementation services. Belgium/Local%20Assets/Documents/EN/Market%20solutions/Innovation/be-innovationimplementation-services-aug2010.pdf Accessed Heldoorn M. & Veereschild, S. (2011) Patiëntportalen in Nederland Accessed Internal documentation Lange, M. de (2011) Presentation slides Vital Innovators. ehealth Masterclass October 14 th 2011, Den Dolder. Rietveld, M. & Dekker, M. (2009) Plan van aanpak Implementatie pilot PAZIO bij LRJG. PAZIO project management Well, M. van (2010) Plan van aanpak voor implementatie van PAZIO bij de GezondheidsCentra Maarssenbroek. PAZIO project management PAZIO grant application (2009). Project plan Pieken in de Delta. Minutes Consortium Meeting (January 5 th 2009) Minutes Consortium Meeting (April 22 nd 2009) Minutes Consortium Meeting (November 9 th 2009) Gezondheidscentrum Maarssenbroek ICT Visie (2010) Jurjen Julianus 73

84 Websites Broadband TV Nieuws (2007), Broadband TV Nieuws Woordenlijst. Accessed Centraal Bureau voor de Statistiek, CBS (2011) - Gemiddeld inkomen; particuliere huishoudens naar diverse kenmerken. =a&hdr=g1,g2,g3&stb=t&vw=t Accessed Dutch GP Association (2011), NIVEL: Zorgverleners willen regionale start EPD Accessed Emazing (2010), Emazing Webdesign >> Verklarende woordenlijst. Accessed Frankwatching (2011), Telehealth & Telecare - de toekomst van e-health Frankwatching Accessed KNMG (2010), ehealth praktijkvoorbeelden Accessed Miljoenennota 2012 (2011), Box 1.9 Zorgkosten Online Miljoenennota Zorgkosten.aspx Accessed Skipr (2011), Miljoenennota 2012: plannen voor de zorg - Actueel Skipr Accessed UMC Utrecht (2011), Missie & Strategie - UMC Utrecht Accessed Website Senate (2011), Eerste Kamer der Staten-Generaal - Elektronisch patiëntendossier (31.466) Accessed Wikipedia (2011), Web portal - Wikipedia, the free encyclopedia. Accessed Jurjen Julianus 74

85 Zoeken-en-vinden.nl (2011), Woordenboek met algemene internet termen Accessed Jurjen Julianus 75

86 LIST OF ABBREVIATIONS Abbreviation App CBS CoE DigiD EHR GCM HIS ISO IT / ICT LRJG LSP MGN NICTIZ NIVEL SSO Full Application (piece of software) Centraal bureau voor de statistiek Center of Excellence Digital Identity (login mechanism for Dutch government websites) Electronic Health Record Gezondheidcentrum Maarssenbroek (primary healthcare center in the Netherlands) Health Information System (in this setting Huisartsen Informatie Systeem) International Organization for Standards Information (Communication) Technology Leidsche Rijn Julius Gezondheidscentra (primary healthcare center in the Netherlands) Landelijk Schakelpunt MijnGezondheid.net (portal solution of HIS supplier PharmaPartners) Expertise Center for ICT in care sector in the Netherlands Institute for research in the care sector in the Netherlands Single sign on Jurjen Julianus 76

87 APPENDICES APPENDIX A: INTERVIEW QUESTIONS What were your objectives with regard to the portal implementation? Which functions and processes were affected by the portal implementation? What was the implementation supposed to change? What stakeholders were involved in the implementation process? What were the interests of those stakeholders? How did each stakeholder influence the process? How did the implementation process unfold? What phases and steps can be distinguished? What problems arose during implementation? How did the you / project team deal with those problems? What lessons can be learned from this implementation process?

88 APPENDIX B: FULL STAKEHOLDER ANALYSIS LRJG PAZIO IMPLEMENTATION Board of managers The original board of managers identified the need of online communications between their general practitioners and patients in 2006 (Product manager PAZIO, interview, November 28 th 2011). They think that a health portal is an important link between the care supply and the patient, in a sense that substitution of work should occur with regard to logistical processes. Therefore, the board of managers was involved in the PAZIO programme right from the start. Another reason for the close involvement of the management of LRJG is the fact that they have strong relationship with the UMC Utrecht. The board of managers more or less forced LRJG Parkwijk to act as pilot location for the first release of PAZIO. Because they felt that PAZIO would increase efficiency, and therefore higher care quality could be achieved, it can be concluded that they had a patent interest in successful implementation. As such, the original board of managers can be characterized as a definitive stakeholder. However, during the implementation of the first release of PAZIO in early-2009, financial problems were the issue within LRJG. Due to financial problems, by March 2009 the original board of management was replaced by an interim management team which was supposed to solve the financial troubles. This resulted in a lack of interest in PAZIO. Moreover, the PAZIO project was set on-hold by the interim management; sheer exercise of power and urgency, a combination that resulted in becoming a dangerous stakeholder. Once the financial problems were solved, the interim management was replaced by a new board of managers (October 2009). The new board was determined to revitalize the project. Subsequently, conversations with the PAZIO project team were arranged, which resulted in a second pilot phase in LRJG Vleuterweide, which started in June The management delegated responsibility for the second pilot to a general practitioner at Vleuterweide, and therefore became dormant stakeholder from that point in time. General practitioners Although the management forced their general practitioners in Vleuterweide to be involved in the project, the general practitioners attitude can be characterized as quite enthusiastic (General practitioner LRJG, interview, September 6 th 2011). Interest in

89 implementation of the general practitioners is especially provision of an additional means for patients to communicate with their general practitioner, which should result in an increase in satisfaction of the patient. They do acknowledge that this will mean change of work processes for them (General practitioner LRJG, interview, September 6 th 2011). The majority of the general practitioners in Vleuterweide were involved from the start of the project (PAZIO v2.0), and were asked to participate during development. This caused them to be very well informed regarding the portal and its implementation. They are the ones who actually have to work with the portal, and have the legitimacy to demand certain functionality. However, they lack power and urgency because they are forced by the management to be involved in the implementation; therefore they act as discretionary stakeholders. Doctor s assistants Another group that is able to influence the implementation process is the group of doctor s assistants. The senior assistant of the center is member of the project group within LRJG and is therefore involved in the project from the start in Vleuterweide. Objective of implementation in this group is increasing accessibility of the center by decreasing pressure on the telephone (Senior assistant LRJG, interview, September 6 th 2011). Observation has indicated that the other doctor s assistants have less motivation to adapt their work processes to the new situation with the portal. They indicate that the major reason for the lack of motivation is the bugs in the software, and the variety of login codes that are necessary. Although the fact that doctor s assistants actually use the system and their claims therefore can be characterized as legitimate, they do not have the power to fulfill these claims. Furthermore, the doctor s assistants lack the attribute of urgency, since their claims are not accepted as being important. For instance, the board of managers has decided to delay the development and implementation of eprescription, despite the fact that the doctor s assistants think this really has added value for their work process (Senior assistant LRJG, interview, September 6 th 2011). For this reason, the doctor s assistants are discretionary stakeholder in implementation.

90 Software developers (platform supplier and application supplier) In case of development of the software, or problems with it, both the platform supplier and the application supplier of econsult and eappointment are appointed to deal with these issues. They, however, do not have similar objectives regarding implementation. The platform supplier is partner in the programme consortium, and has the objective to obtain knowledge in the healthcare-ict domain (Platform supplier representative, interview, December 1 st 2011). While the application supplier in this case has a customersupplier relationship with the project team. For this reason, they have the objective to provide a solid application for the platform, which can be distributed to other healthcare centers later on (App supplier representative, interview, December 1 st 2011). An application supplier of econsult or eappointment can relatively easy be replaced by another supplier, therefore they have limited power. They however, do have legitimacy, because they are involved in the development process as well. They attend meetings with the LRJG project group, and deal with the feedback provided during these meetings. This makes the application supplier in the LRJG case a discretionary stakeholder. The platform supplier can be characterized as a dominant stakeholder. They have power, because they are the organization that has delivered a customized and (possibly) unique platform. Legitimacy is acquired by the fact that they are part of the project consortium. HIS supplier The HIS supplier of this healthcare center is required to facilitate integration between the HIS of the general practitioner and the portal solution. The HIS supplier has the objective to offer an integral ICT solution for their customers (the healthcare centers) (HIS supplier representative, interview, December 14 th 2011). Such an integral solution also means a solution for communication with patients. They think that HIS integration is the critical success factor for the portal implementation to succeed (HIS supplier representative, interview, December 14 th 2011). As they are the only party that is able to open up their own HIS for portal integration, they can be characterized as quite powerful. This form of power has a utilitarian basis. They have a commercial interest in the ehealth market, therefore their claims are not completely legitimate. There is, however, some extent of

91 interdependence between the PAZIO project team and the HIS supplier, they need each other for the creation of an integral solution (HIS supplier representative, interview, December 14 th 2011). As a result of this interdependence, they do possess urgency, because their claims can be characterized as important for the project, which in turn means that they ask for immediate attention from the PAZIO project team. For this reason, the HIS supplier in this implementation can be characterized as a dangerous stakeholder. PAZIO project management The project management is deeply involved in this implementation process because this process can be characterized as a development process as well. Their objective is to achieve a successful implementation which enables them to obtain knowledge for PAZIO implementations in other healthcare centers. The PAZIO project team is dependent on all other stakeholders during the implementation. Although they are the party that offers the other stakeholders to engage in health innovation, they do not have the power to force their claims to other stakeholders. For instance, the project team is part of the consortium. According to one of the project leaders, this sometimes causes difficulties. Particularly in conversations with the platform supplier, (which is part of the consortium as well) because due to that partnership situation there are only limited possibilities to demand things from each other. Furthermore, the project management possesses legitimacy because of the fact that they are the party that connects the other stakeholders in order to create a sustainable health innovation. Urgency is acquired by the fact that claims of the project team can be considered as important, their interdependence with the other stakeholders strengthens their urgency. They have the overview of the project, and are therefore able to prioritize their claims towards the other stakeholders very well. Within the LRJG case, the project team can thus be characterized as a dependent stakeholder. This finding is supported by the fact that the project team uses the board of managers of LRJG to impose their will onto the platform supplier and the application supplier. Patients Last stakeholder in this implementation is patient population of LRJG. Objective of this group is difficult to catch in a unified formulation, because of the mutual diversity.

92 Therefore, this research does not attempt to formulate such a unified objective. During the first three stages of implementation (initiation, adoption and adaption; Cooper & Zmud, 1990) patients are not involved. In these stages of implementation they can be characterized as non-stakeholder. However, the group of patients is the stakeholder that actually has to use the portal functionality, before implementation can be called finished. The implementation stages of routinization and infusion (Cooper & Zmud, 1990) cannot be reached without regular usage of the portal by patients. This provides patients the attribute of power, because they can choose whether to use the portal or not. Moreover, they have the freedom to change from healthcare center if the current portal functionality does not live up to their expectations (Patient Y, interview, January 18 th 2012). Patient X (interview, January 18 th 2012) even argues that he considers changing from healthcare center if another healthcare center offers a portal functionality without DigiD login. However, it must be noted, that this power is not useful for patients as individuals. They have to act as a group before they can exercise this power. Furthermore their claims can be considered as legitimate since they are customer of the healthcare center, which means that it concerns their healthcare. What is more is that they are subject of implementation without choosing to do so. Because patients are customer of the healthcare center, they possess the attribute of urgency as well. Claims of patients call for immediate attention. One of the interviewed patients argues that he finds that problems with the portal functionality should be solved within four hours, because otherwise it would be more convenient to schedule an appointment by telephone (Patient Y, interview, January 18 th 2012). To sum up, the patient population of LRJG can be characterized as definitive stakeholder in this implementation (from the acceptance stage to the infusion stage; Cooper & Zmud, 1990).

93 APPENDIX C: FULL STAKEHOLDER ANALYSIS GCM MGN IMPLEMENTATION Board of managers The board of managers at GCM created an ICT vision plan in consultation with one of their general practitioners and their IT support provider. The ICT vision document states that GCM wants to have one front door for their online services toward the patient (GCM ICT Visie , 2010). They want to become frontrunner in the field of ehealth for primary healthcare instances. For this reason, they engaged in conversations with PAZIO. The management has a clear interest in successful implementation, since it contributes to their own policy vision (CEO GCM, interview, December 8 th 2011). Therefore, they can be characterized as definitive stakeholder in the beginning. As the project becomes more defined, and actual implementation starts in July 2011, the management hands over the responsibility for the project to their project leader and the external project team (CEO GCM, interview, December 8 th 2011). As a result, they became dormant stakeholder from that point in time. General practitioners The objective of creating one front door for all online services toward the patient, and therefore becoming frontrunner in the field of ehealth for primary healthcare centers was shared by the general practitioners at GCM. However, initially their attitude can be characterized as skeptical. By means of several training sessions, their eagerness to work with the portal was triggered (General practitioner GCM, interview, December 20 th 2011). The general practitioners were involved immediately in the implementation process. They are those who actually have to change their work processes in favor of the portal so their claims are legitimate, moreover, they also have the power to veto the portal implementation. Furthermore, the general practitioners have urgency because they are customer, this relationship with the supplier provides them with urgency. For this reason, general practitioners can be considered as definitive stakeholder in this implementation. Doctor s assistants In addition to general practitioners, doctor s assistants are also involved in implementation. Their objective concerning implementation has its foundation in the innovative character, they aim to be ahead of other healthcare centers (Senior assistant GCM, interview, November 29 th 2011). Furthermore, the doctor s assistants were not

94 involved in implementation from the beginning. Although they have been informed by the internal project leader, the actual start for them was during the kick-off meeting of the portal. The senior doctor s assistant commented: In my opinion it is fine that I am not involved in the preparation process. As long as we are informed. (Senior assistant GCM, interview, November 29 th 2011). In this implementation process, the doctor s assistants can be characterized as discretionary stakeholder. First, they are obliged to work with the portal. Second, they do not possess urgency, since they are not consulted in the preparation process. Third, doctor s assistants claims can be considered legitimate, because they actually experience how a portal implementation changes their work process. HIS and portal supplier The HIS and the portal software in GCM are both provided by PharmaPartners. PharmaPartners has the objective to offer an integrated ICT solution for their customers that enables them to communicate with their patients. As a portal supplier, they have the implementation objective to actually change the work processes at their customers in favor of the portal, until these changed processes become routine (HIS/portal supplier representative, interview, December 14 th 2011). In this implementation, PharmaPartners has a powerful position, in a sense that they already were HIS supplier of this particular healthcare center, which cause a vendor lock-in effect (Liebowitz & Margolis,1995). Vendor lock-in entails that it is virtually unthinkable for a customer to switch from supplier because of the switching costs incurred (Liebowitz & Margolis,1995). In addition, they now provide the portal as well. They also possess the attribute of urgency, since they have an interdependent relationship with their customers and with the project team. Because of these interdependencies, their claims ask for immediate attention in this implementation. In this particular implementation, PharmaPartners claims are legitimate as well, because for them this is the first pilot location for their cooperation with PAZIO. Therefore, they have a clear interest in successful implementation of the portal. It can thus be stated that PharmaPartners is a definitive stakeholder in this implementation. Project management The external project management in this situation consists of an implementation manager from PharmaPartners and an implementation manager provided by PAZIO. As mentioned,

95 triangle conversations were arranged since March 2011 to ensure integration between PharmaPartners portal and the PAZIO platform, these conversations are still ongoing. The implementation manager provided by PAZIO had a patent interest in successful implementation of PharmaPartners portal, because this would be the first step towards integration with PAZIO. The PAZIO implementation manager is not able to force the other stakeholders to cooperate. Furthermore, his claim can be considered urgent as he has the exact knowledge about what is happening in implementation. In addition, legitimacy is acquired by the fact that the implementation manager has a clear interest in successful implementation. This combination of relationship attributes leads to the classification of dependent stakeholder. Patients It is dangerous to formulate a unified objective for all patients of GCM, therefore we will not attempt to express a unified objective. Patients within Gezondheidscentrum Maarssenbroek have the same position as those at LRJG. They are not involved in the initiation, adoption and adaption stage (Cooper & Zmud, 1990) of implementation. For this reason, initially they are non-stakeholder. However, as the portal implementation project comes to the acceptance stage, patients become more important because they have to start using the portal. In this stage, first contact with patients is made. Furthermore, the patient becomes even more important in the routinization and infusion stages of implementation, because they actually need to use the portal on a regular basis before the healthcare center can adapt its work processes in favor of the portal. Therefore, the patient is definitive stakeholder in from the acceptance to the infusion stage (Cooper & Zmud, 1990).

96 APPENDIX D: PAZIO & MGN SCREENSHOTS PAZIO Home screen (LRJG version) PAZIO eappointment functionality (LRJG version)

97 MijnGezondheid.net home screen (GCM version) MijnGezondheid.net eappointment functionality (GCM version)

98 APPENDIX E: INTERVIEWEES # Organization Function Role PAZIO 1 LRJG Medical manager 2 LRJG General practitioner 3 LRJG Senior assistant 4 Vital Innovators Innovation consultant Implementation manager 5 Vital Innovators CEO & Innovation consultant Product manager 6 UMC Utrecht Manager ehealth & Innovation Programme manager 7 GCM Senior assistant 8 Pharmeon Product owner App supplier 9 Imtech SharePoint consultant Platform supplier 10 PharmaPartners Sales manager HIS / Portal supplier 11 GCM CEO 12 GCM General practitioner 13 Patient 14 Patient