DIGITAL INNOVATION
IN DANISH HEALTHCARE AND ELDERCARE
EVIDENCE FROM A LARGE-SCALE TELEMEDICINE
PROGRAM
BY JEPPE AGGER NIELSEN, PROFESSOR (MSO), AALBORG UNIVERSITY,
DEPARTMENT OF POLITICAL SCIENCE, CENTER FOR IS MANAGEMENT
RESEARCH INTERESTS
Digital innovation
• Diffusion, adoption, implementation, and use
Elderly care and Healthcare (eHealth)
• Telemedicine, robotics, and mobile technology
Management concepts
• Leadership Pipeline, Lean, IT PPM
Current research project (2018 – 2021)
• Welfare Technology Implementation: From Vision to Value • WP1: Scaling-up WT innovation
• WP2: WT and value creation
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AGENDA
(1) The Danish welfare system
(2) Digital innovation in healthcare and eldercare: The case of Welfare technology
• Strategies, practices, and challenges
(3) Evidence from a large-scale telemedicine program in Denmark
• From pilot project to large-scale: Effective scaling in an interorganizational context
• From vision to value: Mixed results
(4) Lessons learned and conclusion
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THE DANISH WELFARE SYSTEM
• 5.4 mio. inhibitants
• The basic principle of the Danish welfare system, often referred to as the
Scandinavian welfare model, is that all citizens have equal rights to social
security
• A number of services are available to citizens, free of charge. This means
that for instance the Danish healthcare, eldercare, and educational systems
are free of charge.
• Key components of the Danish welfare model
• Denmark has one of the highest rates of taxes in the world
• Like many other countries, Denmark is faced with the challenge of an
ageing population
TECHNOLOGY USE IN HEALTH SYSTEMS ACROSS EU CONTRIES
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ORGANIZING HEALTHCARE AND ELDERCARE IN DENMARK
Danish health care system: a public and politically led system that is primarily
financed by taxes.
The Danish health care system is divided into three administrative and political
levels: the state, 5 regions, and 98 municipalities.
• The state takes care of overall financing and regulation.
• The hospitals are owned and administered by the 5 regions.
• The 98 municipalities finance and administer home care and nursing homes.
• 3,500 general practitioners (family doctors) act as gatekeepers of specialist
hospital care.
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WELFARE TECHNOLOGY IN USE: EXAMPLES FROM DK
Social
robots
The robotic seal
'Paro' for dementia.
Sensors and
wearables
GPS-tracking, e.g.
to track people with
dementia.
Service
robots
The 'Melvin' robot is
used to help elder
and disabled people
get clothes on and
off in the bathroom.
Apps
How’R’You-app,
daily journal, and
follow-up during
the course of an
illness.
VR-
technology
VR-training, e.g. for
rehabilitation of
brain-damaged
patients.
Relocation
lifts
Multi-Tower Robot
for relocation of
patients.
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WELFARE TECHNOLOGY
Welfare technology (WT) – “technology capable of assisting citizens in their daily lives, reduce costs, and provide a better work environment for health care professionals” (Hofmann 2013) – offers a potentially radical solution to innovate and transform healthcare and eldercare services
The promise of welfare technology (a term coined in the Nordic countries) manifests itself in many Western countries’ IT policies and strategies, and a variety of emerging technologies, such as VR, robots and telemedicine, are increasingly being adopted by contemporary healthcare and eldercare organizations
Denmark is a frontrunner (Östlund et al. 2015), thereby providing a unique case for exploring the WT phenomenon
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THE PROBLEM OF UP-SCALING
The transformative power of WTs is widely recognized but many projects tend to fail.
It is notoriously difficult to realize the expected benefits;
The long-term co-operation of multiple actors is hard to sustain.
Despite promising results from various WT pilots throughout the world, scaling up WT pilot
projects often fails (Bartel & Garud, 2009; Dougherty & Hardy, 1996).
Even when WT innovations demonstrate viability in initial pilot testing, it is not a given that they
survive beyond the pilot phase and become implemented at a wider scale (Garud et al. 2013).
Especially not when funding runs out!
Focusing on the early phase of innovation diffusion that I label “scale-up” draws attention to the
critical transformation of new ideas and practices from a small-scale setting to a more complex
setting with a larger population.
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EVIDENCE FROM TELEMEDICINE IN DENMARK
Pilot project:
TELEKAT
Large-scale program:
TeleCare North
Health
care
actors
2 hospitals
2 municipalities
4 GP´s
4 hospitals
11 municipalities
225 GP´s
Patients 111 1225
Budget $1,6 million $10 million
Period 2008-2010 2012-2015
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THE DANISH TELEMEDICINE INITIATIVE
• Telemedicine technologies facilitate delivery of health
care services at a distance.
• The Danish telemedicine service is characterized by
remote home monitoring of COPD patients. Health
care service is installed directly in the homes of the
patients.
• COPD = Chronic Obstructive Pulmonary Disease,
including people with chronic bronchitis. Usually
caused by smoking (and air pollution) and symptoms
include shortness of breath.
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THE DANISH TELEMEDICINE INITIATIVE
• COPD is a common and cost-intensive disease that constitutes 10% of the overall healthcare budget for citizens above the age of 40 in Denmark.
• COPD patients measure their oxygen levels,
blood pressure, pulse, and weight themselves.
These measurements are sent to a database that is
monitored by GPs and healthcare professionals from
municipalities and hospitals.
• Expected benefits: Prevention of hospitalization (save money), empowerment of patients, and decrease in demand for eldercare services.
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FROM PILOT PROJECT TO LARGE-SCALE PROGRAM
From pilot project to large-scale program
Pilot (2008-2010) Transformation (2011-2012) Large-scale (2013-)
Main activity User-driven
development and
experimentation
Backstage activities, decision-
making, planning, and building
the project organization
Launch and top-down
implementation
Change actors Researchers Managers and project
secretariat
Health care professionals and
patients
Main translation
activities
Translating
telemedicine ideas
into practice
prototypes
Translating the pilot findings into
a business case, work
instructions, and plans of action
for the large-scale program
Re-translation of the objectives
and practices developed in
phase 1 and 2 to a workable
large-scale solution
FINDINGS [1]: SCALING AS A POLITICAL PROCESS
Scaling up the telemedicine pilot project was a difficult task.
The period after the end of TELEKAT (pilot) was a critical period without funding or
visible project management. A period of silence followed, which involved waiting time,
back-stage activities, and networking.
Tensions between the interests of municipalities and hospitals were a recurring issue in
the transformation from pilot to large-scale, since it was “difficult for the participants to
think out of their own silos” (project manager). Actors from hospitals were guided by a
“medical logic,” emphasizing telemedicine as a treatment tool, whereas actors from the
municipalities were guided by a “care logic”, focusing on telemedicine as a rehabilitation
tool.
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FINDINGS [1]: SCALING AS A POLITICAL PROCESS
Although the case represents a successful example of upscaling, the process
was loaded with different motivations for participation, disagreements about
who should perform telemedicine tasks, different professional standards for
treatment, and protection of own interests.
Political behavior at the local and institutional level
• Region (hospitals) vs. municipalities
• Region (hospitals) vs. general practitioners
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FINDINGS [2]: HANDLING POLITICAL DYNAMICS
Observation of how the transformation into a large-scale program was facilitated by intensive efforts of
a group of managers. They used their social capital to mobilize resources and their alliances to
support the large-scale vision.
(1) Re-mobilizing networks
• Establish new constellations of actors
• “Behind the scenes” management
(2) Aligning interests
• Negotiate feasible compromises
• Create a flexible vision
3) Connecting to the field-level (national strategies and networks)
• Handle cross-level interdependencies
• Navigate field-level battles
Re-mobilizing network
When I left the closing conference on
TELEKAT, it was obvious that we had
achieved excellent results in the pilot.
However, if we were to be able to use them
for anything, we had to go large scale. Our
municipality couldn’t do such a project on our
own. It would have to include more parties.
Together with a regional top manager, we
started deliberating how we could realize a
large-scale project (Municipal top manager).
“Behind the scene” management
The work prior to the official project initiation
is invisible to others. However, it takes an
extreme amount of time and effort to mobilize
a network that supports a large-scale
telemedicine program. This work is not so
much about telemedicine – it relates to all
kinds of other things, for instance,
communication, networking, and the ability to
organize and think strategically. (Regional top
manager).
Negotiate feasible compromises
It was crucial to make a separate organization
the project secretary who is anchored at
neutral place. It is not the municipalities’ or
the hospitals’ organization. Instead, the
project secretary is our shared organization.
Create a flexible vision
Drafting a BC and highlight market potential,
efficiency gains and empowerment of
patients, thereby legitimating telemedicine as
a win-win situation for involved actors,
including financial and non-financial reasoning
Handle cross level interdependencies
The regional manager has put a lot of effort
into promoting our project in national
networks. So has the manager of the project
secretary. Thanks to their effort we became
visible outside of our region.
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Source: Christensen, Nielsen, Gustafson Seemann, forthcoming
LARGE-SCALE
Expected economic benefits difficult to realize. Economic benefits only realized for the group with ”severe COPD.” (not mild and moderate). The goal of significantly fewer hospitalizations was not achieved (Udsen, 2016)
*The benefits realization of WT is dependent on the technology being targeted at those citizens who get the most use out of it (in this case people with severe COPD)
In a survey about COPD patient experience, 88% of participants expressed that telemedicine is easy to use, while 72% experienced an increased feeling of safety and 62% felt more in control over their disease by using the technology. Half of the respondents experienced greater attention paid to their COPD symptoms, while 16% experienced more freedom during the course of their illness (Lilholt et al. 2015)
TeleCare North has launched by Danish Government as a model for nationwide telemedicine in Denmark
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FINAL REMARKS
• Zoomed-in on the critical phase of upscaling WT innovation, which is a notoriously difficult task that often results in failure
• Revealed how upscaling WT is not merely about enlarging a pilot project but rather about transformation, legitimacy building, and handling political dynamics to make the pilot eligible for a large-scale context
• Leadership support and professional acceptance key factors in facilitating the upscaling of telemedicine services. This case also show the importance of understanding and handling political dynamics (re-mobilizing networks, aligning interests and connecting to national strategies) in the scale-up process
• Scaling up WT innovations in health care settings is a political process and managers must master the politicized context to succeed
• Expected (economic) benefits difficult to realize
THANK YOU
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