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journal homepage: www.intl.elsevierhealth.com/journals/ijmi

New e-service development in the homecare sector: Beyond

implementing a radical technology

Anna Essén a,∗ , Moya Conrick b,1

a School of Business, University of Stockholm, Stockholm, Sweden
b School of Nursing, Griffith University, Nathan, Brisbane 4111, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This paper explores the constituents of and challenges related to the innovation of
Received 4 September 2007 technology-based services in the long-term homecare sector.
Received in revised form Methods: This research used purposeful extreme case sampling, a mixed methods approach
22 February 2008 to research that included focus groups and interviews, to learn from the experiences of
Accepted 27 February 2008 an innovative telehomecare project. The paper uses a framework that integrates service
management; information systems innovation and medical informatics theory.
Results: The findings indicate that the claimed and the rather abstract benefits of the technol-
Keywords: ogy espoused by information technology vendors were difficult to transform into a service
Elderly homecare services concept. The organization studied is still struggling with conflicts between technological
Technology possibilities on the one hand, and the prevailing service delivery systems and user prefer-
Organizational innovation ences on the other. Decisions about the extent to which the service needs to be reengineered,
Telemedicine what non-technology resources are required, what should be the role of the consumer in
Smart home technology the new care process and identifying who is actually the primary beneficiary and user of
Aged care the new service remain.
Conclusions: A comprehensive development model and ‘mindfulness’ is necessary for radical
service innovation in the long-term homecare sector. Creating new services that exploit
the capability of radical technical innovations requires organizational development and the
use of many non-technology innovations and resources. To understand what combinations
of technological and non-technological resources can provide sustainable benefit, all key
internal and external stakeholders must be involved from the beginning of the project.
© 2008 Elsevier Ireland Ltd. All rights reserved.

1. Introduction setting [3–5]. While there is a growing body of technology-

Numerous international reports emphasize the need to
develop new models of care service delivery to deal with
the escalating demands and massive increase in costs in the
healthcare sector [1,2]. The potential for new information and
communications technology (ICT) to underpin these mod-
els has been mooted, especially in the long-term homecare
oriented literature discussing telehomecare or smart home
technologies for seniors [6], less attention has been paid to
organizational perspectives in this context. That is, research
has focused on the technical accuracy of specific telehome-
care applications rather than highlighting more general issues
related to how organizations can develop effective ways of
using such technologies in their everyday work [3,6].

Corresponding author. Tel.: +46 8 16 11 83; fax: +46 8 674 74 40.

∗

E-mail address: aes@fek.su.se (A. Essén).

URLs: http://www.annaessen.blogspot.com/ (A. Essén), http://members.optusnet.com.au/conrick/index.html (M. Conrick).
1
Moya Conrick passed away in January 2008. She was a very special person and an excellent co-author. This paper is dedicated to her.
1386-5056/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijmedinf.2008.02.001
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This paper seeks to redress this imbalance particularly in
the telehomecare area, by shifting the focus from technology
to the innovation of new care services. It highlights the issues
involved in the process of integrating telehomecare technol-
ogy in the daily delivery of long-term elderly care services.
The paper is organized into five sections. These present: the
research background and the frameworks used; data genera-
tion and analysis methods; empirical findings; discussion and
conclusions.
1.1. Background
This research was undertaken in Sweden where community
care providers are responsible for serving the broad group of
seniors who need general help with managing their everyday
life at home, as opposed to providing hospital care to patients
who have medical needs. It was triggered by a group of man-
agers in a community care organization who envisioned that
information technology (IT) could enable them to use their
scarce resources more effectively.
They decided to invest in an in-home monitoring system
that continuously monitors the activity level of seniors. This
system is sensor-based and would not require any active input
from the senior (and computer illiterate) beneficiaries of care.
The managers identified that this area of information tech-
nology may hold some of the answers to their resourcing
challenges, they had no explicit strategy concerning how to
use it or how to develop new IT-based services on basis of it.
This paper is based on a case study that focused on how this
new telehomecare technology was introduced in the organi-
zation. It elicits the elements and challenges associated with
this process in the public elderly care context.
1.2. Frameworks
Research on the use of remote and sensor-based telemoni-
toring to enhance long-term elderly homecare is scarce in
the medical informatics literature [5]. However research about
implementations of healthcare information systems (HIS)
more generally provides insights that are relevant to this con-
text. This literature has increasingly broadened its focus from
the technical to the socio-technical dimensions of information
systems suggesting that the success of IT implementations
not only depend on the quality of hard- and software used
[7–9,39]. The literature also argues that organizational fac-
tors are also the key to success [10–12]. Several organizational
prerequisites for ‘successful’ IT implementations are iden-
tified by a number of authors and these include financial
and structural support, mobilizing ‘champions’ during imple-
mentation, involving, educating and motivating users, and
dealing with confidentiality, standardization and legal-related
issues [7,10,11,13–19]. In general, the importance of embed-
ding the technology in practice is underlined and this involves
a mutual adjustment of both technology and care practices
[7,13,16,17,20,21]. These are crucial insights that inform the
current research. However, while claims about the impor-
tance of introducing the technology with consideration to the
organizational context abound, there are still uncertainties as
regards how this can be achieved in actual work settings [10].
This is particularly the case as regards the use of telehealth in
the care of frail elderly living in their ordinary homes. Indeed,
there is a lack of studies that outline the issues involved in the
organization of telehealth technologies into long-term elderly
care practice and the wider public care service delivery [10]. We
argue that this is a question of e-service innovation and believe
that the service management and information systems liter-
ature provide insights helpful in this context. Theories from
this body of literature were drawn on to create a functional
framework for the present study.
At the heart of new e-service development is innovation.
This is broadly defined as an idea, artifact, or behavior that is
new to the organization adopting it [22,23,38]. Edvardsson and
Olsson [24] suggested that at general level, service innovation
includes the development of: (1) the service concept (consumers’
needs and how these are to be satisfied); (2) the service sys-
tem (static resources required, the organizational, physical and
technical environment); and (3) the service process (the chain
of activities that must occur for the service to function). As
regards to how these dimensions should be innovated studies
on new product/service development proposed a number of
success factors. These include engaging in internal communi-
cation, in particular involving front-line employees [25–28] and
engaging in external communication with consumers, suppli-
ers, competitors and other stakeholders in all stages of the
innovation process. It has been argued that this leads to more
comprehensive and varied information and thus to a higher
performing development process [29–34].
While the service management literature provides insights
about the issues involved in service innovation, it says little
about the specificity of using a new technology that may con-
stitute a radical innovation. However, the information systems
(ISs) literature is helpful in this context. What emerges from
this literature resonates with argument in the medical infor-
matics literature, namely that introducing new ICT systems
in an organization often entails changes in work process and
the organizational structure as well as in the ICT system itself
[35,36]. Swanson and Ramiller [37] identify the issues involved
in this process. In their model, an organization’s interest in
new technology is often sparked by an “organizing vision”,
which is described as the decontextualized and general advan-
tages of a new technology and often espoused by groups such
as technology vendors, consultants and academics. The orga-
nizing vision typically defines the IT system in broad strokes,
which helps to legitimize it [36,37]. A ‘mindful’ organization
is not seduced by the organizing vision but will objectively
evaluate a system’s suitability for their needs. This is what
Swanson and Ramiller [37] refer to as comprehension. If adoption
is entertained, a deeper consideration of the system follows.
Here a context-adjusted supportive rationale is developed by
paying attention to issues specific to the organization. The
implementation phase involves a “myriad of considerations,
choices, and actions” (p. 557). The ‘mindful’ enterprise will
make adaptations during implementation in either the sys-
tem or organization to address unanticipated problems or
realize unforeseen potential. A reliance on expertise over for-
mal authority and a readiness to relax formal structure is
important in this stage. Assimilation commences as the IT sys-
tem is absorbed into the organization’s work practices and its
usefulness is demonstrated. In time, the innovation becomes
infused and routine [37].
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Fig. 1 – An ideal framing of the process of innovating technology-based services.
Combining insights from Swanson and Ramiller’s [37] ideal
model of IS innovation and Edvardsson and Olsson’s [24]
model of new service development, the framework in Fig. 1
was created. This depicts an “ideal” innovation process and
has been inspired by the service management, information
systems innovation and medical informatics literature. This
framework has been used in the generation and analysis of
empirical data in this study.
2. Method
This study forms part of a larger research program on tech-
nology in elderly care. It is based on empirical data collected
over several years (2003–2006) during a Smart Home Devel-
opment project in a small municipal care organization in
Sweden. It uses purposeful extreme case sampling; satisfy-
ing the requirements for this method by selecting a case that
was “information rich and special in some way” [40,41]. A case
study approach allowed the researcher to follow the service
innovation process over time and to use a variety of informa-
tion sources [42].
Participants in the study included the Home-help man-
agers and Home-helpers involved in the development project
from its inception. The primary researcher (and author) gath-
ered data using e-mail, phone and large numbers of formal
and informal meetings (31 meetings) over a 3-year period. This
was followed by 10 semi-structured, face-to-face interviews
with operational and management personnel in the organiza-
tion who had been directly involved in making the investment
decision and/or using the technology. Except for one section
manager, there was no turnover of personnel during the study
period. The researcher used an interview schedule that con-
tained both open and closed ended questions (see Appendix
A). One hour long non-participant observation of employees
using the new technology was also performed at five occa-
sions.
Data were analyzed, using a combined inductive and
deductive approach [43,44]. The authors departed from the
681
theoretical framework at an overall level while attempting to
inductively infer and be attentive to themes emerging from the
empirical material. In all, the analysis process went through
three iterative rounds of culling the interviews, consulting
the tentative framework, adjusting the analysis and refining
conclusions as required by the research approach [45]. The
findings presented here represent broader sets of empirical
data; the quotes chosen are typical for the interviews and
observation. The names of respondents are excluded for pur-
poses of confidentiality and the study fully complied with
ethical standards for this type of research and was approved
by the Regional Research Ethics Committee of Stockholm.
It should be noted that in this paper the term The Man-
ager is used for the person making the corporate decisions
and interviewed separately while the term ‘managers’ refers
to the group of section managers in the organization.
3. Results
The results of this study must be considered in light of the
municipal care organization managers’ lack of an explicit
strategy concerning how to develop new IT-based services and
their scant knowledge about the technologies available. In this
environment, it is not surprising that this study found the
development process used by the organization deviated from
the ‘ideal’ framework presented in Fig. 1. In the current climate
this is probably not a unique circumstance.
3.1. Comprehension and adoption
The managers scanned the market for potential healthcare
technologies and in doing so uncovered a vast number of
radical technologies in the market. They rejected many prod-
ucts because they focused on providing new medical services
to certain groups of chronic patients at home, as a way of
reducing hospital admissions. Few products were promoted
as providing benefits for either the senior consumers mar-
ket or personnel in this non-medical, long-term care context.
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The managers finally selected an activity monitoring system,
which they thought would bring benefits to the broad group
of homebound seniors “in general” and independent of their
medical diagnosis. Twenty-three units were purchased. These
units replaced the pendant safety alarms that were currently
in use.
The system included monitoring units worn on the wrist,
in similar fashion to traditional alarms. They offered sim-
ilar functionality to traditional alarms with a button that
seniors press in an emergency situation. The new units also
included sensors that continuously monitored non-critical
activity level, which indicated the sleep/wake rhythm of the
seniors. These sensors detect and send automatic alarms to
healthcare personnel if significant changes in activity level
are detected for example, if a person is inactive due to a fall.
The systems could provide both non-emergency and emer-
gency information, something that the managers found very
appealing. Because data could be continuously gathered by
remote sensing and subsequently presented in graphical form
for analysis either in real time or retrospectively, they believed
that the technology represented a radical new way of under-
standing the health-state and needs of their consumers.
3.1.1. Translating the organizing vision into concrete
benefits
The technology was adopted after the vendor assurance that it
could enhance the organization’s capacity to ensure the safety
of seniors and act as a preventive measure. The Manager
was convinced that seniors would feel safe in their homes,
knowing that they were monitored and that the information
collected by the technology would enable the organization
to know their seniors and their needs better. Initially, The
Manager saw the potential for the information provided by
the system to be used in developing customized care ser-
vice processes. For example, if the client had a disturbed
night Home-helpers “could let this senior sleep a bit longer
in the morning and prepare the breakfast one hour later than
usual. . .” [The Manager, Group meeting, 2005]. Beyond this, the
benefit was unclear; The Manager reported that they “found it
difficult to predict. . . At this stage, the implicit understanding
was that the detailed advantage of the monitoring technology
would emerge along with the personnel starting to use it. . .”
[Interview 8, 2006].
3.2. Implementation
The managers were involved in the purchase of the new
technology. However, they were not engaged in the implemen-
tation phase, which involved many decisions related to the
configuration of the technology as well as decisions related to
the adjustment of the organization.
3.2.1. Adjusting the technological infrastructure
The system included many features that could be applied and
customized to each individual, or they could be kept latent.
It was possible to configure the technology so that various
alarms were triggered for example, if the senior leaves the
apartment. The decision on what software features to activate
was delegated to the front-line employees; the home-health
aids and their group leader. Their decision was to use only the
most basic functions and to send alarms to the home-health
aids on duty in the same manner as the traditional alarm this
new system was replacing.
Only the home-health aids were given access to the
information showing seniors’ longitudinal activity patterns
although this non-emergency activity information could be
made available to others like. The senior’s general practi-
tioner and family. As these external parties were not involved,
their potential needs and roles are not discussed. Ideally,
organizational issues should have been dealt with before the
implementation of the system, as the reconfiguration of the
system is a way of implementing these roles [24]. In this
research knowledge of all the internal and external actors who
were to use the system was extraneous and therefore a model
of usage and workflow was not mapped.
3.2.2. Adjusting the organizational infrastructure
The managers were not engaged in developing an organiza-
tional infrastructure supporting the use of the new monitoring
technology. “. . .Tasks need to be performed, but we never really
decided who should do what, and we never really allocated
resources to this. . .” [The Manager, Interview 5, 2006].
Hence, the myriad of choices related to how to use the new
technology and who should use it were delegated to opera-
tional personnel. This presented this group of personnel with a
number of challenges. For one, they did not possess the power
to provide resources for the new service system: The Group
Leader explained: “. . .I cannot employ new personnel. . .I have
been able to spend time on the monitoring system by spending
less time on other tasks. . .” [Interview 2, 2006]. It was decided
informally that the Group Leader should install the monitoring
units in the senior households and no maintenance routines
were developed to cover for when this person was away.
There were four automatic alarms sent by the equipment
during the study period and in all of these cases healthcare
personnel responded in exactly the same way as for the old
system; that is, two Home-helpers immediately drove to the
senior’s residence to check on them. In none of these cases,
there was a real emergency. Alarms were rather caused by
various more subtle reasons such as seniors being unusually
weak. The seniors were happy to be paid a visit at these occa-
sions. There was no routine for examining the longitudinal
non-emergency information gathered by the system. Conse-
quently a Home-helper [Interview 3, 2006] reported, “. . .I look
now and then, when I have a free moment. . .”. The Group
Leader was the most frequent user of the data devoting a few
minutes to analyze them every third day.
The Group Leader reported findings of abnormal activity
patterns or seniors not wearing their alarm to the Home-
helpers on duty. The system was effective in identifying these
anomalies but work process remained the same. That was,
during their next scheduled visit the seniors not consistently
wearing their monitor were reminded to do so. Additional vis-
its were not activated based on the activity information. This
was partially due to the Home-helpers being time poor and
unable to provide “new” or extended services within their tight
schedules. These workers lack the authority to change or add
to the services they deliver. Social workers make these deci-
sions and their budget is provided by government and funds
predefined needs with pre-determined services. Maintaining
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a “normal” activity pattern among seniors is not seen as a part
of this. A home-health aid talked about her limited possibil-
ities to attend to activity or sleeping disorders illustrated by
the activity curves:
“. . .There is not much one can do though. I may ask the
senior how he has been sleeping lately and may ask if he
has sleeping medication etc during my scheduled visit. Of
course, there is much more that one would like to do. For
example activate those seniors who are too often inactive
during the day – this would most likely make them sleep
better during night. . .but there is no time for that. . .I can
only provide services that are formally granted by the social
workers. . .”
[Home-helper, informal meeting, 2005]
In some cases the personnel also had difficulty interpreting
the ‘problems’ detected by the system and deciding how to
respond to them.
“. . . how long is it normal to have a ‘low activity’ level?
Some seniors may need a lot of rest while in other cases
low activity level can be a signal that something is wrong
health-wise. . .a sign of depression. . . something that could
get worse if we do nothing about it. . .but we don’t want to
turn the seniors into hypochondriacs. . . preventive services
are not easy. . .”
[Home-helper, Interview 6, 2006].
Home-helpers were hesitant to intervene in the non-urgent
reports. They describe not knowing how to approach the client
without sounding as if they were “watching” them in a nega-
tive “big brother” sense and without alarming the senior. This
applied to activity information as well as to information about
those not wearing their alarms.
“. . .If an activity curve indicate that something is not OK,
you feel like asking the senior about this. . . But we cannot
say to a senior that ‘We have seen on the curves that you
are very inactive during the days’. This might make the
seniors feel watched in a negative sense. . .how do you ask a
senior about her activity level without sounding strange? It
is easy to make seniors worried. . .we found it very difficult
to define a routine for this. . .”
[Group Leader, Informal meeting, 2006]
“. . .I saw that Anton never wears his alarm during the night.
I told one of the girls to remind him to wear his alarm dur-
ing her regular visit, but she did not really know what to say
to him. She didn’t want to say that we “can see” if he wears
it or not. However she managed to tell him in a nice way
and now we see on the curves that he is always wearing his
alarm. . .”
[Group Leader, Personal communication, 2006]
The seniors were informed about the new service via letter
and phone. The personnel had not given much thought to fur-
ther educating the seniors, fearing that “this would make the
seniors worried and confused” [Group Leader, Project meeting,
2005]. They implicitly assumed that the monitoring technol-
ogy was ‘passive” and did not require any input from the user.
As a result, a few of the seniors described being unclear as to
what to expect from the new service or how they should use
683
it. Some began to over rely on the technology, believing that
it could detect any change in their health status. For example
one Home-helper reported that:
“. . .Jim told me he had felt really bad before my visit. But
he didn’t call for help, or press the alarm button, as he
thought the technology would notice this. ‘You could see
this on the computer, couldn’t you’ he said. . .but of course
we couldn’t. . .”
[Interview 1, 2006].
In this case, the Home-helper tried to make clear to the
seniors the limits of the new technology—without eroding
the seniors’ faith in the new technology completely. A true
challenge.
3.3. Assimilation
The general claims that inspired the managers’ adoption of
the monitoring technology were not shared by the operational
employees. They generated their own ideas about the benefits
that could flow from using the technology. Some of these were
expected while others were unforeseen.
Not surprisingly, the operational employees believed that
the new automatic inactivity emergency alarm function could
increase their responsiveness in certain emergency situations,
particularly if the person was physically unable to manually
call for help. This would mean shorter delays that, according
to the Group Leader, could produce qualitative and economic
benefits by “reducing the likelihood of permanent functional
impairments among seniors. . .” [Interview 4, 2006].
Less expected was the fact that seniors were more likely
to wear their monitor, because, they realize that staff could
tell if they were not, unlike with the previous untraceable
alarms. According to the Home-helpers, the seniors them-
selves appreciated this function as they are aware of their
tendency to forget to wear their alarms and the reduced safety
this implies in cases of incidents such as fall accidents. This
function also reassured both staff and relatives and was seen
as “economically important for the service because usually
the relatives apply for nursing home placements. . .” [Group
Leader, Meeting, 2006]. Interviewees also reported the abil-
ity for early client interventions and congruent with The
Manager’s initial vision—to provide new customized services
that could lead to an improved general health status of the
seniors. However, not all section managers shared this vision
considering the provision of such services economically unvi-
able. One of them remarked: “. . .we do not have capacity to
address all seniors’ sleeping and activity disorders. . . This is
beyond our commitment. . . we will suffer increased produc-
tion costs. . .without being reimbursed for this. . .” [Manager 2,
Interview 10, 2006].
Hence, during the study period Home-helpers responded
immediately to emergency calls but were hesitant to intervene
in the non-urgent reports. They had ideas about how to act on
the non-urgency activity data but found it difficult to realize
such ideas.
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684 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 7 ( 2 0 0 8 ) 679–688
Fig. 2 – The major issues in radical ICT services development.
4. Discussion
This research illustrates that innovating services based on new
radical technology is a complex and multidimensional under-
taking. Not all of the issues that arose were expected and
participants in this research dealt with them in a variety of
ways. Some of the issues emerged because of lack of through
decision-making and planning by management and other per-
sonal. The major issues are presented in Fig. 2 in which the
stages are depicted in the observed rather than an ideal order.
The project studied began with ‘comprehension’ and
‘adoption’ [37] as the managers took the essential first step
when learning about the new available technologies. The
lack of involvement of the front-line home-help employees
in this phase was unfortunate and ultimately damaging to
the project, as they could have provided crucial insights into
operational specifics of the organization. The elderly clients
and their family were similarly excluded from the decision-
making in the comprehension and adoption phase, contrary to
recommendations in the literature [30,31,47,48]. Instead, the
managers selected and adopted a new technology on the basis
of the vendor-claimed benefits. They assumed that benefits
would emerge in use.
The managers did not participate in the implementation
although this phase involves many crucial decisions. Indeed,
although the managers selected an intelligent technology,
which included many automated functions, providing the
monitoring service required the execution of several human
tasks. Someone needed to design the human service elements,
that is, they needed to formulate the complete service pro-
cess with routines for how to use the technology and so forth.
This instead was delegated to the operational personnel, who
developed some new informal routines (or service elements).
This implied incremental rather than radical change in the
existing service processes. Further, these changes were not
transformed into routines and assimilated.
These results need to be understood in light of how the
project commenced. As the elderly care recipients were not
involved in the first phase, their needs and possible user roles
were overlooked in the selection of the system. It is impor-
tant to recognize that another technology would perhaps have
been selected had the seniors and their family been involved
in the first place. In general, the needs of the consumer were
not central and did not guide the project studied. There was
only a diffuse managerial wish to improve the effectiveness of
care. As a result, there was a lack of direction and the target
group for whom the service was being developed was unclear.
It is also important to question why considering that the
monitoring technology was installed only modest service
changes were achieved in this study. This answer to this lies
in the failure to reengineer the organization to accommodate
for the possibilities inherent in the new technology. In general,
there were several conflicts between the action made possible
by the technology on the one hand, and the activity ‘allowed’
by prevailing systems on the other. For example, the technol-
ogy enabled the provision of customized services based on
real time data about the consumer. To realize this potential,
front-line employee must possess the power to continuously
adjust the services they provide. In the care setting studied,
this would require giving the Home-helpers the authority to
change their schedule and the content of the services they pro-
vide on basis of the “latest consumer data available”. This is far
from today’s situation in the Swedish National Health System,
where the Home-helpers cannot make any changes in situ, but
have to defer to the social workers decisions about what ser-
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i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 7 ( 2 0 0 8 ) 679–688
vices are to be provided to what seniors. These conditions are
contingent on the prevailing hierarchical system of author-
ity and the financial reimbursement system. There is nothing
a regional care manager can change in this. Hence, issues
related to the national health system impeded the effective
integration of the new technology in existing practice. The
presence of structures served as a barrier to radical service
innovation in this context [10].
Not only the presence but also the absence of systems
impeded a constructive development of new services in the
setting studied. Guidelines and criteria for the use of the
monitoring system were not developed and quality assurance
systems were not in place. Important in this context is defin-
ing who should be made accountable if the monitoring system
is deliberately misused, or leads to negative effects in unpre-
dictable ways.
The findings in this study illustrate that the lack of infor-
mation provided to consumers about their user role could
threaten their safety. To manage risk effectively, accountabil-
ity for such unintended but negative consequences must be
established; is it the responsibility of front-line employees,
the managers or the technology vendor? Further, to ensure
fairness in public service delivery it is important to define the
criteria that should be used by the social workers when deter-
mining which seniors are eligible for the new service. Such
criteria were not developed during the study period. This is
related to the fact that the “need” to which the new monitoring
service actually responds was not clear.
There were further conflicts between the technological
possibilities and the needs and preferences of the senior con-
sumers. More specifically, the workers struggled with bridging
the gap between
• what the technology could monitor and the seniors’ concern
about privacy,
• the possibilities for preventive care and early stage response
to health changes and the risk of exaggerating the impor-
tance of such changes leading to seniors excessively
worrying about their health and
• the actual capability of the technology and seniors inappro-
priate expectations of the technology.
The development process studied began with the man-
agers making a new technical resource available to their
personnel. This approach may have its merits as it enables
experiential learning and enhances the chances of the orga-
nization staying open to the unforeseen potential of the
new resource [22]. Indeed, unexpected possibilities emerged.
However, the managers in this case failed to recognize that
selecting and implementing a radical new technology is not
the same as producing a radically new service innovation.
Hence, the operational employees had to bridge the gap
between the new technology and the new service. This is not
necessarily negative; involving the operational personnel in
the service process innovation is in line with the literature
[24,32–34,51–54].
However, contrary to the literature, in this study (and the
Swedish National Health System overall) the operational per-
sonnel were not given the power necessary to enforce changes.
In general, there were no rewards or other incentives for oper-
685
ational employees to innovate new services into their setting.
Home-helpers were not encouraged to be creative and explore
new models of care delivery partly due to a fear for harm-
ing the consumers and possible legal consequences. In short,
there was no climate for innovation as described in the litera-
ture [32–34]. These factors are very likely to have affected the
development process performance.
This study lends support to other work that has argued
that in practice telehealthcare systems are highly problematic
and demand that the organization of care work is radically
re-engineered [10]. Other scholars have also underlined the
need for adjusting technology to existing ways of organizing
care work, and vice versa, and pointed to the practical difficul-
ties that it poses for care personnel [10,17,21,49,50,55]. In the
project studied the need to make various design choices were
brought to the fore, to operational personnel as well as man-
agers (see Fig. 2). Much work remains to effectively make these
decisions. Hence, the development project can be described as
a learning process and it is difficult to categorize the project as
a success or failure at this stage. In Zoë Stavri and Ash [56] par-
ticipants define successful IT implementations as those where
the system is accepted and remains operational. According
to this modest definition, the project discussed here was not
a failure. The organization continues to work with the new
technology and as a result valuable learning for the sector
has resulted. Their perseverance will see this continue in the
future.
5. Conclusion
This study explores the constituents of and issues involved
in the development of new technology-based care services in
the long-term elderly care setting. The framework developed
for this project and inspired by insights from the normative
medical informatics, service management and information
systems literature quickly demonstrated that the project stud-
ied deviated from the ideal model in several ways. This
had vast implications on what new service processes could
be developed. Although a technology enabling quite radical
changes was used, only incremental changes in care work
were realized.
This paper identifies several reasons for such deviance and
modest result. The presence of national hierarchical deci-
sion systems and rigid financial reimbursement systems are
important here. As is the absence of quality assurance and
accountability systems related to the use of IT in service deliv-
ery. Most importantly, the paper highlights that there is no
innovation friendly climate in the public long-term elderly
care setting in Sweden. What dominates the care managers’
agenda is rather an ambition to survive financially.
The managers appeared to have little knowledge about
change management and further, there was no research and
development department who had the financial resources,
competence and authority to formulate a service concept.
Therefore no one undertook to identify latent consumer needs
or to develop a technology-based solution that satisfies these
needs. Indeed, while the community care providers may have
been aware of the problems, they possessed little knowledge
about how technology could be used to solve them.
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686 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 7 ( 2 0 0 8 ) 679–688
In these kinds of projects, it might be expected that
development process start with care providers learning from
technology providers and trialing existing technologies. Yet,
it is important to recognize that this leads to a technology-
oriented rather than user-needs driven approach. In order
for truly innovative and effective IT-based care services to
develop, operational employees and clients need a much
more salient role in development projects. Further, opera-
tional employees need to be empowered. This in turn requires
political decisions about changes in the National Health Ser-
vice delivery structure and new kinds of competences.
5.1. Study limitations and research suggestions
This study illustrates the innovation process observed in one
case with a particular technology used in the particular set-
ting and so the findings reported here cannot be generalized.
The organization studied faced challenges related to the public
reimbursement system, and the centralized decision hierar-
chy characterizing the Swedish public care system. Private
firms obviously operate under completely different condi-
tions. The development of preventive care services added to
the challenges in the situation studied here. As did the use of
a radical technology in the community care setting, which is
far from computerized.
While this study does not offer definitive answers related
to the innovation of technology-based services, it does provide
insights, an in-depth account of the organizations struggles to
implement a high technology solution into a low technology
setting and this experience may no doubt resonate with expe-
riences in other settings. Most importantly though it reports
the learning and knowledge gained during this challenging
process. The lessons learned here will be valuable for other
care providers if they are to avoid the pitfalls experienced by
the actors in this study. It will also improve the chances for the
successful deployment of innovative information technology
into new models of service delivery.
This study may further inspire others to investigate the rel-
evance of the model presented as Fig. 2 in contexts other than
the public care setting studied in this paper. This is needed in
order to advance and further validate the model to prove its
suitability to underpin the use of technology into the home-
care sector. This is fundamental to successful ‘Smart Home’
innovations and deployments wherever they take place. With-
out a workable model it seems that these innovations will
fail.
What emerge from this study are several other questions
that need to be answered by further research.
From the organizational perspective:
• How can public healthcare organizations become more
innovation oriented?
• What does an innovation-friendly climate imply in the
public care setting?
And concerning the preferences and possible role of con-
sumers:
• Is there necessarily a trade-off between the consumers’
perceived privacy and safety when developing new care
services on basis of new digital consumer data?
Summary points
What was known before the study?
• The interest in Telehomecare and Smart Home
technology is increasing as Governments world-
wide plan for the future healthcare needs of the
elderly.
• New telehomecare technology in terms of hardware
and software is continuously emerging and gaining
attention as “promising”.
• Studies have focused on demonstrating the technical
feasibility of specific applications rather than high-
lighting the role of telehomecare in care organizations
that is, the total picture is missing.
• The medical informatics literature underlines the
importance of integrating technology into the organi-
zation but offers little guidance as regards how elderly
care providers can exploit technological advance-
ments to provide new care services.
What has the study added to the body of knowledge?
• As Telehomecare applications can be used in sev-
eral different ways, understanding the technological
possibilities inherent in a telehomecare application
and installing new hardware and software are only
the first steps in the process of new care service
innovation.
• Service innovation involves developing a sustainable
service concept, service process and service system.
Generally, if telehomecare technology complement
rather than supplement existing services, short-term
production costs will rise. Public care providers may
not be reimbursed for such increases in production
cost.
• Hierarchical management structure where front-line
employees do not possess the authority to make
changes in the service content impedes the effective
use of real-time patient data generated by many mon-
itoring technologies.
• Defining the “user-role” related to the care consumer
is necessary even in passive technologies, for example
sensor-based monitoring technologies still assumes
certain consumer behavior that needs to be clarified.
• Personnel play an important role in using the technol-
ogy in ways that do not intrude on consumers’ privacy.
• How can consumers be involved in the development of
new technology-based services?
• How can the role of consumer in service settings, where
passive technologies with completely automated func-
tions are used, be mapped?
Finally, it is crucial that further research examines the “thorny
issues” related to the use of technology in long-term elderly
care in order to understand the promises and perils of these
new technologies.
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