Article
Developing Public Policies for New Welfare
Technologies: A Case Study of Telemedicine and
Telehomecare
Torben Tambo
Abstract
Technology has for long been predicted to be a key development factor in answering the
difficult questions on how to secure welfare in industrialised countries as life expectancy
increases and the working population and taxpayers diminish. This is particularly assumed
for information and communication-based technologies (ICT) for homecare and monitoring
(telemedicine, telehomecare). Despite major investments and national commitment, public
policies have not yet found a general approach to move from technological and clinical
opportunity and into large-scale regular use of the technology (normalisation). This article
provides two case studies from Denmark; one case with hypertension monitoring at a local
level and another case on national policy implementation through funding of selected
demonstration projects. Among the findings are that policy-making processes certainly face
major challenges in capturing research and development for the transition of technologies
into working practice. Furthermore, policy approaches of supporting experimentation and
demonstration are found inadequate in promoting technology into a level of normalisation
in highly cross-organisational operational environments. A research lens and a policymaking process are suggested upon balancing the rationales of infrastructure, business
case, strategy and organisational constructivism over time with continuous review of the
qualitative dimension of public policies in securing the fulfilment of societal needs.
Improvements of policies have critical social implications in development of future
technology-based welfare systems.
Keywords: welfare technology, telemedicine, telehomecare, welfare policy, ageing
Introduction
The world’s industrialised nations are facing major challenges in the years to come.
Demographic changes are leading to an ageing population (Koch 2006) requiring more
care, suffering from more health issues, lifestyles creating chronic diseases, ever increasing
limits for the medical science’ ability to treat patients, and shrinking budgets (Saha 2011).
Technology could be the solution. Particularly technologies in the home or in the ambience
of the citizen (patient) seem attractive as they reduce the need for physical presence of
health care professionals, but introduce pervasive monitoring and hence comfort to the
patient (Dinesen et al. 2008, Andreassen 2011, Rouck et al. 2008, Cegarra-Navarroa and
Sanchez-Polo 2010, Essén and Conrick 2008, Prinz et al. 2008, Al-Qirim 2007, May and Ellis
2001, Takahashi 2001). Telemedicine has thus for long been predicted to be transforming
the welfare services in Europe providing safety and quality-of-life to ageing patients
(Bashshur and Shannon 2009, Hebert et al. 2006, Varghese and Scott 2004, Brender et al.
2000). Public policies, however, seem to lack systematic in conversion of expectations and
experimentation into implementation, operations and normalisation (Murray et al. 2011);
Miller (2007) calls this the lack of disjuncture between research and practice; Ekeland et al.
(2010) talk about the need for “more focus on patients’ perspectives, economic analyses and
on telemedicine innovations as complex processes and ongoing collaborative achievements”.
The purpose of this article is to review and discuss mechanisms affecting the conversion
process of shifting policies from loosely expressed ideas and intents into workable policies
at relevant political and operational levels.
Policy-making in the welfare sector (Beland 2010, Field 1996) is characterised by a limited
amount of resources – or more correctly a fixed amount – that need to be allocated within a
social and political acceptance (Nicolini 2008). Typically, policies need to defend rather
static and conservative approaches – frozen (Beland 2010) – to budgeting as citizens rely
on the services in their long-term planning for e.g. the retirement age. Furthermore,
policies are limited by certain implied or external factors loading existing services and thus
limiting the window for new activities. Ageing and growth in the groups of the oldest
citizens are strongly impacting without policy-makers having means to cope with this;
likewise with novel and expensive medicine. New technologies, new services and
preventive medicine are often seen down-prioritised in favour of defending existing
services; however, Health Consumer Powerhouse (2009) uses the adoption of novel
treatment as one out of six key assessment parameters of national health care systems.
Policy-making in the welfare sector is furthermore affected by the necessity to establish
viable coalitions between citizens, organisations, professionals/employees, suppliers and
policy-makers at all levels. These coalitions tend to institutionalise the individual services
in the system, but are also to be considered as prime stakeholders (Lockamy and Smith
2009, Miller 2007) in planning of change. Interesting in the study of technology adoption is
when technological maturity can be connected to a momentum of change within the
stakeholder coalition (Nicolini 2010).
In the research on policy development on a single-country basis, it is noteworthy to
consider factors linking this to international perspectives, such as technological
development and proliferation, the global market for health care professionals, and the
push for international benchmarking with relevant linkage to national and regional policies
(EHTEL 2008). In Europe, EU suggests guidelines and provides funding for
experimentation on a super-national basis (EU Commission 2008). The global development
of technological consumer products for home health monitoring is also increasing,
potentially known as gadgetry, with the risk of loss of the egalitarian principles behind the
welfare systems, and a risk of breakage between the stressed health care systems and the
highly informed citizen.
Telemedicine is a technology approach to a social and societal challenge where the classic
approach to development in health care would be doctors, nurses and pills, with
technology versus human professionalism as a potential axis of conflict or scepticism.
Telemedicine in the actual context is in the home of the patient and is left to the patient’s or
the patient’s family’s ability to respond to self-care; this is itself a source of concern on
weaker patients. From both the general health care regime and from a policy perspective,
this is a disruption to established conservatism of policy-making. There has not yet been
found a successful conversion strategy for developing public policies from technology
opportunity to full-scale normalisation of the use of telemedicine in the patient’s homes.
This article is to highlight critical barriers in policy-making.
Theory
Welfare technology is a relatively new term also known as ambient assisted living. Welfare
technology supports a palette of services provided for citizens by the governmental taxfunded social system to promote the quality of life for the citizen in any kind of health,
social or other dysfunctional situation. Welfare technologies are provided to disabled,
ageing, chronically ill and temporarily ill citizens. Examples of welfare technologies are
wheel chairs, special cars, implements of Activities of Daily Living (ADL) (Eschenbeck et al.
2010) and hospital and nursery products. With the emergence of information and
communication technologies (ICT), welfare technologies can have such properties
embedded, and communication – in particular mobile communication – can ensure
connectedness between the government and the citizen (Tambo et al. 2012). Connected
welfare technologies may follow the guidelines of the Continua Health Alliance (2012) and
encompass any vital sign such as falling, function of lungs, heart, blood, seizures and
general alarming (Ekeland et al. 2010, Prinz et al. 2008, Koch 2006).
Public policies (Mack et al. 2008) are to ensure the combination of necessary means to
make private and governmental services function within a civil and moral, legal and
financial frame (Field 1996). In medical services, and particularly in the telemedicine
technologies discussed in this article, public policies must provide a technological
translation framework (Nicolini 2010) that manages a holistic understanding of factors.
Policy-makers are assumed to be aware that promises of solutions to critical challenges
need translation into practice if trustworthiness and political capital should be kept intact
(Lind et al. 2009, Lang and Mertes 2011).
Telemedicine is a specialised case of health care information technology (HIT) that is
largely regarded to be a main transformation agent of health care services in industrialised
countries (Abraham et al. 2010) with non-industrialised and new-industrialised countries
coming up (Ekeland et al. 2010, Judi et al. 2009, Varghese and Scott 2004). HIT provides
core systems for health care professionals both GPs and hospitals; telemedicine must
generally obtain some kind of connectedness to the core systems to provide professional
credibility and effectiveness (Bashshur and Shannon 2009, Kraetschmer et al. 2009,
Ekeland et al. 2010).
Policies governing technology need attention to citizens affected (Finch et al. 2008).
Enforcing technology can be a necessity, a part of a momentum or generally accepted or
even expected. Such acceptance can be made by the general public, the patients and
importantly the health care professionals. Technology acceptance by groups of patients is
discussed intensely (Lockamy and Smith 2009, Field 1996). May et al. (2003) bring this
further to an assessment of normalisation where telemedicine is naturally included in daily
procedures. Technology acceptance is by Kim et al. (2009) suggested to be studied from an
attitude strength perspective. Or and Karsch (2009) provide a systematic analysis of
patient acceptance of telehomecare as well as an elaborate discussion on acceptance
models in their study of consumer health information technology. Patients’ perceptions of a
home telecare system are researched by Rahimpoura et al (2008), and Jean-Jules and
Villeneuve (2009) understand acceptance as assimilation of telehomecare.
Health care professionals have a critical role in the public policy-making as promoters or
barriers for implementation. Taracki et al. (2009) give an account of the staffing policy and
technology investment in a specialty hospital offering telemedicine. Currell et al. (2009)
provide a review of telemedicine versus face-to-face interaction in health care services.
Mack et al. (2008) research change and development in the public sector, suggesting an
inspiration within entrepreneurship. Caro (2008) discusses employees’ role of
transformation in telemedicine using a model of relational capital, transactional capital,
transformational skills and a ‘transgenic’ dimension. Schmeida et al. (2007) point to
relationships and political position of groups within and outside the health care system as
critical policy determinants, especially the interest groups.
Telemedicine is a technological solution to issues of age, chronic and life-style diseases as
well as welfare. Ekeland et al. (2010) contribute with a critical review of 80 reviews and
conclude that many scholars are expressing telemedicine as incomplete, and patients and
professionals views are not yet fully understood. Pelletier-Fleury et al. (1997) also add to
the critical view in terms of telemedicine service providers’ rights to continuously profit
from the governmental services and the lack of large-scale cost justification. Telemedicine
assume uniformity of services (Lehoux et al. 2002) with the scoped area of services; this
assumption is not always true, but must be understood in the policy-making context. Prinz
et al. (2008) emphasise that telehealth is also a matter of political feasibility.
At the organisational level, telemedicine must obtain acceptance and the technology as a
workable system must be infused and routinised within the organisational context (JeanJules et al. 2009). At patient level, telehealthcare Finch et al. (2008) point to issues of
fragmentation, self-treatment regimes and holistic patients’ treatment. Andreassen (2011)
highlights the shifts in relationships between patients and health care professionals with
the change to electronic communication. Thobaben (2000) raises concerns on the
obligations and reservations of homecare nurses in patient relationships based on
telemedicine.
Telemedicine is more than a regional and national prioritisation; EU has requested its
member states to adopt an e-Health Action Plan. Lang and Mertes (2011) demonstrate a
strong differentiation across EU in the scope and level of adoption and implementation
primary related to political factors. World Health Organisation (WHO) is also suggesting
technology included in national policies (Saha 2011).
Public policies on telemedicine obviously address development and change of health care
and welfare services, but it is critical to include the technology perspective; Abraham et al.
(2011) view technology as a transformation agent; Duplaga and Zielski (2006) describe the
ongoing policy making process of dealing with the social issues of technology (Nicolini
2008). Technology raises a plethora of specific issues within policy-making of e.g.
development, acquisition, life-cycle-management, uncertainty, training, risk management,
shifts in responsibilities and power and “real” costs. Policy-makers have the difficult role of
balancing between optimistic and sceptic views on technology. Sceptical positions are e.g.
discussed by Lehoux et al. (2002) and Rigby et al. (2011). Curell et al. (2010) describe
reluctance among patients and professionals. Kraetschmer et al. (2009) investigate
telemedicine as mean of crossing organisational and geographic barriers, but conclude that
successful projects follow and support existing provisioning structures. Among challenges
in policy-making in telemedicine are the dual reliance of policy-makers on clinician and
technologists each within their respective and professional bias. Hjort-Madsen (2009) and
Ahsan et al. 2009 suggest to establish a sound enterprise architecture creating systematic
links between policy-making and corresponding infrastructure. The infrastructural
approach (Broadbent et al. 1999) for data architecture of home-monitoring health care
applications is found in (Lin et al. 2007). From vendor side, Microsoft (2011), among
others, has proposed a Connected Health Framework Architecture and Design Blueprint.
Saha (2011) proposes a holistic view on policy formation and system design architecture in
Singapore for chronic diseases. In contributions like (Savel et al. 2010, Tambo et al. 2012),
proposals are discussed in the interrelation between policy and technology in health care.
Method
This article is methodologically based on studies of two aggregated cases (Bryman and Bell
2007). One study at a local level is testing telemedicine in measuring and monitoring
hypertension at home on a broad cohort of citizens from 55 to 64 years of age in a city. The
other study seeks to establish a national technological platform for demonstration,
communication and implementation in telemedicine. Overarching to the two projects is the
general governmental policy of telemedicine. The local project had a pre-cursor 2004-2007
(Madsen et al. 2008a, Madsen et al. 2008b) with the aim of assessing the technology’s
feasibility, the citizens’ technology acceptance and influence of the technological approach
on quality of life for the patients.
The method is qualitative, interpretivistic and sociologically-inspired with elements of
action research and follow-on research of the two cases. As the studied context addresses
inclusion of technology in an organisational framing, the method furthermore draws on
case study systematic in information systems research (Klein and Myers 1999, Baskerville
and Wood-Harper 1998).
For the national project, an observer role was granted. Thus, meetings have been observed
and meeting documents, agendas and technological and policy suggestions have been
identified and analysed. Actors have been registered and the institutions represented by
the actors have been recorded, including motives, incentives and barriers.
For the local project, the study was conducted with project meeting participation, writing
funding applications, communicating to the funding office and having the dialogue with the
project consortium. Calculation of business cases was also part of the study, and likewise
with observation of the interaction between citizen and health care professional. The
project has been presented at conferences and workshops to receive feedback from clinical
and administrative officers. Through the presentations, a dialogue has been kept with
policy-makers, broadly-based stakeholders and nomenclatures at local, regional and
national level.
The material gathered in this study is mostly primary, since the local project – and the
national observed-ship – was pursued by a joint group of researchers with both
operational and analytical responsibilities.
A case of hypertension from a policy-making view
As a modern welfare nation, Denmark offers a high-quality level of health care services
based on the Beveridge model with a high level of tax funding (Pedersen et al. 2011).
According to Health Consumer Powerhouse (2009), Denmark has the second best health
care system out of 29 industrialised countries based on six key parameters. Home care,
nursery homes and post-hospital care are in most cases also based on the welfare system of
governmental funding. With the changing demography, technological solutions seem
attractive, and according to (Protti and Johansen 2010, Christensen and Remler 2009,
Wanscher et al. 2006) Denmark is a world leader in Health Informatics, particularly based
on a highly efficient and mostly compulsory document exchange system governed by one
institution called Medcom (Pedersen 2010, Medcom 2010, Juhl 2007). Early success has
been based on a national adaption of international standard. For future use, it is expected
that Denmark will switch of full use of international standards, especially the HL7 standard
(Benson 2010) with the opportunity to exploit standard technologies and the risk of losing
the past momentum.
The health care system is organised with the central government mainly in a regulatory
role for regional and local level services. Primary care is given by 3,600 self-employed
General Physicians (GPs) working under a governmental contract. The secondary care is
provided by hospitals organised in five geographically divided operational clusters.
Tertiary care is the responsibility of 99 municipalities and includes services for
handicapped, elderly, post-hospital care, nursery homes, home care and some preventive
medicine activities.
Late 2008, a research team from the Regional Hospital of Holstebro in Western Denmark
made a call for participation (Hoffmann-Petersen et al. 2009) in a project for using
telemedicine in hypertension measurement in a large-scale demonstration and research
project directed towards a large population of the surrounding municipality. An earlier
project from 2004 to 2007 had promising results on both patients’ technology acceptance
and clinical value (Madsen et al. 2008). The team founded a project consortium through a
series of meetings engaging data integration specialists (Medcom), equipment suppliers
(Tunstall Healthcare), an engineering group at the university campus (AU Herning), health
economists (DSI), funding authorities at a local and regional level, GP’s organisation and
relevant professional associations. The project was motivated by hypertension as the
number one chronic condition in Denmark, as well as most in other industrialised
countries, with around 17% of the population in regular treatment and another 5-7% of the
population left with unrecognised and untreated hypertension conditions (Tambo et al.
2010). Telemedicine used in the home of the patients seem ideal for hypertension as
measurements in doctor’s office can distort the results (White Coat Hypertension).
The project had a number of branches. (1) The equipment underwent a feasibility study in
the hospital’s renal (kidney) out-clinic with 100 patients. (2) The equipment was used on a
cohort of around 6000 citizens who in turn were called in to a citizen’s health care clinic to
receive the equipment, appropriate training and later on feed-back on results. (3) Citizens
with hitherto unrecognised hypertension were forwarded to their respective General
Physician (GP) for treatment with half of this cohort using the telemedicine equipment and
half kept as reference group in traditional treatment.
The project and its branches were mainly to be financed by a governmental foundation for
demonstration of productivity-enhancing technology in the public sector (for short The
ABT Foundation). First time the project applied was in June 2009. The application was
rejected mainly with the reason from a governmental chief systems architect “that there
are (too) many telemedicine projects around and they all need a lot of careful coordination”.
The project applied the same foundation again in February 2010. The application was one
of seven telemedicine projects. The five projects were suggested to make an alliance:
Chronic Obstructive Pulmonary Disorder (COPD), Diabetes, Gastroenterology and
Pregnancies with/without complications. This project and another one was granted
observatory status.
The concern about lack of coordination remained through 2010 where none of the projects
were given signal to start. In November 2010, the ABT coordination office invited the seven
projects to join a series of meetings at the Medcom institution with the purpose of
suggesting a national project for making a general infrastructure to support of telemedicine
systems in question and also a breadth of potential new projects. During the meetings, a
suggestion for a national platform was developed (Petersen et al. 2011). The platform was
designed from the requirements and existing structures within the two dominating
hospital clusters (RegionM and RegionH). It was in nature highly generic using the
international standard HL7 (Benson 2010) and a ‘vendor neural archive’ (Hilbel et al.
2007) form to avoid any kind of bias to any kind of system. Communication between
patient-side and a central place of data integration was suggested to be associated with the
equipment suppliers, presumably using the public cell-phone network. Voice and video
were suggested to use existing communication infrastructure. Remaining information was
conceptually to be integrated with in-hospital Electronic Health Records (EHR), but
practically several telemedicine systems would have to integrate to specialised systems
underlying EHR, e.g. pregnancy systems. Blood pressure values out of the present project
were interesting in the sense that the citizen did not necessarily have to be a patient; as a
patient, data will most likely be associated with the GP’s systems and not the hospital’s EHR
system (Medcom 2011). The answer to this was to associate data with a newly made
national personal health care portal (Sundhed.dk 2011a, Sundhed.dk 2011b, Pedersen
2010).
After completion of the proposal for a national infrastructure in April 2011, the
government was to give the start signal to the projects in June 2011. However, in the last
minute, this was postponed to August 2011 where the decision once again was postponed
as a general election was announced. As a result, the decision-making was delayed further
until January 2012 where it was announced that projects with a binding approval given
before March 2010 could continue and all other projects were rejected.
A national policy view
In 2008, the Danish centre-right government established The ABT Foundation as the policy
mean to promote effectiveness in the governmental services at all levels. The
understanding of effectiveness was the ability to create financially positive business cases,
not as implementation projects, but more as demonstration projects based on mature
technology that just needed an organisational context of actual and practical use. The ABT
Foundation did not request particular projects, but called broadly for applications for
funding from governmental institutions, hospital clusters and municipalities. The
applications needed to have a fairly brief technological and organisational motivation
(“elevator pitch style”), but an extensive business case justification was required on the
intended model scenario. Business cases on perceived future scenarios beyond the actual
demonstration obviously require a strong set of assumptions.
The ABT Foundations core organisation had no policy-making role, but with direct
reference of the Foundation to the Minister of Finance, the politicising aspect was
immediate. Formally, there was a technocrat advisory board and a political steering
committee. Much effort among the applicants seemed to have been to influence and
convince both advisory board and the steering committee. A sense of divide and conquer
remained with an attempted equal geographic distribution of grants. However,
municipalities failed strongly to receive grants leaving most grants to larger urban centres
and high-profile hospitals.
In the later months of the centre-right government, The ABT Foundation was announced to
change name to ‘The Foundation for Welfare Technology’. This name change was instated
with a change in October 2011 to a centre-left government. On telemedicine, the
Foundation was to change policy-making from centralised demonstration projects for
evaluation and approval to support of regionally-oriented telemedicine centres co-located
with the hospital clusters. The new government expresses the following statements on
telemedicine in its inauguration document:
-
“The government will work for a more coherent prioritisation of telemedicine with
binding and ambitious targets on large-scale adoption of welfare technologies in
hospital clusters.
-
New telemedicine departments must be included in the planning of future hospitals for
national telemedicine pervasiveness.
-
It must be investigated how to make telemedicine services a legal right for chronic
patients to choose”. (Government 2011)
Here, the departure from the national approach to the support of telemedicine at a regional
hospital cluster level is interesting to notice: The strategic policy-making at national level
had repeatedly conflicted with regional policies. The regional level adapted policies to
claim special local conditions, but indication remain that regional policies were
differentiated out of rivalry among the regional cluster. Ongoing benchmarking of local
governmental services encourages this rivalry and must be considered in the analysis of
motives for policy making at local level.
The centre-right government stated in its final months that the hospital clusters should be
terminated and merged in the one national organisation to avoid the dual – and often
conflicting – levels of policy-making. The centre-left government has chosen to keep the
regional level and respect the regional translation of national policies; this is in line with
the switch in telemedicine policy funding.
Learning from the cases
The hypertension project has interacted with around 500 citizens in the cohort and around
25% were referred to their GP. The telemedicine monitoring showed better adjustment of
the final blood pressure using telemedicine compared to traditional measurement.
Knowing that smaller improvements in blood pressure values can significantly reduce the
risk of more serious cardio-vascular problems, the business case seems fine. The
engagement of the municipal preventive care centre has created a side-effect of general
public awareness that isolated is expected to improve the general health condition.
At the regional level, the patterns in the project granting indicate that 5-10 key senior
physicians per hospital cluster act as opinion makers. Formal policy-makers will strongly
include and respect the senior physicians. The study indicates a paradoxical approach to
breadth and depth in telemedicine implementation: For special conditions, e.g. complicated
pregnancies, a full-scale implementation can be done using e.g. 250 telemedicine kits; for
conditions with much larger populations, experimentation and demonstration projects are
still carried out with no specific roadmap on how to roll out telemedicine to thousands of
patients.
The national government has largely attempted to enact policies through support to local
strongholds. The process has been very idealistic but has created few sustainable results.
With the governmental declaration above, policy-making has to take a new dimension
when nationwide telemedicine services can be provided as welfare rights. This suggests
that the national government is trying to take a clearer role in making policies at a strategic
level with interesting assumptions on establishment of infrastructure, organisational game
rules and funding.
Discussion
On regarding policies as expressions of societal priorities, policy-making should be
expected to be the responsibility of governing bodies of the political system (Prinz et al.
2008, Lind et al. 2009, EHTEL 2008). Policy-makers, however, seem to face numerous
impressions of pro and con arguments; as stated by MacFarlane et al. (2006): “Networks
and alliance between policy-makers, clinical champions, technology manufacturers are
required to generate interest and establish telemedicine services”. During the projects,
welfare technologies have gained much positive attention from policy-makers as they
provide opportunity to generate positive exposure and display willingness to re-thinking
welfare services (Beland 2010). An interesting dialectic is found between the formal policymakers and lead health care communities where both parties are dependent on each other
but also dependent on keeping an arm’s length distance. Many of the factors presented
above lead to a set of rationales for the policy-making process. A model of suggested
rationales will be presented below.
With the promises of technology, as found in telemedicine, for solving major future societal
challenges, the chase for a systematic process of developing public policies is stepping up.
The cases present a schism of conflict between upper and lower levels in the general
policy-making, and furthermore a more detailed understanding of quality and adequacy of
policies as well as the aspect of policy-making failures. Failures could be
(1) the inability to convert unquestionable prospective technologies into full-scale
implemented policies,
(2) the lack of policies to guide a systematic of exploring, selecting and (large-scale)
implementing technologies,
(3) policies not clearly resolving sharing of cost and benefit between organisational units,
(4) the inadequacy of policies for telemedicine at an operational level with e.g. economic
and legal aspects, and
(5) the absence of transparent policies to prioritise and especially reject and terminate
economical or medical infeasible technologies.
Here it is relevant to emphasise that telemedicine in small-scale is relatively cheap, and
smaller organisations can easily initiate projects without central attention. In a part of the
above process, the hospital cluster wanted to make its telemedicine policy more explicit; a
consulting organisation started to investigate and found that beside 30 known projects
there were 26 more unknown projects within the hospital cluster (RegionM 2011). Many
projects were funded out of general hospital research and development, e.g. a PhD project.
Many projects were internal enablers inside the health care system, typically
videoconferencing (EHTEL 2008). Many projects were funded out of very indirect funds,
such as making telemedicine part of e.g. a learning initiatives (pedagogical funds), public
outreach (communication department funds), reduced driving (transportation budgets).
The public polices therefore need to be studied from positions of quality and sufficiency.
Inter-organisational, cross-organisational and inter-agency issues have an important role
(Pedersen 2010, Dinesen et al. 2007, Kun 2001). The hypertension project above was
designed to create a technological collaboration platform between GPs, municipal
preventive care, hospital and municipal homecare that could also include nursery homes.
There was little understanding on the practical level of making the cross-organisational
project run smoothly, e.g. IT systems could not be shared across organisations and cost
versus benefit were continuously discussed. In trying to deal with this issue, the central
government has introduced penalty systems for municipalities resubmitting the same
patients to the hospitals instead of implementing preventive actions. However, these
penalties are not sufficiently significant to create policy change, and in one the sessions
described above, two city mayors were unaware of the penalty-systems effect on the
municipal economy. At the same time, no clear operational policy exists on how to avoid
the penalties, e.g. by implementing systematic preventive care. The sub-optimisation found
in the classic governmental organisational design may in this case seem detrimental to
linking cost and benefit and thereby contribute to the policy-making failure discussed
above.
There is, in the empirical presentation above, no policy pointing towards a national
implementation of any single telemedicine technology. More regional initiatives are
expected to inspire and spread. There is little evidence in the literature that such diffusion
is happening with a breadth of European initiatives remaining on regional level (Lind et al.
2009, MacFarlane et al. 2006, Varghese and Scott 2004). This is paradoxical in comparison
with the overall policy agenda of regarding telemedicine as a general societal challenge.
However, the EU e-Health (EU Commission 2008) doctrine suggests both national and
regional policy approaches. Solutions to policy implementation may thus lie at local levels
which again may prove paradoxical to general business case considerations and
undermining economies of scale in development, acquisition and operations of systems and
equipment.
The findings above indicate that at least the national level of policy-making is reactive is the
sense where it relies on a rendezvous of interests and opportunities: Since an idealism of
roles, time and place is needed, stakeholders at underlying levels must be ready all the
same time. This is in contrast to traditional health care technologies, such as medicine
where approval processes might guide medication policies simultaneously. An apparent
absence of normativity in policy-making in telemedicine is likely to erode but also explains
the prolongation of diffusion.
Based on the case study above, a model is subsequently proposed (Figure 1) for the
continued studies of telemedicine public policy-making. The model is also to support
considerations for transformation of technological opportunity into policies. The model
assumes a multitude complex of factors leading to four key rationales. Public policy is thus
derived from the balance between these factors with the technological outcome based on
the sufficiency of the policy at whichever governmental level the policy is directed to.
Important is also the requirement recognising continuous adaption of the policy given the
dynamics of most of the factors and henceforth the rationales.
Figure 1. Welfare policy development factors and rationales
The infrastructural rationale. Technologies or policies assuming existence of a wellworking infrastructure will face much less barriers. Policies of creating infrastructure
might provide a broader base of benefits given relevant equipment for utilising the
infrastructure. A part of this could be adherence to (inter-)national standards and
technologies for low-cost adaption of each specific telemedicine technology. This could
reduce scepticism within cost and risk. The cases however show significant differences in
the interpretation of the specificity requesting e.g. live video to psychiatric patients, but
complex data structures for multi-chronic patients. The infrastructural considerations must
clearly address the end-to-end support of the telemedicine solutions in questions. Having
the citizen in the one end, the infrastructure must support meaningfulness in the other end,
e.g. should a doctor or a nurse be ready to react, or is a computerised monitor acceptable?
The strategising rationale. All policy-making levels must be able to set out binding strategic
prioritisations. Lockamy and Smith (2009) suggest addressing strategic alignment of
telemedicine, but telemedicine policies must potentially be expressed as independent
strategies where lower level issues need to be aligned. This is exemplified with the Danish
government’s policy on the rights of chronic patients. Policy-makers on national levels
must be assessed from their ability to clearly express the ability of policies to encompass
relevant aspect of a prioritised technology and lead it from initial concept to
implementation and normalisation (Nicolini 2010, May et al. 2003). This seems to impose
difficulties, presumably from responsibility concerns of wrong decision-making and
overruling professional and local competencies. The typical response from lower level
organisations to higher level policy-makers has been: Give us the money and we will do it.
With the welfare and health care system seen as a highly structuralised zero-sum game, the
policy prioritisation and strategising ability is a matter of policy-making leadership.
The business case rationale. Telemedicine is to be prioritised from regular business cases,
and even if welfare services tend to freeze structurally, financial rationales must be
constructively considered. Formal frameworks exist to develop business cases. This was
mandatory in the ABT Foundation application but the business case development was
highly speculative as the demonstration project should mirror a full-scale application
context. In terms of business case considerations, cost and benefit responsibilities must
also be made visible as well as end-to-end logistical and operational cost together with
direct and indirect effects. The Hypertension project wanted to engage health economics
specialists in the project, but the Foundation just asked for ‘best man’s best guess’; in
policy-making, independent assessment of business cases is probably required as various
bias otherwise could influence. Delineation in business case scoping is interestingly
illustrated by the cases where COPD resubmission was allowed to be included in the
business case, but avoidance of cerebral haemorrhages in the hypertension was rejected.
The organisational constructivist rationale. In the health care system described, sharply
defined organisational units operate in parallel. Policy-makers must be able to set up
requirements for the executing organisations on interaction, cross-collaboration and
defined relationships. Increasingly medical issues are complex and organisational by
nature, but increasingly health care professionals are assessed from specialisation and
routinisation. Telemedicine is dependent on broader organisational approaches and thus
need an institutionalisation of its own. Policies must include organisational design. In the
studies above there were a very few policy directives for organisational design. The
Foundation only asked for a “contract holder” to account for the funds and “not too small
and not too large consortiums”; the organising of consortiums were left fully to informal
processes of collaboration. Lind et al. (2009) talk about “legal and organisational conditions
for long-term interorganisational cooperation at large”; Brender et al. (2000) rank “Needs
for organisational change and the role of IT in this context” the forth-highest criteria for
telemedicine success; Koch (2006) likewise points to organisational changes as closely
associated with telemedicine.
The interrelationship between the rationales is best expressed as a balance giving highly
different weights to each rationale depending on context. If good regional systems exist,
then strategising could be the only rationale. For complete new technologies, all rationales
would need equal inclusion. For technologies highly complementary with existing work
procedures, the organisational constructivist might have a weaker role, but probably not
due to the implied changes when adapting telemedicine.
In a Danish policy-making context, it is notable to observe that beside telemedicine as a
mean for coping with future welfare challenges, an industrial agenda predicting
telemedicine also exists, and complementary technologies as an economical growth
potential in the design, manufacturing and jobs. Despite the difficulties in implementation,
telemedicine is (Murray et al. 2011) in growth in most larger markets. It must be assumed
that public policy-making will not overlook the industrial potential in specific priorities.
As mentioned in the introduction, telemedicine policies have to be understood in broader
international context (Haux 2010, Miller 2007, EHTEL 2008). The technological
development on the patient-oriented equipment side mostly takes place within the global
market for ICT products with e.g. The Continua Alliance as standardisation organisation.
The development of national infrastructures has successfully been conducted on a bespoke
basis in Denmark, but the momentum is now to follow international standards for
infrastructure although these are far more complex and potentially will force every country
to license expensive standard software. The ABT Foundation was initially made to deal
with shortages in health care and homecare professionals, and even if the purposes have
turned more qualitative, the shrinking workforce and the increasing group of elderly and
care-demanding populace will stress the welfare system beyond its limits. Carefully
managed technology thus seems the only answer, if serious erosion of welfare privileges
should not be the result with associated social unrest and loss of political capital among the
policy-makers.
Conclusions
The reported study has been following a concrete case of demonstration and large-scale
implementation of telehomecare in hypertension monitoring and treatment as a case of
welfare technologies incited by the governmental policy of requesting local projects for
funding. The case has had a reflection within a regional and a national context of public
policy development.
The case study employed suggests a deeper research engagement in technological and
medical projects to obtain proper insight in shortcomings in the conversion from feasibility
and demonstration studies into public policies. The policy view is to support practitioners
in lowering barriers of implementation. In the further studies, small/medium
implementations are interesting as some are approaching a full-scale roll-out with maybe
100 patients or telemedical systems. Increasing much in size seems to face many of the
shortcomings described above. Research has not yet justified, where the turning point is
that dictates the difference.
Of major findings in the study are the general difficulties in transformation of relatively
vague, very strategic and idealistic expectations on new welfare technologies into a full
public policy framework on implicated participating levels. The case studies illuminate key
activities in multi-level, cross-organisational policy-making push. A modelling approach is
discussed upon the policy-making in order to suggest increased risk-taking of regular
implementation contrary to experimentation and demonstration.
As major breakthrough has yet to be seen in implementation of welfare technology, this
study provides an account of mechanisms affecting practical results and suggests measures
for improving public policy-making. Demographic and economic changes in industrialised
societies are increasingly stressing classical governmentally funded or facilitated welfare
services. Technology is expected to provide answers to this situation. Technology has,
however, had difficulties in obtaining a momentum into policy and application
normalisation, thus pushing broad implementation into the future. Broad-based
implementation of the technology is to be important for maintaining a host of welfare
services.
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Torben Tambo is associate professor at Aarhus University, Faculty of Business and Social
Science in technology-based business development. Previous to this he served 17 years in
IT, management and consultant roles within manufacturing and trading companies.
Research interests include the interface between organisation and technology as found e.g.
in information systems, enterprise architecture and supply chain management. He has
previously published with Journal of Economic Dynamics and Control, Journal of Enterprise
Architecture, International Association for Management of Technology, and various book
chapters.