Identifying the Role of General Practitioners in Dutch Telemonitoring Business Models

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1 Running head: ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 1 Identifying the Role of General Practitioners in Dutch Telemonitoring Business Models Vincent Christiaan Laban [1] and Morten Grau Jensen [2] Delft University of Technology, The Netherlands [1] v.c.laban@student.tudelft.nl [2] m.g.jensen@student.tudelft.nl

2 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 2 Identifying the Role of General Practitioners in Dutch Telemonitoring Business Models Vincent Christiaan Laban, Morten Grau Jensen Delft University of Technology, The Netherlands ABSTRACT With an increasingly greying population, adoption of telemonitoring technology has been expected to accelerate in the health-care sector. However, research has pointed out several barriers for successful diffusion of telemonitoring, among others insufficient business models (Gruber, Wolf and Reiher, 2009) which will be the overall focus of this research. This paper first presents an initial research suggestion that the Dutch general practitioner (GP) might have potential to be a key resource for telemonitoring business models in the Netherlands. Next a qualitative research study is carried out among Dutch GPs, medical specialists and closely affiliated stakeholders to identify the current role of the GP in telemonitoring business models. The research was conducted from a grounded theory approach with value propositions in business models (Osterwalder, 2009) and innovation-decision making (Rogers, 2003) as theoretical framework. The results show that Dutch GPs currently do not play a significant role in telemonitoring business models. However, the results strongly indicate that an increasing use of telemonitoring products will lead to a significant shift in the future roles of medical professionals in Dutch health-care, because of telemonitoring's strong economic and professional value propositions. The use of telemonitoring enable medical tasks currently carried out by specialists to be delegated to other (cheaper) medical professionals such as GPs and nurse practitioners, thus changing the context of telemonitoring considerably with different users, needs, decision makers, and financial models. These findings lead to a list of recommendation and suggestions for further research, among others for telemonitoring technology companies, to take this likely future scenario into account during the product development processes and business model designs, and understand how new telemonitoring users preferences and needs differ from current users and how that affects the new users adoption of telemonitoring. Keywords Telemonitoring, General Practitioner, Value Proposition, Decision Making, Innovation, Business Models 1 INTRODUCTION In the last decade researchers have discussed the progress and implementation of telemonitoring technology in medical sectors and identified several barriers for the adoption of telemonitoring innovations (Cho, Mathiassen, and Robey, 2005; Barlow, Bayer, and Curry, 2006; Gruber et al., 2009; Ortega Egea, Román González, and Recio Menéndez, 2010; nstra, Broekhuis, and Van Offenbeek, 2010). It was highly expected that telemonitoring would diffuse into the medical sectors (hospitals, GPs and specialists practices and health care), but has turned out to be very limited (Korb, Denz, and Nerlich, 2010; Boonstra et al., 2010) despite the growing elderly population where the use of telemonitoring already have proven to have great potential (Ni Scanaill, Carew, Barralon, and Noury, 2006). To shed light on this development this research has been initiated from the faculty of industrial design engineering of Delft University of Technology (TU Delft), to explore how business model designs in Dutch home healthcare affects the development and spread of telemonitoring technology. This research is part of a larger group of similar research projects within the topic of business model designs in home health care telemonitoring from the Product Innovation Management (PIM) department of the industrial design engineering faculty of TU Delft, supervised by Dr.ir. W.L. Simonse. The initial briefing circled SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

3 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 3 around the fact that there have been many telemonitoring pilot projects carried out in home health-care and other medical fields. Despite the benefits that were discovered during these pilots, and despite the big number of pilots, there are still only a minor use of these systems outside research and pilot projects. This paper deals with the role of general practitioners (GPs) and current telemonitoring business models in implementation of telemonitoring in The Netherlands. Based upon the literature the definition of telemonitoring used in this report is: of medical data from patient to medical professional allowing the professional to read, record, and analyse the data and make a diagnose on a distance, without the patient being present. Communication in this case means both measuring and monitoring of data. Measuring data is an active process, often over a limited period of time where the patient can enable data recording in critical situations or professional can obtain data for a diagnosis. Data monitoring is a constant process in which the data is constantly recorded and monitored over long periods of time, so that a professional can intervene if critical changes occur in the data. Other terms connected to telemonitoring such as ehealth, telecare, and telemedicine are also mentioned in this paper, but should not be confused with the term telemonitoring. The research consisted of a literature study followed by a qualitative research study based on 9 interviews with GPs, specialists, and managers from related companies. Our research will mainly contribute to the academic knowledge on business models of telemonitoring and the implementation of telemonitoring by providing a closer look at the barriers and enablers of adoption of telemonitoring among Dutch GPs. The results of this paper also offer insights relevant for entrepreneurs in telemonitoring industry and decision-makers in the medical sector and governments on where to put attention for increasing implementation of telemonitoring technology. That will hopefully lead to benefits for end-users (patients, GPs, specialists) through the use of these new technologies in the medical sector. Our findings can also be used as reference for research on business model generation in complex medical applications such as telemonitoring and offers a usable theoretic framework for further research in this topic. The first section of the paper elaborates on the theoretical framework and research question, followed by a review of existing literature in the field. In section three the methodology and process of the qualitative study is presented and afterwards research results are presented and discussed before final conclusions are drawn. 2 RESEARCH FOCUS As mentioned in the introduction we focus this paper on the role of the GP in telemonitoring business models in the Netherlands. In the coming section we describe our research question and how it is related to theory. 2.1 Main Research Question During the introduction to the subject of telemonitoring the GP seemed to be a potential key resource in telemonitoring business models as a link between industry, specialists and patients. His/her role in current business models, however, was not clear. Was it an active role? Or a passive role? How significant? This was the initial thoughts that formed the main research question and thus the topic of this paper: What is the current role of the GP in telemonitoring business models in The Netherlands? The role of the GP is important to know for several other stakeholders in telemonitoring business models. From a economic point of view it could be relevant for companies and home healthcare facilities, as well as entrepreneurs in the care taking industry to know how GPs are taking part in the adoption and use of this new technology. Next to that the information could be beneficial for decision-makers in the medical sector and the government. It allows them to anticipate on the effect that certain decisions will have concerning telemonitoring business models. To be able to investigate the role of the GP and answer the main question a group of subresearch questions needed to be answered for clarification of uncertainties such as what the key roles in telemonitoring business models are and what other stakeholders are currently involved? How does adoption of innovations such a SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

4 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 4 telemonitoring occur and what main barriers and enablers affect the adoption of telemonitoring systems among medical professionals? 2.2 Sub-research Questions The current roles in Dutch telemonitoring business models have not been clarified, so to support our research we formed the sub-question: Who are the current stakeholders in telemonitoring business models? To be able to conclude on the advice that this paper gives regarding telemonitoring business models we needed to know: How is telemonitoring adopted in the medical sector? This information is also of great value to decision makers in the medical sector and the government, because it displays current issues facing telemonitoring and can be used to generate possible solutions. Two other sub-questions related to the how the need for this new technology is formed: What are the value propositions that GPs associate with telemonitoring? How is adoption of telemonitoring in the medical sector carried out? That lead to a total of five research questions: MRQ: What is the current role of the GP in telemonitoring business models? SRQ1: Who are the current stakeholders in telemonitoring business models? SRQ2: How is telemonitoring adopted in the medical sector? SRQ3: What are the value propositions that GPs associate with telemonitoring? SRQ4: How is adoption of telemonitoring in the medical sector carried out? 3 FRAMEWORK To be able to frame the research topic and answer the MRQ this following sections describes the current state of knowledge in literature on telemonitoring development in Dutch health-care, through main points from literature available on this subject and connects it with theories on business model design and adoption of innovation. After first presenting the current state of knowledge in the literature organized by the research questions theory will briefly be presented and related to the literature to shape the framework of this research paper 3.1 Literature Review MRQ: What is the current role of the GP in telemonitoring business models? There is not much information on the role of the GP in telemonitoring business models in academic literature. The information available is fragmented and not complete. Some discuss the direct tasks of the GP, others describe the relation to other stakeholders. Schiff (2010) states that GPs should just monitor the results of their treatments by use of telemonitoring - a minor role in the whole business model. Ortega Egea (2010) describes the medical role of the GP as responsible for the first contact for patients, application of medical techniques, and disease treatment in relation to ehealth (Ortega Egea et al., 2010). This means the GP has a much bigger role in the business model and is an important stakeholder. The following will provide more information on the stakeholders involved: SRQ1: Who are the current stakeholders in telemonitoring business models? Although there are more literature on stakeholders in telemonitoring business models, it is also very fragmented and diverse because of the amount of different business models for telemonitoring. It is not always clear who the stakeholders are, because different organisations work together (Barlow et al., 2006). Also the context of each project is unique although telehealth innovations share a set of common characteristics (Cho et al., 2009). Telecare implementation projects are complex because of the large number of stakeholders and the wide range of population groups and health conditions (Barlow et al., 2006). Some researchers name stakeholders in the business models. Abrahama et al. (2011) note the stakeholders as patients, physicians, ancillary service providers, family of the patients, and community caregivers. Cho et al. (2009) describe the stakeholders (actors) in a telecare innovation (telestroke) as specialists (neurologist), system developers, hospitals, consulting and insurance firms, competitors and consumers. Other researchers group the stakeholders in segments, for example in the research of Lievens where four segments were identified, that consist of citizens, patients, professionals and employees (Lievens et al., 2004). We conclude that there is no SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

5 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 5 general stakeholder description available that can be used to analyse the role of the GP. If there is more clarity on the most usual stakeholders, other stakeholders can get a better perspective of their own role and anticipate on the effect that certain decisions cause for other stakeholders and for themselves. SRQ2: How is telemonitoring adopted in the medical sector? Already in 2003, May et al. (2003) discovered that the diffusion of telecare (in the medical sector) remained limited, despite high expectations. Boonstra et al. (2011) add that telemedicine has largely failed to systematically penetrate the market in the US and the EU. The integration of innovative technologies into medicine and into the healthcare system is still not under control (Korb et al., 2010). These findings support that telemonitoring is not adopted by the medical sector as expected. Many researchers mention barriers for the adaption, and some also mention some enablers of adoption. Therefore this sub-research-question is split into two, namely: SRQ2a: What are barriers for the adoption of telemonitoring by the medical sector? SRQ2b: What are enablers for the adoption of telemonitoring by the medical sector? SRQ2a: What are barriers for the adoption of telemonitoring by the medical sector? There is a large amount of literature on possible barriers of adoption by the medical sector, and the literature clearly distinguish some barriers of the adoption. A possible barrier is given by Cho et al. (2006), that states that - despite the potential of telehealth innovations - these innovations are either not successfully implemented or not accepted, due to poor technology performance, organizational issues, and legal barriers (Cho et al., 2006). Cho et al. (2006) also states that a variety of possible explanations for implementation can be provided, such as knowledge barriers and management issues, people and organizational factors, social patterns and cultural, and enactments of different structures of reference by different stakeholder groups. Organizational factors are mentioned by Rogers (2003) and also by Tsiknakis (2009), saying that the implementation of a medical innovation such as telemonitoring means changes in daily activities and organizational roles, combined with complete documentation that is necessary for the innovation to work, always encounters resistance of the medical staff (Tsiknakis et al., 2009). In Gruber et al. s (2009) paper on innovation barriers for telemonitoring he interviewed 23 experts in the field of telemonitoring and discovered that missing reimbursement by health insurances is the most important barrier according to the experts. Confronted with this information, health insurances replied that the studies they know do not convince them as to telemonitoring systems reducing their expenditures (Gruber et al., 2009). Next to that, constraints in insurance reimbursement are often not adequately considered in the early s of project development (Cho et al., 2009). In his research Huang found out that a barrier for adoption is the concern for the accuracy and reliability of the instruments of telemonitoring (Huang, J.C., 2009). Also lack of ICT maintenance and support is a barrier, as well for the early adaptors of this innovation, as the laggards (Dobrev et al., 2008). Problems with ICT are a commonly mentioned in the literature as important barriers. Gruber (2009) states highly technical complexity and missing security of data transmissions are barriers in the adoption of the telemonitoring innovation (Gruber et al., 2009). This is not only noticeable in telemonitoring, but also in other ehealth industries. According to Middleton et al. (2005) is the adoption of Electronic Health Records (EHR) too slow, despite growing support for the EHR to improve the U.S. health care delivery, due to a fundamental failure of the health care information technology development. Also the medical staff can be accounted for an ICT barrier, because physicians and other medical staff are in most cases notorious for their non-responsiveness and resistance to the use of information technologies in the medical environment (Cho et al., 2009). To continue on the medical staff there are tensions within health and social care politics, between the desire for modernization - including the introduction of telecare - and the requirements for evidence based innovation (Barlow et al., 2006). Finally, older general practitioners find it hard to work with these new technologies, they are novice computer users and due to the lower exposure to SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

6 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 6 technology in private and professional settings, a cohort effect is arising (Ortega Egea et al., 2010). A final barrier for the adoption of innovation of telemonitoring by the medical sector is the nebulosity of the business models for telemonitoring. Especially for providers it is unclear how to shape their provided solution and how to charge for it (Gruber et al., 2009). Also the business models that are available are still unstructured, fractured and disorganized (Lievens et al., 2004). Research Cho et al. (2006) Cho et al. (2006) Tsiknakis et al. (2009) Gruber et al. (2009) Gruber et al. (2009) Cho et al. (2009) Huang et al. (2009) Gruber et al. (2009) Middleton et al. (2005) Cho et al. (2009) Barlow et al. (2006) Ortega Egea et al. (2010) Gruber et al. (2009) Lievens et al. (2004) Barrier Poor technology performance, organizational issues, and legal barriers Knowledge barriers and management issues, people and organizational factors, social patterns and cultural, and enactments of different structures of reference by different stakeholder groups Changes in daily activities and organizational roles, combined with complete documentation Missing reimbursement by health insurances Health insurances are not convinced that the application of telemonitoring systems can reduce their expenditures Constraits in insurance rembusrement are often not adequately considered in the early s of project development Concern for the accuracy and reliability of the instruments of telemonitoring Lack of ICT maintenance and support Fundamental failure of the health care information technology development Medical staff are in most cases notorious for their non-responsiveness and resistance to the use of information technologies in the medical environment Tensions within health and social care policities, between the desire for modernization Novice computer users due to the lower exposure to technology in private and professional settings The business model is unclear Business models that are available are unstructured, fractured and disorganized Table 1: Summary of barriers of adoption of telemonitoring by medical sector, found in literature. SRQ2b: What are enablers for the adoption of telemonitoring by the medical sector? There are, however, also some enablers of adoption of innovation of telemonitoring by the medical sector. Some are for example focused on economic benefits. Already more than a decade ago ehealth could generate substantial benefits and returns on investment, when the medical process was redesigned to make best use of the technology (Bonder et al., 1997). Studies showed that telemonitoring can deliver health care service without using hospital beds and that it reduces patient travel, time off from work and overall costs (Buysee et al., 2008; Meystre S., 2005). Specific benefits for telemonitoring of heart patients are mentioned by Cleland (2005): The combined benefits on mortality and consumption of health care resources suggest that home telemonitoring may have an important role in the management of heart failure (Cleland et al., 2005). Also patients see a lot of benefits of telemonitoring, described by Rahimpour (2008), such as patient that does not have to visit the doctor frequently, emergencies are avoided by early diagnose and quick data transfer between GP s and specialists is enabled (Rahimpour et al., 2008). Finally there is some positive feedback of elderly users of telemonitoring equipment, that say that SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

7 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 7 they would be encouraged to use this if they feel the system benefits them (Ni Scanall et al., 2006). This means that there is still some space here to identify more specific benefits of telemonitoring, that enable the adoption by the medical sector. Tabel 2 gives a summary of enablers found in literature. Research Bonder et al. (1997) Buysee et al. (2008) and Meystre S. (2005) Cleland et al. (2005) Rahimpour et al. (2008) Ni Scanaill et al. (2006). Enablers ehealth can generate substantial benefits and returns on investment Can deliver health care service without using hospital beds and that it reduces patient travel, time off from work and overall costs Combined benefits on mortality and consumption of health care resource Patient does not have to visit the doctor frequently, emergencies are avoided by early diagnose and quick data transfer between GP s and specialists is enabled Elderly are encouraged to use the telemonitoring equipment if they feel the system benefits them Table 2: Summary of enablers and benefits of adoption of telemonitoring by medical sector, found in literature. SRQ3: What are the value propositions that GPs associate with telemonitoring? This is a very interesting question, because there is not much literature about it. The value propositions that the GP associates with telemonitoring can determine the success of the adoption and implementation of telemonitoring. Studies have shown that innovation outcomes, such as benefits for certain stakeholders, play a big role in the diffusion of technology (Bunduchi et al., 2011). As mentioned before, some of the benefits that GPs identify are that better health-care can be provided (Rahimpour et al., 2008; Cleland et al., 2005), economical benefits are gained (Bonder et al., 1997; Buysee et al., 2008; Meystre S., 2005) and effciency of medical treatment is enhanced (Rahimpour et al., 2008; Buysee et al. 2008; Meystre S., 2005). To be able to conclude on the VPs that GPs associate with telemonitoring, we use the theory of Osterwalder (2009). SRQ4: How is adoption of telemonitoring in the medical sector carried out? The diffusion of technology is an overly researched area of science, especially in technical developments and currently in software to support the innovation process (Konh and Husig, 2006). About diffusion of technology in the medical sector, and in particular the adoption of telemonitoring a similar extensive body of literature is not available. The literature that is available describes that the diffusion did not go as expected and mentions some possible explanations to what is wrong with the adoption of telemonitoring in the medical sector (May et al., 2003): strategies and business models of potential telemonitoring services are either underdeveloped or unproven, customer needs are not clearly expressed and there a no brand names (Barlow et al,. 2006). There seems to be a lot to learn about current diffusion of telemonitoring in the medical sector. Knowledge that can proof very beneficial for the stakeholders involved. 3.2 Framework Based on the outcome of the literature review we relate our RQs to theories on value propositions in business models (Osterwalder and Pignuet, 2009) and innovation-decision making (Rogers, 2003) in order to be able to address the white spots identified in literature through our empirical research study Value Propositions in Business Models A value proposition, the value a product or service can offer, is (as mentioned earlier) very important for the diffusion of innovating technology (Bunduchi et al., 2011). Osterwalder (2009) defines the value proposition as follows: the value proposition describes the bundle of products and services that create value for a specific customer segment, and is the reason why customers turn to one company over another (Osterwalder et al., 2009). It can solve a customer problem or satisfy a SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

8 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 8 customer need, it is an aggregation of benefits that a product or service offers to customers. Osterwalder et al. (2009) identified 11 value propositions, that have either a qualitative or quantitative character. Newness is a value proposition that can satisfy complete new needs, that customers did not perceive before. Performance is a value proposition focused on improving the product or service performance. Customization offers a value proposition by tailoring products and services to the specific needs of individual customers or segments. Getting the job done covers the value that can be created by simply helping a customer getting certain jobs done. Design, this could be an important value proposition to diversify from other products or services. Brand/status, customers may perceive value by using and displaying a specific brand. Price is offering a product or service with value for a lower price. This is connected to Cost reduction, offering customers value by reducing their costs. Risk reduction is connected to the value of reducing the risks for customers when they buy and use products or services. Making products accessible for customers that lacked access to the product or service is described by Accessibility. Convenience/usability is making products or services more convenient and easier to use (Osterwalder et al., 2009) The Innovation-Decision Process As a part of the theoretical framework supporting this research we will make use of Rogers (2003) theories on decision making in innovation processes to describe and analyze diffusion of telemonitoring technologies in The Netherlands. In this study telemonitoring technology is considered an innovation - which Rogers define as such: an innovation is an idea, practice or object that is perceived as new by an individual or other unit of adoption. According to Rogers (2003) the entire innovation-decision process can be defined as an information-seeking and information-processing activity in which an individual is motivated to reduce uncertainty about the advantages and disadvantages of the innovation. Once an individual or unit have passed through the five s of innovation-decision making (Knowledge, persuasion, decision, implementation, and confirmation ) this learning process will eventually lead to either adoption or rejection of a given innovation by that individual or unit. The information-seeking and processing activities going on through the decision process are closely connected to use of channels - either interpersonal or mass media channels. Especially in the first phase (the knowledge phase) most individuals play a rather passive role (adopters), meaning that these individuals need to become exposed to an innovation and be presented with a relevant need for it (value proposition) before they take further action. For these groups interpersonal plays a key role, especially in the persuasion where the positive image of the innovation is formed. A smaller group (innovators) are actively seeking information about new innovations and are in general more prone to mass media than adaptors (partly because innovators are first to try new innovations so the innovations have not spread to the innovators peers yet). 3.3 Conclusion This research set out to identify the role of Dutch GPs in telemonitoring business models after an initial Only little and fragmented information was available on the GP s role in telemonitoring business models. Most literature discuss GPs tasks and medical role, and therefore we will use Rogers (2003) work to understand the GP s role and how GPs are approached by the medical sector in the context of developments in Dutch telemonitoring. The literature review showed that current business model designs form barriers against the adoption of telemonitoring products among medical professionals in Dutch healthcare: hospitals, specialists and GPs and home healthcare. It is clear that current telemonitoring business models are insufficient, and a main hurdle seems to be that medical professionals (users) strongly resist use of new technology, because of lack of skills, change of roles and routines, and uncertainty about technical performance and reliability. That might suggest that the current value propositions does not match well with GPs real needs. Regarding the SRQs the literature is also quite vague on GPs relations to telemonitoring development. It is ambiguous on who current SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

9 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 9 stakeholders are, but imply three to four overall segments consisting of citizens, patients, professionals and employees. However, this is vaguely defined and does not include for example the technology developers. There are many benefits (value propositions) in using telemonitoring equipment including quick data transfer between GPs and specialists. However, it is not clear whom the different benefits work in favor of. Enablers are more scarce in literature. One enabler though is that redesigning medical processes to fit the new technology seems to trigger adoption. Economic benefits for the medical sector also seem to have a positive effect. The value propositions/benefits that GPs see in telemonitoring is not covered well in literature, even though the correlation between expected/promised value propositions and what is actually received by the GP seems to play an important role in diffusion. Available literature mainly recognize the fact the the diffusion did not go as expected and pinpointing barriers, without explaining what strategies were actually used and how they were carried out. In combination with Osterwalder s (2009) value propositions concept we will investigate where telemonitoring technology creates value in GPs practices and what values are most important. We will also investigate to what extend the industry is (mis)matching these needs and how well the telemonitoring industry is able to span the various decision-making s and different adopter roles among GPs. That way we will be able to provide guidance on how the telemonitoring industry can choose the right value proposition strategies to address GPs with different adoption roles in different s of their decision process. 4 METHODOLOGY This section document the intended and executed methodological approach of this research project and the reasoning behind our choices through the research process. As part of the larger group of similar research projects, our research team had three shared meetings with the other research teams throughout the project. The meetings acted as project milestones as well as opportunities for sharing knowledge and getting feedback on progression, direction and approach of our research. However, being part of a master course the research projects were from the beginning limited by a five months time frame wherein an entire research process should take place, from conducting initial research and designing a research study to presentation of final research paper. 4.1 Initial Research Process Based on an initial literature study of introductory articles on business model theory and telemonitoring definitions in order to get into the subject, we moved on to initial research of studying existing and recent scientific literature relevant to the topic business model designs in home health care telemonitoring in order to find research focus. This was mainly done through studying reports, literature reviews and articles found using key words search in scientific databases and search engines. From these results we were able to chain backwards by following referenced literature and find more basic and extensive reports that could support our study. The literature study led to an identification of a gap between the speed of technological development which has enabled the medical technology industry to offer new products/services such as telemonitoring and the speed by which these new technologies are adopted and implemented in medical and health care practices. From this finding we decided to focus on identifying potential explanations for what have caused this gap between the business model designs of the medical technology industry and medical professionals - GPs and specialists. To provide a framework for our research we chose to examine this gap through business model theory (Osterwalder, 2009) and innovation diffusion theory (Rogers, 2003). However, from our first feedback meeting we realized that we had to sharpen our focus even more. After a second round of literature study we focused our research question around the GP s role in implementing telemonitoring in his/her own business models as seen from the main stakeholders identified (GPs, specialists and technology industry, patients) SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

10 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING Research Design and Procedure Based on our new research question we decided to conduct a qualitative research study of our problem field. From our second feedback session we realized that we had to be more specific in linking our research to the theoretical framework. That led to a focus on Rogers work on innovation-decision theory and how that might be able to explain the implementation of telemonitoring among doctors in the Netherlands. And for the same reasons we decided to highlight to what extend value propositions (Osterwalder, 2009) were used in doctors decision making process. The empirical approach would better enable us to catch implicit knowledge and get the detailed observations. Details that would be necessary to clarify what parameters are important for the GP s role and understand the relations to the other stakeholders. For the same reasons and because no secondary data was directly applicable to our problem field we decided to go for a grounded theory approach. The data collection was intended to be based on a series of semi-structured interviews from two telemonitoring projects. The interview sample should represent the main stakeholders involved in the two specific case studies. A grounded theory method would enable us to get the flexibility to explore our problem field by analyzing relatively many parameters from few observations in a research area unknown to us. An analysis that eventually would lead to one or more hypotheses for future research (Charmaz, 2006). Based on these criteria we designed a data plan for our research and started arranging interviews. However, it turned out to be very difficult to find usable cases since two of four key stakeholders were almost unreachable - lack of interest from technology companies involved in telemonitoring projects and patients being inaccessible due to privacy issues. Before we reached a critical point in the research project plan we decided to take a drastic decision and revise the entire data plan. As a result the research question also had to be revised. It had to reflect that the research data would be based on a sample of GPs and specialists only. Because of the sample changes we had to create a new sample composition to keep the study and the results reliable and relevant. Instead of having a research sample of main stakeholders from two case studies we decided to compose a diverse sample based on a number of parameters to make it representative of the population of Dutch medical professionals. Thereby we would secure external validity of the data and thus make sure that the results would be generalizable. And by having a diverse sample we would be able to look for similarities among doctors across these parameters (See Appendix I: Data Plan). Based on the new research question we created a new interview guide for a semi-structured interview with 4 main questions closely related to our overall research question and a number of sub questions for each main question, estimated to fit a thirty minute interview. Before we went for the interviews we conducted a pilot interview to test if our questions worked out and was understood by the interviewee as intended. The pilot interview was also a good chance to practice interview techniques such as probing and follow up questioning (Patton, 2002), dividing roles and getting to know our recording equipment. Half of the interviews were carried out in English and half were done in Dutch. All interviews were first transcribed in original language and then coded before all results were translated into English (See Appendix II: Interview Guide). 4.3 Analysis Phase After transcribing the interview data we moved on to the analysis process of coding and writing the data. Based on our theoretical framework and research question we developed a code book consisting of 6 overall categories with a total of 29 codes to analyze the data from (Locke, 2001). Since the coding technique works as a filter for the treated data sets it was important for us to construct a set of codes that took the influence codes have on the outcome of the coding process into account. Exploratory research must be open towards finding unexpected links and relations in the collected data, so aside from codes deducted from the theoretical framework we created a coding category to unknown, but interesting factors that didn t fit within the theoretical codes (See Appendix III: Code Book). SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

11 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 11 The actual coding process was done in several steps. First by assigning relevant code(s) to all sentences or paragraphs from the transcribed interviews, which led to a number of quotes filed under one or more codes (See Appendix IV: Full Codes Scheme). As a second step these collections of quotes were summarized into one resume pr. code pr. respondent through writing as explained by Corbin & Strauss (2008). Next step was to compare the summaries to the related code and to the literature. The entire procedure was done as an active analysis process (Silverman, 2010). As this section shows the research process has been a continuous adjusting process from beginning to end, and that way it reflects very well the learning process that this has been aside from being a research project. The planning and inclusion of theory has been sharpened and improved through the process through feedback received from other participating groups and supervisor as well as from our own team discussions. The resulting process has changed direction over time, and some blind spots/dead ends have been experienced on the way to the end result, as well having to cope with the conditions provided along which forced us to change scope - a concrete example being the impossibility to get the wanted respondents. 5 Results The following tables present the results of the interviews. Table 3 gives overview of respondents and table 4-9 provide summaries of the interviewee s responses, sorted by code. Sample Parameter: Wanted Actual Sample Comment: Age Varied years Only older respondents were available. Gender Varied Male, 1 Female High male percentage, typical for the current medical sector Geographic location Individual/shared practices Technology knowledge Varied Varied Zuid Holland, Friesland, Groningen. Varied Varied Both individual and shared practices. Varied Varied From technology enthusiasts with ipad2 to reluctant technology pessimists Profession Varied Varied Aside from GPs and specialists one TM pilot project manager (MAN) and one industry representative (IND). Professional Experience Level Varied Similar Since the sample only consists of older doctors the level of professional experience is also quite similar all respondents had years of experience in their field. Table 3: Sample Composition SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

12 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 12 Category MAN GP1 GP2 GP3 GP4 SP1 SP2 SP3 IND1 Definition Quantitative VP 1 Performance A wide selection of interactions and measurement s in TM will lead to more effective and precise treatment - better for both organization and patient - and saving money on staff. More patient treatments pr staff. Monitoring of patients medical data on a distance GP contacts a specialist and sends data of the patients, this data is professionally reviewed and a quick diagnose is provided 2 Price Receive more 3 Cost reduction TM can reduce staff pr patient (and improve patients' life quality) through centralizing communicatio n money than for a normal consult TM companies offer monetary benefits, in kind or in the form of discounts on equipment Monitoring of physical values on a distance by equipment For certain diseases and medical purposes where advanced features, higher performance and continuously updated data are crucial TM is needed. Video calling will enhance patient communicatio n. Saves on specialist costs because hospitals' efficiency focus give the work to GPs. Time and cost reduction and maybe give refund are important when evaluating TM. Qualitative VP 4 Newness TM can 6 Getting the job done TM is used for medical diagnoses of lungs and dermatology related problems extend lives and gives new/improved communicatio n possibilities TM can give GPs work in preparing patients for specialists. Speeds up the treatment process. communicati ng and receiving physical or medical data for urgent + other issues. At the end the GP will have more satisfied patients and then get quick and precise and more up-todate reliable information about his patients The government benefit from it if the cost of care is reduces. You can have reduced tax income. 8 Brand/Status Doctors trust new medical Table 4: Interview Results Memo Overview practice that have been approved by 'the professional board' follow results and take action based on accurate values With TM such as a camera or ECG meter the GP can faster finish make a diagnose and treat the patient. Measuring patients data on a distance TM allows doctors to make better diagnoses and find solutions to cure vital problems Price benefits of using TM are higher than not using it TM allows patients to stay home with the monitoring equipment, saving on expensive hospital costs TM should be used to diagnose not to monitor, except for applications where it is really useful (We use it by) working on a distance and work with the digital data of the patient More flexible and more convenient work by using TM Every stakeholder in the medical industry is afraid to lose money It can be used for planning medication and diagnosing rutgen images from a distance, instead of going there Monitor data of the patient on a distance Use TM for enhancing the flexibility and the convenience for the patient and the medical staff, making it more efficient and improving the quality of care Implementation will cost money, but the GP can charge on new diagnostic methods GP has to administer treatment budgets for certain diseases. With TM large distance can be crossed, improving the efficiently and the quality of care TM should improve the quality of care, the efficiency and cut on costs of healthcare For investments in TM solutions, the need of the customer should be clear, such as visual contact and the possibility to alarm someone SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

13 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 13 Category MAN GP1 GP2 GP3 GP4 SP1 SP2 SP3 IND1 9 Risk reduction Allowing a specialist to have a look at a dermatologic problem 10 Accessibility Low barrier for getting to know 11 Convenience/ usability TM enables better and clearer communicatio n between medical staff and patient and enhances the feeling of being safe at home as patient. New flexibility in schedules gives less restrained life for patient. The innovation Decision-process 12 Knowledge 13 Persuation 14 Decision 15 Implementation Having insider understanding and bridging users' world with the new technologies makes acceptance easier among otherwise reluctant users. the possibilities of TM, including facilities When there is doubt, specialist can give their professional opinion, within a day, without fuss for the GP Approached by company with an about TM, for the rest not informed about existence Companies try to force a decision with a contract, that has a negative impact on the use of TM Improved performance in TM can decrease risks by better spotting details. Making GPs + specialists days flexible, tasks easier and improve collaboration. TM leads to exciting work for specialist and better base for GPs' decisions. Patients get convinced to stay home. Plays on doctors' aspiration to be a better doctor. New technology is current based on own initiative. GP s take long to adopt new technology GP takes decision to use TM. His decisions are based on practical reasons such as space, implementatio n time and costs, Table 5: Interview Results Memo Overview GP s use TM to get direct advice from a specialist, quickly get a diagnose and safe time. This wil also benefit the patient in the end Companies should convince the GP s that is easy in use and that there is something in for them, because of quick results In the decision, comments from colleagues are more trusted than from brochures Easy, fast and usable TM products is important for patients' benefit. For doctors it is convenient to send a picture and get a quick advice from a specialist. The GP can have a motivating effect in the beginning of the development Because GP s are important in the development, hospitals focus on them with training Decisions for GP s depend on the possibility to integrate it into their practice Can be used analysing heart problems, not getting visits from irritating patients and enhancing the convenience for the patients Companies should visit doctors, visit congresses, lobby politicians to make TM known Companies should persuade politicians that TM devices can offer benefits in the medical industry The implementati on of TM equipment might bring new and more responsibilitie s TM allows specialist to diagnose medical problems Low barrier for discussion makes work more fun and more flexible TM allows working from other locations, making the work more flexible and more efficient The Martini- Hospital offered a training on TM In dentalsurgery there are not many innovations to implement The equipment should be safe, but that is why the control is so strict TM offers convenience in dividing the work, working from more locations and make the work more flexible Companies visit hospitals to explain about TM, universities are sometimes also involved Allowing patients to make social contacts in home healthcare TM could be a solution for reducing traveling time, waiting lists. introduction to the involved parties should be provided, including explanations, trainings and press releases It is hard to involve all parties that are needed, at least a specialist and an enthusiast GP should be persuaded to become involved The health insurance influences the desicion negatively, when other stakeholders already agree Implementing TM in healthcare is hard; getting everyone on a par, discovering boundaries and the rates, and how can everyone collaborate SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

14 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 14 ory Categ MAN GP1 GP2 GP3 GP4 SP1 SP2 SP3 IND1 16 Confirmation Communication channels Conformation is affected by whether it allows the specialist to continue his work c onformation by showing results from the past is not enough 17 interpersonal 18 mass media 19 Systemische/ organized 20 Fragmented/ disorganized Personal contact from industry to health organization through network organization was what initiated a new TM project Some initiatives are taken to bridging the gap between health and technology. The healthcare world see a gap between themselves and technology, caused by lack of knowledge (information) about what needs the technology is fulfilling. Specialists update GPs on new developments in their field through mandatory sessions every month. There is a good, close collaboration. promotion is used by the industry and it works to trigger interested with GPs. A certain amount of time every months and year is assigned to provide GPs with new knowledge from local specialists. There are only few training moments and cooperating specialist are not close situated Stakeholders 21 GP GP s can benefit from TM because of its support and help in making decisions 22 Patiënts Patients that use TM receive benefits in the form of quick results and consulting time reduction Table 6: Interview Results Memo Overview GPs listen to closely and are likely to try out of new technology if their patients or colleagues have had good experiences. Professional gathering such as congresses, experimental groups and fairs, and media as magazine are used to spread the info. Industry make themselves present in medical events and media and by collaborating with the Dutch Association of Doctors There is no information available about TM GP can translate a problem into a product that the industry could make. They can also translate to patients how they could use TM If patients do not accept TM, it won t work. Patients should ask for TM in the doctor s office. They are not aware of the cost, they should be educated. Equipment, knowledge, technologies are often spread from hospital specialists via personal connections or lists. Pharmacies are close to secondary stakeholders. General lists are used to share Info by specialists and industry about TM to GPs in the ZH region. Hospitals spread new TM to GPs in special meetings and via and provide advice and a chance to try it. There is not much development in primary care, although there is a way of communicati ng between local GP s GP can motivate people to use TM systems Supply of TM equipment is structured TM can improve the convenience for the GP and allows the GP to delegate certain tasks TM can be used for patients that demand constant treatment and can make this easy There is communicati on between hospitals and universities about medical questions Structured collaboration and structured roadmaps are important when innovating in the medical industry Calls from dentist for help are not appreciated and consults are conducted without the use of the computer because of the business like character of that GP's have a difficult relation with specialist, that can slow down cooperation The patient is best assessed by a specialist, also at night There is between GP s and specialist, and with universities about medical questions Information about radical innovations in healthcare are featured on news broadcasts, more than in hospitals themselves ICT is not used that much in hospitals by doctors, because some things are easier to take care of in person Patients demand a new approach and treatment can be much easier for the patients It is hard to communicate with all the parties in the beginning of a pilot, but later it is beneficial if the lines are short to discuss things On relevant moments information is released to the press Supply structured training to educate stakeholders of TM There are no specified rates and boundarie s of TM, and training outcomes are not evaluated GP's question the new way of working with TM, but when enthusiastic they can pull the project SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

15 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 15 Category MAN GP1 GP2 GP3 GP4 SP1 SP2 SP3 IND1 23 Industry Some parts of the industry is involved in bridging the gap to the health world. Ksyos is a company that allows GP's to use TM services 24 Specialist Specialist like radiologist and 25 Other stakeholders Others Politics 26 cardiologist also monitor their patients from home From the Hospitals healthcare's POV is family and relatives important stakeholders in the patients' experience of TM. When bridging the world of healthcare and technology new stakeholders will appear. 27 Role of GP GP's have to get the approval of patients to use TM, but can also pursued them to use it Focuses on the value for the patient, if you do not offer this you are a bad doctor TM is more and more important for specialist Trained nurses, Insurance companies and hospitals GPs mainly follow development in TM, do not initiate it, because of a lack of time and expertise. GPs do advice patients to take TM solutions and take work away from the specialist by using TM solutions Table 7: Interview Results Memo Overview Companies should not only target the medical professionals but also focus on patients Insurance companies, government Some treatments and experiments are not considered to be politically favaroble. GP s are responsible for their patients, they can advise what TM can do for them. In the future he should have a bigger key function in medical care Companies are developing new technology, but should be aware where and how to distribute this Hospitals, Pharmacy and Insurance companies GP is the most important in the development of TM, he can motivate the use it. In the future the GP will get more responsibilitie s and treat more chronic patients Companies can use political lobby to bring their product under the attention, but this should be done because it is a good product, not because of the money Health Insurance Companies could lobby in politics to focus attention on TM GP's can persuade patients to use TM, but should also consider the responsibilitie s and the new ways of working Specialist demand the best medical systems, because they can make the best assessments and diagnoses Dentists The relation between GP's and specialists is the field of subcutaneou s politics The GP should get a certification when working with TM Companies have great stakes in selling medical treatments A specialist can be cocky, but TM can take the sharp edges of the work Hospitals, Politics, Universities Politic parties should be aware of the possibilities of TM GP's can select patients for TM, discuss with specialist, and work out easy tasks that were first specialist tasks Enthusiast specialists play an important role in the success of a TM project Health care organisati ons, health insurance s,hospital s, health regulation from the governme nt Because of the high stakes in the choice of medical care, there are effects of subcutaneous politics, between hospitals, specialist, GP's and the government The GP has the task to form the new possibilities into a workable concept, and become an ambassador of TM SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

16 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 16 Category MAN 28 Barrier The gap of shared understanding between technology companies and healthcare makes it difficult to spread TM. Currently the machines represent all the things that the carer despise, and are seen as solutions in opposition to improved health care. GP1 - Patients get the bill for TM, because of the specialist character of the treatment - Contracts force GP's to conduct TM treatment more times a year - People that need personal medical care, cannot work with TM GP2 - Money, logistics, experience and central coordination lacks to implement TM - There are not enough people that have the PAL4 system, we need at least 20/30 to make it work - Medical centres are too small to start pilots with TM, compared to hospitals - Equipment is expensive, there are a lot of people needed and a lot of training Table 8: Interview Results Memo Overview GP3 - (Older) doctors need to see the patients in person, not only from a picture - Treating elderly patients with TM can be difficult because of patients dealing with multiple problems - The quality of the infrastructure is not good enough and safety is important - If patients do not accept TM, the system does not work - Doctors are very conservative in adopting new technology - The rate are too low, there is no incentive GP4 - Initiators of innovation actually have no time to do this, because they are testing people - (Older) doctors have established a trust relation with their coworkers, TM might disturb this - No wellarranged financial procedures - Big barriers are money and time - TM is not easy to integrate in a normal practice offering primary healthcare SP1 - Proliferation of treatments that could be done with TM, that nonsensical - Patients might panic because of false alarm of the TM equipment - Because of this kind of equipment, patients suffer more from the fear of being ill, than of being ill - Medical staff is obliged to investigate every (wrong) output of the TM equipment - 90% of the aberrant data is probably fine, but it cannot be ignored by the medical staff - Dutch people are less concerned with their health, than for example German people SP2 - Patient can only be assessed well in person, not on a distance - Specialist are not happy with the specialized treatments that GP's perform - Rules and regulations about declaring treatment do not exist - Specialist are not comfortable with the responsibilitie s of GP's in TM - Money can be a limiting factor in the application of TM SP3 - No interaction on distance possible due to the nature of the treatment - - Specialist want to cooperate but that should be at the expense of working time - Medical staff is afraid for reorganisations that might cause faults in the system - Implemntation of TM cost a lot of money, and it is not sure where this money comes from - In IC units doctors do not have time to react on TM emergencies - Communicatio n between specialist and GP's can be difficult IND1 - There are no set rates for conducting TM treatments - Uncertainties in responsibilitie s and effects of TM limit the willingness to innovate - It is uncertain where innovations have effect - The effect of changes in rates is uncertain - Medical industry has a conservative attitude - Working more efficient may prove less profitable SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

17 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 17 Category MAN 29 Enabler If the technology can lead to better solutions than what can be provided by any means available today and in the future then TM will be seen as beneficial to healthcare. Or when/if there turns out to be no alternatives left. A key to that is shared understanding of each other s problems - e.g. through personal communicatio n. GP1 GP2 - Working with TM on an island is more efficient - With TM it is easier to plan consults while all parties involved stay at their location You feel like a better doctor if you improve on health solutions Specialist value that they can delegate tasks to GP s, allowing them to focus on their core speciality Preparation for hospitalization can be much more efficient by using TM Table 9: Interview Results Memo Overview GP3 - Visual consult can be more rewarding for the doctor - Doctors will embrace TM when they can make quick diagnoses, save time, be able to treat more patients GP4 - Medical centres have more potential to use ECG when they house more doctors - There is a mailing list for contacting GPs in the region of Delft, information about new technologies is shared here A collaboration between GP s and specialist can be very promising - TM adoption is enhanced by cooperation with pharmacies that have closer ties with the insurance companies than the GP s Insurance companies pay projects when they are good ideas SP1 - For people that use blood thinning medicines, it can increase the overall convenience SP2 - If you are able to get financial aid from the board, innovation is possible - Because of the fibre network in the Netherlands a high quality and secure connection can be set up for not so much money Specialisms like dental surgery, that deal a lot with runtgen diagnostics, can use TM Dental surgeons can use normal consumer monitors to make a diagnose SP3 - Next generation is probably better with this kind of technology - Medical innovations can limit the waiting lists in healthcare GP's can take over specialist tasks that are not relevant anymore to specialist IND1 - A health insurance is willing to spend money on better healthcare, when innovations can increase quality, efficient and bring costs down - TM can decrease traveling time, waiting time and increase efficiency TM can be used to increase social contact for patients If the quality of the connection is good, patients value the direct visual contact If TM becomes a regular treatment, patients will eventually ask for it SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

18 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 18 6 Discussion In this section we will present and discuss main findings and interesting insights from the analysis of the collected data, here structured according to the codes from the analysis phase. Definition/understanding of Telemonitoring among respondents: When asked directly the respondents agree across professions on telemonitoring as being communicating data about the patient on a distance. Mainly quantitative, measurable data such as heart rate and blood pressure meters, but also qualitative data that need a different kind of interpretation such as video and pictures. Value proposition In the interview guide we made a clear distinction between the theory that we use for our framework, from Osterwalder (2009) and Rogers (2003). In this section we will discuss the results of the value proposition, starting with performance. Performance The participants all mention performance a very important value proposition of telemonitoring. With this technology it is possible to work more effective, efficient and more professional. For GP s, this means that they can send their patients data quickly to a specialist and get results back fast. Also the quality of health-care GP s can offer in increased by telemonitoring. For the specialist the performance value proposition is more related to the flexibility of work, but also the quality of health-care, both for the patient as for the medical staff. The industry mentions the fact that because of telemonitoring large distances can be crossed and the efficient and quality of care is improved. Price The price value proposition is less mentioned by the participants. From the GP s point of view it is possible to receive more money for a telemonitoring consult, than for a normal consult. Specialist say that there are price benefits, and they are higher than not using telemonitoring at all. Also they give a solution for the implementation costs; a GP that uses telemonitoring is able to charge on new diagnostic methods, so he is able to recover his investments in the equipment. Cost reduction Most participants value the cost reduction aspect of telemonitoring. Most stakeholders can profit from it. Medical centres and hospitals are able to reduce staff, save on specialist costs and get discounts from medical equipment suppliers by using telemonitoring. Also the patients and the government benefits from reduced costs on medical care. Specialists say expenses can be limited on expensive treatment, and this is very positive because all stakeholders are afraid to lose money in their practice. Industry mentions also that telemonitoring allows cost reduction on medical treatment. Newness Only one GP mentioned the value proposition newness; telemonitoring can provide new and improved ways of. Getting the job done This value proposition is also important for the medical professionals. Telemonitoring helps GP s to perform medical diagnoses, prepare patients for specialist and offer quicker results. For specialist it helps in planning medication and diagnosing images on a distance, instead of going there. One specialist mentions also the danger of telemonitoring, that it could also be used for unnecessary things, that should be avoided. The industry says that first the need should be clear for users where telemonitoring can help, for example in visual contact and the possibility to warn someone. Brand/status The brand of telemonitoring equipment and the status that it provides the user (GP or specialist) is not that important for the users. Only one GP mention that when the equipment is approved by professional experts, GP s would trust the equipment more and implement it faster in their practice. This could be connected to brands and the status of treatment with particular systems and equipment. Risk reduction Reducing the risks of medical treatment with telemonitoring is a valid value proposition. GP s mention that it allows them to spot details better, by allowing a specialist to have a look at particular SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

19 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 19 problems. Specialist can provide the GP s with a professional diagnoses. The risk is also reduced because of the strict control on the safety of medical devices. Accessibility Companies try to introduce GP s to telemonitoring by offering them accessibility to the technology, knowledge about it and the actual equipment. This is best illustrated by this quote (Dutch): En dat was dan zoiets van je krijgt vier punten, en een fototoestel en iemand komt je op de praktijk uitleggen hoe het allemaal werkt, en ik dacht toen dat is een soort van win win situatie! (GP1). Specialist say that telemonitoring gives access to discussion, that was not possible before, and makes the work more fun and more flexible. The industry mentions a very valid value proposition; telemonitoring can give patients access to social contacts in their home health-care situation. Convenience Together with performance this is the most important value proportion identified by our participants. Telemonitoring enables better, clearer and easier between medical professionals. It makes the work more convenient, fun and flexible and allows professionals to work on multiple locations, including at home. It decreases traveling time and costs, and the convenience for both the patients and the medical staff. Next to that the quality of health-care is enhanced by improving the convenience for the patients, and it is much easier to deliver high quality health-care because of the possibility to have a specialist opinion and diagnoses in a fraction of the time that it would take normally. The Innovation-Decision Process In the knowledge the initial encounters with the new innovations seem to be based much on local initiatives. Some specialists have experience with companies approaching their hospital, whereas most of the GPs initial knowledge about telemonitoring products are based on the own initiatives and a few visits by specialists from a local hospital. For specialists this means that there is a focus on the passive knowledge whereas for GPs the knowledge is initiated by interested GPs own initiatives. It is not clear who, when and how GPs are approached and to acquire knowledge on own initiative is difficult. Something that we also experienced in the first phases of our research process. Focus in the persuasion from the hospitals and industry is on the products ease of use and that it enable GPs to provide better treatment for their patients - become better doctors. Information on economic and practical implications for GPs are only very vaguely mentioned, however this study shows that GPs want information about how easy and cheap the products are to implement in the practice. GPs are responsible for all telemonitoring products getting into their practices but they are also very busy keeping their practices running: Can I do it? Do I have room? Do I have time? What does it cost? Is there a system to get refund for it? It takes time to introduce them [telemonitoring products] to your practice so everybody knows how to do it. GP2 Having an insider from the medical world to explain and translate the reasons for applying technology makes it easier to get reluctant doctors and nurses interested in telemonitoring. To enhance persuasion politicians, specialists and GPs should work closer together to share knowledge about the benefits and barriers of telemonitoring. Finding enthusiastic GPs make it easier. Some hospitals provide GPs with handson experience with trying out equipment to cope with the uncertainty that most individuals have in the decision. However, it seem to happen very sporadically. GPs seem to base their decision to accept telemonitoring mainly through information provided through meetings, s and personal referrals. It was difficult to get very useful information on how the implementation and confirmation s work in the process of adopting telemonitoring solutions. This might imply that implementation and confirmation of telemonitoring among the GPs does not seem to be of focus from the industry, even though it has priority among GPs. If that is the case then it could be a barrier to the adoption of telemonitoring because it means that many uncertainties with the GPs are difficult to get answered. SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands

20 ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING 20 And since the research results also suggests that Dutch GPs overall are rather conservative when it comes to new technology (and practices in general) as well as being very busy with the organization of their practices, presumably many GPs are lost before they reach final confirmation and consolidation. As stated by Rogers (2003) problems of implementation are more serious in an organizational setting and the organizational structure might resist the implementation of an innovation. Communication Interpersonal seems to be widely used in the medical sector in relation to telemonitoring according to our study. Rogers diffusion theory suggest that innovators are much more prone to mass media channels than interpersonal channels in the and that the first s of innovation-decision making is highly based on information retrieved from mass media channels. However our study indicates otherwise. Both in the knowledge and the continuing s the main takes place through personal contacts between GPs and hospitals/specialist/companies. That might be based on the fact that there does not seem to be many good mass media channels for getting information. Apart from the companies own information material, only ing lists and notes in professional publishing seem to exist and they mainly work as one way with the GP as the receiver. There are some organized activities that brings GPs closer to specialists. To keep their license GPs needs 40 hours of training every year, and telemonitoring is one of the topics dealt with in those courses. There is also a development bringing 2 or more GPs together in Medical Center where they can share facilities and assisting medical staff. This enhance between the doctors, but mainly on the interpersonal level. Role of stakeholders in telemonitoring GPs benefit from the development of the telemonitoring products since it enable them to conduct more and better treatments of their patients. They also have the close patient contact and trust that is important to explain patients the benefits of using telemonitoring and how to use it properly. Aside that the GP, because of his inside knowledge, is also able provide the technology companies with information on where and for what parts of his daily work it might be beneficial to apply modern technologies. GPs are historically very conservative in general when it comes to applying new knowledge. Both the implementation of echo-grammes in GPs practices, implementing new specializations such as cardiology in hospitals and recently the slow adoption rate in using in consulting patients suggest that telemonitoring does not easily spread among doctors. Relation between involved stakeholders The relation between specialists and GPs are good in a sense that knowledge seem to spread continuously during the ongoing training sessions as well as collaboration on specific tasks such as analyzing dermatology photos to discuss further treatment, however it seems like both professions are reluctant to pass on their work to other medical professionals; GPs taking over specialists tasks/domain and similarly nurses taking over GPs work is not happening without problems. Specialists are key stakeholders in developing the new technologies because they have close connections to the telemonitoring industry due to their specialized expertise, higher volume of patients with similar conditions, and often the facilities of a hospital or clinic. Telemonitoring enables the specialist to dig deeper into his/her subject because he/she will be provided with more detailed information. Nurses are involved in telemonitoring through their close work with doctors. Many nurses are working in the home health-care sector where many elderly are taken care of. Nurses tend to see bring the patients perspective and needs into discussions on new technologies in health-care. Due to telemonitoring and the high costs of GPs and specialists they are slowly beginning to take over chronic patients and treat them by checking meters and follow fixed procedures. Patients benefit directly from use of telemonitoring by getting more flexible and faster treatment of higher quality, especially patients with chronic diseases. Patients also play a central role in implementation because the adoption depends on the patients being willing to accept treatment by SPD Research Project Master in Strategic Product Design Faculty of Industrial Design Engineering Delft University of Technology The Netherlands