Strategic alternatives in telecare design

Journal of Strategic Information Systems 20 (2011) 198–214

Contents lists available at ScienceDirect

Journal of Strategic Information Systems journal homepage: www.elsevier.com/locate/jsis

Strategic alternatives in telecare design Developing a value-configuration-based alignment framework Albert Boonstra ⇑, Manda Broekhuis, Marjolein van Offenbeek, Hans Wortmann Faculty of Economics and Business, University of Groningen, The Netherlands

a r t i c l e

i n f o

Article history: Available online 2 February 2011 Keywords: Strategic alignment Telecare Value configurations Design

a b s t r a c t In telecare adoption, the lack of a strategic vision and of consistency in design choices have been identified as critical problems. Existing IS alignment literature only offers limited answers to these problems and does not acknowledge the different value configurations that telecare technology can enable. This paper, therefore, integrates work on strategic value configurations with the strategic IS alignment model in order to widen the latter’s applicability. Based on the value configurations and related service management literature, a framework involving three distinct alignment configurations is developed for telecare. An analysis of two Dutch telecare projects shows how the proposed alignment profiles can explain the contrasting project outcomes more effectively than the traditional strategic alignment model would have done. The discussion reflects on the generalizability and contribution of an extended strategic alignment model. Ó 2010 Elsevier B.V. All rights reserved.

1. Introduction Although healthcare systems differ considerably from country to country, ongoing changes in government policies and regulations on the one hand, and in patient populations and demands on the other, seem to share certain aspects. Moreover, a globalising market, increasing demand and advances in medical science mean that healthcare expenditure continues to grow whilst there is a continual pressure for efficient use of resources on the supply side. Therefore, many policymakers in healthcare are looking for both cost reductions and quality-increasing innovations, such as e-health, so as to be able to deliver affordable and accessible care, and are wrestling with their services’ strategic positioning much more than they did in the past. The problems faced by these practitioners inform and inspire a scientific debate, of which this special issue and recent contributions by Porter and Teisberg (2006) and Hwang and Christensen (2008) are typical examples. Hwang and Christensen (2008) have argued that information technology can enable strategic choices not only in sustaining, but also in disruptive, ways. Coupling advances in information technologies with suitable business models, and appropriately aligning information systems with healthcare processes and operations, seem to be important factors in creating well performing healthcare systems. This paper develops an alignment framework that is specifically for healthcare providers. The framework’s applicability is demonstrated by analysing the strategic alignment of two telecare programmes. It is argued that this healthcare-specific alignment framework can contribute to improved dialogues among stakeholders on how to realize strategic alignment.

⇑ Corresponding author. Address: Faculty of Economics and Business, P.O. Box 800, 9700 AV Groningen, The Netherlands. Tel.: +31 50 363 7289; fax: +31 50 363 7110. E-mail address: [email protected] (A. Boonstra). 0963-8687/$ - see front matter Ó 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.jsis.2010.12.001

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

199

Earlier work has shown that strategic alignment is a prerequisite for the effective positioning of service organizations, such as the providers of healthcare (Johnston and Clark, 2001; Silvestro and Silvestro, 2003). Strategic alignment involves giving attention to interacting organisational domains in order to ensure that the strategy matches other important domains in an integrated way (Henderson and Venkatraman, 1992). In the IS field, Venkatraman’s (1991) strategic alignment model (SAM), which originates from hospital research (Henderson and Thomas, 1992), is the best known approach. Within the SAM, the business strategy domain has largely been conceptualised in terms of Porter’s ‘Value Chain’ framework (e.g. Porter and Millar, 1985; Tallon et al., 2000). In a parallel research stream, Stabell and Fjelstadt (1998) extended Porter’s work by proposing two additional value creation configurations: the ‘Value Shop’ and the ‘Value Network’. Stabell and Fjelstadt’s work, however, does not address how these two additional value configurations can be aligned with the IT domains, most notably with the IS strategy and the IS structure. It is this gap that the present paper aims to fill. As such, this paper’s theoretical contribution is the integration of Stabell and Fjeldstad’s value configurations with the SAM in order to enhance the latter’s applicability and as a contribution to the theoretical logic underpinning the ‘what’ in strategic alignment. In so doing, we focus on telecare applications in healthcare. Chan and Reich (2007) argue that alignment research that focuses on specific industries has the potential to result in more refined findings, and a deeper understanding of how IT enables value creation. Having accepted their advice, we chose telecare as our specific field of study for two reasons. First, telecare is a promising e-health technology that delivers healthcare services to clients’ homes. As a virtual operational organization, it is even capable of providing telecare-based services anytime and anywhere (Hebert and Korabek, 2004). Building on Stabell and Fljeldstadt, it has been argued that telecare applications can enable a range of value configurations for healthcare services, and that these may stimulate revolutionary business models (Hwang and Christensen, 2008; Christensen et al., 2008). Therefore, our aim of extending the traditional SAM to encompass value configurations other than the ‘Value Chain’ is relevant to the field of telecare. Second, while telecare has inspired strategists to theorise about disruptive business models, the technology’s adoption in routine clinical practice has repeatedly proven to be difficult (see reviews by Berg, 1999; Broens et al., 2007). Ironically, the critical factor seems to be the lack of a strategic vision (Porter and Teisberg, 2006; Broens et al., 2007), or of its translation into a consistent service design (Silvestro and Silvestro, 2003) involving both organizational and technological design choices (Wortmann et al., 2009). A more comprehensive strategic IS alignment model would offer a framework that could explain the design choices involved and the required fit between them. Such a framework could support both healthcare providers and researchers interested in studying the alignment challenges in telecare design. Within the telecare literature itself, there has been little work on the formal modelling of telecare (Adriano-Moran et al., 2005). Collinge and Liu (2009) constructed a telecare information architecture that describes the system components needed, and details their requirements. However, they do not touch on the need for strategic alignment between these components, nor do they consider the possible tensions between requirements. Gortiz (2007) does stress the importance of (re-)designing the interactions between organisational domains on an operational level. His work, however, does not contain the strategic focus required to clarify telecare’s potential contributions. To summarize, this paper contributes by developing a framework for aligning choices in telecare technology with the strategies of healthcare providers. The field-specific character of the framework stimulates explicit analysis of the fit between business and IT domains. More generally, this framework shows how placing alternative value configurations within a strategic alignment model enables the SAM to be applied to existing business models in service industries, in this instance healthcare. In developing this framework, we build on work that has, so far, been carried out in distinct research streams (as will be explained in Section 2). In Section 3, we present the extended and adapted framework in which we outline three strategic alternatives for telecare. The paper’s empirical part uses this framework to analyse two projects from a well-known Dutch telecare programme. These projects are described in Section 4, which also explains the method used in the investigation. Our in-depth data collected on these projects facilitate an evaluation of the consistency among the interrelated strategic design choices involved and of the projects’ outcomes. In Section 5, we start by mapping each of the two projects, one successful and the other considerably less so, to evaluate their alignment. In Section 6, based on a cross-case analysis, we subsequently discuss how the degrees of alignment realized in the different profiles may explain the telecare projects’ respective performances. The concluding Section 7 evaluates the extent to which our study supports the enhanced SAM framework. Based on this, the need for further development and the use of detailed alignment profiles in healthcare and other service sectors are articulated.

2. Backgrounds 2.1. Telecare – the concept and its promises Telehealth – or, more specifically, telecare and telemedicine – services are increasingly being established as ways to speed up processes, to reduce costs, to improve accessibility to high quality care, to empower patients and to bridge the gaps between mutual providers and between providers and patients. Telehealth covers a broad spectrum of services such as teleconsultation, second opinions, telecare and teletraining, and builds on various technologies such as videoconferencing

200

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

and remote monitoring. Here, we focus on the use of telecare in the sense of ‘‘a combination of equipment, monitoring and response that can help individuals to remain independent at home’’ (Department of Health, 2005, p. 8). Telecare is often portrayed as one of the most promising IT applications in terms of costs and quality (Rojas and Gagnon, 2008; Britton et al., 2000). Despite these high expectations, the diffusion of telecare remains limited, mainly due to the huge implications in developing and implementing such a service innovation. The introduction of telecare – as with other similarly radical service innovations – seems to have a more disruptive impact on the organization than is often anticipated (Broens et al., 2007; Christensen et al., 2008). Two forms of disruption have been distinguished: (1) new forms of care that were previously not covered by healthcare providers, and (2) substitution of traditional care by cheaper, more accessible or otherwise more convenient forms of care. Reviews of telecare projects show the impact of these innovations to include the strategic repositioning of the organization in its environment, the emergence of new distributed temporal and spatial working arrangements that affect internal relationships and a power to extend collaboration with other healthcare organizations (Broens et al., 2007; Collinge and Liu, 2009; Nicolini, 2007). As such, telecare diffusion seems to require, as with many service innovations, a clear view of the strategic position of the organization, and of its service offerings (Terrill, 1992). One route to understanding and guiding this strategic repositioning is to analyse changes in value creation and the logic involved.

2.2. Value configurations – conceptualizing strategic alternatives for telecare As healthcare providers increasingly face some competition, and calls to account for rising costs and to offer transparency in service quality, they have a strategic interest in explaining, and also reconsidering, the ways in which they create value. Value creation is traditionally conceptualised using the value chain concept (Porter, 1985). The value chain contains the various activities that a firm performs to deliver low-cost or differentiated products. The activities in the value chain framework (Porter, 1985) include inbound logistics, operations, outbound logistics, marketing and sales, and services. The value creation logic of a value chain is the transformation of inputs into products or services. The main inter-activity relationship is a sequential one. Although standardized care paths have been developed for routine interventions, such as hip replacements, value creation does not, in most healthcare services, seem to take the form of a planned chain of events. This led us to consider the more recent work of Stabell and Fjeldstad (1998) who propose two additional value configurations, namely the value shop and the value network. In the value shop configuration, a firm concentrates on discovering what the client wants, works out a way to deliver value, determines whether the customer’s needs are then fulfilled and repeats the process if necessary. The main activities are problem finding and acquisition, problem solving, choice, execution, control and evaluation. The interaction between provider and client is cyclical. This value creation logic revolves around solving the client’s problem. This configuration can be easily recognized in healthcare services such as general practitioner consults or a multidisciplinary clinic offering diagnostic services to the elderly. In the value network, value is created by linking clients who wish to remain independent. The firm itself is not the network, but provides a network service (Stabell and Fjeldstad, 1998). In this configuration, the firm is an intermediary that focuses on network promotion, contract management, service provisioning and infrastructure operations. The logic of value creation is linking clients, and the main inter-activity relationship is a mediating one. Although less prominent, this value creation logic is present in the increasing use of gate-keeping, case management plus transfer and liaison roles in healthcare. Such roles are typically supported, if not enabled, by IS applications. Given the strategic role of information and communication technologies in healthcare, it is not surprising that Stabell and Fjeldstad’s work has been picked up in the health IS field. Hwang and Christensen (2008) and Christensen et al. (2008) show that the above three value configurations can be used to envisage alternative e-health strategies. For the specific context of ehealth, Christensen et al. (2008) proposed the terms Value-adding Process Chain, Solution Shop and Self-Help Network, which are conceptually similar to the terms value chain, value shop and value network. Although these authors recognize the relevance of the additional value configurations for e-health – as Laffey and Gandy (2009) have for e-commerce, they do not explicitly address the alignment issues, nor do they provide an alignment framework.

2.3. Strategic alignment – towards a coherent design Nevertheless, the importance of strategic alignment is widely recognized in the broader IS literature, and based on the view that it is only when IT is effectively aligned with corporate strategies, processes and practices will IT enable companies to achieve their performance goals (Brynjolfsson and Hitt, 2000; Chan and Huff, 1993; Croteau and Bergeron, 2001; Croteau and Raymond, 2004; Levy et al., 2001). Such an alignment ensures that managers allocate IS resources to strategically important applications and that other dimensions of the organization are changed in ways that are consistent with the business strategy and the IS strategy. Whilst alignment seems to promote performance (e.g. Sabherwal et al., 2001; or specifically for hospitals: Bart and Tabone, 1998), few organizations are able to achieve and sustain it (Grant, 2003; McKeen et al., 2003, p. 93). According to Chan and Reich (2007), this reflects the fact that many business managers and IT managers lack the knowledge and awareness needed to define business strategy, IS strategy and business structures in coherent ways: ‘‘IT executives are not always privy to corporate strategy, and organizational leaders are not always knowledgeable to IT’’ (p. 299).

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

201

2.4. Strategic alignment – a tough agenda for healthcare alignment This seems to be particularly the case in healthcare, our chosen field of study, where managers, healthcare professionals and IT executives follow different rationalities, have different domain knowledge and use different terminologies (Glaser, 2002; Heeks, 2006). In addition, healthcare executives often experience difficulties in achieving alignment by relating new technologies, such as telecare, shared medical records and e-cure, with their business strategies and structures. Accordingly, they fail to achieve alignment (Broens et al., 2007; Silvestro and Silvestro, 2003) and this may well account for the disappointing outcomes of many telecare projects to date. However, it is not only practitioners that lack an integrated knowledge base. Chan and Reich (2007, p. 310) argue that current alignment research itself largely lacks a theoretical basis. Therefore, they call for research that reopens the ‘what’ question of alignment, and for a greater use of well-established theories in alignment research. They anticipate that this could lead to both minor and major adjustments to alignment models. Thus, while disappointing telecare project outcomes have recently acted as drivers in the development of design requirements for telecare, the theoretical basis for these requirements is often insufficient or unbalanced. In response, Gortzis (2007) and Collinge and Liu (2009) have developed multi-component models that should provide support to those designing and reviewing telecare systems. These authors argue strongly for the need to match human, technological and structural components when adopting telecare. Further, telecare often requires the development and redesign of other design elements in the service system (Gortzis, 2007) since each structural and managerial element contributes to the strategic mission (Fitzsimmons and Fitzsimmons, 2008). Although the above-mentioned contributions provide useful guidelines when developing telecare for healthcare purposes, they lack a comprehensive view on how telecare technology can contribute to achieving strategic goals in healthcare settings. Consequently, it is also unclear how telecare affects, or requires the redesign of, other service elements in healthcare providers’ portfolios. 2.5. Strategic alignment – integrating theory within a field-specific model If managers are to develop strategic alignment profiles, they need to be able to anchor their choices to a validated framework. Henderson and Venkatraman (1992) provide such an option through their research-based strategic IS alignment model (SAM). Their model has been applied, validated and extended by Avison et al. (2004), Sabherwal et al. (2001) and others. The SAM is based on four interrelated key domains of strategic choice: business strategy; business structure; IS strategy; and IS structure (see Fig. 1). The model distinguishes the business domain (on the left), the technology domain (on the right), an external perspective (at the top) and an internal perspective (at the bottom). Alignment between business strategy and IS strategy is referred to as ‘strategic alignment’, between business strategy and business structure as ‘business alignment’, between business structure and IS structure as ‘structural alignment’ and between IS strategy and IS structure as ‘IS alignment’ (Sabherwal et al., 2001). Specifying the interrelationships between these domains requires a sound theoretical basis, and such theory may need to be field-specific. While traditional SAM applications draw exclusively on Porter’s value chain in operationalizing the business strategy domain, alternative configurations can be conceived for the positioning of telecare. Moreover, Rivard et al. (2006) recently added a resource-based view to the SAM, one that may appeal to healthcare managers who experience strong resource dependencies in their strategic positioning. It is on this basis that we want to contribute further to the literature. Applying a detailed strategic alignment framework is expected to increase telecare’s contribution to performance in a range of strategic configurations of healthcare settings. For each alignment profile, we will describe distinctly different design choices.

Business domain External perspective

Business strategy

Technology domain

Strategic integration

Business fit

Internal perspective

Business structure

IS Strategy

IS fit

Structural integration

IS Structure

Fig. 1. Strategic alignment model (Henderson and Venkatraman, 1992; Henderson and Thomas, 1992), adapted.

202

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

3. Three strategic alternatives and their corresponding alignment profiles This section describes how telecare can support the three value configurations presented earlier, and then outlines possible telecare alignment profiles. As such, this section contributes to the ‘what’ question in the alignment literature by outlining profiles that also incorporate the IS domains; something that is lacking in Stabell and Fjellstadt’s work. The profiles are summarized in Table 1. We focus our discussion not only on those dimensions that belong to the traditional SAM description (Henderson and Venkatraman, 1992), but also on dimensions adapted from the resource-based view of the SAM (Rivard et al., 2006). 3.1. Business strategy The business strategy domain is broken down into three dimensions: Scope, Distinctive Competencies and Governance (Henderson and Venkatraman, 1992). With regard to scope, the Value-adding Process Chain is restricted to those services that provide the organization with a distinctive market position. The scope of the Solution Shop is focused on generating solutions to complex issues. With a Self-Help Network, the value offered is an empowering service, and one that is usually superimposed on other services. The scope can vary from a single network focusing on, for example, pregnancy, to a network that relies on, and offer connections to, other networks to deliver its unique value. Stabell and Fjeldstad (1998) characterize the latter as ‘‘layered and interconnected networks’’. As shown in Table 1, we draw on Rivard et al. (2006) in adding two dimensions that characterize telecare’s enabling role in the business domain for each of these value configurations: IT support for strategy and IT support for structure (for the latter, see below under Business Structure). IT support for strategy reflects Table 1 Framework of three telecare alignment configurations. Domain

Business strategy

Dimension

Value-adding Process Chain e.g. General Practitioners, Classical Hospital

Self-Help Network Chronic care, e.g. weight watchers, alcoholics anonymous

Scope

Niche – (service) product differentiation

Narrow (on top of wide network)

Distinctive Competences Governance

(Service) product leadership

Niche – market differentiation focus Broad – referring shop Client and solution orientation Externally: Referred shops

IS strategy

IS structure

Externally: interlinked chains

Building and serving a community Layered and interconnected networks

Internally: tightly coupled Cost leadership by substitution

Internally: Loosely coupled Personalized and high quality problem-solving

IT support for structure Service delivery interdependencies Operational processes Skills (front office) Skills (back office) Customer role and added value

Smooth remote process execution

Support for social networks and communities of interest Pooled and reciprocal

Predefined (sequential)

Broad connectivity in medical realm Pooled, sequential, customized and reciprocal Tailored (cyclical, spiralling)

Communicative Professionally specialized Process orientation

Sensitive Professionally broad Client orientation

Creative, stimulating Medical moderation of community Infrastructural service orientation

IT Scope

Narrow – dedicated to particular treatment

Broader, but shallow

Broad collaborative technologies

Generic and standard advanced technologies Reliability/usability Support through linking to a network of referral partner shops

Knowledge technology

Generic collaborative facilities; EPF; medical applications Installation and support of broad communication platform Responsiveness and flexibility Technology facilitated

Social network systems; social media; CRM

IT support for strategy Business structure

Value configuration Value-adding Process Chain e.g. Herniorrhaphy, Angioplasty

Pooled and sequential, standardized

IT Competences IT Governance

Cost performance Support of interlinked chains

IT Applications infrastructure

Workflow management; monitoring equipment

IT Processes

Immediate installation and support of narrow communication and monitoring equipment Understanding and support of the business process Technology mediated

IT Skills IT in service encounter

Innovative complementary services eventually leading to substitution elsewhere

Ad hoc (simultaneous, parallel)

Connectivity capabilities Support of layered and interconnected networks

All processes required to run an IT platform for consumers Managing a large IT operation Technology generated

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

203

the competitive advantage gained through a technology-enabled business strategy expressed in terms of, for example, service differentiation, customization or production volume. 3.2. Business structure The term IT support for structure refers to those assets of a firm that have a direct effect on its profitability through telecare support. Furthermore, we adapt the SAM’s three business structure dimensions to better suit a service context. In this, we propose a dimension service delivery interdependencies that refers to the interdependencies between front-office activities and back-office activities (Larsson and Bowen, 1989). Consequently, the Skills dimension is then split between front-office skills (activities with client interfaces) and back-office skills (activities with no client interface). Finally, the customer role and added value dimension describes the generic orientation of the business structure: process, client or infrastructure. 3.3. IS strategy Central to the framework is the IS strategy domain, with its dimensions of IT Scope, IT Competences and IT Governance (Henderson and Venkatraman, 1992), since this describes the added value of telecare. Telecare in a Value-adding Process Chain would be expected to contribute to streamlining operations for patients and to excel in internal cost control. In a Solution Shop, telecare should offer clients intimacy and comfort, as well as information richness, such as by supporting a referral function to specialists. Such wide access to external expertise, as well as intensive contact between provider and client, requires generic, easy-to-use communication technology. In a Self-Help Network, the IT strategy should focus on connectivity but be well-balanced with privacy issues (to varying degrees of sophistication). 3.4. IS structure The main characteristics of the IS structure in a Value-adding Process Chain are the need for specialized workflow applications and facilities that support the remote execution of routine business activities. In contrast, a Solution Shop needs generic collaboration and multimedia facilities that support rich problem diagnosis and solution finding plus monitoring processes. Further, distributed access to full medical records and to a variety of medical applications and guidelines are necessary to support the healthcare providers’ non-routine investigations and interventions. For Self-Help Networks, social network systems are required for the clients, while CRM-type applications are needed for the supplier. We have added IT in the service encounter to the dimensions proposed by Henderson and Venkatraman (1992) because, in service organizations, IT often has a profound effect on the ways in which customers interact with service providers (Froehle and Roth, 2004). In the Value-adding Process Chain, the customer and the provider are often not physically co-located and the technology mediates the contact. In the Solution Shop, customer and provider technology facilitates contact, with both parties having access to the same technology; whereas, in a Self-Help Network, the provider is replaced by the technology which allows customers to serve themselves. 3.5. Four means for achieving alignment Having positioned the four SAM elements in each of the three strategic telecare alternatives, we are now in a position to describe the four aspects of alignment (see Fig. 1). Business alignment refers to the alignment between business strategy and business structure. Here, we refer to Stabell and Fjeldstad (1998) whose arguments and underlying studies underpin this particular alignment. Strategic alignment refers to what the IT organization, the IT competences and governance can contribute to the business strategy. In developing telecare services, the alignment of IS strategy and IS structure (i.e. IS alignment) should be focused on the service encounter (Froehle and Roth, 2004). Telecare’s role and function – as formulated in the IT strategy – should be supported by the appropriate IS infrastructure, processes and skills. Finally, structural alignment requires a match between business and IT processes and skills and the administrative infrastructure. This leads to the following requirements for process alignment:  Value-adding Process Chains require workflow applications to be seamlessly coupled with timely and smooth installation of standardized home equipment;  Solution Shop processes require a swift, but more importantly flexible, roll-out of communication equipment and tools adaptable to any handicaps that a client may have;  Self-Help Network processes require advanced IS structures that are highly reactive to any server problems. 4. Method 4.1. Two telecare projects We adopted an explanatory multiple case study design (Ragin, 1999) consisting of two contrasting projects to provide empirical evidence for the existence of different alignment profiles, and to demonstrate how the extended strategic

204

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

alignment framework can better explain project outcomes than the traditional SAM (Dubé and Paré, 2003). As such, we used replication logic to verify whether the expected contrasting results occurred across cases (Eisenhardt and Graebner, 2007; Yin, 2003). A qualitative design allows one to describe projects within their context. As our central premise was that an alignment among several dimensions within four domains was required, the boundaries between the phenomena and the context are relatively unclear. The major drawback of our research design is that only preliminary evidence can be provided, and that further development of the theory – looking at negative cases – will be necessary. The selection of particular projects here was based on a combination of: (1) relevance (both projects encouraged senior management to reconsider the role of IS and the wider strategy), (2) cross-case diversity (apparently contrasting strategic configurations) and (3) accessibility (to the major stakeholders in the project). Studying strategic alignment requires data to be gathered on all the elements involved in terms of the characteristics needing to be aligned. We derived such data from two implementation projects within an extensive telecare programme in the Netherlands referred to as ‘Koala’. The focus of the study was on identifying their respective strategic configurations, any correspondence with the alignment profiles and the resulting outcomes. The telecare system included, in one project, a video connection and a camera at each client’s home and, for some, measurement equipment and, for the other project, a 24/ 7 medical service centre that handled video calls and processed patient data. Table 2 shows the range of services offered and the respective client groups. 4.2. Sources and data gathering methods Data collection took place over 18 months (October 2006–March 2008). To promote reliability, the procedures followed during data collection were documented according to a protocol, and a project database was used to store raw materials, coded data, preliminary reports and other analytical material (Dubé and Paré, 2003). To ensure internal validity (Jick, 1979), several data sources were used, including interviews, workshops, written reports, operations data, policy plans, minutes from meetings and observations. The data for determining the actual degree of alignment were mainly derived from 28 semi-structured interviews with representatives of the major stakeholders. On the strategic level, homecare managers (2) insurance managers (2), a telecom manager (1) and a senior telecom technician (1) were interviewed at least once. On the operational level, we interviewed care coordinators (6), carers (4), telenurses (3) and medical service centre managers (3). Two rounds of telephone interviews were conducted with 30 Care clients, and 214 Cure clients completed a questionnaire (77% response rate). The semi-structured interviews consisted of open-ended questions about the telecare system, its context, its purposes and its design. In a later stage, interviewees were also invited to reflect on their experiences with the telecare system. Either interview reports were sent back to the interviewees for comments, or the interviews were taped and then transcribed. The operations data helped us to describe the designed systems in use, and covered the number of connections per week, the time-of-day, the nature and the length of the calls. Further, the medical service centre was regularly observed to capture the care services offered and the system in use. Twice during the data-gathering process, preliminary syntheses of the data were presented to, and discussed with, the strategic actors in workshops to ensure that the envisaged business and IS strategies were well understood by the research team. This resulted in us gaining additional insights into the views of strategic actors and led to refined, and more comprehensive, narratives of the two projects within the telecare programme. 4.3. Data reduction and analysis methods With each project, we examined the value configuration and the alignment profile through rigorous analysis of the materials collected in the data collection phase. The data analysis process followed is described below. 4.3.1. Data reduction All primary data sources were carefully read and checked against the complementary data sources, including the views of the strategic actors within both projects. The relevant data elements from each source were identified, coded and then compared by at least two of the authors. All the authors together carefully interpreted and assessed the coded data elements Table 2 Virtual services offered to client groups. Project

Services offered

Targeted clients

Telecare components

Number of connections

Koala Care

Ad hoc advice, support, referrals, daily monitoring (including medication)

Homecare clients

Video channel; telephone

335

Koala Cure

Registration, monitoring and control

Chronic heart failure (post-clinical or stable) Diabetes mellitus type II

Video channel; clinical data measurement and transfer equipment; Automatic alert; telephone Video channel; clinical data measurement and transfer equipment; automatic alert; telephone

146

Registration, monitoring and control

20

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

205

– by project, by domain and by value configuration – according to the framework (Table 1). Discrepancies were discussed until agreement was reached. This procedure enabled the inclusion of different perspectives on each case, and minimized the chances of missing something important. 4.3.2. Data analysis Based on this process, the extent of alignment was individually assessed by each author, leading to provisional alignment profiles. Then, these four assessments and provisional alignment profiles were compared. Differences in interpretations were discussed, which led to some revisions of initial judgements, until a consensus was reached. Within each case, once the extent of the alignment had been determined, this was then considered in the light of the three alignment profiles (see Table 1). Following this, the underlying reasons for the resulting project outcomes were discussed. Finally, the degree of alignment was related to each project’s performance. 4.3.3. Cross-case analysis We compared the value configurations of the two cases, and the alignment profiles. While the two telecare projects were to an extent similar in terms of context and technology, they differed in terms of crucial dimensions of the proposed framework. Moreover, we reflected on the differences in the extent to which their characteristics had been mapped within a single profile. Was this difference in alignment between the two cases reflected in the discussions we had witnessed among the strategic actors? Did the revealed patterns cover the concerns raised during the project evaluation? That is, alongside analysing whether the degree of alignment was in line with the project outcomes (predictive validity), we also estimated the face validity. 5. Results This section presents the analysis of the two telecare projects adopting the perspective of the framework outlined in Table 1. In this section, the two cases are outlined separately, and the cross-case analysis of the four ‘alignment fits’ follows in Section 6. Relating these findings to the performance achieved in the two projects, highlights strategic and design factors that are relevant when implementing telecare. 5.1. Telecare in a homecare setting: Koala Care The homecare organization that we assessed was pursuing multiple objectives when applying telecare within their service delivery system: the main objectives were an increase in customer service levels and a reduction in costs. From project documents and interviews with various stakeholders, we could discern that clients were supposed to use the telecare homevideo system to contact telenurses located at a medical service centre. These contacts would, wherever possible, replace home visits by district nurses. Furthermore, clients would be better served because direct access to registered nurses was guaranteed around the clock. At a later stage, the telecare system was expected to also be able to support contacts and connections between other client system members, more specifically between clients and their families, friends and volunteers. Table 3 summarizes our evaluation of the alignment of telecare in this homecare setting. An in-depth analysis showed that the business strategy of the homecare organization, with respect to the use of telecare, was unclear, although the relevance of choosing a particular business strategy and of elaborating this strategy in a consistent way was recognized. An insurance company manager stated: ‘‘these variables are all related – at least on paper. The issue is how many different strategies one can outline: I think at most two or three. All options can be reduced to two or three main strategies. You should choose a dominant strategic position and then elaborate all the variables in a consistent way’’. During the entire project, the Koala Care organization was exploring how they could best use telecare. The telecare-enabled goals were not clearly determined. On the one hand – and this was regarded as its main purpose – Koala Care was designed to provide comprehensive, personalized and customized care, which reflects a Solution Shop business strategy. On the other hand, Koala Care was aimed at finding ways in which telecare could cut the number of physical service encounters in order to reduce costs. This suggested the development of standardized ways to deliver remote homecare, which more closely reflects features of the Value-adding Process Chain configuration. Further, elements of a value network configuration can be recognized, with the organization anticipating connecting clients to their social environment (relatives and friends) in order to increase client empowerment and to support self-help. This view was supported by an insurance manager with a medical background, who stated: ‘‘Okay, which role do we play here: a supportive role or a managerial role? This also depends on the nature of the delivery process. Is this process aiming at providing information? Is it consultation? Is it a medical cure such as therapy? Are we in the role of a broker?’’ In such ways, traces of various value configurations could be found in the Koala Care data (Table 3). In reality, the delivery of customized remote solutions turned out to be difficult. Interviewees pointed to the variety and ambiguity in the demands, as well as the ‘hands-on’ character of much homecare work, with activities such as cleaning wounds and applying dressings: ‘‘homecare is very diffuse and much work has a hands-on character. This makes it hard to use telecare within our setting’’ (project manager homecare). Furthermore, the misalignment between the business domains was visible in Koala Care’s multichannel design. That is, telecare was offered alongside face-to-face and phone contacts with district nurses but without the design being based on a

206

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

Table 3 Koala Care mapped on the framework of telecare alignment configurations.

Legend: dark grey = fully applies; light grey = partially applies; white = not applicable.

clear multichannel policy. This caused confusion and led to coordination problems. An external consultant said: ‘‘The current organisation of the care system is a problem. There are several call centres: the national emergency line, the GP emergency line, the hospital call centres and, on top of all that, we introduced the Koala MSC. A related problem is that the roles of various actors are not well defined. These issues have caused much delay to the project’’. Consequently, the scope of Koala Care in terms of services offered was unclear. Further, no clear care chain could be defined. Log data and evaluations of calls by telenurses and by clients show that the circumstances in which clients should contact the medical service centre were largely undefined. Most calls were unforeseen and unplanned, although the percentage of planned calls increased during the project. This increase could, however, be attributed to just a few clients. The search for what exactly to deliver to clients reflects two choices within the business strategy domain: (1) which role should clients take, and what should clients experience as added value? (or, stated differently, what is the exact nature of the telecare offering?); and (2) what IT support for strategy should be applied in terms of the degree of product customization, production volume and degree of service differentiation? These two dimensions reflect relevant strategic decisions when implementing telecare. For this reason, we extended the business strategy domain accordingly (see Table 3). The multiple scopes of the business strategy were also reflected in the business structure. Characteristics of the value shop business structure could be traced, as well as features of the other two value configurations. For the skills dimension, we found that broadly educated and highly competent nurses were employed at the medical service centre. A manager from the homecare organization explained: ‘‘A telenurse should have special skills and competencies to make Koala successful’’. These telenurses were selected based on their experiences in nursing care, their ability to analyse questions from clients, their sensitivity in responding to vague problems and their ability to deal with a large variety in demand. They would try to find solutions in close consultation with their clients (a reciprocal service design) or refer to a wide range of specialized healthcare providers (a sequential customized service, with a professional and broad back office). Moreover, as the homecare project manager explained, employees with different skills were deliberately selected and trained. For example, the telenurses had held various former jobs such as a district nurse, psychiatric nurse or medical nurse. This dimension corresponds with a Solution Shop configuration.

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

207

In other respects, the operation reflected the business structure of a Value-adding Process Chain. Although employees commented on the lack of standard procedures and protocols at the start, over time the medical service centre did increasingly develop administrative procedures and clinical protocols for specific client demands (a sequential standardized service design). Especially during work meetings, telenurses discussed protocols and procedures that could standardize the less unique and analysable parts of the service processes. Further, traces were seen of a Self-Help Network to the extent that effort was put into creating a social contact network around the clients. Finally in this area, the lack of clarity in the business structure also became evident in coping with the existence of two forms of client contact alongside each other, i.e. virtual and physical. In particular, district nurses and clients expressed confusion as to which ‘channel’ they should use in which situation. As the innovation manager of an insurance company observed: ‘‘a problem is that clients can use several ways to contact us, the medical service centre and the district nurse. This increases the complexity for clients who tend to appreciate simplicity as they age’’. The lack of clarity also showed in coordination problems between the telenurses at the medical service centre and the district nurses and other service providers. The IS Strategy at Koala Care indicates elements of a Solution Shop. Homecare clients mainly used the telecare home-video system for checking their adherence to medication schedules, advice, consultation and referral. As such, the IT scope was both broad and limited. It was broad in the sense that the home-video system was viewed by the implementers as a sophisticated virtual channel that facilitated the provision of a large range of advice and consultation services within the homecare setting. It was limited in the sense that clients and telenurses observed a gap between the specific and distinct character of client demands and the telecare system’s capabilities. For instance, there was no generic integration of the video system with other communication facilities for clients of Koala Care. The telenurses had access to only a short summary of their clients’ medical histories, and there was no automatic file updating as a result of an interaction; for example, no automatic messages were generated for other healthcare service providers, and no recordings made in clients’ medical files. This lack of IT support for the chosen structure is evident in the following comment by a homecare manager: ‘‘a huge barrier is that telenurses cannot look in a client’s nursing file. These are not available electronically’’. Further, the system was not always able to support the delivery of specific homecare services, such as caring for wounds, or to effectively support requests for clarification. Overall, the scope of the IT system was therefore rather limited and lacked many functionalities. The main IT competences of the telecare system were its reliability and accessibility: the medical service centre was always open, and nearly all clients agreed that the system was very easy-to-use. A major task of the medical service centre was to refer clients to other providers, and other channels, such as telephone and fax, were needed to realize this. There were no generic collaborative facilities available, nor could providers make use of a comprehensive shared client nursing file. The IT organization was not prepared for the task of providing such additional IT functions or for integrating the home-video with other communication channels or IT systems. IT Governance was restricted to the video channel, and mainly outsourced. Further, the IS strategy did include the connecting of different members of the client system (the Self-Help Network configuration), but this application faced technical problems. The IS Structure showed one particular feature of the Solution Shop: the service encounter had been transformed from a faceto-face contact, with a delay between expressed need and contact, into an immediate technology-facilitated encounter. However, it is noteworthy that other IT structural choices were not explicitly present in the design. The IT application infrastructure was not equipped to support collaboration, nor monitoring, nor interconnectivity, and no specific IT processes and skills were rolled out. 5.2. Conclusions on Koala Care The Koala Care case clearly demonstrates that the value configurations introduced in Section 2 are needed to provide an adequate SAM analysis of telecare. The main conclusion from the above analysis is that the Koala Care project lacked a well defined scope. Although the situation most closely corresponded to a Solution Shop, the Koala Care project also had features of the Value-adding Process Chain and of the Self-Help Network. This lack of a strategic choice for a particular configuration led to a lack of alignment in other areas. Furthermore, as shown in Table 3, Koala Care provides evidence that the inclusion of the following dimensions enhances the original SAM model:     

IT support for strategy (degree of product customization, the product volume, degree of service differentiation); IT support for structure; a differentiation between front-office and back-office skills; the customer role (in relation to the service offering) and created added value; the role of telecare in the service encounter.

5.3. Telecare in a medical setting: Koala Cure The second case concerns telecare use in cure-oriented processes (see Table 4). Here, telecare’s ability to monitor clients’ chronic conditions in their own homes was seen as the distinctive advantage. Here, medical specialists selected those patients with chronic heart failure or suffering from diabetes mellitus as appropriate participants for this project.

208

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

Table 4 Koala Cure mapped on the framework of telecare alignment configurations.

Legend: dark grey = fully applies; light grey = partially applies; white = not applicable.

As such, the telecare-enabled goal was clear. The telecare system would provide clients with facilities to collect their own clinical data and transfer this information to telenurses who would then evaluate the data. The monitoring by the telenurses was not real-time, but it was linked to automated control of the client’s condition and included protocol-based event handling if the monitored values deviated from the norms. Moreover, the telenurses scheduled video calls with clients to review their healing processes. From their side, clients could contact the medical service centre with questions related to their specific illness. Nevertheless, in the event of an emergency, clients were still expected to call the national emergency number. The business strategy of Koala Cure, in keeping with a Value-adding Process Chain, was to cut costs by reducing the number of hospital visits and the length of stay of a clearly targeted client group. In addition, telecare provided clients with an increased sense of wellbeing by reducing the number and length of their hospital visits. As such, Koala Cure was focused on cutting costs by remote client monitoring and process control, and the operating strategy was clearly focused on a high production volume and a low degree of customization. Within this Value-added Process Chain, the telenurses acted as gatekeeper and remained in control of interactions with clients. With regard to business structure, strict evidence-based medical guidelines and protocols guided the operational behaviour of the telenurses, and the processes were precisely defined, reflecting the characteristics of a Value-added Process Chain. Clients delivered data that were sequentially processed by the medical service centre (a sequential standardized service design). The telenurses, and the specialized nurses in the hospitals, can be seen as employees executing front-office tasks, while the specialists and laboratories act as back-office service providers. Telenurses stated in interviews and in their questionnaire responses that their work in the Cure project was clearly defined and described, which generated commitment and confidence. In terms of its IS strategy, the scope of the Koala Cure project was rather narrow, as it focused on monitoring a specific client group. Likewise, the video interactions supported only a few distinct, standardized sequential steps in this specified healthcare process to which specific patient monitoring services were added.

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

209

As such, the competences of the IT organization in integrating video and monitoring were properly present. Accordingly, clients used standard measuring equipment that was integrated with the video technology platform. However, the required IT support skills were outsourced. Monitoring and video facilities were drawn from an external business partner who was specialized in supporting these particular monitoring processes, while providing a broadband connection and installation were assigned to another party. In other words, the governance was dispersed over several parties. Collectively, these parties often failed to deliver monitoring equipment in a timely way. Clients who agreed to be monitored at home needed the equipment within 24 h if this was to enable significantly shorter stays in (expensive) hospital beds. This requirement was not met by the IT delivery organization in one-fifth of cases. This led to much frustration with the suppliers of medical services, as seen from the following comment by a manager from the medical service centre: ‘‘Getting ADSL in place also takes far too long – 4 to 6 weeks! This has to be accelerated, to also allow the realisation of short-term connections’’. The IS Structure showed typical features of the value chain: the integrated platform for monitoring and video was appropriate for the application. Although proprietary technology was used, the IT functioned in line with the requirements of the medical specialists. The IT infrastructure and skills were therefore aligned with the IS strategy. However, it is noteworthy that the broadband delivery and the installation processes were not aligned. This relates to the weak governance structure highlighted above. The technology mediated the service encounters between telenurses and clients who were not co-located, and both made use of the same technology but without a real-time connection. Video calls from regular clients concerning their periodical check-ups were transferred to specialized nurses within the hospital. This created some dissatisfaction with the role of the medical service centre in this activity. As an innovation manager from an insurance company commented: ‘‘in a manner of speaking there is no added value. It is an extra link in the chain that could, I suppose, be removed. The role of the telenurse in the check-up calls - that is a difficult issue’’. Having an IT-supported workflow (in line with the value chain alignment profile, Section 3) could have resolved this issue, but this was not in place. In terms of Fig. 1, this suggests a lack of structural alignment. 5.4. Conclusions on Koala Cure Koala Cure was a balanced and aligned telecare project with elements of a Value-adding Process Chain found in all four domains. There was a clear vision and a plan to align the business strategy of a value-added process chain with the required IT investments. Although there was some politicking surrounding the specific software choice, the functional requirements seemed clear. The strategy and structure business domains were closely aligned, and both strategic and structural alignment were realized. However, one important failing could be distinguished: the unreliable delivery of monitoring equipment, and this reflects a misalignment between IS strategy and structure. Further, there is, as yet, no workflow support. Overall, the Koala Cure project demonstrates the relevance of considering the following additions to the adapted SAM model:  IT support for structure;  differentiation between front-office and back-office skills;  the role of telecare in the service encounter. 6. Cross-case analysis: alignments and performance outcomes in Koala Care and Koala Cure 6.1. Degree of business alignment The description of the Koala Care project shows a lack of focus in setting business objectives. Both the business strategy, in terms of scope and competences, and the business structure, in terms of processes and skills, reflected a mix of objectives that the homecare organization was pursuing. This led to misalignments, such as the mismatch between the skills of the telenurses and the skills required to meet service demand. Koala Cure was evaluated as a considerably better balanced and aligned telecare project. The business strategy and structure domains showed close alignment with each other, and in line with the principles of a value chain. The business scope (to provide medical treatment and monitor its effects remotely) was well aligned with the organization of the operational processes, and the required competences were translated into skills. Business governance resided with medical specialists who could set up the administrative infrastructure for the whole value chain, including the remote and the physical activities, in line with their own vision. The different alignment profiles found in Koala Care and Koala Cure were reflected in the relatively low (Care) and high (Cure) performance scores (see Table 5). 6.2. Degree of strategic alignment In Koala Care, the IS strategy supported the main objective within the business strategy of the homecare organization: by primarily providing a reliable system it supported the provision of a broad service package. Nevertheless, the IT system was incapable of providing the generic collaborative facilities needed to support the referral service. Moreover, users reported a misfit between the specific characteristics of the demands of homecare clients (albeit ambiguous and vague demands) and the shallow character of the IT system. The Koala Cure business scope was well aligned with the IT scope: the medical specialists were very clear on the services required from IT, and these were properly documented. Accordingly, the competences required were precisely expressed. The only issue where some misalignment could be observed was in IT governance where

210

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

Table 5 Alignments based on cross-case analysis and their relationships to performance. Alignments

Cross-case analysis

Performance

Strategic and design issues

Business alignment

Care: the dominant strategic asset of ‘‘client comfort and intimacy’’ was not entirely and consistently elaborated in the business structure: (a) back office expert support skills were barely arranged, and (b) use was made of standardized work processes, which does not fit with the unique character and complexity of the type of work expected Cure: a close fit between business strategy and elements of the business structure: (a) a staff expert (a hospital physician) strictly organized (b) narrowly described procedures and protocols that fit the character of the work Care: attempt to integrate the telecare service within and alongside existing services. Care clients were unsure when to use which channel Cure: applied telecare in well-demarcated subprocesses for well-defined client segments

Care: highly skilled telenurses felt the nature of this work was ‘too soft’ for them; employees reported low autonomy and medium job complexity. Calls regarding Care did not call upon their competences, whereas Cure calls did. They experienced Care-related calls as disturbances to their real work Care: most clients call during office hours, calls have a short duration and routine character, which shows an imbalance with the round-the-clock, highly skilled, staffing Cure: patients reported high trust in the delivered service (almost 80%)

Care: shows the relevance of developing a realistic operating strategy (level of product customization, product volume and product complexity), which should be elaborated in a consistent way in the business structure

Strategic alignment

Care: no integration of telecare facility with other communication facilities such as the electronic patient file. This negatively affected the ‘‘client comfort and intimacy’’ configuration. The managers interviewed mentioned the technology push; strategic alignment was not disputed Cure: There was a clear vision and plan to align the business strategy of a value-added process chain with the IT investments required. However, governance was dispersed and timely delivery could not always be realized Discussions on use started with asking how IT options could support the business strategy, and subsequently moved on to how to integrate telecare use in the business structure

Care: high costs of coordinating with district nurses and other service providers. Only a few individual clients used the system sufficiently intensively and effectively that cost savings exceeded investment and operational costs Cure: all clients became telecare users where the service was offered, nearly 70% of the users remarked that they used the service intensively, and overall satisfaction was high However, timely delivery of medical equipment was not always achieved, which increased hospital costs (due to longer stays)

IS alignment

Care: many video calls could have been handled using cheaper phone calls (79%) Cure: the use of monitoring equipment particularly replaced the need for hospital visits; again the phone could have replaced many of the video calls (91%) Care: dispersed IS strategy made it hard to make choices in the IS structure

Both: relevance of clearly identifying both back-office and front-office skills

Care: no clear multichannel policy developed (the use of multiple channels based on strategic choices and client segments)

Care: less than half of calls replaced a home visit (only 37%), and clients often unsubscribed from the service during the pilot period (low perceived usefulness, low frequency of use). Only a few clients used the system sufficiently intensively for savings to exceed costs Cure: remote access reduced length of hospital stays and resulted in fewer unplanned readmissions. Many clients favoured telecare over traditional hospital consultations

Care and Cure: operational costs were too Clear identification of the use of telecare high in service encounters Care: clients often experienced the system as complex, whereas the targeted client segments were aging and appreciative of simplicity Cure: most clients appreciated the easy use of the system (video connection 89%, monitoring equipment 78%) which stimulated use, and the majority of clients experienced the system as providing security and increasing their life skills Cure: the clear and consistent IS strategy drives Care and Cure: limited scalability, no choices in the IS structure significant economies of scale Care: high material and operational costs per client hindered expansion Cure: use of dedicated equipment hindered expansion

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

211

Table 5 (continued) Alignments

Cross-case analysis

Performance

Structural alignment

Care: installers of the service did not always have enough skills to communicate adequately with elderly clients Care: logs show a low volume of calls and a large variety in call subjects during the day

Relevance of finding a balance between Care: increased costs because both nurses and mechanics were involved in IT skills and the role of telecare in the service encounter installing the service Care: telenurses experienced Carerelated calls as disturbances to their Cure-monitoring work Care: employees reported low autonomy and unbalanced tasks, responsibilities and authorities, and poorly supported telecare encounters Cure: a clear balance between tasks, authorities and responsibilities, all well supported by available IT systems

Cure: processed a steady workload and could plan work

Care: telenurses had the authority to assess a client’s care needs but no access to electronic patient records or any other communication facilities Cure: telenurses experienced a well-defined balance between authorities and responsibilities regarding monitoring tasks that were supported by the IT system

Strategic and design issues

the medical specialists had agreed to outsource IT delivery. The different alignment profiles resulted in different performance scores for Koala Care and Koala Cure (see Table 5, third row). 6.3. Degree of IS alignment In both Koala Care and Koala Cure, most of the content of the video calls could have been adequately conveyed in less expensive telephone calls (see Table 5, fourth row). This reflects a misalignment between IS strategy and IS structure, and shows the importance of giving adequate consideration to technology choice in a service encounter. Further, the IT system could not provide the communication services required when the homecare organization wanted to support contacts and links between clients and other relevant stakeholders within their own client system. Applications that would have supported the value shop configuration, such as groupware and collaboration tools, document sharing facilities, search tools for navigating in medical databases and a shared use of client medical files, were simply not available. Accordingly, an alignment between the IS strategy and the IS structure only existed in the short-term. In Koala Cure, one important failing could be distinguished: the unreliable delivery of monitoring equipment. This reflects a misalignment between IS strategy and IS structure on this important point. In both cases, scalability was limited, i.e. the ability to improve margins (revenue minus variable costs) as sales volume increases. In Koala Care, the reason was the high material and operational costs per client and, in Koala Cure, the use of dedicated equipment. 6.4. Degree of structural alignment In Koala Care, the skills of the IT organization showed some misalignment as the mechanics who installed the service failed to communicate well with Koala Care clients. Further, the round-the-clock staffing did not fit with the pattern of incoming calls, and telenurses also felt that they were sometimes responsible for tasks which were not well supported by the IT system (the lack of referral facilities). Furthermore, telenurses experienced problems in combining Koala Cure monitoring tasks, which generated a planned and steady workload, with unplanned Koala Care calls. In Koala Cure, the telecare delivery organization and the IT delivery organization were aligned well. This was partially due to good personal relationships between the managements of the IT organization and of the homecare organization. Telenurses felt supported by the IT system when executing their tasks. 7. Conclusion Our research has integrated Stabell and Fjeldstad’s value configurations, as applied to healthcare by Christensen et al. (2008), into the strategic alignment model. This has led to two extensions to the SAM that are not based on Porter’s Value Chain framework (1985) but, rather, on the Value Shop and on the Value Network respectively. These extensions for healthcare services have also led to sector-specific adaptations of the model’s dimensions, such as our drawing on the work by Rivard et al. (2006) to add a resource-based view to the SAM. For each of their value-creating configurations, namely the Value-adding Process Chain, the Solution Shop and the SelfHelp Network, a telecare alignment profile has been tentatively developed, and then discussed in Section 6. These profiles are described in terms of the strategic alignment model domains, namely business strategy, business structure, IS strategy and IS structure (Table 1). In so doing, concepts from the respective literatures that are relevant for strategic IT management were connected within the SAM. This framework for aligning telecare technology with healthcare providers’ strategies may

212

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

contribute to avoiding the lack of alignment that has been observed in the field by systematically identifying strategic design choices and alignment issues. As a preliminary test of this tentative framework, the design characteristics of two telecare projects were mapped onto the alignment profiles (Tables 3 and 4). This analysis pointed towards the relevance of the proposed adaptations in terms of the following strategic design dimensions: IT support for structure, the determination of client roles and client added value, the identification of required front- and back-office employee skills, the role of the technology (i.e. telecare) in the service encounter, and the development of a consistent multichannel policy. In both projects, the importance of a balanced alignment between the employees’ focus and skills and telecare’s role within the service encounter was acknowledged. The central finding in the subsequent cross-case analysis (Table 5) was that the least aligned telecare project was also the least successful in terms of client adoption. This indicates that the enhanced strategic alignment model is applicable to telecare. The first case studied, Koala Care, suffered from a low degree of alignment between all four domains. Since no strategic alignment activities were undertaken, intermediate changes in one domain yielded, at best, ad hoc changes in other domains, and led to an unstable and indistinct telecare service. In contrast, Koala Cure benefited from the active involvement of physicians who had a vision of what should be achieved. Nevertheless, political and supply issues hampered a smooth implementation and sustainable adoption. Our framework-based evaluation explains the ways in which the Care project was less aligned than the Cure project. Moreover, these theoretically underpinned conclusions are in line with the lack of alignment experienced by interviewees in the Care project. An alternative explanation for this significant finding could be that only a ‘value-chain-based’ business model (as in Koala Cure) can succeed, and that the other two value configurations are not viable in healthcare. This explanation seems less convincing considering the strong arguments put forward by Hwang and Christensen (2008) in favour of innovative e-health business models. Nevertheless, longitudinal studies to evaluate the long-term viability of each of the telecare alignment profiles are recommended. Both the timespan (see Sabherwal et al., 2001) and the number of cases in our study were limited. The strategic alignment model and its anticipated benefits have been well researched (Chan and Reich, 2007) and the model has been applied in many industries. The argument presented here is not that one should replace the traditional SAM dimensions; rather, we are suggesting additions and adaptations that broaden the SAM’s applicability to business models other than ‘value-chain-based’ ones. In this instance, we have elaborated on telecare applications within the healthcare sector. The strategic challenges facing healthcare providers, in combination with the opportunities new technologies offer, question the sector’s existing value configurations. The proposed framework helps to phrase relevant questions, and draws attention to specific design issues that have come to the surface in strategic IS (e.g. Rivard et al., 2006) and service management (e.g. Christensen et al., 2008). It is our view that expounding on and framing these questions and issues is especially relevant for healthcare services. Healthcare’s ongoing reconfiguration and globalisation requires researchers to develop integrative frameworks that facilitate dialogue among professionals with diverse backgrounds. Despite the contribution noted above, the proposed framework has the limitation that it focuses on strategic choices and design consistencies, the so-called ‘what’ of alignment. As such, it ignores the complexities of the implementation process. Implementation does, as the Koala Cure project showed, involve social, political and cultural changes, and also learning processes. Our position is that these processes, unlike consistent design options, cannot be captured in profiles. Studies adopting a process perspective on alignment (such as Rondinelli et al., 2001) complement the design perspective adopted here. 7.1. Implications for practitioners A coherent strategic IS alignment framework, offering generic and widely accepted theoretical concepts, may help to bridge professional and institutional differences. It would do so by offering a common terminology that outlines design options and highlights alignment issues. Despite these benefits, one must accept that stakeholders may see the desirability of each profile differently. They may still feel tempted to emphasize different domains, or to stress different performance areas, such as accountability over innovation. Further, the ongoing changes during the duration of the telecare projects emphasize the suggestion by Henderson and Venkatraman (1992) that there is a need for continuous re-evaluation and readjustment of the strategic alignment. Finally, a single healthcare providing organization may need to develop a range of telecare applications for ‘client demand’ categories that require different value configurations if they are to be competitive. A hospital’s business model can be seen as a ‘Solution Shop with a broad scope’ but, at the same time, it will also refer clients to medical service delivery units that amount to a ‘value-chain configuration’. 7.2. Future research From a theoretical perspective, we aimed to deliver a framework that would support the alignment of telecare technologies with the strategies of healthcare providers. Although the profile descriptions are not necessarily exhaustive, their application to Dutch telecare services has proved useful. The framework’s ability to align other e-health technologies requires further study. Such studies should measure both the degree of alignment and the effects of alignment on performance indicators for healthcare services. Furthermore, action-oriented research could determine whether this adapted SAM framework can also support innovative developments involving the reconfiguration of healthcare services, such as through multilayered networks in which healthcare, insurance and telecom providers cooperate.

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

213

The starting point for this analysis was the business strategy domain. Based on Stabell and Fjeldstad (1998), this led to the development of three strategic alternatives for telecare. An alternative route is to start with the IT domain, and ask what forms of support IT can offer. This results in a number of strategic alternatives as one can, for example, conceive of telecare applications that fit differently-positioned value configurations. For example, we could think of a specialist rather than a more generalist Solution Shop (see Stabell and Fjeldtad, 1998, p. 427). One could also argue that even hybrid value configurations, such as the comparison websites described by Laffey and Gandy (2009), may survive as long as crucial alignment issues can be managed, and performance trade-offs accepted. Acknowledgements This paper has benefited substantially from conversations with and comments from John van Meurs and Jacob Wijngaard. We are also indebted to the clients, carers, care coordinators, managers and others who participated in the Koala projects. We thank KPN, TZG and Menzis for cooperating with us in this project. References Adriano-Moran, J., Leicester, H., Roudsari, A., 2005. A web-based decision support system for modelling telecare. MEDNET – New Tasks in Internet Use in Health Care, 355–356. Avison, D., Jones, J., Powell, P., Wilson, D., 2004. Using and validating the strategic alignment model. Journal of Strategic Information Systems 13 (3), 223– 246. Bart, C.K., Tabone, J.C., 1998. Mission statement rationales and organizational alignment in the not-for-profit health care sector. Health Care Management Review 23 (4), 54–69. Berg, M., 1999. Patient care information systems and health care work: a sociotechnical approach. International Journal of Medical Informatics 55 (2), 87– 101. Britton, B.P., Engelke, M.K., Rains, D.B., Mahmud, K., 2000. Measuring costs and quality of homecare. Home Health Care Management & Practice 12 (4), 27– 32. Broens, T.H.F., Huis in’t Veld, R.M.H.A., Vollenbroek-Hutten, M.M.R., Hermens, H.J.J., van Halteren, A.T., Nieuwenhuis, L.J.M., 2007. Determinants of successful telemedicine implementations: literature study. Journal of Telemedicine and Telecare 13 (6), 303–309. Brynjolfsson, E., Hitt, L.M., 2000. Beyond computation: information technology, organizational transformation and business performance. Journal of Economic Perspectives 19 (4), 23–28. Chan, Y.E., Huff, S.L., 1993. Investigating information systems strategic alignment. In: Proceedings of the Fourteenth International Conference on Information Systems, Orlando, pp. 345–363. Chan, Y.E., Reich, H.H., 2007. IT alignment: what have we learned? Journal of Information Technology 22 (4), 297–315. Christensen, C.M., Grossman, J.H., Hwang, J., 2008. The Innovator’s Prescription: A Disruptive Solution for Health Care. McGraw-Hill, New York. Collinge, W.H., Liu, K., 2009. Information architecture of a telecare system. Journal of Telemedicine and Telecare 15 (4), 161–164. Croteau, A.M., Bergeron, F., 2001. An information technology trilogy: business strategy, technological deployment and organizational performance. Journal of Strategic Information Systems 10 (2), 77–99. Croteau, A.M., Raymond, L., 2004. Performance outcomes of strategic and IT competencies alignment. Journal of Information Technology 19 (3), 178–190. Department of Health, U.K., 2005. Building Telecare in England. DH Publications, London. Dubé, L., Paré, G., 2003. Rigor in information systems positivist case research: current practices, trends and recommendations. MIS Quarterly 27 (4), 597– 635. Eisenhardt, K.M., Graebner, M.E., 2007. Theory building from cases: opportunities and challenges. Academy of Management Journal 50 (1), 25–32. Fitzsimmons, J.A., Fitzsimmons, M.J., 2008. Service Management. Operations, Strategy, Information Technology. McGraw-Hill, New York. Froehle, C.A., Roth, A.V., 2004. New measurement scales for evaluating perceptions of the technology-mediated customer service experience. Journal of Operations Management 22 (1), 1–21. Gortiz, L.G., 2007. Designing and redesigning medical telecare services: a forces-oriented model. Methods of Information in Medicine 46 (1), 27–35. Glaser, J.P., 2002. The Strategic Application of Information Technology in Healthcare Organizations. Jossey Bass, San Francisco. Grant, G.G., 2003. Strategic alignment and enterprise systems implementation: the case of Metalco. Journal of Information Technology 18 (3), 159–170. Hebert, M.A., Korabek, B., 2004. Moving research intro practice: a decision framework for integrating home telehealth into chronic illness care. International Journal of Medical Informatics 75 (12), 786–794. Heeks, R., 2006. Health information systems: failure, success and improvisation. International Journal of Medical Informatics 75 (2), 125–137. Henderson, J.C., Venkatraman, N., 1992. Strategic Alignment: A Model for Organizational Transformation Through Information Technology. In: Kochan, T.A., Useem, M. (Eds.), Transforming Organisations. Oxford University press, Oxford, pp. 97–116. Henderson, J.C., Thomas, J.B., 1992. Aligning business and information technology domains: strategic planning in hospitals. Hospital & Health Services Administration 37 (1), 71–87. Hwang, J., Christensen, C.M., 2008. Disruptive innovation in health care delivery: a framework for business-model innovation. Health Affairs 27 (5), 1329– 1335. Jick, T., 1979. Mixing qualitative and quantitative methods: triangulation in action. Administrative Science Quarterly 24 (4), 602–611. Johnston, R., Clark, G., 2001. Service Operations Management. Pearson Education, Harlow. Laffey, D., Gandy, A., 2009. Applying Stabell and Fjeldstad’s value configurations to E-commerce: a cross-case analysis of UK comparison websites. Journal of Strategic Information Systems 18 (4), 192–204. Larsson, R., Bowen, D.E., 1989. Organization and customer: managing design and coordination of services. Academy of Management Review 14 (2), 213–233. Levy, M., Powell, P., Yetton, P., 2001. SMEs: aligning IS and the strategic context. Journal of Information Technology 16 (3), 133–144. McKeen, J., McKeen, J.D., Smith, H.A., 2003. Making IT happen. Critical Issues in Information Technology. John Wiley, New York. Nicolini, D., 2007. Stretching out and expanding work practices in time and space: the case of telemedicine. Human Relations 60 (6), 889–920. Porter, M.E., 1985. Competitive Advantage. Free Press, New York. Porter, M.E., Millar, V.E., 1985. How information gives you competitive advantage. Harvard Business Review 63 (4), 149–161. Porter, M.E., Teisberg, E.O., 2006. Redefining Health Care: Creating Value based Competition on Results. Harvard Business School Press, Boston. Ragin, C.C., 1999. The distinctiveness of case oriented research. Health Services Research 34 (5), 1137–1151. Rivard, S., Raymond, L., Verreault, D., 2006. Resource-based view and competitive strategy: an integrated model of the contribution of information technology to firm performance. Journal of Strategic Information Systems 15 (1), 29–50. Rojas, S.V., Gagnon, M.P., 2008. A systematic review of the key indicators for assessing telehomecare cost-effectiveness. Telemedicine and e-Health 14 (9), 896–904. Rondinelli, D., Rosen, B., Drori, I., 2001. The struggle for strategic alignment in multinational companies: managing readjustment during global expansion. European Management Journal 19 (4), 404–416.

214

A. Boonstra et al. / Journal of Strategic Information Systems 20 (2011) 198–214

Sabherwal, R., Hirschheim, R., Goles, T., 2001. The dynamics of alignment: insights from the punctuated equilibrium model. Organization Science 12 (2), 179–197. Silvestro, R., Silvestro, C., 2003. New service design in the NHS: an evaluation of the strategic alignment of NHS direct. International Journal of Operations & Production Management 23 (4), 401–417. Stabell, C.B., Fjelstadt, Ø.D., 1998. Configuring Value for Competitive Advantage: on Chains, Shops and Networks. Strategic Management Journal 19 (5), 413– 437. Tallon, P.P., Kreamer, K.L., Gurbaxani, V., 2000. Executives’ perceptions of the business. Value of information technology: a process-oriented approach. Journal of Management Information Systems 16 (4), 145–173. Terrill, C.A., 1992. The ten commandments of new service development. Management Review 81 (2), 24–28. Venkatraman, N., 1991. IT-induced business reconfiguration. In: Scott-Morton, M.S. (Ed.), The Corporation of the 1990s: Information Technology and Organizational Transformation. Oxford University Press, Oxford, pp. 122–158. Wortmann, J.C., Boonstra, A., Broekhuis, M., Meurs, J. van, Offenbeek, M.A.G. van, Westerman, J., Wijngaard, J., 2009. Is telecare feasible? Lessons from an indepth case study, 246–251. In: Proceedings of the 18th IEEE Conference on Enabling Technologies: Infrastructures for Collaborative Enterprises, Groningen. Yin, R.K., 2003. Case Study Research: Design and Methods, 3rd ed. Sage, Thousand Oaks, CA.