Identifying the Role of General Practitioners in Dutch Telemonitoring Business Models

Running head: ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING

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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] [email protected] 1259989 [2] [email protected] 4120469

ROLE OF GENERAL PRACTITIONERS IN DUTCH TELEMONITORING

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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

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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


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: communication 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

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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.

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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



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?

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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

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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



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 communication patterns and cultural, and énactments 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

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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 stages 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 ádoption 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



technology in private and professional settings, a ćohort effect´ is arising (Ortega Egea et al., 2010).

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)

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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).

Barrier Poor technology performance, organizational issues, and legal barriers Knowledge barriers and management issues, people and organizational factors, social communication patterns and cultural, and énactments 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 stages 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



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

Enablers

Bonder et al. (1997)

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

Buysee et al. (2008) and Meystre S. (2005) Cleland et al. (2005)

Combined benefits on mortality and consumption of health care resource

Rahimpour et al. (2008)

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

Ni Scanaill et al. (2006).

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.,

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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. 3.2.1 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



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customer need, it is an aggregation of benefits that a product or service offers to customers.

eventually lead to either adoption or rejection of a given innovation by that individual or unit.

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 information-seeking and processing activities going on through the decision process are closely connected to use of communication 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 communication plays a key role, especially in the persuasion stage 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 communication than adaptors (partly because innovators are first to try new innovations so the innovations have not spread to the innovators‟ peers yet).

3.2.2 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 stages of innovation-decision making (Knowledge, persuasion, decision, implementation, and confirmation stage) this „learning process‟ will

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



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 stages 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 stages of their decision process.

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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

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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)



4.2 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.

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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 memo 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).

Because of the sample changes we had to create a new sample composition to keep the study



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 memo 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

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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.

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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 Gender

Varied Varied

40-60 years Male, 1 Female

Geographic location Individual/shared practices Technology knowledge Profession

Varied

Varied

Only older respondents were available. High male percentage, typical for the current medical sector Zuid Holland, Friesland, Groningen.

Varied

Varied

Both individual and shared practices.

Varied

Varied

Varied

Varied

Professional Experience Level

Varied

Similar

From technology enthusiasts with iPad2 to reluctant technology pessimists Aside from GPs and specialists one TM pilot project manager (MAN) and one industry representative (IND). Since the sample only consists of older doctors the level of professional experience is also quite similar – all respondents had 20-30 years of experience in their field.

Table 3: Sample Composition



Category

MAN memo

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.

GP2 memo

GP3 memo

Monitoring of patients medical data on a distance

Monitoring of physical values on a distance by equipment

communicati ng and receiving physical or medical data for urgent + other issues.

GP contacts a specialist and sends data of the patients, this data is professionally reviewed and a quick diagnose is provided

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.

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

TM can reduce staff pr patient (and improve patients' life quality) through centralizing communicatio n

TM companies offer monetary benefits, in kind or in the form of discounts on equipment

Qualitative VP 4 Newness

6 Getting the job done

GP4 memo

follow results and take action based on accurate values

Receive more money than for a normal consult

2 Price

3 Cost reduction

GP1 memo

TM is used for medical diagnoses of lungs and dermatology related problems

12

SP1 memo

SP2 memo

SP3 memo

Measuring patients data on a distance

(We use it by) working on a distance and work with the digital data of the patient

Monitor data of the patient on a distance

TM allows doctors to make better diagnoses and find solutions to cure vital problems

More flexible and more convenient work by using TM

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

Price benefits of using TM are higher than not using it

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.

The government benefit from it if the cost of care is reduces. You can have reduced tax income.

TM can extend lives and gives new/improved communicatio n possibilities TM can give GPs work in preparing patients for specialists. Speeds up the treatment process.

With TM such as a camera or ECG meter the GP can faster finish make a diagnose and treat the patient.

TM allows patients to stay home with the monitoring equipment, saving on expensive hospital costs

Every stakeholder in the medical industry is afraid to lose money

TM should be used to diagnose not to monitor, except for applications where it is really useful

It can be used for planning medication and diagnosing rutgen images from a distance, instead of going there

Implementation will cost money, but the GP can charge on new diagnostic methods GP has to administer treatment budgets for certain diseases.

Doctors trust new medical practice that have been approved by 'the professional board'

8 Brand/Status

Table 4: Interview Results – Memo Overview


IND1 memo

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


Category

GP1 memo

GP2 memo

9 Risk reduction

Allowing a specialist to have a look at a dermatologic problem

Improved performance in TM can decrease risks by better spotting details.

10 Accessibility

Low barrier for getting to know the possibilities of TM, including facilities When there is doubt, specialist can give their professional opinion, within a day, without fuss for the GP

11 Convenience/ usability

MAN memo

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 Approached by 12 Knowledge company with stage an email about TM, for the rest not informed about existence

13 Persuation stage

14 Decision stage

Having insider understanding and bridging users' world with the new technologies makes acceptance easier among otherwise reluctant users.

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.

GP3 memo

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

New technology is current based on own initiative.

GP4 memo

SP1 memo

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.

Can be used analysing heart problems, not getting visits from irritating patients and enhancing the convenience for the patients

The GP can have a motivating effect in the beginning of the development

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 MartiniHospital offered a training on TM

GP´s take long to adopt new technology

Companies should convince the GP´s that is easy in use and that there is something in for them, because of quick results

Because GP´s are important in the development, hospitals focus on them with training

Companies try to force a decision with a contract, that has a negative impact on the use of TM

GP takes decision to use TM. His decisions are based on practical reasons such as space, implementatio n time and costs,

In the decision stage, comments from colleagues are more trusted than from brochures

Decisions for GP´s depend on the possibility to integrate it into their practice

SP2 memo

SP3 memo

TM allows specialist to diagnose medical problems

The equipment should be safe, but that is why the control is so strict

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

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

IND1 memo

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 stage negatively, when other stakeholders already agree

The implementati on of TM equipment might bring new and more responsibilitie s

15 Implementation stage

13

In dentalsurgery there are not many innovations to implement



Implementing TM in healthcare is hard; getting everyone on a par, discovering boundaries and the rates, and how can everyone collaborate


Categ ory

MAN memo

GP1 memo

GP2 memo

GP3 memo

GP4 memo

SP1 memo

14

SP2 memo

16 Confirmation stage

SP3 memo

IND1 memo

Conformation is affected by whether it allows the specialist to continue his work

c onformation by showing results from the past is not enough

There is communication between GP´s and specialist, and with universities about medical questions

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

Information about radical innovations in healthcare are featured on news broadcasts, more than in hospitals themselves

On relevant moments information is released to the press

Communication channels 17 interpersonal communication

Personal contact from industry to health organization through network organization was what initiated a new TM project

18 mass media communication

19 Systemische/ organized

Some initiatives are taken to bridging the gap between health and technology.

20 Fragmented/ disorganized

The healthcare world see a gap between themselves and technology, caused by lack of knowledge (information) about what needs the technology is fulfilling.

Stakeholders 21 GP

22 Patiënts

Specialists update GPs on new developments in their field through mandatory sessions every month. There is a good, close collaboration.

GPs listen to closely and are likely to try out of new technology if their patients or colleagues have had good experiences.

Email promotion is used by the industry and it works to trigger interested with GPs.

Professional gathering such as congresses, experimental groups and fairs, and media as magazine are used to spread the info.

A certain amount of time every months and year is assigned to provide GPs with new knowledge from local specialists.

Industry make themselves present in medical events and media and by collaborating with the Dutch Association of Doctors

There are only few training moments and cooperating specialist are not close situated

There is no information available about TM

GP´s can benefit from TM because of its support and help in making decisions

Patients that use TM receive benefits in the form of quick results and consulting time reduction

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 email lists. Pharmacies are close to secondary stakeholders. General email 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 email and provide advice and a chance to try it.

There is communicati on between hospitals and universities about medical questions

Supply of TM equipment is structured

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

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

TM can improve the convenience for the GP and allows the GP to delegate certain tasks

GP's have a difficult relation with specialist, that can slow down cooperation

TM can be used for patients that demand constant treatment and can make this easy

The patient is best assessed by a specialist, also at night

Supply structured training to educate stakeholders of TM

ICT is not used that much in hospitals by doctors, because some things are easier to take care of in person

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

Patients demand a new approach and treatment can be much easier for the patients




Category

MAN memo

GP1 memo

GP2 memo

GP3 memo

GP4 memo

SP1 memo

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

Focuses on the value for the patient, íf you do not offer this you are a bad doctor´

Companies should not only target the medical professionals but also focus on patients

Companies are developing new technology, but should be aware where and how to distribute this

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

Specialist like radiologist and cardiologist also monitor their patients from home

TM is more and more important for specialist

24 Specialist

25 Other stakeholders

From the healthcare's POV is family and relatives important stakeholders in the patients' experience of TM.

Hospitals

Trained nurses, Insurance companies and hospitals

Insurance companies, government

Hospitals, Pharmacy and Insurance companies

15

SP2 memo

SP3 memo

Companies have great stakes in selling medical treatments

Specialist demand the best medical systems, because they can make the best assessments and diagnoses Dentists

A specialist can be cocky, but TM can take the sharp edges of the work

Companies could lobby in politics to focus attention on TM

The relation between GP's and specialists is the field of subcutaneou s politics

Politic parties should be aware of the possibilities of TM

GP's can persuade patients to use TM, but should also consider the responsibilitie s and the new ways of working

The GP should get a certification when working with TM

GP's can select patients for TM, discuss with specialist, and work out easy tasks that were first specialist tasks

Health Insurance

IND1 memo

Hospitals, Politics, Universities

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

When bridging the world of healthcare and technology new stakeholders will appear.

Others Some treatments and experiments are not considered to be politically favaroble.

26 Politics

27 Role of GP

GP's have to get the approval of patients to use TM, but can also pursued them to use it

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

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

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



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


16

Category

MAN memo

GP1 memo

GP2 memo

GP3 memo

GP4 memo

SP1 memo

SP2 memo

SP3 memo

IND1 memo

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.

- Patients get the bill for TM, because of the specialist character of the treatment

Money, logistics, experience and central coordination lacks to implement TM

- (Older) doctors need to see the patients in person, not only from a picture

- Initiators of innovation actually have no time to do this, because they are testing people

- Proliferation of treatments that could be done with TM, that nonsensical

- Patient can only be assessed well in person, not on a distance

- No interaction on distance possible due to the nature of the treatment -

- There are no set rates for conducting TM treatments

Contracts force GP's to conduct TM treatment more times a year

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

(Older) doctors have established a trust relation with their coworkers, TM might disturb this

No wellarranged financial procedures

Patients might panic because of false alarm of the TM equipment

Specialist want to cooperate but that should be at the expense of working time

- Big barriers are money and time

Uncertainties in responsibilitie s and effects of TM limit the willingness to innovate It is uncertain where innovations have effect

- Equipment is expensive, there are a lot of people needed and a lot of training

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

- 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

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

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

- The effect of changes in rates is uncertain

Communicatio n between specialist and GP's can be difficult

Working more efficient may prove less profitable

- People that need personal medical care, cannot work with TM

- If patients do not accept TM, the system does not work

- TM is not easy to integrate in a normal practice offering primary healthcare

- Money can be a limiting factor in the application of TM

- Medical staff is afraid for reorganisations that might cause faults in the system

- Doctors are very conservative in adopting new technology - The rate are too low, there is no incentive



Medical industry has a conservative attitude


Category

MAN memo

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 memo

17

GP2 memo

GP3 memo

GP4 memo

SP1 memo

SP2 memo

SP3 memo

IND1 memo

- Working with TM on an island is more efficient

- Visual consult can be more rewarding for the doctor

Medical centres have more potential to use ECG when they house more doctors

- For people that use blood thinning medicines, it can increase the overall convenience

- If you are able to get financial aid from the board, innovation is possible

Next generation is probably better with this kind of technology

- A health insurance is willing to spend money on better healthcare, when innovations can increase quality, efficient and bring costs down

- With TM it is easier to plan consults while all parties involved stay at their location

- Doctors will embrace TM when they can make quick diagnoses, save time, be able to treat more patients

- 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

- 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

Medical innovations can limit the waiting lists in healthcare

- TM can decrease traveling time, waiting time and increase efficiency

GP's can take over specialist tasks that are not relevant anymore to specialist

TM can be used to increase social contact for patients

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



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


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.

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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 communication. 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



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 communication 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 stage 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 stage is initiated by interested GPs‟ own initiatives. It is not clear who, when and how GPs are approached and to acquire knowledge on

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own initiative is difficult. Something that we also experienced in the first phases of our research process. Focus in the persuasion stage 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 stage. However, it seem to happen very sporadically. GPs seem to base their decision to accept telemonitoring mainly through information provided through meetings, emails and personal referrals. It was difficult to get very useful information on how the implementation and confirmation stages 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.



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.

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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 email in consulting patients suggest that telemonitoring does not easily spread among doctors.

Communication Interpersonal communication 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 stages of innovation-decision making is highly based on information retrieved from mass media channels. However our study indicates otherwise. Both in the knowledge stage and the continuing stages the main communication 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 emailing lists and notes in professional publishing seem to exist and they mainly work as one way communication with the GP as the receiver.

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.

There are some organized communication 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 communication between the doctors, but mainly on the interpersonal level.

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.

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

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



use of telemonitoring instead of traditional means. According to our research most patients are excited about the possibilities and freedom that telemonitoring provides. The main issue is patients with multiple diseases - elderly patients especially where the GP cannot rely on telemonitoring for sufficient examination. One GP suggests that patients should drive the adoption because patients seem to be more open to telemonitoring than their GPs and therefore they will be able to convince their GP to try out telemonitoring. A few big companies are involved in telemonitoring, but it seems like there are mainly some small, independent companies trying out new technologies in collaboration with doctors. Health insurance companies are mentioned by a few respondents and have also been identified by literature as a key stakeholder in creating incentives for the GPs to speed up development, since insurance companies are the ones who determines the rates for GPs‟ declarations. Barriers In this section we elaborate on the barriers for adoption of telemonitoring by the medical sector mentioned by our participants. We will compare these barriers with barriers from the theory and see what are new barriers that are not mentioned by the literature. A barrier that is often mentioned by GP‟s as well specialist and the industry is the lack of regulations on rates for conducting telemonitoring treatments or consults. There are no documented financial procedures and there is a grey area who receives what money. In most cases this is because of the unwillingness of insurance companies to pay for treatment, the fact that patients have to pay themselves and the overall uncertainty about the business model, so how to earn money. This is mentioned in the literature by Gruber (2009), Cho (2009) and Lievens (2004). Lack of communication between GP‟s and specialist is also mentioned as a barrier of adoption, by as well GP‟s and specialists. This is mainly because of the friction between the professions. We found out that there is a significant difference in the mean income of GP‟s (132.000 Euro in 2007) and specialists (207.000 Euro in 2007), this may be of influence on their relation, but we can only assume

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this (Hilten et al., 2011). Another reason for friction could be the responsibility issue, mentioned by the specialist. How do the specialist know whether certain telemonitoring treatments are conducted in the right way and what is the responsibility of the specialist when things go wrong? This barrier is also mentioned by the literature by Cho (2009) and Barlow (2006). That telemonitoring is hard to integrate in current medical centres and hospitals is another valid barrier. The equipment is expensive and the users and facilitators need a lot of training. It is hard to improve current communication networks, to allow the application of telemonitoring on these networks and the logistics, experience and a central coordination lacks in current medical centres and hospitals. Next to that some doctors would like to innovate or test certain things, but there is simply no time to start a pilot or a test case. In the literature, this is mentioned by Gruber (2009), Cho (2009) and Middleton (2005). We found that GP‟s do not say anything about that they are novice computer user and that this may be one of the barriers for adoption, but some do say that doctors in general are very conservative in adopting new technology. This could be because of the stakes at risks (money, quality of health) and the fact that there is no information on where the innovation might have effect. There is a doubt about the quality of the machines, one specialist mentions that 90% of all the alarming data is because of faults in the system or the placement of sensors. This is actually also mentioned in the literature, by Huang (2009), that states that there is a concern for the accuracy and the reliability of the instruments of telemonitoring. Cho (2009) writes about the non-responsiveness and resistance of medical staff towards the use of innovating ICT in the medical environment. Enablers Specialists value that they can delegate tasks to GPs, allowing them to focus on their core speciality. This gives GPs higher incentive to make use of telemonitoring products, because it enables them to take on more tasks than they previously have been able to. This also makes preparation for hospitalization much more efficient. By using telemonitoring it becomes easier to involve specialists on the distance, and that way GPs can



take care of a lot of work before the patient is sent to the specialist. Sometimes the GP might even be able to treat a patient merely with a specialist‟s advice based on telemonitoring data. Even though a big part of the studied literature explicitly mention the growing greying population as a key reason for expanding the use of telemonitoring in the medical sector, our research implies that several factors makes this group less obvious as a target group, at least as catalyst for speeding up the diffusion of telemonitoring: Often this patient group have more than one disease to treat, so only telemonitoring that includes some kind of initial contact in-person before monitoring start. In some environments telemonitoring is more obvious to use because threshold is higher towards contacting a specialist directly - eg. in areas where specialists are not as readily available is in major urban areas. This could be exploited to make complex user tests in such areas, because the need will already be there. Medical Centers with more GPs collaborating are growing in numbers and that will enable more GPs to get access to advanced equipment. In chronic health-care and in visual communication (videoconsultations) there seem to be great potential for expanding the use of telemonitoring in the Netherlands. Economic support from insurance companies to „subsidize‟ telemonitoring treatments so that they are equally (or even more) economically appealing to GPs than existing solutions. Then the development will go fast, according to more of the interviewees. And with closer collaboration between doctors and technologists the telemonitoring companies will enable telemonitoring companies to offer products/services that better fit with the doctors‟ needs. Currently there is a big difference between the value propositions treasured by GPs and those emphasized by the industry. Future Developments Related to Telemonitoring: Our research have identified the following factors most likely to impact the Dutch telemonitoring area in the coming years: - More doctor will be placed in doctor centers more centralization.

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- More technology prepared patients. - Chronic diseases will slowly become the responsibility of GPs. With the specialist in an advisor role - Continuously tight budget? Most likely the current tight healthcare budget will continue. - Doctors working less pr week. The old generation of GPs working 50-60 hours pr week will be replaced with „modern‟ GPs working 30-40 hours. It seems like the technological and medical developments is beginning to give the GP access to areas previous held by specialists, but also enabling the specialist to let go of trivial work and get the opportunity to dig deep into his own field and make more sophisticated and detailed diagnoses easier. A lot of the initiatives among GPs to use telemonitoring seem to be taken by those who can see a purpose in and understand the benefits of new technology. These individual initiatives/experiments going on in GP practices should be encouraged and collected and supported. At the moment they seem to live their own life and have to struggle with even simple ideas because of legislation, so how is it possible to get to the sophisticated solutions? GPs should be more involved in the product development as users so that the telemonitoring products are adjusted to doctors‟ routines. Making the GP adjust his/her routines seems to be difficult unless it can be proved that it will improve the treatment/diagnose or make his/her consults shorter/more effective. From our troubles arranging interviews we suggest that the organization of telemonitoring is too fragmented. Since it was difficult to find information for us it would also be difficult for curious doctors, patients (and interested stakeholders in general) to find information. According to Rogers (2003) this kind of information is very important to get through the knowledge stage, both for the passive and active knowledge seeker. And as our results have shown, currently a lot of initiative is up to the doctors themselves. So the industry should probably focus more on getting the message through about the benefits and recommendations and good experiences that arise from pilot projects. Is the role division clear?



Chronic diseases are now being handed over from specialists/hospitals to GPs (and sometimes from GPs to nurse practitioners) but the product development still needs to include the specialists who have the expert knowledge. The GPs (especially individual practices but even medical centers) do not have many patients with each disease and implementation of these new technologies takes up many resources. That also means that the telemonitoring industry should come up with a different business Model for individually operating GPs and smaller practices (or the practices need to change their business models), or make some kind of collaborative telemonitoring organizations, so they can get access to the new telemonitoring equipment. There seems to be a big difference between what the industry emphasize as value propositions and are the practical and economic reasons that the doctor focus on. However, the doctors claim that the advertising work. Could mean that industry is addressing doctors‟ latent needs and that they are tempted by irrational reasoning or that it feels like it works, but many doctors‟ never see the potential because. The GPs we talked to about this were mainly innovators who have different objectives for adopting new technologies than adapters who are more practical and less experimenting/curious. If experiments going on around in organizations/GPs‟ offices is a general phenomenon, then it is a great source of inputs for improvements of the health care system from „inside the walls‟. These experiments are probably quite fragile. However, they are based on GPs‟ own experiences so there are probably a real need that should be addressed. However, doctors don‟t have much spare time, resources or expertise in these kinds of developments so these initiatives should be encouraged and supported and spread out throughout the country. In our small research we already encountered project ideas involving iPads, digital email assistants, reading rehabilitation by use of computers, dietitians‟ teleconsult, and communication platform PAL4. Technology preparedness Are younger doctors and medical education better at using modern technologies? If it is not the case then even new doctors who will be in practice the

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next 30 years will not be prepared for new technologies. There might be a big potential for the telemonitoring industry if they look at who of the involved stakeholder groups are most adoptive, and then design and market the technology towards their needs – e.g. the younger patients – and let that group push the development and convince the medical professionals. When addressing the least adoptive group (Conservative doctors) and try to make them drive the development then it goes much slower. Young patients are more adoptive because they are already used to have technology integrated in many aspects of their life. They have old relatives and will become old themselves, so they will drive the development that way around. 6.1 Limitations One of the limitations that we identified in our research is that we almost only interviewed doctors (GP´s and specialists) and had only one interview with a company. Of course the focus of the research was the role of the GP, but the industry could give us more varied opinions on this we think. Since we were not able to get in contact with more companies in the industry we were not able to get an overview of their communication channels. Neither did we study the promotion material sent to the doctors to see what the industry emphasize in their material. Next to that, we only interviewed experienced GP´s and specialist so we can‟t say much about the younger professions attitude towards new technology. Although the economic conditions also apply to younger doctors we imagine they are better with ICT than professionals from generations before the extensive use of computers and the Internet. This is just a thought, future research should find a fitting answer to this. Finally we mainly generated codes based on the theoretical framework - not from a bottom up approach. That way we might miss some unexpected elements from the interviews that we hadn‟t thought of while developing the codes/filters for the data processing. This is also a lesson to draw and take in consideration for future research on this topic. An interesting outcome from the result of the coding work was that quite some variations



between the most and least used codes showed up. The codes that was used the least were some of the value proposition codes: newness, customization, design,and brand/status. An explanation might simply be that telemonitoring products currently is not focused on these parameters in the development of telemonitoring. It might other be that the interviewees were not able to recognize these propositions from their experience or don‟t find them relevant or important. Anyhow, the propositions are very tangible ways to improve telemonitoring even more. Especially through branding and design might the industry be able to develop new telemonitoring solutions that take the emotional sides of medical treatment into account, and might be a way to leverage the use of telemonitoring in one area to many new areas through creating a strong telemonitoring brand.

7

CONCLUSION

This extensive study have resulted in many findings and interesting insights. In the following section we will present the main conclusions that can be drawn from this research study and explain what the results mean for the development of telemonitoring in The Netherlands as described in the introduction. Role of the GP Based on the discussions of our study results we can say that the current role of the GP in driving the development of telemonitoring technologies in the Netherlands is not significant. Some GPs apply simple telemonitoring products in their everyday practice but it is our clear impression that this only holds true for few GPs with interest in new technologies and with economic foundation and patient volume to introduce it to their practice. There are also signs of interest to experiment with the use of new technologies video conferencing etc - but this is still only in its initial phase and currently only supported by the GPs‟ own enthusiasm. The simple products in use enable the GP to help specialists carry out some of the specialist‟s more trivial pre-diagnose tasks that used to be for specialists only. This gives more work to the GP, relieves the specialist in his/her work and benefits

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the patients because contact with specialists often includes both waiting and travelling time. In relation to Osterwalder‟s business model theory the GP is currently holding a role as the relation to the customer (patient) as well as filling out a key activity as primary user of the telemonitoring products. So even though the research has shown that the GP might not hold a key position he/she is still important for the development and diffusion of telemonitoring products. However, the environment of specialized expertise and patient volume required for effective development is much more extensive among the specialized medical professions in hospitals as well as practices. A new shift? This research has highlighted several factors that indicates that a shift might be on its way: As stated earlier most treatments using telemonitoring are currently carried out by specialists, but because of the requirements for increased efficiency in the Dutch health-care system, these tasks are very likely to be delegated to GPs in the future due to professional and economic concerns. Telemonitoring products are very suitable for treatment of chronic diseases, where the doctor require very specific data on a continuous basis from the patient. Telemonitoring enables this treatment to be easier, more flexible and efficient, and thus more convenient for both doctor as well as patient. This means that GPs will play an increasing role in the future as potential main users of the telemonitoring products, and the barriers identified in this study therefore needs more attention. Among our recommendations are: This that can be used by companies, but also by GP‟s to argue for the use of telemonitoring when talking to decision-makers in for example a hospital. The other way around, these arguments can also be used by decision-makers in a hospital to persuade GP‟s and other medical staff to join telemonitoring pilots or projects. This research set out to identify the role of Dutch GPs in telemonitoring business models after an initial research implied that the GP might have potential to hold a central role. Most literature only discuss GPs‟ tasks and medical role, and therefore we used Rogers‟ (2003) and Osterwalder‟s (2009) work to get closer to an understanding of the GP‟s



role and how GPs are approached by the medical sector in the context of developments in Dutch telemonitoring. Value propositions in decision making 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 do not match well with GPs‟ real needs. The research also showed that the telemonitoring industry mainly approach the GPs about new products via interpersonal communication channels by making specialists present new developments for GPs, whereas Rogers‟ show that to spark interest and persuade innovators mass media communication channel would normally be preferred. So when the research shows that not many GPs are currently using telemonitoring products, another reason for the low usage apart from GPs‟ not being the main target group, could be that the industry is approaching them with wrong/insufficient information compared to what they need for taking the decision to implement telemonitoring products in their practices. Another reason for GPs‟ not playing a significant role at the moment is related to the value propositions offered by the telemonitoring industry. There are many benefits (value propositions) in using telemonitoring equipment including quick data transfer between GPs and specialists and the telemonitoring industry spend a lot of time explaining GPs how good this would be for their patients. However, it is not clear whom the different benefits work in favor of. 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.

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From out research we can say that the most important value propositions for GP‟s and specialists are cost, performance and convenience. When talking about performance focus is on cost and time efficiency, quality of care through more precise diagnoses, and flexibility through the mobile features. When talking about convenience, mention convenience of work, receiving the best diagnoses in a fast way, and the enhanced communication between professionals. What is also noticeable in relation to this is that even though the GPs recognize the benefits for the patients as important value propositions for telemonitoring, patients are not mentioned when GPs are asked about what are important factor in the decision to implement telemonitoring in the practice. Telemonitoring can provide more healthcare for less cost; the price and cost reduction value proposition are also important. It can help medical professionals and GPs do their work faster, better and safer. Telemonitoring offers a variety of possibilities that were not possible before, and it might lead to change in roles and routines that will change health care dramatically in the coming years. Recommendations:

- Technology companies have to step out of their protective mindset and get together to form alliances for shared interests and knowledge sharing - And open up to research from the outside because an academic angle might provide them with fresh, new insights to the problems they deal with. - encourage GPs, specialist and industry to collaborate closer. Involve central governmental actors or at least make the market more attractive for industry. - agree on and apply clear definitions and distinctions of „telemonitoring‟ and related terms such as telecare will help clarifying the research area on these topics. From our research it has shown to vary how the terms are used, and that way results are less comparable. - getting the current projects collected and share knowledge. - make the GP‟s situations fit with the value propositions offered by the telemonitoring industry. - Make sure that the doctors and patients who is projected to be involved in chronic diseases 10-15 years from now are prepared properly.



8

Future Research - Are younger doctors and medical education better at using modern technologies? - Are individually initiated experiments with digital solutions in GPs‟ practices a widespread phenomenon? - What are main drivers behind new, emerging telemonitoring companies? - What telemonitoring technologies and target groups/diseases seem to have more potential than others?

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We want to take this opportunity to thank a few people that contributed to this paper. First we like to thank the general practitioners that allowed us to interview them, the specialist that also made time free for us, and the company Nijfinster, that offered us a great insight into the world of telemonitoring. We would like to thank our fellow research groups, that shared the same topic, and last, but definitely not least, our research supervisor Dr. Ir. Lianne Simonse.

Acknowledgement



9

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Appendix I: Data Plan


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1

Data Plan Research Topic: Adoption of Telemonitoring Products Purpose: Provide new knowledge to the understanding of diffusion of telemonitoring in Dutch healthcare Main Research Question: - What is the current role of the GP in telemonitoring business models in The Netherlands? Research Method: Literature Review Grounded Theory Data Collection: Scientific papers and articles Semi-structured interviews Sample Selection: Maximum variations in sample on following parameters to identify important common patterns. Sample population will be defined through literature review. Sample Parameters Variations: Age Gender Geographic location Individual/shared practice Technology knowledge Profession Professional Experience Level Data Analysis: deductive coding/memo writing Outcome: Research paper: Time Plan:

Time Plan:


Appendix II: Interview Guide


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1

Interview Guide Intro: Thank you Presentation of us Presentation of topic Interview Length Recording permission

Questions: - Can you explain your professional background? - How do you define Tele Monitoring? - What is your overall impression of TM in the Netherlands? - Why good/bad? - Can you describe the stakeholders involved in telemonitoring? - Who is the key stakeholder, and what is their role? - What is the role of the GP? Please elaborate? - How is the industry promoting their Tele Monitoring products, in your opinion? - What is the main focus of the industry in addressing GPs? - How is the industry trying to convince the GPs of the added value of TM? - What is the procedure of addressing GPs? - How would you personally like to see this? - How should GPs get knowledge about telemonitoring - Who has the main interest in making TM successful? - How important is the GP for the industry in promoting TM products, in your opinion? - Why? - Who has the responsibility of promoting TM in general?

2

- Where do the Industry and the GP complement each other? - What main challenges are there in bringing TM to the market? - for the industry - for GPs - Why? - What is your experience with TM? - Will the role of the GP's change in the future? - How?

Thank you very much for your time!

Outro: Name Age Profession Experience Can we get back in contact?

Probing: Probing Customer Value Propositions: - What is the most relevant problem telemonitoring tries to solve? - What is the most relevant benefit for patients to use telemonitoring? Probing future concepts: - What is necessary to implement telemonitoring for current patients? - What is your opinion on the future of TM in the Netherlands? - Patients will benefit from TM (Boonstra et al. (2011)), but who will eventually pay for the TM implementation? - What is, in your opinion, the best way to make telemonitoring affordable?


Appendix III: Codebook


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1

Code Book Overview: Quantitative VP 1 Performance 2 Price 3 Cost reduction Qualitative VP 4 Newness 5 Customization 6 Getting the job done 7 Design 8 Brand/Status 9 Risk reduction 10 Accessibility 11 Convenience/usability The innovation Decision-process 12 Knowledge stage 13 Persuasion stage 14 Decision stage 15 Implementation stage 16 Confirmation stage Communication channels in decision making processes 17 interpersonal communication 18 mass media communication 19 Systemized/organized 20 Fragmented/disorganized Stakeholders 21 GP 22 Patients 23 Industry 24 Specialist 25 Other stakeholders Others 26 Politics 27 Role of GP 28 Barrier 29 Enabler

2 Explanations: Quantitative VP Measurable parameters such as speed, efficiency, price, time, money 1 Performance Satisfies the need for better or improved performance of products and services. (Example: the PC industry growed traditionally based on this factor, constantly improving processor speed, better graphics and more disk storage; improving performance of the total system) 2 Price Satisfies the need of price-sensitive customer segments by offering similar value at a lower price (Example: Companies like Ryanair and Easy Jet offer fast and reliable customer air traffic for a much lower price than competitors) 3 Cost reduction Helping customers to reduce costs in their personal or professional environment (Example: Salesforce.com offers customers a hosted Customer Relationship management (CRM) application, hence reducing the cost of acquiring, installing and maintaining CRM software itself) Qualitative VP Intangible parameters such as customer experience, feelings, service, care, design 4 Newness Satisfies an entirely new set of needs, that customers previously didn‟t perceive because there was no similar offering. (Example: cell phones created a whole new industry around mobile telecommunication) 5 Customization Satisfies the need for tailored products and services to the specific need of the individual customer or customer. (Example: customers are now able to customize their own backgrounds in browsers or alter profile styles, while still taking the advance of economies of scale) 6 „Getting the job done‟ Create value by helping a customer to get certain jobs done (Example: Rolls Royce manufactures and maintain aircraft engines, so that airlines can keep their aircrafts in the air) 7 Design A product or service that stands out because of superior design (Example:In fashion and consumer electronics design can be particularly important) 8 Brand/Status Using and displaying a specific brand that radiates a certain status, lifestyle or wealth (Example: Wearing a rolex signifies wealth, skateboarders may wear the newest “underground” brands to show that they know “whats up”) 9 Risk reduction Reducing the risk that customers incur when purchasing products or services (Example: Offering a service-level guarantee for the purchase of outsourced IT-services, that the risks of the purchase are reduced) 10 Accessibility Making products and services available to customers who previously lacked access to these products and services (Example: NetJet offers individuals and corporations access to private jets, a service previously unaffordable to most customers) 11 Convenience/usability Making products or services more convenient or easier to use for the customers

3 (Example: Apple offered customers convenience in searching, buying, dowloading and listening to digital music, with iTunes and the iPod) The innovation Decision-process is the process through which an individual or other decision making unit passes from first knowledge of an innovation, to forming an attitude toward the innovation, to a decision to adopt or reject, to implementation of the new idea, and to confirmation of that decision. This process consists of five stages: 12 Knowledge stage when the individual is exposed to the innovations existence and gains and understanding of how it functions 13 Persuation stage when the individual forms a favorable or unfavorable attitude toward the innovation 14 Decision stage when the individual engages in activities that lead to a choice to adopt or reject the innovation 15 Implementation stage When the individual puts an innovation into use 16 Confirmation stage when the individual seeks reinforcement for an innovation-decisions already made but may reverse the decision if exposed to conflicting messages about it. Communcation channels in decision making processes The means by which an innovation gets from a source to a receiver 17 interpersonal communication channel involve a face-to-face exchange between two or more individuals. 18 mass media communication channel means of transmitting messages that involve a mass medium such as radio, tv, internet, newspapers etc., that enable a source of one or a few individuals to reach an audience of many. - Cosmopolite channels Are those channels linking an individual with sources outside the social system under study. Interpersonal channels maybe either localite or cosmopolite whereas mass media channels are almost entirely cosmopolite. - Localite channels Are those channels linking an individual with sources within his/her social system under study. 19 Systemized/organized the communication is planned, targeted, thought, managed, centralized, clear 20 Fragmented/disorganized unclear, based on current needs, ever-changing, inconsistent, personally initiated Stakeholders 21 GP The general practitioner is a stakeholder in Tele monitoring, that we identified in the literature research. Is the GP also a stakeholder in the eyes of the interviewees? 22 Patients

4 The group of patients is a stakeholder in Tele monitoring, that we identified in the literature research. Are they also a stakeholder in the eyes of the interviewees? 23 Industry The TM device manufacatoring and offering industry is a stakeholder in Tele monitoring, that we identified in the literature research. Is this industry also a stakeholder in the eyes of the interviewees? 24 Specialist The specialist is a stakeholder in Tele monitoring, that we identified in the literature research. Is the specialist also a stakeholder in the eyes of the interviewees? 25 Other stakeholders Are there other stakeholders involved that the interviewees mention? Others 26 Politics Are their political issues concerning Tele monitoring? 27 Role of GP What is the role of the GP in the tele monitoring business model in the eyes of the interviewees? 28 Barrier What are barriers that limit the succes of the TM business model? 29 Enabler What are enabelers that enhance the succes of the TM business model?


Appendix IV: Full Codes Scheme


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Category Definition

Quantitative VP

MAN Definition Telemonitoring

1 Performance We want to step by step build up the technical devices. It’s video, it’s information, monitoring sensors. Information like going out, social information, general information they need from the news or from the shop. They can get that from their device. Movement, chock, falling sensors are right now used in the care homes, not in private homes (e. g. bed sensors). Measurements of primary body functions, e.g. heart rate, blood pressure, blood sugar, drop speed of medicine via infusion. It’s things that we would like to learn to use in the home care, but it is not common yet. It is slowly beginning.

with video, sensors and measurements they can better judge the situation there, without the patient having to live in a care home or go to hospital.

MAN memo Definition Telemonitoring

1 Performance

a wide selection of interactions and measurements 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.

GP1 Definition Telemonitoring

GP3 Definition Telemonitoring In my words TM is looking at some patient without being in his neighborhood in person on specific topics. That can be very medically and physically related and it can also be "Ik ken het what we use for eigenlijk alleen van dementia patients wat ze in het with sensors - if ziekenhuis doen, they fall or if they dat ze op de ene come out of bed. afdeling een So TM is both to patient aan de I think it is solve medical telemetrie ligt, met monitoring the issues that can’t hartslag en physical values of be solved by zuurstof saturatie a patient on a means of existing en dat soort distance by means solutions, but also dingen, en dat ze of equipment like Monitoring of ways to replace op een andere Monitoring of patients heart rate physical values on existing solutions afdeling dat in de medical data on a monitoring and a distance by with easier ways to gaten houden" distance blood pressure. equipment do it. 1 Performance 1 Performance 1 Performance 1 Performance 1 Performance

"Als ik dan denk, wat zou dit toch zijn, dan zet ik dat op de foto en dan stuur ik dan via Ksyos, en dat wordt dan dezelfde dag beoordeeld en dan meestal dezelfde dag en soms de volgende dag krijg ik dan antwoord"

"De informatie die de huisarts krijgt van de dermatoloog, krijgt hij nadat de dermatoloog de foto’s heeft gezien, de dermatoloog hoeft daarom de patiënt dan ook niet te zien"

GP1 memo Definition Telemonitoring



For certain diseases and If you are medical purposes monitoring people where advanced with heart failure, features, higher you want to check performance and GP contacts a from day to day continuously specialist and sends what is their updated data are data of the patients, conditions, how is crucial TM is this data is their weight, are needed. Video professionally reviewd they building up calling will and a quick diagnose fluids or not. And enhance patient is provided then you need TM. communication.

What triggers me [about TM] is if I can get a better view in what the patients’ condition are. Like special equipment to check the ears of children

At the end the GP will have more satisfied patients and then get quick and precise and more up-to-date reliable information about his patients



Doctors communicating with patients and receiving related physical or medical data to solve urgent and other health related issues. 1 Performance 1 Performance


A camera where you can take a picture, or if you give an advice to patients to follow the results and take some action. To introduce devices for specialized chronic devices to patients so the patients use them very well and the GP can take action on the information. Eg. Is blood pressure is often over-treated. We know that blood pressure measured in the practice is always higher than at home, but very often people are treated by the results from the practice. And that is an example of something that could make good use of telemonitoring, because such a device would provide the GP with more accurate values.

1


SP1 Definition Telemonitoring

1 Performance

"Wij gebruiken het zelf eigenlijk niet, wat we wel veel doen is werken op "Wat ik afstand, waarbij je voornamelijk ken is dus in de digitale het princiepe van status van de telemetrie, meten Measuring patients patiënt kan werken op afstand" data on a distance thuis" 1 Performance 1 Performance 1 Performance

"Het andere is dat als je ook iemand in een ziekenhuis laat rondlopen dat dat niet zijn natuurlijke omgeving is en dat je dan anders leeft en anders belast wordt dus dat je ook eigenlijk follow results and minder kans hebt take action based dat je ondekt wat on accurate values er aan de hand is"

"Ik denk eigenlijk dat dat hele telemetrie, voor op de consumentenmarkt zoals in Japan, dat de meeste mensen daar ongelukkiger van worden, dus ik denk dat het echt toegepast moet worden op nuttige dingen waar vitale problemen mee opgelost worden"

SP1 memo Definition Telemonitoring


"Net was ik bijvoorbeeld medicatie aan het invoeren voor patiënten die Telemonitoring morgen allows docters to opgenomen make better worden, en een diagnoses and find jaar geleden moest solutions to cure ik daarvoor naar vital problems het ziekenhuis"

"Dat werkt heel prettig en maakt je ook flexibeler, dat je minder aan het ziekenhuis gebonden bent, en maakt dat je ook laagdrempeliger kunt overleggen dus werkt ook voor de spoed artsen prettig, dat ze kunnen zeggen van joh, kun je eens kijken want ik kom daar en daar niet uit"



“Ik denk dat er meerdere definities zijn maar dat, hmm de definitie van op afstand medische (We use it by) data in de gaten working on a houden wel het distance and work beste past bij het with the digital woord, toch? data of the patient haha” 1 Performance 1 Performance

More flexible and more convenient work by using telemonitoring

“Ik weet van collega’s die er veel meer mee werken dat het net als de veranderingen thuis ook gewoon veranderd in het ziekenhuis. Ze kunnen hun werk meer van thuis doen en zijn flexibeler met dienst en noodsituaties. Vaak weten ze dan al precies wat er speelt als ze in de auto stappen”

“Patienten hebben er ook wat aan, vooral die vaak naar de dokter of het ziekenhuis moeten als ze dat ook vanaf thuis kunnen. Dat is veel efficienter voor de patienten en de keren dat ze naar het ziekenhuis gaan worden ze meteen geholpen. Ik zie daar wel wat in”


IND1 nijfinster Definition Telemonitoring

IND1 memo Definition Telemonitoring

Monitor data of the patient on a distance 1 Performance 1 Performance

1 Performance

Use telemonitoring for enhancing the flexibility and the convenience for the patient and the medical staff, making it more effcient and improving the quailty of care

With telemonitoring large distance can be crossed, improving the effcienty and the quality of care

"Een gedeelte van de consulten werd dan in samenspraak met de huisarts op Ameland gedaan"

"Helemaal vervangen kan teleconsult de normale consulten natuurlijk niet, net als in de thuiszorg, je kunt geen steunkousen aantrekken met een camera, zo zijn er natuurlijk een hele hoop dingen die niet kunnen via een video verbinding, maar er zijn een hele hoop dingen die wel kunnen of die je extra kunt doen met behulp van een video verbinding"

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MAN MAN memo If the machine is giving an alarm then you have to push a button and the pills come out. If you don’t push the alarm, then it gives an alarm to the central. Then the central can call the patient and maybe send someone from the care house. And we save a lot of money. When we go there it is three times as expensive as using this machine. We don’t have many ‘care takers’ so we can only help a few people with medication. With this device we can help three times as many, so that way around it’s safer.

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We are trying to develop for ourselves something with a very good camera and internet. Because when I currently send a picture it is a frozen picture. So if you can move with your camera and make sort of a movie with it then the specialist knows better what to do with it.

And I think that phone calling with imaging would give a better performance. It’s different when I speak to you on the phone or in Video will improve person. communication

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"Dat ging dan zo, dan kon ik daar teledermato voor declareren en daar kreeg ik dan volgens mij meer geld voor dan voor een gewoon consult, ja en die dermatholog kreeg dan ook weer, omdat dan werd het als het ware een specialistische verichting dus die dermatoloog kreeg er ook geld voor, en Ksyos dan Recieve more money waarschijnlijk ook than for a normal een beetje" consult

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"Denk ik dat de zorgverzekeraar, zeker bij die diagnostische telemetrie, met telemonitoring, dat als ze de keuze hebben tussen iemand in een ziekehuis laten liggen of rondlopen thuis met een apparaatje zullen ze bijna altijd kiezen voor de laatste oplossing, want een ziekenhuis is vreselijk duur"

Price benefits of using telemonitoring are higher than not using it

SP2

SP2 memo

"De huisartsen gaan er nu mee aan de haal, die schaffen allemaal zo'n ECG apparaat aan, die gaan dat dan door mailen, ik heb daar helemaal geen zin in" "Het moet patiënt gericht zijn, vanuit het gemak, dat die niet een uur hoeft te wachten voor dat stomme vlekje wat je ook wel in een keer ziet, ik denk ook vanuit patiënt veiligheid, dat je op een eiland, dat daar ook een geoefend oog mee kijkt en dat ook een helikopter niet voor niets vliegt, als de huisartsen het toch anders hebben ingeschat" "Het verhoogt gewoon heel erg de efficiëntie, en het gemak en het plezier in het werk doen zeg maar" 2 Price 2 Price

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“Wat ik wel denk is dat het er op deze manier wat gedaan kan worden aan de wachtrijen in de zorg, als je in het buitenland eerder terecht kan dan in Nederland dan is er toch iets mis, dan moet daar een oplossing voor te vinden zijn, bijvoorbeeld in de techniek, maar ook in hoe we met zorg in het algemeen omgaan”

2 Price “Ik denk dat de kosten voor een aantal dingen in de medische wereld overdreven zijn, maar dat heeft allemaal met testen en veiligheid te maken, al zijn sommige producten gewoon echt gemaakt voor de winst denk ik. Maar dat zorgt er ook voor dat het implementeren van zulke systemen gewoon heel veel geld kosten, en als niet duidelijk is waar dat geld vandaag komt dan gaan zulke plannen gewoon niet door”

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"Waardoor je iets in de reistijden en de routeplanning kunt doen, of in de wachttijden of in je hele logistiek en efficiëntie kan je natuurlijk heel veel bereiken op deze manier"

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Implementation will cost money, but the GP can charge on new diagnostic methods

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3 Cost reduction "De toepassing op mensen met hardritme stoornissen die op een gegeven moment door rare pauzes in hun hardslag bewusteloos worden en van de trap af donderen, dat hebben ze soms een keer per maand ofzo, en dat is natuurlijk erg inefficient en duur om iemand een maand door het ziekehuis te laten lopen met een ECG apparaatje aan" "Denk ik dat de zorgverzekeraar, zeker bij die diagnostische telemetrie, met telemonitoring, dat als ze de keuze hebben tussen iemand in een ziekehuis laten liggen of rondlopen thuis met een apparaatje zullen ze bijna altijd kiezen voor de laatste oplossing, want een ziekenhuis is vreselijk duur"

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"Iedereen is bang om geld te verliezen, echt hoor, dat is heel verschrikkelijk, maar dat hoor je echt"

"Een zorgverzekeraar wil het wel betalen, ze zijn er altijd op uit om hun zorg te verbeteren, het In the past when moet een you had a diabetes kwalitatieve patient you send verbetering zijn, the bill to the aangetoond het insurance liefst, of het moet company. Now you GP has to efficiënter of Every stakeholder get one specific administer goedkoper in the medical amount of money treatment budgets worden, industry is afraid to for the whole care for certain aangetoond, en lose money as GP. diseases. het liefst allebei"

So we wanted to decrease the travelling to homes and keep people at home longer

We think that with ‘care on a distance’ we can do parts of the interventions from the call centers so we don’t need to go. If the machine is giving an alarm then you have to push a button and the pills come out. If you don’t push the alarm, then it gives an alarm to the central. Then the central can call the patient and maybe send someone from the care house. And we save a lot of money. When we go there it is three times as expensive as using this machine. We don’t have many ‘care takers’ so we can only help a few people with medication. With this device we can help three times as many, so that way around it’s safer.

TM can reduce staff pr patient (and improve patients' life quality) through centralizing communication

"Ik heb van hun een fototoestel daarvoor gekregen en zelfs nog vier nascholingspunten dus dat was ook gunstig [...] en je krijgt ook korting op ECG apparatuur en spirometrie apparatuur"

Telemonitoring companies offer monitary benefits, in kind or in the form of discounts on equipment

You can keep the patient in your own practice with you longer before you have to wait for a specialist. I think it is a good thing, because specialized treatment is very expensive.

Save on specialist costs because hospitals' efficiency focus gives the interesting work to GPs. Time and cost reduction and maybe even get refund are most important factors for GPs when evaluating TM.



What do you look at when you decide on these products? 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? For the cardiac thing we get money if we use it. You can make a declaration to the insurance company.

And that’s a new development. The hospital want to work as efficiently as possible. And for the GPs it is not only to earn some money because you can charge for the service. It is also satisfaction in what you do professionally. You feel yourself as a better doctor if you can do more.

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Telemonitoring allows patients to stay home with the monitoring equipment, saving on expensive hospital costs

SP3 SP3 memo “Wat natuurlijk ook een goede is dat de huisarts klusjes doet die de specialisten alleen tijd kost en die de huisartsen ook nog wat geld opleverd terwijl het maar heel weinig werk is. Maar dat kunnen alleen de taakjes zijn die echt zonder specialist kunnen, want anders krijg je problemen met wie is er verantwoordelijk en wie krijgt waar voor betaald” 3 Cost reduction 3 Cost reduction

IND1 nijfinster

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Telemonitoring should improve the quality of care, the effcienty and cut on costs of healtcare

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Qualitative VP

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GP2 TM is moving inside the field of specialists which is very interesting for me to do, but it takes a lot of time. And if I do a thing like that it must be cost efficient. 4 Newness If you are living at the borders of your capabilities now we can stretch it so you can live longer. There was a meeting and they presented it. And then said that this is the new development. This is good for the patients, and you as a GP can have this And I think that phone calling with imaging would give a better performance. It’s different when I speak to you on the phone or in person. 5 Customization

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6 Getting the job 6 Getting the job done done

"Ook wel, longfuncties beoordelen"

Telemonitoring is used for medical diagnoses of lungs and dermatology related problems

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"Tele-dermatologie voegt wel echt iets toe, daar vind je heel snel antwoord, mensen hoeven daarvoor niet helemaal naar de dermatoloog, meestal is maar een heel klein dingetje en dan denk je tja..." 7 Design 7 Design

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In preparing the patient for referring to a hospital TM has potential. If I can send someone to the cardiologist and say I did TM and I found this problem, then he knows from the start what the problem is. It’s more efficient.

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A camera where you can take a picture, or if you give an advice to patients to follow the results and take some action.

"Net was ik bijvoorbeeld medicatie aan het invoeren voor patiënten die With TM such as a Telemonitoring morgen camera or ECG "Telemetrie wordt should be used to opgenomen meter the GP can dan echt gebruikt diagnose not to worden, en een faster finish make om iets uit te monitor, exept for jaar geleden moest a diagnose and zoeken en niet om applications where ik daarvoor naar treat the patient. iets te controleren" it is really useful het ziekenhuis"

TM can extend lives and gives new/improved communication possibilities

TM can give GPs work in preparing patients for specialists. Speeds up the treatment process.

"Je hebt ok mensen die bloedverdunners gebruikern, die moeten dan een keer per week hun bloed controleren en dan moet de dosering van de middlen worden aangepast, nouja, dat er daar echt wel dingen zijn waar het nuttig zou zijn" 7 Design 7 Design

"Wij zijn bij uitstek een specialisme waarbij we gebruik maken van röntgen diagnostiek, en dat is juist zo handig om op afstand te doen" 7 Design 7 Design

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6 Getting the job done "Ze deden veel investeringen in de Kadaka (Kastje dat alles kan), maar ze hielden zich niet bezig met welk verdienmodel past daar dan onder, is er wel behoefte van de mensen en kan zo'n zorgorganisatie daar wel mee weken" Mensen waarderen beeldcontact enorm, alle projecten die er zijn springt dat er wel uit, als het beeldcontact goed is, dan is dat een van de fijnste dingen die er zijn, verder is er heel veel behoefte aan alarmering of iets wat daar op lijkt, van als er wat met mij is dan kan ik ergens op drukken en dan hoort of ziet iemand mij en dan komt er hulp, dat is iets wat mensen graag willen" 7 Design

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We take an ECG, send it to the cardiologist and he gives advice. 7 Design 7 Design

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8 Brand/Status And they have trust in this information. If it is approved by the professional board then doctors will accept it over time. If there is a sticker on it ‘approved by PB’ it’s a selling point if you can manage that for telemonitoring. 9 Risk reduction

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Doctors trust and will faster implement new medical practice that have been approved by 'the professional board' 9 Risk reduction 9 Risk reduction

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It can be used for planning medication and diagnosing rutgen images from a distance, instead of going there

For investments in telemonitoring solutions, the need of the customer should be clear, such as visual contact and the possiblity to alarm someone

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SP2 SP2 memo SP3 SP3 memo IND1 nijfinster IND1 memo "Het moet patiënt gericht zijn, vanuit het gemak, dat die We are trying to niet een uur hoeft develop for te wachten voor ourselves dat stomme vlekje something with a wat je ook wel in "Ik heb trouwens very good camera een keer ziet, ik “Belangrijk is de ook and internet. denk ook vanuit veiligheid van de teledermatologie Because when I patiënt veiligheid, patiënten dat er gedaan, dus dat ik currently send a dat je op een geen fouten zitten een foto maak van picture it is a eiland, dat daar in de data en dat een huidafwijking frozen picture. So ook een geoefend er niets over het en die stuur ik dan if you can move oog mee kijkt en hoofd wordt en dan krijg ik with your camera dat ook een gezien. Daarom is weer terug wat de and make sort of a Improved helikopter niet voor natuurlijk de The equipment dermatoloog die ik movie with it then performance in TM niets vliegt, als de Telemonitoring controle op de should be safe, but dus helemaal niet Allowing a specialist the specialist can decrease risks huisartsen het toch allows specialist to apparaten zo that is why the ken, denk dat het to have a look at a knows better what by better spotting anders hebben diagnose medical streng, maar dat controle is so is" dermatologic problem to do with it. details. ingeschat" problems moet ook.” strickt 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility 10 Accessibility "Dat werkt heel prettig en maakt je ook flexibeler, dat je minder aan het "En dat was dan ziekenhuis zoiets van je krijgt gebonden bent, en vier punten, en maakt dat je ook een fototoestel en laagdrempeliger iemand komt je op kunt overleggen de praktijk dus werkt ook voor uitleggen hoe het de spoed artsen allemaal werkt, en prettig, dat ze "Zeker in de ik dacht toen dat is Low barrier for getting kunnen zeggen Low barrier for thuiszorg kun je een soort van win to know the van joh, kun je discussion and het ook voor het Allowing patients win situatie, dus possibilities of eens kijken want ik makes the work sociale contact to make social dat heb ik toen telemonitoring, kom daar en daar more fun and more voor de patiënten contacts in home maar gedaan" including facilities niet uit" flexible gebruiken" healthcare 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability Convenience/usability One of the most important reasons behind TM I think is to collect data Give GP and from patients. If specialists control “Ik weet van you are able to by making their collega’s die er communicate via day flexible and veel meer mee internet you are tasks easier an werken dat het net able to do this improves als de whole thing via collaboration. TM veranderingen TM enable better, "Als ik dan denk, internet. People leads to exciting thuis ook gewoon and clearer wat zou dit toch don’t have to come work for the veranderd in het communication zijn, dan zet ik dat by in person. It’s specialist and "Net was ik ziekenhuis. Ze between medical op de foto en dan efficient for the provide a better Easy, fast and bijvoorbeeld kunnen hun werk "Waardoor je iets staff and patient stuur ik dan via patients. People base for GPs' usable TM medicatie aan het meer van thuis in de reistijden en Then for one or and enhance the Ksyos, en dat will have their own decision making. GP´s use TM to products is Can be used invoeren voor doen en zijn de routeplanning two years we have feeling of being wordt dan dezelfde meters, they send TM gives patients We use TM for get direct advice A camera where important for analysing heart patiënten die Telemonitoring flexibeler met Telemonitoring kunt doen, of in de used video, so that safe at home as dag beoordeeld en When there is doupt, their reports to the the convenience of dermatology. to from a specialist, you can take a patients' benefit. "Die telemetrie bij problems, not morgen allows working dienst en offers convenience wachttijden of in je we cannot only patient. New dan meestal specialist can give specialized centers staying home and classify big quickly get a picture, or if you For doctors it is die hart getting visits from opgenomen from other noodsituaties. in dividing the hele logistiek en Telemonitoring hear, but also see flexibility in dezelfde dag en their professional and they get plays on doctors' wounds. To follow diagnose and safe give an advice to convenient to send toestanden denk ik irritating patients worden, en een locations, making Vaak weten ze dan work, working from efficiëntie kan je could be a solution those people when schedules gives soms de volgende opinion, within a day, advice on how aspirations of it and to send to time. This wil also patients to follow a picture and get a dat dat heel handig and enhancing the jaar geleden moest the work more al precies wat er more locations and natuurlijk heel veel for reducing they are in front of less restrained life dag krijg ik dan without fuss for the many tablets they striving for become dermatologists for benefit the patient the results and quick advice from is enzo, nuttig en convenience for ik daarvoor naar flexible and more speelt als ze in de make the work bereiken op deze traveling time, their PC. for patient. antwoord" GP should take. better. advice. in the end take some action. a specialist. practisch" the patients het ziekenhuis" efficient auto stappen” more flexible manier" waiting lists. "Ik zou het niet weten wat een dokter er aan “Net als bij andere persoonlijk belang toepassingen bij zou hebben wordt het wel iets "In grotere They explain what waarom hij dit makkelijker en is praktijken hebben As a health care is in it for me as doet, behalve als het werk efficiënter ze dan van die professional I can professional. It’s je soms hele te verdelen tussen To keep people ECG apparaten, benefit from TM easy, you can use ververlende "Als er een foto thuis en op de longer at home. en laten dat dan because it can it quickly. We take . We take an ECG, patienten hebt, wordt genomen op locatie, maar They have the bekijken door ehm support me and care of it. You get send it to the zodat hij ze niet de spoedopvang, natuurlijk ligt het feeling of being specialisten help me take the result within 3 cardiologist and he meer hoeft te zien, dan kan ik die aan de data waar safe at home bekijken" right decisions. days. gives advice. zo vaak" thuis beoordelen" het over gaat” "Dat werkt heel prettig en maakt je ook flexibeler, dat je minder aan het ziekenhuis “Op de IC kunnen Another reason is At the end I think gebonden bent, en patiënten in de that people need the patients will maakt dat je ook gaten worden care on a not"Voordeel voor de There was a have the most laagdrempeliger gehouden terwijl planned moment. specialisten en meeting and they benefits from it. "De kunt overleggen wij op een andere (to go to toilet, or huisartsen is dat je presented it. And Not financial, but toepasbaarheid is dus werkt ook voor locatie zitten of move to another er helemaal geen then said that this the comfort. Now Between the lines natuurlijk heel de spoed artsen koffie zitten te place in the home rompslomp van is the new he doesn’t have to the benefits belangrijk, als jij prettig, dat ze drinken. Er zit altijd some need a hebt, dat doen zij development. This go to the GP, and mentioned in the met een grote kast kunnen zeggen iemand mee te nurse), and before (Ksyos) allemaal, is good for the with my patients email list is moet rondlopen of van joh, kun je kijken met de we had a zij hebben dat patients, and you that they can stay efficiency, but also met een kastje, dat eens kijken want ik gegevens, en die maximum of three helemaal opgezet, as a GP can have in their benefit for the is natuurlijk een kom daar en daar kan reageren als times a day. van hoe dat werkt" this. environment patient. groot verschil" niet uit" dat nodig is”

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MAN

We think that with ‘care on a distance’ we can do parts of the interventions from the call centers so we don’t need to go. We want to step by step build up the technical devices. It’s video, it’s information, monitoring sensors. Information like going out, social information, general information they need from the news or from the shop. They can get that from their device. Movement, chock, falling sensors are right now used in the care homes, not in private homes (e. g. bed sensors). Measurements of primary body functions, e.g. heart rate, blood pressure, blood sugar, drop speed of medicine via infusion. It’s things that we would like to learn to use in the home care, but it is not common yet. It is slowly beginning.

with video, sensors and measurements they can better judge the situation there, without the patient having to live in a care home or go to hospital.

MAN memo

GP1

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GP2 GP2 memo What do the industry focus on? Always that it is better for our patient. You are a better doctor if you do this. Nothing about saving money. It’s the same as with the pharmacies: The pharmacies give you the feeling that if you do not give this tablet you are a bad doctor, because this is the best and you should give the patients the best. The advertising works.

Often it’s much easier if you make an appointment that someday between four and five a clock we can see through some patients together, and the dermatologist stays in the hospital – no travelling needed. That’s possible. And then you can save the patient from physically going there. And the patients are glad. If I propose that I can take a picture of it and send it to a specialist with a response within one or two days, they say ‘is that possible? Nice!’. They do not complain. They do not ask to see the specialist.

In preparing the patient for referring to a hospital TM has potential. If I can send someone to the cardiologist and say I did TM and I found this problem, then he knows from the start what the problem is. It’s more efficient.

GP3


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GP4

Easy, usable devices for chronic diseases that are connected with the internet. I think the people with chronic diseases are the most important ones. For other patient groups it seems less important to me.

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SP1

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SP2

"De specialist die meerdere dependances onder zijn hoede heeft met zijn grote maatschap, is denk ik heel interessant, ze hoeven niet ter plekke te zijn, dus daar is het wel nodig denk ik"

"Ik denk dat het heel erg afhankelijk is van hoe de zorg georganiseerd is, en dat betekend dat als jij heel veel uit handen gaat geven, naar nursepractitioners, verpleegkundige of mensen in opleiding of basisartsen en als specialist thuis kan gaan zitten he of dat je je visite loopt in je eigen hoofdziekenenhuis en in de dependance ook nog twee mensen hebt liggen kan ik mij voorstellen dat dat wel heel gemakkelijk kan zijn"

Industry’s main challenge: Make it easy and understandable. For medical: To make a switch and incorporate TM aspects in the routine ways of handling. That’s a big challenge. If you are used to do it that and that way all life then it is difficult to change If the doctor can benefit quickly from it then it’s easier to change. Quick diagnoses. Saving time. Then he can do other things with his patients. It’s time consuming if you want to make a diagnose or a treatment, then you have to wait a day on your lab results. If you can have it instantly you can go on with your process. It’s much easier. Then the time is very short. Then you don’t have to think all the time about ‘I have to go to her’. That’s why doctors are so fond of all these dipsticks and so on. Doctors just want a stick they can put in. Afterwards they can send it to the lab and meanwhile go on with the treatment, without having to wait 2-3 days. That makes it easier.

"Het verhoogt gewoon heel erg de efficiëntie, en het gemak en het plezier in het werk doen zeg maar"

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The innovation Decisionprocess

MAN MAN memo If the machine is giving an alarm then you have to push a button and the pills come out. If you don’t push the alarm, then it gives an alarm to the central. Then the central can call the patient and maybe send someone from the care house. And we save a lot of money. When we go there it is three times as expensive as using this machine. We don’t have many ‘care takers’ so we can only help a few people with medication. With this device we can help three times as many, so that way around it’s safer. 12 Knowledge 12 Knowledge stage stage

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The GP should be the most important one involved in the development seen from the primary health care. Because he is able to motivate people to use the equipment.

"Wat ze zouden kunnen doen is dokters bezoeken, praatjes op congressen en natuurlijk lobbyen The GP can have bij politici, omdat te a motivating effect propageren, maar in the beginning of bij de dokters zelf the development ook wel"

12 Knowledge stage “Natuurlijk komen er geregeld studenten langs met nieuwe dingen maar vaak gaan die naar de onderzoeksafdeling waar bijna alle artsen die daar rondlopen met hun scripties of onderzoeken bezig zijn, daar heb ik niet zo veel mee te maken” “Hoe ze er aan komen weet ik niet, ik kan me zo voorstellen dat er een financiële man van een bedrijf langs komt bij het bestuur van het ziekenhuis, of bij het afdelingshoofd, want die hebben ook veel te zeggen, en dan presenteren ze dingen die mogelijk zijn, maar het gaat vooral over hoeveel ze kunnen besparen op dingen denk ik”

"Ik had eigenlijk helemaan niet door dat dat er al was" "Maar wat je inderdaad zei van ameland en zo, kan ik me best iets voorstellen dat dat wel kan"

Approached by company with an email about telemonitoring, for the rest not informed about existance

so if you want [to have] the new development you need a special interest as GP – some of us have that.

New technology is current based on own initiative.

Companies should visit doctors, visit congresses, lobby politicians to make telemonitoring known

"Volgens mij heb ik daar een keer een mailtje van gekregen, en dat was net toen ik die nascholings cursus van het Martiniziekenhuis van die dele-dermatologie had gemist"

13 Persuation stage

13 Persuation stage

13 Persuation stage

13 Persuation stage

What do the industry focus on? Always that it is better for our patient. You are a better doctor if you do this. Nothing about saving money. It’s the same as with the pharmacies: The pharmacies give you the feeling that if you do not give this tablet you are a bad doctor, because this is the best and you should give the patients the best. The advertising works. 13 Persuation 13 Persuation stage stage

13 Persuation stage

13 Persuation stage

13 Persuation stage

7

13 Persuation stage

13 Persuation stage

13 Persuation stage

13 Persuation stage

13 Persuation stage

13 Persuation stage

"Voordat je zover bent dat je dit aangetoond hebt gaan er heel wat Companies visit pilots en jaren van hospitals to explain innovatie en about pionieren telemonitoring, overheen voordat universities are het zover is en sometimes also eigenlijk zitten we involved daar nog wel in"

A good introduction to the involved parties should be provided, including explanations and trainings and press releases

"Helemaal in het begin van het project is er een uitleg en een klein traininkje van zo en zo werkt het"

13 Persuation stage

"Op momenten dat het relevant is doen we natuurlijk ook dingen in de pers, en op andere momenten gaat dit dan ook weer over" 13 Persuation 13 Persuation stage stage

Category

MAN

I have a nurse background myself so I’m not a technology guy. My job is thinking from the nurse world about how we can get to our goals. And because of that position I can better convince them than a technology man.

14 Decision stage

MAN memo

Having an insider understanding and bridging users' world with the new technologies makes acceptance easier among otherwise reluctant users.

14 Decision stage

GP1

GP1 memo

"Het martiniziekenhuis heeft dus al eens een keer zoiets doorgestuurd, een nascholingsavond waar je dan uitgelegd kreeg waar het werkt en waar je je in kon schrijven en ik weet dat de dermatologen in Drachten die volgens mij al, die The Martini-Hospital deden dat al in offered a training on 2004-5 ofzo" telemonitoringing

14 Decision stage "Alleen hun volgende stap was dus dat contract, en toen dacht ik van nu wil wil ik niet meer, want toen was het ook niet meer vrijblijvend want dan moest ik dus minimaal vier keer per jaar zo'n teleconsult doen, en daar heb dus echt geen trek in, want als ik dan geen vier teleconsulten heb, dan wordt het zoiets van dan máák je een tele-consult, om daaraan te voldoen omdat je anders een boete krijgt ofzo en dat ga ik niet doen"

14 Decision stage

GP2

About taking in new technology GPs are slow.

14 Decision stage

What do you look at when you decide on these products? 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? For the cardiac Companies try to thing we get force a decision with a money if we use it. contract, that has a You can make a negative impact on declaration to the the use of insurance telemonitoring company. Most of the times I take the decision when a patient has to use such equipment 15 Implementation 15 Implementation 15 Implementation 15 Implementation 15 Implementation stage stage stage stage stage

GP2 memo

GP´s take long to adopt new techonlogy

14 Decision stage

The GP takes the decision to use TM in the practice. His decisions are based on practical reasons such as space, implementation time and how costly the TM product is.

GP3

GP3 memo

The GP should be the most important one involved in the Companies should development seen convince the GP´s from the primary that is easy in use health care. and that there is Because he is able somting in for to motivate people them, because of to use the quick results equipment.

They can explain what’s in it for me if I use their products. And it is not too difficult to use. They explain what is in it for me as professional. It’s easy, you can use it quickly. We take care of it. You get result within 3 days. 14 Decision stage 14 Decision stage

The best way is a good rumour. If a colleague says something it has more implications compared to a brochure. I trust my colleague. If he says it’s good then I’ll try it. The best way to hear about it I think is by stories from patients who tell what is good with it 15 Implementation 15 Implementation stage stage

GP4

In the decision stage, comments from colleauges are more trusted than from brochures

GP4 memo

"Op zich is het natuurlijk niet raar als jij als bedrijf een bepaald product op de markt denkt te moeten brengen en dat je daarvoor gewoon probeerd om reclame te maken, en een van de vormen van reclame maken is dat als jij dus politici ervan kan Because GP´s are overtuigen dat jou important in the middelen, dat dat development, simpel is en hospitals focus on handig, dan them with training waarom niet?"

I think especially the hospitals go to the GPs with the new equipment, give advice, we can try it 14 Decision stage 14 Decision stage

A normal GP sees 30-40 people a day and you take 10-15 mins per patient, most days are filled. If you are going to start making your own ECGs it takes a quarter of an hour/half an hour – you can do it yourself or train your staff – and it is not that easy to integrate in a normal practice. I think that is a big problem in primary healthcare in general.

SP1

Desicions for GP´s depend on the positiblity to integrate it into their practice

14 Decision stage

SP1 memo

SP2

SP2 memo

SP3

SP3 memo

Companies should persuade politicians that telemonitoring devices can offer benefits in the medical industry

14 Decision stage

14 Decision stage

14 Decision stage

14 Decision stage

14 Decision stage

IND1 nijfinster "Nou ik weet dat Priscilla, een van jou collega's studenten, of ze is dan onlangs gepromoveerd op dit verhaal, heel veel moeite gehad, samen met ons en iemand van Kabel Noord, Gijs, en ik ben er ook betrokken bij geweest in het begin, heel moeite heeft gehad om dit van de grond te trekken, en dat komt gewoon omdat zo'n zorgorganisatie, je moet een professional vinden, dat was in dit geval de internist, nou die zag er wat in, dus die ging wel lopen, en dan moet je nog een of twee huisartsen vinden die daar dan ook echt wat in zien, maar dat heeft echt wel wat voeten in de aarde gehad voordat dat, alle kogels door de kerk waren en iedereen het ook zag zitten"

IND1 memo

14 Decision stage

14 Decision stage

"Je merkt bijvoorbeeld dat het ziekenhuis opzich wel wilde en de betrokken internist is ook hartstikke enthousiast, maar zo'n bestuurder van zo'n ziekenhuis zegt: ja, zolang de zorgverzekeraar niet over de brug komt met de tarieven; als wij niet vergoedt krijgen wat wij doen, he, ook al doen we dit via een scherm, dan gaan we dat ook niet breder uitrollen"

The health insurance infulences the desicionstage negatively, when other stakeholders already agree

It is hard to involve all parties that are needed, at least a specialist and an enthousiast GP should be persuated to become involved

15 Implementation 15 Implementation 15 Implementation 15 Implementation 15 Implementation 15 Implementation 15 Implementation 15 Implementation 15 Implementation 15 Implementation 15 Implementation stage stage stage stage stage stage stage stage stage stage stage

8

Category

MAN


Communcation channels in decision making processes

17 interpersonal communication

MAN memo



GP1



GP1 memo

GP2

16 Confirmation 16 Confirmation stage stage



GP2 memo



GP3



GP3 memo



GP4



9

GP4 memo



SP1

SP1 memo

SP2

SP2 memo

"Als jij een patient hebt die aan een meetappartuur hang, dan ben jij daar ook voor verantwoordelijk, dat betekend dus ook dat als de bloeddruk van een patient voor mijn part boven de 200 gaat, dat jij dan moet uitzoeken of er echt iets aan de hand is, of dat er gewoon storing van het apparaatje is"

The implementation of telemonitoring equipment might bring new and more responsibilies

"Ik denk voor de kaakchirurgie dat er niet meer te ontwikkelen is, hebt genoeg kaakchirurgen om Nederland te dekken zeg maar, dus zoals de zorg ingericht is heb je gewoon genoeg mensen die de acute dingen kunnen opvangen"

In dental-surgery there are not many innovations to implement







“De IC is natuurlijk een heel technisch terrein, waar veel innovaties worden toegepast. Daar worden ook constant nieuwe dingen getest maar die moeten ons niet in de weg zitten.” 17 interpersonal communication




SP3

SP3 memo

IND1 nijfinster IND1 memo "Maar waar je nu tegen aanloopt, want technisch gezien kan het meeste wel zo ongeveer, dat de implementatie in het zorgproces in het staande proces zoals een Implementing zorgorganisatie telemonitoring in a gewend is om te healthcare werken, binnen de organisation is kaders die ze ook hard; getting hebben financieel, everyone on a par, dat veranderen is discovering the een veel grotere boundries and the klus dan hoe doen rates, and how can we dat nou everyone technisch" collaborate "Die projectontwikkelingsfase heeft vrij lang geduurd, voordat dan, het zijn maar een paar neuzen, maar voordat die paar neuzen dan dezelfde kant op staan en iedereen dan denkt ja dit gaan we ook echt doen" "Daar loopt iedereen nu een beetje tegenaan, er zijn nog niet echt goed tarieven, de kaders waarbinnen je dat zou moeten doen binnen ons zorgstelsel die zijn er eigenlijk niet of nauwelijks" "Je kunt dit alleen doen als iedereen samen meewerkt in dit geval" 16 Confirmation 16 Confirmation 16 Confirmation stage stage stage "Het hele wereldje met ontwikkelingen in eHealth, gaat vrij snel, het geheel gaat natuurlijk langzaam, maar je kan niet met een projectje blijven zwaaien, dan moet je zelf ook door Conformation is naar het volgende, Getting affected by wheter doorpakken, of de conformation by it allows the organisaties om je showing results specialist to heen gaan weer from te past is not continue his work naar het volgende" enough 17 interpersonal 17 interpersonal 17 interpersonal communication communication communication

Category

MAN

I didn’t know him but he knew we had this problem. They are working together with Focus Cura who we are doing PAL4 together with.

MAN memo

Personal contact from industry to health organization through network organization was what initiated a new TM project

GP1

GP1 memo

GP2

They [specialists] try to keep us as suppliers for new customers. So they give trainings, I have to do 40hs of training every year to keep my license and they offer it. They also have special evening cycles, where they present themselves if there are new technologies or new developments in their working fields. Every year there is one afternoon and evening for better contact between specialists and GPs. The collaboration is good. I have direct numbers of them and they have special numbers for me.

There was a meeting and they [specialists] presented it. And then said that this is new development . This is good for the patients, and you as a GP can have this.

GP2 memo

Specialists update GPs on new developments in their field through mandatory sessions every months. There is a good, close collaboration.

GP3

The best way is a good rumour. If a colleague says something it has more implications compared to a brochure. I trust my colleague. If he says it’s good then I’ll try it.

The best way to hear about it I think is by stories from patients who tell what is good with it

I think the patients will push the GPs to use the TM products. If they have seen something, then the GP will say ‘let’ s have a look at this’.

GP3 memo

GPs listen to closely and are likely to try out of new technology if their patients or colleagues have had good experiences.

GP4

GP4 memo


New equipment, knowledge and technologies are often spread from hospital specialists via personal connections or emaillists and trigger many GPs to try it out. Pharmacies have close relationships with secondary stakeholders.

I think especially the hospitals go to the GPs with the new equipment, give advice, we can try it

I think it just goes by mail, and you also have some regular meetings with the specialists from the hospitals for GPs. Often it is started by a person who is more closely connected to a hospital and who talks with specialists.

10

SP1

SP1 memo

SP2

SP2 memo

SP3

SP3 memo

IND1 nijfinster "Nou ik weet dat Priscilla, een van jou collega's studenten, of ze is dan onlangs gepromoveerd op dit verhaal, heel veel moeite gehad, samen met ons en iemand van Kabel Noord, Gijs, en ik ben er ook betrokken bij geweest in het begin, heel moeite heeft gehad om dit van de grond te trekken, en dat komt gewoon omdat zo'n zorgorganisatie, je moet een professional vinden, dat was in dit geval de “Ik zelf niet, maar internist, nou die soms krijgt een zag er wat in, dus collega een die ging wel lopen, belletje van een en dan moet je huisarts met een nog een of twee "Veel van dit soort vraag of een huisartsen vinden dingen hebben probleem en die die daar dan ook altijd een bespreken dat dan echt wat in zien, commerciële en als er echt iets maar dat heeft bijsmaak, maar als is dan gaan ze echt wel wat zoiets vanuit de There is samen een There is voeten in de aarde universiteit communication oplossing zoeken communication gehad voordat dat, gebeurd zijn between hospitals of iets dergelijks, between GP´s and alle kogels door de mensen vaak and universities maar dat kan specialist, and with kerk waren en minder snel about medical natuurlijk ook via universities about iedereen het ook terughoudend" questions skype of zo” medical questions zag zitten" "De lijnen zijn “Waar we met natuurlijk vrij kort huisartsen kunnen hier, Kabel Noord communiceren bijvoorbeeld de binnen het moeder van ziekenhuis loopt Nijfinster, die zit het soms nog een zelf ook in beetje stroef met Dokkum, en alle huisartsen buiten mensen hebben het ziekenhuis, zoiets van ah ik maar ehm, dit valt kom wel even wel heel erg mee langs en ik vertel hoor” je nog wel even" “Natuurlijk komen er geregeld studenten langs met nieuwe dingen maar vaak gaan die naar de onderzoeksafdeling waar bijna alle artsen die daar rondlopen met hun scripties of onderzoeken bezig zijn, daar heb ik niet zo veel mee te maken”

IND1 memo

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

Category

MAN

MAN memo

GP1

GP1 memo

GP2

GP2 memo

GP3

GP3 memo









The industry is promoting it by mail. Every doctor gets a lot of spam. But you see it and you become interested and say ‘I want to know more about this. What I can do myself.’

On congresses and fairs and educational magazines for doctors that’s where they get there information Email promotion is from. Apart from used by the Kyos I have not industry and it very much works to trigger experience. And interested with some experimental GPs. groups.

Professional gathering such as congresses, experimental groups and fairs, and media as magazince are used to spread the info.

19 Systemized/ organized








GP4 GP4 memo Another important stakeholder would be the pharmacy of course. The pharmacies are very interested in developing their services. They often play an important role in diabetes and astma and should also play a role in TM, explaining people the use of the devices, introducing them. Because the difference between the pharmacies and the industry is much smaller than between the GP and the pharmacy. The pharmacy knows how to deal with the industry. That’s their job – buy medicine, see where it is cheapest. And beside that a lot of large organizations that sell the medicine to the pharmacies also have relations with a lot of other organizations. So it is much shorter connection for pharmacies. 18 mass media 18 mass media communication communication

I think it just goes by mail, and you also have some regular meetings with the specialists from the hospitals for GPs. There is a mailing list for GPs in the region about ECG and telemonitoring. I have been on the mailing list for 1015 years. It’s a general emailinglist that also concerns other topics than new technologies. It is mainly used for topics which affect all GPs. 19 Systemized/ organized

11

SP1

SP1 memo

SP2

SP2 memo

SP3

SP3 memo

IND1 nijfinster

IND1 memo





18 mass media communication “Eerlijk gezegd hoor ik ook vaak echt nieuwe dingen gewoon op het nieuws ofzo, helemaal niet in het ziekenhuis. Daar heb ik nog nooit zo over gedacht, maar dat komt natuurlijk ook omdat het gewoon zo groot is die medische wereld en dat er zo veel afdelingen zijn, in een ziekenhuis al”




Information about radical innovations in healthcare are featured on newsbroadcasts, more than in hospitals themselves

"Op momenten dat het relevant is doen we natuurlijk ook dingen in de pers, en op andere momenten gaat dit dan ook weer over"

On relevant moments information is released to the press





General email lists are used to share Info by specialists and industry about TM to GPs in the ZH region.






Category

MAN

PAL4 is a bridging organization between technology and care.


MAN memo

GP1

GP1 memo

Some initiatives are taken to bridging the gap between health and technology.


The healthcare world see a gap There is this gap between between the world themselves and of technology and technology, the world of care. caused by lack of They make knowledge beautiful things but (information) about we don’t know how what needs the to use the technology is technology. fulfilling.


"Ik weet dat het Martiniziekenhuis dat dan doet, maar die hadden dan een keer per jaar zo'n nascholing en die had ik dan gemist, dus toen dacht ik dan doe ik dat met hun"

"Ik stuurde het naar een dermatoloog, die zat ergens in het westen, want hier in het noorden deed nog niemand hieraan mee"


There are only few training moments and cooperating specialist are not close situated

GP2 They [specialists] try to keep us as suppliers for new customers. So they give trainings, I have to do 40hs of training every year to keep my license and they offer it. They also have special evening cycles, where they present themselves if there are new technologies or new developments in their working fields. Every year there is one afternoon and evening for better contact between specialists and GPs. The collaboration is good. I have direct numbers of them and they have special numbers for me.


GP2 memo

GP3

On congresses and fairs and educational magazines for doctors that’s A certain amount where they get of time every there information months and year is from. Apart from assigned to Kyos I have not provide GPs with very much new knowledge experience. And from local some experimental specialists. groups. One year there is congresses by NHG and in all regions there are schooling boards because GPs have to earn 40 points/40hs education every year. And that is a way to update the GPs on new developments.



GP3 memo

Industry make themselves present in medical events and media and by collaborating with the Dutch Association of Doctors

GP4

GP4 memo

SP1

"Ik heb niet de indruk dat er I think especially Hospitals spread mensen waren die the hospitals go to new TM to GPs in aan de telemetrie the GPs with the special meetings moesten maar niet new equipment, and via email and konden omdat er give advice, we provide advice and geen apparatuur can try it a chance to try it. was"

SP1 memo

SP2

Supply of telemonitoring equipment is structured

"In deze fase van mijn werk ga ik dan nog wel kijken in het ziekenhuis, maar ik weet bijvoorbeeld vanuit Zwolle waar de spoed artsen een grotere verantwoordelijkheid hebben waarbij de kaakchirurg thuis de foto beoordeeld en dan het verhaal erbij en dan wordt het onderzoek overgedragen dan telefonisch en dan moet er dan via de Structured telefoon een collaboration and afweging worden structured gemaakt of de roadmaps are patiënt wordt important when opgenomen of innovating in the niet" medical industry


"Eigenlijk moet je gewoon mensen van de werkvloer betrekken, bij een brainstorm in het begin en dan telkens betrokken houden" "Ik zou een groep specialisten die ongeveer hetzelfde belang hebben, waarbij de diensten ongeveer hetzelfde uitzien, zou ik daarbij betrekken" 20 Fragmented/ 20 Fragmented/ disorganized disorganized


"We werken heel veel met schap lijsten, digitaal, maar die vul ik dan in als de patiënt weg is, want ik vind het heel onpersoonlijk als je zo loopt te klikken dan als je ene vragenlijst af ga. Het lijkt naar een patiënt to wat minder hard en minder zakelijk als ik het gewoon op papier doe"

"Daar loopt iedereen nu een beetje tegenaan, er zijn nog niet echt goed tarieven, ICT is not used de kaders that much in waarbinnen je dat hospitals by zou moeten doen doctors, because binnen ons some things are zorgstelsel die zijn easyer to take care er eigenlijk niet of of in person nauwelijks" "Je moet natuurlijk met open standaarden werken, want je bent gek als je met dingen gaat werken die niet open zijn, dan beperk je je eigen markt uiteindelijk, maar daarvan denk ik daarvan walkeert het schip wel, dat lost de markt dan zelf wel op, daar hoef je niet zoveel in te investeren, maar wel in het verdienmodel en die schotten"

I think it just goes by mail, and you also have some regular meetings with the specialists from the hospitals for GPs.


How it is now? I don’t know. I don’t think that TM is so widely known among patients now. We don’t have much There is no information about information it. available about TM


I think in primary care itself there is not much development. At least I don’t see them.

There is a mailing list for GPs in the region about ECG and telemonitoring. I have been on the mailing list for 1015 years. It’s a general emailinglist that also concerns other topics than new technologies. It is mainly used for topics which affect all GPs.

12


There is not much development in primary care, aldough there is a way of communicating between local GP´s


SP2 memo

SP3

20 Fragmented/ disorganized “Het is nog niet echt vanzelfsprekend dat artsen in het "Een tandarts die ziekenhuis zoveel een röntgen beeld de computer doorstuurt om gebruiken als dat even mee te je je misschien kijken, daar wordt voorstelt, want met je toch niet zo Calls from dentist de computer zijn gelukkig van, je for help are not bepaalde dingen denkt wel zo van je appriciated and gewoon moeilijk en zet wel zo'n consults are dan kan je beter apparaat neer, conducted without even langs lopen snel geld the use of the bij wie je nodig verdienen, maar je computer because hebt, dat werkt het kan niet eens of the business like ook nog eens beoordelen" character of that sneller”

SP3 memo

IND1 nijfinster

IND1 memo

"Als je andere projecten in de zorg, als je het grootschalig neerzet, natuurlijk komt er dan even een Supply structured trainingsprogrammatje training to educate of een educatie stakeholders of traininkje" telemonitoring



There are no specified rates and boundries of telemonitoring, and training outcomese are not evaluated

Category

MAN

MAN memo

GP1

GP1 memo

GP2

GP2 memo

GP3

GP3 memo

GP4

GP4 memo

SP1

SP1 memo

SP2

SP2 memo

SP3

SP3 memo

IND1 nijfinster IND1 memo "Als je handelingen die nu beschreven zijn en ook op afstand zou kunnen doen, dat dat dan ook telt, dus voor mij, als ik dan iets via het scherm doe wat ik ook live kan doen, maar ik doe het via het scherm, dat ik daar dan ook gewoon mijn tarief voor krijg, hetzelfde tarief, want het is dezelfde handeling met dezelfde deskundigheid" "Er staat mij bij dat in het begin dat er ook een presenter package hete dat, dat je ook documenten kon uitwisselen met hetzelfde systeem maar of ze dat nou heel veel gebruikt hebben dat weet ik eigenlijk niet zo goed"

Stakeholders

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

21 GP

22 Patients

22 Patients

21 GP 21 GP "Zo'n huisarts heeft dan ook zoiets van wat betekend dat voor mijn praktijk en heb ik dan nieuwe verantwoordelijkheden, word ik daar dan op afgerekend of niet, kan ik dat consult, krijg ik dat nog vergoedt, of is dat dan het consult van de internist? Nou allemaal van GP's question the dat soort vragen, new way of die spelen in de working with eerste instantie telemonitoring, but een hele grote rol when enthousiastic in het: we willen they can pull the wel, máár" project "De internist en een van de twee huisartsen hebben de belangrijkste rol gespeeld. Deze huisarts was erg enthousiast en de andere was wat minder enthousiast, dan doet de meer enthousiaste natuurlijk iets harder mee, en de minder enthousiaste iets minder" "Dus ze deden wel allebei mee, maar de een had wat meer met het onderwerp en met het project dan de ander" 22 Patients 22 Patients

As a health care professional I can benefit from TM because it can support me and help me take the right decisions.

GP´s can benefit from TM because of its support and help in making desicions

GP can translate a Role of Medical problem into a Professionals: can product that the translate the industry could wishes of the end make. They can consumer to also translate to products that the patients how they industry can make could use TM

The GP should be the most important one involved in the development seen from the primary health care. Because he is able to motivate people GP can motivate to use the people to use TM equipment. systems

It can be the GPs role to advice the patients with what they can do with some equipment. I don’t think the GP is the most important. He is very close to the patient but not the most important.

22 Patients

22 Patients

22 Patients

22 Patients

22 Patients

22 Patients

22 Patients

"Ik ben de expert, je moet je niet vergissen dat er ook heel veel ego's rondlopen, dat is dan toch weer een ander slag dan de huisarts, dat daar ook heel veel "Dat is ook typisch frictie is tussen die iets wat dokters Telemonitoring can twee, dat is ook door andere improve the nog iets wat tegen mensen willen convenience for kan werken als je laten doen, want the GP and allows het inzet tussen de dan verdienen ze the GP to delegate huisarts en de meer geld" certain tasks specialist"

"Dingen die nu ook moeten en heel belangrijk zijn, maar met telemetrie gemakkelijker kunnen, dat is natuurlijk een kwestie van meer gemak voor de dokter en patient"

22 Patients

22 Patients

13

22 Patients

22 Patients

GP's have a difficult relation with specialist, that can slow down cooperation

"De huisartsen gaan er nu mee aan de haal, die schaffen allemaal zo'n ECG apparaat aan, die gaan dat dan door mailen, ik heb daar helemaal geen zin in"

22 Patients

22 Patients

22 Patients

Category

MAN

23 Industry

MAN memo

23 Industry

GP1

23 Industry

GP1 memo

23 Industry

GP2 Often it’s much easier if you make an appointment that someday between four and five a clock we can see together and see through some patients, and the dermatologist stays in the hospital – no travelling needed. That’s possible. And then you can save the patient from physically going there. And the patients are glad. If I propose that I can take a picture of it and send it to a specialist with a response within one or two days, they say ‘is that possible? Nice!’. They do not complain. Do not ask to see the specialist.

23 Industry

GP2 memo

GP3

GP3 memo

GP4

GP4 memo

23 Industry

SP1 memo

SP2

SP2 memo

SP3

“Ik denk dat patienten er ook wel wat aan "Je hebt ok hebben, vooral die mensen die vaak naar de bloedverdunners dokter of het gebruikern, die ziekenhuis moeten moeten dan een als ze dat ook keer per week hun vanaf thuis bloed controleren kunnen. Dat is veel en dan moet de efficienter voor de dosering van de patienten en de middlen worden Telemonitoring can "Ik denk dat de keren dat ze naar aangepast, nouja, be used for patiënt het beste af het ziekenhuis dat er daar echt patients that is als de The patient is best gaan worden ze wel dingen zijn demand contstant kaakchirurg hem assessed by a meteen geholpen. waar het nuttig zou treatment and can beoordeeld, ook s’ specialist, also at Ik zie daar wel wat zijn" make this easy nachts" night in” “Patienten zijn ook aan het veranderen hoor. Ik weet nog dat er mensen begonnen te zeuren over internet bij het bed en toen hadden wij thuis nog helemaal geen internet. Maar dat is nu wel anders hoor, nu hebben ze "Dingen die nu ook allemaal internet moeten en heel en een tv en zitten belangrijk zijn, ze de hele dag maar met achter hun telemetrie "De patiënt moet telefoon of ipad gemakkelijker centraal staan, ofzo, maar niet de kunnen, dat is maar ik denk dat mensen op de IC natuurlijk een het heel vaak te natuurlijk die kwestie van meer herleiden is tot liggen aan de gemak voor de zulk soort beademing en dokter en patient" mechanismen" kunnen niet veel”

If patients do not accept TM, it won´t work. Patients At the moment its should ask for TM driven by the in the doctors technology. If you office. Now they Patients that use ask the patients are not aware of TM recieve perhaps they have the cost they can benefits in the form other ideas. If they reduce, they of quick results don’t accept the should be and consulting systems, the TM, educated to know time reduction then it won’t work. whats in it for them

In another scale I think the medical professionals have to be pushed by patients. At this moment it is the other way around I think. Its Philips who is pushing the the doctors and the nurses are pushing the patients. And I think the patients ARE asking for TM. I don’t think the patients are very interested in how the care is cost effective. Not too much technology should be involved but the patient should understand that’s in it for him. I think the patients will push the GPs to use the TM products. If they have seen something, then the GP will say ‘let’ s have a look at this’. 23 Industry 23 Industry

SP1

23 Industry

14

23 Industry

23 Industry

23 Industry

23 Industry

23 Industry

23 Industry

SP3 memo

IND1 nijfinster

IND1 memo

23 Industry

23 Industry

Patients demand a new approach and treatment can be much easier for the patients

23 Industry

Category

MAN


24 Specialist

MAN memo

Some parts of the industry is involved in bridging the gap to the health world.

24 Specialist

GP1

"Dat is een organisatie en die heeft Ksyos, die doen dat wel meer, van dat soort dingen"

24 Specialist "En wat je natuurlijk wel heb, maar dat is ook weer iets anders, dat ehm bijvoorbeeld radiologen en cardiologen thuis dingen bekijken, deels fotos bekijken en ECG's bekijken, maar dan is de patient in het ziekenhuis, maar dan zijn de specialisten thuis"

GP1 memo

GP2

Ksyos is a companie that allows GP's to use telemonitoring services

What do the industry focus on? Always that it is better for our patient. You are a better doctor if you do this. Nothing about saving money. It’s the same as with the pharmacies: The pharmacies give you the feeling that if you do not give this tablet you are a bad doctor, because this is the best and you should give the patients the best. The advertising works.

GP2 memo

GP3

GP3 memo

Focuses on the value for the patient, íf you do not offer this you are a bad doctor´

In another scale I think the medical professionals have to be pushed by patients. At this moment it is the other way around I think. Its Philips who is pushing the the doctors and the nurses are pushing the patients. And I think the patients ARE asking for TM.

They can have the resources to respond to the wishes of the end consumer. And they can benefit from it. It cost something of course. And by industry I also mean all the research being done around them to give content to TM. 24 Specialist 24 Specialist

24 Specialist

24 Specialist

24 Specialist

Specialist like radiologist and cardilogist also monitor their patients from home

TM is moving inside the field of specialists which is very interesting for me to do, but it takes a lot of time. And if I do a thing like that it must be cost efficient.

Telemonitoring is more and more important for specialist

Companies should not only target the medical professionals but also focus on patients

GP4

For instance ECG is more interesting if you are in a practice with more elderly people. Who has most interest in making TM successful? The industry at this moment. I don’t think most patients are aware of the benefits of TM, the expectations with the GP are also quite low. Maybe a bit more with specialists. But especially the industry that are developing all the new devices. 24 Specialist

15

GP4 memo

SP1

SP1 memo

Companies are developing new technology, but should be aware where and how to distribute this

"Op zich is het natuurlijk niet raar als jij als bedrijf een bepaald product op de markt denkt te moeten brengen en dat je daarvoor gewoon probeerd om reclame te maken, en een van de vormen van reclame maken is dat als jij dus politici ervan kan overtuigen dat jou middelen, dat dat simpel is en handig, dan waarom niet?"

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

24 Specialist

"Dan heb je ook allerlei van die mensen van de farmcuitische industrie die allerei politici een beetje informeren en geld toe stoppen, weet ik veel wat, om gewoon de aandacht op bepaalde dingen te vestigen" 24 Specialist 24 Specialist

SP2

24 Specialist

SP2 memo

24 Specialist

SP3 “Bedrijven hebben soms zulke grote belangen om een bepaald procedé of medicijn te verkopen, omdat ze daar jaren onderzoek naar hebben gedaan, maar daar moet je als arts goed mee kunnen omgaan, anders krijg je van die situaties van een paar jaar geleden toen alle artsen de hele wereld over vlogen op kosten van de farmaceuten. Maar daar hebben ze nu regels voor gelukkig”

SP3 memo

24 Specialist

24 Specialist

IND1 nijfinster

IND1 memo

Companies have great stakes in selling medical treatments

24 Specialist "De internist en een van de twee huisartsen hebben de belangrijkste rol gespeeld. Deze huisarts was erg enthousiast en de andere was wat minder enthousiast, dan “Haha, maar dan doet de meer Specialist demand heb je wel met enthousiaste "Als er een foto the best medical specialísten te A specialist can be natuurlijk iets wordt genomen op systems, because maken, die hebben cocky, but harder mee, en de de spoedopvang, they can make the toch echt een heel telemonitoring can minder dan kan ik die best assesments eigen idee over take the sharp enthousiaste iets thuis beoordelen" and diagnoses dingen” edges of the work minder" “As specialist ben je natuurlijk eigenlijk nooit vrij, ook niet als je thuis bent, hoor. Dit kan "Stel dat ik over wel een beetje de een half jaar kom stress opvangen te werken op een als je daar echt plek waar dat niet mee zit. Ik zelf zit is, dat ik op er niet zo mee, dat afstand patiënten was de uitdaging kan beoordelen, die ik juist voor dan zou ik me erg ogen had, al komt druk maken dat er wel veel op mijn het er wel komt" pad” "Een tandarts die een röntgen beeld doorstuurt om even mee te kijken, daar wordt je toch niet zo gelukkig van, je denkt wel zo van je zet wel zo'n apparaat neer, snel geld verdienen, maar je kan niet eens beoordelen"

24 Specialist

Enthusiast specialists play an important role in the succes of a telemonitoring project

Category

MAN

MAN memo

GP1

GP1 memo




25 Other 25 Other stakeholders stakeholders

We see ‘the Informal care’ (family, neighbors) as very important. When the button is pushed, then the center (nurses) will call the family or the care, depending on the problem

From the healthcare's POV is family and relatives important stakeholders in the patients' experience of TM.

"Van dat soort dingen kun je ook met de plaatstelijke ziekenhuizen doen"

Hospitals

GP2

The specialized fields that we do is done by trained nurses. There is always a limit to my own experience in certain fields, so eg. The nurse who works in the room next to me and does all the diabetes patients, she knows more about diabetes on a practivcal level than I do now.

GP2 memo

GP3

GP3 memo

GP4

GP4 memo






Trained nurses, Insurance companies and hospitals

In the end, financially, I think it will be the insurance companies because they have to pay. When you can decrease the costs of care. They Insurance will have biggest companies, financial benefit. government

I think especially the hospitals go to the GPs with the new equipment, give advice, we can try it

16

Hospitals, Pharmacy and Insurance companies

SP1

SP1 memo

SP2 "Ik denk dat het heel erg afhankelijk is van hoe de zorg georganiseerd is, en dat betekend dat als jij heel veel uit handen gaat geven, naar nursepractitioners, verpleegkundige of mensen in opleiding of basisartsen en als specialist thuis kan gaan zitten he of dat je je visite loopt in je eigen hoofdziekenenhuis en in de dependance ook nog twee mensen hebt liggen kan ik mij voorstellen dat dat wel heel gemakkelijk kan zijn" "Ik denk wel dat specialisten daar bang voor zijn, dat lager opgeleiden, dat die er met de buit vandoor gaan, ik denk dat je daar niet per se bang voor hoeft te zijn maar ik denk wel dat dit soort mechanismen mee spelen" 25 Other 25 Other 25 Other stakeholders stakeholders stakeholders "Iets vergelijkbaars bij ons is, heel veel tandartsen schaffen dure röntgen apparatuur aan, en kunnen eigenlijk niet beoordelen en dan zeggen ze, ja kun je even naar die foto kijken, de policy bij ons op de afdeling is niet alleen geld, maar achter die foto hangt een patiënt, we zijn geen "Zorgverzekeringen radiologen, zo zijn zijn er natuurlijk bij we ook niet betrokken, want opgeleid, daar die moeten dat hoort een verhaal allemaal bij en een Health insurances onderzoek bij" vergoeden"

SP2 memo

SP3

SP3 memo

IND1 nijfinster

IND1 memo






Dentists

"Een zorgverzekeraar wil het wel betalen, “Ja ik begrijp het ze zijn er altijd op wel van de uit om hun zorg te ziekenhuizen dat verbeteren, het ze hun bedden het moet een liefste vol hebben kwalitatieve want dan hebben verbetering zijn, ze inkomsten, aangetoond het maar ik denk niet liefst, of het moet dat ze daar op efficiënter of gefocust zijn, dan goedkoper zou het er heel worden, anders uitzien in Hospitals, Politics, aangetoond, en Nederland” Universities het liefst allebei"

Health care organisations, health insurances, hospitals, health regulation from the government

Category

MAN


MAN memo

GP1

GP1 memo

GP2

GP2 memo

Some people are coming from home care services, and we took them in our services here as employees and then we trained them for the job. This lady and another one have done a special nurse practitioner post-master.

When bridging the world of healthcare and technology new stakeholders will appear.

GP3

GP3 memo


As a health care professional I can benefit from TM because it can support me and help me take the right decisions. Another one who can benefit from it is the insurance company because if you can prevent people from being treated that do not need it

Others

26 Politics

26 Politics

26 Politics

26 Politics

But our insurance company did not approve that so they said that all this pictures should be taken in our hospital. And that’s a new development. The hospital want to work as efficiently as possible. 26 Politics 26 Politics

GP4 GP4 memo Another important stakeholder would be the pharmacy of course. The pharmacies are very interested in developing their services. They often play an important role in diabetes and astma and should also play a role in TM, explaining people the use of the devices, introducing them. Because the difference between the pharmacies and the industry is much smaller than between the GP and the pharmacy. The pharmacy knows how to deal with the industry. That’s their job – buy medicine, see where it is cheapest. And beside that a lot of large organizations that sell the medicine to the pharmacies also have relations with a lot of other organizations. So it is much shorter connection for pharmacies.

SP1

SP1 memo

SP2

SP2 memo

26 Politics

26 Politics

17

26 Politics

SP3 memo

“Een ziekenhuis is en blijft heel hiërarchisch, maar iedereen heeft met elkaar te maken, alleen soms is het niet helemaal duidelijk bij welke afdeling verantwoordelijkheden liggen, vooral in dit soort dingen waarbij er iets op afstand wordt gedaan met patienten. “Nouja je ziet wat er met dat EPD gebeurt, de politiek is wel een beetje raar, het ene moment is het dit, het andere moment moet er dit gebeuren of kan dat niet meer. Misschien is dat hele zorg op afstand ook gewoon een hype en liggen er op heel andere gebieden kansen. Maar dat moet wel bekend zijn bij de politiek, en er moet niet domweg worden bezuinigd op wat er is opgebouwd in al die jaren. Dat moet heel aandachtig gebeuren en worden uitgevoerd” “Natuurlijk komen er geregeld studenten langs met nieuwe dingen maar vaak gaan die naar de onderzoeksafdeling waar bijna alle artsen die daar rondlopen met hun scripties of onderzoeken bezig zijn, daar heb ik niet zo veel mee te maken”

And then of course the insurance companies are very important. Sometimes insurance companies also pay for projects if you have a good idea.

26 Politics

SP3

26 Politics

26 Politics

26 Politics

26 Politics

26 Politics

26 Politics

IND1 nijfinster

IND1 memo

"Een ziekenhuis is er gewoon bij gebaat om hun bedbezetting gewoon in feite rond te hebben, dus als er iemand eerder naar huis kan omdat je zorg op afstand levert, voor wie doe je het dan?"

Dan moeten dus partijen als de gemeente, de verzekeringen en de zorgorganisaties veel meer samen moeten werken, en die hebben ook daarin: wie schiet er in wiens voet, of schiet je in je eigen voet" "Nog iets anders, dat is heel lastig in Nederland, we hebben de AWBZ, we hebben de WBO, en ziektekosten verzekering, en het kan heel goed zijn dat als je binnen de AWBZ iets doet, dat de besparing binnen de verzekering valt, of andersom"

26 Politics

26 Politics

Category

MAN

MAN memo

GP1

GP1 memo

GP2

GP2 memo

GP3

There are some ethical problems. We don’t use TM to monitor people with dementia at home for example. Why don’t we give them a foot and ankle device so we can leave those people? It’s a grey area but why don’t we experiment with it? The digital infrastructure also needs to be better and everyone needs a network connection, and at the moment it has to be very safe and have a too high standard. I was responsible for the dieticians as well, and wanted to make a teleconsult and make it very easy. The patient just google the dietician and then make a connection, very low standard. But it was not possible. It had to be more safe. Why should you make it so difficult if the patient is on accord with it and the dietician is on accord with it? When why bother about safety? Why not experiment with it?

GP3 memo

GP4

GP4 memo

SP1

"Wat ze zouden kunnen doen is dokters bezoeken, praatjes op congressen en natuurlijk lobbyen bij politici, omdat te propageren, maar bij de dokters zelf ook wel"

Some treatments and experiments are not considered to be politicly favaroble.

"Dan heb je ook allerlei van die mensen van de farmcuitische industrie die allerei politici een beetje informeren en geld toe stoppen, weet ik veel wat, om gewoon de aandacht op bepaalde dingen te vestigen"

18

SP1 memo

Companies could lobby in politics to focus attention on telemonitoring

SP2

SP3 “Nouja je ziet wat er met dat EPD gebeurt, de politiek is wel een beetje "Uiteindelijk draait raar, het ene het in de zorg heel moment is het dit, vaak om geld, en het andere ik denk dat moment moet er niemand te dit gebeuren of beroerd is om in kan dat niet meer. acute situaties op Misschien is dat dit soort hele zorg op technieken de afstand ook gemakken van te gewoon een hype hebben, maar ik en liggen er op denk dat op het heel andere moment dat dit gebieden kansen. standaard wordt, Maar dat moet wel en dat huisartsen bekend zijn bij de ECG's gaan politiek, en er moet draaien en dan niet domweg een ECG worden bezuinigd declareren en op wat er is vervolgens een The relation opgebouwd in al cardioloog dat niet between GP's and die jaren. Dat moet meer kan doen, specialists is the heel aandachtig dan krijg je field of gebeuren en gewoon scheve subcutaneous worden gezichten" politics uitgevoerd”

"Ik denk wel dat specialisten daar bang voor zijn, dat lager opgeleiden, dat die er met de buit vandoor gaan, ik denk dat je daar niet per se bang voor hoeft te zijn maar ik denk wel dat dit soort mechanismen mee spelen" "Dat geld ook voor de huisartsen hoor, de uroloog die het niet leuk vind dat de huisarts sterilisaties doen, en de dermatoloog die er niet blij van wordt dat de huisarts allemaal dingen eruit snijd, en dan: oh toch kwaadaardig, of dat die dermatoloog zegt van dat had ik van honderd meter afstand kunnen zien dat het kwaadaardig was"

SP2 memo

SP3 memo

IND1 nijfinster

"Je merkt bijvoorbeeld dat het ziekenhuis opzich wel wilde en de betrokken internist is ook hartstikke enthousiast, maar zo'n bestuurder van zo'n ziekenhuis zegt: ja, zolang de zorgverzekeraar niet over de brug komt met de tarieven; als wij niet vergoedt krijgen wat wij doen, he, ook al doen we dit via Politic parties een scherm, dan should be aware of gaan we dat ook the possibilities of niet breder telemonitoring uitrollen"

"De zorg, het zijn allemaal eigenwijze professionals, specifieke mensen zijn het, en ze zijn ook opgeleid om zelf deskundig te zijn over hun eigen vak en het liefst ook nog over wat een ander met jouw patiënt zou moeten doen, dus dat zijn niet de mensen die je nou eens even makkelijk hup zo dezelfde kant op draait, nee het zijn eigenwijze mensen, maar dit moeten ze ook zijn"

"Er zijn ook wel voorstellen gedaan, naar de Nederlandse zorgautoriteit, zo van als je met zorg op afstand iets wil dan moet je het op die en die manier doen, nou dat betekend dat je een stelselwijziging moet doorvoeren en daar moet je dan als ministerie maar op zitten wachten"

IND1 memo

Because of the high stakes in the choice of medical care, there are effects of subcutaneous politics, between hospitals, specialist, GP's and the govenment

Category

MAN

MAN memo

GP1

GP1 memo

GP2

GP2 memo

GP3

GP3 memo

GP4

GP4 memo

27 Role of GP

27 Role of GP

27 Role of GP

27 Role of GP

27 Role of GP

27 Role of GP

27 Role of GP

27 Role of GP

27 Role of GP

27 Role of GP

"Ik zeg wel dat we dat gaan doen, je moet ook wel een vakje aankruisen dat je dat met toestemming van de patiënt doet, dus dat moet wel, en zeker toen ik erachter was dat zij daar dus een rekening van krijgen"

"Er zijn al mensen die al een bloeddruk meter aanschaffen, die kopen hem dan gewoon zelf, en dan zeg ik tegen ze: dat moet je gewoon niet doen, dat moet je hooguit een keer per drie maanden doen, en als ie goed ingesteld is dan zeggen de richtlijnen dat je dat een keer per jaar moet doen, maar dan wel goed"

"Dat ligt wel een beetje aan de wijk, want als ik zeg van dat gaan we zo doen, dan doen ze het"

GPs mainly follow development in TM, do not initate it, because of a lack of time and expertise. GPs do advice patients to GP's have to get the Our role as GPs in take TM solutions approval of patients to specialized TM and take work use telemonitoring, products is to be away from the but can also pursude followers, not specialist by using them to use it developers. TM solutions

The nurse who works in the room next to me and does all the diabetes patients, she knows more about diabetes on a practivcal level than I do now. So we also need people to support us. My role as GP is more in the background.

I don’t see GPs playing a more active role in TM. Because of lack of time and expertise

Because the doctors are educated that way, they are in the end responsible for the patient. And they translate it into I’m responsible so I have to see the patient. Doctors in general are very conservative. They don’t follow your books until they know that it works. A good example is the echograph. For a long time doctors still used the xrays next to the echographs to be sure and it took a long time to ban the x-rays in favor of the echographs. When I was educated we used both. Dutch doctors are very conservative in adopting new technology.

It can be the GPs role to advice the patients with what they can do with some equipment. I don’t think the GP is the most important. He is very close to the patient but not the most important.

GP´s are responsible for their patients, they can advice what TM can do for them. In the future he should have a bigger key function in medical care


Often a few GPs have a special interest and they start. When it’s working well you gradually see that more GPs start using it. In first instance it’s mainly driven by GPs’s own interests. The general picture of the future of healthcare is that there is a substitution of care from the hospitals to the primary care. That’s is also happening because of money. Hospital care is more expensive, which means that especially a lot of people with chronic diseases that are now in going to the hospital to meet a specialist will in the future be seen by the GP and left to his responsibility. In the future the GP is going to have more chronic patients.

19

SP1

27 Role of GP "Ik denk ook eigenlijk niet dat patienten door een doctor moeten worden overgehaald, ik zou niet weten waarom eigenlijk, je hebt natuurlijk patienten die het griezelig vinden om met zo'n kastje rond te lopen, dan GP is the most zal de dokter wel important in the proberen de development of patient te TM, he can overtuigen, maar motivate the use it. om iemand over te In the future the halen heb je altijd GP will get more het gevoel dat de responsibilities and dokter er een treat more chonic persoonlijk belang patients bij zou hebben"

SP1 memo

SP2

SP2 memo

SP3

SP3 memo

27 Role of GP

27 Role of GP

27 Role of GP

27 Role of GP

27 Role of GP

IND1 nijfinster IND1 memo "Je schiet in je eigen voet al snel, dat geldt voor een thuiszorg organisatie op dit moment net zo, als een thuiszorgorganisatie hun eigen werk beter en efficiënter kan doen door dingen op afstand te doen, en de productie wordt daardoor minder, dan schiet je in je eigen voet" 27 Role of GP 27 Role of GP

GP's can select patiets for telemonitoring, discuss with specialist, and work out easy tasks that were first specialist tasks

"Zo'n huisarts heeft dan ook zoiets van wat betekend dat voor mijn praktijk en heb ik dan nieuwe verantwoordelijkheden, word ik daar dan op afgerekend of niet, kan ik dat consult, krijg ik dat nog vergoedt, of is dat dan het consult van de internist? The GP has the Nou allemaal van task to form the dat soort vragen, new possiblities die spelen in de into a workable eerste instantie concept, and een hele grote rol become a in het: we willen ambassador of wel, máár" telemonitoring

“Een huisarts kan misschien kijken welke patiënten dit kunnen gebruiken om het wat makkelijker voor die mensen, maar dat ligt een beetje aan wat de GP's can pesuade "Verantwoordelijkheid mogelijkheden zijn patients to use model is ook voor die huisarts, telemonitoring, but belangrijk naast misschien vind hij should also het verdien model, het wel heel fijn consider the wie zegt me dat The GP should get om die mensen te responsibilities and die huisarts de a certification zien als er weer the new ways of datastickers goed when working with iets aan de hand working geplakt heeft" telemonitoring is”


“Wat natuurlijk ook een goede is dat de huisarts klusjes doet die de specialisten alleen tijd kost en die de huisartsen ook nog wat geld opleverd terwijl het maar heel weinig werk is. Maar dat kunnen alleen de taakjes zijn die echt zonder specialist kunnen, want anders krijg je problemen met wie is er verantwoordelijk en wie krijgt waar voor betaald”

"Dat is ook de weerstand die je bij verzorgende en verpleegkundige ziet, die hebben allemaal een beeld van hun vak en zeker de mensen die er al zitten waarom ze daarvoor hebben gekozen, hebben ze een beeld van hun eigen hulpverlener zijn, en als je een deel daarvan invult met ook techniek, dan zeggen ze: zo hoort, zo moet het niet"

"En wat een dokter tegen de ene mens zegt, dat zegt die ene mens tegen andere mensen, de dokters dragen dus ook een soort propagana werk uit, om hun eigen brood zeker te stellen"

“Ik zelf niet, maar soms krijgt een collega een belletje van een huisarts met een vraag of een probleem en die bespreken dat dan en als er echt iets is dan gaan ze samen een oplossing zoeken of iets dergelijks, maar dat kan natuurlijk ook via skype of zo”

"Dat was al vanaf het begin van de ontwikkeling, maar dat heb je altijd in projecten, de een doet net even wat harder mee en rent net iets harder voor dingen dan de ander, dat is maar net waar je hart naar uit gaat, maar ze hebben wel samen besloten om het te doen"

Category

MAN

MAN memo

GP1

"Dat hoor ik soms dat dat op andere plaatsen anders is, zoals in Haren, dat is een beetje het Wassenaar van het noorden, dat dat daar ook wel een beetje anders gaat, dat geloof ik dan ook wel" "Over opzoeken op internet, bij mij is het zo of ze zoeken het niet op of ze zoeken het op en ze snappen er geen bal van, vooral als ze op een of ander forum terecht komen, en dan heb ik zelf een website en die linkt door naar informatie van het NHG, dus dat raad ik ze dan aan"

GP1 memo

GP2

Most of the times I take the decision that someone has to use such equipment

GP2 memo

GP3

GP3 memo

GP4

The role of GPs in the future depends on how we want to organize the healthcare system. I’m a big supporter of the GP as having a key function. The gate keeper. I don’t want free admittance to hospital care. He’s the front officer of the healthcare system.

GP4 memo

SP1

"Een dokter die de hele dag achter een schermpje zit om te kijken hoe het met patienten gaat, dat lijkt me een vreselijk bestaan, voor zowel de patient als voor de dokter"

So in most cases where TM is used in the practice the GP is the one who takes the decision to use the TM product. Most times they [modern doctors] are married to a partner who also have good financial situation. So there is no need to work so hard and so much. What we do here is to make a substitution. Not everything that a doctor does is a doctors work. A nurse can tell you. They do chronic healthcare. So it is delegating so that the doctors can do the complicated stuff. We had connection to Careyn, because we believe that in the future doctors and nurses should work together as much as possible. So they need medical information if they have to treat patients. And we need nurses and soon as a nursing problem comes up. if it is not a medical problem but more the care situation then I need a nurse to arrange it.

20

SP1 memo

SP2

SP2 memo

SP3

SP3 memo

IND1 nijfinster IND1 memo "Wie zou nou de ambassadeur van zorg op afstand kunnen zijn, ik denk niet dat je een actor kunt aanwijzen, ik denk wel dat het belangrijk is dat elke zorg verlener, wie je ook bent in de keten, de huisarts, of de verpleegkundige die daar over de vloer kont of een ziekenhuis, dat als je met dit soort dingen bezig bent en je weet de waarde daarvan, dat je daar dan de ambassadeur van bent"

Category

MAN

MAN memo

GP1

GP1 memo

28 Barrier

28 Barrier

28 Barrier

28 Barrier

GP2 GP2 memo Does the new technology enable you to take over specialist areas that you were not able to do before? Yes you can keep the patient in your own practice with you longer before you have to wait for a specialist. I think it is a good thing, because specialized treatment is very expensive. Is the role between GPs and specialists changing? Yes, somehow. If I’ m doing echogrammes the radiologist in the hospital is not happy. I take work from him. But what we do as GPs, to have our routine jobs done by other people, that is what the specialist is doing now. Routine jobs are referred back to the GP. And the patient stays in my hands. The specialist is only giving advice and I continue the relation with the patient. And that’s the new way things are going. What is the role of the GP in TM? He’s not in the front line anyhow. Not at all. The GP is following. If things are developed and they are ready, then we can take it into our practice. It’s the same when I make a reference to the hospital. They want to know what the real problem is before the person enter. So if I have someone with memory problems – is it Alzheimer or not? – then I fill in a form on the internet, and they ask me to hand out a paper from the lab to certain tests. So I have to 'precook' the patients before they start the treatment. In a GPs office you are healthy until we suspect that there could be something wrong. In a hospital you are a patient and you have a disease until they have skipped away all the possibilities and say ‘we cannot find anything’ so you must be healthy. 28 Barrier 28 Barrier

GP3

GP3 memo

GP4

GP4 memo

SP1

SP1 memo

SP2

SP2 memo

SP3

SP3 memo

IND1 nijfinster

IND1 memo

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21

Category

MAN

MAN memo

The gap of shared understanding between technology companies and healthcare makes it difficult to spread TM from one side to the other. Currently the There is this gap machines between the world represent all the of technology and things that the the world of care. carer despise, and They make are seen as beautiful things but solutions in we don’t know how opposition to to use the improved health technology. care.

‘Caretakers’ are people working with people and not with machines. So it is almost a cultural problem I think. Carer people want to have personal contact, and everything that is decreasing that contact they don’t want to use. There is resistance to think about and to use this kind of machines.

GP1

"Alleen daar waren dus wel, daar had ik dus helemaal niet bij stilgestaan, daar krijgen de patienten dus een rekening van, dat het specialistische zorg is, dus dat valt dan niet meer onder huisartsenzorg"

"dat doe ik nu eigenlijn niet meer want op een gegeven moment moest ik daar een contract voor tekenen, dat ik dat met hun deed en dan moest ik dan ook vier keer per jaar sowieso doen, en toen werd het mij een beetje irritant, dan ga ik het niet doen"

GP1 memo

- Patients get the bill for telemonitoring, because of the specialistic character of the treatment

- Contracts force GP's to conduct telemonitoring treatment more times a year

GP2 What are the main benefits for GPs in using TM? Difficult to say because the development comes from specialized clinics. If you come from a specialized clinic then you have a lot of patients, and you have a good environment for testing and using TM. I also have some heart failure patients, but most of the time they stick to their specialist. And even if I want to take over I have a big problem with logistics and experience. You need money, you need a central that can lead everything. We don’t have the volume of patients to set up such a complicated system

GP2 memo

We also have smaller locations where it is more difficult for doctors to go to and I don't know why the doctors don't send the nurse practitioner with a camera more often instead of going there themselves. they feel they have to be there themselves to see, and smell the patient, too look at - Money, logistics, the general picture experience and not only the central wound. that's the coordination lacks way they are to implement TM educated.

What the doctors have to learn now is to trust other people, trust the nurses. That they can also get info about the patients. And you also have to look at the wound from a picture and start a treatment. I think most of them find that very difficult. They find it very difficult to delegate work.

I don’t see GPs playing a more active role in TM. Because of lack of time and expertise

PAL4: At the moment there is not so much going on, because there is not enough people who have the system. At the moment 5-6 persons. They need 20-30 to make it work

For the development of TM in the same way [as spirogramme] it is difficult, because it is a limited subject. For instance people with heart failure. In the hospital they might have 200 patients, here we might have 10. That’s not enough to make a platform for the new development to rise.

GP3

GP3 memo

GP4

One of the big problems in primary health care, and that is also blocking for the development, of TM is that the persons who should start the development, who should put their energy into it are GPs because they - (Older) doctors have the overview, need to see the they have the patients in person, responsibilities to not only from a treat people. And picture they have no time.

GP4 memo

SP1

- Initiatiors of innovation actually have no time to do this, because they are teating people

"Het gevaar wat ik wel zie is dat je het gaat uitbreiden naar allemaal dingen die onzinnig zijn, die je anders niet zou doen, omdat het met telemetrie makkelijk is om bij te houden"

It is not very good arranged how the financial procedures are. When you give an advice through a computer to a patient you can’t send a bill to the insurance company. When you have a phone call with a patient you can send the - (Older) doctors bill to the have established a insurance trust relation with companies. If you their co-workers, do it via internet it - No well aranged TM might disturb is not well financial this arranged. procedures

- There are not enought people that have the PAL4 system, we need at lest 20/30 to make it work

The doctors want to get the whole picture. And that why they find it difficult to use this telemonitoring equipment.

As often in primary healthcare money and time are some of the barriers for making these solutions work. Money is a problem if you can’ t send a declaration for the work you do, then you don’t have much motivation to - Big barriers are do it. money and time

- Medical centres are too smaal to start pilots with TM, compared to hospitals

That makes it difficult to use TM for this specific group [of elderly patients], because you are dealing with patients with multiple problems. Especially with elderly you have to see the whole patient. You can monitor e.g. the ECG when you have first seen the patient, but you can’t diagnose only based on the ECG.

A normal GP sees 30-40 people a day and you take 10-15 mins per patient, most days are filled. If you are going to start making your own ECGs it takes a quarter of an hour/half an hour – you can do it yourself or train your staff – and it is not that easy to integrate in a normal practice. I think that is a big problem in primary healthcare in general.

- Treating elderly patients with TM can be difficult because of patients dealing with multiple problems

22

- TM is not eays to integrate in a normal practice offering primary healthcare

SP1 memo

SP2

"Als je een consult doet moet je de hele patiënt zien, dat gaat ook over mijn vak, bij een dermatoloog is het natuurlijk heel - Proliferation of vaak van nou als treatments that je het ziet dan kun could be done with je al wat zeggen telemonitoring, that op basis van de nonsensical eerste indruk" "Dat geld ook voor de huisartsen hoor, de uroloog die het niet leuk vind dat de huisarts sterilisaties doen, en de dermatoloog die er niet blij van wordt dat de huisarts allemaal dingen eruit snijd, en dan: oh toch "Dan gaat het kwaadaardig, of apparaat de hele dat die tijd registreren en dermatoloog zegt ongewenst - Patients might van dat had ik van alarmeren, raken panic because of honderd meter mensen in paniek false alarm of the afstand kunnen terwijl er niets aan telemonitoring zien dat het de hand is" equipment kwaadaardig was"

SP2 memo

SP3

SP3 memo

IND1 nijfinster

IND1 memo

"Daar loopt iedereen nu een beetje tegenaan, er zijn nog niet echt goed tarieven, de kaders waarbinnen je dat zou moeten doen - There are no set - No interaction on binnen ons rates for distance possible zorgstelsel die zijn conducting due to the nature er eigenlijk niet of telemonitoring of the treatment - nauwelijks" treatments "Zo'n huisarts heeft dan ook zoiets van wat betekend dat voor mijn praktijk en heb ik dan nieuwe verantwoordelijkheden, word ik daar dan op afgerekend of niet, kan ik dat consult, krijg ik dat nog vergoedt, of is “Samenwerken is dat dan het consult wel een goede, van de internist? maar natuurlijk Nou allemaal van moet dat niet ten dat soort vragen, - Uncertainties in - Specialist are not koste gaan van je - Specialist want to die spelen in de responsebilities happy with the werk en van de cooperate but that eerste instantie and effects of specialized rest van de tijd, should be at the een hele grote rol telemonitoring limit treatments that want je zit er al zo expence of in het: we willen the willingness to GP's perform veel” working time wel, máár" innovate “Wat lastig kan zijn is de afstemming op de functies "Nog iets anders, binnen de IC en op dat is heel lastig in "Dan heb je andere afdelingen, Nederland, we verzekeraars, en nu weet iedereen hebben de AWBZ, dan zeg de wat ie moet doen, we hebben de cardioloog van ik maar bij nieuwe WBO, en kan alleen maar dingen of ziektekosten een eerste consult reorganisaties gaat verzekering, en het declareren, of wat altijd heel veel fout kan heel goed zijn mág ik declareren, en dan hoor je het - Medical staff is dat als je binnen ik kan in ieder - Rules and later in het nieuws, afraid for de AWBZ iets geval niet mijn regulations about misschien gaat het reorganisations doet, dat de ECG declareren declaring daarom niet zo that might couse besparing binnen - It is uncertain want ik heb dat treatment do not snel, dat zou faults in the de verzekering where innovations niet gedraaid" exist kunnen” system valt, of andersom" have effect "Uiteindelijk draait het in de zorg heel vaak om geld, en ik denk dat niemand te beroerd is om in acute situaties op dit soort technieken de gemakken van te hebben, maar ik denk dat op het moment dat dit “Misschien wordt standaard wordt, het op de lange "Als je en dat huisartsen termijn anders componenten van ECG's gaan maar nu lijkt het dat tarief draaien en dan me wel lasting om veranderd, maar je een ECG zulke dingen door weet nog niet wat declareren en te voeren, meer daar het effect van vervolgens een met de computer is dan weet je dus cardioloog dat niet gaan doen, want ook niet zo goed meer kan doen, mensen zijn wat het tarief moet dan krijg je gewend hoe het nu zijn, daar stoeit - The effect of gewoon scheve gaat en het gaat iedereen nu changes in rates is gezichten" goed” ontzettend mee" uncertain “Maar in mijn baan heb ik er toch maar weinig mee te maken want ik ben het grootste gedeelte met de mensen - Patient can only persoonlijk bezig be assesed well in en veel dingen kun person, not on a je toch niet op distance afstand doen”

Category

MAN

MAN memo

GP1

GP1 memo

It takes time to introduce them to your practice so everybody knows how to do it. And the refund is never so much that I get a profit out of it.

"Dat gaat dan van je no-claim af" "Voor de mensen die dit als enige sociale contact hebben, die kunnen waarschijnlijk dit ook niet zelf doen, dus dan móet de zuster wel langs komen, het is vooral voor de jongere vitalere mensen, van 50 die dingen willen doen en niet elke 3 dagen geprikt willen worden"

GP2

- People that need personal medical care, can not work with telemonitoring

GP2 memo

GP3 The infrastructure also needs to be better and everyone needs a network connection, and at the moment it has to be very safe and have a too high standard. I was responsible for the dieticians as well, and wanted to make a teleconsult and make it very easy. The patient just google the dietician and then make a connection, very low standard. But it was not possible. It had to be more safe. Why should you make it so difficult if the patient is on accord with it and the dietician is on accord with it? When why bother about safety? Why not experiment with it?

It depends on the problem. If you have a headache I think you would be happy to be able to speak to the specialist with focus on headaches. Then you know you have the best. If the problem is complicated.

At the moment its driven by the technology. If you ask the patients perhaps they have other ideas. If they don’t accept the systems, the TM, then it won’t work. Doctors in general are very conservative. They don’t follow your books until they know that it works. A good example is the echograph. For a long time doctors still used the xrays next to the echographs to be sure and it took a long time to ban the x-rays in favor of the echographs. When I was educated we used The equipment is - Equipment is both. Dutch very expensive, expensive, there doctors are very you need a lot of are a lot of people conservative in people and a lot of needed and a lot adopting new training. of training technology.

The GP is not so important for the TM industry. He is more important in eHealth, but in general eHealth and specialized things (TM) can grow much easier in surroundings of big masses of people who are having the same problem. And I’m general.

You can’t declare much [for TM or email consults]. It [Main barrier] is routine, and of course you need an incentive.

GP3 memo

GP4

- The quality of the infrastructure is not good enough and safety is important

GP4 memo

SP1

SP1 memo

SP2

SP3

“Ik denk dat de kosten voor een aantal dingen in de medische wereld overdreven zijn, maar dat heeft allemaal met testen en veiligheid te maken, al zijn sommige producten gewoon echt gemaakt voor de winst denk ik. Maar dat zorgt er ook voor dat het implementeren van zulke systemen "Verantwoordelijkheid gewoon heel veel model is ook geld kosten, en als belangrijk naast niet duidelijk is het verdien model, - Specialist are not waar dat geld wie zegt me dat comforable with vandaag komt dan die huisarts de the resposibilities gaan zulke datastickers goed of GP's in plannen gewoon geplakt heeft" telemonitoring niet door”

- If patients do not accept TM, the system does not work

"Dat de ziekte vaak minder erg is dan de angst voor de ziekte" In princiepe ben ik niet zo voor, in mijn ervaring, mensen die zich erg zorgen maken over hun gezondheid, en daar intensief mee bezig zijn, met is mijn bloeddruk wel goed en dat soort dingen, dat die mensen eigenlijk veel meer lijden van die angsten en van de paniek enzo, dan van het echte ziektebeeld

"Op het moment dat er een financieel gewin speelt, dan gaan - Because of this er misschien weer kind of equipment, heel andere patients suffer dingen werken, more from the fear dan de focus niet of being ill, than of meer op de patiënt being ill ligt"

- Doctors are very conservative in adopting new technology


"Er zijn heel veel mensen en die zijn ook wel innovatief, maar dan als er geen geld uit het rijk of de raad van bestuur, subsidies komt, dan raken mensen erg gefrustreerd, en dan is het ook snel klaar"

- The rate are too low, there is no incentive

"In 90% zal er waarschijnlijk niets aan de hand zijn, en dan wordt je dus de hele tijd door allerlei piepjes gestoord, maar je kan ze ook niet negeren en jij hebt een registratieapparaatje- 90% of the bij je staan, dat lijkt aberrant data is mij iets gruwelijks probably fine, but it om allemaal can not be ignored schermpjes na te by the medical moeten kijken" staff

23

SP2 memo

- Medical staff is obliged to investigate every (wrong) output of the telemonitoring equipment

"Iedereen is bang om geld te verliezen, echt hoor, dat is heel verschrikkelijk, maar dat hoor je echt"

- Money can be a limiting factor in the application of telemonitoring

“Eigenlijk helemaal geen slecht idee, alleen moet je dan bereikbaar kunnen zijn en als je op de IC staat ben je dat toch minder dan dat je koffie zit te drinken of thuis”

“Waar we met huisartsen kunnen communiceren binnen het ziekenhuis loopt het soms nog een beetje stroef met huisartsen buiten het ziekenhuis, maar ehm, dit valt wel heel erg mee hoor” “Het is nog niet echt vanzelfsprekend dat artsen in het ziekenhuis zoveel de computer gebruiken als dat je je misschien voorstelt, want met de computer zijn bepaalde dingen gewoon moeilijk en dan kan je beter even langs lopen bij wie je nodig hebt, dat werkt het ook nog eens sneller”

SP3 memo

IND1 nijfinster

IND1 memo

"Tja, conservatisme, je schets een houding van huisartsen, maar - Implementation dat is in de hele of telemonitoring zorg wel, ziet het cost a lot of er een beetje zo money, and it is uit, er zitten ook te - Medical industry not sure where this weinig prikkels bij has a consevative money comes from om het nu te doen" attitute

- In IC units doctors do not have time to react on telemonitoring emergencies

"Je schiet in je eigen voet al snel, dat geldt voor een thuiszorg organisatie op dit moment net zo, als een thuiszorgorganisatie hun eigen werk beter en efficiënter kan doen door dingen op afstand te doen, en de productie wordt daardoor minder, - Working more dan schiet je in je efficient may prove eigen voet" less profitable

"Eigenlijk heb je als thuiszorgorganisatie, - Communication als je puur between specialist bedrijfseconomisch and GP's can be kijkt, geen belang difficult om dat te doen"

"Dat zijn weerstanden in de zorgcultuur, in de beroepsethiek, dat heb je niet zomaar overwonnen, daar ligt ook zeker een crux"

Category

MAN

MAN memo

GP1

GP1 memo

GP2

GP2 memo

GP3

GP3 memo

GP4

GP4 memo

SP1

SP1 memo

SP2

SP2 memo

"Stel dat je iets in je mond hebt, een plekje, dan wil je daar aan voelen. "De ene kant van Dat klinkt heel gek, de zaak is dat het maar stel iets wat misschien wel een kwaadaardig is beetje nederlandse voelt vaak heel erg instelling is in verhard aan en vergelijking met iets wat niet Duitse mensen, kwaadaardig is die hebben heel voelt vaak heel andere zacht aan, en ik opvattingen, die - Dutch people are zou dus op basis zijn veel meer met less concerned van een plaatje hun gezondheid with their health, niet zo snel een bezig dan than for example uitspraak durven nederlanders" German people doen"

29 Enabler the reason to go to a care home is mainly because of the need of help in unexpected moments. And if we can provide the same kind of help in the home care then people can decide to stay at home longer. And it is necessary because they group of greying people is growing. At a certain moment there will not be enough rooms in the care houses, and people will have to stay at home,

The manager of the medicine dispenser company came to me and said that they had the solution.

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 others problems - e.g. through personal communication.

29 Enabler

29 Enabler

29 Enabler

29 Enabler

29 Enabler

If you make an email consult as a visit then they might change very quickly. And I think the other ones will pick up quite quickly. I don’t think they can And the GP is declare an email supported by these consult and if they organizations [who can they can only take care of declare it as a logistics, etc.] so - GP´s can join a teleconsult, which you can do a lot TM program where is half or a quarter more. You join a he is supported in of a face-to-face kind of program. his work consult. If the doctor can benefit quickly from it then it’s easier to change. Quick diagnoses. Saving time. Then he can do other things with his patients. It’s time consuming if you want to make a diagnose or a treatment, then you have to wait a day on your lab results. If you can have it instantly you can go on with your process. It’s much easier. Then the time is very short. Then you don’t have to think all the time about ‘I have to go to her’. That’s why doctors are so fond of all these dipsticks and so on. Doctors just want a stick they can put in. Afterwards they (...) there is a can send it to the higher threshold. lab and meanwhile You need to take go on with the the boat to go to treatment, without see a specialist [if - Working with TM having to wait 2-3 you live on the on an island is days. That makes islands]. more efficient it easier.

29 Enabler

- Visual consult can be more rewarding for the doctor

29 Enabler

For instance ECG is more interesting if you are in a practice with more elderly people.

There is a mailing list for GPs in the region about ECG and telemonitoring. I have been on the mailing list for 1015 years. It’s a general - Doctors will emailinglist that embrace TM when also concerns they can make other topics than quick diagnoses, new technologies. save time, be able It is mainly used to treat more for topics which patients affect all GPs.

24

29 Enabler

29 Enabler

- Medical centres have more potential to use ECG when they house more doctors

"Je hebt ok mensen die bloedverdunners gebruikern, die moeten dan een keer per week hun bloed controleren en dan moet de dosering van de middlen worden aangepast, nouja, dat er daar echt wel dingen zijn waar het nuttig zou zijn"

- There is a mailing list for contacting GPs in the region of Delft, information about new technologies is shared here

29 Enabler

29 Enabler

"Je moet ook wel - For people that financiële use blood thinning middelen en die medicines, it can ruimte krijgen van increase the een raad van overall bestuur, om zoiets convenience op poten te zetten"

"Doordat we in Nederland een snel glasvezelnetwerk hebben denk ik dat het eigenlijk wel relatief goedkoop kan zijn, je moet gewoon een bestand op een computer hebben en dat veilig kunnen versturen"

SP3

SP3 memo

29 Enabler

IND1 nijfinster "Maar het light eigenlijk op meer fronten, het zit dus daar, in de zorgwereld, in de zorgcultuur in Nederland maar het zit ook in de financiële randvoorwaarden die er niet of nauwelijks zijn, ook in ons stelsel, dat als jij bespaart op je eigen productie dat je daarmee jezelf in de vingers snijdt als zorgorganisatie" "Er zijn een paar dingen lastig, in de zorg is iedere scheet die je laat, daar hoort een indicatie bij en een bedrag per uur en een functie, een uur verpleegkundige dat kost zoveel, en die mag die en die handelingen verrichten, dat zit helemaal dicht zeg maar" 29 Enabler

- Next generation is probably better with this kind of technology

"Een zorgverzekeraar wil het wel betalen, ze zijn er altijd op uit om hun zorg te verbeteren, het moet een kwalitatieve verbetering zijn, aangetoond het liefst, of het moet efficiënter of goedkoper worden, aangetoond, en het liefst allebei"

- A health insurance is willing to spend money on better healthcare, when innovations can increase quality, efficienty and bring costs down

- Medical innovations can limit the waiting lists in healthcare

"Waardoor je iets in de reistijden en de routeplanning kunt doen, of in de wachttijden of in je hele logistiek en efficiëntie kan je natuurlijk heel veel bereiken op deze manier"

- Telemonitoring can decrease travelingtime, waiting time and increase effciency

“De IC is natuurlijk een heel technisch terrein, waar veel innovaties worden toegepast. Daar worden ook constant nieuwe dingen getest maar die moeten ons niet in de weg zitten.”

29 Enabler

29 Enabler

- If you are able to get financial aid from the board, “Dat is echt iets innovation is voor de volgende possible generatie haha”

- Because of the fiber network in the Netherlands a high quality and secure connection can be set up for not so much money

“Wat ik wel denk is dat het er op deze manier wat gedaan kan worden aan de wachtrijen in de zorg, als je in het buitenland eerder terecht kan dan in Nederland dan is er toch iets mis, dan moet daar een oplossing voor te vinden zijn, bijvoorbeeld in de techniek, maar ook in hoe we met zorg in het algemeen omgaan”

IND1 memo

- Every medical treatment has a fixed rate 29 Enabler

Category

MAN

And is a lot of work pressure for the nurses since they become more busy with their patients, and are sensitive to changes in their schedules. But I also think that our goals are better reached with technology than without.

MAN memo

GP1

GP1 memo

GP2

GP2 memo

Often it’s much easier if you make an appointment that someday between four and five a clock we can see together and see through some patients, and the dermatologist stays in the hospital.

- With TM it is easyer to plan consults while all parties involved stay at their location

And that’s a new development. The hospital want to work as efficiently as possible and they ask us to do that. And for the GPs it is not only to earn some money because you can charge for the service. It is also satisfaction in what you do professionally. You feel yourself as a better doctor if you can do more. And I think the specialists also like this development [tasks handed over to GPs]. They can focus more on the specialized things. Now you have cardiologists, hematologists, nematologists, oncologists, stomach and liver doctors for the intestines, and all these specializations makes the specialists do more. And the government is saying yes. And the insurance companies are saying yes. And the patients are saying yes. TM is moving inside the field of specialists which is very interesting for me to do, but it takes a lot of time. And if I do a thing like that it must be cost efficient.

GP3

GP3 memo

GP4

- You feel like a better doctor if you improve on health solutions

Often it is started by a person who is more closely connected to a hospital and who talks with specialists. Another important stakeholder would be the pharmacy of course. The pharmacies are very interested in developing their services. They often play an important role in diabetes and astma and should also play a role in TM, explaining people the use of the devices, introducing them. Because the difference between the pharmacies and the industry is much smaller than between the GP and the pharmacy. The pharmacy knows how to deal with the industry. That’s their job – buy medicine, see where it is cheapest. And beside that a lot of large organizations that sell the medicine to the pharmacies also have relations with a lot of other organizations. So it is much shorter connection for pharmacies.

- Specialist value that they can delegate tasks to GP´s, allowing them to focus on their core speciality

And then of course the insurance companies are very important. Sometimes insurance companies also pay for projects if you have a good idea.

25

GP4 memo

- A collaboration between GP´s and specialist can be very promising

- TM adoption is enhanced by cooperation with pharmacies that have closter ties with the insurance companies than the GP´s

- Insurance companies pay projects when they are good ideas

SP1

SP1 memo

SP2

SP3 “Wat natuurlijk ook een goede is dat de huisarts klusjes doet die de specialisten alleen tijd kost en die de huisartsen ook nog wat geld opleverd terwijl het maar heel weinig werk is. Maar dat kunnen alleen de "Wij zijn bij uitstek taakjes zijn die een specialisme echt zonder waarbij we gebruik specialist kunnen, maken van - Specialisms like want anders krijg röntgen dental surgery, je problemen met diagnostiek, en dat that deal a lot with wie is er is juist zo handig runtgen verantwoordelijk om op afstand te diagnostics, can en wie krijgt waar doen" use telemonitoring voor betaald”

"Radiologen zijn er van overtuigd dat je dan een hoog, een hele goede monitor moet hebben, om alles te kunnen zien, wij zijn geen radiologen, we willen de patiënt eromheen zien, dus heb je iets minder behoefte aan, als je gewoon een voldoende scherm hebt, een consumenten scherm hebt kan dat al"

SP2 memo

- Dental surgeons can use normal consumer monitors to make a diagnose

SP3 memo

IND1 nijfinster

IND1 memo

- GP's can take over specialist tasks that are not relevant anymore to specialist

"Zeker in de thuiszorg kun je het ook voor het sociale contact voor de patiënten gebruiken"

- Telemonitoring can be used to increase social contact for patients

Mensen waarderen beeldcontact enorm, alle projecten die er zijn springt dat er wel uit, als het beeldcontact goed is, dan is dat een van de fijnste dingen die er zijn, verder is er heel veel behoefte aan alarmering of iets wat daar op lijkt, van als er wat met mij is dan kan ik ergens op drukken en dan hoort of ziet iemand mij en dan komt er hulp, dat is iets wat mensen graag willen"

- If the quality of the connection is good, patiens value the direct visual contact

"Als het gewoon een reguliere mogelijkheid wordt, dan zullen uiteindelijk de cliënten en patiënten om gaan vragen"

- If telemonitoring becomes a regular treatment, patients will eventually ask for it

Category

MAN

MAN memo

GP1

GP1 memo

GP2 In preparing the patient for referring to a hospital TM has potential. If I can send someone to the cardiologist and say I did TM and I found this problem, then he knows from the start what the problem is. It’s more efficient. And I think that phone calling with imaging would give a better performance. It’s different when I speak to you on the phone or in person.

GP2 memo

GP3

GP3 memo

GP4

- Preparation for hospitalization can be much more efficient by using TM

- Visual connection improves performance

26

GP4 memo

SP1

SP1 memo

SP2

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SP3

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Category

MAN

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GP1

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GP2

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GP3

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GP4

27

GP4 memo

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SP1 memo

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SP3

SP3 memo

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