Telehomecare Challenge Collaboration Among Healthcare Professionals

Wireless Pers Commun (2009) 51:711–724DOI 10.1007/s11277-009-9767-3

Telehomecare Challenge Collaboration AmongHealthcare Professionals

Birthe Dinesen · Egon Toft

Published online: 7 July 2009© Springer Science+Business Media, LLC. 2009

Abstract The aim of this study was to identify the organizational problems that emergewhen telehomecare technology for heart patients is implemented across healthcare sectors.The overall methodology of the study is the case study. A triangulation of data collectiontechniques was used in order to provide multiple sources of evidence for identifying theproblems. During the design and implementation phases of a telehomecare system, severalproblems emerged: hospital nurses feared losing control over their job content, district nurseswere confronted with more clinical tasks, there were competing visions about patient treat-ment and care between healthcare professionals, new patterns for collaboration across sectorsemerged, and the lack of payment structure for home hospitalisation of patients created noincentives for telehomecare. These issues should be taken into account when implementingwireless telehomecare technology. If attention is not paid to these challenges telehomecarewill remain marginalized and not be able to be implemented effectively.

Keywords Telehomecare technology · Home hospitalisation · Wireless technology ·Organisational problems · Heart patients

1 Introduction

How do we implement telehomecare technology successfully? Success demands insight andunderstanding into how technology and organisation work together. The development oftelehomecare technology is occurring in an international context. The term ‘telehomecare’denotes care and treatment cutting across sectoral lines by means of information or com-munication technology. Telehomecare technology is expected to reduce the need for thereadmission of the chronically ill, as well as to enhance the quality of life for patients whoremain at home while still being monitored by healthcare professionals.

B. Dinesen (B) · E. ToftDepartment of Health Science and Technology, Center for Sensory-Motor Interaction, Aalborg University,Fredrik Bajers Vej 7 D-3, 9220 Aalborg, Denmarke-mail: [email protected]

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712 B. Dinesen, E. Toft

In this case study, we focus on home hospitalisation of heart patients by the use oftelehomecare technology. The findings in the study showed that the patients believe thathome hospitalisation speeds up the process of recovery and re-establish the routine of every-day life), both physically and mentally. The patients experienced a sense of security, freedom,increased awareness of own symptoms for the benefit of own well being [1].

The implementation of telehomecare technologies across sectors poses not only technicalchallenges, but also brings up organisational issues such as merging of work flows, clash ofwork cultures, coordination tasks and structuring patient care.

There is limited research on the process of implementation of telehomecare technologyacross sectors. Studies have been carried out on the implementation processes in connec-tion with the use of telehomecare technology in rural and remote areas [2–7]. These studiestypically identify a series of barriers and opportunities when implementing telehomecaretechnology; overcoming these barriers is therefore a key to successful implementation [8].However, this developmental approach has weaknesses, in that it gives a static picture ofan implementation process. Moreover, there remains a gap in our current knowledge andexisting research as to the nature and extent of the problems that emerge when telehomecaretechnologies are implemented.

The aim of this study was to describe the problems that occurred during the process ofdeveloping and implementing the concept of home hospitalisation for heart patients by meansof telehomecare technology. To avoid unnecessary repetition, we refer to this type of care asthe ‘home hospitalisation concept’ or simply ‘home hospitalization’.

The study is based on a case study and qualitative research. Therefore the paper isorganised in sections with a theoretical framework, description of the case study, methodsused for collecting data, findings of the study, a discussion and conclusions at the end.

2 Theoretical Framework

Within traditional organisational theories, the world is regarded from a hierarchical perspec-tive. We therefore have difficulties grasping inter-organisational challenges. Organisationaltheories tend to overlook network issues, paying attention only to the parties carrying outtheir respective share of the combined processes and tasks [9,10]. A combined inter-organ-isational and inter-professional perspective constitutes the theoretical framework for thisstudy. Inter-organisational theory opens up the boundaries of the organisations. By using aninter-professional perspective, it is possible to elucidate the interactions between the actorsacross organisational and professional boundaries.

In this study, the Scandinavian research tradition [11–13] serves as the basis for the inter-organisational perspective. Several of the Scandinavian researchers are inspired by Alter andHage [9], who define networks as:

the basic social form that permits inter-organizational interactions of exchange, con-verted action, and joint production. Networks are unbounded or bounded clusters oforganizations that, by definition, are non-hierarchical collectives of legally separateunits. [9, p. 46]

A healthcare network consists of four main elements: healthcare professionals, processes,vision and architecture [10]. Healthcare professionals are the resources of the network. Theprocesses are centred on information exchange, coordinated action and joint problem-solv-ing between the organisations and are determined by the situations and contexts. A net-work vision reflects the mutual interest among the parties and encapsulates the goal of the

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Telehomecare Challenge Collaboration Among Healthcare Professionals 713

collaboration. The architecture of a network is the structural framework that constitutes theform and content of collaboration.

Trust between the parties in a network is a crucial element in the relations between organ-isations. Network culture can be defined as the norms and values for the interaction betweenthe parties and organisations. The culture may consist of informal rules of conduct or rulesof the game in the network. Network competences are attached to the parties in the network,such as the mental models and attitudes of the parties or their knowledge and skills.

Outside the network are the parties′ parent organisations, illustrating relations to othernetworks. The term ‘technology’ is attached to the parties. In an organisation, technologydenotes the knowledge, tools, techniques and actions used to transform input into output.Technologies appear in the processes related to the total problem-solving in the network.These technologies can be mechanical, human or knowledge technologies [14]. Mechanicaltechnologies refer to the physical machines, tools and equipment, e.g. the hardware of tele-homecare technology. Human technologies consist of the skills and physical energy involvedin producing goods or services, e.g. the clinical skills of healthcare professionals. Knowl-edge technologies refer to the abstract meaning and concepts used in production or servicedelivery, e.g. clinical procedures for taking blood samples.

The theory of sociology of professions by Abbott [15] is used in this study in order toexplore the interplay and dynamics between the healthcare professionals across borders. Thistheory focuses on the system of professions, where the structure of the professionals links theprofession with a task. Below the system level, Abbott investigated the differentiation withinthe professions themselves. Above the system level, Abbott explored the larger social forcesand focused on the forces that affect the individual professions under certain conditions.The system model is based on the assumption that tasks are constantly changing, such thatany change in jurisdiction—the struggle about tasks and domains leads to professional chal-lenges across occupational boundaries. Abbott emphasises that technology can either createa jurisdiction in order to re-establish the social order or destroy a jurisdiction. Challengesover professional jurisdiction can have a variety of outcomes [15].

The profession seeks full ownership of a specific professional domain and endeavours todefend and expand this domain. This is the goal of all types of professional groups whenfaced with challenges to their domain. Normally, there are clear areas of responsibility withinthe professional division of labour. A conflict may typically arise when the contesting partiesare forced to work together. A profession may also seek to maintain control over the cognitiveknowledge of its domain while allowing practice by competitors on an unrestricted basis insome areas within the profession.

Jurisdictional problems can take place in different arenas: the legal system, the arena ofpublic opinion and the workplace. The conceptual framework of inter-organisational theoryand the sociology of professions will be used here to identify those problems to professionaljurisdictions that emerge during the process of developing and implementing the home hos-pitalisation concept. In particular, we will be concerned with professional problems betweenhospital nurses and doctors and district nurses.

3 Case Study: Home Hospitalisation of Heart Patients by Use of TelehomecareTechnology

Organisational problems within telehomecare was studied by focusing on the cardiologyward at Vendsyssel Hospital in Frederikshavn, Denmark and the ward’s collaboration withthe district nurses working for the Municipality of Frederikshavn. The study was initiated in

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collaboration between the clinical partners and Aalborg University. The study focused on thedevelopment and implementation of the home hospitalisation concept and lasted 11 months.Included in the study were patients with heart failure and arrhythmia and patients beingtreated for medicine adjustment. It should be noted that the development and implementa-tion of the home hospitalisation concept was a departure from current practice for patients,nurses and doctors at the hospital as well as for the district nurses and general practitioners inthe municipalities. The project had both a design phase and an implementation phase. Therewere used wireless telehomecare technologies in the study (see Fig. 1 for details). Overall,the study was performed according to the Helsinki declaration Ethical approval was obtainedfrom the local Ethics Committee.

3.1 The Design Phase

The design phase of the project lasted 5 months. A design panel was set up in order to developthe home hospitalisation concept for heart patients. The design panel had 12 members andincluded several health care professional groups: a head nurse, two staff nurses, three hos-pital nurses, a representative of the general practitioners, three managers of district nursingcommunities and three district nurses. The work of the panel was to design of cross-sectorworkflows and integrate these with telehomecare technology. The activities included delega-tion and division of clinical tasks and responsibility between hospitals and district nursing,command and communication structures and an agreement on procedures for care and treat-ment of the heart patients, and dissemination of information to patients and relatives. Thepanel convened for six meetings, each meeting lasting 2 h. These meetings provided a forumfor cross-sector discussions among the health care professionals in a wider context.

3.2 What is the Concept of Home Hospitalisation for Heart Patients?

The traditional patient care process for patients with heart failure and arrhythmia and forpatients being considered for medicine adjustment typically involves three to six days’ admis-sion to the cardiology ward. During the term of admission, the following procedures takeplace:

• Patients are continuously monitored by means of telemetry applications, 24 h a day, in theacute phase (2 days) and subsequently by means of an electrocardiogram (ECG) recordingonce a day.

• Anti-arrhythmia, diuretics and anticoagulation medicine are prescribed and adjusted.• Day-to-day monitoring of blood pressure, pulse, weight and blood samples; International

Normalized Ratio (INR)—measuring the blood coagulation time.• Daily ward rounds attended by nurse and doctor between 9 and 11 a.m. and again at 6 p.m.

At the time the patients were selected for home hospitalisation, they were typically past theacute phase of their condition and able to walk around without dyspnoea when they weretransferred to admission in their own homes. Once in their homes, the home hospitalisationof heart patients under the telehomecare system took place as follows (see also Fig. 1):

• District nurses visited the patients’ homes mornings and evenings.• By means of wireless equipment, the district nurses collected and transmitted data on blood

pressure, pulse, weight, INR and ECG. The hospital staff received the ECG recordings inthe hospital e-mail inbox.

• Data were transmitted to the hospital for the usual ward round attended by doctor andnurse at the hospital.

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Fig. 1 Home hospitalisation by the use of wireless telehomecare technology

• Via a joint web-portal, the healthcare professionals at the hospital and the district nursescould enter data on blood pressure, pulse, weight, and INR for the individual patient.

• During home visits, the district nurse would telephone the hospital nurses for an exchangeof information, e.g. prescription and adjustment of the patient’s medicine.

• In the event of emergency, e.g. patient anxiety or complications, the patient could at anytime be re-admitted to hospital.

• Clinical responsibilities for the patients remained with the doctor at the hospital.

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Measuring INR, recording ECG—via wireless technology—and observing heart patients incollaboration with the hospital staff represented new tasks, and indeed new areas of responsi-bility and competencies for the district nurses. The nurses therefore received relevant trainingin these areas. All the health care professionals involved in the project received training inusing the joint web-portal and its functions. The major new area of responsibility for thehospital doctors and nurses was to ensure that patients were receiving the correct treatmentby the district nurses, even when they were not in the hospital.

3.3 The Implementation Phase

The technical aspects of the telehomecare system were tested in a pilot project involvingthree patients admitted to home hospitalisation. Subsequently, the design panel convened foran evaluation meeting during which experiences were discussed and relevant issues resolved.The issues included the adjustment and coordination of work flows across sectors, the com-prehension of written documentation by other healthcare professionals on the joint web-portalas well as the difficulties encountered by the hospital staff in reaching the district nurses onthe phone. This implementation phase lasted 6 months.

4 Methods

The case study [16] approach was applied as the overall methodology of the study. Accordingto Yin, a case study is an empirical inquiry that: ‘Investigates a contemporary phenomenonwithin its real-life context, especially when the boundaries between phenomenon and contextare not clearly evident’ [16, p. 13].

In view of the aim of the study, an approach is required that makes it possible to studyinter-organisational and inter-professional challenges in situations where these conflicts aretaking place. The study included an ongoing process analysis during the design and imple-mentation of the home hospitalisation concept in order to identify problems to professionaljurisdiction.

4.1 Action Research

Action research [17–19] was part of the overall methodology as well. The deployment ofaction research was chosen because it facilitated an exploration of various current topics,issues and observations in a dialogue with the participants throughout the process. At thesame time, it helped to improve the design and implementation of the home hospitalisationconcept. Action research was carried out when it was necessary to intervene: to facilitateorganisational and technical changes through dialogue and action, or to facilitate new formsof understandings. In particular, intervention was used when discussions reached a dead-lock or became too personal. To avoid bias in the use of action research, discussions werecarried out with colleagues and student assistants, and field notes were written prior to theintervention being carried out.

4.2 Data Collection Process

A triangulation of data collection techniques was used in order to provide multiple sources ofevidence [16] for identifying problems. All respondents gave their oral consent to interviewparticipation. Interviews were tape-recorded and transcribed. The same person carried outall the transcriptions.

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Table 1 Survey of interviewedrespondents in the design phase

Respondent Number of inter-views conducted

Nurses at hospital (from cardiology ward) 2Nurses in the design panel (from cardiology ward) 2Doctor in the design panel (from cardiology ward) 1Doctor at the hospital (from cardiology ward) 1General practitioner in the design panel 1District nurses 2District nurses in the design panel 2Managers of hospital in the design panel(from cardiology ward) 4Managers of district nursing in the design panel 3Focus group interview with design panel 1Total number of interviews carried out 19

4.3 Design Phase

Documents: In the initial phase, documents such as homepages, public reports, staff news,descriptions of task and work processes were studied in order to obtain basic knowledge ofthe institutional context of the case.

Participatory observations: Participatory observations [20,21] were conducted at meet-ings in the design panel through the discussions and development of the home hospitalisationconcept. Participatory observations were also carried out while accompanying nurses anddoctors on the cardiology ward, while accompanying the district nurses on their home visitsand while attending the training of district nurses in ECG recording and training of health-care professionals in new technology. Observation checklists were used, and field notes weretaken.

Qualitative interviews: The data also includes 18 qualitative interviews [22,23] conductedduring the design phase of the study (see Table 1).

Respondents not participating in the design panel were interviewed on the same issuesin order to ensure that new themes could emerge, thus facilitating a wider perspective. Asummary of the design phase interviews is shown in Table 1.

The interviews were conducted as semi-structured interviews lasting 1–1.5 h. Interviewguides were used for all interviews. The same person was responsible for planning and con-ducting all interviews. The schedule of interviews was adjusted to the specific issue andguided by the dynamics of the patient’s condition.

Focus group interview: At the end of the design phase, a focus group interview [24]was carried out with the design panel. The purpose was to validate data collected throughobservations and interviews. An interview guide was used.

4.3.1 Implementation Phase

Participatory observations: In this phase, participant observation was carried out duringmeetings in the design panel, with accompanying nurses and doctors on the cardiology ward,and with district nurses on home visits. Observation checklists were used and field noteswere taken.

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Table 2 Survey of interviewed respondents in the implementation phase

Respondent Number of inter-views conducted

Nurses at hospital in the design panel (from cardiology ward) 3Nurses at hospital (from cardiology ward) 3Doctor in the design panel (from cardiology ward) 1Doctor at the hospital (from cardiology ward) 1Secretaries at the hospital (from cardiology ward) 2District nurses in the design panel 2District nurses 3Managers of hospital in the design panel (from cardiology ward) 4Managers of district nursing in the design panel 3Focus group interview with nurses at hospital from the

cardiology ward (four persons not in the design panel)1

Focus group interview with district nurses (four persons not in the design panel) 1Focus group interview with design panel 1Total number of interviews carried out 25

Qualitative interviews: The same procedure for conducting qualitative interviews in thedesign phase was used in the implementation phase. A summary of interviews is shown inTable 2.

Focus group interviews: By the end of the implementation phase, the two focus groupinterviews (see Table 2) had been carried out with the nurses from the cardiology ward andthe group of district nurses.

The purpose of using two separate focus groups, i.e. one with nurses from the cardiologyward and one with district nurses, was to discuss different aspects of potential jurisdic-tional/professional challenges and to validate data from other sources. A third focus groupinterview was conducted with the design panel. An interview guide was used.

5 Data Analysis

All the interviews were coded with Nvivo 2.0 software. The transcribed interviews wereanalysed in steps, inspired by the work of Kvale [22]. A code tree was designed at the start,comprising nodes, descriptions/definitions of nodes and child nodes. This was done in dia-logue with a research colleague. The code tree was formed on the basis of central conceptsfrom the conceptual frame of reference and from interviews. When formulating the conceptsfrom the respondents, eleven qualitative interviews were studied and coded on the basis of afirst-off impression. These interviews introduced three hospital nurses, three district nurses,one hospital doctor, two hospital managers and two managers of district nursing commu-nities. Half the interview hours took place at project start, half at project completion. Thenext step was a rough coding and refined coding as a result of reviews of coded material andadjustments. This step sought to identify topics and patterns, and the interpretation was wid-ened to include a framework of understanding beyond the respondents. This phase includedan in-depth interpretation. the interviews were analysed with a view to inferring motivationsof the respondents and their underlying perceptions.

The application of a computer programme for data analysis is associated with a certainbias. There are several sources of bias. First, computer coding entails a decontextualisation ofthe data. Second, the programme has been developed on the basis of ground from an inductive

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approach—and in this project a combined code strategy is deployed. Third, the applicationof the software gives the researcher a ‘feeling of being distant’ from the data [25].

All data collected in the two phases were validated throughout the process of the projectin collaboration with research colleagues, an ongoing dialogue with healthcare professionalsand through the triangulation of data sources.

6 Findings

In the data analysis process, the following problems arose in connection with professionaljurisdictions.

6.1 Problems Emerging During the Design Phase

Hospital nurses feared that they would lose certain job responsibilities. The nurses at thehospital felt that the district nurses threatened to take over their tasks. As one nurse com-plained: ‘How can you put together a project that will deprive others of their livelihood?Field notes from meetings in the design panel showed that this fear prevailed in the nursesfrom the hospital.

Clinical nurses questioned the qualifications of district nurses after they have been allo-cated new clinical tasks. The telehomecare technology used in the home hospitalizationprocess made it possible to transfer new clinical tasks from the hospital to the district nurses.This issue as on the agenda in the discussions in the design panel at several meetings andwas a central theme in the interviews. Hence, one of the nurses asked, ‘Do the district nurseshave the qualifications for taking an ECG?’ As an outcome of the discussions, an agreementwas reached between hospital and district nurses on a division of labour between them.

Hospital nurses were unwilling to train district nurses in clinical skills. The healthcareprofessionals at the hospital were unwilling to take part in the training of district nurses totake blood samples and ECG due to disagreement concerning competencies as to who wasqualified to observe and provide patient care and treatment. In meetings of the design panel,the district nurses took pains to point out that they knew their own capabilities and did notintend to become cardiology nurses. They only wanted to take better care of the patients.Observations also showed that the parties disagreed as to whether the training in taking bloodsamples (INR) should take place in hospital laboratories, on patient’s wards or in connectionwith patients visits to their GP for a check-up.

Differing visions between healthcare professionals across sectors impeded the develop-ment of a common vision for the telehomecare technology network. Hospital nurses preferredmaking their own home visits with the patients admitted to home hospitalisation, i.e. thevision known as ‘the outgoing hospital’. District nurses wanted to monitor home hospitalisa-tion patients in collaboration with the hospital staff. Observations and interview data confirmthat this difference of perspective persisted throughout the design and implementation phases.Each group tended to hold onto their own vision and were unable to formulate a joint visionfor the telehomecare patient care process. Hospital nurses and district nurses have insufficientknowledge of each other’s competencies and limitations and outdated images of each other.

6.2 Problems Emerging During the Implementation Phase

Difficulties in merging and adjusting clinical decision-making processes across sectors.Observations showed differences in understanding the contexts of work, including local

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work practices and workplace culture. Each party thought that it was the other who had toadjust its work routines.

Adverse effects of joint administration of medicine. The adjustment, prescription andadministration of medicine for patients admitted to home hospitalisation involve multipleplayers across sectors, with the inherent greater risk of a breach of security. Typically, discus-sions centred on how to adjust workflows across sectors irrespective of time, place and context.Problems evolved regarding consensus on coordinating workflows. Only after the first fourpatients had been admitted at home did a consensus evolve on administration of medicine.

Lack of payment and incentive structure for patients being home hospitalised. The presenteconomic organisation of the health system did not have administrative and financial proce-dures for patients being home hospitalised which confused the health care professionals andmangers.

7 Discussion

It has not been possible to identify other studies in this field that adopt an inter-organisationaland inter-professional approach—to the implementation of the home hospitalisation conceptby the use of telehomecare technology.

After identifying problems in the design and implementation phase, the key questionhere concerns why it is that some of these problems can be resolved whereas others keepre-occurring?

The findings in the design phase indicate that the hospital nurses fear they will looseresponsibility for their job content, as tasks are transferred to the district nurses under thetelehomecare technology procedures. The healthcare professionals found themselves in afield between different contexts and procedures for clinical practice and responsibility. Imple-menting telehomecare technology forced the healthcare professionals to navigate across thecontexts and to search fornew pathways in the network in order to care for the patientstogether with another group of professionals. Other studies show the same cross-sector juris-dictional issues [26,27]. Viewed from an inter-professional perspective [15], telehomecaretechnology challenges professional domains. New relations evolved between the healthcareprofessionals, and negotiation about new collaboration patterns were reframed in the net-work. Other findings [28] confirm that health care professionals perceive that the concept ofhome hospitalisation has led toward more integrated clinical task implementation processesacross sectors for the benefit of the patients.

In the design phase, action research was undertaken in order to help the healthcare profes-sionals to overcome the challenges and help them see new ways of solving the joint problems.Introducing new technologies in an organisation calls for action research in some situationsin order to facilitate changes in social practice among the healthcare professionals [29].

Some problems were resolved by agreements about intellectual jurisdiction and divisionof labour. The question is whether these negotiated agreements are indicative of a develop-ment of mutual understanding that evolves over time, i.e., a common vision, and whetherthis can create new relations based on trust between the group of nurses and doctors fromthe cardiology ward and the district nurses.

When telehomecare technologies are used, the healthcare professionals are brought closertogether in work routines. The challenges generated by this new form of work integrationrequire new kinds of training and knowledge when implementing the concept of telehomecaretechnology. Clinical procedures across sectors need to reflect a new balance between occu-pational groups and tasks in order to cope with the different contexts. Other studies show that

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working with telehomecare or telemedicine produces learning, and healthcare professionalsmust learn new skills and competencies [26,29–31].

In the study a major problem was to improve the hospital nurses’ and district nurses’images of each other. Interventions via action research were necessary in order to facilitate adialogue between the two groups. An ethnographic study [32] indicates that the implemen-tation of new technology poses a to existing professional practices and relationships. It isimportant to be aware that implementing new technology is more than simply an issue ofbeing trained how to use the machinery.

The competing visions of ‘outgoing hospital’ versus ‘home hospitalisation’ were visiblein both phases of the case study. Seen in an inter-organisational perspective, the healthcareprofessionals are again placed in a field of tension between parent organisation and the net-work. The motivations of the health care professionals can also be viewed in light of therecent administrative reform in Denmark, whereby hospital admissions are now charged tothe municipalities and relevant nursing care is to a larger extent provided by district nurses.

Developing new patterns for collaboration joint administration of medicine, for exampleis complex from an inter-organisational perspective, and it takes time to develop. Therefore,improvements are likely to be slow and incremental [33]. The clinical decision-making pro-cesses and clinical procedures are challenges related to the network architecture, as shownby Gustafsson [10]. The home hospitalisation concept thus requires that health care profes-sionals operate within a structure with which they are familiar. A study of managed clinicalcardiac networks shows that clinical networks are complex because clinicians with differentbackgrounds and from different sectors must work together across traditional boundaries.The issue remains as to whether these challenges can be resolved with the development ofthe network. This issue could not be dealt with within the present study because of its limitedtime frame of only 11 months.

The logic of specialised care confronts the logic of primary care, with a focus on theindividual patient’s social status. The challenge is to establish a system, which can deter-mine which party’s logic, should be considered when workflows and knowledge are to bedivided across sectors between the healthcare professionals. This kind of problem is iden-tified in another study [26,34]. How do patients perceive this encounter between the twologics? Studies show patient satisfaction with telehomecare services, although we lack moredetailed research [35].

Introducing the new concept of home hospitalisation revealed a lack of administrative andfinancial infrastructure across sectors. The healthcare authorities are faced with the challengeof building up new systems and procedures as telehomecare technology takes its place as anew health care strategy.

In this article, we have identified problems that take on different forms in the two phasesof implementing telehomecare technology across sectors. The problems are typically elim-inated, only to re-emerge later on. Inter-organisational and inter-professional perspectiveswere applied to help shed new light on the process. It is not simply a question of identifyingbarriers to be resolved here and now, but of becoming aware of emerging points of contention,which can be resolved through dialogue. Future research is needed in order for telehomecaretechnology to develop as a part of network processes.

8 Conclusions

It is expected that telehomecare will progress rapidly over the next few years, as it is preferredby the patients and has been shown to be cost effective. The limitations of telehomecare are

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related to the organisation of and barriers in the health care system. It is very import to developa collaborative understanding of telehomecare, involving both researchers and practitionerswho can provide insight into the problems present in the health care system and the relevanttechnology. The more complicated the health care system organisation, the more importantis it to take the organisational emerging problems into account at the earliest stage. If this isoverlooked, valuable techniques and products may be lost.

Acknowledgements We wish to thank the management and staff of the cardiology ward at Vendsyssel Hos-pital, Frederikshavn, Denmark and the district nursing service in the Municipality of Frederikshavn, Denmarkfor their cooperation in this study. For making equipment and know-how available, we also express our grati-tude to RTX HealthCare A/S, KMD A/S, Roche Diagnostics A/S, NorDiaTech A/S and Aalborg University,Denmark. The research project was funded by Spar Nord Fonden, Det Obelske Familiefond, Jyske Bank aswell as by Aalborg University, Denmark.

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Author Biographies

Birthe Dinesen is an assistant professor at the Department of HealthScience and Technology at Aalborg University. She has a Ph.D. in tele-homecare for chronic patients and her research is centred on telehome-care, user driven innovation, implementation of technology in organi-sations and networks. She has a Master in Public Administration anda background as a registered nurse. She has a broad background as aclinical nurse within the field of cardiology, intensive care and districtnursing. She has had managerial positions in the healthcare sector formore than 6 years.

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http://dx.doi.org/10.1186/86/1748-5908-1-26

http://dx.doi.org/10.1186/1748-5908-1-16


Egon Toft is Associate Dean, Professor, Specialist in Cardiology, MD,DMSc, F.E.S.C. Educated at Århus University MD in 1984, Defendedthe Doctoral Thesis at Copenhagen University in 1995 and was trainedas an invasive cardiologist with focus on arrythmia. In 11 years hewas responsible for the treatment of arrythmia at Aalborg UniversityHospital. The number of peer-reviewed papers is close to 100, and hehas filed seven patents, out of which three are issued. He has startedthree Med tech companies based on the research results. He is pres-ently responsible for health science at Aalborg University introducingnew educations and attracting new research groups to the university.The research include telehomecare as a focus area and has resulted intwo Ph.D. studies and a number of scientific papers together with thedevelopment of equipment dedicated to the purpose.

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Telehomecare Challenge Collaboration Among Healthcare Professionals

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