Business Modeling to Implement an eHealth Portal for Infection Control: A Reflection on Co-Creation With Stakeholders.

BACKGROUND: It is acknowledged that the success and uptake of eHealth improve with the involvement of users and stakeholders to make technology reflect their needs. Involving stakeholders in implementation research is thus a crucial element in developing eHealth technology. Business modeling is an approach to guide implementation research for eHealth. Stakeholders are involved in business modeling by identifying relevant stakeholders, conducting value co-creation dialogs, and co-creating a business model. Because implementation activities are often underestimated as a crucial step while developing eHealth, comprehensive and applicable approaches geared toward business modeling in eHealth are scarce. OBJECTIVE: This paper demonstrates the potential of several stakeholder-oriented analysis methods and their practical application was demonstrated using Infectionmanager as an example case. In this paper, we aim to demonstrate how business modeling, with the focus on stakeholder involvement, is used to co-create an eHealth implementation. METHODS: We divided business modeling in 4 main research steps. As part of stakeholder identification, we performed literature scans, expert recommendations, and snowball sampling (Step 1). For stakeholder analyzes, we performed "basic stakeholder analysis," stakeholder salience, and ranking/analytic hierarchy process (Step 2). For value co-creation dialogs, we performed a process analysis and stakeholder interviews based on the business model canvas (Step 3). Finally, for business model generation, we combined all findings into the business model canvas (Step 4). RESULTS: Based on the applied methods, we synthesized a step-by-step guide for business modeling with stakeholder-oriented analysis methods that we consider suitable for implementing eHealth. CONCLUSIONS: The step-by-step guide for business modeling with stakeholder involvement enables eHealth researchers to apply a systematic and multidisciplinary, co-creative approach for implementing eHealth. Business modeling becomes an active part in the entire development process of eHealth and starts an early focus on implementation, in which stakeholders help to co-create the basis necessary for a satisfying success and uptake of the eHealth technology.

Evaluation of early implementations of antibiotic stewardship program initiatives in nine Dutch hospitals.

BACKGROUND: Antibiotic resistance is a global threat to patient safety and care. In response, hospitals start antibiotic stewardship programs to optimise antibiotic use. Expert-based guidelines recommend strategies to implement such programs, but local implementations may differ per hospital. Earlier published assessments determine maturity of antibiotic stewardship programs based on expert-based structure indicators, but they disregard that there may be valid deviations from these expert-based programs. AIM: To analyse the progress and barriers of local implementations of antibiotic stewardship programs with stakeholders in nine Dutch hospitals and to develop a toolkit that guides implementing local antibiotic stewardship programs. METHODS: An online questionnaire based on published guidelines and recommendations, conducted with seven clinical microbiologists, seven infectious disease physicians and five clinical pharmacists at nine Dutch hospitals. RESULTS: Results show local differences in antibiotic stewardship programs and the uptake of interventions in hospitals. Antibiotic guidelines and antibiotic teams are the most extensively implemented interventions. Education, decision support and audit-feedback are deemed important interventions and they are either piloted in implementations at academic hospitals or in preparation for application in non-academic hospitals. Other interventions that are recommended in guidelines - benchmarking, restriction and antibiotic formulary - appear to have a lower priority. Automatic stop-order, pre-authorization, automatic substitution, antibiotic cycling are not deemed to be worthwhile according to respondents. CONCLUSION: There are extensive local differences in the implementation of antibiotic stewardship interventions. These differences suggest a need to further explore the rationale behind the choice of interventions in antibiotic stewardship programs. Rather than reporting this rationale, this study reports where rationale can play a key role in the implementation of antibiotic stewardship programs. A one-size-fits-all solution is unfeasible as there may be barriers or valid reasons for local experts to deviate from expert-based guidelines. Local experts can be supported with a toolkit containing advice based on possible barriers and considerations. These parameters can be used to customise an implementation of antibiotic stewardship programs to local needs (while retaining its expert-based foundation).

Participatory eHealth development to support nurses in antimicrobial stewardship.

BACKGROUND: Antimicrobial resistance poses a threat to patient safety worldwide. To stop antimicrobial resistance, Antimicrobial Stewardship Programs (ASPs; programs for optimizing antimicrobial use), need to be implemented. Within these programs, nurses are important actors, as they put antimicrobial treatment into effect. To optimally support nurses in ASPs, they should have access to information that supports them in their preparation, administration and monitoring tasks. In addition, it should help them to detect possible risks or adverse events associated with antimicrobial therapy. In this formative study, we investigate how nurses' can be supported in ASPs by means of an eHealth intervention that targets their information needs. METHODS: We applied a participatory development approach that involves iterative cycles in which health care workers, mostly nurses, participate. Focus groups, observations, prototype evaluations (via a card sort task and a scenario-based information searching task) and interviews are done with stakeholders (nurses, managers, pharmacist, and microbiologist) on two pulmonary wards of a 1000-bed teaching hospital. RESULTS: To perform the complex antimicrobial-related tasks well, nurses need to consult various information sources on a myriad of occasions. In addition, the current information infrastructure is unsupportive of ASP-related tasks, mainly because information is not structured to match nurse tasks, is hard to find, out of date, and insufficiently supportive of awareness. Based our findings, we created a concept for a nurse information application. We attuned the application's functionality, content, and structure to nurse work practice and tasks. CONCLUSIONS: By applying a participatory development approach, we showed that task support is a basic need for nurses. Participatory development proved useful regarding several aspects. First, it allows for combining bottom-up needs (nurses') and top-down legislations (medical protocols). Second, it enabled us to fragmentise and analyse tasks and to reduce and translate extensive information into task-oriented content. Third, this facilitated a tailored application to support awareness and enhance patient safety. Finally, the involvement of stakeholders created commitment and ownership, and helped to weigh needs from multiple perspectives.

A holistic framework to improve the uptake and impact of eHealth technologies.

BACKGROUND: Many eHealth technologies are not successful in realizing sustainable innovations in health care practices. One of the reasons for this is that the current development of eHealth technology often disregards the interdependencies between technology, human characteristics, and the socioeconomic environment, resulting in technology that has a low impact in health care practices. To overcome the hurdles with eHealth design and implementation, a new, holistic approach to the development of eHealth technologies is needed, one that takes into account the complexity of health care and the rituals and habits of patients and other stakeholders. OBJECTIVE: The aim of this viewpoint paper is to improve the uptake and impact of eHealth technologies by advocating a holistic approach toward their development and eventual integration in the health sector. METHODS: To identify the potential and limitations of current eHealth frameworks (1999-2009), we carried out a literature search in the following electronic databases: PubMed, ScienceDirect, Web of Knowledge, PiCarta, and Google Scholar. Of the 60 papers that were identified, 44 were selected for full review. We excluded those papers that did not describe hands-on guidelines or quality criteria for the design, implementation, and evaluation of eHealth technologies (28 papers). From the results retrieved, we identified 16 eHealth frameworks that matched the inclusion criteria. The outcomes were used to posit strategies and principles for a holistic approach toward the development of eHealth technologies; these principles underpin our holistic eHealth framework. RESULTS: A total of 16 frameworks qualified for a final analysis, based on their theoretical backgrounds and visions on eHealth, and the strategies and conditions for the research and development of eHealth technologies. Despite their potential, the relationship between the visions on eHealth, proposed strategies, and research methods is obscure, perhaps due to a rather conceptual approach that focuses on the rationale behind the frameworks rather than on practical guidelines. In addition, the Web 2.0 technologies that call for a more stakeholder-driven approach are beyond the scope of current frameworks. To overcome these limitations, we composed a holistic framework based on a participatory development approach, persuasive design techniques, and business modeling. CONCLUSIONS: To demonstrate the impact of eHealth technologies more effectively, a fresh way of thinking is required about how technology can be used to innovate health care. It also requires new concepts and instruments to develop and implement technologies in practice. The proposed framework serves as an evidence-based roadmap.

Why business modeling is crucial in the development of eHealth technologies.

The impact and uptake of information and communication technologies that support health care are rather low. Current frameworks for eHealth development suffer from a lack of fitting infrastructures, inability to find funding, complications with scalability, and uncertainties regarding effectiveness and sustainability. These issues can be addressed by defining a better implementation strategy early in the development of eHealth technologies. A business model, and thus business modeling, help to determine such an implementation strategy by involving all important stakeholders in a value-driven dialogue on what the technology should accomplish. This idea also seems promising to eHealth, as it can contribute to the whole development of eHealth technology. We therefore suggest that business modeling can be used as an effective approach to supporting holistic development of eHealth technologies. The contribution of business modeling is elaborated in this paper through a literature review that covers the latest business model research, concepts from the latest eHealth and persuasive technology research, evaluation and insights from our prior eHealth research, as well as the review conducted in the first paper of this series. Business modeling focuses on generating a collaborative effort of value cocreation in which all stakeholders reflect on the value needs of the others. The resulting business model acts as the basis for implementation. The development of eHealth technology should focus more on the context by emphasizing what this technology should contribute in practice to the needs of all involved stakeholders. Incorporating the idea of business modeling helps to cocreate and formulate a set of critical success factors that will influence the sustainability and effectiveness of eHealth technology.