1) The document summarizes research on how stakeholder engagement can help national eHealth programs lead to improved patient care and sustainable organizational change. 2) Case studies in England and Wales found that top-down, technocratic approaches in England led to failures, while bottom-up collaboration in Wales engaged stakeholders and led to success. 3) Effective stakeholder engagement requires viewing them as a resource, involving clinicians and end-users early, and facilitating empowerment and learning while retaining overall control of implementation.

1. Innovation and Sustainability in
the National Implementations of
e-Health: an International
Perspective on the Role of
Stakeholders
Dr. Rasa Rotomskiene
Mykolas Romeris University, Vilnius, Lithuania
STS Roundtable, 2-5 October, 2013 Boston
This research was partly funded by the European Social Fund under the Global Grant measure under the Project
„Integrated Transformations of eHealth Development: the Perspective of Stakeholder Networks“.

2. The main statement of this
research
Stakeholder engagement does create the
conditions under which national programmes
for the introduction of ICT in healthcare
sector lead to improvement and innovation in
patient care and to sustainability of
organisational change.

3. Main research object
The national process of ICT implementation
in healthcare sector and the strategies used
for related changes to be transferred and
embedded within a workplace level (a
comparative analysis of the UK (English and
Welsh) experience).

4. Main focus of this research:
• to deliver new insights in relation to the
national delivery of eHealth (integrated
information systems in the healthcare
sector); and
• explaining the conditions under which
national programmes for introduction of ICT
lead (or fail to lead) to improvement and
innovation in patient care and to
sustainability of organisational change.

5. Key findings:
• ICT implementation in healthcare is more socioorganisational process than a technical one;
• patient-focused approaches of healthcare delivery require
changes in work organisation and in an overall delivery of
healthcare services;
• stakeholder engagement in the process of ICT
implementation in healthcare has multi-dimensional
effects and can offer the potential to improve change
effectiveness and sustainability;
• the way stakeholder engagement is undertaken has an
ultimate role for achieving innovation in patient care and
sustainability of organisational change.

6. Relevance of the research (1)
• growing importance of ICT in human life
including public policy domains and the
delivery of public services.

7. Relevance of the research (2)
• Nationally integrated eHealth infrastructure
and information systems are now viewed
as key enablers for safe, efficient, high
quality, patient-centred and seamlessly
delivered healthcare.

8. Relevance of the research (3)
• yet high failure rates of complex ICT
projects often lead to wasted public finance
investments and failed processes in a
highly risk-sensitive environment such as
healthcare.

9. Relevance of the research (4)
• practitioners and academics alike still know
little about what mechanisms are effective
and which factors influence IS process
innovations.

10. Relevance of the research (5)
• this research extends the growing
knowledge of the new direction of IS
research with its new and empirically
grounded insights on the importance that
the stakeholders can play in the (national)
processes of eHealth developments.

11. Findings from the case studies:
England
The implementation process (key features
leading to failure):
- A top-down change implementation approach;
- A technocratic view towards ICT-led organisational
change;
- Unbalanced power of large IT suppliers and
management consultants and the NHS;
- ‘Big bang’ approach / ‘Rip and replace’ strategy;
and
- Lack of stakeholder engagement.

12. Key obstacles: England
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Delivered IS were difficult or not possible to use;
Resistance to change by the staff in the NHS;
Lack of local change ownership and commitment by the stakeholders;
Lack of real expectations and deadlines;
IT suppliers trying to hide their difficulties;
Hindered conditions to become an ‘intelligent client’;
The process is led by large IT companies rather than the needs of the
NHS;
Disappearing locally accumulated knowledge and skills;
Hindered NHS’ capabilities to innovate;
Service fragmentation instead of cooperation / integration;
IT failures hurting patient care;
No value for money.

13. Findings from the case studies:
Wales
The implementation process (key features leading to
success):
•A bottom-up incremental change implementation approach,
where the national programme (the national coordinating
body) works as a change management organisation
providing a platform for stakeholder cooperation;
•Multi-level organisational communication with the NHS
Wales and stakeholder engagement;
•An extensive involvement of end users into the delivery of
service improvement projects (path-finder pilot projects).

14. Findings from Wales: the contribution
stakeholder engagement can make:
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stakeholder engagement improves change communication;
improves change receptivity;
increases change ownership / commitment towards change;
improves internal cooperation;
increases trust;
enables crossing organisational boundaries;
creates conditions for organisational learning;
contributes to cooperation / quality of healthcare;
contributes towards sustainability of achieved changes in
healthcare delivery.

15. Diagram 1. The Conceptual framework of
the national eHealth development

17. Technical deployment of ICTs &
Stakeholder engagement

18. Management of organisational
change & Stakeholder engagement

19. Stakeholder engagement (stakeholder
management tool & nature of response;
ladder of stakeholder engagement (Friedman
& Miles, 2006: 162)

20.
11. Delegated power
10. Partnership
Jodint decision-making power over specific
projects
Multi-way dialogue, e.g.
joint ventures
Some decision-making power afforded to
stakeholders over specific projects
Multi-way dialogue, e.g.
strategic alliance
9. Collaboration
8. Involvement
Stakeholders provide conditional
support; it conditions are not met
support is removed. The organization
decides the extent of conformity
7. Negotiation
Organization has the right to decide.
Stakeholders can advice.
6. Consultation
Appease the stakeholder
5. Placation
Stakeholders can hear and be heard,
but have no assurance of being heeded
by the organization
4. Explaining
Multi-way dialogue, e.g. board
representation
Minority representation of stakeholders in
decision-making process
Multi-way dialogue, e.g.
constructive dialogue
Multi-way dialogue, e.g.
reactive: bargaining
Two-way dialogue, e.g.
questionnaires, interviews,
focus groups, task forces,
advisory panels
Educate stakeholders
Two-way dialogue, e.g.
workshops
Educate stakeholders
One-way dialogue, e.g. verified
corporate social reports
3. Informing
2. Therapy
1. Manipulation
„Cure“ stakeholders of their
ignorance and preconceived beliefs
„Misleading“ stakeholders, attempting to
change stakeholder expectations
One-way dialogue, e.g.
briefing sessions, leaflets,
magazines, newsletters, green
glossy social corporate
reports, or other publications

21. Theoretical research results (in
brief)
The research has identified the link between
the stakeholder engagement and innovation
and sustainability in patient care and
organisational change in relation to the
national eHealth development processes and
identified the reasons why this happens.

22. Recommendations for practitioners:
• viewing stakeholders (first of all the end user) as a valuable
resource;
• involving clinicians and especially the end users’ of planned
health information systems at the outset of the service
improvement projects,
• undertake an incremental implementation process with an
extensive multi-dimensional stakeholder engagement (taking
into account the width and multi-level nature of the
institutional context of a national health service) at every
stage of agreeing eHealth national implementation strategy
and undertaking service improvement projects,
• facilitating stakeholder (user) empowering and
organisational learning in overall, but retaining control over
the entire implementation process.

23. Key findings (1):
1. As revealed by the theory review and the empirical evidence delivered
by this research, there are significant limitations in current IS
research:
•for a long time there was an over-reliance on the functionalist
paradigm in IS research, where social process models of IT-induced
change have remained rare in the literature;
•in this way this piece of research has provided additional new
empirically grounded evidence, which in the scientific discussions
support the position of IS research aiming to expose the shortcomings of
the yet predominant technical/functionalist paradigm and to offer new
alternatives corresponding better to the contemporary needs of the
society (evolutionary and organisational change models such as
‘integrated socio-technical’ approaches started to emerge emphasizing
‘social learning’ and ‘orchestrated organisational change’).

24. Key findings (2)
2. This piece of research has brought additional evidence that the
involvement of stakeholders within clinical contexts of
organisational change might have even greater importance than in
other sectors. This happens for a number of reasons:
•Firstly, underlying causes of power and influence of healthcare
organisations are linked to the specifics of ‘professional bureaucracies’
(Mintzberg, 1979) (medical staff, administrative staff, managers or IT
specialists and others; hybrid roles (Fitzgerald et al., 2006);
•Secondly, the environment and policy context in which healthcare
is operating are very complex and involve many challenges, and
where the national implementation of eHealth additionally puts its own
requirements. Therefore to achieve effective problem solving, it is
necessary to involve in the process as many necessary stakeholders as
possible.

25. Key findings (3)
3. From the two in-depth empirical case studies new insights in
relation to ICT implementation in healthcare sector were
revealed:
•Evidence was found that innovations in relation to the national
processes of eHealth development were or had the potential to
become both disruptive and sustaining, but in both cases an
additional complexity was added by the multi-level nature of
the national process as such and especially the multiplicity of
players, their interests and ability (or inability by some) to
influence the process or exercise their own power;
•eHealth implementations usually call for major changes in
the way healthcare has previously been delivered. ‘Patient at
the centre’ and ‘patient centred-care’ require an effective working
across organisational and professional boundaries.

26. Key findings (4)
4. Empirically grounded findings have provided additional evidence to
support and broaden the position of Davidson (2006), aiming to
strengthen the aspect of dynamism of the Technological Frames of
Reference concept (TFR) (Orlikowski and Gash, 1994, Orlikowski,
2000) as a theory framework through which ICT development and use in
organisations can be analysed:
•the findings of this research suggest that stakeholder theory in general
and stakeholder engagement in particular has the power to
integrate both the IT project management and organisational
change perspectives of technology-led change, and deliver new
insights regarding innovation and organisational change sustainability in
healthcare sector: stakeholder engagement has the potential to
contribute to change communication, change receptivity, change
ownership and commitment towards change, internal (within the
healthcare sector) cooperation and trust, as well as to the ability of
crossing organisational and professional boundaries, improve
organisational learning.

27. Key findings (4)
• contribute to the capacity to innovate, the quality of healthcare and
sustainability in organisational change – the main aspects that were
derived from empirical research as being among the main obstacles
in the national deployment of eHealth solutions;
• Moreover, by taking an interpretive rather than a positivist stance
towards ICT-led organisational change (Orlikowski and Baroudi,
1991, Orlikowski & Yates, 2006, Davidson, 2004), the research
suggests that stakeholder engagement highly contributes
towards the interpretive process of organisational change. The
main suggestion of this research is that multi-level continuous
stakeholder engagement is an effective intervention strategy aimed at
overcoming incongruence and has the potential to result in frame
alignment and improve organisation outcomes. Moreover it also is
able to account for a more dynamic perspective of frame change as
an ongoing interpretive process, triggered by variety of organisational
circumstances in time (Davidson, 2006, Simmon & Lovegrove, 2005);

28. Key findings (5)
5. At the same time, user / stakeholder engagement as such does not
always lead to successful project / process outcomes. Certain
conditions on how to involve stakeholders to achieve innovation in
patient care and sustainability in
organisational have to be met:
•Regarding the levels of stakeholder engagement and management
identified by Friedman & Miles (2006: 162), levels 9 (collaboration) – 11
(delegated power) are most suitable in relation to the engagement of end
users in the national process of eHealth development.
•Several aspects were derived from the empirical data, which
contribute to a more effective stakeholder engagement in a national
process of eHealth development:
- such as viewing stakeholders as a valuable resource,
- involving clinicians and especially the end users’ of planned health
information systems at the outset of the service improvement projects,

29. Key findings (5)
- undertake an incremental implementation process with an extensive
multi-dimensional stakeholder engagement (taking into account the
width and multi-level nature of the institutional context of a national
health service) at every stage of agreeing eHealth national
implementation strategy and undertaking service improvement
projects,
- facilitating stakeholder (user) empowering and organisational learning
in overall, but retaining control over the entire implementation
process.
• The role of the national coordinating body (such as the national
programme) mainly should focus on creating a platform of
stakeholder interaction and organisational learning for the entire
national health service by facilitating internal cooperation, providing
strategic direction, reducing risk and dependency on IT suppliers and
breaking professional and organisational boundaries by stakeholder
empowering, but at the same time retaining control over the process.

30. Key findings (5)
• Only then stakeholder engagement may result
improved change communication, increased change
receptivity, change ownership and commitment towards
change, internal cooperation and trust, ability to cross
organisational and professional boundaries, stakeholder
engagement and organisational learning / innovation /
quality of healthcare and sustainability in organisational
change that actually contribute to the innovation in patient
care and sustainability of organisational change and
therefore an overall quality of patient care.

31. THANK YOU FOR YOUR ATTENTION
Dr. Rasa Rotomskiene
Mykolas Romeris University, Vilnius, Lithuania
E-mail: rjuciute@mruni.eu
Phone: +370 612 48 391
This research was partly funded by the European Social Fund under the Global Grant measure under the Project
„Integrated Transformations of eHealth Development: the Perspective of Stakeholder Networks“.