Business School
DIGITALITY IN A NETWORKED HEALTHCARE SERVICE
Master’s thesis, Health and Business Ann-Marie Asikainen (274597) 15 November 2019
Abstract
UNIVERSITY OF EASTERN FINLAND Faculty
Faculty of Social Sciences and Business Studies
Department
Business School
Author
Ann-Marie Asikainen
Supervisor
Hanna Lehtimäki
Title
Digitality in a networked healthcare service
Main subject
Health and Business Level Master’s degree Date 15.11.2019 Number of pages
86 + 2
Abstract
This research examines the sociomaterial approach to services, where services are created through practices and constantly transforming networks of human and non-human actors.
The study describes and analyzes the sociomaterial network of a healthcare service as well as the effects of digitality on the current actor-network. The research subject is the heart rehabilitation service process and it is explored through the novel application of a network approach to service development.
This research is executed as a qualitative intensive case study that adheres to the actor- network theory approach. With the help of the actor-network theory the relationships among actors in the service network can be examined without the typical boundaries between humans and technology. The data was collected through five individual semi-structured theme interviews. In this paper the abductive logic and theory-driven content analysis are employed as primary analysis methods in the examination of the rehabilitation service’s actors, phases and challenges. The research questions are answered with the theoretical literature review and the analysis of the empirical data.
As the most significant theoretical contribution, this thesis presents three ways that digitality affects the current sociomaterial network of the heart rehabilitation service. The impacts are related to the network dynamics and the service actors. Especially the role of the main actor, the customer, is influenced by the increase of digitality in the service process. Additionally, a holistic description of the sociomaterial network of the heart rehabilitation service is provided, which serves as a solid foundation for the development of the service. Another theoretical contribution is the novel consolidation of the actor-network theory and service development literature, which together formulate a framework for the development of a networked service.
This study presents essential information regarding digitality in the development of a healthcare service for healthcare professionals and managers operating in the healthcare sector. The results show that digitality enables a more customer-centered service, which is seen as a primary goal in all healthcare services. The results moreover provide novel insights to the network perspectives in service development research whilst launching new directions for future studies.
Key words
service development, digitality, networked service, sociomateriality, actor-network theory
Tiivistelmä
ITÄ-SUOMEN YLIOPISTO Tiedekunta
Yhteiskuntatieteiden ja kauppatieteiden tiedekunta
Yksikkö
Kauppatieteiden laitos
Tekijä
Ann-Marie Asikainen
Ohjaaja
Hanna Lehtimäki
Työn nimi
Digitaalisuus verkottuneessa terveydenhuollon palvelussa Digitality in a networked healthcare service
Pääaine
Health and Business
Työn laji
Pro Gradu
Aika
15.11.2019
Sivuja
86 + 2
Tiivistelmä
Tämä työ tutkii sosiomateriaalista näkemystä palveluihin, jossa palvelut syntyvät käytäntöjen kautta sekä alati muuttuvien inhimillisten ja ei-inhimillisten toimijoiden verkostoina. Tutkimus kuvaa ja analysoi terveydenhuollon palvelun sosiomateriaalista verkostoa sekä digitaalisuuden vaikutuksia nykyiseen toimijaverkkoon. Tutkimuskohteena on sydänkuntoutuksen palveluprosessi, jota tutkitaan hyödyntämällä uudenlaista verkostonäkemystä palvelukehityksessä.
Kyseessä on kvalitatiivinen intensiivinen tapaustutkimus, joka perustuu toimijaverkkoteoreettiseen lähestymistapaan. Toimijaverkkoteorian avulla pystytään tutkimaan verkostotoimijoiden välisiä suhteita ilman tyypillistä jakoa ihmisten ja teknologian välillä. Aineisto on kerätty viiden yksilöllisen puolistrukturoidun teemahaastattelun avulla. Tutkimuksessa hyödynnetyn abduktiivisen päättelyn sekä teoriasidonnaisen sisällönanalyysin avulla tutkitaan kuntoutuspalvelun toimijoita, vaiheita ja haasteita. Tutkimuskysymyksiin vastataan kirjallisuuskatsauksen ja empiirisen aineiston analyysin avulla.
Merkittävimpänä tieteellisenä panoksena esitetään kolme tapaa, joilla digitaalisuus vaikuttaa nykyisen sydänkuntoutuspalvelun sosiomateriaaliseen verkostoon. Vaikutukset koskettavat verkoston dynaamisuutta ja palvelun toimijoita. Lisääntyvä digitaalisuus vaikuttaa etenkin päätoimijan eli asiakkaan rooliin palveluprosessissa. Tutkimus tarjoaa kattavan kuvauksen sydänkuntoutuspalvelun sosiomateriaalisesta verkostosta, mikä toimii pohjana palvelun kehittämiselle. Työssä on lisäksi yhdistetty toimijaverkkoteoreettista ja palvelukehittämisen kirjallisuutta, minkä avulla on luotu viitekehys verkottuneen palvelun kehittämiselle.
Tutkimus tarjoaa hyödyllistä tietoa digitaalisuuden roolista terveydenhuollon palvelun kehittämisessä sekä terveydenhuollon ammattilaisille että terveydenhuollon toimialalla vaikuttaville johtajille. Tutkimustulokset osoittavat, että digitaalisuus mahdollistaa asiakaslähtöisemmän palvelun, mitä pidetään ensisijaisena tavoitteena kaikissa terveydenhuollon palveluissa. Lisäksi tulokset tarjoavat uudenlaisia verkostonäkökulmia palvelukehittämisen tutkimuksiin sekä avaavat uusia suuntia jatkotutkimusta varten.
Avainsanat
palvelukehittäminen, digitaalisuus, sosiomateriaalisuus, toimijaverkkoteoria, verkottunut palvelu
TABLE OF CONTENTS
1 INTRODUCTION………...6
1.1 The topic of the research………....6
1.2 The purpose of the study……….…...8
1.3 Key concepts………...….10
1.4 The scope of the research and the structure of the thesis……….….…...11
2 THEORETICAL BACKGROUND……….…………...……….…..14
2.1 Digitality transforms services……….…………..….………..14
2.1.1 Technology in services……….…...………14
2.1.2 Various digital services……….……..15
2.1.3 Digitality in healthcare………18
2.2 New service development………....19
2.2.1 A brief background of service development………...19
2.2.2 The service development process………...21
2.2.3 Network perspectives in the development of services………23
2.3 The social and the material in organizations………25
2.3.1 Sociomateriality………..25
2.3.2 Actor-network theory……….………29
2.4 Theoretical framework……….………31
3 RESEARCH METHODOLOGY………...35
3.1 Methodological approach……….…35
3.2 Data collection……….36
3.3 Analysis of the data………..38
4 THE ACTOR-NETWORK OF THE HEART REHABILITATION SERVICE……….…..41
4.1 Research context………..41
4.2 The main themes………..43
4.2.1 The actors and their roles………43
4.2.2 The phases in a heart rehabilitation service………49
4.2.3 The challenges……….……52
4.2.4 Developing the rehabilitation service process……….………55
4.2.5 Digitality in heart rehabilitation………….……….…….58
4.3 A summary of the empirical results……….63
5 DISCUSSION AND CONCLUDING REMARKS………...66
5.1 Summary of the study and conclusions………66
5.2 Theoretical implications and the results in relation to previous research………72
5.3 Evaluation of the study………75
5.4 Managerial and practical implications……….78
5.5 Future studies………...79
REFERENCES……….……….80
LIST OF FIGURES
Figure 1. The division of technology-mediated services
Figure 2. The main steps in model for patient co-creation and learning Figure 3. Theoretical framework of this study
Figure 4. The progress of the heart rehabilitation process
Figure 5. The effects of digitality on the healthcare service actor-network
LIST OF TABLES
Table 1. Comparison of agential realism and critical realism for study of sociomateriality Table 2. The five notions of sociomateriality
Table 3. Conducted interviews
Table 4. The phases of actor-network theory research Table 5. The identified actors and their roles
APPENDICES
Appendix 1. Interview scheme in Finnish
Appendix 2. Interview scheme translated into English
1 INTRODUCTION
1.1 The topic of the research
The digitalization of services appears to be an emergent international focal point within public services (Carroll, 2014). In addition, one of the most current discussions within the Finnish healthcare industry is related to the opportunities that digitality can provide various healthcare services. Firstly, the digitalization of healthcare services is seen as a means to increase service availability, quality and productivity. Furthermore, digitality can help relieve and allocate healthcare resources to areas that require more human contact and interaction. (Virtanen, Smedberg, Nykänen & Stenvall, 2017.)
Secondly, the population is aging and will thus require more support and care. The increased demand alongside the growing healthcare costs leads to a situation where more healthcare services must be provided with less resources. (Ministry of Social Affairs and Health, 2016a.) For this reason it is vital to find new and more effective ways to provide healthcare to an increasing amount of people with altogether less resources. Digitalization offers a solution.
(Froehle & Roth, 2004; Schumann, Wünderlich & Wangenheim, 2012.)
Digitality in healthcare services is moreover seen to offer tools for prevention and earlier interference, for instance in the form of digital screening methods. The increased amount of data gathered through digital solutions provides better support for decision making, and it also enhances communication between various actors in the service network. (Malmström, Leskelä, Lindh, Kajova, Niemelä, Rissanen & Salmisaari, 2018.) Nevertheless, digitality in services involves some drawbacks, which need to be considered in service development. One of the main concerns is related to digital alienation or exclusion. Healthcare services must be provided in a way that does not exclude any group from said services due to for instance the unavailability of technology or the lack of technology-related skills and know-how. (Ministry of Social Affairs and Health, 2016b.)
One of the main themes in digital service development and provision is customer-centrism. A recent government funded development project, the Virtual Hospital 2.0, strives to provide customer-oriented digital health services for all citizens. The digital services complement,
standardize and develop traditional care processes. Moreover, the relevancy of preventive care is augmented and the opportunities for citizens to influence their own wellness maintenance increase substantially. The digital services furthermore streamline and diversify working in the healthcare industry. One of the most visible parts of the project is the ‘Virtual village’
website that offers information, digital treatment pathways, and tools for citizens, patients and professionals, among other things. (HUS, 2016.) The Virtual village is composed of different virtual houses, one of which is the ‘Rehabilitation house’ that provides rehabilitation-related information, guidance and support for patients and their loved ones (Terveyskylä.fi, 2019).
The need for rehabilitation is expected to rise in parallel with the aging of the population and the political goal to elongate careers (Rajavaara & Lehto, 2013). Thus, the development of rehabilitation services as well as connecting various organizational interfaces and actors is seen as crucial. Rehabilitation services should be seamlessly connected to the patient’s care process and thus be a fixed part of the customer’s overall service package. Through seamless collaboration among organizers, financiers and service providers and with uniform care processes, it is possible to achieve better cost-effectiveness, productivity and efficacy among rehabilitation services. (Nordic Healthcare Group & Kuntoutussäätiö, 2019.) Hence, incorporating a network approach to service development offers a novel viewpoint to rehabilitation service development in practice.
The significance of digitality in organizational activities has proliferated substantially, which in turn has escalated the need to understand the role of technology better. Sociomateriality offers means to research and understand how technology interacts and performs in organizational processes (Orlikowski, 2007; Jones, 2014). One rising sociomaterial approach is the actor-network theory. By utilizing the concepts of the theory, it is possible to analyze the role of technological actors within the service network. Furthermore, through this approach the relationships among actors in the service network can be examined without the typical boundaries between humans and technology. (Carroll, 2014.)
In the network studies carried out in service development research, the human and organizational actors have been seen as the foci. Moreover, the network has often been defined as co-operative relationships between organizations or as a network between human actors. The non-human material actors have typically been regarded as resources that actors such as humans and organizations utilize or are in control of. (Edvardsson & Olsson, 1996;
Syson & Perks, 2004.) More studies on the active and collaborative role of technology in service development and provision are required (Lusch & Nambisan, 2015). Additionally, the research field of new service development requires more cohesion and more studies that rely on their own frameworks instead of those from product development research (Stevens &
Dimitriadis, 2005; Smith, Fischbacher & Wilson, 2007; Biemans, Griffin & Moenaert, 2016).
The actor-network theory utilized in this study offers a novel network approach to service development research. The approach provides tools for the examination of the heart rehabilitation service process. This is conducted through the description and analysis of the sociomaterial service network, and moreover with the examination of the effects that digitality has on the current actor-network. Additionally, more research is provided on the implications of sociomateriality and the active role of technology in organizations. Utilizing the actor-network theory or the sociomaterial approach in healthcare and service development contexts is still in its early stages. Therefore, the exploration of the rehabilitation service from these viewpoints offers a novel outlook in relation to theoretical research as well as practical rehabilitation work and healthcare service development in general. The assumption that guides this study is that digitality will increase in the healthcare industry, which will furthermore affect healthcare services significantly.
1.2 The purpose of the study
The goal of this study is to describe and analyze the effects of digitality on a networked healthcare service, which in this thesis is a heart rehabilitation service. This research is executed as a qualitative case study that adheres to the actor-network theory approach. This study indicates that the actor-network theory approach can complement the previous network research conducted in service development. It furthermore shows that the heart rehabilitation service is a networked process, which is composed of numerous human and non-human actors. When the service actors interact with each other, they create practices through which the phases of the rehabilitation service shape over and over again. This study adds to the understanding of the networked healthcare service and to the implications of digitality to the rehabilitation service and its development.
The main research question is:
How does the digital development of a heart rehabilitation service unfold in an actor-network?
To help answer the main research question three sub-questions are formulated:
1. What kind of actors and phases form a rehabilitation service?
2. What kinds of challenges occur in a rehabilitation service?
3. How does technology transform a healthcare service?
Both the literature review and the empirical results are utilized to provide answers to the sub- questions, which ultimately contribute to the understanding of the impact of digitality on the heart rehabilitation service actor-network. I answer to the first and second sub-questions mainly through the analysis of the empirical data. Nevertheless, the sociomaterial approach to services, the concepts of the actor-network theory and the service development research in the literature review provide vital information, which is relevant to the analysis of a networked healthcare service, and thus relevant to the first two sub-questions. The first question is answered through the recognition and analysis of the rehabilitation service’s actors and their roles in the network. Moreover, the phases in the service are described. The second question is covered by the examination of the challenges that occur in the service. The conception of the networked service and its development opportunities are thus increased, and simultaneously the challenges related to digitality are explored. The third sub-question is answered with the help of the empirical data and the literature review. The sociomaterial approach to services and the research on service development and digital services are utilized to examine the holistic repercussions of technology in the heart rehabilitation service.
Through the analysis of the rehabilitation service’s actors, phases and challenges, the understanding of the effects of digitality on the service’s sociomaterial actor-network is increased. Furthermore, by combining the results to the current service development and digital services literature, a conception is formulated on how the effects of digitality proceed in practice. Moreover, opportunities in digital services become more easily recognizable.
1.3 Key concepts
Sociomateriality and the actor-network theory
Orlikowski (2007) describes sociomateriality as the fundamental and constant intertwining of the social and the material in everyday organizational life. Sociomateriality tries to understand how humans, spatial arrangements, physical objects, and technologies are intertwined with language, interaction and practices (Pickering, 1995; Schatzki, 2006; see Jarzabkowski &
Pinch, 2013, 581). Orlikowski and Scott (2008) present sociomateriality as an umbrella term, which embodies many approaches. These orientations are presented in subchapter 1.4.
The actor-network theory (ANT), or the sociology of translation (Callon, 1986) is one of many approaches to sociomateriality. Through ANT the complex and changing networks formed by human and non-human actors are examined (Latour, 2005). Moreover, it provides a way to understand the merger of the social and the material in organizations. The actor- network theory is based on weak sociomateriality. (Leonardi, 2013.) ANT considers social and technological actors as equal components in a network (Orlikowski & Scott, 2008). The actor-network theory stems from the 1980s, and its original developers are French sociologists Bruno Latour and Michael Callon as well as English sociologist John Law. An actor-network is defined as a group of actors that through the process of translation are combined into a network, which functions and develops continuously. (Latour, 2005.)
Digitality
Digitalization does not have an unequivocal and standardized definition (Koistinen-Jokiniemi, Koskiniemi, Lehtinen, Lindroos, Martikainen, Montonen, Savela, & Tuomaala, 2017, 6).
Itkonen (2015) considers it as storing, transferring and handling data in a computerized format. With the concept he also refers to the wider economic and societal change process that is a result of the development of ICT (information communications technology).
Digitality is seen as a tool that models real world phenomena and transfers real world interaction into the computer world, as well as clears the path for computers to function within the real world. Digitality is furthermore a more efficient way of working. (Jungner, 2015.) In this thesis, I understand digitality as various software, devices, applications and methods that impact current services substantially and enable a new way of thinking about and developing services.
Service
Orlikowski and Scott (2015) define services as the constant entanglement of the human and the material. They furthermore indicate that services are created in practice through distinct materializations, which compose activities, humans, and objects in certain ways in certain places and times. Similarly, Carroll (2014) characterizes a service as consisting of human and technological elements that trade competencies and resources. Lusch and Nambisan (2015, 156) on the other hand focus on the active processes of serving rather than on the outcome in the form of a product offering that is exchanged. In the context of this study, I understand services as comprising of human and non-human actors that are in relationship with each other, and that are seen as equal actors in the service network.
Healthcare service and rehabilitation service
There is no universal standard definition of a healthcare service. At its most fundamental level it can be defined as “a procedure performed on a person for diagnosing or treating a disease”
(McGraw-Hill Concise Dictionary of Modern Medicine, 2002). Healthcare services can be divided into health prevention and promotion, primary healthcare, specialized medical care, occupational healthcare, and private healthcare (Ministry of Social Affairs and Health, 2019).
In this research I concentrate on private healthcare services, in particular rehabilitation services. A rehabilitation service has many associations, and therefore does not possess one unified definition. In light of this, Rajavaara and Lehto (2013) state that rehabilitation can be defined as anything the different parties in each specific context want to define it as.
Generally, though, the aim of rehabilitation is to further a person’s functional capacity, independent coping, and wellbeing, as well as support their participation and employment opportunities (Ministry of Social Affairs and Health, 2019). The research subject in this study is the heart rehabilitation service process, which is presented in subchapter 4.1.
1.4 The scope of the research and the structure of the thesis
The sociomaterial research contains multiple interesting concepts, such as the actor-network theory, mangle of practice, human-machine reconfigurations, digital formations, technological information and algorithmic configuration (Orlikowski & Scott, 2008). While all of these concepts study sociomateriality from a different viewpoint, this paper will focus solely on the actor-network theory to keep the scope of the research manageable. Moreover, the actor-
network theory offers a meaningful way to examine sociomateriality (Leonardi, 2013) and digitality in the rehabilitation service. Furthermore, sociomateriality research typically encompasses highly philosophical discussions, which has led to some criticism regarding the practical value of the approach (e.g. Leonardi, 2013). Again, to conduct a feasible research, the philosophical dialogue on sociomateriality is excluded from this paper; however, its theoretical background is introduced.
In this paper I apply the abductive logic, which resides between deduction and induction. In abduction, theory facilitates the analysis process and prior knowledge partially steers the analysis. (Tuomi & Sarajärvi, 2003.) Moreover, in the abductive logic theory and empirical data run side by side: at times theoretical concepts can be utilized over the empirical data and vice versa. Additionally, it should be noted that social research is seldom purely inductive or deductive; most social research typically contain attributes from both logics (Eriksson &
Kovalainen, 2008). Eskola (2001), on the other hand, presents a division of empirically based, theory-driven and theory-based content analyses. This division takes better account of the factors guiding the analysis compared to the division of induction and deduction. (Tuomi &
Sarajärvi, 2003, 97-99.) Theory-driven content analysis is utilized in this study.
The study is primarily conducted from the viewpoint of service providers in order to be able
‘to follow the actors themselves’ (Latour, 2005, 12) and thus formulate a conception of the networked healthcare service. However, whilst conducting the thesis, I have been mindful of the important role of the patient within service development and even service provision.
Additionally, the patient-centric view is highly present in the theoretical and empirical data. I have notified the need for future patient-centric research in sub-chapter 5.5.
This research paper is divided into five sections. In the introduction the reasoning behind the study topic is provided and the goals and research questions are presented. Moreover, the main concepts of the research are defined. Finally, the scope and structure of the thesis are described.
The second chapter contains the theoretical review, which is divided into three parts. Firstly, the implications of digitality in services are explored through different categorizations of digital services and the implementation of technology in healthcare services. Secondly, service development is examined through the NSD process and the network aspects that have
been utilized in service development research. And thirdly, an outlook on various approaches to sociomateriality is provided alongside a more detailed description of the actor-network theory and its concepts. Finally, a theoretical synthesis and framework are formulated based on the theoretical approaches.
In the third main chapter of the thesis, the methodological choices regarding data collection, examination and analysis are justified. In the following fourth chapter, the research subject, the heart rehabilitation service process, is portrayed and the results of the empirical data analysis are provided. The results describe the rehabilitation service network’s actors, phases and challenges. Furthermore, the service development and the opportunities of digitality in the heart rehabilitation service are examined. In the end, a summary of the empirical results is formulated.
In the fifth and final main chapter the whole study is concluded and key theoretical contributions are presented. The research is discussed in relation to previous studies and managerial and practical implications are mentioned. Moreover, the study is critically evaluated and propositions for future studies are considered.
2 THEORETICAL BACKGROUND
2.1 Digitality transforms services
2.1.1 Technology in services
The role of technologies in services has changed tremendously. Even though there is vast NSD research, little emphasis has been given to technology-centered services and in particular to the effects they have on service provision (Schumann et al., 2012). Traditionally, technology has been considered a tool for productivity and efficiency, not so much an actor that alters services significantly or empowers new innovations (Barrett, Davidson, Prabhu &
Vargo, 2015). More recently, though, it has attained the role of an enabler and actor in service development. Technology can for example enable better resource and knowledge sharing within the network. Furthermore, it is often an actor that inspires or triggers a new service innovation. (Lusch & Nambisan, 2015.)
On the one hand, incorporating technology to service development and provision has many benefits. It oftentimes offers significant cost savings (Froehle & Roth, 2004), more flexibility, comfort (Fitzsimmons & Fitzsimmons, 2010), and better service availability (Schumann et al., 2012, 137). On the other hand, it can sometimes cause a lack of human contact and interaction, which can lead to the decrease of empathy and kindness in services, and eventually to the reduction of customer loyalty and trust (Luarn & Lin, 2003; Wilson, Straus
& McEvily, 2006; see Schumann et al., 2012, 137). For instance, studies regarding self- services have demonstrated that depending too much on automated self-services may diminish customer satisfaction (Ba, Stallaert & Zhang, 2010). As a preemptive solution to this, providing a combination of self-services and services with human interaction could help sustain customer loyalty and retention (Scherer, Wünderlich & von Wangenheim, 2015).
Lusch and Nambisan (2015, 155) discuss how in the past decade organizations have shifted their views on the nature and process of innovation to more network-, information-, and value-centric perspectives. Innovations are advanced together with suppliers, customers and other actors in the network; innovations also consist of intangible offerings where information content is high; and the main focus has moved from the innovation’s features to its values that
are co-created with other actors. All of these shifts have broadened the role of IT in innovations giving way to more intangible ones. Fairly recent intangible digital innovations such as social media platforms, eBooks, movie and music streaming, and cloud computing all have something in common: the role of IT has been fundamental in them, and it has in many cases, made those innovations technically and economically feasible. Many of the previously mentioned may be termed as digital or digitally enabled innovations, which incorporate novel combinations of digital and physical factors to construct new market offerings (Yoo, Henfridsson & Lyytinen, 2010, 156).
2.1.2 Various digital services
Schumann et al. (2012) present a framework for the division of digital services. In their study they examined technology-mediated services, and defined them in accordance with Froehle and Roth (2004), as services that are provided by a technological interface between provider and customer (Schumann et al., 2012, 133). This type of service interaction enables an immediate exchange of information over long distances, which in turn delivers more functionality to said services. It allows a suitable substitution to those services, which previously had to be provided through direct contact between the provider and the customer and/or service object.
In their study, Schumann et al. (2012) further divide technology-mediated services into self- services and delivered services, as visualized below in figure 1. Customer self-service has recently raised a great amount of research enthusiasm in the field of service management (Barrett et al., 2015). Self-services are defined as services that a customer produces for themselves and actively participates in the service process, by utilizing a technological solution granted by the service provider. There is no need for direct service employee involvement during the service process. Online banking, ATMs, and online booking services are examples of customers utilizing a service provider’s technological infrastructure to provide a service for themselves at their own convenient time and place. (Schumann et al., 2012.) Technology-enabled self-services are regarded as opportunities for greater efficiency, cost minimization, and better service accessibility and comfort for customers (Bitner, Brown
& Meuter, 2000; Meuter, Bitner, Ostrom & Brown, 2005). On the downside, self-services are typically quite standardized and automated, which leaves little room for the customer to influence the service production process (Schumann et al., 2012). So, even though the
customer is an active participant in the service process itself, they have little say over what features and possibilities exist in their bank’s online banking platform, for instance.
The model by Schumann et al. (2012) further subdivides delivered services into remote services and interactive consulting services. Remote services can be defined as a service type provided in a technology-mediated production process, where the provider is able to remotely and actively influence the service object (Wünderlich, 2009). For instance, IT-support services, repair and maintenance services, and remote diagnosis and surgery in healthcare are examples of the widespread application possibilities of remote services. With technology- mediated consulting services, however, there is more interaction between provider and customer or service object during the service process. Distance learning, call centers, and remote consultation in healthcare are examples of interactive consulting services. The multimedia communication involved, for instance in video-conferencing, diminishes and compensates for the drawbacks of participants not physically being in the same space. In both types of delivered services, the provider generally has a more active role in the service production process. The customer nevertheless helps co-create the service, but does not actively co-produce the firm’s output such as in self-services. The division of technology- mediated services is summarized below in figure 1. (Schumann et al., 2012.)
Figure 1. The division of technology-mediated services (Schumann et al., 2012, 136)
Wünderlich et al. (2012) also research different forms of digital services. Their study explores customers’ attitudes toward and use of smart interactive services, which they consider as technology-mediated services where customers and employees act as integral participants in the service delivery process. In addition to substantial human-to-human interaction and collaboration, the service provided by the embedded technology itself is required. Remote diagnosis and telemedicine, as well as remote repair of equipment are examples of smart interactive services.
The framework for the separation of digital services by Wünderlich et al. (2012, 5) is presented as a smart service interactivity matrix containing four types of smart services. These are categorized by the levels of activity that the provider and user/customer manifest during the delivery of the smart service. Each type is further subdivided into business-to-business (B2B) and business-to-customer (B2C) services. Type 1 involves the highest level of both user and provider activity, whilst technology acts as a mediator between the two. This type includes interactive services such as remote diagnostics in healthcare as well as remote troubleshooting and repair services. In type 3, contrarily, there is hardly any human interaction during service provision. Examples of such machine-to-machine services include order tracking and automated software updates. Type 2 presents self-services such as online banking, self-check outs and online order management. Customers independently produce the service for themselves utilizing the technology arranged by the provider. On the contrary, in type 4, the provider is the main actor in service delivery with little to no user activity needed.
Various remote maintenance services belong to this group.
The role of human interaction and collaboration in technology-mediated services is more apparent in the model by Wünderlich et al. (2012) compared to that of Schumann et al.
(2012). Interestingly, Schumann et al. (2012) do not distinguish a machine-to-machine service, although their framework is more technology-oriented. Another differentiating factor between the two models is that Schumann et al. (2012) do not make a division of B2B and B2C services. However, both frameworks disclose self-services as one technology-mediated service type. Moreover, type 1 interactive services by Wünderlich et al. (2012) are closely linked to the interactive consulting services by Schumann et al. (2012), as they both involve a decent amount of interaction between the provider and customer during the service process.
Finally, the remote services of Schumann et al. (2012) resemble the type 4 provider active services of Wünderlich et al. (2012). In both types, the role of the provider is prevalent.
2.1.3 Digitality in healthcare
In today’s society, information technology (IT) acts as an enabler of progress. It is a tool that can help mobilize resources and create impressive effectiveness and economies of scale.
Moreover, comprehensive ICT usage in healthcare enables the development, implementation and further generation of innovative health care technologies. (Gole, Sharma & Misra, 2017.) It also has a great impact on health education as it connects to the prevention, diagnosis and treatment of the symptoms of disease (Ortega-Navas, 2017, 23). Furthermore, incorporating technology in the healthcare sector augments the productivity and quality of patient care, reduces administrative and operational costs (Ortega-Navas, 2017), as well as promotes the provision of healthcare services to the masses. Effective and holistic technology adoption, however, requires investing in infrastructure development to enable stakeholders to utilize digital resources efficiently. Moreover, it may be necessary to reshape the mindset of some healthcare professionals as well as customers, for instance, by educating and helping them overcome any prejudices towards new technological solutions. (Gole et al., 2017.) Below are presented a few ways that innovative technologies have been adopted in healthcare.
Additionally, the shortcomings of digital solutions in the healthcare context are examined.
Niemelä, Pikkarainen, Ervasti and Reponen (2019) study disruptive connected health technologies, which are proposed to combat healthcare challenges and reconstruct traditional care models. Their qualitative case study takes place in two Finnish hospitals that are under transformational change. The aim is to understand how the co-creation of connected health solutions shapes a pediatric day surgery practice in the digital hospital context. The key findings suggest that previously passive patients will become active agents increasing their role in the service process. This is partly due to enhanced communication between the patient and the health professionals, which is enabled through expanded digital communication. With the help of intelligent integrated solutions patients are able to communicate with the service employees throughout the process, and moreover, health professionals can utilize the received data as part of their own patient record systems. Both patients and health professionals regarded a mobile application as a viable solution to augment and facilitate the service process. The above mentioned reformations would ultimately transform the process into a more patient-centric practice. Niemelä et al. (2019) concluded that connected health solutions, such as the exchange of health data, can reconstruct the process content by eliminating and/or adding some clinical tasks throughout the provided service.
Ortega-Navas (2017) discusses the effects of technology on healthcare from a health education and promotion viewpoint. Technological solutions help share information and thus enhance communication among health professionals as well as between health practitioners and their patients. This is in line with the findings of Niemelä et al. (2019). Furthermore, the use of technologies diminishes the time between diagnosis and therapy and new modes of care, due to the faster flow of information. This consecutively improves practitioner efficiency, decreases waiting lists, and ultimately enhances patients’ quality of life as hospital stays are shortened. Additionally, technologies are seen to improve patients’ adherence to treatment and participation in their own health decisions making their role more integral in the service process. Finally, the utilization of technologies offers a social aspect for all of the patients and their relatives that are willing to indulge it. Different online and social media platforms provide good opportunities for peer support and the exchange of experiences with people in similar life situations. (Ortega-Navas, 2017.)
It should also be noted that utilizing technology in the field of health is not without drawbacks. For example, there is a risk of misdiagnosis that may occur as a result of software errors. This in turn raises the matter of ethical responsibility. Furthermore, people should be provided adequate knowledge on what digital health information is reliable and how to interpret that data. Critical reading skills must be emphasized to decrease self-diagnosis related negative effects as people educate themselves on their disease. A study performed in the United States revealed that 50% of people talk to their doctor about the information they find online (Wright & Moore, 2008; see Ortega-Navas, 2017, 28). Finally, there is the concern regarding the way increased technology use may influence the practitioner-patient relationship, as well as their engagement in the service process. (Ortega-Navas, 2017.)
2.2 New service development
2.2.1 A brief background of service development
Compared with the research activity in the development of tangible goods, the development of intangible services has received little research attention, although it too has slowly started to accumulate traction (Syson & Perks, 2004, 255). New service development (NSD) is widely considered to have emerged from the new product development (NPD) research (Mendes, Oliveira, Gomide & Nantes, 2017). Previously, new service development has
mainly been interpreted through the fundamentals of new product development research (Johne & Storey, 1998; Storey & Easingwood, 1998).
In fact, the ‘Early Writings’ period (1984-1995), as Mendes et al. (2017) refer to the first wave of published NSD research papers in their extensive literature review, were highly influenced by the service marketing and product development disciplines. Moreover, the focus of the early writings was on understanding success factors, whereas the most researched industry at that time was financial services. Similar findings have been made by Biemans et al. (2016) in their extensive literature review containing 230 NSD studies published during 1985-2012. The most popular single industry investigated during this time period was financial services. Especially during 1985-2001 financial services dominated the NSD research arena, and it was not until 2002 that also other single industries, such as telecom/ICT, started to gain research traction. Moreover, the most investigated NSD topics during 1985-2012 were process and execution (over 50% of all articles), strategy (about 20%) and customer and market research (about 20%). However, technology does not seem to have attracted nearly any research enthusiasm as there were only two papers investigating this topic during this same time period, one in the era 1985-1995 and the other in the era 2009-2012.
Droege et al. (2009), in their literature review, present four NSD schools of thought, namely technologist, assimilation, demarcation and synthesis. According to the technologist school of thought, new service development is related to technological advancements. The assimilation approach states that the theories and concepts of product development can conveniently be transported over to service development. Contrarily, the demarcation school of thought underlines the idiosyncrasies of services, which makes it more problematic to convert know- how from manufacturing to services. Finally, in the synthesis outlook, an effort has been taken to combine the development of services and products, rather than study both fields independently.
New service development (NSD) is defined as implementing better service. The execution begins from an idea, which is then conceptualized. After this the concept is launched. In the literature, new service development is commonly used interchangeably with a similar and close concept, namely service innovation. (Droege et al., 2009; Biemans et al., 2016.) There are, however, some differing nuances in their significance. Biemans et al. (2016) state that NSD is closer to the marketing and service management domains and that it involves stages
from idea generation to market launch of new service offerings. Alternatively, service innovation embraces any change that affects one or more service characteristics. Furthermore, it involves economic and strategic aspects, as well as technological development and entrepreneurship matters (Mendes et al., 2017.)
2.2.2 The service development process
Although there are plenty of studies on NSD processes, Smith et al. (2007) state that more studies in this field are justifiable due to the fact that the process is expensive, time- consuming, and yet often ineffective. Moreover, Stevens and Dimitriadis (2005) mention that NSD process research is rather shattered, and that more industry-specific research are needed.
Biemans et al. (2016) also state that NSD research should be steered further away from product development research and more towards its own field in order to create a more cohesive NSD research arena. To a large point, so far, the frameworks utilized in NSD process research have been copied from product development research, which can also be considered the “origin” of NSD. The utilized frameworks include e.g. service blueprinting, quality function deployment (QFD), the stage gate model, the prerequisites model, and the stakeholder model. (Smith et al., 2007.)
The majority of the utilized models in a case study by Smith et al. (2007) stem from product development. In this case study regarding the design and development of a new hospital, new service development is considered vital for augmenting the profitability of an existing service, for instance by acquiring new customers and retaining existing ones, or through cost reduction and increased sales. According to the case study’s results, there are seven factors or criteria which lead to successful innovation in services. The first three have to do with the service design, i.e. (1) the service design must align with the organization’s strategies and goals, and therefore also with the aspirations of key stakeholders; (2) the needs and requirements of customers have to be taken into consideration; and (3) the service design must be flexible and adaptive to change. Furthermore, the remaining four criteria have to do with the NSD process:
(4) customer and stakeholder involvement; (5) a structured NSD process; (6) an organizational structure, which focuses on the role of communication, coordination and control; and (7) effective leadership in the sense that senior management is involved and an organizational culture, where information and ideas flow freely, is developed and sustained.
Elg, Engström, Witell and Poksinska (2012) study patient co-creation and learning based on diaries for use in healthcare service development. They focus on the patient co-creation process and provide different ways that healthcare service providers can learn from patients.
This outside-in viewpoint emphasizes the functionality of the healthcare service - it can be considered a refreshing outlook on healthcare service development, that has typically been executed from an inside-out perspective (Bitner & Brown, 2008), which contrarily accentuates the organization’s outlook on the efficiency of service development. (Elg et al., 2012.) Moreover, the study by Elg et al. (2012) emphasizes the greater and more active role of the patient in the service development process, which is in contrast to previous research where the customers have had a more narrow and passive role (Nambisan, 2002).
Elg et al. (2012) present a model for patient co-creation and learning as an outcome of their study. This is presented below in figure 2. The model includes three main phases:
preparation, execution and learning, respectively. In the first phase, the care process is selected, the process and diary designed, and the medium selected. In the second step, the patients are recruited and their writing is supported, which is then followed by the final phase of learning. In this final stage patients’ experiences are analyzed to explore possible new ideas for healthcare service development, create summary reports of the specific patient group, and create educational patient narratives.
Figure 2. The main steps in model for patient co-creation and learning (Elg et al., 2012, 333)
Stevens and Dimitriadis (2005) criticize the direct use and adaptation of new product development models to new service development. Since services possess different characteristics compared to products (such as inseparability) they argue that NSD frameworks
cannot be structured and simplified in the same fashion as NPD counterparts can. Directly applying NPD to NSD would mean slowing down the process due to time-consuming and bureaucratic procedures, as well as overlooking cross-functional teamwork and informal steps. According to Stevens and Dimitriadis (2005), it is more beneficial to build an organization that already from the start supports development, rather than later follow strict service development guidelines and stages.
The results of the research were presented along three dimensions: the actors and their organization involved in the NSD process, the decision-making process, and the changes necessary for the successful completion of the NSD process. According to the research, the teams involved in the NSD process changed continuously, and hence, none of the members were directly associated with the process throughout. This disruption in the development project workforce demanded continuous and open communication among the ever-changing teams and individuals. Moreover, this type of multi-team effort relied heavily on exchanging ideas and declarations and building on others work. The organizational learning process was the sole recognizable common factor in the decision-making processes. The NSD process modified the interaction process between the company and the client, as well as the information systems. Furthermore, there were alterations to the organizational chart, which meant modifying existing job contents, creating new positions and streamlining old ones.
(Stevens & Dimitriadis, 2005.)
2.2.3 Network perspectives in the development of services
Service development within a network environment has received little research attention compared to that of product development. To employ a network perspective to NSD, a relationship outlook of a company’s environment is crucial. Implementing a network outlook helps recognize actors’ participation in service development and increase the understanding of the trajectory of actor interaction and relationships. Furthermore, it enables increased insight about the service development process itself. (Syson & Perks, 2004.) The service development literature defines a network as all of the “formal and informal ties between stakeholders in the NSD process” (Smith & Fischbacher, 2005), and as a service-delivery network (SDN), where two or more organizations from the customer’s standpoint are in charge of providing the overall service experience (Tax, McCutcheon and Wilkinson, 2013).
The ARA framework is a model that enables the examination of businesses in terms of their relations and it was developed by the Industrial Marketing and Purchasing (IMP) group (Håkansson & Snehota, 1995; see Syson & Perks, 2004). The network components consist of actors, resources and activities. Actors include individuals, groups and organizations.
Moreover, actors control or have access to the resources, which can be physical and intangible, financial and human. (Syson & Perks, 2004.) Once one or more actors develop, exchange or create resources by utilizing other resources, activities occur (Easton & Araujo, 1996; see Syson & Perks, 2004).
In the case study conducted by Syson and Perks (2004), the ARA framework was utilized to examine and analyze the internal (employees and teams from different departments) and external (customers, suppliers, distributors, agents and competitors) actors’ roles and participation in the service development process. The study revealed that the evident majority of service developments in the case company are implemented by internal actors. Moreover, 90% of these service developments were either service improvements or service line extensions. The remaining 10% were categorized as new services for the currently served market. The development of entirely new services is the most time-consuming and complex of the three categories. Therefore, it also involves the most actors and demands the most iteration in the development process.
Syson and Perks (2004) claim that organizations can benefit from applying a network approach to NSD. However, the distinct attributes of services, namely intangibility, inseparability, perishability and heterogeneity, may hinder this endeavor and, thus, have to be taken into account when developing services. Moreover, to enable a network perspective in service development, a relationship view of an organization’s environment must be adopted.
Smith and Fischbacher (2005) studied NSD from a stakeholder perspective through four case studies; half of them concerned financial services, and the other half health services. The study revealed that managers choose which stakeholder groups are involved in NSD processes depending on their importance, centrality to the process, and abilities to impact the final service design. Customers were regarded as dormant stakeholders and, hence, were not directly involved in the development process, as managers considered them to lack expertise and experience to participate substantially in the NSD process.
Tax et al. (2013) in their study of the service-delivery network (SDN) utilize a focal net or ego network approach where the service is examined from the viewpoint of a single actor. In their case it was the customer, who acted as the hub or focal point to the service network.
Furthermore, the network only included actors that were in direct contact with the customer (i.e. service providers). A service is generated by a constellation of service providers that each contribute to the overall service through a unique customer encounter. The holistic customer experience is thus created and affected by this entire network. Hence, it is imperative that there is collaboration amidst various service providers, at least to some extent.
2.3 The social and the material in organizations
2.3.1 Sociomateriality
Sociomateriality can simply be defined as the continuous interconnectedness of the social and material aspects in an organization’s everyday life (Jones, 2014). According to Orlikowski and Scott (2008, 463), sociomateriality suggests that organizations (the social) and technology (the material) are not independent entities, but instead “inextricably fused” or
“constitutively entangled” (Orlikowski, 2007, 1437). In the sociomaterial outlook, technology is thought as one actor alongside all human actors. In other words, technology and humans are considered as equal and connected instead of separate or unattached. (Jones, 2014.)
Jones (2014) points out two prevalent and distinctive viewpoints in the sociomateriality literature, under which the sociomaterial research has accumulated. These perspectives are described as strong and weak sociomateriality or agential and critical realism, respectively (Leonardi, 2013; Mutch, 2013). The following table 1 presents the differences in these viewpoints as presented by Leonardi (2013).
Table 1. Comparison of agential realism and critical realism for study of sociomateriality Agential realism Critical realism
General ontology There is no separate social interaction that is not distinct from materiality — there is only a fused “sociomaterial”.
The social context and the materiality that exist in it are separate. The social and material become “sociomaterial”
as people imbricate social and material agencies.
General epistemology
Analysts make arbitrary distinctions about what is
“social” and “material” when looking at a unified whole
“sociomaterial”.
Analysts determine how and why the separate “social” and “material”
become the “sociomaterial” and persist that way over time.
What is materiality?
There is no materiality. There is only sociomateriality.
The setup of an artifact's physical and/or digital materials into certain forms that endure across differences in place and time.
What is social? There is no social. There is only the sociomaterial.
Abstract concepts such as norms, policies, communication patterns.
What is
sociomateriality?
The inherent inseparability between the material and the social.
Enactment of a distinct set of actions that meld materiality with discourses, institutions, and other phenomena we usually define as social.
What is the
"practice"? A sociomaterial
accomplishment. The space in which social and material agencies become
constitutively entangled through the process of imbrication.
Methodological unit of analysis
The sociomaterial practice. Social and material agencies.
Methodological focus
Identify what implications sociomaterial practices have for organizational processes (e.g.
identification, negotiation).
Identify how social and material become sociomaterial and what implications this has for organizing (e.g. communication networks).
Potential conceptual contributions
Show how all organizational processes are sociomaterial and how notice of this can improve our theorizing about them.
Show that organizing occurs in practice, which is neither social nor material; it is both.
Show how organizations and
technologies become as they are and why people think they had to be so.
Move technology into a constitutive role in organizing and organizational processes while showing how
organizing shapes technology.
Source: Leonardi (2013, 74)
According to Leonardi (2013) and Orlikowski (2007), strong sociomateriality can be defined as the innate inseparability of the social and the material. Moreover, this viewpoint recognizes how all organizational processes are sociomaterial and that organizing occurs in practice, which is neither social nor material, it is both. Weak sociomateriality, however, is categorized as actions that merge the material and social in discursions, organizations, and so forth. Thus, the social and the material are seen as separate entities, which become sociomaterial through human actions. Furthermore, it recognizes the meanings this transformation into sociomaterial has on organizations, for instance on their communication networks. (Leonardi, 2013.)
Wanda Orlikowksi is one of the most renowned researchers of sociomateriality in organizational practices, whose work has influenced the development of the field. A considerable amount of research articles regarding the topic of sociomateriality refer to Orlikowski’s work (Jones, 2014). Her research elevated the use of technology into a central role in organizational processes. Orlikowski (2007) contends that research, in particular organizational research, has long neglected the material aspect of organizing, even though it is evident in every organization’s day-to-day practice. People, clothes, computers and phones are much more noticeable than for instance organizational culture or leadership. Yet, it has not attracted a great deal of research enthusiasm. Orlikowski (2007, 1436) continues that when materiality has been the subject of research, it has been viewed through “technology adoption, diffusion and use within and across organizations”. This take is problematic for two reasons. Firstly, it considers materiality as an occasional occurrence which requires attention only when, for instance, a new technology is adopted in an organization. And secondly this view tends to retain either a purely techno-centric perspective, which emphasizes how technology exploits human behavior, or alternatively a human-centered one, which is interested in how humans engage with technology. Orlikowski’s research has been influenced by agential realism or strong sociomateriality (Leonardi, 2013; Mutch, 2013).
Further perspectives on sociomateriality in organizational research are presented by Jarzabkowski and Pinch (2013). The first one, named affordances, underlines various possible applications of the material according to its attributes. In the second perspective, scripts, material is seen as actors that create an operational model. The outlook originates from the actor-network theory. Moreover, Jarzabkowski and Pinch (2013) examine the interaction between humans and materials and the multifaceted social context with a complementary approach to sociomateriality, namely the “accomplishing approach”. This previously
overlooked approach focuses on the activities as they are performed with objects, instead of simply concentrating on the materials or objects themselves.
Jones (2014) offers five notions of sociomateriality based on the identifications of Orlikowski and Scott (2008). These include materiality, inseparability, relationality, performativity and practice and they are described in table 2. Both strong and weak sociomateriality recognize all notions, however, their interpretation and approach to them vary.
Table 2. The five notions of sociomateriality
Materiality Although materiality is regarded vital, the interpretation of it in the sociomateriality literature is inconsistent. Below are presented three main discrepancies of the notion:
1. The sociomateriality literature contains many varying interpretations of the notion of materiality, albeit all referring to the same concept; i.e. material, artefacts, the tangible, machine, nonhuman, and technology. This is problematic, since e.g. technology does not always possess a physical substance (e.g. Leonardi, 2010).
2. Furthermore, the meaning of materiality itself may be subject to discrepancies even within the same study. The Oxford English Dictionary relates materiality to solidity and physicality (Jones, 2014); however, e.g. Orlikowski and Scott (2008) utilize it to refer to intangibles, such as data (Leonardi, 2010).
3. Finally, Leonardi (2010) highlights that matter and material may, apart from being physical, also be considered as a significance (consider essential or relevant), and that many authors simultaneously utilize the term in more than one of these senses. Likewise, Callon and Muniesa (2005) remind us not to mistake materiality with physicality.
Inseparability The notion of inseparability is rather well-established in the sociomateriality literature. Orlikowski and Scott (2008), Orlikowski (2007) and Pels, Hetherington and Vandenberghe (2002) all underline this inextricable relation between the social and material.
“...There is no social action that does not entail material means.”, Jones (2014) seconds. Regardless, however widespread acknowledgement of the inseparability notion exists, there still remains a lack of mutual understanding on the underlying meaning of this notion. This can be noticed by the colorful use of terminology that describes the socio-material relationship; the terms include e.g. entangled, inseparable, intertwined, intermingled, interpenetrated, and fused. (Jones, 2014.) Some emphasize the consolidation of entities, while others accentuate their mutual positioning (Jones, 2014).
Relationality Orlikowski and Scott (2008) argue that sociomateriality assumes a relational ontology that diffuses the constraints between humans and technology. This ontology proposes that “people and things only exist in relation to each other”. Thus, the relationality notion posits that neither social nor material entities possess innate attributes or abilities, but instead develop them through interaction with one another. Similarly, Pickering (1993) notes that material and social entities generate and affect one another. Furthermore, Law (2004, 42) states that “materials—and so realities...do not exist in and of themselves”.
However seemingly alike, these theoretical viewpoints according to Jones (2014) convey varying outcomes of the relation:
1. Orlikowski and Scott (2008) emphasize the attributes of entities;
2. Pickering (1993) mentions the existence of agency, and;
3. Law (2004) specifies the existence of entities.
Performativity The performativity notion (Barad, 2003) and the notion of performance, although related to one another, are not direct synonyms. Performance indicates the execution of an activity (e.g.
to perform a surgery), whereas performativity suggests application (consider e.g. language that executes action; “I do”). Moreover, the notion of performativity emphasizes that the barriers and relations between technologies and humans are not predefined or static, but instead emerge in practice. (Orlikowski & Scott, 2008.)
Practice In the sociomateriality literature, the notion of practice typically manifests in two ways: firstly, through the emphasis on material in everyday work and scientific practice (Jones, 2014); and secondly, with regard to practices as the execution of performativity.
(Orlikowski & Scott, 2008.) Source: adapted from Jones (2014)
2.3.2 Actor-network theory
One popular sociomaterial approach is the actor-network theory (ANT). The actor-network theory is considered more of a systematic approach than a theory, although its name suggests otherwise. Carroll (2014) explains that ANT investigates the scientific and technological achievements within a network, which makes it suitable for researching service networks.
Moreover, it allows the examination of the linkages between the social and the technical.
Utilizing the concepts of ANT, it is possible to analyze the role of technological actors within the service network. ANT provides a vocabulary to examine how powerful networks emerge
