innovation as integration: evidence from the assembly ...

1 downloads 47 Views 204KB Size Report
innovation through these types of large-scale changes recognises the key role of broader impact. ...... In some cases there may be some bespoke software.
Nyberg, R. 2015 – Unpublished working paper

INNOVATION AS INTEGRATION: EVIDENCE FROM THE ASSEMBLY OF MOBILE HEALTH

NB: This is an unpublished working paper for which there is not yet a published version. Please contact the authors (roy.nyberg(a)oba.co.uk) before citing.





Abstract

Research exploring the phenomenon of ‘innovation’ has evolved from earlier perspective of merely technical improvement to take into account broader social and contextual effects. Yet, the Schumpeterian insights about the primacy of products, services and product development has persisted in much of the literature. More recent innovation research has examined large-scale technical transformations in society, under various labels such as ‘technological transitions’ (Geels, 2002), ‘large technical systems’ (Hughes, 1983), ‘technological regimes’ (Nelson and Winter, 1982). I suggest this shift has been welcome, as seeing innovation through these types of large-scale changes recognises the key role of broader impact. Yet, even in these types of studies there has been a conspicuous insistence of defining innovation through products and the ability to develop objects. I present evidence from a case study on the efforts to introduce mobile technology solutions to health care, and argue for a distinctive concept of ‘innovation as integration’. This conceptualisation directs attention away from product features to those efforts that enable implementation and wide-spread adoption of a solution that is being offered. These are efforts by entrepreneurs to integrate their solutions with the existing technical, institutional and organisation relational arrangements. 1

Nyberg, R. 2015 – Unpublished working paper

INTRODUCTION

Innovation is one of the cornerstone concepts in contemporary economic development. Freeman noted that technological innovation is an “essential condition of economic progress and a critical element in the competitive struggle of enterprises and of nation-states” (1974, p.15). Firms, it has been argued, are able to sustain profitability with repeated introduction of innovations (Roberts, 1999). Joseph Schumpeter (1934, 1943) is considered the ‘seigneurial’ author of innovation literature, and much of the subsequent work is either based on his propositions or at least takes Schumpeter’s ideas as a starting point. Schumpeter’s (1934, 1943) powerful arguments about how innovation drives change in the economy were particularly focused on product development, markets and ways of organising business (Fagerberg, 2006). His framework assembled together core factors such as the importance of entrepreneurs, the act of combining existing resources, and inertia that the entrepreneurs face at various levels of society (Fagerberg, 2006). These arguments concerned at first entrepreneurship at a smaller scale, but in later work he expanded his views to cover large firms whose research and development departments provided a more formal setting for product development, or innovation, activities (Cantwell, 2001). While Schumpeter’s work was wide ranging (Fagerberg, 2006), this attention on innovation as a source of new products and services can be seen as the more influential in later work.

2

Nyberg, R. 2015 – Unpublished working paper With Schumpeter’s arguments as a basis and inspiration (Tzeng, 2009), subsequent work has shifted to study how organisations are able to create innovations. The focus on organisations has brought with it new areas of interest, such as how to develop the necessary knowledge basis for innovating (Phene, Fladmoe-Lindquist and Marsh, 2006; Cohen and Levinthal, 1990). While further development has expanded the scope of research to cooperation between organisations in innovation (Hargadon and Sutton, 1997), the focus of innovation work has remained mostly in the development of products and services, and in related processes. The agency in innovation has eventually expanded into networks and ecosystems of innovation (Hughes, 1983; Dougherty and Dunne, 2011), yet the focus of innovation activities has largely remained the same.

Perceiving the concept of innovation through products and services, or organisations that are able to create winning versions of these, is to see innovation through objects of development. This has been a dominant and distinct feature of innovation literature, which however is analytically problematic if we think that theories ought to provide guidance for new entrepreneurial ventures. Reflecting on known success stories, there are obvious questions that an entrepreneur would pose: How do I create the next iPhone? How do I build that next Google? Focus on developing objects directs attention to advancing the product features, or capabilities of an organisation. This approach neglects the various elements of context that are likely to resist the introduction of new technologies or practices, which was already recognised by Schumpeter. A theoretical perspective that provides guidance how to overcome this resistance would be analytically more useful for a start-up entrepreneur. 3

Nyberg, R. 2015 – Unpublished working paper I argue in this paper that innovation is essentially a process about fitting one’s solution into the contemporary technical, institutional and organisational arrangements of a given industry or sector. I propose a new conceptualisation of the concept of innovation as ‘innovation as integration’. My argument rests on the assumption that impact is the fundamental aim of innovation. I attempt to show that this is a analytically distinctive approach, and in the next section I provide a theoretical framing that illustrates how innovation has been conceptualised in past literature. I then describe the research design of my empirical work for this paper, and in the following section I provide empirical evidence for my argument. My evidence is a case study of the emergence of mobile health, in Finland and England. The discussion and conclusion sections pull together the evidence and theoretical distinctiveness for the argument.

THEORETICAL BACKGROUND

I argue here that the development of objects, such as products, services, production processes, and organisational capabilities, has been the dominant theme in innovation scholarship. The original work by Schumpeter (1934, 1943) was focused on these aspects, and later authors have developed these ideas further. While Schumpeter’s ideas have been employed in a quite a wide range of arguments, at their foundation they display a pivotal role for the type of objects that I have argued above, i.e. products and services. For example, in his review Tzeng (2009) categorises innovation literature under three streams of work that 4

Nyberg, R. 2015 – Unpublished working paper all provide a distinct view of innovation. But, as Tzeng argues, the roots of all three streams are in Schumpeter, and in their essence they all maintain the central role for object development.

In the “Corporate capability school” of thought, based on economics, a range of authors have made the argument that innovation is about making new capabilities part of the organisational routine, in order to enable the development of new technologies and to accomplish broader technological change. This position is focused more on a single organisation, even though other organisations figure in this perspective as affiliates. These other organisations may “stimulate and enhance the power of R&D done in industry” (Rosenberg and Nelson, 1994, p.340, quoted in Tzeng, 2009) by their support and by opportunities for technical development (such as through the R&D in universities and in government R&D laboratories) (Corrocher, Malerba and Montobbio, 2007, in Tzeng, 2009). This position could be seen as a more of a ‘large organisation perspective’, with main attention directed at the optimum functionality of organisational processes.

The attention in the “Corporate entrepreneurial school” is more directed at social considerations. This position appears more of a ‘small organisation perspective’ with a central concern in how to acquire resources and how to foster creativity. According to this view, corporate entrepreneurs build teams or networks for innovation (Freeman, 1991, in Tzeng, 2009) and use improvisation as a means to develop new technology. The “Cultural school” is also about the development of skills, but this could apply to either large or small organisations. This perspective suggests that technical innovation is about “deep craft”, i.e. craftsmanship (Arthur, 2001, p.7, quoted in Tzeng, 2009), by which advanced technology is created. 5

Nyberg, R. 2015 – Unpublished working paper Despite their relatively different approaches, for all of these three schools of thought the central problem to answer is how to enable better processes of development of products and technology – i.e. how to facilitate object development.

More recent work has expanded from a view of innovation within organisations to incorporate some elements of their environment, but I suggest they have still remained focused on the development of objects. Some examples of these more expansive perspectives have introduced such ideas as ‘ecologies of innovation’ (Dougherty and Dunne, 2011), ‘open innovation (Chesborough, 2003), or networks of organisations developing new technologies (Hughes, 1983). These are approaches that can be branded ‘systems’ views of innovation, which seek to include various factors other than technologies and industries. These other factors may be for example institutional (rules and regulations), the political process, public research infrastructure and the educational system (Fagerberg, 2006).

The ‘systems’ perspectives provide a multi-level view into the development of innovations. Sectoral systems consist of a group of firms that develop and make products, while they may also still compete against each other (Breschi and Malerba, 1997). While the focus in this perspective is clearly still in the development of products and services, also the organisations involved tend to be part of the same industry. This sectoral view could thus be seen as a rather narrow version of a systems perspective.

A broader systems perspective invokes also other types of organisations. Hughes’ (1983) work examined how electrical systems were introduced to the Western 6

Nyberg, R. 2015 – Unpublished working paper countries (in Europe and North America). Despite his concept of a ‘system builder’, which is reminiscent of the capable actor of the Schumpeterian ‘entrepreneur’ (Geels, 2004), his case study illustrates how the introduction of electricity and especially electric lighting was not a heroic tale of a single entrepreneur, but involved a broad range of entrepreneurs and companies, working simultaneously in different countries. He employs the term “technological systems” which consist of technical, physical artefacts, organisations involved in manufacturing and providing services and financing, legislative organisations, and even entities supplying resources for the manufacturing. Thus, Hughes’ perspective provides a view into the many factors and actors in a process where new technology or practices are being introduced. Yet, as being in the SCOT tradition of research indicates, also Hughes’ idea of innovation is about the technology, even if he incorporates a multitude of different elements in its creation.

A more recent attempt at merging systems theory and innovation by Geels (2004) comes far to explain how to introduce a solution while taking into account the existing contextual arrangement. In Geels’ model of the ‘socio-technical systems’ the innovation activities occur by organisations at three levels: ‘Landscape developments’ are broader phenomena such as climate change that place pressure on the lower level systems. ‘Socio-technical regimes’ such as energy systems or the transport sector are entities with many institutionalised arrangements such as stable organisational networks of relationships, operational practices and professional norms and sets of capabilities. ‘Technological niches’ feed new elements into the socio-technical regimes, such as information on technology, user preferences, and policies (Geels, 2004). Over time these elements link together, 7

Nyberg, R. 2015 – Unpublished working paper stabilise and gather momentum to challenge the existing socio-technical regime, thus producing change as a result of a process of innovation.

While Geels (2004) has sought to shift the focus of attention from artefacts to systems, his view is decidedly large-scale. The ‘technological niches’ is the space where entrepreneurs may operate, but this model looks daunting from the perspective of a single entrepreneur. The two levels would need to align with the entrepreneurial efforts, and there needs to occur ‘tensions and mis-alignment’ between the different elements of the existing socio-technical regimes in order for there to appear an opportunity for change. Thus, Geels’ framework offers a window in which to see the elements of context that may resist propositions of new solutions. The analytical value of this model is somewhat diminished by the proposition that entrepreneurs need to be able to wait for, and recognise, the occurrence of the abovementioned tensions and mis-alignments in the existing regimes before initiating their ventures. If such tensions and mis-alignments are difficult to recognise, then the entrepreneurial assault, from the niche, may never take place. I now turn to presenting my case study evidence, which illustrates micro-level efforts of innovation, in an emerging field of mobile health.

EMPIRICAL CASE EVIDENCE AND METHODS

I used a distinct empirical site to study ‘innovation-in-the-making’ (cf. “technologyin-the-making” by Garud and Rappa, 1994). I studied the efforts to implement 8

Nyberg, R. 2015 – Unpublished working paper novel solutions by collecting data on the emergence of mobile health in Finland and England. Mobile health, or mobile technology use in health care, has been an ongoing process of efforts for two decades. At the time of my data collection in 2011 no settlement was yet in sight for a dominant design (Anderson and Tushman, 1990) in mobile health, that would be a new assemblage of mobile technologies, health-related professional practices, business models and regulatory guidelines. This field of activity, with no clear outcomes at the time to taint respondents’ views about how to achieve success, was opportune and timely for examining what innovation is.

In order to gain a broad view into this field’s development, and to remain open to all of the variety in the field’s events, ideas and challenges, I employed what I call an “organisational field -method”. This method follows the Powell and DiMaggio (1983) definition of organisational fields:

“By organisational field we mean those organisations that, in the aggregate, constitute a recognized area of institutional life: key suppliers, resource and product consumers, regulatory agencies and other organizations that produce similar services or products.” (1983, p.148)

I thus sought to collect data in many and at wide variety of types of organisations, as long as they were active, or expected to become active (or take stand in, e.g. a ministry or other public sector agency) in mobile health. This resulted in interview and documentary data from 54 organisations in the two countries. In addition to interviews and documentary data, I attended 8 mobile health related conferences, workshops and seminars, and studied the Nexis UK database for all European 9

Nyberg, R. 2015 – Unpublished working paper news articles on mobile health. In face-to-face interviews I asked the respondents to draw sketches of the emerging mobile health field in order to see how actors perceive and visualise the development of the field as network relations.

In my data analysis, conducted with NVivo analysis software, I employed a distinctive strategy that was partly deductive and partly inductive. Following Miles and Huberman (1994, 2002), I tackled the sometimes “unwieldy and unstructured” (2002, p.309) qualitative data by adapting a “general accounting scheme” (1994, p.61) from Van de Ven and Poole (1990) for first level coding. I considered actors, context, activities, meanings and timeline to be appropriate for this study as first level coding categories. The second and third level coding categories needed to be more inductive in nature, in order to let in the variety of views and experiences of organisations at early moments of mobile health. In other words, I allowed the second and third level coding items to arise from the data.

In the analysis, after coding the material I ran coding queries to find out which categories of activities, ideas, challenges and other contextual aspects had occurred most frequently and when. From my coding I drew conclusions about what are the efforts that actors have been engaged in, as well as what are the obstacles these efforts have faced. I time-stamped the data events whenever possible in order to produce timelines of different efforts, ideas and challenges.

EMPIRICAL CASE EVIDENCE

10

Nyberg, R. 2015 – Unpublished working paper In the following I present the empirical evidence for the argument ‘innovation as integration’. My presentation of evidence consists of relatively detailed description of how organisations, in Finland and England, have attempted to implement their mobile health solutions or promote their interests in this area. In other words, these are descriptions of mobile health as an innovation-in-the-making. I also describe what has been the resistance, or the obstacles, to those efforts. Indeed, I place more emphasis in this account on these obstacles, as they are particularly illustrative of the early moment context that is given to the actors pursuing their goals. They also show how the unsettled field of mobile health has provided few successes but many tales of disappointments, difficult decisions, uncertainty and struggle. This is the major finding in the study, which leads to the argument about ‘innovation as integration’.

Technology development

First, organisations in Finland and England tried to advance mobile health with a variety of technical initiatives. Most common among these were software applications for mobile phones and tablet computers, which enable the patientuser to monitor and maintain their health in various ways: They may gather movement related data of their exercise; they may forward vital signs data with a mobile device to a health clinic server; and they may communicate with health professionals, either to make queries about health issues, or to make a reservation for seeing a doctor or a nurse. Doctors and nurses use mobile devices to retrieve patient records while on the move; by looking at radiology images or the patient record they provide secondary opinions remotely about patients, and they check medication information from a database with a mobile device. There have been 11

Nyberg, R. 2015 – Unpublished working paper these, and other, kinds of development efforts by both large and small technology firms.

At the same time, these organisations have faced several technical challenges in their efforts. There have been technical challenges that operate at the level of individual devices and applications, and those that operate at the level of technical systems.

One of the challenges of devices and applications has been that the technology has not provided the expected performance. During the 1990’s and first half of 2000’s the mobile networks were unable to transmit large amounts of data, e.g. radiology images, and as mobile data was not widely available, there was no easy online access to patient records. Equally, most mobile phones had a very limited battery life, which did not allow for extensive daily use, and GPS positioning was unstable. Other problems were caused by unreliable technology standards. Technical standards that were considered universal, such as Bluetooth and others, were employed by device manufacturers in many different ways. This forced the application developers to work with each model separately, thereby adding to the development effort.

Moreover, inconsistencies in these standards have complicated also the efforts at integrating their applications with back-office health IT systems. These standards problems were compounded by the abundance of mobile phone models that came into the market over the years, putting a significant strain on these often small developer firms. Lastly, mobile phones of 1990’s and of the first half of 2000’s, with their small screens, were not well designed for displaying data from patient 12

Nyberg, R. 2015 – Unpublished working paper records. Developers had to think how to re-fit content from websites and documents to be presented on these smaller devices, while ensuring that pertinent information is delivered.

System-technical challenges

There were also more IT-system related technical challenges. One challenge has been the legacy of decades of building up health care IT. As one industry association representative explained, a fundamental problem is that health care applications have been built for large IT-systems, and they do not work in a “mobile friendly way”.

“One is that if you come from a fixed broadband perspective, then power consumption and bandwidth are really not an issue at all, connectivity is not an issue. So you have a luxury of being lazy with all those sorts of things, whereas mobile forces a different discipline on designers.” (Industry association representative, England) The different design disciplines of the mobile devices and the back-office IT systems have caused interoperability problems. However, if these devices were to be used in new care processes, same functionality as with traditional processes needed to be ensured, which posed significant challenges for developers.

According to some, the larger problem is that the whole philosophy of health care IT has actually been to serve the care organisation rather than the individual:

“Undeniably, we are still in the beginning, as really none of our systems support well [patient use of their data].... Health care IT-systems serve now health care operations, they serve the professionals. A little bit the idea that if we record there data about the patient, we are not really recording data about the patient, but about the care we have given. It is an instrument for documenting our own work... This 13

Nyberg, R. 2015 – Unpublished working paper thinking is quite dominant that the information is not there for the patient’s best, but for our purpose. To begin with, data is categorised in these systems by organisation, and it is very difficult for me to find all the data about me. It is much easier for the hospital X to find all data about itself.” (Ministry official, Finland) Thus, there have been several technical efforts, but the corresponding technical obstacles have been considerable.

Business model and service concept development

Another set of efforts has been to develop business models and service concepts. Small technology firms, together with care organisations, have attempted to introduce new service concepts that involve patients more in their own care. Patients are offered tools to measure their vital signs independently and to communicate the results to care organisation’s server. These firms have also developed software for community matrons, who can thus use mobile devices during their home visits, in order to transmit patient related data directly to the care clinic servers.

Also the large mobile technology firms have been developing new business and service concepts. One of their interests has been to try to alter the current paradigm of health care services. Much of health care provision in England and Finland functions between organisations, whether reflected in the reimbursement schemes (with no or minimum patient payment) or in the assignment of ‘own’ General Practitioner (with little patient choice in the matter). These firms, most of which have had large individual customer facing businesses, have been trying to reorient health care services towards ‘consumers’:

14

Nyberg, R. 2015 – Unpublished working paper “What we are doing is we are trying to move the demand from the B2B side to the B2C side. So we are slowly trying to also develop solutions where the consumer sees immediately the benefit and is willing to pay for the solution.” (Large software and telecommunication services provider, England) Furthermore, some of the technology companies have developed concepts to offer data analysis services. In their view, using mobile devices to gather frequently or even continuously health data is leading to a significant increase in the amount of patient data. They have designed data analysis services that they see indispensable for enabling adequate decision support for care professionals and patients alike.

Yet, there have also been challenges that relate to business models and service concepts. Uncertainty of business models has persisted throughout the two decades of mobile health developments. One frequent participant to health technology and mobile health conferences aptly noted in 2011:

“And someone used a joke about it last year that ‘the only people making money in mHealth are the conference organisers’.” (Industry association representative, England) Perhaps the most significant reason for the difficulty of creating a model for a profitable mobile health business has been the need to merge two quite different fields, namely the health care sector and the telecommunications industry. Mobile and telecommunications industries are highly focused on commercial viability, and one of their characteristics is to be very precise about the cost effects of regulation. They market their products and services to mass markets and thus need to operate at cost levels that allow for relatively low prices for these markets. The priorities of the health care sector are elsewhere than cost, namely in patient safety and health outcomes, and thus cost points tend to be relatively high. As a result, the cost point 15

Nyberg, R. 2015 – Unpublished working paper that emerges from health care regulation poses a challenge for the mobile and telecommunications industry to provide mass-market solutions. In practical terms these considerations of cost point and value for money have confronted mobile health ventures in procurement processes, as well as when soliciting for own funding.

Part of the ambiguity has been that mobile health opens up the discussion of who will pay for the devices. While traditionally, in most cases devices for monitoring and other care were paid by care organisations or even insurance schemes, lengthy approval processes at care organisations have raised the argument that patients could pay for devices. Thus, the companies active in mobile health would need to convince the patients to accept this new role.

On the care organisation side the development of new service concepts around mobile health often founder at the short sightedness of planning. The local care organisations are happy to run pilot projects to trial new service solutions, but these are not sustained because no funds are made available when the project ends. Even solutions that in trial phase were unequivocally successful are merely abandoned and any momentum for transforming services is lost.

Thus, also the business models and service concepts are still under development, with the different values and approaches to operations of the health care sector and the telecommunications industry clash at critical points of contact.

Creating collaborations

16

Nyberg, R. 2015 – Unpublished working paper Creating organisational collaborations has been another dominant activity around mobile health. Organisations have sought partners for their projects, and have participated in those initiated by others. One pattern has been for the large, incumbent organisations to seek collaboration with organisations that are already known to them, while the smaller newcomers have tended to establish cooperative relations with organisations previously unknown to them, and often also outside of health care sector.

Establishing new networks of relationships around mobile health has been common, but there have been many challenges also in this area. One of the core barriers to mobile health progress has been a disconnect between small application developers and large IT-system providers. Many small software providers have reported of the difficulty to create partnerships with the large, established IT-providers that control the back office IT in health care. According to one software provider the typical paradigm is that lack of access to proprietary systems, and in the absence so far of public integration platforms, the only option for the small, new software developers has been to build point-to-point solutions that collect data and store it on an isolated server. Such data thus remains de facto outside of the main health care system. In order to trial their new systems, the software developers have sought to run pilot projects for their applications, as a consequence of which the field has been full of pilots by small developers that nevertheless have not lead to solutions that have been sustained.

“Pilots begins, pilot ends, but they do not scale. One is forced to sell isolated systems, and consequently most of the firms [that begun early on] in this business are gone, probably 90% or more, both in Finland and elsewhere.” (CEO of a small software company, Finland) 17

Nyberg, R. 2015 – Unpublished working paper In conclusion, seeking partnerships has been common, but the large corporations have clearly been careful to protect their dominant market positions in health care IT. As a result, the small software developers have had insurmountable problems in gaining access to the mainstream care processes.

Other efforts

In the following I will provide short descriptions of some other types of efforts beyond the three dominant activities of developing technology, business models and service concepts, and creating partnerships that I have already mentioned above. In the following section I will describe other types of challenges that organisations have faced as part of their mobile health efforts.

Research

Research into technology and new practices has been another popular initiative in mobile health. First activities in mobile health, particularly in Finland, were about research into the technical feasibility of mobile devices to deliver health related messages and large radiology images. Subsequent investigations, often criticised for their small scale, have studied the health impact from the use of these devices. For example, medication and appointment adherence on mobile devices have been some of the popular topics in terms of research.

Establishing new organisational units

New organisational units have been founded to advance mobile health. There have been new business units within larger organisations, such as a small unit within a 18

Nyberg, R. 2015 – Unpublished working paper telecommunications operator tasked with commercialising the company’s vision for mobile health business. There have also been completely new organisations, usually small start-ups, aiming to capitalise on a perceived opportunity and capabilities in software programming and health care technology business. Other new organisations have been created when industry players have come together, either as industry associations or as regional collectives to promote the implementation of these technologies in health care.

Providing funding mechanisms

Also few funding mechanisms have been created to support the research and entrepreneurial efforts in mobile health. Particularly in Finland the public sector funding has been made available for development projects in this area. In most cases, however, the funding has had a broader remit of supporting technology development in health care sector, and Finland’s strong mobile technology industry, emerged in the shadow of the mobile device and network manufacturer Nokia Corporation, has resulted in many projects on mobile health.

Making publicity for mobile health

There have also been some publicity making efforts in both countries. In both countries organisations have made exhibition, seminar and workshop presentations to disseminate their experiences with mobile devices in health care. Some organisations have displayed their mobile health solutions on their websites and prepared brochures, but curiously many organisations have practically nothing about mobile health on their website – which may indicate that these 19

Nyberg, R. 2015 – Unpublished working paper projects are still considered to be at a trial stage. There is also a rare example of an effort to place mobile health as part of a broader cultural project. In England there was a campaign in which a group of cyclists with a long-term health condition demonstrated how mobile devices allow them to stay active (e.g. by cycling long distances) while managing their condition.

Other challenges

In the following I describe a range of additional challenges that have coincided the development of mobile health both in Finland and England.

Resistance towards technology

One of the additional challenges has been resistance towards mobile technology. Organisations trying to advance mobile health have described hostile attitudes towards solutions that involve mobile technology, particularly among some of the care professionals. According to the data, common fault line seems to run between technology geek doctors and older nursing staff. However, some of the distaste and suspicion for technology seems to be institutionalised. Some of the respondents describe how most health care facilities are still paper-based, while others had found that advanced telecommunications technology is still not considered a high priority at 2011, but something that is nice rather than a need to have. A view from an NHS agency that intermediates between technology companies and NHS care organisations is that there is a lack of ‘pull’ for technology as a solution, either from health care organisations or health care professionals. Within health care there

20

Nyberg, R. 2015 – Unpublished working paper appears to be a tendency to search for people based solutions, rather than ones that are technology based, as described by an innovation promotion respondent:

“If your average commissioner or your average senior manager in health care, in public health care organisation, will have a list of potential solutions, on the list of 1- 10 I would say that 8 out of those would be people based solutions. These would be changing the way you deliver services, changing clinical pathways, changing how you manage demand.... Without technology being at the core of the solution, if that makes sense. It does not seem to be a natural choice.” (Innovation promotion agency official, England) One typical effect of these attitudes towards new technical solutions has been the difficulty of un-learning, which has meant that service has become slower or worse. Some of the staff have done things twice, just in case, as they have not trusted the new technology. At the same time, general attitudes towards telecommunications technology, as indicated by adoption rates, in both England and Finland have been very positive already for many years.

Regulatory challenges

The basic regulation related challenge has been the uncertainty regarding how mobile health should be regulated. European regulation on medical devices has not provided clarity on this question, and this has caused considerable anxiety in both England and Finland, especially among entrepreneurs, but also others that wish to see mobile health become institutionalised practice. One of the regulatory uncertainties relates to liability – if something goes wrong in a care process that has involved a mobile device, is the physician still liable? Or does the liability shift to the mobile network operator, the device manufacturer, the application developer, or the patient that has used the device? These are still open questions 21

Nyberg, R. 2015 – Unpublished working paper that have lead to other questions: whether to extend the medical device regulation to devices and applications? In cases where patients have generated data about their physical activity, how should physicians access that data, how should they use it, and how to verify the accuracy of the data? All of these issues still being unsettled, especially the mobile software developers have been struggling to make decisions about the products and services they are developing, and thus this has hindered mobile health from developing.

Data protection and privacy regulations have also become part of the set of core issues in mobile health development. While these are important matters to take into consideration, they have also complicated efforts to make mobile devices usable in health care. For example, these legal conditions require perfect traceability for how the health data travels in the communication networks. Until recently, however, messages sent would take the least congested path in the telecommunications network, and thus it was not possible to know with certainty their path in advance. Only recent technology has allowed the guiding of messages through a specific pathway.

Complexities of procurement in the health care sector

Procurement has been another complicating element for mobile health entrepreneurs. To begin with, procurement for providing health related services or products is complex, understandably so considering the seriousness of health issues. For example, in order to qualify for procurement in the NHS one has to overcome the formal obligations, i.e. to provide the necessary evidence regarding

22

Nyberg, R. 2015 – Unpublished working paper positive health or financial outcomes and to fulfil the data protection requirements.

Competing to win contracts places other hurdles in front of a prospective mobile health entrepreneur. One aspect of this is the centrality of ‘cost’ considerations in procurement decisions, as opposed to more holistic ‘best value’ assessment. When selling new technology, where cost advantages may not be visible already in the first year, such procurement principles are likely to be detrimental. Even in cases where one has won a contract in one care unit, there may be difficulties to scale the solution to other organisations within the NHS, due to the often-criticised fragmentation of the NHS.

Another complaint that relates to the way the NHS has been structured is that in many cases the benefit of a new solution is gained by a different budget holder than the one that is responsible for the cost of the solution. As a result, the overall benefits are more difficult to account for and consequently this structure offers little support for the adoption of a solution on a broader scale. Furthermore, in some cases the financial incentives for the provision of services do not support the adoption of self-care type of technology. The provision of health care services is built around service events, and their funding arrangements reflect this. How services are paid for can make it disadvantageous for health care professionals and organisations, as well as individuals, to adopt new solutions. In addition to this, there is evidence of the “not-invented-here” –syndrome in many NHS care units, according to one NHS innovation promotion agency official, generating further resistance to the procurement of novel technology. In other words, common

23

Nyberg, R. 2015 – Unpublished working paper reaction to proposals of novel solutions and new arrangements is that they do not fit our organisation or situation because we are different.

Constraints from national politics

There have also been constraints from national politics. On the one hand there has been a clear lack of political leadership that would facilitate broad adoption of technology in health care. At the same time, especially in England but also in Finland, drastic cuts to public sector spending have been introduced, which could prompt leaders to look for ways to reform health care. Thus far there have been only efforts to cut back from existing services, as well as from the funding to third sector organisations providing care services. In some cases, NHS organisations have been restrained by departmental or ministerial guidance, in order to be doing what the minister wanted, as opposed to the plans and the interests of the organisation’s own leadership.

Organisational structures as obstacles to mobile health development

There have also been challenges that relate to the ways in which the current health care organisations operate. One complication in current health care from the perspective of new care solutions is the strategic purpose of care organisations themselves, which does not reward patient independence. Whether reflected in the salary incentives of a single doctor or in the functions of a single health care organisation, health care is organised at the moment with the aim to receive and process large numbers of sick people - as opposed to trying to prevent them from coming to be processed. These misguided system incentives then also hinder 24

Nyberg, R. 2015 – Unpublished working paper moves to assign more responsibility to patients, i.e. to keep them away from care organisations and to encourage more self-care with the help of new technologies.

Another aspect is the resources available at local units for the needed development work, particularly in Finland where health care is the responsibility of local governments. This means that any development towards new forms of service is highly dependent on the resources of the local government. These resources tend to be meagre in most places, and consequently the possibilities for developing new care services are bound to be very limited. One effect of this has been that as these local and regional entities decide independently on their IT- systems, it has had the effect of creating rather fragmented procurement markets for technology providers. This fragmentation in turn has resulted in a culture of local and independent solutions in the Finnish health care sector.

Challenges of framing mobile health

Lastly, there have been challenges that relate to how the promoters of mobile health have framed this new concept. One typical framing has conceptualised mobile health as a process improvement, made up of devices, applications and rearranged practices. However, such argument calls for evidence of improvement over time. The challenge has been to provide such evidence. While the information on the costs of the investment tend to be easily available, in the form of device and system investment and expenses for staff training, some of the benefits are often more difficult to gauge. It has proven difficult to show how these technologies are able to produce such efficiency improvements in care.

25

Nyberg, R. 2015 – Unpublished working paper Many pilot projects have been initiated to test these applications. Various types of organisations have started pilot projects to demonstrate the advantages from mobile health. However, these projects have been as a rule small in scale, as largescale pilots are costly and difficult to arrange. However, these small scale attempts to ‘validate’ mobile health have largely been rejected by the organisations that currently operate the health care system. They have argued that these pilots do not provide adequate evidence of the health and cost outcomes, especially on large populations. Thus this framing of mobile health as process improvement has caused an evidence problem, which has been extremely difficult to solve.

These efforts and challenges summarise the mobile health development in these two countries over two decades until 2011. Without knowledge about how success is measured in this field, what business models will be dominant, what uses of technology will be most effective for health and financial outcomes, and what types of organisational coalitions will be best fitted to reap the benefits in this field, mobile health has been an awkward space of activity. In short, there have been many sincere and spirited efforts to create mobile technology solutions for and bring them to health care, but even greater number of obstacles have rendered most of these efforts unprofitable.

The attention here is consequently directed at how to manage these obstacles in order to facilitate the implementation and adoption of the mobile technology solutions. In the case of many of these obstacles, they are very firmly entrenched in the texture of how health care is provided, such as: the procurement processes are complex and intertwined with many other organisational processes; the recording of patient data has been organised in a way that makes obtaining data from 26

Nyberg, R. 2015 – Unpublished working paper different care organisations difficult. It is therefore very complicated to remove many of these obstacles, at least by entrepreneurs. This leaves the option to try to fit, or integrate, the solutions with these factors that are the obstacles. Thus I offer the concept of ‘innovation as integration’, which I seek to explain further in the section below.

DISCUSSION

What is innovative in mobile health? This case history of the emergence of mobile health in England and Finland allows one to think about innovation in a new way. I suggested above that in prior work on the concept of innovation scholars have continued to stand by with the Schumpeterian idea of product, service and process development as the focus of activity, or what Fiol calls “innovative outputs” (1996, p.1018). In those arguments the efforts may take place at the level of single or of ecosystems of organisations. Yet, in the case of mobile health emergence at early moments, the challenges have mostly not been about the product or service quality. Instead of object development, the challenges have been about integrating the new solutions into the existing systems. In other words, the core task of innovation in mobile health, i.e. of achieving change in how health care is provided, has been the effort of integrating the proposed solutions with the existing technical, institutional and organisational arrangements.

27

Nyberg, R. 2015 – Unpublished working paper I raise the three following points to elucidate the argument about ‘innovation as integration’. First, the various obstacles in the mobile health case demonstrate the need for entrepreneurs to integrate their solutions with the existing arrangements. Most of these obstacles arise from the existing ways of how health care and the telecommunications services are provided. The obstacles are less about the quality of the technology.

In some cases it may be that the solution may need adjusting. In other cases it may be that the existing arrangements require adjusting, if they seem to be hindering technical and other progress more broadly. This could involve working, together with partners, to influence the regulatory regime of an industry, to develop new professional norms and practices, or to realign supply or other organisational relationships to match new business models or technical arrangements. I have described an example of the latter in the previous section, with a software organisation offering a platform to share patient records between care organisations in a way that largely removes the thorny issue of patient consent. As a result of the focus on integration with existing arrangements, innovation is less about the highest possible advancement in technical sophistication, but more about the activities of fitting, which are the types of activities such as negotiation, brokering and settling.

Second, this argument about ‘innovation as integration’ stands in obvious contrast with the object-oriented perspectives of innovation. As I have discussed in the section on theoretical literature, the arguments in regards the latter have extended to consider radical (Shinn, 2005; van Dijk et al., 2011) or disruptive (Christensen, 1997) innovations. These conceptions of innovation offer, however, tools for 28

Nyberg, R. 2015 – Unpublished working paper analysing a solution with paramount impact only after the fact, i.e. when it is clear that a solution has indeed become ‘radical’ or ‘disruptive’, but they tell us relatively little of how to accomplish such an impact.

The ‘innovation as integration’ concept, on the other hand, provides a description of how to pursue the implementation of the solution in a way that it has an impact. It provides a broad guide for course of action (integrate the solution into the existing technical, institutional and organisational arrangements), which presupposes an analysis of what are the existing, institutionalised arrangements that govern the technical, institutional and organisational patterns of action. This concept does not prescribe a type of outcome, such as ‘radical’ or ‘disruptive’, but it suggests ‘impact’ as the measure of success. It is of course difficult to determine with precision what kind of impact qualifies the integration effort as success, i.e. as an ‘innovation’ as this depends on the solution, the context and the audience of impact in each case. The impact should, nevertheless, be significant and enduring.

First, one aspect that distinguishes the ‘innovation as integration’ concept from how innovation has been conceptualised in past literature is visible through the term ‘recombination’. This new conception of innovation does share some interests with earlier arguments about innovation in terms of recombination, but it is nevertheless fundamentally distinct. Recombination has been one of the core terms in innovation theories ever since Schumpeter (1934) introduced it. In the hands of contemporary scholars, innovation has been about recombining ideas (Van de Ven, 1986) or knowledge across organisations to develop new products and services (Dougherty and Dunne, 2011; Howells, 2006; Shafique, 2013).

29

Nyberg, R. 2015 – Unpublished working paper The idea of innovation as recombination is a recognition that solutions that are likely to be a source of change in their context are not standalone artefacts, but are created from a number of elements. However, the underlying purpose in this idea of ‘innovation as recombination’ is still about the development of objects. For example, Dougherty and Dunne (2011) argue that organisations share roles, social rules, routines and most of all knowledge in their interactions. A core element in this argument is the organising for ‘ecologies of organisations’, i.e. constellations that allow these interactions. Nevertheless, for Dougherty and Dunne, the objective of recombining these elements is still to generate products and services.

The ‘innovation as integration’ argument recognises similarly that singular solutions require other elements to have impact. Yet, whether the integration occurs through the creation of coalitions, or by entrepreneurs engaging with their contextual elements singularly, is not the focus of this argument. The mobile health case suggests that this may occur by individual companies, although coalitions may be likely agents of change in this model too. Rather, integration involves a variety of elements to produce systems of practice that consist of technologies, organisational roles, professional routines, regulatory norms, and patterns of use activity, among other things. Thus, this integration perspective is broader than merely perspective on a product and service development, encompassing a wider set of changes.

Two, the ‘innovation as integration’ concept is different from the previous innovation concepts in terms of the idea of ‘new’ in innovation. Newness has been one of the criteria in the use of the term ‘innovation’, whether as new products and services (Robbins, 1996; Farr and West, 1990) or as new technology or new 30

Nyberg, R. 2015 – Unpublished working paper applications of technology (Freeman, 1974). This interest in ‘new’ in past innovation literature follows logically the emphasis in this work on objects and their features. The most recent version of a product, with previously inexistent features, is ‘new’ in relation to the prior versions. The unfamiliar features of the latest version allows one to recognise distinctiveness between the versions, and thus enables one to draw the conclusion that a realised change has been caused by the previously unseen features.

In ‘innovation as integration’ concept this interest in newness is absent. Even though one of the core efforts in the mobile health case has been software development, arguably there is little that is new in terms of technology of mobile health. By this I mean that the technical solutions are mostly proven solutions from other areas of society where mobile technology has already been adopted. Mobile health is mostly about taking advantage of widely known and used mobile technology, such as mobile phones and especially smart phones, tablet computers, laptops and various types of sensors, as well as of course of servers and other background IT systems. In some cases there may be some bespoke software development, which allows the use of these devices for specific health care needs. However, much of the software for mobile health takes advantage of proven mobile technology concepts of other areas of society. Therefore, mobile health solutions are not new but already in use elsewhere.

The pivotal change from the past, i.e. what is ‘new’ here, takes place in the process of integration of the mobile technology solution to the existing arrangements of health care.

31

Nyberg, R. 2015 – Unpublished working paper But at the same time, it makes little sense to discuss a ‘new integration’ as this would suggest that on a prior occasion the same solution has already been integrated. Therefore, it is a distinct feature of the ‘innovation as integration’ concept that newness is not part of the vocabulary. Furthermore, the empirical effect of this conception is that there may be no necessity for the entrepreneur to generate ‘new’ ideas, but to take advantage of any ideas and products that are in use, and invest their efforts into combining, or fitting, them with the existing arrangements.

CONCLUSION

I have developed in this paper an argument about a new way of thinking about the concept of innovation. This new conceptualisation directs attention away from objects towards actions that are needed in order to achieve wide adoption and impact. As a consequence, the research programme that results from this ‘innovation as integration’ concept will require more wide-scale studies that examine the interaction of solutions and their contexts. The core objective in such studies will be to map how the efforts of integration are reacted to among the organisations that control the existing arrangements: the IT-systems companies that operate the background IT e.g. for hospitals and health care clinics; the regulatory and executive public agencies that monitor and determine the direction in sectors of the economy; and the established product and service firms that make up the networks of currently dominant organisations and supply ecosystems in 32

Nyberg, R. 2015 – Unpublished working paper industries. ‘Innovation as integration’ provides a distinct perspective that includes strong consideration for context as well as entrepreneurial action, while the common attention on product features is in a minor, even if not forgotten, role.

33

Nyberg, R. 2015 – Unpublished working paper

WORKS CITED

Breschi, S. and Malerba, F. (1997) ‘Sectoral innovation systems: technological regimes, Schumpeterian dynamics and spatial boundaries’, in Systems of Innovation: Technologies, Institutions and Organizations. London/ Washington: Pinter, pp. 130–156. Cantwell, J. A. (2001) ‘Innovation, profits and growth: Schumpeter and Penrose’. (University of Reading Working Paper), 423, pp. 1–28. Chesbrough, H. W. (2003) Open innovation : the new imperative for creating and profiting from technology. Boston, Mass: Harvard Business School; Maidenhead McGraw-Hill. Christensen, C. M. (1997) The innovator’s dilemma : when new technologies cause great firms to fail. Boston, Mass: Harvard Business School (Management of innovation and change series Y). Cohen, W. M. and Levinthal, D. A. (1990) ‘Absorptive Capacity: A New Perspective on Learning and Innovation.’, Administrative Science Quarterly, 35(1), pp. 128–52. Van Dijk, S., Berends, H., Jelinek, M., Romme, A. G. L. and Weggeman, M. (2011) ‘Micro-Institutional Affordances and Strategies of Radical Innovation’, Organization Studies, 32(11), pp. 1485–1513. DiMaggio, P. J. and Powell, W. W. (1983) ‘The iron cage revisited: Institutional isomorphism and collective rationality in organizational fields’, American sociological review, pp. 147–160. Dougherty, D. and Dunne, D. D. (2011) ‘Organizing ecologies of complex innovation’, Organization Science, 22(5), pp. 1214–1223. Fagerberg, J. (2006) ‘Innovation: A Guide to the Literature’, in The Oxford Handbook of Innovation. Oxford: Oxford University Press. Farr, J. L. and West, M. A. (1990) Innovation and creativity at work : psychological and organizational strategies. Chichester: Wiley. Fiol, C. M. (1996) ‘Squeezing harder doesn’t always work: Continuing the search for consistency in innovation research’, Academy of Management Review, 21(4), pp. 1012–1021. 34

Nyberg, R. 2015 – Unpublished working paper Freeman, C. (1974) The economics of industrial innovation. Harmondsworth: Penguin (Penguin modern economics texts : industrial economics). Garud, R. and Rappa, M. A. (1994) ‘A Socio-Cognitive Model of Technology Evolution: The Case of Cochlear Implants’, Organization Science, 5(3), pp. 344–362. Geels, F. W. (2002) ‘Technological transitions as evolutionary reconfiguration processes: a multi-level perspective and a case-study’, Research Policy, 31(8), pp. 1257–1274. Geels, F. W. (2004) ‘From sectoral systems of innovation to socio-technical systems: Insights about dynamics and change from sociology and institutional theory’, Research Policy, 33(6), pp. 897–920. Geroski, P. (2003) The evolution of new markets. Oxford: Oxford University Press. Hargadon, A. and Sutton, R. I. (1997) ‘Technology Brokering and Innovation in a Product Development Firm’, Administrative Science Quarterly, 42(4), pp. 716–749. Howells, J. (2006) ‘Intermediation and the role of intermediaries in innovation’, Research Policy, 35(5), pp. 715–728. Huberman, A. M. and Miles, M. B. (2002) The qualitative researcher’s companion. Thousand Oaks, CA: SAGE publications, Inc. Hughes, T. P. (1983) Networks of power : electrification in Western society, 18801930. Baltimore ; London: Johns Hopkins University Press. Miles, M. B. and Huberman, A. M. (1994) Qualitative data analysis: An expanded sourcebook. Thousand Oaks ; London: SAGE publications, Inc. Nelson, R. R. and Winter, S. G. (1982) An evolutionary theory of economic change. Cambridge, MA: Belknap Press. Phene, A., Fladmoe-Lindquist, K. and Marsh, L. (2006) ‘Breakthrough innovations in the U.S. biotechnology industry: the effects of technological space and geographic origin’, Strategic Management Journal, 27(4), pp. 369–388. Robbins, S. P. (1996) Organizational behavior : concepts, controversies and applications. 7th ed. London: Prentice-Hall International. Roberts, P. W. (1999) ‘Product innovation, product-market competition and persistent profitability in the US pharmaceutical industry’, Strategic management journal, 20(7), pp. 655–670. Schumpeter, J. A. (1942) Capitalism, Socialism, and Democracy. 3rd edn. New York: Harper. 35

Nyberg, R. 2015 – Unpublished working paper Schumpeter, J. A. and Opie, R. (1934) The Theory of Economic Development... by Joseph A. Schumpeter, Translated from the German by Redvers Opie,... Cambridge, MA: Harvard University Press. Shafique, M. (2013) ‘Thinking inside the box? Intellectual structure of the knowledge base of innovation research (1988-2008): Intellectual Structure of Innovation Research (1988-2008)’, Strategic Management Journal, 34(1), pp. 62– 93. Shinn, T. (2005) ‘New sources of radical innovation: research-technologies, transversality and distributed learning in a post-industrial order’, Social Science Information, 44(4), pp. 731–764. Tushman, M. L. and Anderson, P. (1986) ‘Technological discontinuities and organizational environments’, Administrative science quarterly, pp. 439–465. Tzeng, C.-H. (2009) ‘A review of contemporary innovation literature: A Schumpeterian perspective.’, Innovation: Management, Policy & Practice, 11(3), pp. 373–394. Van de Ven, A. H. and Poole, M. S. (1990) ‘Methods for studying innovation development in the Minnesota Innovation Research Program’, Organization Science, 1(3), pp. 313–335.







36