Mobile technology and healthcare: the adoption issues and systemic ...

Int. J. Electronic Healthcare, Vol. 4, Nos. 3/4, 2008

Mobile technology and healthcare: the adoption issues and systemic problems Susan Standing and Craig Standing* School of Management Edith Cowan University 100 Joondalup Drive, Joondalup Western Australia, Australia E-mail: [email protected] E-mail: [email protected] *Corresponding author Abstract: Although the benefits that are associated with mobile technology have been recognised as offering great potential in the healthcare sector, its widespread adoption has been lagging. We propose that fundamental systemic issues are likely to be the main barriers to adoption. We explain that the fragmented nature of the conservative healthcare system, the contradictory incentives and improper outcome measures conspire to make the innovative adoption of mobile technology problematic. Researchers can only gain a limited understanding of a technology’s potential success by using technology adoption frameworks and need to supplement this with a ‘systems’ perspective that takes a more strategic view. Keywords: mobile technology; e-healthcare; Technology Adoption Models; TAMs; systems perspective. Reference to this paper should be made as follows: Standing, S. and Standing, C. (2008) ‘Mobile technology and healthcare: the adoption issues and systemic problems’, Int. J. Electronic Healthcare, Vol. 4, Nos. 3/4, pp.221–235. Biographical notes: Susan Standing is a Research Fellow in the School of Management, Edith Cowan University, Western Australia. She holds degrees in Accounting and Information Management and has worked on a number of funded research projects. Her research interests include accounting information systems, e-healthcare and electronic marketplaces. Craig Standing is a Professor of Strategic Information Management in the School of Management at Edith Cowan University, Australia. His current research interests are in the areas of electronic markets, Information Systems (IS) evaluation and mobile commerce and e-healthcare. He has published in the European Journal of Information Systems and IEEE Transaction on Engineering Management.

Copyright © 2008 Inderscience Enterprises Ltd.

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S. Standing and C. Standing

Introduction

Mobile technology offers great potential to improve the level of service, provide productivity gains and reduce costs in the healthcare sector. Mobile applications can be used to access and update patient records, input the results of tests, monitor patients and provide clinical information to support doctors and other healthcare workers. A number of trends suggest that mobile technology adoption should increase rapidly. These include the increased personal use of mobile devices brought about by their reduced costs and more reliable and usable technology and telecommunications infrastructure. Even though this potential has been recognised, widespread adoption of mobile applications has not occurred in most advanced healthcare systems. This paper examines the role that mobile technology can play in the healthcare sector and examines its potential and the barriers to its widespread adoption. In investigating adoption of mobile technology in the healthcare sector we seek to identify the extent to which adoption is influenced by cost, usability, managerial, strategic or systemic factors. We use this analysis of mobile technology adoption in the healthcare sector to question whether Technology Adoption Models (TAMs) can provide full explanatory capabilities or whether more complex and fundamental systemic problems are the barriers to adoption.

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Definition of mobile technology

Information technology is the technology required to transmit, store, modify and retrieve data. Mobile technology, as discussed here, includes a technological device that can be easily transported from one place to another and utilised in these differing locations to access and update information. Mobile technology would not be possible without the telecommunications infrastructure to support the devices. Mobile technology uses can be as simple as a phone call made via a cellular network, sending and receiving e-mail messages on a mobile device or involve more complex transmissions such as those that involve transmitting images and large amounts of data. Developments in hardware including laptops, mobile phones and PDAs and improvements in telecommunications will assist the growth of mobile technology use in the healthcare sector. Technological devices are becoming ubiquitous, less expensive, smaller, and more wearable (Heinzelmann et al., 2005). Communication technology, nanotechnology and sensor devices are all part of the way in which communication can be passed from user to user through the healthcare information system.

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Different applications in the healthcare sector

Mobile technology can be used for administrative and clinical applications in the healthcare sector. User groups include doctors, nurses, administrators and patients. Each type of application has its particular benefits and set of issues related to adoption (Table 1).

Mobile technology and healthcare

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3.1 Improve communication Work is performed in a variety of locations in hospitals, surgeries and within the community involving diverse informational needs according to the task and location. Mobile devices will be increasingly important tools for facilitating communication, accessing and updating information within the healthcare environment. The growth and integration of technology and communication within the healthcare sector has great potential for patients and providers (Heinzelmann et al., 2005). Table 1

Benefits associated with mobile-technology adoption in the health sector

Benefit of mobile-technology

Reason for benefit

Mobile-technology application examples

Improved communication Reduce costs

Reference

More timely communication of information Direct data input at source

E-mail, voice, SMS

Heinzelmann et al., 2005

Inventory management

Bhattacherjee et al., 2007; Freudenheim, 2004; Mitchell and Sullivan, 2001

Reduce errors

Patient data input at source avoids transcription errors

Patient records

Bates et al., 1998

More data

Patient monitoring can capture more data

Patient records

Haverstein, 2005

Better patient care

Access to up-to-date medical records

Patient records

Dwivedi et al., 2007

Improved monitoring of patients

Patient records

Puentes et al., 2007; Kirsch et al., 2007

Fewer errors in patient data

Patient records

Better system load

Allows more decentralised/community patient care

Hardware and telecommunication mode

Fitch and Adams, 2006; Kirsch et al., 2007

Cost effectiveness

Mobile technology is less expensive than PC technology and wireless less expensive than hardwire technology

Telecommunication mode


Leverage expertise

Shortage of doctors and highly skilled healthcare workers requires their expertise to be leveraged

Heinzelmann et al., 2005

3.2 Improve efficiency There is general agreement that the use of technology in the healthcare sector can improve efficiency and help to deliver a quality service to the client. The use of paper based systems can lead to inaccuracies and inefficiencies. The implementation of healthcare information technologies such as Computerised Physician Order Entry (CPOE) systems, Electronic Medical Records (EMRs) and electronic prescriptions help to facilitate improvements in patient care and administrative efficiency, reduce medical errors and lower overall healthcare costs (Bhattacherjee et al., 2007; Bates et al., 1998; Freudenheim, 2004; Mitchell and Sullivan, 2001).

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Hospitals are increasingly using mobile technology to make patient care more efficient, especially in the area of medication. Patients in some hospitals have bar coded wrist or ankle bands which can be scanned to obtain accurate patient data and the prescribed medication details, the bar coded medication is also scanned. This has improved medication administration and enhanced quality assurance. To provide more accurate, up-to-date information data should be entered as soon as possible which means at the point of care. However, problems arise if care has to be interrupted to input information (policies and procedures need to reflect real life working conditions not be imposed as an interference to patient care, etc.). “At a Sydney hospital voice-activated, hands-free communications improved efficiency and freed up doctors’ time. Efficiency gains included 20 hours of staff time saved per day which equates to more than a $7 million annual saving based on average hospital salaries. The probability of a fast or very fast triage response also increased from 38 per cent to 46 per cent while the probability of a slow or very slow triage response decreased from 42 per cent to 34 per cent.” (Sydney Morning Herald, 2007)

3.3 Leverage expertise through greater efficiencies Anticipated shortages in skilled healthcare professionals increases the need for communication and adoption of technologies into clinical practice (Heinzelmann et al., 2005) and will contribute to the increasing use of mobile technologies.

3.4 Community healthcare The use of mobile technology allows informational needs to be taken from the static desk environment into the workplace and out into the community. The nature of healthcare involves moving from patient to patient and through many work areas. Accessing the necessary information and updating information at the point-of-care will improve efficiency and the quality of care. Technology promises to enhance patient care and also make home visits more efficient and help in responding to the increasing need for long term care and caring for patients at home or in remote areas. Community healthcare is an area where mobile communication is clearly helpful but more sophisticated systems may require reengineering of systems and work protocols (Fitch and Adams, 2006). Coordination of services and support can be improved by the use of mobile technology resulting in improved patient care and efficiency (Fitch and Adams, 2006). The ageing population, increase in numbers of people in nursing homes, strain on hospital resources and bed numbers, access to remote areas, decreasing numbers of doctors and nurses are all drivers of the trend towards community care.

3.5 Access to more and better information Taking mobility to the next level will involve the use of more wireless technologies and communication channels to enable secure access from more locations. Presently “within healthcare some of the most popular uses of wireless technology include accessing and updating EMR at patients’ bedsides, matching bar-coded patient wristbands and medication packages to physician orders, and using wireless badges for voice communication” (Haverstein, 2005).


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3.6 Less expensive than hardwire Implementing wireless technology can overcome some of the difficulties of hardwired systems especially in older buildings where wiring is deteriorating and access is restricted. The introduction of Wireless Local Area Networks (WLANs), for example, can be less expensive than installing a totally hard wired system.

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Barriers to mobile technology adoption

The adoption of mobile technology in the healthcare sector is not without its problems (Table 2). Table 2

Barriers associated with mobile-technology adoption in the healthcare sector

Barrier to mobile-technology

Implication of barrier

Organisational impact

Reference

Lack of system integration

Data exchange between systems is poor

Reduced service to patient


Centralised systems

Strain on central hospitals

Duplication of input Long waiting lists for patient care

High reliability requirement for patient care

Costly systems

Systems do not get implemented

Freudenheim, 2004

Conservatism

Lack of innovation

Fails to meet patient expectations

Haverstein, 2005

Lack of expertise

Lack of technology champions

Lost opportunities for cost reduction and service improvement

Wickramasinghe et al., 2008

Poor change management skills

Rejection or partial use of technology

Wiredu and Sorenson, 2006; Wiredu, 2007

Lack of training and support

People do not use systems fully

Partial or low levels of adoption

Zheng and Yuan, 2007

Security and privacy issues

Added complexity in system design

Risk aversion

Meletis et al., 2007

Von Lubitz and Wickramasinghe, 2006

4.1 Need for integration of systems Healthcare information systems are large, complex systems that are usually poorly integrated, having been under funded for many years. This means that the benefits of mobile applications in relation to data access and integration are not easily realised because the core applications of the system are not fully integrated.

4.2 Centralised systems Healthcare administration and management has been developed along centralised lines with larger hospitals being developed to improve economies of scale. These systems have been supported by centralised IT systems. However, this type of architecture does not reflect the distributed nature of work or patient needs. Recently, there has been a trend back to ‘community care’ where patients are supported in their homes. Therefore,

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there is a need for healthcare systems to become more flexible and support the distributed nature of patient care and the mobility required, inside and outside of hospitals, by doctors and nurses.

4.3 Critical applications The critical nature of healthcare applications dictates the need for high reliability. According to some developers the primary reason why projects fail is a lack of physician buy-in. “It could be because they find some mistakes in how the system is set up... and lose faith in it and feel like they are better off sticking with paper and pen” (Haverstein, 2005; Gebauer and Tang, 2008).

4.4 Conservatism The conservative nature of the healthcare sector means that change occurs slowly and fewer risks are taken when changes to a system are needed. This risk-aversion can apply to the adoption of technology.

4.5 Fear of control Global Positioning Satellites (GPS) can monitor peoples’ whereabouts through mobile devices. One of the benefits of being a mobile worker is the freedom and flexibility associated with not working in an office or at a desk (Wiredu and Sorenson, 2006).

4.6 Security and privacy issues The use of mobile technology in the healthcare sector creates concerns related to security and privacy. As mobile healthcare professionals often store confidential patient data the loss of such a device or unauthorised access to it can be highly problematic (Fitch and Adams, 2006).

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Theoretical perspectives on technology adoption

In this section of the paper we examine two alternative theoretical perspectives on technology adoption, namely the TAM (Davis, 1989) and a systems perspective (Waldman, 2007). These two perspectives are used to frame the case study of mobile technology adoption in a healthcare firm and to analyse the findings from the case study.

5.1 Adoption models The literature on technology adoption identifies a number of factors as important in influencing the use of a technology in an organisational setting where the use of the technology is mandated. The factors that are relevant to the adoption of mobile technology are listed in Figure 1 and also shown in Figure 2 and are based on the combined principles of the TAM (Davis, 1989) and the Theory of Reasoned Action (TRA) (Ajzen and Fishbein, 1980). TAM seeks to explain consciously intended behaviours across a wide range of end-user technologies and user populations (Davis


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et al., 1989). According to TAM, the beliefs held about an innovation, and the resultant attitude formation lead to an individual’s decision to use or not to use an innovation. The beliefs of perceived usefulness and perceived ease of use are considered the most important constructs in predicting technology acceptance in TAM. Attitude and intention to use a technology are the intervening variables that help to conceptualise and explain the causal relationships (Fowler, 1993; Cavana et al., 2001). Usage is the intended outcome of the expected behaviour. TAM has been refined and extended with TAM2 (Venkatesh and Davis, 2000) and the Unified Theory of Acceptance and Use of Technology (Venkatesh et al., 2003). Figure 1

Factors impacting on intention to use and use of mobile technology Performance expectancy (perceived usefulness) I find the system useful in my job Using the system enables me to accomplish tasks more quickly Using the system increases my productivity Using the system will increase my chances of getting a raise Effort expectancy (perceived ease of use) My interaction with the system is clear and understandable It would be easy for me to become skilful at using the system I find the system easy to use Learning to operate the system is straightforward for me Attitude towards the technology Using the system is a bad/good idea The system makes work more interesting Working with the system is fun I like working with the system Social influence (subjective norm) Work colleagues think that I should use the system Friends think that I should use the system The senior management of this business has been helpful in the use of the system The organisation has supported the use of the system Facilitating conditions I have the resources necessary to use the system I have the knowledge necessary to use the system The system is not compatible with other systems I use A specific group (or person) is available for assistance with system difficulties Intention to use I intend to use all/part/no aspects of the system (list each feature of the system) Use of the system I use all/part/no aspects of the system (list each feature of the system) Self-efficacy I could complete a job or task using the system …. If there was no-one around to help me If I could call someone for help if I got stuck If I had a lot of time to complete the job for which the software was provided If I had only the built-in help facility for assistance Anxiety I feel apprehensive about using the system It scares me to think I could lose a lot of information using the system I hesitate to use the system for fear of making mistakes I cannot correct The system is intimidating to me

Source: Based on TAM (Davis, 1989)

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Figure 2

Conceptual model for mobile technology adoption

Performance expectancy Effort expectancy Social influence

Attitude

Intention to use

Use

Facilitating conditions Self-efficacy anxiety

Although technology adoption can help developers and managers consider the key factors in adoption success they focus on the user and do not take a strategic perspective. For example, senior managers should develop a vision for the use of mobile technology in the healthcare sector and assess how it can support a transformation of working practices and changing patient needs and expectations. At the same time a strategic perspective should take a systems view to explore the potential and barriers to adoption and transformation. In the following section we examine specific systemic problems with large healthcare systems.

5.2 Systemic issues Some argue that the major healthcare systems in countries such as the USA and UK have a number of systemic problems that are impediments to learning and therefore, by default, making improvements (Waldman, 2007). For example, Waldman (2007) states that “among doctors and nurses admitting ignorance or incomplete understanding is considered weakness or a personal failing, and is therefore avoided, even rejected”. In addition, the culture in healthcare is highly risk averse and typically protective of the status quo. Below are listed what Waldman (2007) describes as the root causes of healthcare dysfunction and we assess their implications for mobile technology adoption. •

Timeline of causality There is a long delay between action and consequence, especially in preventative medicine. In other words, the outcome (success or failure) of treatment today for a patient may not be known for months or even years. In a system that emphasises cost effectiveness there is a tendency to only support initiatives that demonstrate improvements or reductions in the short term. Mobile technology, can demonstrate short term productivity improvements on an administrative level more quickly than on a clinical level. However, any barriers to adoption such as ‘conservatism’ may reduce the perceived short term productivity gains and so provide a rationale for not adopting the technology.

Mobile technology and healthcare •

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Improper outcome measures National health systems metrics emphasise costs and death rates rather than what is desired (life and productivity). This emphasis on costs is an impediment to the adoption of mobile technology that offers productivity improvements and better quality information and service.

•

Healthcare is a people processing system People often act in unintended ways and their behaviour is difficult to predict. Adoption of mobile technology has to be supported by layers of participant groups to be effective: patients, nurses, doctors and administrators.

•

Micro-economic disconnections The consumer (patient) is different to the person who drives the cost (doctor) who is different to the entity that pays (government or insurance company). This means it is a complex system that has multiple objectives to achieve. The business case for mobile technology adoption would have to satisfy these multiple groups.

•

Contradictory incentives As Waldman (2007) states: “Patients want care but the system rewards productivity.” This leads to doctors spending little time with their patients. Uses of mobile technology that improve the quality of service by providing better quality information may not be as highly regarded as applications that reduce the time spent with patients.

•

Organisational structure Some believe that the healthcare system is not a system at all but silos of individual interest groups (insurance companies, doctors, etc.), each with their own agenda. The implications of technology adoption are likely to run across these interest groups with their individual agendas making widespread support difficult.

•

Cosmology episode Waldman (2007) describes the healthcare system using Weick’s (1993) term to explain the situation “when people suddenly and deeply feel that the universe is no longer a rational, orderly system”. This type of worldview can make the ‘selling’ of a new technology difficult as people may have lost hope of improvement feeling that any new initiative is doomed to failure.

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Case study

To determine the benefits and barriers of mobile technology in the healthcare sector we undertook a case study of a major healthcare provider’s adoption of mobile technology by nurses. We refer to the organisation as Home Care to maintain a level of anonymity for the participants. Home Care is a major player in the healthcare sector and employs a large number of nurses who provide patient care within the patient’s home.

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The project involved developing a mobile technology solution for 500 nurses, 600 home help personnel and 710 care aid workers. Our research focused on a pilot study where the mobile technology was trialled with 50 nurses. The mobile applications linked to Customer Relationship Management (CRM) software currently provide: •

Access to patient records. This involved downloading patient records to the mobile device each day and an updating the data during the course of the day. Updated patient records are then stored on the centralised database.

•

Each mobile device has a camera and a graphical interface to be used for wound management purposes. Pictures of wounds are taken, matched and analysed in a central database and recommendations are given on the appropriate treatment.

•

Timesheets to be completed on a real-time basis where the mobile phone time is used as a time stamp. Through this accurate records could be maintained of actual hours worked.

•

Questionnaires from head office to be completed on the mobile device.

•

E-mail services for communication.

•

Barcode scanning to allow recording of stock usage. Each nurse typically kept a substantial amount of inventory such as bandages and pharmaceuticals. These could be managed more efficiently through the mobile application.

The objectives of the study were to evaluate: •

The benefits of mobile technology adoption.

•

The barriers to mobile technology adoption.

Both of these objectives are examined from a corporate and user perspective. In order to identify how nurses are using the mobile solutions in practice and their perception of the benefits, issues and changes to work practices interviews with 12 nurses were conducted. In addition, several interviews were conducted with the project manager and the information technology manager to obtain a corporate perspective of the issues. The interviews lasted between 20 min and 40 min and were conducted on Home Care premises and in some cases the interviews were conducted by telephone.

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Findings

The pilot study of mobile technology adoption by the nurses of Healthcare identified a number of benefits (Table 3). Management felt that the improved accuracy of patient data and the potential reduction of data entry staff that resulted from the direct data entry by nurses were the most significant benefits delivered by the new system. The IT manager confirmed this “This pilot project has shown conclusively that the mobile devices will save the organisation considerable amounts of money, far outweighing the costs of the devices and the telecommunications overheads.”

Mobile technology and healthcare Table 3

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Benefits of mobile-technology adoption in the case study

Benefit of mobile-technology

Reason for benefit

Home care case study

Improved communication

More timely communication of information

The use of e-mail on mobile devices improved communication between nurses and head office

Reduce costs

Direct data input at source

Reduced number of data entry operators at head office

Reduce errors

Patient data input at source avoids transcription errors

Transcription errors avoided as previously manual cards were used

More data

Patient monitoring can capture more data

Nurses has access to more patient information

Better patient care

Access to up-to-date medical records

Patient database was updated immediately

Better monitoring of patients

Improved information meant better patient care

Fewer errors in patient data

Transcription errors avoided as previously manual cards were used

Better system load

Allows more decentralised/community patient care

Better decentralised patient care meant fewer hospital visits for patients

Cost effectiveness

Mobile technology is less expensive than PC technology and wireless less expensive than hardwire technology

Management found the mobile devices to be a cost effective solution

Leverage expertise

Shortage of doctors and highly skilled healthcare workers requires their expertise to be leveraged

Not applicable at Home Care

The high quality mobile devices stored custom developed applications and the data could be displayed and input in an efficient manner. The frequently suggested barrier in the literature for mobile applications relates to usability. It was thought that the small screen size would impact upon usability but this did not appear to be an issue. Cost reductions could also be achieved by better inventory management as the nurses typically held a significant amount of medical inventory in their cars to be used when visiting patients. The technology would facilitate better communication between administration, management at the head office and the nurses. For example, it would support the management of timesheets for nurses more efficiently and accurately. A number of barriers to effective adoption of the mobile technology were identified (Table 4). The nurses were quite apprehensive about using the technology. It was seen as a significant change to their work practices and they were concerned that the adoption of the devices may detract from them focusing on the patients. They could generally see that the up-to-date and accurate information on patients would be an improvement. For example, when a doctor had examined the patient and updated the database, the nurses would have access to this information when they started their shift. Also when taking over a shift from another nurse the communication and information flow would improve. The nurses were concerned that the use of the mobile devices for timesheets and the GPS application could be used as a monitoring system with the potential to reduce the flexibility of their working conditions. If a nurse visited a store during working hours it may be construed as taking time off during working hours.

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Table 4

Barriers to mobile-technology adoption in the case study

Barrier to mobile-technology

Implication of barrier

Home care case study

Lack of system integration

Data exchange between systems is poor

Integration challenges were evident at Home Care but not insurmountable

Centralised systems

Strain on central hospitals

Fewer hospital visits were required by patients

High reliability requirement for patient care

Costly systems

This was understood and not a barrier as the systems were less critical

Conservatism

Lack of innovation

Nurses were more conservative and not used to mobile technology

Lack of expertise

Lack of technology champions

Mobile technology champion existed

Poor change management skills

Did not communicate rationale for adoption clearly enough to nurses

Lack of training and support

People do not use systems fully

Poor levels of support and no help desk provision meant nurses easily gave up use of the devices

Security and privacy issues

Added complexity in system design

Security issues not perceived as a barrier

A major obstacle to the effective adoption in the pilot study was the lack of training and help desk support. When nurses were faced with difficulties in using the applications most tended to revert to previous methods rather than persevere with the new system. Quality help desk support would have alleviated many of the difficulties experienced by the nurses. A consequence would have been reductions in the number of nurses who only partially used the applications and those who abandoned the device altogether.

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Discussion

We have presented the notion that there are different perspectives on technology adoption that provide different insights on how to effectively adopt a technology. Information technology adoption models such as TAM (Davis, 1989) use a well defined set of factors to determine adoption success. On the other hand, systems perspectives identify the system itself and the relationships between factors as being important. TAMs deconstruct the system into factors which can be examined independently of other factors whilst a system’s character is defined by the interrelatedness of its components. Using TAM as a conceptual framework to examine mobile technology adoption highlights the need to address the following factors in particular: •

Facilitating conditions

The users did not have the knowledge to use the system, training was minimal and adequate assistance was not available to help with system difficulties. •

Self-efficacy and computer anxiety

The lack of support and help desk provision meant that users abandoned the system when they ran into difficulties. The help provided on the system was quite rudimentary and insufficient to support users through problems. The group of nurses felt apprehensive about using the systems and were worried about losing patient data or entering data incorrectly.


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A systems approach for understanding the pilot study highlights a range of other issues not directly identified through TAM. The project managers should emphasise to nurses the improved quality of care to patients through using the mobile devices rather than administrative improvements and cost reductions. Management should explain how the timesheet application will be used and make it clear that it will not be used as a monitoring and control tool. If the nurses are assured that they will retain a certain level of flexibility in their jobs they would be less likely to react negatively to the project. Developers of the system should understand that healthcare is a people processing business and so should not focus on technology. This mismatch in worldviews is a fundamental difference between parties that can lead to adoption failure. The evaluation and measurement of the benefits of the system are difficult to determine beyond administrative benefits and cost reductions. Instead, management should try and consider how patient care has improved. Even so, such improvements in patient care are difficult to determine in the short term. Of course, the two perspectives are not mutually exclusive and project managers and system developers would do well to consider both approaches when implementing technology. The healthcare sector is characterised by a specialised set of features and a systems perspective is particularly relevant in identifying fundamental barriers to mobile technology adoption. Systems approaches encourage developers to examine a situation from multiple stakeholder perspectives. Indeed, different stakeholders may have alternative world-views and some understanding of these would help developers present the rationale of a new system in a manner that would be relevant. For example, developers of the mobile technology applications should emphasise to the nurses the potential to improve patient care but emphasise the administrative efficiencies and cost reductions to management.

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Conclusion

Technology adoption frameworks can be used to explain some aspects of the problems associated with the complexities of adopting mobile technology in the healthcare sector. For example, facilitating conditions and self-efficacy and computer anxiety factors can explain some of the systemic issues described by Waldman (2007). However, systems are often described as being greater than the sum of their parts and equally the problems associated with systems cannot be addressed by tackling problems in a piecemeal fashion. To make sustainable improvements, executives and senior managers need to identify deep seated system problems and examine technology adoption potential from a systems perspective. In other words, a strategic perspective is required that embraces systems thinking. The problems inherent in the healthcare system identified by Waldman (2007) are useful for identifying the issues developers and implementers of mobile technology may encounter. Whether developers can affect major systemic issues is perhaps unlikely but a deeper understanding of the system they are interacting with can only help in setting and achieving realistic goals. In addition, developers can bring significant system issues to the fore in discussions with senior management so that organisational expectations take into account the nature of the context.

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