National Strategy for eHealth

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Theoretical framework

By the extensive literature review, the authors present a conceptual framework in this chap-ter. The content of this chapter will include key concepts like eHealth, innovation and HIS, relevant theories derived from key concepts and the model adopted in this research. In or-der to show the research foundation, a conceptual map has been drawn in Figure 3.1.
The focus of this study will be on evaluation of eHealth. This chapter will present a com-prehensive conceptual framework which has been developed during this study. The content of this chapter includes, Definitions of key concepts within the research area such as eHealth, innovation and health information system (HIS);
Relevant theories generated by the key concepts, for example, innovation in the public sector, IT innovation in the healthcare sector and eHealth evaluation;
Some important factors that are considered when performing evaluation of eHealth, such as innovation input, output, effect and indicators;
The introduction of the IT investment evaluation model in this thesis adapted to anal-ysis of the case selected.
In order to present those ideas more explicitly, the authors drew a research map to display all the key concepts, relevant theories and key factors included in this study, as well as their relationships and possible interactions which will affect the outcome of the evaluation (see figure 3.1). Key concepts and theories presented in this section will give an overview to the reader.

Innovation

Four Types of Innovation

Innovation has attracted attention along with the evolution and proliferation of technology products, e.g., digital camera, smart phone and electronic paper. However, innovation actu-ally has a broad meaning in research. According to Bloch (2011), an innovation is the im-plementation of a significant change in the way an organization operates or in the products it provides. The term ‘innovation’ appears in the previous studies often together with terms like ‘improvement’, ‘evolving’, ‘enhance’ and ‘effective’. As discussed in the Copenhagen Manual (Bloch, 2011), innovation could be classified as product innovation, process inno-vation, organizational innovation and communication innovation, follows are brief intro-duction about those four types of innovations:
Product innovation is “the introduction of a service or good that is new or significantly improved com-pared to existing services or goods in your organization” (Bloch, 2011, pp14). This includes upgrad-ing of key characteristics of the goods or service. Key characteristics could be better mate-rials, which will improve the quality of the product, new component, which will add the use value, updated software, which will improve user experience, etc. For example, an upgrade of an operation system for a smart phone will make the smart phone a new product inno-vation by the update of the major feature, and in parallel make upgraded operation system itself a product innovation compare to the previous version of the operation system or old fashion operation system.
Process innovation is “the implementation of a method for the production and provision of services and goods that is new or significantly improved compared to existing processes in your organization” (Bloch, 2011, pp14). Process innovation is usually not visible to the customers, but brings signifi-cant benefit to the organization. It usually makes improvement by technology which will simplify or make progress on efficiencies of processes. The organization makes more profit by saving the cost of new processes rather than charging a higher price from the customer.
Organizational innovation is “the implementation of a new method for organizing or managing work that differs significantly from existing methods in your organization” (Bloch, 2011, p.14). It is concerned with the perspective of organizational management, business practice, and intra-and inter-organizational processes. For example, organizational innovation could be the change of administration coordination or change the relationship for different actors hav-ing various management functions.
Communication innovation is “the implementation of a new method of promoting the organization or its services and goods, or new methods to influence the behavior of individuals or others” (Bloch, 2011, pp14). Communication innovation is interpreted as “marketing innovation”, but in the public sector there is no “market” in the business meaning. However, promotion or cham-pions for different stakeholders are needed. According to Bloch (2011), there are three types of communications innovations have been identified; new methods of promoting the organization or its products and services, new methods to influence the behavior of various users, and first time commercialization of goods or services.
The innovation that will be discussed in this thesis the IT-based applications. Innovations applied in health care are various and ubiquitous. Innovation brings enormous changes in health care organization not only by upgrading medical device or treatment programs but also by changing work processes, organizational management and/or communication channels.

Innovation in the public sector

Public sector and private sector differ essentially in ownership. Examples of public sector activities are social security, national defense, education and public health care which could be considered as state and government activities that mainly contribute to public welfare. Whereas the private sector is owned and run by private individuals or groups for pursuing profit in the market. Many people argue that the public and the private sector are radically different when it comes to innovation. Some of them believe that the private sector get more incentive and more innovative than the public sector, as they need to respond to market pressures and to stay competitive, whereas government agencies are relatively pas-sive since they are not required to show a profit on their revenues (West & Lu, 2009). Oth-er researchers state that the public sector is not a passive recipient of innovations from the private sector; it is the public sector that plays the role as influence to the private sector’s capability to innovate. The reasons are mainly due to the close interaction between the two sectors in many domains and the role of facilitator of infrastructure for the private sector (Bloch, 2011). Take knowledge development and management through research and educa-tion as an example, it is generally supported by public education and research sectors, but the outcome obviously also benefit to the private sector innovative.
As the authors have mentioned above, the public sector work as a facilitator to the private sector in terms of being innovative. However, innovation in the public sector is mainly contributed to the quality and efficiency of the public well-being, improvement of econom-ic performance and environmental protection. The changes brought by innovation of the public sector will eventually benefit to the quality of people’s life. Take one of eHealth ap-plication – ePrescribing as an example, ePrescribing is a system in health care that use computing devices to enter, modify, review and communicate prescriptions in order to im-prove the quality of prescribing by avoiding medicines management errors and iatrogenic harm (Car et al, 2008).

IT innovation in healthcare sectors

Healthcare industry innovations have primarily concerned improvement of the quality of patient care, enhancing life expectancy, facilitating better diagnostic and treatment options, as well as the efficiency and cost effectiveness of the healthcare system (Varkey, Horne and Bennet, 2008). Information technology as a powerful technology element has been ex-plored and adopted in different industries and the benefits brought by IT have been well recognized.
According to Gupta (2008) ‘there are four major ways in which Information Technology (IT) will revo-lutionize health care, more offshore services, integration of health information systems, drug safety monitoring on a global scale and more high quality information to doctors and patients.’
Offshore service – offshore service refer to offshore outsourcing of diagnostic services, such as remote consultation by specialists (Omachonu & Einspruch, 2010). It enable ad-vanced specialist to serve to areas with poor medical conditions and that are hard to reach. Offshore service is a feasible measure for making up for the regional differences in medical conditions. Take Teleradiology as an example, it is an approach to transmit X-rays result to doctors at the other site to enable clinical support (Gupta, 2008).
Integration of health information systems – The current situation is that health care cen-ter in different regions usually have their own systems, and even within the organization, the information in different system is not shared. The systems for various uses tend to build on their own rules, standards and have different encryption, which makes the system stand alone. The integration of health information systems is a vision to create of the medi-cal record that can travel with the patient (Omachonu & Einspruch, 2010). The benefits brought by integration are mainly in convenience of patient and accessible data for research.
Drug safety monitoring on a global scale – Gupta (2008) point out that the need for an international database on drug safety has steadily increased for the reason that people travel all over the world. To date, the medication system in a different country is varying. People travel and take different medicines which sometime make their medication history a mys-tery. Unknown drug history and unknown drug safety information are significant risks for patients.
More high quality information sharing/exchanging to doctors and patients – According to Gupta (2008),the information exchange pathway could include publishing ar-ticles on online media, having speech on an open platform like wiki, as well as the exchang-ing of knowledge enabled by certain clinical information systems. The scale of knowledge sharing supported by information technology will be universally, and the interaction will be easier than before. It is worth noting that functions that enable knowledge exchange has been reorganized as a necessary module for many health information system, it could be ei-ther a simple message/note box for doctors or patients or a database contain patient record open for research use.
Along with the development of network and internet security, the impact and effect of IT in healthcare has been dramatically enlarged. IT innovation in health care develop from lo-cally innovation in computerization of patient records, diagnosis, treatment, healthcare cen-ter procedures, to innovation that integration of different healthcare systems, communica-tion and knowledge learning from each other between units. It is apparent that, in the near future, old fashion healthcare sectors will lose advantages in handling the clinical outcomes and become isolated while others are using advanced systems, which are enabling them to integrate with other systems or databases, and remotely use resources and sharing knowledge with each other.

Innovation Input, Output, Objective and Effects

To illustrate the state of innovation and its development process, IPO Model has been adopted in previous research. The IPO Model is an abbreviation of Input – Process – Out-put analysis model which is used as a functional model and conceptual schema to describe general systems. As showed in Figure 3.2, the original IPO Model defined the innovation process as a system starting from innovation input, by transforming innovation input by a process; innovation input is expected to eventually generate some innovation output; by the end of this process, the feedback in the entire system will be delivered and contribute to improvement in the beginning of the process. There is a small cycle embedded in the in-put to output cycle, which is the interaction between processing and storage. This cycle is a small learning loop. The processing will be stored every single round and the effect of the processing will be enlightened and enhanced when new round start.
In order to adopt the IPO model in the context of IT innovation evaluation and deepen the discussion, the original IPO model was adapted as in Figure 3.3.
Innovation input could be considered as the starting point for innovative activity. Ac-cording to OSLO Manual, it is functional forms analysis related to problem-solving. In or-der to have a good startup to innovate, organization need to figure out whether there is an opportunity for changing/improving the situation or solving problems and how to arrive there. For the accomplishment of the objective, input is used for transforming those capa-bilities into a real innovation (European Commission, 2005).
Innovation output is the target of measuring. It could be marginal revenue from new product or service which is easy to be measured by accounting techniques. It could also be intangible and difficult to measure as the change of business processes, which contribute to smooth the communication within the organization, could be more tacit.
In order to illustrate the relationship between input and output, two fundamental concepts need to be introduced – ‘objective’ and ‘effects’. Bloch (2011, p.21) has a comprehensive and precise described the interaction of those factors for performing development of inno-vation:
“Objective and impacts of innovation are at opposite ends of the innovation process; objectives are at the be-ginning and shape how innovation processes are conducted, while effects are the actual outputs at the end of the process. However, they both concern the same aspects, thus making sense to consider them together (where objectives can be considered as measures of intended outputs).”
Adapting the IPO model according to Bloch’s view, which is showed in Figure 3.3, objec-tive and input are on the left side of the process. Objective could be considered as the mo-tivation or incentive to make input transform into processes while the output is separated into actual output (effects) and intended output, which are the consequences of the innova-tion.
It is noteworthy that the IPO model is more than a process that simply describes the flow of information. It is also considered as a learning loop. As Bloch (2011) argues, objectives could act as measures of intended outputs. Assume that there is a pre-implementation of an innovation project; the objectives should be used to check if intended outputs are con-sistent. Furthermore, when the process start to generate actual output, it is time to go back to confirm if the objectives/intended output has been realized as the actual output (effects) The feedback about whether intended output is able to reflect the objectives or whether objectives/intended output is corresponding to actual output are contributed to keep mak-ing progress of the innovation before, during or post implementation.
As discussed above, objective and effects are contributors of measuring innovation. The authors tend to believe that effects are more useful than objectives while measuring inno-vation. Unlike objectives, effects are in real, not only planned. However, effects might not easy to locate. Firstly, effects generated from innovations are also being affected by the IT productivity paradox (Vimarlund & Koch, 2011). Santos and Sussman (2000) argue that the IT productivity paradox refers that to each IT investment should contribute to enable an organization to be more efficient and or effective. Yet, frequently, few of the anticipated benefits are obtained within the projected time frame. Thus is believed to be due to that many IT investments require for reengineering of the processes and/or restructuring of the organization to acquire anticipated effects. Once organizations fail to adjust to meet the re-quirements of new resources, the expected effects will fail to be achieved. Moreover, as Bloch (2011) argues, some effects may require complicated analysis and evaluation to dis-cern whether they have actually taken place. Even though there are barriers for measuring innovation by evaluating effects, if appropriate and systematic indicators are used, effects could act as the key factor when it comes to evaluation of innovation.

Indicators

The output of innovation activities is the effect of the introduction of the new resources which are provided by innovation. It could be new products, improved business processes, and changes of the organization culture or innovative method in the administration etc. In-dicators are not included in the IPO Model. They could be the complementary or extended part of IPO Model, but when it comes to completing measurement of innovation, they are necessary. As discussed before, effects are the actual output, which are used to measure in-novation. They refer to acquired results from innovation. Indicator measures to what de-gree effects enable the changes and to what extent value is added by innovation. A simple instance to interpret the general meaning of indicators is, an organizational attempt to use a computerized database to replace a manually paper-based database. One of the effects in this case would be to enable an electronic searching engine for staff’s information; To measure the effects, indicators would be reduced time for accessing the required infor-mation, high precision of returned information and avoiding manually information error occurrence during searching and archiving information. Unlike some other evaluation, in-novation measuring in this thesis is focused on the non – quantifiable and non – financial perspective, thus, indicators identification is asked for multiple considerations.

eHealth

eHealth in general

As there has been a rapid development of information technology (IT) during decades, the e-terms began to emerge in different occasions in different use. For example, well-known e-terms are “e-mail”, “e-commerce”, “e-learning” etc. E-terms usually refer to IT enabled innovations, which facilitate traditional interaction activities by electronic way, thus in all of the e-terms, “e” stands for “electronic”. The term, eHealth, like the other e-terms, are de-rived from the term “Health”, the value adding is enabled electronically. The introduction of eHealth represented the promise of information and communication technologies to improve health and the health care system (Alvarez, 2002, cited in Oh, Rizo, Enkin, Jadad, 2005). “eHealth” usually appears in publications as “eHealth”, “e-Health”, “electronic health”, “health informatics”, “electronic health care”, “medical informatics”, “biomedical informatics” etc.
As with most neologisms, the authors of this thesis found that it is difficult to locate a uni-versally applied definition of eHealth. According to Oh et al. (2005), even though defini-tions of the term “eHealth” differ from each other in various ways, settings and contexts where it is used, it encompasses a set of disparate concepts, including health, technology, and commerce.
Health as a key factor in the definition of eHealth usually refers to the process of perform-ing health care rather than a simple clinical outcome. For example, Grantmakers in Health (2002) define eHealth as “use of ICT (information and communication technology), especially (but not only) the internet to enable health and health care.” Health is not a common sense term as the ab-sence of disease or infirmity; it is more closely referred to the process and/or functions in the health care area which aims to lead to a state of physical health for patients or public welfare. eHealth is expected to bring large changes to the process of health care. For ex-ample, in patient care, some eHealth tools are capable of providing a checklist of activities and save the medical outcome record electronically for each medical move. In this case, the change from paper-based processes proceeding to the computerized system will avoid missing out on patient care steps by providing alerts automatically.
Technology could be considered as a tool to enable process, function and service, and act as the embodiment of eHealth itself (Oh et al. 2005). “Technology” is developed for realiz-ing the “health” in this case. The technology embodiment in eHealth could be a health website on the internet, a simple application for certain functions or services, a database of the clinical center and a hospital’s information system etc. Technology make eHealth as a promising new arrival and the nature of technology makes eHealth as an IT product. Inter-ventions of information technology in healthcare or other industries shared a common ad-vantage which is making things effective and efficient. No matter how different specific de-tails in various services, functions and processes, the reason why eHealth are developed today are the strength brought by technology are outweighed to the risk brought by technol-ogy in average occasion.
Commerce is the value of where the technology brought and the human activity improved by technology. According to definition by Wysocki (2001), the value brought by e-Health refers to all forms of electronic healthcare delivered over the Internet, ranging from infor-mational, educational and commercial ‘product’ to direct services offered by professionals, nonprofessionals, businesses or consumers themselves (Wysocki, 2001, cited in Oh et al, 2005). The value will include financial and nonfinancial benefits. Financial benefit appar-ently refer to the cost saving or other input saving like manpower input saving which will eventually lead to cost saving. Nonfinancial benefit refers to the improvement which is dif-ficult to measure quantitatively, such as innovation effects where the finding of this evalua-tion is taking place. eHealth with commerce is expected to emphasized on deliver benefits or value adding to health care industry in various ways. For example, some decision making support modules of health information systems are capable of data collection and organiza-tion and provide support for decision making by intelligent analysis of the data. In this case, how much information error reduced by this module and to what extent the module im-prove the precise of decision making could be considered as the commerce value brought by the module. To what extent this change happens is the key concern of evaluation of commerce, as well as the objective of evaluation of eHealth.
General speaking, eHealth is the intersection of information technology, computer science and health care. IT applications, information systems, database or business intelligent mod-ules are developed and adopted for supporting management and control in medical pro-cesses, health organization administration and communication. The objective of eHealth is various, either for making sure that the biomedical information is collected comprehensive and used effectively and efficiently, or improving the organizational management and communication. Benefits brought by eHealth in the clinical perspective are mainly focused on improvement of healthcare processes through improving the quality of management of biomedical data, by information systems for intelligent analysis and decision making. Bene-fits brought by eHealth in the organizational perspective are mainly improved the interac-tion among actors, and avoiding error by manual operation. For example, in order to moni-tor patients’ recovery situation after surgery, surgeons and nurses need to have a compre-hensive review of the record in different specialties. For example, a patient who is pregnant might have problems while and after having cardio surgery and integrated information about both fetus and patient is required for having preoperative and postoperative patient care. In this case, databases shared across all the specialties are the basis for the corporation within or between health care units. Someone might argue that information could be shared even in the paperwork era. However, when it comes to countrywide or international cooperation for a single patient or a case, databases could be considered as significant tools which contribute to providing records and share data in real time across different health care units in various locations.

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Health information systems (HIS)

Health information systems (HIS) is an important concept which needs to be further classi-fied in order to understand a study of eHealth. In a broad sense, health information sys-tems are information management systems which capture and display data related to the delivery of health care services (Chinn, 2010). They could be paper-based or computers based, which includes clinical guidelines, medical terminology dictionaries, various diagnos-tic devices and other clinical and business information databases, such as laboratory, phar-macy and diagnostic imaging (Chinn, 2010). In this thesis, the authors intend to delimit research of HIS to computer based. The relationship between HIS and eHealth is that HIS is generated by the development of eHealth, and the study of HIS is taken place in the field of eHealth.
For creating improvement of health care service, HIS could be considered as a promising IT involved approach which has been explored for a long time. HIS as information system are not omnipotent when it comes to contribution to health care. HIS is not capable of improving health care fundamentally, as IT contributes to other subjects. Changes brought by HIS are about its effectiveness and efficiency. A minor change in the beginning will bring a tremendous difference in the end that is called the Butterfly Effect. HIS are taking the effort from the minor changes by avoiding flaws caused by old-fashion or traditional inefficient processes to facilitate the overall reorganization of clinical process. In the history of development of HIS, HIS started from contributing to free up manpower. Now HIS ac-tually play a significant role to bring health care into best practice.
To be specific, in what HIS is capable to deal with, for the patient record, HIS are making data comprehensive, mobilized and traceable. Even though paper based records are neces-sary for some reasons, HIS are more capable and essential. The ideal scenario is that all health care providers shared a database, like a national or worldwide identity system, the record of medical history are continuous and accessible in different locations. Secondly, because of the nature of IT, the patient record by HIS is allowed to validate by definition of rules, that will improve the accurate and integrity of the patient record. Thirdly, for the interaction between health care receiver and provider, according to previous literature, some HIS are able to provide reminders generate by the system easily and quickly for in-forming about the coming of the routine check or result of the laboratory. Sometimes sys-tems automatically send messages to both patient and provider. Fourthly, for decision mak-ing support, for example, it is capable of notifying health care professionals of errors in pa-tient care and coming up with a recommended clue for it. Furthermore, for health care compliance, statistic and analysis, HIS facilitate customized statistic and analysis dash-boards which are fit for different requirements.
As discussed before, the contribution of HIS to health care is enlarging over time. A suc-cessful HIS, like other IT application adopted in health care, is supposed to improve the quality of work and the quality of patient care. According to the previous studies , the ideal HIS does not exist yet not only because HIS is a relatively new area, but also as the defini-tion of “ideal” changes over time along with the development of both health care and in-formation technology. Hence, there is no consistent argument of “ideal”. “Ideal” in an un-derserved location, the optimal situation is limited by shortage of resources and equipment. Thus, the definition of an optimal situation varies with overall medical condition of certain health care setting. Furthermore, since the health care setting will change over time, the op-timal situation will change along with it.

Evaluation

Evaluation is a term with a broad meaning and could be used in many scenarios. It could use to assess the value of some objectives – in this case, evaluation is monetary; it could al-so be used to examine the quality of a product or service – in this case, evaluation is proba-bly a process or criterion. eHealth is an introduction of modern technology into the health care area. The modern technology here concerns web-based technology, software, database or other electronic media. By the introduction of modern technology, the merits and bene-fits of health care appear with its shortcomings and risks. As a new development area, eHealth grows rapidly. And also because it is new, evaluation of it become much more significant for the reason that the evaluation result could contribute to know better of it and explore its uncertain benefits and risks and make progress for eHealth in technically or medically.

Information system evaluation

Information systems are implemented within an organization for the purpose of improving the effectiveness and efficiency of that organization (Silver et al, 1995). Drivers of invest-ment in information system are mainly focused on the promise of quality improvement, capability of process efficiency and further development possibilities. By adopting infor-mation systems, more and more traditional industries have been changed. Information sys-tems are capable to embed traditional processes into the new system and essentially im-prove work quality. However, the barriers of investment in information system are note-worthy, as well. Introduction of new things within an organization usually cause resistance at different levels among staff, which could be seen as another important barrier for apply-ing IT application. However, the drivers of advanced technology are is generally stronger than the barriers. Thus new technology is able to replace the traditional ones gradually in the history of technology development.
Along with increased adoption of information systems in various industries for different use, the investment in information system is raising which imply that the evaluation of IS is significant and necessary. Evaluation of IS could contribute to make sense to cost and/or benefit. By identifying the cost and/or benefit for alternative investments, investors could find solid arguments for investment.

eHealth evaluation

Quynh (2007) pointed out that one of the first and most important questions in eHealth evaluation is to identify the targets of evaluation. According to Quynh (2007), the targets of evaluation in eHealth are mainly in user satisfaction, usability and accessibility issues and cost implications (cost effectiveness and/or cost benefit). Specifically, various users repre-sent different interests and needs. For example, doctors as users ask for eHealth programs including comprehensive and up-to-date patient’s information for making prescriptions. User evaluative feedback helps to determine the content of information and create knowledge about priority and quality of information (Quynh 2007). Usability and accessi-bility are important when developing an appropriate user interface for different target users (Gustafson & Wyatt, 2004; Wyatt & Liu, 2002 cited from Quynh 2007). For example, the interface of the website for local citizen’s health care consultation will be very different with the education and/or research public website for professionals. Cost effectiveness and/or cost benefit is highly meaningful and valuable when making an investment decision and ROI (Return on Investment) analysis in post implementation period.
The evaluation model validated in this thesis focus on the innovation effects and its conse-quences enabled by IT, which means the point of concern is mainly in improvement of quality of processes rather than the cost effectiveness and/ or cost benefit. The benefit brought by innovation effects and its consequences could be identified and categorized in-to user satisfactory and usability and accessibility issues according to Quynh (2007). The evaluation of user satisfaction is mainly taking place in the individualized service/care, maintain the quality and exchange of information, inner/outer organizational coordination etc. The emphasis of the evaluation is on the value added of information provided accu-rately, timely and effectively which meet the need of different user groups. For evaluation of usability and accessibility issues, the model includes different concerns between the health care providers (doctors, nurses, anesthetists, care workers and other medical staff), receivers (patients) and the interaction requirements between the providers and receivers, such as consideration of various knowledge background and interested by different target users; thus, there is an indicator for the possibility to personalize information on virtual networks. Personalized information provides maximized flexibility to different users for ensuring usability and accessibility.

Generic E-health evaluation Process

The generic E-health evaluation process, according to Quynh (2007), adapted from Phillips et al (2004) and LTDI (1998) has been adopted for this study. As shown in Figure 3.4, the 1st stage of the process is Needs Analysis and Design; in order to determine the needs of the target groups and project feasibility. In this study, stage 1 was conducted by the in-terview of potential adopters of ERAS care system (Jönköping County Council). Through the initial interview with Niklas Zar and Jenny Silfverhjelm, responsible person of ERAS in Jönköping County Council, Needs Analysis and Design was conducted and needs were identified as – a new IT system is required to have a better support for ERAS protocol. That was the starting point of the study.
The 2nd stage was Development / Selection of E-Health applications; for produc-ing/selecting a working model for E-Health applications. In this study, stage 2 was referred to chosen information system – EIAS. However, the selection was made by suggestion of Jönköping County Council. They suggested this information system as they were looking for arguments weather the information system was worth investing in.
The 3rd stage was Formative Evaluation for finding out if the product meets the aims of stage 1. By comparison of current the information system (MOA) with the new infor-mation system (EIAS) benefits that EIAS bring to Jönköping County Council turned out to response to the needs identified in the first stage. Vimarlund & Koch’s (2011) evaluation model could be seen as a generic eHealth evaluation framework and was possible to use in this stage. The evaluation process conducted by the guided of this evaluation model is also a process of its validation of practicability.
As described above, we considered that Jönköping County Council was in the first three stages. The 4th stage Implementation/Decision for Implementation of EIAS by Jön-köping County Council is expected to be made in the near future.
The 5th stage Summative Evaluation was conducted to determine the adequacy of the E-Health program for the needs of its target users. The evaluation conducted in this study was interviews with the adopters of ERAS care system. Among the hospital who adopted ERAS concepts, there are only two hospitals in Sweden which has implemented the ERAS care system. As early adopters, identification of effects that EIAS brings to the hospital can be drawn from experience of use of EIAS. Moreover, Vimarlund & Koch’s (2011) evalua-tion model, a generic eHealth evaluation framework worked as a guide for questionnaires and interview design for data collection. The result from this stage was expected to provide reference for late or potential implementers, like Jönköping County Council. On the other hand, interviews with the two adopters of ERAS care system will also allow us to conduct a more practical and fact based discussion based on the effects and indicators which has been identified.
When it comes to the 6th stage Long Term Impacts / Learning for future service de-livery, its aim is to determine the effects of the E-Health program on the organization and individual level. The outcome is primary for providing research material for researcher and organization that care about the future’s service delivery, such as application providers.

Table of Contents
1 Introduction
1.1 Background
1.2 Case Background
1.3 Problems
1.4 Purpose and Research Questions
1.5 Use of Previous Studies
1.6 Perspective
1.7 Delimitation
1.8 Interested Parties
1.9 Key Terminologies
1.10 Summary of each chapter
2 Methods
2.1 Research Purpose
2.2 Research Approach
2.3 Research Choices
2.4 Research Strategy
2.5 Data Collection
2.6 Data Analysis
2.8 Credibility of Research Findings
3 Theoretical framework
3.1 Innovation
3.2 eHealth
3.3 Evaluation
3.4 Classification of IS evaluation
3.5 Chosen types of evaluation for this thesis
3.6 IT investment evaluation model
3.7 Summary of theoretical framework
4 Case Description
4.1 Swedish healthcare system
4.2 National Strategy for eHealth
4.3 Current situation of Jonkoping county council
4.4 ERAS Care System
5 Result
5.1 Interview with Jönköping County Council
5.2 Findings from documents study and observations
5.3 The general description of EIAS
5.4 Identifying Innovation effects and indicators of EIAS
6 Analysis
6.1 Level of Innovation Effects
6.2 Innovation effects and indicators of EIAS
6.3 MOA vs. EIAS
6.4 Validation of Vimarlund & Koch’s (2011) Model
7 Conclusion and Reflection
7.1 Summary of Results
8 Further study
References
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