service innovation in healthcare

Service Innovation in Healthcare: A Path to Value Constellations

Mahmoud Elzein

Cecily Quintana

Karen Shrock

Merissa Sibley

Spring Wedlund

MKTG 410

Service Innovation

Spring 2013

Dr. Harmon

June 3, 2013

Agenda• Intro to Service Innovation in Healthcare……………….3• Recap of findings…………………………………………………4-9• Telemedicine Case Study 1………………………………10-13• Telemedicine Case Study 2………………………………14-16• Telemedicine Case Study 3………………………………17-19• Co-creation Innovation Model: The Portland

Experience……………………………………………………...20-29• Conclusion……………………………………………………………30• Future Research……………………………………………………31• References………………………………………………………32-33

Regulations and Stakeholders Major regulations that will affect the future of innovation in healthcare include:• American Recovery and Reinvestment Act (ARRA) 2009, enacted the Health Information Technology for

Economic and Clinical Health Act (HITECH Act). Under ARRA the US Department of Health and Human Services (HHS) is spending $25.9 billion to promote and expand the adoption of health information technology.

• Patient Protection and Affordable Care Act (PPACA) 2010, also known as “Obamacare”, will require all Americans to have health insurance. This affects service innovation of healthcare because as a country that is trying to provide affordable healthcare to all citizens, the goal is to find a cost-effective method to achieve this, while reducing waste and inefficiencies within the system.

Regulatory bodies under HHS that impact service innovation in healthcare include:• Agency for Healthcare Research and Quality (AHRQ)• Centers for Disease Control and Prevention (CDC)• Centers for Medicare and Medicaid Services (CMS)• Health Resources and Services Administration (HRSA)• National Institute of Health (NIH)

Stakeholders:• Doctors, nurses, healthcare providers, front & back office staff• Customers: patients, caregivers, and families• Communities

Early Technology BarriersBenefits of technology

• Improved quality• Prevent medical errors• Reduce health care costs• Increase administrative efficiencies• Decrease paperwork• Expand access to affordable care

Issues to Overcome

• Managers & policy makers lack of access to information

• Gaps in care provided• Inconsistent quality among professionals• High expenditures, lack of infrastructure• Legal and privacy issues• Limitations of individual technologies

Overview Significance Future Research/Challenges Application

Interviews with IT experts from for medical universities and health provider, and a medical research expert

As of 2008: Service portion of health care is not as advanced in technology as other service industries. Health care is not taking advantage of improving efficiency and quality. The authors foresee the following benefits of better technology for a health care provider: improve health care quality, prevent medical errors, reduce health care cost, increase administrative efficiencies, decrease paperwork, and expand access to affordable care

Health care data have diverse information but staff representing many fields ranging from medical to administrative will be using it. A major challenge will be to get the collective responsibility of government, managers, planners, and policy makers. Future research: E-health, wearable monitors, radio frequency identification

The health care service industry can highly benefit from using technology to increase efficiency and health care quality while reducing costs.

FrameworksImpact of Network and Environmental Factors on SI• Looked at the direct and indirect effects of formal and

informal institutional pressure, and competitive pressure on SI in healthcare.

• Found that large networks and informal regulatory forces limit and even stifle providers’ service innovation, while competition increases it.

• Questions whether regulation is good for SI.

Experience-based Design: Reframing• Identify every touch point where customers interact with

healthcare service, identify best and worst practices, and work with patients and providers to design healthcare experiences, versus systems and processes.

• Open Door Community Hospital prototype

Balanced Scorecard Study in Taiwan• First study to shed light on the role of department-level

strategic planning tool for service innovation.• Interactive system for providing signals to the organization

about management objectives, stimulating debate, improving quality, and achieving organizational learning

Innovative Solutions

Medical Tourism:• Increasing in popularity due to increases in medical

costs in developed countries, diminishing staff, increased pressure of aging populations, long wait times, and globalization

• Lack of global governing legislation and benchmarks for medical tourism enterprises creates a barrier for many consumers

Remote Healthcare:• Remote patient monitoring (RPM) enables monitoring of patients outside conventional clinical

settings (e.g. in the home). May increase access to care and decrease healthcare delivery costs• MeMD based in Albuquerque, NM offers doctors’ visits and urgent care services over the internet,

webcam and telephone , 24 hours a day, seven days a week• Telecardiology uses electrocardiogram (ECG) signals from a patient, acquired by sensors, and

transmits them in real time to medical personnel across a wireless network• INCASA, an IT SI architecture unlike any other remote healthcare model. Focuses on citizen-centric

technologies that protect frail, elderly people, prolonging the time they can live well in their home• Teledermatology represents part of a general shift in medicine towards the increasing use of

technology to address problems of inefficiencies in healthcare provision in the context of increasing demand for services, and to overcome inequities in access to services across geographical regions.

IT: Enabling Healthcare Service Innovations

Four major areas in which (IT) will revolutionize healthcare:• More offshore services (Telemedicine and Teleradiology) • Integration of health information systems (RFID, electronic personal health

record solutions (ePHR), and electronic clinician record solutions (eCHR)• Drug safety monitoring on a global scale (Medwatch)• More high quality information to doctors and patients (WebMD, Epocrates)

The role of SmartPhones and Smart Devices:• Patient care and monitoring (iWander, Diabeo and other similar apps)• Health apps for the layperson (iTriage, ZocDoc, fitness, weight loss, etc.)• Communication, education, and research (“Outbreaks Near Me” app, etc.)• Physician or student reference apps (Epocrates, Skyscape, etc.)• Context Awareness Computing – the Future of Healthcare

The Linear Innovation Model

Step by step process that hinders co-creation. Patients, caregivers and medical providers and staff must be able to communicate their needs with each other, and to be able to integrate and translate those needs into ideas that engineers can understand in order to provide IT solutions that improve the service for all stakeholders. Therefore a new model is required that will allow for this communication exchange to take place: a Co-Creation Model.

The Co-creation Service Innovation ModelCo-experience: Enabling the co-creation of an environment where personalized, evolvable experiences are the goal, and products and services are a means to that end. Co-experience is the result of medical lead users co-creating their own unique value with patients, supported by technological change from firms and a community of practice.

Co-definition: When physicians use and experiment with medical solutions among their patient communities a collaborative learning process occurs, where firms and medical lead users learn from each other and build a shared knowledge model, or co-definition.

Co-elevation: Creation of a positive feedback loop when knowledge from one entity is diffused among other entities, therefore closing the cognitive knowledge gap among practitioners, and service to patients.

Co-development: Co-innovation generated by the relations among the various entities. The cognitive gap among entities is the driver of a collaborative process where entities exchange heterogeneous knowledge bases to contribute to a co-development of solutions.

Successful Telemedicine Case StudyAlaska’s Underserved: Throughout 2011, provide breast cancer risk-reducing counseling for high risk native Alaskan women.

Collaboration: • Alaska Native Medical Center: Main hub of medical care for native Alaskans supporting regional

clinics throughout Alaska.• Mayo Clinic Breast Clinic: Provided specialized breast cancer physicians for the counseling.• Mayo’s Center for Innovation: Employed a team to design and enable the telehealth platform.• Alaska Federal Health Care Access Network: provided telehealth sharing of medical information

through firewalls.

Model: Using a navigator to facilitate patient interactions, subscription billing contract, and a Cisco networking system

handling audio and video conferencing to connect Alaskan clinic to Mayo physician.

Survey recipients after implementing the telemedicine service model which consisted of a Cisco network system that allowed both video and phone communication

Overwhelming success with remote patients. Overall satisfaction was 99%. The lowest rate of 93% was for quality of seeing and hearing the specialist. There were three rated 100%: satisfied with consultation, questions answered, and patient would use telemedicine service again.

Better implementation strategies would help reduce costs. And future locations need to be closer to patient's home. Need to expand licensing and credentials for US-wide telemedicine license. Government needs to lift barriers of licensing that discourage telehealth models.

With the use of a person facilitating the process, telemedicine can be well received by patients. Once implemented it is possible to reduce costs and stress of traveling for patients when a specialist in another city is needed.

Successful Telemedicine Model

Source: Pruthi, 2013

Successful Telemedicine Findings

Survey: Random sample of 60 patients were selected, 15 (25%) recipients completed the survey.

Source: Pruthi, 2013

Successful Telemedicine Lessons Learned

Authors’ Key Takeaways:• Make sure enough time is scheduled for implementation of the model.• Technology is matching for all involved and support is available.• Logistics for dual site coordination, transfer of medical records and maintaining

documentation.• Cost of coordination and downloading of patient records.• Scheduling appointments, licensing, and credentialing• Recruitment of dedicated navigator and telehealth coordinator.

Future Research:• Appropriate reimbursement payment models need to be supported by

government procedures.• Lifting of licensure barriers to expand to additional remote areas closer to

patient’s home.• Integration into collaborating clinics varying workflows due to differing size,

location, and specialty care.

Case Study: TeledermatologyThe U.K.’s Underserved: Throughout 1994-2005, provide dermatology access remotely to patients in the U.K., where inequities in access to services across geographical regions result in long waiting lists.

Collaboration:• National Health Service (NHS) provision of teledermatology in the U.K. consisting of 12 known

services dating back from 1994 to 2006.• One government sponsored (T1)• A commercial provider (no longer in operation – T4)• Research studies that were discontinued (T2, T3, T5, T6)• GP-based systems still in operation (T7, T8, T10)• Nurse-led systems still in operation (T9, T11, T12)

Methods:• A longitudinal (1997-2005) qualitative study was conducted in the U.K. including data from in-depth

semi-structured interviews, observations of systems in practice, and public meetings

Overview Significance Future Research/Challenges

Applications

Paper identifies factors that promote successful use of teledermatology as a part of routine service provision. A longitudinal qualitative study of teledermatology was conducted, drawing on data from in-depth structured interviews; observations of systems in practice; and public meetings. Data was analyzed collectively by the research team using established qualitative techniques to identify key thematic categories.

This study is unique in that is analyzes the development of most of the known teledermatology services on a national level (in the U.K.), over a significant period of time (8 years), thus providing a sound analysis of the differences between success and failure in implementation efforts in this context.

The original 'policy' vision of how teledermatology would be utilized, as a technological fix for long waiting lines and consultant shortages, failed to be realized.

This technology is revolutionary to service innovation in the field of healthcare. However, it brings up some questions and fears among practitioners who must implement it. In order to provide truly innovative service, what are the ethical and political implications?

Teledermatology

Teledermatology has been practiced both in real time through the use of live interactive videoconferencing and as store-and-forward systems which transmits still images and textual information for remote assessment and later view. There has been considerable global research done to demonstrate and evaluate the potential of teledermatology. In the U.K, efforts were initially focused on real-time teledermatology, but store-and-forward systems have become increasingly preferred as being more cost-efficient and convenient for health care providers. Teledermatology is also used for various purposes, including triage, diagnostic and management services, and advice/opinion for primary care practitioners.

Finch, Tracy L., F.S. Mair, and C.R. May. (2006) “Teledermatology in the U.K.: Lessons in Service Innovation.” British Journal of Dermatology, 156 (June) 521-527.

Teledermatology Lessons LearnedAuthor’s Key Takeaways:

• By enabling access to specialist services remotely, teledermatology has the potential to revolutionize the delivery of dermatology services.

• Results of the study indicated that requirements for using and integrating teledermatology into practice include:

• Perceived benefit and relative commitment that outweighs effort• Pragmatic approaches to proving efficacy and safety• Perception of risk as being manageable on the basis or professional judgment• High levels of flexibility in practice (in terms of individuals, technology and organization)• Reconceptualizing professional roles• Political support

• Successful execution of teledermatology as a routine service necessitates better understanding of and attention to the relationship between technical and social aspects of teledermatology, and how this is accommodated by health care professionals and the organizations in which they work.

Challenges:

• Respondents of the study questioned whether the additional effort needed to conduct teledermatology was worth it, unless the objectives were clear.

• Concerns were occasionally raised about whether teledermatology services and telehealthcare services in general, were trying to shift responsibility for care from secondary to the primary care sector.

Finch, Tracy L., F.S. Mair, and C.R. May. (2006) “Teledermatology in the U.K.: Lessons in Service Innovation.” British Journal of Dermatology, 156 (June) 521-527.

Failure in TelemedicineCase Study

Michigan’s Underserved: isolated Beaver Island, MI, population 550, encounters harsh weather and transportation issues to and from the island, making it difficult to obtain emergency or specialized healthcare.

Collaboration: • Beaver Is. Rural Health Center: Gatekeeper for island health services, providing a full range of

primary care and minor emergency services• Healthcare organizations and health related educators in the region

Model in Theory: • Create Telemedicine technical infrastructure• Staff clinic with a second nurse practitioner or physician assistant• Build a new heath-care complex that supports telemedicine• Increase in-home access to telemedicine

Case study of a success and failure in two rural telemedicine projects. Multiple data collection strategies were employed during the study period of one year. Methods included patient, administrator and health service provider interviews, surveys of physicians, nurses and patients, clinical outcomes, and archival data.

This study shows that in t is imperative to have resources and expertise in place to ensure success. In addition, success was due to a more formalized organizational structure for the telemedicine application. Telemedicine programs must not exist in a vacuum and must exist in a larger healthcare organization that has been carefully examined.

Rural communities lack essential resources including technical infrastructure and support, stable administrative staff and long term financial support. There are existing successful models in telemedicine that must be researched going forward to enable the success of future projects.

By studying the effects of not having a co-creation or constellation service innovation model in place, future rural telemedicine projects can learn valuable lessons regarding the early identification of major barriers an/or inefficiencies before embarking on a telemedicine project in their communities

Failure in TelemedicineLack of Service Innovation Model

• No initial adoption of a co-creation or value constellation service innovation model

• Lack of technical infrastructure or innovations to support service distribution

• No defined model of service innovation created through collaboration between patients, the Beaver Island Medical Board and mainland healthcare organizations

• No co-definition process built on shared knowledge between experienced practitioners of telemedicine and the key stakeholders of the Beaver Island project.

• Unable to contain costs in order to create a stable network structure that would create a successful telemedicine model.

• No co-creative “Value Constellation” conceptual flowchart created emphasizing the collaborative, collective, and path dependent function of innovation.

Co-Experience: Enables the co-creation of an

environment.Personalized, evolvable experience are

the goals.Requires I.T. infrastructure for

communication exchange.Requires cross licensing agreement.

Requires custom co-experience function in H.I.T. system.

Requires knowledge management model.

Co-Elevation:Value generated from one particular entity, in which the value generated diffuses among the other entities.

Entity focused, in terms of co-innovation led by particular group.

Co-Definition:Shared access that integrates all participating entities user-based

knowledge.Requires I.T. infrastructure.

Requires cross licensing agreement, joint patents, co-innovation patents.Requires knowledge management

model.Requires diluting exclusive property rights control in order to pursue joint

invention.Requires access and communication

between health providers L.I.M.S. and manufacturers M.E.S.

Co-Development:Co-innovation generated by the

relation among the various entities.Entities exchange heterogeneous

knowledge to contribute to co development solutions.

Relation focused, in terms of co-innovation generated by the relation

among various entities.

Adoption

Whitten, Pamela, Inez Adams (2012), "Success and Failure: a Case Study of Two Rural Telemedicine Projects." Journal of Telemedicine and Telecare, 9(3), 125-129.

Issues in TelemedicineLessons Learned

Authors’ Key Takeaways:

o Telemedicine programs must be positioned within a larger health organization rather than operate in a vacuum

o The people who would benefit most from telemedicine face the greatest barriers due to lake of essential resources including:o Technical

o Lack of telecommunications infrastructure in rural communities that would enable the transmission of data and video

o Unreliable mode of transportation for shipping key equipment and supplieso Unreliable technical support in the case of system failures or equipment malfunction

o Administrativeo Lack of qualified health professionals in the rural communities o High turnover of key personnel o Resistance from mainland doctors to use telemedicine to treat patients

o Financialo No stable funding sourceo Community reliant on grants and volunteerism to keep programs afloat

Future Research:

o Organizational and cultural models that focus on fiscal, geographical, technical and personnel environments to ensure successful telemedicine projects in rural communities

New Model: A Co-Creative Value Constellation

New Model: A conceptual flowchart indicating heterogeneous entities and

their relationships in a context of co-creation for medical innovations, in which technological innovation is a service distribution function among entities

Enables firms, manufacturers, researchers, and medical lead users to be included in a different conception of “open innovation”

Emphasizes the collaborative, collective and path-dependent function of innovation in medical technology and the salient aspect for service innovation through medical lead users organized within a community of practice

New Model: Co-Creative Value Constellation Flowchart

H1 H2 H3

H.I.T.

Co - Exp

H.I.T.Co - Exp

Co-Experience

Co-Elevation

Co-Definition

Co-Development

Path Dependencies for Co-Creative (VC) Flowchart

Success of flow chart relies on all participants: Initiated into co-creation initiative by firm Connected by common mission, vision, goals, and values Connected by compatible I.T. infrastructures Connected by contracts of joint invention, cross-licensing

agreement, joint patents, co-innovation patents In agreement over the knowledge management model for co-

experience and co-definition function

Co-creation Service Innovation Model

A service dominant logic to thinking about medical innovation in terms of service provision, in which technological innovation is a service distribution function among entities. The view contributes to bridge service systems and lead user innovation in the context of progress in healthcare by focusing on the unique processes linked to user knowledge for incumbent service innovation.

The model explores and elaborates on the concept of value co-creation by distinguishing different underlying stages for its generation and diffusion, and it develops a model of service innovation from a complex and adaptive network of defined entities, namely, firms, medical organizations and patients. Lead user knowledge, both in relation to the entity where it is generated and to the interactions among other entities, can affect future service innovation.

“Spill overs” of knowledge and their artifacts, patents and licenses, are therefore limited to allow knowledge transfer between users and firms.

Co-definition process requires a shared knowledge model built between firms and medical lead users where learning from each other is pivotal.

Driven by the capabilities of I.T.

In depth exploration of innovation process for new ideas into the ongoing debate over a cost-containment environment and medical technological innovation.

The very network structures that support the discovery and the diffusion of clinical innovations represent an important and unique repository of outside knowledge that can be accessed by firms. Along with other firms and universities for basic research, medical lead users can now be included in a different conception of “open innovation”

Galbrun, J.; Kijima, Kyoichi (2010), “Innovation in Medical Imaging Technology: Toward a Systemic Service Perspective,” Service Systems and Service Management (ICSSSM), 2010 7th International Conference on, 1(7) 28-30.

Diffusi

Path Dependencies for Model: Co-Creative Service Innovation Model

Path Dependencies for Model: Patents Patents represent valuable innovation milestones within R&D strategies and inform the future market options

available to a firm Co-innovation patents, joint patents, cross licensing agreements enable joint invention strategies in which firms

leverage and share knowledge that may have utility for each individual participant, which can lead to synergetic outcomes beyond the individual knowledge inputs

Before agreeing to joint invention strategies participating entities should: Balance intellectual and transactional ownership costs and interests that arise from jointly owned inventions Consider how collaboration addresses the interests and private benefits of the external actors participating Understanding why, when, and with whom firms should consider diluting exclusive property rights control in

order to pursue joint inventions

Study proposes that capabilities evolve by way of a firm’s solo and joint invention experiences, and contends that these capabilities are uniquely shaped by the firm’s history of patenting with two specific types of ties, upstream and down stream

Prior joint invention experiences diversifies the capabilities of the firm and broadens its strategic options. Capabilities evolve differently according to the firms unique joint invention experiences

Path-dependent outcomes are difficult to untangle with aggregated patent data. Initially, firms regard joint-patents as a “second best option” to solely owned patents.

Research on How R&D strategies impact capability development. Research on capabilities by accounting for how the path dependent role of shared property rights influences the technological trajectory of the firm Research on joint invention conditions and the moderating roles

Khoury, T. A., Pleggenkuhle-Miles. E. (2011). “Shared Inventions and the Evolution of Capabilities: Examining the Biotechnology Industry.” Research Policy, 40(7): 943-956

Path Dependencies for Model: I.T. Infrastructures

I.T. system Definition Functions Application

Health information technology H.I.T.

Umbrella framework to describe the comprehensive management of health information across computerized systems and its secure exchange between consumers, providers, governments, and quality entities

Improve healthcare quality and effectiveness. Reduce health care costs. Technical and social framework that enables information to move electronically between organizations. Tracks data overtime. Sharing laboratory results with providers.

Source for data exchange from lead user to external entities

Laboratory information management system L.I.M.S.

A software based laboratory and information management system that offers a set of key features that support a modern laboratories operations.

Enables workflow and data-tracking support. Flexible architecture. Enables smart data exchange interface

A functional database that can be used to exchange qualitative and quantitative data from lead users to external entities

Manufacturing execution systemsM.E.S.

Concept conceived from the demand on the manufacturing enterprise to fulfill the requirements of the markets from a point of view of reactivity, quality, respect of standards, reduction in costs, and deadlines

operations scheduling, resource allocation and status, dispatching production units, document control, product tracking and genealogy, performance analysis, labor/ maintenance/process/quality management, data collection/acquisition

Program provides a common user interface and data management system for integrating multiple point systems.

Stephan, C., Kohl, M., Turewicz, M., Podwojski, K., Meyer, H. E. and Eisenacher, M. (2010), Using Laboratory Information Management Systems as central part of a proteomics data workflow. Proteomics, 10: 1230–1249. doi: 10.1002/pmic.200900420B. Saenz de Ugarte, A. Artiba, R. Pellerin (2009), “Manufacturing Execution System-A literature review.” Production Planning & Control, 20(6)

Path Dependencies for Model: Shared Knowledge Management Model

• Knowledge management (KM) is a concept that has been applied in other settings to explain performance differences among organizations and improve outcomes.

• (KM) reflects an integrated framework focusing on effective knowledge process management to impact performance and work relationships in ways that enhance learning and decision making

• (KM) model consists of:• Enablers – provide the foundation necessary for the organization to increase its

effectiveness • Critical processes – basic operations • Outcomes of (KM) – facilitates decision making, sense making, and learning to achieve

mission and enhance performance

In an environment of burgeoning body of healthcare research and the adoption of technology tools, physicians can benefit from understanding effective (KM) practice. A (KM) model is presented that borrows from recent information science scholarship in (KM) and is intended to inform intervention protocols for effective (KM) to improve quality of care

(KM) is a beneficial framework to help healthcare professionals manage their practices and ultimately administer quality care to their patients.

Research in how (KM) is employed in organizations informs us that (KM) methods can not be implemented haphazardly as they can interact to enhance or detract from desired outcomes

KM could be viewed as a partial solution to inadequate knowledge sharing between lead users and external actors, (KM) provides essential insights into understanding successful primary care practice improvement, and as a result, has the potential to influence favorably the overall improvement in the health of residents in the United States and around the world

Orzano, John, Claire R. McInerney, Davida Scharf, Alfred F. Talia, and Benjamin F. Crabtree (2008), “A Knowledge Management Model: Implications for Enhancing Quality in Healthcare.” Journal of the American Society for Information Science and Technology, , 59(3) 489-505.

(KM) Model

Orzano, John, Claire R. McInerney, Davida Scharf, Alfred F. Talia, and Benjamin F. Crabtree (2008), “A Knowledge Management Model: Implications for Enhancing Quality in Healthcare.” Journal of the American Society for Information Science and Technology, , 59(3) 489-505.

Hypothetical Case Study

H1 H2 H3

H.I.T.

Co - Exp

H.I.T.Co - Exp

Co-Experience

Co-Elevation

Co-Definition

Co-Development

Conclusions• By forging external collaborations and facilitating the cross-fertilization of ideas,

firms can actively manipulate their capabilities to better guide their market pursuits, gain access to complementarities, and shorten development time, while spreading the significant costs and risks associated with R&D .

• Offers implications for how inventions, their attributes and their defined ownership boundaries can be more aptly leveraged within R&D strategies to evolve a firm’s capabilities.

• The co-creative model infrastructure is an In-depth exploration of innovation process for new ideas into the ongoing debate over a cost-containment environment and medical technological innovation.

• The intensity and variety of interactions between all participating actors indicates the value network/value constellation.

Future Research• What are the incentives for entities involved in program other than

progress for greater good?• How to measure success and failures of model application, to

indicate usefulness of entities participating.• Future research on the variables necessary in the co-experience

function of the systemic service model. • Future research on the models affect on free-market medical

systems and universal healthcare systems in an effort to understand bureaucratic pressures.

• Future research on refining the conceptual framework of the co-creative service innovation model towards a functional framework.

• Future research on steps/guidelines to manage co-creative service model in context of value constellations.

ReferencesBessant, John and Lynne Maher (2009), “Developing Radical Service Innovations in Healthcare – The Role of Design Methods,” International Journal of Innovation Management, 13(4) (December), 555-568.

Caballero-Daniel, Sara, Chipo Mugomba (2007), “Medical Tourism and its Entrepreneurial Opportunities – A Conceptual Framework for Entry into the Industry.” Master Thesis, School of Business, Department of Economics and Law, Goteburg University.

Daim, T.U., Tarman Tarcan, and N Basoglu (2008), “Exploring Barriers to Innovation Diffusion in Health Care Service Organizations: An Issue for Effective Integration of Service Architecture and Information Technologies,” Proceedings of the 41st Annual Hawaii International Conference on System Sciences, Conference Publications, 7-10 Jan. 2008 IEEE, 1-10.

Dearden, A., P. Wright, S. Bowen, F. Rahman, M. Cobb, and D. Wolstenholme (2010), "User-Centered Design and Pervasive Health: A Position Statement From The User-Centered Healthcare Design Project," 2010 4th International Conference on Pervasive Computing Technologies for Healthcare, Conference Publications, 22-25 March 2010 IEEE, 1-4

Errol Ozdalga. Ark Ozdalga. Neera Ahuja (2012), “The smartphone in medicine: A review of current and potential use among physicians and students,” Journal of Medical Internet Research (JMIR), J Med Internet Res; 14(5): e128.

Finch, Tracy L., F.S. Mair, and C.R. May. (2006) “Teledermatology in the U.K.: Lessons in Service Innovation.” British Journal of Dermatology. 156 (June) 521-527.Galbrun, J.; Kijima, Kyoichi (2010), “Innovation in Medical Imaging Technology: Toward a Systemic Service Perspective,” Service Systems and Service Management (ICSSSM), 2010 7th International Conference on, 1(7) 28-30.

Giegerich, Andy (2012), “Quick-care Medical Clinic Models Grow,” Portland Business Journal, 7 (September) 24-25.

Khoury, T. A., Pleggenkuhle-Miles. E. (2011) “Shared Inventions and the Evolution of Capabilities: Examining the Biotechnology Industry.” Research Policy, 40(7): 943-956.

Lamprinakos, George E., Kosmatos, D. Kaklamani, I.S. Venieris (2010), “An Integrated Architecture for Remote Healthcare Monitoring,” Informatics (PCI), 14th Panhellenic Conference n, 12(15) 10-12.

References (Continued)Luo, Chih-Ming A., Hung-Fan Chang and Chi-Hung Su (2012), “’Balanced Scorecard’ as an Operation-Level Strategic Planning Tool for Service Innovation.” The Service Industries Journal. 32(12) 1937-1956.

Nair, M. (2011), “Understanding and Measuring the Value of Social Media.,” J. Corp. Acct. Fin., 22: 45–51. doi: 10.1002/jcaf.20674

Oliveri, Denise (2007), ” Pros and Cons of Urgent Care Centers,” (accessed on 4/29/13) [Available at http://suite101.com]

Omachonu, Vincent K., Einspruch, Norman G. (2010), “Innovation in Healthcare Delivery Systems: A Conceptual Framework,” The Innovation Journal: The Public Sector Innovation Journal, Volume 15(1), Article 2.

O’Malley, Ann S., Joy M. Grossman, Genna R. Cohen, Nicole M. Kemper, and Hoangmai H. Pham (2010) “Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices.” J Gen Intern Med. 25(3) (March) 177–18

Orzano, John, Claire R. McInerney, Davida Scharf, Alfred F. Talia, and Benjamin F. Crabtree (2008), “A Knowledge Management Model: Implications for Enhancing Quality in Healthcare.” Journal of the American Society for Information Science and Technology, , 59(3) 489-505, 2008

Ruby P. Lee, Ginn, Gegory O., & Naylor, Gillian (2009), “The Impact of Network and Environmental Factors on Service Innovativeness,” Journal of Services Marketing, 23(6), 397-406

B. Saenz de Ugarte, A. Artiba, R. Pellerin, (2009) “Manufacturing Execution System – A Literature Review.” Production Planning & Control, 20(6)

Saviano, Marialuisa, Clara Bassano, and Mario Calabrese (2010) “A VSA-SS Approach to Healthcare Service Systems: The Triple Target of Efficiency, Effectiveness and Sustainability.” Service Science, 2(April) 41-61.

Stephan, C., Kohl, M., Turewicz, M., Podwojski, K., Meyer, H. E. and Eisenacher, M. (2010), Using Laboratory Information Management Systems as central part of a proteomics data workflow. Proteomics, 10: 1230–1249. doi: 10.1002/pmic.200900420

Whitten, Pamela, Inez Adams (2012), "Success and Failure: a Case Study of Two Rural Telemedicine Projects." Journal of Telemedicine and Telecare, 9(3), 125-129

http://www.hhs.gov/regulations/index.html

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