The implementation of health information technology interventions is at the forefront of most policy agendas both nationally and internationally. In Norway, there is a National Welfare Technology Program (NVP).

Norway has a national guideline for the NVP:
– National welfare technology program – benefits realization reports
– Welfare technology in central introduction of welfare technology in the city boroughs of Oslo (1/2)
– Welfare technology in central introduction of welfare technology
– Meld. St. no. 29 (2012-2013) “Tomorrow’s care” (regjeringen.no)
– Technical report on welfare technology
– NOU 2011: 11 “Innovation in care” (regjeringen.no)
– Future aging and new technologies (teknologiradet.no)
– Organization and Design of Response Center service (2016)
– Organization of alarm reception in Norway and abroad (2014)

However, such undertakings are often far from straightforward as they require complex strategic planning accompanying the systemic organizational changes associated with such programs. Building on experiences of designing and evaluating the implementation of large-scale health information technology.

Introduction
Large-scale, potentially transformative, implementations of health information technology are now being planned and undertaken in multiple municipalities, 32 municipalities are part of the National Welfare program in Norway.

The aim is that 80% of the population in 2020 living in a municipality that offers health care services where welfare technology is part of ordinary services.

The hope is that the NVP and that Welfare technologies will streamline individual and organizational work processes and thereby improve the quality, safety, and efficiency of health care. The reality is, however, that these technologies may prove frustrating for frontline health care personnel and organizations as the systems may not fit their usual workflows, and the anticipated individual and organizational benefits take time to materialize.

Through this article, I hope to inform policy and practice development to support the more successful integration of technology into complex healthcare environments.

Factors associated with effective implementation identified in the following research report the latest years:
– Erfaringer fra pilotering av velferdsteknologi i Sarpsborg kommune, Høgskolen i Østfold, Oppdragsrapport 2015:4 – Cathahrina Bjørnquist
– Prioritering og kompetanse i bruk av velferdsteknologi i Telemark, Vestfold og Buskerud 2015. Høgskolen i Søst Øst Norge, Senter for omsorgsforskning, Per Gunnat Disch og Heidi Johansen
– Velferdsteknologi og hjemmeboende eldre, Høgskolen i Nord Trøndelag, Siri Andersen Devik og Ove Hellzen, Rapport 79 2013
– Velferdsteknologi – en studie knyttet til ledelsesmessige utfordringer ved implementering av velferdsteknologi innen helse og omsorg. Høgskolen i Trøndelag, 2015, Inger Lise Fiskvik
– Velferdsteknologi fra planer til prosjekt. NTNU, Desmber 2015,  Gulizar Astroshi
– Implementering av velferdsteknologi i helse og omsorgstjenesten – Høgskolen i Sør Øst Norge, 2015, Janne Daugstad, Etty R. Nilsen, Monika K. Gullsett, Tom Eide og Hilde EideTechnical: usability, system performance, integration and interoperability, stability and reliability, adaptability and flexibility, cost, accessibility and adaptability of hardware

Research shows:
– That one of the biggest challenge in the development and deployment of welfare technology is communication gap between technicians and health professionals
–  Competence and understanding of digitalization
– Change Challenges
– Change processes, Changing Culture
– Organizational challenges
– Organizational structure, Organizational culture and Organizational anchoring
– Strategic challenges
– Political Anchoring, Collaboration with private suppliers
– Management Challenges
– Change Management, Implementing and Competence

Social: attitudes and concerns, resistance and workarounds, expectations, benefits/values and motivations, engagement and user input in design, training and support, champions, integration with existing work practices

Organizational: getting the organization ready for change, planning, leadership and management, realistic expectations, user ownership, teamwork and communication, learning and evaluation
Wider socio-political: other healthcare organizations, industry, policy, professional groups, independent bodies, the wider economic environment, international developments

To succeed in implementation of Welfare Technology one should use the technology lifecycle approach to highlight key considerations at four stages:
– Establishing the need for change
– Selecting a system
– Implementation planning
– Maintenance and evaluationFigure 1

Summary of the lifecycle stages of welfare technology information and the key considerations.

Key considerations for the successful implementation of health information technology
1. Clarify what problem(s) the technology is designed to help tackle
Many welfare technology procurements are based on assumed benefits, which are often poorly specified. This can result in difficulties agreeing on a shared vision across the healthcare organization. While terms like ‘improved quality of care’ and ‘improved efficiency’ are often used, detailed outcomes resulting from specific functionality are hard to measure and to anticipate as most implementations require fundamental changes to operational processes and many organizations do not even attempt this. Thus, organizations often encounter difficulties conceptualizing the required short-, medium-, and long-term transformations.

2. Build consensus
Professional, managerial, and administrative consensus needs to be built around the strategic vision, in addition to creating the means to support the realization of this vision. This may involve considering whether to aim for radical changes across the, or whether to focus on streamlining specific work processes, initially and then expanding functionality over time. Many authors in the field of organizational change have highlighted that high-level strategic leadership of senior management including both administrative and health care leaders is vital, and this is accurate, but it is also essential to involve and get the buy-in of different professional stakeholder groups (eg, doctors, nurses, administrative staff, managers) to facilitate co-ownership and ensure commitment. From our experience, this balance is best achieved through the creation of a high-level strategic group that not only includes senior managers, but also clinical and administrative leads who represent different end-user groups.

An important factor to keep in mind is that attempts to align perspectives through, for example, consensus building activities, need to be skillfully handled with cognizance of the means to overcome rather than perpetuate existing professional hierarchies. One approach that we have successfully used is to identify domains in which there is already broad agreement versus those which need specific attention from different professional stakeholders. For the latter, efforts promoting the participation and empowerment of different groups by actively searching for inclusive solutions, have the highest potential to achieve coordinated implementation efforts. Nurses, for instance, will have different needs to doctors, but all groups tend to agree that the provision of high standards of care should be the focus of activities. Patient-centered discussions could therefore be a point of convergence between different professional viewpoints.

3. Consider your options
Once the need for a technological system has been established, it is important to commit adequate time and resources to thoroughly consider different options in terms of which system(s) to choose. We have found that this aspect of planning and the associated writing of business cases and procurement considerations are sometimes under-estimated and often rushed. Visiting other healthcare settings that have implemented similar technology can prove very helpful.

4. Choose systems that meet health care needs and are affordable
Once a decision on the basic type of system has been made, it is important to base the final choice not only on organizational, but also on clinical needs. A system should be both fit for organizational purpose and fit for health care practice. There are countless examples of systems that have been procured but never used or are deployed in unintended ways, which will then typically result in a failure to realize the hoped-for improvements

5. Plan appropriately
It takes both targeted and reflective efforts to plan for transformative organizational ventures of any kind. Although flexibility in strategy is required, there are some general pointers that tend to characterize effective preparation across organizations and technologies. These include the aforementioned necessity to engage extensively with potential suppliers and other organizations who have already implemented, but also the decision to prioritize the implementation of functionality that can bring benefits to the greatest number of end-users as early as possible. Other factors relate to the avoidance of ‘scope-creep’ and maintaining open channels of communication between management and users.

Implementation strategies need to be tailored to organizational circumstances and systems, whether they involve ‘phased’ or ‘big-bang’ implementation approaches. The former relates to introducing incremental functionality slowly, while the latter relates to introducing functionality across the organization all at once. We suggest avoiding the running of parallel systems  wherever possible, as this tends to increase workloads for end-users and may inadvertently introduce new threats to patient safety.

6. Don’t forget the infrastructure
Developing the right infrastructure is an essential part of planning activity. If this is not afforded sufficient attention, then software systems may perform sub-optimally, or may be inaccessible to users altogether. Again, this increases the possibility that systems are not used at all or used in ways other than intended, potentially compromising benefits and increasing risks associated with technological systems.

7. Train staff
Trained users tend to be more satisfied with new technologies than those who have not been adequately trained. In the municipality case, we first trained the deployment leaders, then the super users and then the super users trained 4000 end users.

The most effective training is that which is tailored to the individual roles of users, without being too restrictive as this can undermine understanding of how the whole system functions. Training needs to allow users to practice ‘hands-on’ and as closely simulate the actual working environment as possible. It is also ideally conducted shortly before the implementation as otherwise staff may forget important functions. There may be a need for compulsory as well as voluntary components, and some individuals may need more training than others. For instance, older users may never have used a computer and may therefore require more basic training than younger individuals, who tend to be more accustomed to computers. For infrequent users and in relation to systems that are subject to regular upgrades, continuous training may be necessary.

8. Continuously evaluate progress
Although it is now widely recognized that evaluation is important when considering new technologies, the reality is that it is still, more often than not, an afterthought as immediate implementation activities take priority. It is essential to capture user feedback about problems that are identified and respond to it in a timely manner.

9. Maintain the system
Maintenance is in many ways related to all of the above points as these issues need to be re-visited periodically throughout the technology lifecycle. Nevertheless, maintenance deserves particular attention as it is often under-estimated in relation to associated activities and cost. This is not only the case in relation to on-going costs, but also costs relating to potential system changes as the strategic aims of organizations and therefore the capabilities of existing technological systems are likely to change over time

10. Stay the course
The benefits of major transformative programs are notoriously difficult to measure and may take a long time to materialize. However, this is not to say that they are non-existent, rather they need to be tracked by appropriate evaluation work assessing how the new system is used and re-invented locally. This also requires an appreciation of the timelines surrounding the realization of expected benefits, allowing enough time for technologies to embed and data to be exploited for secondary uses. Experience has shown that in many cases the expectations of organizations and individual users far exceed what is achievable in the short term. The managing of expectations is, therefore, important as otherwise there is a danger that stakeholders disengage with the initiative and negative attitudes may emerge.

Conclusions
Careful planning and on-going, critical evaluation of progress are central to the successful implementation of major health information technology. Taking a lifecycle perspective on the implementation of technological systems will, help organizations to avoid some of the all too commonly encountered pitfalls and improve the likelihood of successful implementation and adoption. It is, however, important to keep in mind that, although the stages and considerations discussed here were depicted in a linear manner, they may to some extent overlap.