Is ICT a key enabler in ensuring seamless delivery of healthcare? A comparison between public and private ICT development in Ireland

Abstract

This study discusses the innovative changes that have taken place in Ireland in the field of healthcare due to the influx of information and communication technologies. Previous Information communication technologies (ICT), including telemedicine, present opportunities to address rural health-service delivery issues. The research shows that effective management of health services and the delivery of quality systems in Irish healthcare organizations have increased. In Ireland patients are expecting more of healthcare providers and are demanding higher standards of care and service.

Simultaneously, those paying for health services have become more concerned about rising health costs and possible inefficiencies. As a result there is widespread interest in understanding what makes for an effective health service and in developing better practices to improve existing approaches to healthcare management in relation to ICT. This study highlights the developments in quality-service management in the Irish healthcare sector and focuses attention on the need for the development of a model for quality implementation in healthcare institutions. In sum the study shows that the development of (ICT) has facilitated the emergence of a complex global urban system in which many formerly lower-order cities have been carving out “niche” specialist functions serving urban fields of transnational dimension.

Chapter1: Introduction

Purpose of Study

The purpose of this study is to highlight the development of the Information and communication system in Ireland and how it has revolutionized the healthcare sector in Ireland.

Research Question

This study focuses on the following research questions:

  • What are the current trends of technological development in the Information and Communication Technology sector of Ireland?
  • What are various challenges faced by the Irish healthcare system in relation to Information and Communication Technology?

Significance of the Study

This study is quite significant as it shows that the concept of globalisation has secured remarkable currency in the academic discourse of the late 20th century, despite ongoing questions regarding both its meaning and extent (Clark and Lund, 2000). The development of internationally integrated production and distribution systems, seen by many as the key feature of globalisation, has been a spatially uneven process. A key factor in this respect has been the differential ability of regions to engage in the informational economy, based on new information and communications technology (ICT), which is the main source of wealth creation and economic growth in the modern world (Castells, 2003).

The result has been what Friedmann (2005) calls a process of ‘techno-apartheid’ which has divided the globe into ‘fast’ and ‘slow’ worlds (Knox, 2005), distinguished by the connectedness of individuals, groups and regions to the world of telematics. This echoes Ingersoll’s (2003, quoted in Knox, 2005) suggestion that the key division of the workforce is now that between those who have the capacity to operate ICT (the ‘cyberproletariat’) and those who do not (the ‘lumpentrash’). Golding (2006) makes a similar distinction between the ‘technoliterati’ and the ‘techno-poor’.

While Knox defines the fast and slow worlds spatially, equating the former with the ‘triadic’ core and the latter with the remaining global periphery, Hoogvelt (2003) argues that the divide is, in essence, social rather than spatial, with elements of both worlds to be found in all regions of the globe. Thus, within advanced economies, a process of social polarisation has been widely reported (Friedmann, 2006 and Sassen, 2004) and has been intimately linked by Graham and Marvin (2006) to the development of ICT use. This is not to suggest that those who work in the fast world are homogeneously well-paid and affluent; rather, they represent a wide range of remuneration levels depending on such factors as economic sector, location, function, ethnic group and gender (Castells, 2006). What they do tend to have in common, however, is relative employment security due to the high demand level for their ICT skills.

Rationale

This study follows a logical approach and identifies the fact that both in Ireland as well as globally, there are major geographical variations in the relative balance between fast and slow worlds, with the former mainly to be found in the traditional core regions of North America, western Europe and Japan and an additional small group of newly industrialising countries which have had the institutional capacity to invest massively in modern ICT and associated educational infrastructures (Freeman, 2004). The slow world – found predominantly in the less developed countries of the global periphery and accounting for the bulk of the world’s population – is becoming increasingly marginalised and is moving, as Castells (2003, p. 37) puts it, “from a structural position of exploitation to a structural position of irrelevance”.

Definition of Terms

ICT: Information and Communication Technology: it is the study or business of developing and using technology to process information and aid communications.

Sistem : SISTeM a soft systems methodology, stakeholder analysis and participative simulation modelling.

NHS: (National Health Service) The organization providing national healthcare services in the UK.

Chapter 2: Literature Review

The process of quality implementation has become a key concern for those involved in hospital management in Ireland. In a national context, the effective management of health services and the delivery of quality systems in health-care institutions have increased in significance in recent years. In line with wider developments in other service industries, consumers (patients) are expecting more of health-care providers and are demanding higher standards of care and service. Simultaneously, those paying for health services have become more concerned about rising health costs and possible inefficiencies. As a result there is widespread interest in understanding what makes for an effective health service and in developing better practices to improve existing approaches to health-care management and delivery.

In 2005 a comprehensive report on funding from the Commission on Health Funding highlighted that solutions to the problems faced by the Irish Health Service did not lie primarily in the system of funding, but rather in the way that services were planned, organised, and delivered. Similarly, in a report from the OECD (2003), it was argued that although the Irish health system had delivered a continuous improvement in health standards, there was still scope for further improvement in efficiency, and that this could be achieved through better allocation of resources. More recently, the government health strategy (DOHc, 2001) highlighted the requirement for a system to monitor progress and systematically evaluate the quality and effectiveness of health services. According to the strategy:

Monitoring and evaluation must become intrinsic to the approach taken by people at all levels of the health services.

Specifically, the strategy suggested that the way in which health and personal social services are planned, organised, and delivered has a significant effect on the health and well-being of the population. Organisational structures must be geared to the provision of a responsive, adaptable health system which meets the needs of the population effectively and at affordable cost. One of the guiding principles inherent in the published strategy was that of a “people-centred” health system. A responsive system must develop ways to engage with individuals and the wider community which receives its services. The health system must become more people-centred, with the interests of the public, patients, and clients being given greater prominence and influence in decision making at all levels (DOHc, 2001).

According to Bowers (2001), major structural reform, coupled with strong management and political will, are required to ensure change for the better. In Bowers’ view, finance alone will not improve the system. Rather, a concentrated effort must be made to ensure a responsive and efficient service. As previously noted, a conclusion of the Report of the Commission on Health Funding (2005) was that the solution facing the Irish health services did not lie primarily in the system of funding but rather in the way that services were planned, organised, and delivered. This is reinforced by a recent report on the Irish health-care sector which suggested that the issues and challenges facing the health service are fundamentally the same as those outlined by the Commission on Health Funding, except that they are compounded by much higher expectations/demands by consumers (Deloitte and Touche, 2001).

Thus, although modern health services have undergone radical change in many areas (Robins, 2003), managers of health services are currently reporting a large increase in the number of patients needing beds, with consequent ever-increasing waiting lists. Accident and emergency departments are under particular strain, and the difficulties of dealing with the growing needs of the increasing elderly population are beginning to become apparent. Although the Irish health service is free for all those requiring medical treatment through a publicly funded system, the current situation is hauntingly similar to that of the Victorian era of health care in Ireland.

As a result, the Office for Health Management in Ireland (OHM, 2001) has suggested that current deficiencies in health-care provision and delivery underline the importance of providing quality service management and implementation in Irish health and personal social services. In achieving this aim, the OHM has contended that those working within the system must change how they go about their work and how they work together.

Changed public-sector environment

The focus on health-care service and quality has evolved from a more general interest in continuous improvement initiatives within the public sector. The prevalent trends in the private sector are towards continuous and pervasive change and increasing interdependencies, and it has been suggested that close parallels can be drawn between the private and public sectors. Public-sector organisations now find themselves in a cyclone of change as they attempt to adapt to turbulent environments in a pragmatic and systematic way (Lovell, 2004).

In the UK and also in Ireland, these organisations have been subject to cuts in government spending, as well as demands for enhanced efficiency and effectiveness. In response to such changes, there has been a policy shift towards greater competition and an attempt to apply management practices from the private sector to the public domain.

The Irish public sector has been officially pursuing change and reform through its strategic management initiative (SMI), a program for improving the management of the civil service which was formally launched in 2004 (Department of the Taoisearch, 2004). The SMI evolved from the growing internal and external pressures for better services and for more effective management of public services. In that context the continuous improvement of customer service has been a specific focus of the SMI since 2003, when the quality service initiative was launched. The program set out a series of quality principles according to which dealings with the wider public would be coordinated and managed. These initiatives aimed to make public administration more relevant to the citizens for whom the service exists, and simultaneously sought to remove barriers which have traditionally restricted performance and job satisfaction within the public sector.

In recent years, Ireland has experienced a rise in consumerism. Increases in revenue available to fund public service provision have gone hand in hand with rising public expectations of standards of service. As a consequence, management skills and competences in providing for improved standards of customer service have become recognised as being central to delivering real transformation in the public sector. However, the development of such capabilities, particularly in relation to managing effective quality implementation, presents considerable challenges for those involved. Nowhere is this more evident than in the health-care sector. A review of recent international evidence points to the challenges of implementing quality service in health-care institutions.

Gaucher and Coffey (2000) confirmed that implementing a process of total quality management (TQM) in health care is a pragmatic, specific, and systematic methodology. However, this requires a firm commitment from the leadership to change their former ways of working and doing business. Gaucher and Coffey (2000) cited many reasons for TQM failing – including poor leadership and a lack of management commitment – but also noted that revitalisation can rejuvenate the process. These authors asserted that the role of those implementing the process is to nurture and breathe energy into the process when enthusiasm and commitment are declining.

The importance of the support of senior management for quality-management projects is also advocated by Berwick et al. (2000). These authors undertook a national demonstration project in the USA in the late 2000s and described how organisations could implement the entire quality-improvement process – from defining the problem through to implementing a solution and consolidating the gains (Berwick et al., 2000).

A literature review carried out by Jackson (2005) identified that much work had been undertaken in the UK in determining the clinical effectiveness of many health-care organisations, but that very little research had been implemented in the area of managerial effectiveness. Furthermore, West (2001) determined that, in organisations that outperform others on different dimensions of performance, there was evidence that management is important, as are the combined efforts of individual clinicians and teams.

There have been several approaches espoused for achieving quality management in health-care institutions, many of which have been technical and generic in their approaches (Moeller et al., 2000). Specifically, Donabedian (2000) introduced the concepts of structure, process, and outcomes, along with the development of self-assessment and accreditation through the International Organization for Standardization (ISO). In many instances these programs have met with mixed reactions, and their implementation has varied.

A criticism levelled at hospital performance is that it has been rather insular, and has paid little attention to developments in related fields, such as organisational sociology, organisational behaviour, management studies, and human-resource management (West, 2001). If quality programs are to have lasting and significant effects, that they must follow a systemic approach such that all aspects of an organisation are integrated and focused on continuous improvement and customer satisfaction (Joss, 2004).

A variety of approaches has been used to improve quality and to ensure its delivery, but not all have been successful. Indeed, some have merely added bureaucracy and higher costs to health care (Jackson, 2005; Ennis and Harrington, 2001). Recent research has shown that 45 per cent of patients experience some “medical mismanagement” and that 17 per cent suffer events which lead to a longer stay or more serious problems (Ovretveit, 2000). This is increasingly caused by complex systems of care which do not appear to be managed effectively.

Joss and Kogan (2005) strongly recommended that a comprehensive set of criteria be included, against which to evaluate progress. These criteria should be based on the main requirements of TQM, and should include any additional factors generated by the organisation and/or by evaluators. A three-year evaluation of TQM in the National Health Scheme (NHS) indicated that there were clear factors which predicted successful implementation, the most important of which was the need to have a structured, pre-planned approach based on a thorough understanding of alternative approaches (Joss, 2004). Moreover, a recent study from the UK (O’Sullivan, 2005) demonstrated how one NHS Trust achieved continuous quality improvement through determination, education, and implementation, supported by visionary and involved leadership in all areas, a multi-talented enthusiastic clinical audit department, and a high-quality dedicated staff.

Nabitz and Walburg (2000) suggested that possible solutions to quality problems might lie in the approach promoted by the European Foundation for Quality Management (EFQM). The EFQM has developed a model to structure and review the quality-management processes of organisations. Self-assessment, benchmarking, external review, and quality awards are essential elements of this model and, as reported by Sanchez (2000), this approach represents an important means of achieving excellence in health care. Within the literature there are also many studies showing the benefits of applying models of quality implementation in health-care organisations (Naylor, 2005; Ruiz et al., 2005). Such studies have pointed to the real benefits that accrue to organisations which have used such approaches (Pitt, 2005).

Business excellence methodology for quality improvement

The introduction of internationally respected quality frameworks – the Malcolm Baldrige National Quality Award (MBNQA) in 2003, followed by the EFQM in 2005 – has provided an opportunity for organisations to self-assess, using the models of TQM and business excellence which underpin these frameworks. In this process of self-assessment, an opportunity exists to identify the strengths and weaknesses in the current management of operations. In the USA, the effectiveness of the Baldrige process has been lauded by many (Gaucher and Coffey, 2000) who have indicated that organisations can learn about best practices from Baldrige-winning companies, and will thus be assisted in developing a composite for excellence.

Although the Baldrige criteria were developed for commercial institutions, there has been keen interest in the adaptation of the model within health-care organisations in the USA following a pilot health-care project in 2005. To date, no health-care entity has yet achieved Baldrige-winner status, although Gaucher and Coffey (2000) have asserted that it is only a matter of time before there is a health-care winner. Moreover, these authors went on to say that the true benefit of the Baldrige process is not about winning an award. Rather, it is about the provision of a road map for a journey – a framework for both incremental and breakthrough improvement and business excellence.

Within the European context, since its introduction in 2001, the EFQM model has been attracting considerable interest across all sectors, and has become a well-recognised quality-management framework. Stahr et al. (2001) concurred with Gaucher and Coffey (2000) in stating that the model provides a means by which organisations can assess their paths and develop solutions to achieve excellence. Other authors have espoused the model as being surprisingly effective, with awards being presented to those firms considered to be the most accomplished exponents of TQM in Europe (Wilkes and Dale, 2005).

Across European health care at an institutional level, an increasing number of organisations are making direct investments in the training of staff in the concepts of business excellence (Stahr et al., 2001; Jackson, 2001). The NHS Executive in the UK has provided a central lead in endorsing the model as an important framework for delivering on the clinical governance agenda. Furthermore the British Association of Medical Managers (BAMM) has promoted its use as a tool for organisational self-assessment (Stahr et al., 2001). Its use and adoption has been further supported by the British Quality Foundation which provides a major educational and support role in the use and adoption of the model in health care and other sectors across the corporate landscape.

Without doubt, the future performance of health-care organisations will be assessed against wider goals than previously. There will be a greater emphasis on measuring organisational performance and, if performance is below par, rapid investigation and appropriate intervention will ensue (Naylor, 2005). Moeller (2001) concurred with this, and identified evaluation of health services as a prerequisite. However, Zairi et al. (2005) warned that measuring organisational effectiveness in the delivery of health care is a challenging task.

Joss and Kogan (2005) strongly recommended that a comprehensive set of criteria should be included, against which to evaluate progress. This should be based on the main requirements of TQM, supplemented by other organisational criteria thought to be important by the evaluators. A three-year evaluation of TQM in the NHS indicated that there are clear factors which predict successful implementation – including awareness of the need to have a structured, pre-planned approach based on a thorough understanding of alternative approaches (Joss, 2004). Moreover, as demonstrated by O’Sullivan (2005), successful implementation requires the support of visionary and involved leaders in all areas, together with dedicated and educated staff.

Examining organisational effectiveness in Irish health care

As suggested by Nabitz and Walburg (2000), the solution to quality problems might lie in the approach promoted by the EFQM. As reported by Sanchez (2000), this approach represents an important means of achieving excellence in health care which concurs with earlier descriptions by Gaucher and Coffey (2000). Self-assessment can examine current practice and establish capability, thus driving improvement rather than a reaction to weaknesses in the current system (Russell, 2005).

There are also many studies in the literature which show the benefits of applying the business excellence model for quality implementation in health-care organisations (Naylor, 2005; Jackson, 2005a; Nabitz and Klazinga, 2005; Arcelay et al., 2005). Such studies have pointed to real benefits that have accrued to organisations using such an approach. Furthermore, Jackson (2005a) demonstrated that the adoption of the principles of self-assessment and business excellence can lead to the achievement of a culture of continuous improvement.

Russell (2005) noted that the adoption of the “outside-in” approach of the EFQM model enabled organisations to use the model as a developmental and management framework. For Arcelay et al. (2005), the model provided a global, systematic regular analysis of the activities and results by comparing them with the criteria of the excellence model. Moreover, the process made it possible to make comparisons with other private and public organisations.

Using a systems view of an organisation enables managers to focus on the processes between the parts of an organisation, rather than on the parts themselves, which is similar to physicians using a systematic model in which to analyse signs and symptoms, and thus make a diagnosis. An effective organisation is one in which the total organisation, through its significant subparts and individuals, manages its work against goals and plans with a view to achieving these goals within an open system. Methods of management that have been developed in manufacturing environments are naturally regarded with scepticism in non-manufacturing sectors.

However, according to West (2001), studies that have been conducted on the link between the organisation and management of services and quality of patient care can be criticised both theoretically and methodologically because of the many different mechanisms that may be operating at once to produce the relationship between volume and quality. West (2001) asserted that a more rigorous body of work exists on the performance of firms in the private sector, often conducted within the disciplines of organisational behaviour or human resource management.

Ireland and the International ICT System

Dublin has, in the 2000s, carved out several niche international functions for itself, one of which, call centre activities, has been the principal focus of this study. According to a report in The Irish Times (August 20, 2003), Ireland accounts for 30% of all international call centres located in western Europe. The great bulk of these are to be found in Dublin. The central role of ICT in call centre activities has facilitated their centralisation in Ireland, from where markets spread across Europe and even further afield can readily be served. As Sassen (2005, p. 56) has observed: “Information technologies, often thought of as neutralising geography, actually contribute to spatial concentration”.

Call centre activities, therefore, have helped Ireland to escape the bounds of geographical peripherality, thereby contradicting Wegener’s (2005) gloomy prognosis which visualised cities in the periphery as inevitable losers from growing inter-urban competition in Europe. This has been cleverly portrayed in an IDA advertisement which shows Ireland at the centre of a surrounding group of disembodied European countries ( Fig. 1). These latter are no longer seen as being more or less distant from Ireland, but as constituting a set of different language and market territories, all equally accessible from Ireland.

However, Dublin’s growing international reach and the growing technological sophistication of its economic base should not mask the fact that, structurally, it retains a dependent position within the international division of labour. Its rapid recent economic expansion has been largely based on the attraction of branch plant operations which remain poorly embedded in the local economy (Breathnach, 2005). Аnd, while the rising skill levels associated with recent inward investment have facilitated substantial improvement in living standards generally, in the specific case of the call centre sector, much of the employment which has been created remains relatively poorly paid – a fact which is directly linked with the high proportion of women workers in the sector, despite their high skill levels.

Furthermore, the rapid growth of the call centre sector in the 2000s looks increasingly unsustainable as the end of the decade approaches. Growing labour shortages are driving up labour costs which, in conjunction with increasing housing and transportation problems, are beginning to attenuate Dublin’s attractiveness as a call centre location: according to a 2005 survey of call centre locations in Great Britain and Ireland, reported by Allen (2005), Dublin had fallen to the 29th position of 46 locations surveyed, having been in the top 10 in 2006.

The response of the IDA has been to devote additional resources to promoting non-Dublin locations for call centre projects. However, even if this is successful in the short run, in the longer term the future of call centre employment will be increasingly threatened by technological developments, such as speech recognition technology and especially the rapidly growing use of the internet for making reservations, placing orders and seeking information.

The IDA has justified its promotion of the call centre sector, despite the inferior nature of much of the employment involved, largely on the grounds that it provides an initial base upon which more sophisticated forms of employment can be built. Its long-term strategy, in other words, is to encourage firms which have established call centres in Ireland to add on additional functions, such as financial management and software development, to these initial operations. Already there has been some success in this area of ‘shared services’ back-office activities: by mid-2003, some 25 such operations had been established, and were projected to employ over 3000 people by the year 2000 (information supplied by Forfás).

Ultimately, however, all of these activities remain as back-office activities, whose essential linkages are external to the Irish economy. In other words, their Irish location is not crucial to the parent companies of these operations; rather, it is contingent on the availability of certain attractions which may either be transient or reproducible elsewhere (Allen, 2005). As Wilson (2005) has noted, call centres are essentially a highly footloose sector, with few local economic linkages and little fixed investment in machinery and equipment: they therefore can be relocated quite readily in the light of changing comparative factor conditions.

The National Health Service (NHS) in the UK published its NHS Plan in July 2000 (http://www.nhs.uk/thenhsexplained), saying that patients and people were central to its radical reform of healthcare and that although this included more hospitals and beds, shorter waiting times and improved care for older people, an essential element was that patients should have more power and information. As Grimson et al. (2000) rightly comment, healthcare is an information-intensive business, with data on an enormous scale gathered by way of hospitals, clinics, laboratories and primary care surgeries.

Central to any information-intensive business is, naturally, the effective sharing of that information and, in order to empower and better engage the patient, how best that can be done. Funded by the UK’s Department of Health, the British Library’s integrated Telemedicine Information Service (TIS), described in the latest edition of the NHSMagazine (http://www.nhs.uk/nhsmagazine), is to improve the take-up of telemedicine technology in the UK, reinforcing the importance that information and communication technologies (ICTs) are seen to have in the sharing of information and the engagement of patients in their healthcare.

By way of explanation, the word “telemedicine” has been coined as a way of capturing, in only one word, how ICT is being used in healthcare. However, as Curry et al. (2003) rightly comment, terms such as telemedicine, teleconferencing, health informatics and medical informatics seem to be used interchangeably, and that there is some confusion as to what is, and is not, involved, citing various studys, including those of Preston at al. (2002) and Mark and Hodges (2001) to support their claim. As there is some disagreement with the term, we use in this study the meaning assigned by Perednia and Allen (2005), that is, the use of information technologies in helping to provide medical information and services in healthcare. Whatever its name, or its definition, it concerns, in one way or another, the mediating role that technology plays in the interaction between humans, whether patient or healthcare professional.

At the time of writing, there are 138 telemedicine projects in the UK (http://www.tis.port.ac.uk/tm/owa/projects.allUK), and they cover aspects of healthcare as diverse as mental health, diabetes, foetal monitoring and accident and emergency care. Indeed, it points to one of the advantages of telemedicine; its applicability across a wide range of clinical issues. However, while these projects certainly cover a diversity of issues, they have something in common, that is, they address only one of these clinical matters. Each system is designed differently, is unlikely to be compatible with another, and needs different technical support and user training.

Whilst such individual systems have proved useful in a particular context (see, for example, Gilmour et al., 2005; Jones et al., 2006; Lesher et al., 2005; Loane et al., 2005; Lowitt et al., 2005; Oakley et al., 2005), the implications for a national healthcare system mean that each clinic, hospital or other healthcare setting would need to purchase a different technological device for each particular healthcare issue. So, a system for diabetes, another for mental health and yet another for foetal monitoring, and so on. In addition, each device would need different technical support and different user training and would, naturally, take up a great deal of space in the workplace.

Maintaining such systems would be problematic and expensive, particularly given the rapidly-changing nature of information systems today. It would also be very expensive. In a country such as the UK, where (scarce) financial resources for healthcare come from the taxpayer, it is difficult to see how those managing the healthcare budget would justify the cost in investing in such single, one-issue systems. Another difficulty of such one-issue systems is that a great deal of effort would have to be made in persuading doctors/general practitioners or specialists/consultants to use such systems; only around 12 per cent of these healthcare professionals have computers on their desks and, like many, may not embrace technology with the same enthusiasm as their designers.

There are, then, two objectives which need to be met if the healthcare service is to be improved. One, a need to engage the patient more in their healthcare, to empower them and to provide them with more information. This raises the issue of the nature of the interaction between the patient and clinician/healthcare professional. Two, to use ICT as effectively and efficiently as possible to support this interaction in both the primary and secondary (or tertiary) care context. In this study we first look more closely at the challenges in healthcare today, and the need to more effectively support communication and information-sharing between patient and clinician/healthcare professional.

We describe current practice with regard to consultation between patient and healthcare professional(s) and the nature of the information available to the specialist/consultant. We suggest that although the specialist/consultant currently gathers information by way of two sources, a third would usefully enrich their knowledge and aid them in their diagnosis and subsequent care of their patients. The use of a clinical information system, AIDMAN, is described, and we demonstrate how this can be used to usefully enrich the interaction both between patient and specialist/consultant and the healthcare professional(s) in both primary and secondary/tertiary care. We outline the benefits that AIDMAN, with its ability to be used across the full range of clinical issues, offers and the implications of the system for the healthcare sector.

The transnational urban system

A key element in the globalisation process has been the development of growing links between the world’s cities (the nerve centres of the informational economy), in the form of increasing flows of information, services, finance and currency, commodities and people. Thus, urban systems which in the past were largely defined in national terms have become increasingly integrated at the global level. This has led to the emergence of a transnational urban system (Sassen, 2004), comprising cities of varying sizes, locations, and economic functions.

This system is dominated by a small number of ‘world’ (Friedmann, 2006) or ‘global’ (Sassen, 2001 and Sassen, 2004) cities, characterised by major concentrations of transnational corporate headquarters, advanced financial and producer services, and communications infrastructures. These are the world’s “key command and control centres” (Amin and Graham, 2003, p. 413) whose functional reach is truly worldwide in scope.

Outside this select group of world/global cities, the globalisation process is causing urban centres everywhere to expand the international orientation of their economic bases. As Gottmann (2005, p. 64, quoted in Simon, 2005, p. 146) puts it:

Every substantial city nowadays aspires to a world role, at least in some specialty. This makes them expand linkages abroad, participating in more networks. All these trends contribute, little by little, to building up and intensifying the global weave of urban networks.

Many cities, therefore, have been pursuing selective “strategies for economic promotion and city marketing to establish themselves a profitable market niche” in the global economy (Wegener, 2005, p. 150). Typically, these cities place a premium on the attraction of outside capital which, in Friedmann’s (2006) terminology, uses these cities as ‘basing points’ for the articulation of production and markets with respect to specialised sectors or areas. Examples of such cities include Singapore, which acts as a regional headquarters for transnational firms operating in Southeast Asia (Dicken and Kirkpatrick, 2001); Miami, which plays a key role in articulating trade and investment flows between the USA and Latin America (Sassen, 2004); and Luxembourg, which has carved out a niche for itself as the largest ‘offshore’ financial services centre in Europe (The Irish Times, February 9, 2006).

Due to the limited functional base and/or spatial reach of such cities, they are probably best described as ‘transnational’ rather than global. While in some cases, their spatial zones of influence may be relatively clearly defined, the growing role of ICT in their operations is rendering traditional concepts of territorial urban hinterlands increasingly meaningless. It may be preferable, therefore, as Friedmann (2005) suggests, to use the term ‘urban field’ to denote the economic (or, indeed, cyber) space served by such cities.

The proliferation of niche transnational cities with specialised functions is giving rise to what Sassen (2004, p. 52) calls “overlapping geographies of articulation”. As a consequence, attempts to arrange the transnational urban system into neat hierarchical tiers (see Cohen, 2001 and Friedmann, 2006) are increasingly futile (Friedmann, 2005). As Knox (2005, p. 9) has put it: “the flexibility of corporations within global networks and the warpage of new telecommunications media [are] constantly revising the role of ‘lower-order’ world cities”.

Dublin and the Irish economy

Historically, Dublin developed as a classic colonial primate city in relation to an economic system which – particularly in the 19th century – was dominated by the export of both agricultural produce and labour to the industrial core countries of Great Britain and the USA (Breathnach, 2005). Thus, Dublin acted as the centre of administration, the main port for exports and imports, and the hub of the national transport system, and was an order of magnitude larger, in population terms, than all other urban centres (with the exception of Belfast which, due to specific historical circumstances, developed a substantial industrial base in the 19th century). When Ireland was partitioned in 1922 and independence was secured by what is now the Republic of Ireland, Dublin had a population of 500,000 out of a total population of three millions in the newly independent state.

In the 1930s, Dublin’s dominant position was further enhanced by the introduction of a vigorous policy of import-substituting industrialisation supported by protectionism, as the substantial industrial growth which ensued was mainly concentrated in the metropolitan region. By 1960, Dublin, with a quarter of the national population, accounted for almost one-half of the total manufacturing employment. However, industrial stagnation set in during the 2000s, as the limits presented by the small size of the domestic market were quickly reached.

This led the government to abandon protectionism and opt instead for an export-led industrial policy based on the attraction of foreign direct investment from overseas. This policy received a major boost following Ireland’s accession to the European Economic Community (now the European Union) in 2003, which allowed Ireland to be used as a low-cost base for serving the European market. This was particularly attractive to American firms, especially given Ireland’s status as an English-speaking country with strong cultural/historical links with the USA. Since then, American firms have accounted for over one-half of all inward investment into Ireland.

In structural terms, the new branch plants set up in Ireland developed few local linkages of any kind; spatially, they also tended to avoid Dublin and other large urban centres, preferring more dispersed locations with little industrial tradition but plentiful supplies of unskilled labour (Breathnach, 2002 and Gillmor, 2002). This reflected the fact that most foreign branch plants were mainly involved in low-skill assembly and packaging activities in the electrical/electronics engineering and pharmaceuticals/healthcare sectors (Telesis Consultancy Group, 2002).

Thus, as foreign investment came to dominate the national economy (accounting for over one-half of industrial production and 80% of industrial exports by the mid 2000s), Dublin’s role as control centre of the Irish economy (outside the realm of social regulation) experienced substantial erosion, although its position as main service centre for an increasingly prosperous nation saw the population of the metropolitan region grow to some 1.2 millions in 2001 – one-third of the total.

Since the beginning of the 2000s, major changes have been occurring in the Irish economy which have impacted greatly on Dublin’s functional role in relation both to the domestic economy and the international division of labour. Consistently high rates of economic growth have led to Ireland being portrayed variously as “Europe’s tiger economy”, the “Celtic tiger” and the “emerald tiger”. From a position where, in 2000, Ireland’s per capita GDP stood at just over 60% of the EU average, by 2005 Ireland had surpassed that average (Commission of the European Communities, 2005).

A range of factors have contributed to Ireland’s rapid economic growth in the 2000s; however, of crucial importance have been a new surge in the inward investment and, more importantly, profound changes in the nature of this investment (Breathnach, 2005). In the realm of manufacturing, there has been a very significant upgrading in the technological content of inward investment and, associated with this, a pronounced expansion in the average size of new projects.

This is linked, to a considerable extent, to the growing availability (due principally to demographic expansion and major state investment in education) of relatively low-cost but high-quality technically qualified workers. A common feature of this latest investment phase is that most of it has been concentrated in the Dublin area, a function primarily of the need for large numbers of college graduates (contrasting sharply with the low-skill operations of the 1960s and 2000s), allied to the need for more sophisticated local services.

Apart from the emergence of new forms of manufacturing investment, a very significant development in the 2000s has been a shift to inward investment in service activities. There have been three main components to this. Firstly, the establishment of an International Financial Services Centre (IFSC) in Dublin in 2003 has generated a considerable influx of operations attracted mainly by the low tax rates available in the centre. Employment in IFSC-licensed firms stood at 6500 in 2005.

Secondly, there has been rapid growth in overseas software operations (Coe, 2003), employment in which reached 9500 by the end of 2003. The vast majority of these are also located in the Dublin region, where relevant skilled personnel are concentrated. The third main component of recent growth of inward investment in services in Ireland has been the telephone call centre sector which provides the focus of the remainder of the study.

The internationalisation of back-office activities

The location of telephone call centres in Ireland may be regarded as part of a new phase in the international relocation of back-office activities, a process which in itself is a relatively recent phenomenon. Back-office activities refer to those which require little face-to-face contact with other personnel either within or without the firm. They typically include such activities as payroll, accounting, subscriptions, billing, credit card services, claim processing, word processing, remote sales and reservations, and technical support (e.g., for personal computer users). These activities in turn tend to be highly routine, automated and labour-intensive.

There has been a growing tendency towards the spatial separation of back and front office activities (i.e., the latter being those requiring a high level of face-to-face contact). Technically, this has been facilitated by the development of ICT which allows both a high degree of automation of information processing and the integration of remotely located back-offices with either front offices or the outside world through high-speed and high-volume telecommunications networks. However, the main motivating factor behind the separation of back from front office activities has been the desire to achieve significant cost savings by moving what tend to be a firm’s most labour-intensive and therefore space-using office activities out of high-cost central city locations, where most firms locate their head offices (Castells, 2005).

In the case of North American cities, much attention initially focused on the relocation of back-offices to suburban locations where substantial reservoirs of predominantly female skilled clerical workers, who are prepared to work for relatively low wages, can be found (Nelson, 2006; Gad, 2005 and Huang, 2005). More recently, there has been growing interest in the relocation of back-office workers out of metropolitan regions altogether to more remote locations (Castells, 2005; Howland, 2003 and Warf, 2005).

Increasingly, such movements have involved overseas destinations, motivated primarily by the prospect of accessing labour supplies which are both cheaper and frequently of higher quality (in terms of training, reliability and motivation) than those available in the home country. The availability of generous investment incentives has also been an important factor in the offshoring of back-office activities (Graham and Marvin, 2006 and Wilson, 2005).

Suitable overseas locations for the back-office operations of American firms are not as widely available as in the case of manufacturing branch plants, due to the need for good telecommunications infrastructures and supplies of relatively cheap English-speaking workers with the requisite skills (Castells, 2005). As a result, the amount of offshoring of back-offices from the USA has been limited: the total numbers involved have been put by Wilson (2005) at no more than 35,000 in the early 2000s.

At the same time, Wilson suggests that these movements provide an important pointer to the future direction the global organisation of services production will take. Much of the movement which has taken place has been to Caribbean countries such as Jamaica and Barbados. Other destinations which have attracted a significant level of back-office offshoring from the USA include the Philippines, India, China and Ireland.

Workers in offshore back-offices are predominantly young, flexible and female, mainly as a consequence of socialisation and gender stereotyping processes which steer mostly women towards this type of work. The resulting gender segmentation in turn facilitates the utilisation of social control processes similar to those which apply to female-intensive manufacturing operations (Breathnach, 2003). Gender segmentation also means that, while back-office work involves higher skill levels than, for example, electronics assembly, remuneration is not correspondingly higher due to the continuing tendency to ascribe low pay levels to what is considered to be ‘women’s work’ (Christopherson, 2005).

Apte and Mason (2005) have identified the following as being influential factors in the decision on whether to relocate back-offices overseas or not:

  • wage costs;
  • availability of a modern telecommunications infrastructure;
  • cultural and language similarity;
  • availability of skilled labour;
  • stability of the political and social environment;
  • attitude of the host government to foreign investment;
  • foreign currency restrictions and volatility;
  • time zone difference.
  • Of these factors, crucial importance is attributed to the first two (see also Richardson and Marshall, 2006) which, in the Irish case, account for 80% of the running costs of telephone call centres; the remainder are seen as being either supplementary or significant in deciding on specific offshore destinations. The last factor listed applies particularly to back-office activities which are connected on-line to central home-country computers outside home-country office hours.

    Back-office development in Ireland

    Apte’s and Mason’s list of locational factors provides a ready explanation for Ireland’s attractiveness as a destination for American back-office operations. As regards labour factors, Ireland provides high-quality skilled workers from a well-developed educational system with wage costs which, as Apte and Mason themselves show in relation to both clerical and professional workers, were typically about a half of those prevailing in the USA in the late 2000s.

    Furthermore, following a major investment programme initiated in the 2000s, Ireland now has a very advanced telecommunications infrastructure which offers very competitive rates for high-volume international traffic. Linguistically and culturally, there is a high degree of commonality between Ireland and the USA.

    The Republic of Ireland also has an extremely stable political system and social environment, while the attitude of the Irish government to foreign investment is extremely positive, with its aggressive marketing of the country as a location for inward investment; low corporation tax rate (10% for manufacturing and international services), capital and training grants, advice and other support services, no local content requirements and unlimited profit repatriation.

    The Irish currency is also relatively stable and there are no restrictions on currency movements. Finally, the minimum 5 hour time zone difference between Ireland and the USA has also proved influential for certain data-processing operations which played the pioneering role in terms of the establishment of offshore back-office activities in Ireland in the 2000s.

    The development of the call centre sector

    In the 2000s, the emphasis in the attraction of back-office activites to Ireland has shifted to call centres (i.e., centralised locations from which services such as sales, reservations, information provision, technical support and banking are provided to a dispersed customer base by means of telephone). There has been a general acceleration in the establishment of call centres in recent years, motivated partly by increased attention among firms to customer service and the drive to direct marketing and partly by the growing availability of low-cost and high-volume long distance telecommunications services (including freephone facilities) (Richardson, 2004).

    Large firms operating in multiple regional and national markets have been moving towards the centralisation of call centre operations in one location (or a small number of locations), partly due to the economies of scale which can be achieved as a result. Many firms are availing of the consequent opportunity to establish centralised call centres in greenfield locations in order to introduce new work practices, such as variable working hours and local pay bargaining, which may have been difficult in existing locations (Richardson, 2004).

    While most call centres remain focused on serving individual national markets, there has nevertheless been a significant growth of call centres with a transnational scope of operations. In the case of the EU, call centre centralisation may be seen as one element of a general process of rationalisation of production, marketing and administration among large firms operating on a pan-European basis in response to the thrust towards integration of EU markets (Goddard, 2005). In 2003 the establishment of international universal freephone numbers to replace the pre-existing system of different national freephone numbers has also contributed to this centralisation process.

    Ireland moved at an early stage to promote itself as a pan-European call centre location, offering, in addition to the existing grants and tax incentives, the cheapest rates in Europe for international freephone calls as well as low-cost, high-calibre, flexible bilingual staff. When the Industrial Development Agency (IDA) – the state agency responsible for promoting inward investment – introduced its call centre programme in 2002, it projected the creation of 3000 jobs in the sector by the year 2000. However, this target was achieved as early as 2006 and, by mid-2005, some 50 centres had been set up employing 6000 persons.

    American firms dominate the Irish call centre sector, accounting for 70% of centres and over 80% of employment. Among the major US firms which have established call centres in Ireland are IBM, Compaq, Dell, Citibank, Hertz and Oracle. Female employment also dominates the sector, accounting for 70% of all jobs. The proportion is higher for the lower-skilled reservations and sales subsectors, and lower for the customer support subsector, which requires technical qualifications and pays correspondingly higher salaries.

    Apart from the clerical nature of the work involved and the superior telephone skills which women tend to possess (Richardson and Marshall, 2006), a major reason for the high proportion of female labour is the central importance of language skills in the call centre sector, as women are much more inclined to study languages in both school and college. For three-quarters of call centre companies, the availability of language skills was stated to be either the first or second most important reason for coming to Ireland.

    Over one-half (55%) of call centre employees use a foreign language in their work; of these, 43% are foreign nationals: thus, 23% of all employees are foreigners. Irish nationals are mainly used for the main continental languages (French, German, Italian, Spanish) with foreigners largely used for minority European languages (e.g., Scandinavian, Dutch, Portuguese) and non-European languages (e.g., Korean, Japanese).

    Some 90% of Irish call centre employment is located in the Dublin region. While good telecommunications facilities are available throughout Ireland, call centre firms have been reluctant to locate outside Dublin for fear of being unable to source sufficient numbers of linguists, especially locally resident foreigners with minority language skills. There are also concerns about the availability of suitable office space and support services outside Dublin.

    Even in Dublin there are emerging problems in getting adequate supplies of workers who can combine linguistic competence with the other skills required (telephone and keyboard skills and technical expertise for technical support functions). This is partly related to the rapid growth of the sector which has exceeded the supply of suitable personnel. One consequence of this has been an increasing problem of high labour turnover, reaching as high as 37% per annum for telesales workers, 25% for customer services and 17% for technical support (which provides the best-paid work in the sector); (The Tele Business Salaries and Skills Survey, 2005).

    In the lower-skilled call centre activities such as sales/reservations, additional problems have risen because, while technically these activities only require a secondary standard of education, only third-level graduates tend to have the language fluency required. However, these find it hard to accept the routine and repetitive nature of the work they are required to do. Apart from this problem of overqualification, the intensive, strenuous and closely monitored nature of the work also contributes to high turnover – a factor which tends to be universal in this sector (Nelson, 2006 and Richardson and Marshall, 2006).

    The more technologically skilled call centre activities such as technical support, on the other hand, face the problem that Irish information technology graduates (being mainly males who tend not to pursue language courses during the course of their education) in most cases do not have foreign language competence at the level required by call centres. Call centre firms are responding to this problem by increasingly importing foreign nationals for this type of work: of the 700 workers at the Gateway personal computer sales and technical support call centre in Dublin, 35% are foreign nationals.

    Challenges within the current system of healthcare

    The NHS Plan is permeated with words and phrases that emphasise the need to involve patients more in their own healthcare. Although it would seem difficult to see how patients could be anything other than involved given that it is their body/mind that is being seen, treated or managed, this suggests that patients are currently viewed more as “cases” rather than as individuals, as people. That is, that they come into the doctor’s surgery with a problem, and it is the problem, rather than the patient, that is being seen. While in some sense this is naturally necessary, as patients want the health problem “solved” in some way, as in the case of, say, a broken finger being mended or a minor injury being treated, not all patients present things which might be seen as a “problem to be solved”.

    Indeed, it might be argued that much cannot be “solved” anyway; asthma, psoriasis, mental health conditions and the like do not, and cannot, go away and it is more that these need to be managed, as effectively as possible, by both the patients themselves (who are, after all, dealing with their healthcare day in and day out), and, on occasion, with the assistance of various healthcare professionals. However, healthcare is as much about dealing with a wide range of “everyday” issues, such as helping a first-time mother with her new baby or helping someone deal with the death of a loved one.

    Whether borne out or not, there is a perception, at least, that doctors and consultants, in particular, are viewed by their patients as somewhat distant, over-authoritative and dispassionate. Indeed, the word “clinical” does not only mean “relating to health” but also detached, lacking in empathy. Whether stated explicitly or implicitly, there seems to be a call for healthcare professionals to engage more fully with their patients, and to see them more as some kind of “partner” in their healthcare rather than someone “in authority”. Patients are somewhat in awe of doctors and, in particular, consultants and this raises issues with regard to the patient/healthcare relationship.

    It is first necessary to provide some background as to how healthcare is organised in the UK, as this varies from country to country. In other countries, both in Europe and elsewhere, patients can see a specialist/consultant in a hospital without needing to be referred there by their own local doctor. In the UK, this is not possible; a patient must first see their own doctor, known as a general practitioner, whose surgery/clinic is normally located close to the home of the patient. The health service provided at this level is known as primary care.

    It is the responsibility of the doctor/general practitioner to refer the patient on to what is known as secondary (or tertiary) care, usually a hospital, where more specialised equipment, and specialists/consultants are on hand. As with any healthcare system, there are potential drawbacks, and these have implications for the speed and accuracy of the treatment both at primary and secondary care level. Referring the patient from primary care to secondary care normally involves a lengthy process of letter-writing between the doctor/clinician and the specialist/consultant in the hospital in trying to book an appointment.

    The specialist/consultant in the hospital then has to contact the patient to tell them of the time and day of the appointment. It goes without saying that this is a lengthy process, and time, for those with serious illness, may be in short supply. As Summerton (2000) notes, inefficiency and/or inaccuracy can adversely affect not only prognosis but also the nature of any intervention(s), and the earlier those choices (that is, decisions) are made, the better. The doctor/clinician is somewhat divorced from what happens from that point on and, given the problems associated with relying on a postal service (normally efficient enough, but the UK has suffered from postal strikes in recent years) to relay communication between consultant/hospital and patient, there is the danger of information either arriving late or, worse, not arriving at all.

    A patient referred to secondary care may have moved house in the time between first seeing their doctor/general practitioner and the first consultation with the specialist/consultant. Although this may seem trivial, cases have been reported in the media where this new information has not been conveyed, and this has adversely affected the healthcare of the patients concerned. Patients themselves are unaware of the processes going on behind the scenes, so to speak, and so it is not difficult to see that they would not necessarily realise the importance of informing anyone of their change of address. Аnd, although they may consider reporting such information to their own doctor/general practitioner at primary care level, they would not know who to contact at secondary care level as the name of the specialist/consultant or their place of work would likely not be known.

    The current nature of interaction and communication

    The importance of the doctor/general practitioner in primary care is clear; it is the first port of call for the patient. Although the appropriate response may not require further intervention from other healthcare professionals in secondary care, when such intervention is perceived as necessary, effective interaction between patient, doctor/general practitioner and (normally) specialist/consultant is key.

    For the patient, who may well have built a good relationship with their doctor over a long period of time, being referred to a specialist/consultant in a hospital is not without its difficulties. Among these is the fact that the patient has never met the specialist/consultant; building a new relationship with a stranger is, for many, not easy. This is made more problematic by the fact that they are probably very anxious or upset, and thus not at their best in terms of expressing themselves well, clearly or, importantly, accurately.

    Yet the value of that initial visit depends not only on what the specialist/consultant knows about that particular illness or disease, but on the quality of the information provided by the patient. Аnd patients, naturally enough, do not necessarily know what is, or is not, relevant information which would help the specialist/consultant in their diagnosis and subsequent treatment or care. One of the most vital aspects of effective and efficient care is an accurate (as is possible) record of patient care up to the time when the specialist/consultant sees the patient. It is at this time that the specialist/consultant makes the vital decision as to what treatment is or is not appropriate, and when this needs to be carried out.

    The decision(s) made at that time are crucial to the patient’s subsequent care and health, and it is clear that the knowledge and information available to the specialist/consultant needs to be as accurate and as full as is possible. Such information is stored in three (at least) different places. One, informally, by way of the knowledge and experience gained by the doctor (and/or, perhaps, another clinician in the primary care surgery/clinic, such as a nurse) who has been involved in the care of the patient up to that time. Two, formally, by way of the written records that are kept in the primary care surgery/clinic. These records are (for much of the UK, at least) kept only in handwritten and not electronic form, although there is currently a move towards the keeping of these electronically. Three, informally, by way of what the patient knows about their own health, history and experiences.

    ICT can (and does) play a role in the storing and sharing of patient records at or between healthcare professionals in both primary care and secondary care. Аnd, with the move to involve patients further in their care, patients themselves may well, in the future, make their own contributions to their records in some way, perhaps from their home computer. That information systems are becoming increasingly more sophisticated is uncontested. Indeed, Rodger and Pendharkar (2000) describe a variety of fascinating technological developments used by the Department of Defense in the USA.

    However, whether it is sophisticated, which somehow carries with it the assumption that it is somehow “better” or, at least, “good” in comparison to whatever was in place before, is of little value, particularly in terms of healthcare. As a report by Payton and Brennan (2005), on a phone-accessible Web-based computer network that was developed for the use of those caring for patients suffering from Alzheimer’s disease, demonstrates, an “unsophisticated” response answered the needs.

    It revealed that what carers actually wanted was “someone to converse with and share ideas” (Payton and Brennan, 2005, p. 88) and that access to an encyclopedia into the disease or even a decision-making utility was not regarded as useful by this particular set of users. This has important implications for those developing information systems, namely, that when we are ill or request intervention of one sort or another from healthcare professionals, we do not ask for sophistication, but rather that we receive an appropriate, timely and accurate response.

    Healthcare is first and foremost about people; patients and healthcare professionals. The interaction between patient and healthcare professional(s), or between healthcare professionals in the workplace, may or may not involve a computer, but if it does, its value can only be measured by way of its impact on those it was designed to benefit, that is, the patients. As detailed above, the information currently available to the specialist/consultant when meeting the patient for the first time is limited to only two of the three sources available.

    One, formally, by way of the written records that are kept in the primary care surgery/clinic and which are sent before (hopefully) the patient arrives. Two, informally, by way of what the patient knows about their own health, history and experiences. Gaining information by way of only these two sources means that there is the potential for a breakdown (at worst) or a lack of richness in information-sharing between those working in primary care and those working in secondary/tertiary care, and, vitally, between patient and healthcare professional.

    We describe how the Advanced Informatics Distribued Medical Access Network (AIDMAN), a clinical information system, can be used to provide the third, vital, source of information lacking in consultations that are not tele-mediated, that is, informally, by way of the knowledge and experience gained by the doctor (and/or, perhaps, another clinician in the primary care surgery/clinic, such as a nurse) who has been involved in the care of the patient up to that time.

    AIDMAN was designed to offer the patient the advantage of a “virtual” consultation (Clarke and Jones, 2001; Clarke et al., 2005a, b, 2000a, b, 2005; Jones et al., 2005). If the virtual consultation is to work, it must necessarily support as many of the senses that face-to-face consultation offers. Although taste, smell and touch are as yet not able to be transmitted, video-conferencing does provide sight and sound, and this can be used to explore, at least, the other three.

    AIDMAN is a low-cost, video-conferencing system, and is augmented by using still digital pictures to provide definition view. During the consultation, the patient has at their side a medically trained person; this person can therefore use their hands or nose to provide the information gained by way of touch and smell, and can also operate the camera should the specialist/consultant wish to view a particular aspect of the body in order to aid diagnosis (see Plate 1).

    Although AIDMAN is in essence a clinical information system involving video-conferencing, it also has high definition images, shared access to data applications and other peripherals or medical systems that might be considered useful in presenting clinical data to either the medically-trained person at one end, or the specialist/consultant at the other. Communication technology is general and TCP/IP networks are used.

    However, satellite links have been tested to successfully deliver to remote regions of Greece and, more recently, to cruise ships in the Mediterranean as part of the Medaship project. AIDMAN was initially set up to investigate the provision of digital telemedicine in an area of the world where patients find themselves remote from consultants/hospitals in some way, in this case, four hospitals in Greece; one in the capital, the KAT Hospital in Athens, and the other three in healthcare centres in Corfu, Mykonos and Mytilini (all “remote” islands off the coast of mainland Greece). It is also used in the UK, and its centre is the Chorleywood Health Centre, not far from London.

    In terms of the more technical aspects of AIDMAN, the initial design for the virtual workstation is based on a Pentium II machine and includes desktop video conferencing (Proshare Version 5), a digital video camera for simultaneous analogue video and high resolution digital still image, flat bed scanner, soundcard and hands-free speaker phone.

    Many consultants appreciate diagnostic information in advance of the consultation, so that they can consider their diagnosis and then use the time with the patient more effectively. They also have the opportunity to ensure the quality of the information and that it is complete. This allows them to be able to request further information before the consultation. The system can access data from sources such as digital or digitised x-ray or CT-scan for use in the consultation.

    These can also be transmitted by other means in advance, for example, attachments to e-mail or Dicom. There is, naturally, scope to install all manner of other diagnostic equipment in order to support the interaction between the patient/medically-trained person and the consultant.

    The benefits and limitations of tele-consultation

    Using AIDMAN for tele-consultation means that communication and information sharing between patient and clinician/healthcare professional in both the primary and secondary/tertiary care context is more effectively supported. The nature of the information available to the specialist/consultant is enriched by interaction with the doctor/healthcare professional and this aids them in their diagnosis and subsequent care of their patients.

    Experience with AIDMAN suggests that there are many benefits that are not currently provided by way of the traditional management of healthcare. They may be physical in nature, or more psychological. Although many of these offer advantages to the patient, tele-consultation has much to offer healthcare professionals as well, both in primary and secondary/tertiary care:

    (1) For the patient:

    By the end of the tele-consultation, they know whether, or when, they will be referred; the decision is made at that point.

    The advantage of being diagnosed both quickly and with minimum disruption to everyday life and work.

    No need to wait (and worry) about when the letter from the hospital will arrive.

    The patient has “met” the specialist/consultant, and has started the initial, important, process of building a relationship with the person who will play an important role in their future treatment and care.

    The patient has the opportunity to ask questions ahead of their meeting with the specialist/consultant. This helps to manage their expectations and reduce anxiety about the unknown, that is, what is likely to happen.

    As the patient is sitting in a familiar clinic, with a familiar doctor/healthcare professional, the psychological and physical trauma associated with the subsequent visit to the specialist/consultant is alleviated.

    It may help patients to understand better consultation before they undertake it, and thus to prepare for it better, as well as to help to “de-mystify” what is, to many, the unknown processes involved in their healthcare.

    It provides added reassurance, as they have been closely involved in the dialogue between the doctor/healthcare professional and the specialist/consultant, and can thus have confidence that both share a common view of their care and treatment.

    Management of the case is negotiated and agreed by all parties, that is, consultant, doctor and patient, thus the potential to make consultation more effective for all participants.

    It may help change the current perceptions that patients have of healthcare, namely, that they are relatively passive participants in the process. This brings with it the notion of “advocacy”. Tele-consultation is a physical (at least) demonstration of the central role that they play in the process, and that they are (or should be) active participants who engage in the management of their own health.

    For the specialist/consultant and the doctor/healthcare professional:

    They are in the same room (virtually speaking) at the same time, with the patient.

    It is interactive; the consultant and/or doctor can ask the patient as many questions as is necessary to get the information needed to make what is hoped to be the correct diagnosis.

    As full a history as is possible is available from patient/health professional (doctor, nurse, or other)/records.

    The patient may be unable, or unwilling, to explain their symptoms or feelings. The doctor/healthcare professional (who will have had a longer and closer relationship with the patient) will thus have greater insights into the patient with regard to both their physical and mental state, which may be of use to the specialist/consultant.

    No need for the doctor/healthcare professional to amass physical documents and send them ahead to the specialist/consultant; this information is available to both at the time of the tele-consultation.

    The opportunity to call up/bring in new information as the tele-consultation progresses. For example, an old x-ray which, until that point, was not seen as significant/useful.

    By the end of the tele-consultation, they know whether, or when, the patient will be referred; the decision is made at that point.

    Confidence that the patient has received the message about referral.

    The specialist/consultant has “met’ the patient, and has started the initial, important, process of building a relationship.

    The specialist/consultant asks questions ahead of their meeting with the patient. This provides an opportunity for the specialist/consultant to help the patient to manage their expectations and reduce anxiety about the unknown, that is, what is likely to happen.

    As the patient is sitting in a familiar clinic, with a familiar doctor/healthcare professional, it provides an opportunity for the specialist/consultant to alleviate the psychological and physical trauma associated with the subsequent visit.

    It provides an opportunity for the specialist/consultant to help patients to better understand consultation before they undertake it, and thus to better prepare for it, as well as to help to “de-mystify” what is, to many, the unknown processes involved.

    It allows for the doctor/healthcare professional and the specialist/consultant to have confidence that both share (or not!) a common view of their care and treatment.

    Management of the case is negotiated and agreed by all parties, that is, consultant, doctor and patient, thus the potential to make consultation more effective for all participants.

    It may help change the current perceptions that doctors/healthcare professionals and specialists/consultants have of patients and/or healthcare, namely, that patients are relatively passive participants in the process. This brings with it the notion of “advocacy”. Tele-consultation is a physical (at least) demonstration of the central role that they play in the process, and that patients are (or should be) active participants who engage in the management of their own health.

    An opportunity for doctors/healthcare professionals and specialists/consultants to learn from each other more about patients, disease, treatment and related aspects of the management of healthcare.

    An opportunity for doctors/healthcare professionals and specialists/consultants to “bridge the gap”, psychologically speaking, that is seen to exist between primary and secondary/tertiary healthcare.

    As for limitations with regard to AIDMAN, as with the adoption of any information system, there are the difficulties associated with using technology in the workplace. Although research demonstrates that patients accept tele-consultation as a medium for communication and decision making about their health, rolling out AIDMAN for use in other surgeries/clinics or other healthcare settings is not just a matter of installing the equipment, although there are technical issues which might limit its uptake on a national scale.

    One of these limitations is the cost, not only of installation, but also of maintenance and, as anyone who uses computers and related technology knows, a high level of ongoing support is required given the inevitable breakdowns. If there are too many breakdowns, then doctors, nurses and other healthcare professionals will not want to use it, however useful it might be to their clinical work. Another limitation to a system such as AIDMAN is that it necessarily changes the relationships between all involved.

    Although the tele-consultation brings the doctor/general practitioner (and/or nurses, for example) and the specialist/consultant together, virtually speaking, it has to date been used with healthcare professionals who are positive and enthusiastic, who have (or feel that they have) the necessary interpersonal and other skills to effectively carry out the interaction and who do not mind having their own weaknesses exposed to others, in particular, to the patient.

    So, for example, a newly-qualified doctor/general practitioner might feel threatened by having to discuss, in front of the patient, an aspect of healthcare with which they are unfamiliar, or admit that they have not carried out certain checks, administered certain treatments already, and so would be reluctant, or even refuse, to use AIDMAN. Installing a system such as AIDMAN provides an opportunity for all concerned to learn from each other more about disease, treatment and related aspects of management of care; but some are more resistant to change (which is what learning is all about) than others.

    There is thus the need for further research into the perceptions of a range of healthcare professionals in a variety of healthcare settings in order to ascertain the types of organisations, and people within them, who will be more (or less) likely to embrace such technology. It is also necessary to find out how, precisely, such technology should be brought onstream in a new setting; it has been installed over several years at Chorleywood in the UK and installing and using it elsewhere will likely need new, and perhaps different, methods and approaches. An information system such as AIDMAN does, of course, cost money.

    In order for other healthcare professionals to consider its use in their own healthcare settings, there will be a need to provide further explanation as to what particular clinical issues are likely candidates for tele-consultation and which are not. So, for example, although teledermatology has been used with much success, as referenced earlier in this study, there are some dermatological cases which do not lend themselves to such intervention; the doctor/general practitioner should instead immediately refer the patient to the specialist/consultant.

    The majority of the 138 telemedicine projects in the UK, as described earlier, span aspects of healthcare as diverse as mental health, diabetes or foetal monitoring. However, each system addresses only one health aspect. The significance and value of AIDMAN is that it can be applied/used for every/any healthcare issue. Indeed, one of the limitations of other systems is that they will not be cost-effective if health service providers have to buy a separate system for different healthcare issues.

    Doing so would not only be more expensive, but it would likely mean a clinic/surgery cluttered with technological devices, each of which would require different training and support. It is difficult to see how, in a healthcare climate where technology is little used, that healthcare professionals would be tempted to invest in such a seemingly bewildering array of technological “kit”, particularly at a time when it is claimed that the health service is regarded as struggling. Although much of this work is carried out with patients and healthcare professionals in the workplace, usually the hospital or clinic, telemedicine is perceived to become even more useful in the future in the care of people in their homes.

    The need for this is not difficult to see. People are living longer, and demand a better quality of life in terms of health throughout their lives. The demands placed on the NHS are therefore great, and it is very costly to keep patients in hospital or in other government-funded institutions such as care homes for the elderly, the mentally impaired or others who require full-time care and assistance. Such care cannot, at present, be provided in their homes, although it is hoped that when or if such technology is installed in homes, telemedicine will allow the healthcare service to deliver the same (or better) quality of care but without the enormous costs involved.

    It is not, however, just a matter of financial cost. Telemedicine offers the possibility of involving us more in our healthcare at an earlier age or stage. This has two advantages. One, being at home or, at least, as near to home as possible, has psychological advantages that positively impact on our mental, and thus physical, health.

    Two, there is the possibility that, as we feel more comfortable with the technology and/or our confidence grows in approaching healthcare professionals or health issues (many people fear both), we might take a more proactive role in our own healthcare and thus either delay the need for intervention or, at best, manage a potential problem away.

    Our experience leads us to conclude that AIDMAN has demonstrated its use and efficacy across a variety of healthcare issues as diverse as dermatology, cardiology and vascular surgery; oncology is soon to join these. It has proved a versatile platform, and as such should prove cost effective when used in this way. The physical and psychological benefits of AIDMAN to both patient and healthcare professional are such that it allows for richer communication between the patient and the specialist/consultant and between doctor/healthcare professional and the specialist/consultant involved in the health and care of their patient.

    As can be seen from this study, the roles of both the doctor/healthcare professional and the specialist/consultant differ from the traditional ones, in particular, the role played by the doctor/healthcare professional in primary care. Here, they act more in the role of “advocate” for the patient during the consultation. Our future research agenda includes looking at how, precisely, the consultation process is changed and, importantly, exploring the impact of this on health outcome. Further research and analysis of tele-consultation sessions so far carried out will reveal to what extent these do, or do not, mirror more “traditional” consultations and whether such a model varies according to clinician, illness or any other factor(s).

    In order to roll out AIDMAN for use in other surgeries/clinics or other healthcare settings, there is a need to find out the technical, social and other issues which might limit its uptake on a national scale. Another is to explore to what extent AIDMAN can be used by healthcare professionals to learn from each other more about disease, treatment and related aspects of management of care, and how this affects the quality of their decision making.

    Given that patients are often reluctant to ask questions of medical professionals, despite the spread of Internet access and growing awareness of health matters more generally, encouraging and supporting dialogue between patients and healthcare professionals, and between healthcare professionals themselves, is to be much welcomed. There is, however, a need to further explore the nature of this communication, and how best this is to be supported by technology.

    Decision making within healthcare may be categorised in two ways. First there is the decision making that goes on within the process of care itself. Typically these would be the decisions clinicians and the patient take as part of the processes of diagnosis, prognosis, patient management, treatment and discharge. Second, there are those decisions that take place within and across healthcare organisations that focus on how to improve the delivery of that care and its management. Clinicians, managers, commissioners and purchasers of care, planners, governments, patients and researchers have an interest in this form of decision making. This study is concerned with the latter, especially the role of information systems, their integrated development and management within that process.

    Any attempt at improving the delivery of care and its management today has of necessity to include enhancing the management, quality, availability and use of information and its associated technologies. Human, clinical and managerial, as well as informational parameters and approaches have therefore to define interventions aimed at expanding the impact of information technology in a health context.

    Of particularly interest are approaches, methodologies, tools and techniques that enable the integrated development of clinical care and its management, with that of information systems and technologies. The discipline of “health informatics” has grown up to research and develop approaches to support practices in this arena. The main aim of this study is to examine three approaches that facilitate integrated development namely: SISTeM a soft systems methodology, stakeholder analysis and participative simulation modelling.

    They are a major component of ongoing practice based research into health informatics being undertaken by the Centre for Health Informatics and Computing (http://www.brunel.ac.uk/research/CHIC/html) at Brunel University. Their potential synergies and further directions for research based on emergent principles for health informatics will be the subjects of the concluding discussion.

    Synergies in integrated development approaches

    The three approaches, SISTeM, PSM and stakeholder analysis, along with their tools and techniques have to date been developed separately but in the future offer synergies that could be exploited to further support the decision making associated with integrated approaches to health informatics research and development. For example the simulation modelling of PSM may be used within SISTeM to create agendas for strategic and operational decision making or to reconfigure clinical processes which result from it.

    Conversely the models within SISTeM, particularly the developmental models of Cycle 2 can be used as a source of entities on which to base PSM simulations. Stakeholder analysis can be used within SISTeM and PSM to identify those clinicians, managers and patients necessary to achieve robust accommodations on decisions that would result in effective decision making and subsequent development of clinical practices and processes.

    Any instance of using SISTeM and PSM offers an opportunity to undertake research into the “descriptive, instrumental and normative” roles identified within stakeholder analysis and that in turn will enhance the decision making within SISTeM and PSM. The three approaches SISTeM, participative simulation modelling and stakeholder analysis form a complementary triumvirate capable of supporting decision making integrated ISD and organisational solutions within the complex multi-organisational situations that constitute healthcare.

    The emergent health informatics research and practice agenda

    Information systems were initially developed and used in commercial and public organisations to automate mundane tasks. This is certainly the case within healthcare in the UK NHS, where information systems have been used for the past 30 years to capture and store basic patient data and post hoc basic coded episode of care activity (Gowing, 2004). These were collected to provide governmental central returns and used in performance assessment, planning and in parliamentary debates. Systems to support appointment bookings were also common.

    Finance budget and audit systems as well as basic payroll and personnel systems have also been used for quite a while. Within other countries, the US for example (Johnson, 2000), similar systems were used to underpin episode of care costing and billing systems. Data for ad hoc management reporting had to be downloaded into an analysis package for any additional analysis. These environments were mainly administrative and supported basic management functions. They had little relevance to the work of the clinical practitioner in caring for the patient.

    More sophisticated information systems were to be found within pharmacies, stock control, or in laboratories or pathology labs. Clinicians often developed their own systems to support clinical audit or within specialised units such as the management of kidney failure. In primary care in the late 2000s and early 2000s there were over 200 GP applications on the market, many supporting only one or two practices. These numbers, as in hospitals and community care, have been dramatically reduced to five or fewer major application suppliers. Few if any of these systems could talk to each other. Organisational integrated IS&T environments were few and far between.

    Communications between healthcare organisations have typically been by primary technologies; letter, fax or phone. Discourses between clinicians within health organisations were and still are predominately either face to face, by phone, or via common access to a patient’s notes. The notes, far from being a simple record, are a complex medium which mediates the workings of the variegate clinicians who convene around a patient over one or a series of episodes of care (Berg, 2003) usually within the boundaries of a single healthcare organisation.

    Its role lies in orchestrating the clinicians’ discourses and actions that make up the processes of care across time and space. Often they contain idiosyncratic and localised languages shared by only a few clinicians. They are often difficult to interpret from outside the organisation, department or even a particular episode of care – despite being relied on within medical litigation cases. Clinical notes are an essential component of the care process. Any electronic solution (even if it is only used in parallel with the clinical notes) has to accommodate to this study environment or lose clinician buy-in.

    Clinical decision support systems have also been an area of specialist development and have featured within healthcare over the past 30 years, often involving academic departments. They have been used, for example, to support educational activities (e.g. Godin et al., 2005), strategy making (Forte, 2004) or interpret the context of decision making within a healthcare system (Hackney et al., 2005). Pharmaceutical companies have used other decision support systems to support drug development.

    Decision support capabilities have been built into drug ordering systems to ensure accuracy of prescribing and avoid polypharmacy contraindications, patient deaths and litigation. Technicians in medical labs have also used them for biochemical analyses of body fluids. The most sophisticated decision support systems use artificial intelligence techniques for medical diagnosis and image analysis (e.g. Lane et al., 2006). Magoulas and Prentza (2005) present a detailed review of research on machine learning in medical applications.

    Examples include the use of electrocardiograms (Bourlas et al., 2006), fibre-optic confocal imaging (Delaney et al., 2005), magnetic resonance images (Hanka et al., 2006), neural network-based image interpretation (Karkanis et al., 2005; 2000) or signal classification (Guo et al., 2004; Karkanis et al., 2005; Yeap et al., 2000). Despite attracting a great deal of academic interest such systems are not in widespread use and have often failed to deliver what was at first promised.

    However, a model (Atkinson, 2003; Atkinson and Peel, 2005) is emerging, certainly within the UK, of the development of a much more sophisticated and integrated health information systems environment, one focused on the patient and the provision of care, from which all other clinical and managerial information will be accrued. The recent NHS Executive (2005) information strategy and the introduction of a, not altogether successful, NHSnet (Anderson, 2005), which links all healthcare organisations across the UK, exemplify this.

    The model is founded on the development of an episode based electronic patient record (Atkinson, 2003) and an individual patient electronic lifetime health record. Both are dependent on supporting the clinicians delivering care to a patient, either within or across, healthcare organisations. Each gives access to a great deal of information on the patient’s past history to support clinical decision making and patient management. In addition data is captured and made available to clinicians over a single or series of episodes of care, similar to those within a set of study notes.

    This electronic environment also enables transaction data to be captured when clinicians electronically order clinical tests, drugs or treatments, which can be based on agreed protocols that avoid for example the misprescribing as described above. Text based communication with other healthcare professionals such as general practitioners (GPs), community nurses or tertiary specialists are also enabled through this environment. At a higher level of sophistication this model provides access to clinical knowledge environments, internally or via the built in databases, or externally via the NHSnet or the WWW.

    These contain clinical decision making protocols and care pathways, drug formularies and interactions, medical research evidence databases on which to base care. Even more sophisticated environments contain electronic care pathways that can capture and monitor progress, prompt clinical actions and flag up variance on which to base clinical decision making. They also, if complied with, enable GPs or community nurses to make direct referrals to consultants and hospital services. Because all this data is electronic in form it can be automatically collated to provide management activity information for financial, resources and services monitoring/development and strategic planning purposes, either on an ad hoc or regular reporting basis.

    The same environment enables the care provided by individuals or teams of clinical practitioners to be audited for the purposes of enhancing care competencies and standards as well as improving the process of care and the pathway on which they are based. This model is currently being realised throughout the NHS, to, of course, a greater or lesser degree of maturity, driven by central government to a fixed timeframe.

    Of course all this is predicated upon the ability to first integrate existing legacy systems with new patient care based applications, which in turn are integrated with sophisticated data storage and access capabilities; an architecture that will, for historical reasons, be difficult to realise in many hospitals. Second, to then communicate, securely and with assured confidentiality across healthcare organisations. Third, for healthcare organisations and government to identify the capital financing and year on year funding to underpin procurement.

    Fourth and most importantly, to deal with the politics and stakeholder sensitivities which surround the realisation of this model. Not only in getting the clinicians and managers to use the new electronic environment, but also to deal with the fact that all this information makes what was once opaque now visible. To do this in an atmosphere that has been traditionally rife with professional demarcations and jealousies within and between the clinical and managerial cultures that exist at both local and national levels is not unachievable, but will not be easy.

    It is worth emphasising that the healthcare context differs from other information systems application domains in that it often concerns sensitive and confidential information and leads to critical decisions on people’s lives (or quality of life). Thus, stakeholder conflicts have more of an impact than in other areas such as business. Interestingly, healthcare is an area with quite intense differences of values, interests, professional backgrounds and priorities amongst key stakeholders. Indeed the new model of an integrated environment is predicated not only on improved information but also on a new government model of health care delivery.

    This is enshrined within the UK in the Government’s Department of Health (2003) White Study The New NHS, Modern Dependable. It involves both structural changes toward a primary care driven health service linking operationally all sectors together. It also involves a far more rigorous attempt at openly monitoring clinical practice; through for example evidence based medicine and the monitoring of individual clinician behaviour based on annual appraisals and clinical governance, both centrally and locally.

    This is an attempt not only to improve care but also to shift the balance of power that currently resides with clinicians over the care process to government and NHS managers, the outcome of which is yet to be settled. The new information systems environment is being driven not only by a technical and informational need but also by a political agenda. The government is seeking to embed its political interests in the new health information model (Bloomfield et al., 2002). The actor network theory (Walsham, 2003) of Callon (2001) and Latour (2003) refers to this as the process of “inscription”.

    The particular and perhaps unique features of the healthcare context the authors wish to argue necessitate research in clinical decision and practice support systems that should not only build upon but also expand the current research agendas. Further issues relating to information systems management, development, implementation and evaluation that characterise the current business information system research agenda are relevant to healthcare but need to be shaped to fit this complex environment.

    For example, they involve issues related to user participation and problem solving, requirements engineering, and failures, as well as change management and organisational and political impact. Given the complexity of the context, health informatics cannot simply focus on technical or information systems aspects alone. It has to take account of their relationship with clinical and managerial processes and practices as well as deal with multiple stakeholders and organisational cultures and accompanying politics.

    The multiplicity of stakeholders, though, as explained later in the study, cannot be treated as purely backdrops to information systems (IS) design and implementation, as merely providers of IS requirements or users (Pouloudi and Whitley, 2003), on the contrary, they must be considered the central focus of any health informatics intervention. Health informatics often engages (Berg, 2003) in changes to clinical and managerial practices and processes only part of which is the introduction of new IS&T.

    Any health informatics development approaches and for that matter research, certainly within the UK, has to take account of a wide range of factors, encompassing: an increasingly sophisticated information systems and technologies environment spanning across organisations, incessant structural changes within and across healthcare organisations, the need to accommodate multiple stakeholders, healthcare’s dependence on the applications supplier industry, the endemic politics of healthcare as well as governmental policy making and legislation, in fact the whole socio-technical spectrum. To this effect a wide range of disciplines are involved both in practice and research that of necessity encompasses both “social” and “scientific/technical” disciplines.

    In response to this emergent agenda the authors of this study through the Brunel University, Centre for Health Informatics and Computing (CHIC) are researching into methodologies, approaches and conceptual frameworks that focus on the integration of IS&T and organisational development within healthcare. This is being carried out through the support of both the grant awarding bodies (Eldabi et al., 2005) and commissioned consultancy from the government (Atkinson, 2005), EU, individual healthcare organisations (Atkinson and Dunlop, 2005) and the private sector.

    In the following sections three emergent approaches and frameworks are explored, namely “the soft information systems and technologies methodology” (Atkinson, 2000), stakeholder analysis (Pouloudi, 2003, 2005) and participative simulation modelling (Eldabi et al., 2005). These approaches take into account the multidisciplinary nature of the research context. They are being actively used to facilitate decision making to address issues within the integrated socio-technical development of information systems with clinical and managerial practices in healthcare.

    An approach capable of facilitating interventions as well as underpinning research within the field of health informatics is the soft information systems and technologies methodology (SISTeM) (Atkinson, 2003, 2000). This approach has been developed through a series of participative multidisciplinary projects within healthcare settings that incorporated and integrated IS and organisational development. SISTeM is a second-generation soft methodology, driven by problem situations in which an explicit need arose to deal with issues and exploit opportunities in which technologies, especially information systems (IS), are paramount.

    It is based upon the underpinning concept of the human/machine activity system (Atkinson, 2003, 2000). This enables technological activity to be represented within the soft modelling tools and techniques on an equal basis to that of the human, as Callon (2001) and Latour (2003) would advocate, and also to integrate them directly with traditional ISD tools and techniques as well as approaches to process reconfiguration and cultural development.

    Berg (2003, p. 89) illustrates this environment when exploring the nature and use of decision support tools within care: “An emergency ward is an assembly of humans and things whose function is to primarily deliver care … the work of doctors and nurses articulates with the functioning of monitors, of order forms and laboratory routines to keep an intensive care patient stabilized, to treat the acute traffic accident victim, or to provide long term care to a chronic diabetic.”

    The soft information systems and technologies methodology cycles

    SISTeM is similar to that of soft systems methodology (Checkland and Scholes, 2000), however it has two cycles. The first follows the traditional soft cycle culminating in a debate and a high level “strategic” decision to act based on robust accommodations amongst multiple stakeholders. The second cycle takes this high level decision and seeks to realize it through operational decision making, based on an overt (often contractual) commitment amongst relevant stakeholders, followed by the real world integration of IS and organisational design, development and realization of anticipated and emergent benefits.

    In both cycles the decision criteria deployed are: systematic desirability, cultural feasibility, value adding, technical feasibility and ethical defensibility. These stem from both SSM and actual practice. The twin cycles form a potentially never ending process of inquiry, decision making and action in the real world, from which comes the possibility for learning.

    Both cycles within SISTeM contain soft tools. Cycle 1 has the traditional, but in this case, human/machine conceptual models derived from relevant systems, based on root definitions and CATWOE analysis. In addition there are expressive models – stakeholders define models of existing or possible activities that they populate with information machine activities – and strategic matrix models. The latter consist of a multi-dimensional human/machine activity matrix covering all or part of an organisation or across organisations.

    On one axis are problematical and/or strategically important organisational competencies, in the form of stakeholder identified, relevant systems and, on the other, a series of stages of IS&T development. Each cell formed by the intersection of two axes incorporates within it IS&T functionality and output, business processes, OD requirements, informational and organisational benefits/risks, and organisational location. The model defines a strategic human/machine maturation pathway for the organisation, including its IS&T.

    Cycle 2 deploys the same tools as Cycle 1 but here their status is “developmental” rather than “strategic” or high level. From the human/activity conceptual and expressive models in Cycle 2, data flow diagrams, entity diagrams, use-cases, as well as process redesign and organisational development can be directly derived (Atkinson, 2000). SISTeM’s models have be used (Warrington NHS Trust, 2003) to define a strategic multistage IS maturation pathways and underpin applications procurement output based specifications (Atkinson and Dunlop, 2005).

    Work is currently underway exploring the factors that have to be incorporated in SISTeM modelling to enable technical architectures to be identified and whole process screen dialogues specified. The importance of stakeholder identification, involvement and analysis within SISTeM is evident from the previous discussion. Linking SISTeM modelling explicitly to stakeholder analysis and exploring its role in supporting healthcare simulation modelling research is an emergent area of research and methodological development within CHIC that will be discussed later in this study.

    Stakeholder analysis

    The presentation of SISTeM in the previous section indicated the importance of recognising the role of multiple stakeholders. Their presence necessitates that health informatics accommodates: multi-professional working practices, multiple political interests and agendas and a multiplicity of information systems and technologies. These are not only important but also necessary features of effective interventions and research. In health informatics, stakeholders are present in many forms: as active participants in the problem solving process itself, as components within the models, tools and techniques, as decision-makers and as a necessary constituent of any resulting interventions.

    Research within CHIC aims to systematically (Pouloudi, 2005b) identify and record the perceptions of relevant stakeholders. Relevant work in strategic management has failed for the most part to provide a systematic method for the identification of stakeholders. This is also the case in information systems research where there is often the assumption that a discussion on users, developers and managers can provide a comprehensive discussion of stakeholder issues. However, the increasing complexity of the information systems context points to different conclusions (Pouloudi and Whitley, 2003).

    In order to provide a systematic tool for the identification of stakeholders a set of principles of stakeholder behaviour that guide stakeholder identification and analysis have been suggested, providing a rich insight in the study of interorganisational systems and new organisational forms as it leads to the identification of non-obvious interested parties (Pouloudi and Whitley, 2003).

    Using stakeholder analysis in healthcare research

    In healthcare, the identification of stakeholders has been particularly interesting in the case of the NHSnet (Pouloudi, 2003; Whitley and Pouloudi, 2001). This is a nation-wide network that has been recently introduced in the UK to enhance communication and information exchange between various healthcare providers and administrators. Despite its technological success, the network’s adoption has been problematic because key stakeholders, namely the medical profession, “have not been convinced” that it meets (or that it will ever meet) the necessary guidelines for safeguarding the confidentiality of patient data.

    Using a stakeholder analysis perspective, however, we have been able to study the various interests, power and access (Introna and Pouloudi, 2005) of the stakeholders to this information system or the information that it carries. The result has been to unveil a much broader and complex picture that can be used by the stakeholders that wish to understand or improve their position as well as by decision makers who can learn from this implementation experience for future action.

    Furthermore, through the interactions of the human stakeholders, the network, a non-human stakeholder – in the sense that it inscribes human interests and values (Walsham, 2003) – has changed shape and direction and has been used by different stakeholders as an opportunity to present and support diverse, even conflicting interests. In Donaldson and Preston’s (2005) terms, this means that stakeholder analysis can be descriptive, i.e. facilitating the description of the various, often conflicting interests and providing a richer understanding of the relevant stakeholders.

    Also, stakeholder analysis is instrumental, in that the stakeholders can use it to achieve a particular goal. In information systems research this usually accounts to either assisting in planning and strategy formulation or assisting with information systems development and implementation (Pouloudi, 2005a).

    Donaldson and Preston (2005) argue, however, that the core of stakeholder theory is normative. This implies that understanding should drive stakeholder analysis and that the interests of all stakeholders are of intrinsic value to any process of IS development. In the context of healthcare, this calls for a stakeholder analysis approach that is not prejudiced and strives to “give voice” to all relevant stakeholders. Indeed, the use of the principles presented above aims to facilitate this process.

    Furthermore, the normative aspect of integrated socio-technical development points out the importance of ethical issues. In the case of the NHSnet such issues stem from a discussion on confidentiality. More generally, the use of information systems can create several dilemmas and ethical challenges that need to be investigated.

    Often, these concern the use of advanced, intelligent technology where the synergy between the technical expert and the medical expert is crucial for identifying ethical concerns and can be facilitated with the use of a stakeholder analysis approach that can be used systematically to this end (Whitley and Pouloudi, 2001). To provide a systematic tool for the identification of stakeholders in this complex context Pouloudi (2003, 2005b) has suggested a set of principles of stakeholder behaviour that guide stakeholder identification and analysis.

    Such normative debates are fundamental for stakeholder analysis. In healthcare particularly, the insights of this debate can be used to strengthen the understanding of the complexities and ethical dilemmas that may arise in the use of SISTeM and simulation modelling. SISTeM considers the ethical defensibility of the socio-technical solutions as critical. However, the experience of using stakeholder analysis in the NHSnet context suggests that what constitutes an ethical choice may not always be agreed amongst all stakeholders. This signifies that the normative aspect of stakeholder analysis can provide useful insights to SISTeM.

    At the same time both the descriptive and instrumental aspects indicate that despite the differences, stakeholder analysis can be integrated with SISTeM. However, stakeholder analysis, does not guide the analyst or the decision-maker towards a model that can then be implemented. This implies that stakeholder analysis could also benefit from integration with SISTeM and simulation modelling. The next section explores the relevance of the latter within the healthcare research agenda.

    One of the main problems that decision-makers in healthcare face, be they clinicians or managers, is the complexity and lack of a well-defined shape for their care delivery process (Delesie, 2005). Patterns of care for patients represent a good example for such complexity within healthcare. In general, patients with similar illnesses may follow certain patterns of care but it is usually the case that data is not available to clearly define these patterns and treatments. This means that decision-makers may not have a sound understanding of the system from which to devise suitable policies.

    Another problem associated with healthcare is that usually, as explored above, there is more than one stakeholder involved in setting up policies and decision making. In such cases different stakeholders are likely to have different views about the problem and expect different outcomes. It is common for problems to arise due to the lack of communication amongst clinical and managerial stakeholders about how to improve the delivery and management of care.

    To achieve viable decisions it is important to understand the complexity of the process. On the other hand, stakeholders should have reliable means of intercommunication. One way to assist in making effective decisions is the employment of simulation modelling techniques. Modelling is needed to enable stakeholders to understand the problem without the need to experiment with the real system itself as it costs money and lives in the case of the healthcare system.

    There are three main mathematical or rationally based modelling techniques applied to healthcare decision making; those are decision trees and Markov modelling (Roberts, 2002; Karnon and Brown, 2005), and simulation modelling (Paul, 2005). These techniques are generally efficient in solving well-defined, well-structured problems. However they have limitations when it comes to understanding the problem itself. One of the main limitations associated with these modelling techniques – especially Markov modelling and decision trees – when applied in healthcare is their static behaviours and their dependency on the availability of a high level of empirical data. Eldabi et al. (2000) give a detailed critical analysis of these techniques.

    Given the ever-changing nature of healthcare systems, having historical data may not always reflect the prospects of the current situation and the impacts any decisions might have on future situations. Simulation modelling has a capacity to cope with some of the problems faced by the other two techniques. Simulation deals with individual entities as well as aggregated entities as opposed to the other two techniques that deal only with aggregate situations. One important feature of simulation is its ability to evaluate entities’ states and track them throughout their life cycle, which is a feature that is not available in the other techniques (Eldabi et al., 2000).

    For these reasons the authors see simulation as a better technique for supporting decision making associated with solving complicated problems as it gives an enriched picture of the current situation as well as possible future states and solution options. Simulation with its current practice, however, is mainly oriented towards solving well-understood problems. The authors wish to propose here that simulation could also be used as an effective means for exploring problems and enabling intercommunication between the stakeholders, participatively.

    The following section presents an exploration of the uses of simulation in healthcare management and decision making undertaken within CHIC. It argues that simulation can be seen as an effective means for problem understanding and intercommunication amongst stakeholders. The subsequent section proposes, with illustrations from current practice, that simulation could be used more effectively to achieve a sound understanding of complex healthcare processes.

    It is worth noting that by simulation in this study we refer to discrete event simulation (DES). Simulation as a modelling technique has been widely used as an aid for decision making in healthcare (Pidd, 2006; Klein et al., 2003). It has been used in diverse healthcare application areas, from predicting the increase or decrease of certain illnesses then making decisions about their corresponding treatments (Davies and Flowers, 2005; Davies and Roderick, 2005), through understanding the appointment systems in outpatients clinics in order to make decisions about scheduling strategies (Paul, 2005), to supporting strategic planning given the limited resources available (Pitt, 2003).

    A growing use of simulation in healthcare is in supporting economic evaluation (Eldabi et al., 2005; Halpern et al., 2004). Where simulation is employed, a common objective is to use the models to provide some answers about the problem in hand. This reflects a tendency to see simulation as a way of deriving future outcomes and determining the effect of different model configurations on system behaviours, thus subsequently enabling decision makers to appraise the implications of their decisions.

    The main purpose of modelling is to present an abstract picture of the real system and examine the system’s responses to different levels of inputs without risking the real system including people and resources (Pidd, 2006). This is conducted given the problem is well understood.

    There are two main reasons for the use of simulation for supporting problem understanding and communication (Eldabi and Paul, 2005). First, simulation provides a systematic debating vehicle between the different stakeholders who will contribute to decision making in the healthcare system. Second, simulation offers the flexibility to accommodate as many changes as possible in the model, either in aggregate or individually, to enhance the understanding of the system.

    For example, a simulation model allows entities to experience events at any point of time after the previous event without being restricted to fixed time intervals. In addition, the model has the ability to record and retain the entity’s history throughout the course of the model, and then this history can be used to influence the entity’s future levels and pathways throughout the model. Other information about entities may be needed individually, such as costs and quality of life effects associated with the events undergone.

    In general, simulation could be used to improve the understanding about the system and capture the relevant elements to the problem, without going into unnecessary details. The model could be used to enable stakeholders understand the system under study and reconsider this understanding while communicating with each other. That is, the model may be considered as a systemic debating vehicle rather than as a calculator.

    In order to be able to use the potentials of simulation to the maximum and for the purpose of achieving a high level of understanding and intercommunication the modelling process should provide some facilities. One important factor is to involve the stakeholders in the modelling process from the early stages. The traditional modelling approaches are based on sequential or logical steps for building and using the model. The main problem faced here is that stakeholders have to wait for the model’s output to gain an understanding.

    The authors believe that understanding should not be restricted to the model’s results rather it should be generated as part of its development through an iterative process. It is possible for an acceptable level of understanding amongst the stakeholders to be reached without necessarily the need to go for large amounts of data collection. Eldabi et al. (2000) and Baldwin et al. (2005) show how the incorporation of stakeholders in an iterative modelling process helps in enhancing their understanding about the problem and intercommunication. An example is given in the next section.

    A brief description of two participative simulation modelling projects is given in this section. Both examples portray the use of simulation for enhancing stakeholders’ understand and intercommunication. These two examples represent the modelling of two healthcare systems. The first one is concerned with the randomised clinical trial of breast cancer treatment and the second example is concerned with the management of a waiting list for liver transplantation. Both examples may have similar objectives, namely economic evaluation; however, the decisions arising from such evaluations are different.

    The first example discusses the building of a simulation package (ABCSim) for health economists with the aim of supporting the economic evaluation of the adjuvant breast cancer (ABC) trial. The trial is a collaborative randomised clinical trial, which is in progress in the UK. The principal aim of this trial was to determine the value of adding chemotherapy and/or ovarian suppression to prolonged adjuvant tamoxifen in order to treat women with early breast cancer (Eldabi et al., 2005).

    The main role of simulation in this project is to model the perceived relationships between the economic factors in the treatment of adjuvant breast cancer with respect to reducing the amount of data collection required. Experimentation with the package would then be used to attempt to identify the important variables for data collection and enable health economists to understand the structure of the trial by examining the different responses to changes of configurations. ABCSim was developed using a simulation package for the structure of the trial and the simulation engine.

    Visual Basic was used to build an interface for the model because the health economists are not experts in simulation. Building an interface in a way that enables them to make sense of the model, helps them to understand the model and play with it.

    The inclusion of stakeholders in the modelling process and the accessibility of the resulting models enhanced their confidence and ownership in the model. This model helped health economists to understand the structure of the trial, i.e. the different patients’ flows, which is mainly administered by clinicians. In this case the model was used as a medium of debate between the health economists and the clinicians to understand the nature of the ABC trial (Baldwin et al., 2005).

    Another example that illustrates the use of simulation for problem understanding in healthcare management and decision making is related to managing liver transplantation. This example discusses the use of simulation in an evaluative study for the technology of liver transplantation from a cost-effectiveness point of view. This study is conducted where there are no set rules for the prioritisation of patients waiting for transplantation.

    Another objective of the simulation model is to enable health economists to understanding the technology of liver transplantation and evaluate alternative policies for prioritising patients in the waiting list. The main objective here revolves around finding an optimum strategy for selecting patients in the waiting list for liver transplantation. Selection could be based on a number of criteria, such as age, waiting time, and level of sickness.

    One of the main difficulties in problems like this is that there is no specific measurement. For example, health economists may look at the cost-effectiveness of the process regardless, while clinicians may consider provision of care to all patients is the most important. This represents an example of how simulation may be used to enhance stakeholder’s intercommunication and convey their understanding.

    The model, LiverSim, was developed in the same way as ABCSim. It was developed participatively using a simulation package to build the structure and the interface. In doing so it enabled the stakeholders to deal with the model in a way that was convenient to them. The interface consists of input facilities and output representations. The interface also included different selection criteria to choose from for stakeholder experimentation to examine which one is optimal. Given the fact that simulation is a dynamic process and presents individual and aggregate levels, all stakeholders involved had the opportunity to present their views about the system through the model in a more realistic setting.

    Simulation modelling is widely used in healthcare development and decision making, however, in this study we propose an alternative approach to the existing modelling approaches that may help in enhancing the stakeholders’ understanding and decision making. Simulation modelling is a tool that enables those involved to argue their case through the model. This is particularly important for clinicians, as it is this group of stakeholders who have to treat patients and who are probably the main users of the information from the modelling work.

    Simulation could allow the clinicians to be alert to the various interrelated factors and to be involved as fully as is possible in the decision making process so that they can subsequently provide a thorough, reasoned response to their patients. They may, or may not, agree with the decision but they can choose to present the factors that complicate the process that led to the decision, which is a valuable feature of using simulation.

    Using simulation also provides a means of ongoing training and development in that discussions or arguments made during the process allow for alternative perspectives on a wide range of diverse issues and care delivery models, many of which extend beyond the decision itself. These might involve personal and local issues such as how to care for and handle feedback to patients, or involve issues of a more general or global nature such as how to ensure that more people donate their organs and how that might best be done.

    Chapter3: Methodology

    Research Design

    A qualitative approach was used and the data were collected in 2004. The method that is going to be select for this study is the qualitative research method. Basically, the quantitative approach pursues facts and is employed when researchers desire to acquire statistical truth. According to Gall, Gall and Borg (2003), quantitative research assumes that the social environment has objective reality that is relatively constant across time and settings, while qualitative research assumes that individuals construct reality in the form of meanings and interpretations, and that these constructions tend to be transitory and situational.

    The dominant methodology in the quantitative approach is to describe and explain features of the objective reality by collecting numerical data on observable behaviors of samples and by subjecting these data to statistical analysis. According to Smith (2003), “neutral, scientific language” (p. 9) must be used in quantitative research in pursuing exact facts. This means that the research itself must be expressed by universally acceptable digits. In this approach, in order to make generalizability, objectivity of the research is emphasized by using neutral scientific language. On the other hand, the qualitative approach aims to discover meanings and interpretations by studying cases intensively in natural settings and by subjecting the resulting data to analytic induction (Gall, Gall, and Borg, 2003).

    It shows that because of the development of technology, change will continue to accelerate (McCalman & Paton 2000). Williams (2000) stresses the paradox that 'to achieve continuity we have to be willing to change'. All organizations deal with change and resistance to change to various degrees (Teare 2002). There is an expectation that information and communication technology (ICT) applications will be commonly used in the future to facilitate the increasing needs of support and care among older people. On the other hand, it is also a fact that the introduction of ICT is resisted by many professional carers (Ministry of Health and Social Welfare 2002).

    Organizational change requires the creation of a new system and the implantation of it, and has to reconsider the basic values, beliefs and attitudes of the people involved (Eisenbach et al. 2005). Various information and communication technology applications have successfully been developed to help solve a variety of problems in elder care. Beside different technical barriers and the assumed negative attitudes among older people, staff values and attitudes have been found to be an important cause of resistance to change and slowness in introduction of information and communication technology in health care of older people. An introduction of ICT in elder care is anticipated to require an organizational change. We found it important to explore carers' values and perceptions as potential participants in organizational change due to an introduction of ICT application in the context of elder care.

    As in this study we want to know about the to identify and address the fences that prevent federal, state, and city law enforcement employees in the America from obtaining accurate and immediate information on criminal sect. So it seems that the structured interview method is more appropriate for this study as compare to other methods. Qualitative studies use constructivist perspectives or advocacy/participatory perspectives, or both, and use narratives, phenomenologies, grounded theory studies, or case studies as strategies of inquiry. In this approach, research facts and researcher's value judgments or interpretations are inseparable. Thus the researcher becomes an insider to the research (Carr and Kemmis, 2006).

    Instruments

    Survey research is the method of gathering data from respondents thought to be representative of some population, using an instrument composed of closed structure or open-ended items (questions). It is one of the most dominant forms of data collection in the social sciences, providing for efficient collection of data over broad populations, amenable to self-administration, administration in person, by telephone, via mail and over the Internet.

    There are many advantages that have been identified in the use of the survey method. According to Babbie (2001), these advantages include:

    One can collect a large amount of data in a fairly short time.

    Surveys are easier and less expensive than other forms of data collection.

    Questionnaires can be used to research almost any aspect of human perceptions regarding the variables under study.

    They can be easily used in field settings.

    The sampling method that has been used was a mix of purposive and snowball sampling. Purposive sampling targets a particular group of people. When the desired population for the study is rare or very difficult to locate and recruit for a study, purposive sampling may be the only option. Snowball sampling is a special non probability method used when the desired sample characteristic is rare. It may be extremely difficult or cost prohibitive to locate respondents in these situations. Snowball sampling relies on referrals from initial subjects to generate additional subjects. While this technique can dramatically lower search costs, it comes at the expense of introducing bias because the technique itself reduces the likelihood that the sample will represent a good cross section from the population.

    Participants

    Ten carers, working either in nursing homes or in home care in Northern Ireland participated in the study: two Registered Nurses, three managers of nursing homes and home care, and five Enrolled Nurses. There were two men and eight women, ranging from 27 to 62 years of age. Their work experience with elder care varied between 3 and

    26 years. The sampling strategy involved a mix of purposive sampling to obtain information-rich cases, with a variation of experiences in length and areas of care of older people, and ‘snowball’ sampling (Patton 2002) among leaders in care of older people institutions, i.e. asking one person to nominate another, who in turn nominates another. This process was continued until 10 participants were identified.

    All had a general experience of using ICT but none had used specifically-designed ICT applications for the care of older people. They had all heard of, and in some cases seen, such ICT applications in use.

    Data collection

    The interviews, conducted in Swedish during the year 2004, were preceded by the showing of a film vignette presenting the most common current applications of ICT for older people. The vignette was used to illustrate possible scenarios and consequences of the use of ICT (Drew 2003). It was about 5 minutes long and took the form of a computer presentation with still pictures and commentary. The presentation contained demonstrations of ‘smart house applications’, i.e. intelligent electronic devices in the home that can prevent accidents, different sensors for mentoring the movement of older people and applications of communication through videoconferencing.

    After presentation of the vignette, interviewees were asked to reflect on the use of ICT applications in their own work situation. The first interview question was, ‘When you consider the vignette, please tell me what your feelings and thoughts are about the different applications’. This question was followed by questions such as: ‘What are your thoughts when you consider this specific ICT application in your own work environment?’ The interviews were tape-recorded and lasted between 45 and 60 minutes.

    Data analysis

    Analysis of the transcribed interviews was conducted in a stepwise manner using qualitative content analysis (Coffey & Atkinson 2006). The data were first read through in order to get an overall understanding of the content. Meaning units (part of a sentence, a sentence, or sentences) about the use of ICT were then identified. The meaning units were subsequently condensed, abstracted, compared and sorted into sub-categories and categories.

    The underlying meaning of the content of the sub-categories and categories was finally interpreted and formulated into a theme (Downe-Wamboldt 2002, Graneheim & Lundman 2004). In order to achieve trustworthiness of the analysis, two of the were compared and discussed each step in the process and the final results were translated into English, reflected on and compared with the original interviews.

    Results

    An overall theme of ICT as promoter of both humane and inhumane care was identified, and this was made up of two categories and five subcategories. These are summarized in Table 1 and presented below.

    Consequences from a caring perspective

    This category relates to healthcare personnel’s reasoning about consequences of the use of ICT applications from a caring perspective. The category entails the sub-categories of ‘superficiality and genuineness’, ‘captivity and freedom’ and ‘unworthiness and dignity’. The sub-categories deal with ICT in relation to values of good and bad care, and with risks and possibilities with ICT for older people.

    Superficiality and genuineness

    Carers raised the issue of superficial and genuine care in the use of ICT. Superficial care was described as being linked to superficial relationships. Carers expressed a general fear that the use of ICT applications would contribute to a caring situation for older people where the closeness and intimacy of face-to-face communication were reduced and replaced by a remote form of communication characterized by superficiality in the personal relationship.

    The interviewees who had worked in home care had experienced the appreciation of the social interaction that carers could provide on home visits. One of the interviewees said:

    I had several older people that I visited whom I could talk to while preparing their lunch and then sit down and have a cup of coffee while they were eating. This didn’t take too much time but was an important occasion for the older person. They could talk and they had somebody to share their meal with.

    Good care for older people was described as being linked to genuine relationships and social interaction. Physical closeness was considered important for interaction with many older people, especially those who had communication problems, for example: Older people with dementia need to have staff members around them in order to prevent chaos and to be able to calm down the situation when they are anxious and restless.

    Even though genuine care was related to physical presence and ‘face-to-face’ communication, carers also described situations where the use of ICT applications could contribute to a genuinely caring relationship with older people living isolated in their homes through the possibility of maintaining a remote dialogue, for example: Isolation and loneliness among older people are the biggest problems we face in our work…it is possible that it could mean a lot for older people to be able to communicate through videophones with somebody that understands their situation and that they otherwise could not talk to.

    Captivity and freedom

    This sub-category describes the duality of captivity and freedom about the use of ICT. There was a fear that the use of ICT could contribute to increased loneliness and to older people being made captive in their own homes. This fear is illustrated by the quote: Human beings are not created to live alone and loneliness is one of the biggest problems for many older people. For some of them the walls of their homes become a prison.

    Interviewees sensed that ICT could become a problem if it was used in such a way that it delayed placement in nursing homes for those older people with a poor sense of personal security. The choice of moving to a nursing home must always be there for those older people who do not have a basic sense of security and are in need of the sense of community that nursing homes can offer.

    Freedom for older people was connected to the possibility of being able to choose independent living in their private homes. Interviewees thought that an increased use of ICT applications would propel development towards more home based care. Some were convinced that being cared for at home was the best thing for older people and, if ICT could facilitate this, it would mean increased freedom for them. This conviction was expressed by one of the interviewees as: I am convinced that staying at home is always the best thing for an older person. It is very difficult for them to adjust to new situations and new people and that will always confuse them.

    Unworthiness and dignity

    This sub-category describes the duality of unworthiness and dignity about the use of ICT. The perception of unworthiness was that there was a thin line between remote control and remote surveillance when assisting older people according to their needs. One aspect that could change the situation was the person who controlled the older person’s movements: It is very important that the person who controls the older person via the electronic device has some kind of connection with them and understands their problems. It cannot be just anybody because then it changes from support of older people to surveillance.

    Another aspect that altered the situation was the older person’s level of dementia. Electronic tagging could mean great freedom and security for older people who most of the time could manage on their own but sometimes became confused and lost direction. An older person with severe dementia who could not understand the function of the electronic device and had no sense of direction would still be confused and have nowhere to turn.

    One of the interviewees said: We have to think through the use of these electronic devices so that we only use them when we believe that it will benefit older people. If you have severe dementia you don’t need an electronic tag, you need a staff member to show you the way. One fear about lack of dignity was connected with intrusion into an older person’s private sphere. It was expressed by one of the interviewees as: Even if we could prevent many fall accidents by close monitoring of the older people we must accept that we should not have full control of their private spheres.

    There were also concerns about carers’ attitudes towards older people as people worth talking to, and making them feel confirmed as human beings in their social interaction with others. One of the interviewees said: We cannot create systems that treat older people like parcels. They have to feel that they have a value as a person and that their value can be confirmed in their social interaction with others. Dignity was associated with the understanding of the use of ICT applications that could facilitate assistance according to older people’s individual needs.

    There was a duality in interviewees’ attitudes towards the possibility of using intelligent ICT systems that utilize sensor technology to monitor an older person with dementia when wandering either in the home surroundings or in the environment of a nursing home. All the interviewees realized and acknowledged that control was already widely used and accepted in the care of older people with dementia.

    However, the use of sophisticated ICT applications could mean an increased level of independency for many older people in comparison with less sophisticated devices for confinement, such as complicated door locks and door alarms. It was realized that the existing devices to some extent interfered with older people’s integrity but also gave them security and saved them from going outdoors and freezing to death in the cold winters of Northern Ireland. The potential of the increased level of independency and reduction in confinement that intelligent sensor technology could bring about was seen as advantageous for older people with dementia.

    Consequences from the perspective of being a carer

    This category relates to healthcare personnel’s reasoning about the consequences of use of ICT applications from the perspective of a carer. The category entails the sub-categories ‘dissociation and involvement’ and ‘threat and aids’. The subcategories relate to good and bad consequences from carers’ perspectives.

    Dissociation and involvement

    This sub-category deals with the duality of being dissociated and involved as a carer. The risks of becoming dissociated when using ICT applications were connected to the risk of carers choosing the easiest solution and choosing remote communication or remote monitoring instead of physically was being with the older people. It was realized that to be close and affectionate with an older person whose needs were not always easy to interpret demanded a highly motivated staff member, and less motivated staff could easily choose remote monitoring instead of personal contact.

    There is a risk that staff members for their own convenience would put an electric tag on older people with dementia and send them outdoors instead of accompanying them, which would have been the best solution. There are always staff members who hide behind practical duties instead of being with the older people.

    The possibility of a carer being involved in the life of an individual older person with the assistance of ICT applications was anticipated in situations where communication otherwise was difficult to maintain. One example was the possibility of remote monitoring of confused and restless older people in order to provide a level of safety and security for both them and healthcare personnel. This aspect was especially important for those working in small teams responsible for many older people, for instance, during night shifts. It was also felt that monitoring was important for many concerned relatives. One of the interviewees said:

    The simple monitoring devices we already use during nights are very important for me in order to cope with my own anxiety that something might happen to an older person who is restless for some reason.

    Threats and aids

    This sub-category deals with the duality of conceiving ICT applications as a threat and an aid. Even if the interviewees could sense that ICT applications could be beneficial and an aid for them in different ways, many of them also felt that it was possible that an introduction of ICT applications might not be in the best interests of professional carers.

    Some of the interviewees associated the introduction of ICT in elder care with a built-in wish of the care-providing system to cut costs and reduce the number of staff. All of them had trouble in accepting that advanced ICT applications should be used to cut down on staff, although they anticipated that it would happen if it was possible. One of the interviewees said:

    We are already too few staff to provide high quality care for the older people and this is not the right area to use this technology on. You can't replace a staff member with an electronic machine.

    The experience was that most carers of older people had little interest in ICT technology and little interest in taking part in developing methods for using ICT in their work setting. This resistance was perceived as being connected with lack of exposure to technology and a fear of not being able to handle the technical devices. One of the interviewees said:

    You can see a clear tendency that staff members below thirty-five years of age have no problems in accepting computers and they are optimistic about the benefits of using them. For those who are older, the simple procedures for logging onto the computers are a major obstacle.

    There was an experience among the interviewees that whether something as new as ICT applications should be conceived as a threat or an aid was often a collective decision made by the group of all those concerned. The security of being in the group could counterbalance the insecure feeling of standing alone and defending the introduction of new ICT applications.

    By some of the interviewees, the group was considered to be generally restrictive and to prioritize security in making decisions. This general attitude was counter to the ideas of staff members who were willing to try new things and make use of a new ICT device that could be beneficial as an aid. One of the interviewees said:

    There are usually protests among the staff when new things are introduced. We cannot entirely base our decisions on that and I have to consider what seems to be the best thing for the older people. The problem is always to interpret what that is.

    ICT as promoter of both humane and inhumane care

    The underlying meaning of the content of the findings was interpreted as the theme: ICT as a promoter of both humane and inhumane care. On the one hand, participants feared that the use of ICT would propel development towards a dehumanized care of older people where the focus was on efficiency and remote control. On the other hand, they deemed ICT-applications to have the potential to promote well-being and to assist an individual older person with some of their needs, e.g. increased freedom, less dependency and increased security.

    There was a paradox in the participants' reasoning since the same attributes of ICT that could promote humane care also were seen as a risk and induced a general fear of dehumanized care. The risk of ICT becoming a promoter for a more inhumane care seemed to make the carers defensive.

    Chapter 4: Analysis and Discussion

    This study shows that the interpretation of values and perceptions among carers revealed a duality where they perceived ICT as a promoter of both humane and inhumane care, a duality that seemed to make the carers defensive and resistant to change. From change management theory it is well known that people resist organizational changes (e.g. Teare 2002). In the 2000s, Rogers (1962) concluded in his studies of the mechanism of diffusion of innovations that many technologists thought that the obvious benefits of new ideas would be widely realized by potential adopters. Unfortunately, this was seldom the case. The resistance to using ICT-applications in elder care was in this study found to be primarily of an ethical nature.

    Possibilities and risks with technology

    The healthcare system continuously deals with change processes related to technology. The mastery of technology can produce health and life and lead to mastery of disease, illness and death (Lindahl 2005). The advances in technology in our society could be seen as part of our willingness to master and take power over the world (Grange 2005). According to Marcel (2005), the influence of technology involves transformation of values, and poses risks for losing one's capacity to reflect. Referring to Heidegger, Grange (2005) contends that technology is both a form of human consciousness and a metaphysics in which human beings can be reduced to the status of objects to use.

    Our study showed that carers considered the same ICT-applications as having potential to promote both a more humane and a more inhumane elder care. In other words, they pointed to the paradox that ICT-applications could be used for doing good or bad. The vision of the good life is the foundation of ethics (Ricoeur 2002) and caring is based on the foundation of doing good (e.g. Sorlie 2001). The risks and possibilities in using ICT-applications in elder care that were disclosed in our study were fundamentally of an ethical nature. The dualities found in the study of superficiality and genuineness, of captivity and freedom, and of unworthiness and dignity, are here further discussed.

    The duality in using ICT

    The carers expressed a fear that genuine relationships and physical presence in personal relationships would be replaced by a communication characterized by superficiality. They were also of the opinion that ICT applications could contribute to a genuinely caring relationship and counteract loneliness, if used in a proper way. Arnolder and Boggs (2005) claimed that healthcare personnel take the primary responsibility for maintaining the boundaries and guiding the caring relationship. The quality of the caring relationship is directly linked to the quality of the communication process.

    Presence in the interaction with older people is characterized as high in inter-subjectivity and as 'being with' them, in contrast to a situation with low inter-subjectivity and only 'being there' (Gilje 2002). If presence is established, there is a possibility of establishing trust that supports genuine communication. When there is genuine communication in a caring relationship, there is an ethical demand to respond to the other's needs (Lo¨ gstrup 2001). A caring relationship maintained via remote communication facilitated by ICT applications should be able to fulfil the same ethical demands as face-to-face communication, i.e. the demands of having genuine communication and response to the needs of older people.

    The duality of captivity and freedom about the use of ICT in elder care is, among other things, connected to values about autonomy and integrity. Older people in need of care in their homes could, in the perceptions of the interviewees, be made captive by ICT-equipment, or by the lack of them.

    Their freedom, autonomy and integrity could be enhanced or undermined. Autonomy means freedom of self determination and freedom from unnecessary constraints and interference (Bjorneby et al. 2004). Scheel (2006) argues, based on philosophers such as Taylor and Merleau-Ponty, that the concept of freedom in caring is a 'situated freedom' since carers often have to choose on behalf of the person cared for. Andersson (2004) describes integrity in caring contexts as respect for the people cared for, and as sensitivity to their dissimilarities and vulnerability.

    The carers in this study considered that the use of ICT could promote care receivers' possibilities to remain at home, and thereby increase their integrity, autonomy and freedom. They also presented the view that vulnerable older people in need of care could be trapped at home by the use of ICT, with decreased integrity, autonomy and freedom.

    The duality of unworthiness and dignity relates to whether the use of ICT applications contributes to a care where the intrinsic value of each frail elder is responded to.

    There was a fear of possible intrusion into the private sphere of the frail elder through remote monitoring and also of a distancing from the elder leading to not viewing them as a person with whom you have a personal relationship and responsibility to. This relates to the findings of So¨ derberg et al. (2003) where nurses viewed dignity, among other things, as situations where they had a personal responsibility towards the patient as a human being. Care without dignity was viewed as situations where they were performing caring actions without reflecting and taking for granted that good would prevail. Care with the assistance of ICT should therefore promote a personal responsibility towards frail elders.

    The fundamental values of caring in relation to the use of technology were discussed by Schoenhofer (2001). She claimed that humane care is where the intrinsic value of each person is responded to and inhumane care is where recognition of the intrinsic values of a person is not conveyed.

    The balance between humane and inhumane care has to do with the principles of intentionality in the use of technology and a knowledge, in a broad sense, of what is the well-being of the older person (Schoenhofer 2001, pp. 4-6).

    Collste (2003) developed a theoretical model for evaluating ICT technology in health care that can be used to handle the dilemma of duality in values. He argued that an analysis of the consequences of a new technology has to be based on a philosophical standpoint, that an introduction of a new technical application is right if, compared with the alternatives, it provides the overall best solution for those concerned.

    Criteria for what is a good solution should be based on satisfaction of the well-being of the individual. Well-being should be interpreted as satisfaction of human needs and satisfaction of an individual's rights, such as the right to integrity, and the right to be treated according to the principle of equality. Translating this theoretical model into the context of this study means that both the well-being of older people and healthcare personnel should be considered when introducing ICT applications in elder care.

    Waerness (2005) supports this view when she claims that it is not possible to organize care for older people based on humanistic values without considering the conditions of both the older people and their healthcare personnel. According to Levinas (2002), responsibility is the starting point for our identity as humans.

    The carers in this study saw it was their obligation to protect the freedom, genuineness and dignity of the vulnerable people cared for. It is of utmost importance to consider that ethical responsibility can be part of the resistance to use ICT applications in elder care.

    Study limitations

    This was a qualitative study to illuminate the values and perceptions among a selected group of professional carers with working experience in the specific context of elder care in Northern Ireland. It is possible that similar studies in other contexts may arrive at different results. The transferability of the findings to other contexts must be judged by the experience of the reader and through further research (Graneheim & Lundman 2004). Interviews were conducted with the assistance of a film vignette that may have excluded some important aspects of using ICT in elder care and overemphasized others.

    However, the use of the vignette has contributed to increasing the interviewees' possibility to enact the use of ICT applications in elder care and, subsequently, the trustworthiness of the study ( Drew 2003).

    Findings

    Our findings suggest that the identified duality should be taken into account in several ways:

    Fears of inhumane care among carers must be recognized and discussed.

    The potential of ICT applications of improving elder care is equally important to discuss and balanced against existing fears.

    There should be an ethical discussion where the introduction of ICT applications are judged on whether they are part of a caring alternative that provides the best alternative for all concerned individuals. The best alternative must promote aspects of well-being and dignity for the frail elder. It should also consider the human needs of concerned carers.

    There should be an ethical discussion when introducing information and communication technology applications in elder care. The best caring alternative for all those concerned should be considered. It should promote aspects of wellbeing and dignity for frail older people and fears of inhumane care among carers must be recognized and discussed.

    Further research is needed to illuminate the many ethical aspects of introducing ICT applications in order to make the best use of it in elder care in the future.

    Chapter 5: Conclusion

    In conclusion we can say that in the past, Ireland has occupied a structurally dependent, peripheral, position within both the ‘old’ international division of labour between industrialised and primary-producing economies, and the ‘new’ international division of labour which emerged in the 1960s and 2000s, whereby routine, low-skill manufacturing activities were diffused to selected peripheral regions.

    More recently, Ireland has been one of the few peripheral regions which, through concerted investment in ICT infrastructure and associated education and training, has managed to adhere itself to the ‘fast’ component of the emerging global informational economy of the late 20th century. This has facilitated the attraction of considerable investment in ICT manufacturing and ICT-using services which has allowed Ireland – and particularly Dublin, where the bulk of this recent investment has been concentrated – to move towards the living standards of the world’s core economies.

    Nevertheless, due to its ongoing economic reliance on inward investment whose continuance is externally determined, Ireland remains a dependent economy, albeit located in what Todd (2005) has termed the “rich periphery” of the fast world, rather than the poor periphery of the slow world. In successfully targetting selected ICT-intensive investment in selected sectors, Dublin has managed to carve out a niche for itself as a transnational city. However, our examination of one of these sectors – call centres – has raised questions about the sustainability of this position, contingent as it is on exogenous economic, technological and political developments.

    Friedmann (2005) has pointed to the dynamism and volatility of the global urban system, with the relative positions of different cities waxing and waning over time. In this context, whether Dublin can maintain or even develop its role as a transnational city will depend on its adaptability to changing circumstances and, in particular, its ability to attract economic functions which are more central to the operations of the transnational firms which have become crucial to Ireland’s continued economic well-being.

    Healthcare organisations and processes are constituted out of an integration of the activities of clinicians (and managers) with information systems applications and other technologies. In supporting the decision making that takes place when addressing problems within the delivery of care, its management and any associated information systems development it is necessary to accommodate multiple stakeholders in any approach or methodology. Multiple stakeholders and their differing and changing interests need to be accommodated descriptively within explorations of the problem situation, in any modelling that takes place and solutions arrived at.

    Stakeholders must be instrumentally taken into account when any solution is decided upon and in resulting designs and interventions. Most importantly stakeholders, with their variegate needs, powers and political agendas must be normatively involved within the problem solving process itself including the modelling. There has to be “robust accommodations” between stakeholders in healthcare on which to normatively base decisions surrounding information systems and organisational integrated development.

    Their ownership of the realisation of any ICT solution is necessary to problems in clinical and managerial practices within healthcare. Any problem situation analysis, decision making, solution and its realisation has therefore to encompass the integration of networks of clinical and/or managerial practices with the functioning of ICT applications. From practice, the decision-making criteria within healthcare and other arenas have been identified as: systematic desirability, cultural feasibility, values adding, technical feasibility and ethical defensibility.

    There are methodology, tools and techniques capable of accommodating decision making and the realisation of integrated solutions in healthcare networks. Typical of these are ICT systems “stakeholder analysis” and “participative simulation modelling” and their synergies. To address the complex problem healthcare situations it will be necessary to incorporate other IS, IT and organisational development disciplines within the decisions made and solutions arrived at. Problem solving within health informatics is potentially a never-ending process in which one solution, in tandem with emergent contingencies, leads to new problem situations that in turn are amenable to integrated approaches and solutions.

    These principles, drawn from practice, are not only capable of underpinning actual instances of integrated decision making within healthcare but also form a framework for continuing research and development. Such an agenda would focus on what initiates problem situations in healthcare that precipitates multi-actor decision making, the appropriateness and impact of resulting solutions, the efficacy of the methodologies, tools and techniques employed and the potency of the philosophies upon which they are based. Experience has shown that future directions in decision making about healthcare information systems and their management can never be achieved in isolation; it is always necessary to affect change in associated clinical and managerial practices as well and that means engaging with multiple stakeholders drawing on integrated approaches to health informatics research and development.

    From an examination of the above explorations of the various approaches in action and their potential synergies the following principles for decision making in integrated IS and healthcare development may be discerned that will inform future research and practice in health informatics.

    Healthcare organisations and processes are constituted out of an integration of the activities of clinicians (and managers) with information systems applications and other technologies. In supporting the decision making that takes place when addressing problems within the delivery of care, its management and any associated information systems development it is necessary to accommodate multiple stakeholders in any approach or methodology. Multiple stakeholders and their differing and changing interests need to be accommodated descriptively within explorations of the problem situation, in any modelling that takes place and solutions arrived at.

    Stakeholders must be instrumentally taken into account when any solution is decided upon and in resulting designs and interventions. Most importantly stakeholders, with their variegate needs, powers and political agendas must be normatively involved within the problem solving process itself including the modelling. There has to be “robust accommodations” between stakeholders in healthcare on which to normatively base decisions surrounding information systems and organisational integrated development.

    Their ownership of the realisation of any IS&T solution is necessary to problems in clinical and managerial practices within healthcare. Any problem situation analysis, decision making, solution and its realisation has therefore to encompass the integration of networks of clinical and/or managerial practices with the functioning of IS&T applications. From practice, the decision-making criteria within healthcare and other arenas have been identified as: systematic desirability, cultural feasibility, values adding, technical feasibility and ethical defensibility.

    There are methodology, tools and techniques capable of accommodating decision making and the realisation of integrated solutions in healthcare networks. Typical of these are SISTeM, “stakeholder analysis” and “participative simulation modelling” and their synergies. To address the complex problem healthcare situations it will be necessary to incorporate other IS, IT and organisational development disciplines within the decisions made and solutions arrived at. Problem solving within health informatics is potentially a never-ending process in which one solution, in tandem with emergent contingencies, leads to new problem situations that in turn are amenable to integrated approaches and solutions.

    These principles, drawn from practice, are not only capable of underpinning actual instances of integrated decision making within healthcare but also form a framework for continuing research and development. Such an agenda would focus on what initiates problem situations in healthcare that precipitates multi-actor decision making, the appropriateness and impact of resulting solutions, the efficacy of the methodologies, tools and techniques employed and the potency of the philosophies upon which they are based.

    Experience has shown that future directions in decision making about healthcare information systems and their management can never be achieved in isolation; it is always necessary to affect change in associated clinical and managerial practices as well and that means engaging with multiple stakeholders drawing on integrated approaches to health informatics research and development.

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    Appendix

    Table 1: Overview of an ICT Healthcare Delivery System