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Strategic alternatives in telecare designDeveloping a value-configuration-based alignment framework

Albert Boonstra ⇑, Manda Broekhuis, Marjolein van Offenbeek, Hans WortmannFaculty of Economics and Business, University of Groningen, The Netherlands

a r t i c l e i n f o

Article history:Available online 2 February 2011

Keywords:Strategic alignmentTelecareValue configurationsDesign

a b s t r a c t

In telecare adoption, the lack of a strategic vision and of consistency in design choices havebeen identified as critical problems. Existing IS alignment literature only offers limitedanswers to these problems and does not acknowledge the different value configurationsthat telecare technology can enable. This paper, therefore, integrates work on strategicvalue configurations with the strategic IS alignment model in order to widen the latter’sapplicability. Based on the value configurations and related service management literature,a framework involving three distinct alignment configurations is developed for telecare. Ananalysis of two Dutch telecare projects shows how the proposed alignment profiles canexplain the contrasting project outcomes more effectively than the traditional strategicalignment model would have done. The discussion reflects on the generalizability and con-tribution of an extended strategic alignment model.

� 2010 Elsevier B.V. All rights reserved.

1. Introduction

Although healthcare systems differ considerably from country to country, ongoing changes in government policies andregulations on the one hand, and in patient populations and demands on the other, seem to share certain aspects. Moreover,a globalising market, increasing demand and advances in medical science mean that healthcare expenditure continues togrow whilst there is a continual pressure for efficient use of resources on the supply side. Therefore, many policymakersin healthcare are looking for both cost reductions and quality-increasing innovations, such as e-health, so as to be able todeliver affordable and accessible care, and are wrestling with their services’ strategic positioning much more than theydid in the past.

The problems faced by these practitioners inform and inspire a scientific debate, of which this special issue and recentcontributions by Porter and Teisberg (2006) and Hwang and Christensen (2008) are typical examples. Hwang and Christen-sen (2008) have argued that information technology can enable strategic choices not only in sustaining, but also in disrup-tive, ways. Coupling advances in information technologies with suitable business models, and appropriately aligninginformation systems with healthcare processes and operations, seem to be important factors in creating well performinghealthcare systems. This paper develops an alignment framework that is specifically for healthcare providers. The frame-work’s applicability is demonstrated by analysing the strategic alignment of two telecare programmes. It is argued that thishealthcare-specific alignment framework can contribute to improved dialogues among stakeholders on how to realize stra-tegic alignment.

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⇑ Corresponding author. Address: Faculty of Economics and Business, P.O. Box 800, 9700 AV Groningen, The Netherlands. Tel.: +31 50 363 7289; fax: +3150 363 7110.

E-mail address: albert.boonstra@rug.nl (A. Boonstra).

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Earlier work has shown that strategic alignment is a prerequisite for the effective positioning of service organizations,such as the providers of healthcare (Johnston and Clark, 2001; Silvestro and Silvestro, 2003). Strategic alignment involvesgiving attention to interacting organisational domains in order to ensure that the strategy matches other important domainsin an integrated way (Henderson and Venkatraman, 1992). In the IS field, Venkatraman’s (1991) strategic alignment model(SAM), which originates from hospital research (Henderson and Thomas, 1992), is the best known approach. Within the SAM,the business strategy domain has largely been conceptualised in terms of Porter’s ‘Value Chain’ framework (e.g. Porter andMillar, 1985; Tallon et al., 2000). In a parallel research stream, Stabell and Fjelstadt (1998) extended Porter’s work by pro-posing two additional value creation configurations: the ‘Value Shop’ and the ‘Value Network’. Stabell and Fjelstadt’s work,however, does not address how these two additional value configurations can be aligned with the IT domains, most notablywith the IS strategy and the IS structure. It is this gap that the present paper aims to fill.

As such, this paper’s theoretical contribution is the integration of Stabell and Fjeldstad’s value configurations with theSAM in order to enhance the latter’s applicability and as a contribution to the theoretical logic underpinning the ‘what’ instrategic alignment. In so doing, we focus on telecare applications in healthcare. Chan and Reich (2007) argue that alignmentresearch that focuses on specific industries has the potential to result in more refined findings, and a deeper understandingof how IT enables value creation.

Having accepted their advice, we chose telecare as our specific field of study for two reasons.First, telecare is a promising e-health technology that delivers healthcare services to clients’ homes. As a virtual opera-

tional organization, it is even capable of providing telecare-based services anytime and anywhere (Hebert and Korabek,2004). Building on Stabell and Fljeldstadt, it has been argued that telecare applications can enable a range of value config-urations for healthcare services, and that these may stimulate revolutionary business models (Hwang and Christensen, 2008;Christensen et al., 2008). Therefore, our aim of extending the traditional SAM to encompass value configurations other thanthe ‘Value Chain’ is relevant to the field of telecare.

Second, while telecare has inspired strategists to theorise about disruptive business models, the technology’s adoption inroutine clinical practice has repeatedly proven to be difficult (see reviews by Berg, 1999; Broens et al., 2007). Ironically, thecritical factor seems to be the lack of a strategic vision (Porter and Teisberg, 2006; Broens et al., 2007), or of its translationinto a consistent service design (Silvestro and Silvestro, 2003) involving both organizational and technological design choices(Wortmann et al., 2009). A more comprehensive strategic IS alignment model would offer a framework that could explainthe design choices involved and the required fit between them. Such a framework could support both healthcare providersand researchers interested in studying the alignment challenges in telecare design.

Within the telecare literature itself, there has been little work on the formal modelling of telecare (Adriano-Moran et al.,2005). Collinge and Liu (2009) constructed a telecare information architecture that describes the system componentsneeded, and details their requirements. However, they do not touch on the need for strategic alignment between these com-ponents, nor do they consider the possible tensions between requirements. Gortiz (2007) does stress the importance of(re-)designing the interactions between organisational domains on an operational level. His work, however, does not containthe strategic focus required to clarify telecare’s potential contributions.

To summarize, this paper contributes by developing a framework for aligning choices in telecare technology with thestrategies of healthcare providers. The field-specific character of the framework stimulates explicit analysis of the fit be-tween business and IT domains. More generally, this framework shows how placing alternative value configurations withina strategic alignment model enables the SAM to be applied to existing business models in service industries, in this instancehealthcare.

In developing this framework, we build on work that has, so far, been carried out in distinct research streams (as will beexplained in Section 2). In Section 3, we present the extended and adapted framework in which we outline three strategicalternatives for telecare. The paper’s empirical part uses this framework to analyse two projects from a well-known Dutchtelecare programme. These projects are described in Section 4, which also explains the method used in the investigation. Ourin-depth data collected on these projects facilitate an evaluation of the consistency among the interrelated strategic designchoices involved and of the projects’ outcomes. In Section 5, we start by mapping each of the two projects, one successful andthe other considerably less so, to evaluate their alignment. In Section 6, based on a cross-case analysis, we subsequently dis-cuss how the degrees of alignment realized in the different profiles may explain the telecare projects’ respective perfor-mances. The concluding Section 7 evaluates the extent to which our study supports the enhanced SAM framework. Basedon this, the need for further development and the use of detailed alignment profiles in healthcare and other service sectorsare articulated.

2. Backgrounds

2.1. Telecare – the concept and its promises

Telehealth – or, more specifically, telecare and telemedicine – services are increasingly being established as ways to speedup processes, to reduce costs, to improve accessibility to high quality care, to empower patients and to bridge the gaps be-tween mutual providers and between providers and patients. Telehealth covers a broad spectrum of services such as tele-consultation, second opinions, telecare and teletraining, and builds on various technologies such as videoconferencing

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and remote monitoring. Here, we focus on the use of telecare in the sense of ‘‘a combination of equipment, monitoring andresponse that can help individuals to remain independent at home’’ (Department of Health, 2005, p. 8).

Telecare is often portrayed as one of the most promising IT applications in terms of costs and quality (Rojas and Gagnon,2008; Britton et al., 2000). Despite these high expectations, the diffusion of telecare remains limited, mainly due to the hugeimplications in developing and implementing such a service innovation. The introduction of telecare – as with other simi-larly radical service innovations – seems to have a more disruptive impact on the organization than is often anticipated (Bro-ens et al., 2007; Christensen et al., 2008). Two forms of disruption have been distinguished: (1) new forms of care that werepreviously not covered by healthcare providers, and (2) substitution of traditional care by cheaper, more accessible or other-wise more convenient forms of care. Reviews of telecare projects show the impact of these innovations to include the stra-tegic repositioning of the organization in its environment, the emergence of new distributed temporal and spatial workingarrangements that affect internal relationships and a power to extend collaboration with other healthcare organizations(Broens et al., 2007; Collinge and Liu, 2009; Nicolini, 2007). As such, telecare diffusion seems to require, as with many serviceinnovations, a clear view of the strategic position of the organization, and of its service offerings (Terrill, 1992). One route tounderstanding and guiding this strategic repositioning is to analyse changes in value creation and the logic involved.

2.2. Value configurations – conceptualizing strategic alternatives for telecare

As healthcare providers increasingly face some competition, and calls to account for rising costs and to offer transparencyin service quality, they have a strategic interest in explaining, and also reconsidering, the ways in which they create value.Value creation is traditionally conceptualised using the value chain concept (Porter, 1985).

The value chain contains the various activities that a firm performs to deliver low-cost or differentiated products. Theactivities in the value chain framework (Porter, 1985) include inbound logistics, operations, outbound logistics, marketingand sales, and services. The value creation logic of a value chain is the transformation of inputs into products or services.The main inter-activity relationship is a sequential one. Although standardized care paths have been developed for routineinterventions, such as hip replacements, value creation does not, in most healthcare services, seem to take the form of aplanned chain of events. This led us to consider the more recent work of Stabell and Fjeldstad (1998) who propose two addi-tional value configurations, namely the value shop and the value network.

In the value shop configuration, a firm concentrates on discovering what the client wants, works out a way to deliver va-lue, determines whether the customer’s needs are then fulfilled and repeats the process if necessary. The main activities areproblem finding and acquisition, problem solving, choice, execution, control and evaluation. The interaction between pro-vider and client is cyclical. This value creation logic revolves around solving the client’s problem. This configuration canbe easily recognized in healthcare services such as general practitioner consults or a multidisciplinary clinic offering diag-nostic services to the elderly.

In the value network, value is created by linking clients who wish to remain independent. The firm itself is not the net-work, but provides a network service (Stabell and Fjeldstad, 1998). In this configuration, the firm is an intermediary that fo-cuses on network promotion, contract management, service provisioning and infrastructure operations. The logic of valuecreation is linking clients, and the main inter-activity relationship is a mediating one. Although less prominent, this valuecreation logic is present in the increasing use of gate-keeping, case management plus transfer and liaison roles in healthcare.Such roles are typically supported, if not enabled, by IS applications.

Given the strategic role of information and communication technologies in healthcare, it is not surprising that Stabell andFjeldstad’s work has been picked up in the health IS field. Hwang and Christensen (2008) and Christensen et al. (2008) showthat the above three value configurations can be used to envisage alternative e-health strategies. For the specific context of e-health, Christensen et al. (2008) proposed the terms Value-adding Process Chain, Solution Shop and Self-Help Network, whichare conceptually similar to the terms value chain, value shop and value network. Although these authors recognize the rele-vance of the additional value configurations for e-health – as Laffey and Gandy (2009) have for e-commerce, they do notexplicitly address the alignment issues, nor do they provide an alignment framework.

2.3. Strategic alignment – towards a coherent design

Nevertheless, the importance of strategic alignment is widely recognized in the broader IS literature, and based on theview that it is only when IT is effectively aligned with corporate strategies, processes and practices will IT enable companiesto achieve their performance goals (Brynjolfsson and Hitt, 2000; Chan and Huff, 1993; Croteau and Bergeron, 2001; Croteauand Raymond, 2004; Levy et al., 2001). Such an alignment ensures that managers allocate IS resources to strategically impor-tant applications and that other dimensions of the organization are changed in ways that are consistent with the businessstrategy and the IS strategy. Whilst alignment seems to promote performance (e.g. Sabherwal et al., 2001; or specifically forhospitals: Bart and Tabone, 1998), few organizations are able to achieve and sustain it (Grant, 2003; McKeen et al., 2003,p. 93). According to Chan and Reich (2007), this reflects the fact that many business managers and IT managers lack theknowledge and awareness needed to define business strategy, IS strategy and business structures in coherent ways: ‘‘IT exec-utives are not always privy to corporate strategy, and organizational leaders are not always knowledgeable to IT’’ (p. 299).

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2.4. Strategic alignment – a tough agenda for healthcare alignment

This seems to be particularly the case in healthcare, our chosen field of study, where managers, healthcare professionalsand IT executives follow different rationalities, have different domain knowledge and use different terminologies (Glaser,2002; Heeks, 2006). In addition, healthcare executives often experience difficulties in achieving alignment by relatingnew technologies, such as telecare, shared medical records and e-cure, with their business strategies and structures. Accord-ingly, they fail to achieve alignment (Broens et al., 2007; Silvestro and Silvestro, 2003) and this may well account for the dis-appointing outcomes of many telecare projects to date.

However, it is not only practitioners that lack an integrated knowledge base. Chan and Reich (2007, p. 310) arguethat current alignment research itself largely lacks a theoretical basis. Therefore, they call for research that reopens the‘what’ question of alignment, and for a greater use of well-established theories in alignment research. They anticipatethat this could lead to both minor and major adjustments to alignment models. Thus, while disappointing telecare pro-ject outcomes have recently acted as drivers in the development of design requirements for telecare, the theoreticalbasis for these requirements is often insufficient or unbalanced. In response, Gortzis (2007) and Collinge and Liu(2009) have developed multi-component models that should provide support to those designing and reviewing telecaresystems. These authors argue strongly for the need to match human, technological and structural components whenadopting telecare. Further, telecare often requires the development and redesign of other design elements in the ser-vice system (Gortzis, 2007) since each structural and managerial element contributes to the strategic mission(Fitzsimmons and Fitzsimmons, 2008).

Although the above-mentioned contributions provide useful guidelines when developing telecare for healthcare pur-poses, they lack a comprehensive view on how telecare technology can contribute to achieving strategic goals in healthcaresettings. Consequently, it is also unclear how telecare affects, or requires the redesign of, other service elements in healthcareproviders’ portfolios.

2.5. Strategic alignment – integrating theory within a field-specific model

If managers are to develop strategic alignment profiles, they need to be able to anchor their choices to a validated frame-work. Henderson and Venkatraman (1992) provide such an option through their research-based strategic IS alignment mod-el (SAM). Their model has been applied, validated and extended by Avison et al. (2004), Sabherwal et al. (2001) and others.The SAM is based on four interrelated key domains of strategic choice: business strategy; business structure; IS strategy; andIS structure (see Fig. 1).

The model distinguishes the business domain (on the left), the technology domain (on the right), an external perspec-tive (at the top) and an internal perspective (at the bottom). Alignment between business strategy and IS strategy is re-ferred to as ‘strategic alignment’, between business strategy and business structure as ‘business alignment’, betweenbusiness structure and IS structure as ‘structural alignment’ and between IS strategy and IS structure as ‘IS alignment’(Sabherwal et al., 2001).

Specifying the interrelationships between these domains requires a sound theoretical basis, and such theory may needto be field-specific. While traditional SAM applications draw exclusively on Porter’s value chain in operationalizing thebusiness strategy domain, alternative configurations can be conceived for the positioning of telecare. Moreover, Rivardet al. (2006) recently added a resource-based view to the SAM, one that may appeal to healthcare managers who experi-ence strong resource dependencies in their strategic positioning. It is on this basis that we want to contribute further tothe literature.

Applying a detailed strategic alignment framework is expected to increase telecare’s contribution to performance in arange of strategic configurations of healthcare settings. For each alignment profile, we will describe distinctly different de-sign choices.

External perspective

Internal perspective

Business domain Technology domain

Businessstrategy

IS Structure

IS Strategy

Businessstructure

Business fit

Strategic integration

Structural integration

IS fit

Fig. 1. Strategic alignment model (Henderson and Venkatraman, 1992; Henderson and Thomas, 1992), adapted.

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3. Three strategic alternatives and their corresponding alignment profiles

This section describes how telecare can support the three value configurations presented earlier, and then outlines pos-sible telecare alignment profiles. As such, this section contributes to the ‘what’ question in the alignment literature by out-lining profiles that also incorporate the IS domains; something that is lacking in Stabell and Fjellstadt’s work. The profiles aresummarized in Table 1. We focus our discussion not only on those dimensions that belong to the traditional SAM description(Henderson and Venkatraman, 1992), but also on dimensions adapted from the resource-based view of the SAM (Rivardet al., 2006).

3.1. Business strategy

The business strategy domain is broken down into three dimensions: Scope, Distinctive Competencies and Governance(Henderson and Venkatraman, 1992). With regard to scope, the Value-adding Process Chain is restricted to those servicesthat provide the organization with a distinctive market position. The scope of the Solution Shop is focused on generatingsolutions to complex issues. With a Self-Help Network, the value offered is an empowering service, and one that is usuallysuperimposed on other services. The scope can vary from a single network focusing on, for example, pregnancy, to a networkthat relies on, and offer connections to, other networks to deliver its unique value. Stabell and Fjeldstad (1998) characterizethe latter as ‘‘layered and interconnected networks’’. As shown in Table 1, we draw on Rivard et al. (2006) in adding twodimensions that characterize telecare’s enabling role in the business domain for each of these value configurations: IT sup-port for strategy and IT support for structure (for the latter, see below under Business Structure). IT support for strategy reflects

Table 1Framework of three telecare alignment configurations.

Domain Dimension Value configuration

Value-adding Process Chain Value-adding Process Chain Self-Help Networke.g. Herniorrhaphy, Angioplasty e.g. General Practitioners,

Classical HospitalChronic care, e.g. weight watchers,alcoholics anonymous

Businessstrategy

Scope Niche – (service) product differentiation Niche – marketdifferentiation focus

Narrow (on top of wide network)

Broad – referring shopDistinctiveCompetences

(Service) product leadership Client and solutionorientation

Building and serving a community

Governance Externally: interlinked chains Externally: Referred shops Layered and interconnectednetworks

Internally: tightly coupled Internally: Loosely coupledIT support forstrategy

Cost leadership by substitution Personalized and highquality problem-solving

Innovative complementary serviceseventually leading to substitutionelsewhere

Businessstructure

IT support forstructure

Smooth remote process execution Broad connectivity inmedical realm

Support for social networks andcommunities of interest

Service deliveryinterdependencies

Pooled and sequential, standardized Pooled, sequential,customized and reciprocal

Pooled and reciprocal

Operationalprocesses

Predefined (sequential) Tailored (cyclical, spiralling) Ad hoc (simultaneous, parallel)

Skills (front office) Communicative Sensitive Creative, stimulatingSkills (back office) Professionally specialized Professionally broad Medical moderation of communityCustomer role andadded value

Process orientation Client orientation Infrastructural service orientation

IS strategy IT Scope Narrow – dedicated to particulartreatment

Broader, but shallow Broad collaborative technologies

Generic and standardadvanced technologies

Knowledge technology

IT Competences Cost performance Reliability/usability Connectivity capabilitiesIT Governance Support of interlinked chains Support through linking to a

network of referral partnershops

Support of layered andinterconnected networks

IS structure IT Applicationsinfrastructure

Workflow management; monitoringequipment

Generic collaborativefacilities; EPF; medicalapplications

Social network systems; socialmedia; CRM

IT Processes Immediate installation and support ofnarrow communication and monitoringequipment

Installation and support ofbroad communicationplatform

All processes required to run an ITplatform for consumers

IT Skills Understanding and support of thebusiness process

Responsiveness andflexibility

Managing a large IT operation

IT in serviceencounter

Technology mediated Technology facilitated Technology generated

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the competitive advantage gained through a technology-enabled business strategy expressed in terms of, for example, ser-vice differentiation, customization or production volume.

3.2. Business structure

The term IT support for structure refers to those assets of a firm that have a direct effect on its profitability through telecaresupport. Furthermore, we adapt the SAM’s three business structure dimensions to better suit a service context. In this, wepropose a dimension service delivery interdependencies that refers to the interdependencies between front-office activitiesand back-office activities (Larsson and Bowen, 1989). Consequently, the Skills dimension is then split between front-officeskills (activities with client interfaces) and back-office skills (activities with no client interface). Finally, the customer roleand added value dimension describes the generic orientation of the business structure: process, client or infrastructure.

3.3. IS strategy

Central to the framework is the IS strategy domain, with its dimensions of IT Scope, IT Competences and IT Governance(Henderson and Venkatraman, 1992), since this describes the added value of telecare. Telecare in a Value-adding ProcessChain would be expected to contribute to streamlining operations for patients and to excel in internal cost control. In a Solu-tion Shop, telecare should offer clients intimacy and comfort, as well as information richness, such as by supporting a referralfunction to specialists. Such wide access to external expertise, as well as intensive contact between provider and client, re-quires generic, easy-to-use communication technology. In a Self-Help Network, the IT strategy should focus on connectivitybut be well-balanced with privacy issues (to varying degrees of sophistication).

3.4. IS structure

The main characteristics of the IS structure in a Value-adding Process Chain are the need for specialized workflow appli-cations and facilities that support the remote execution of routine business activities. In contrast, a Solution Shop needs gen-eric collaboration and multimedia facilities that support rich problem diagnosis and solution finding plus monitoringprocesses. Further, distributed access to full medical records and to a variety of medical applications and guidelines are nec-essary to support the healthcare providers’ non-routine investigations and interventions. For Self-Help Networks, social net-work systems are required for the clients, while CRM-type applications are needed for the supplier.

We have added IT in the service encounter to the dimensions proposed by Henderson and Venkatraman (1992) because, inservice organizations, IT often has a profound effect on the ways in which customers interact with service providers (Froehleand Roth, 2004). In the Value-adding Process Chain, the customer and the provider are often not physically co-located andthe technology mediates the contact. In the Solution Shop, customer and provider technology facilitates contact, with bothparties having access to the same technology; whereas, in a Self-Help Network, the provider is replaced by the technologywhich allows customers to serve themselves.

3.5. Four means for achieving alignment

Having positioned the four SAM elements in each of the three strategic telecare alternatives, we are now in a position todescribe the four aspects of alignment (see Fig. 1). Business alignment refers to the alignment between business strategy andbusiness structure. Here, we refer to Stabell and Fjeldstad (1998) whose arguments and underlying studies underpin thisparticular alignment. Strategic alignment refers to what the IT organization, the IT competences and governance can contrib-ute to the business strategy. In developing telecare services, the alignment of IS strategy and IS structure (i.e. IS alignment)should be focused on the service encounter (Froehle and Roth, 2004). Telecare’s role and function – as formulated in the ITstrategy – should be supported by the appropriate IS infrastructure, processes and skills. Finally, structural alignment re-quires a match between business and IT processes and skills and the administrative infrastructure. This leads to the follow-ing requirements for process alignment:

� Value-adding Process Chains require workflow applications to be seamlessly coupled with timely and smooth installationof standardized home equipment;� Solution Shop processes require a swift, but more importantly flexible, roll-out of communication equipment and tools

adaptable to any handicaps that a client may have;� Self-Help Network processes require advanced IS structures that are highly reactive to any server problems.

4. Method

4.1. Two telecare projects

We adopted an explanatory multiple case study design (Ragin, 1999) consisting of two contrasting projects to provideempirical evidence for the existence of different alignment profiles, and to demonstrate how the extended strategic

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alignment framework can better explain project outcomes than the traditional SAM (Dubé and Paré, 2003). As such, we usedreplication logic to verify whether the expected contrasting results occurred across cases (Eisenhardt and Graebner, 2007;Yin, 2003). A qualitative design allows one to describe projects within their context. As our central premise was that an align-ment among several dimensions within four domains was required, the boundaries between the phenomena and the contextare relatively unclear. The major drawback of our research design is that only preliminary evidence can be provided, and thatfurther development of the theory – looking at negative cases – will be necessary. The selection of particular projects herewas based on a combination of: (1) relevance (both projects encouraged senior management to reconsider the role of IS andthe wider strategy), (2) cross-case diversity (apparently contrasting strategic configurations) and (3) accessibility (to the ma-jor stakeholders in the project).

Studying strategic alignment requires data to be gathered on all the elements involved in terms of the characteristicsneeding to be aligned. We derived such data from two implementation projects within an extensive telecare programmein the Netherlands referred to as ‘Koala’. The focus of the study was on identifying their respective strategic configurations,any correspondence with the alignment profiles and the resulting outcomes. The telecare system included, in one project, avideo connection and a camera at each client’s home and, for some, measurement equipment and, for the other project, a 24/7 medical service centre that handled video calls and processed patient data. Table 2 shows the range of services offered andthe respective client groups.

4.2. Sources and data gathering methods

Data collection took place over 18 months (October 2006–March 2008). To promote reliability, the procedures followedduring data collection were documented according to a protocol, and a project database was used to store raw materials,coded data, preliminary reports and other analytical material (Dubé and Paré, 2003). To ensure internal validity (Jick,1979), several data sources were used, including interviews, workshops, written reports, operations data, policy plans, min-utes from meetings and observations. The data for determining the actual degree of alignment were mainly derived from 28semi-structured interviews with representatives of the major stakeholders. On the strategic level, homecare managers (2)insurance managers (2), a telecom manager (1) and a senior telecom technician (1) were interviewed at least once. Onthe operational level, we interviewed care coordinators (6), carers (4), telenurses (3) and medical service centre managers(3). Two rounds of telephone interviews were conducted with 30 Care clients, and 214 Cure clients completed a question-naire (77% response rate). The semi-structured interviews consisted of open-ended questions about the telecare system, itscontext, its purposes and its design. In a later stage, interviewees were also invited to reflect on their experiences with thetelecare system. Either interview reports were sent back to the interviewees for comments, or the interviews were taped andthen transcribed. The operations data helped us to describe the designed systems in use, and covered the number of connec-tions per week, the time-of-day, the nature and the length of the calls. Further, the medical service centre was regularly ob-served to capture the care services offered and the system in use. Twice during the data-gathering process, preliminarysyntheses of the data were presented to, and discussed with, the strategic actors in workshops to ensure that the envisagedbusiness and IS strategies were well understood by the research team. This resulted in us gaining additional insights into theviews of strategic actors and led to refined, and more comprehensive, narratives of the two projects within the telecareprogramme.

4.3. Data reduction and analysis methods

With each project, we examined the value configuration and the alignment profile through rigorous analysis of the mate-rials collected in the data collection phase. The data analysis process followed is described below.

4.3.1. Data reductionAll primary data sources were carefully read and checked against the complementary data sources, including the views of

the strategic actors within both projects. The relevant data elements from each source were identified, coded and thencompared by at least two of the authors. All the authors together carefully interpreted and assessed the coded data elements

Table 2Virtual services offered to client groups.

Project Services offered Targeted clients Telecare components Number ofconnections

Koala Care Ad hoc advice, support, referrals, dailymonitoring (including medication)

Homecare clients Video channel; telephone 335

Koala Cure Registration, monitoring and control Chronic heart failure(post-clinical orstable)

Video channel; clinical data measurement andtransfer equipment; Automatic alert;telephone

146

Registration, monitoring and control Diabetes mellitustype II

Video channel; clinical data measurement andtransfer equipment; automatic alert;telephone

20

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– by project, by domain and by value configuration – according to the framework (Table 1). Discrepancies were discusseduntil agreement was reached. This procedure enabled the inclusion of different perspectives on each case, and minimizedthe chances of missing something important.

4.3.2. Data analysisBased on this process, the extent of alignment was individually assessed by each author, leading to provisional alignment

profiles. Then, these four assessments and provisional alignment profiles were compared. Differences in interpretations werediscussed, which led to some revisions of initial judgements, until a consensus was reached. Within each case, once the ex-tent of the alignment had been determined, this was then considered in the light of the three alignment profiles (see Table 1).Following this, the underlying reasons for the resulting project outcomes were discussed. Finally, the degree of alignmentwas related to each project’s performance.

4.3.3. Cross-case analysisWe compared the value configurations of the two cases, and the alignment profiles. While the two telecare projects were

to an extent similar in terms of context and technology, they differed in terms of crucial dimensions of the proposed frame-work. Moreover, we reflected on the differences in the extent to which their characteristics had been mapped within a singleprofile. Was this difference in alignment between the two cases reflected in the discussions we had witnessed among thestrategic actors? Did the revealed patterns cover the concerns raised during the project evaluation? That is, alongside ana-lysing whether the degree of alignment was in line with the project outcomes (predictive validity), we also estimated theface validity.

5. Results

This section presents the analysis of the two telecare projects adopting the perspective of the framework outlined in Table1. In this section, the two cases are outlined separately, and the cross-case analysis of the four ‘alignment fits’ follows in Sec-tion 6. Relating these findings to the performance achieved in the two projects, highlights strategic and design factors thatare relevant when implementing telecare.

5.1. Telecare in a homecare setting: Koala Care

The homecare organization that we assessed was pursuing multiple objectives when applying telecare within their ser-vice delivery system: the main objectives were an increase in customer service levels and a reduction in costs. From projectdocuments and interviews with various stakeholders, we could discern that clients were supposed to use the telecare home-video system to contact telenurses located at a medical service centre. These contacts would, wherever possible, replacehome visits by district nurses. Furthermore, clients would be better served because direct access to registered nurses wasguaranteed around the clock. At a later stage, the telecare system was expected to also be able to support contacts and con-nections between other client system members, more specifically between clients and their families, friends and volunteers.Table 3 summarizes our evaluation of the alignment of telecare in this homecare setting.

An in-depth analysis showed that the business strategy of the homecare organization, with respect to the use of telecare,was unclear, although the relevance of choosing a particular business strategy and of elaborating this strategy in a consistentway was recognized. An insurance company manager stated: ‘‘these variables are all related – at least on paper. The issue is howmany different strategies one can outline: I think at most two or three. All options can be reduced to two or three main strategies.You should choose a dominant strategic position and then elaborate all the variables in a consistent way’’.

During the entire project, the Koala Care organization was exploring how they could best use telecare. The telecare-enabledgoals were not clearly determined. On the one hand – and this was regarded as its main purpose – Koala Care was designed toprovide comprehensive, personalized and customized care, which reflects a Solution Shop business strategy. On the other hand,Koala Care was aimed at finding ways in which telecare could cut the number of physical service encounters in order to reducecosts. This suggested the development of standardized ways to deliver remote homecare, which more closely reflects featuresof the Value-adding Process Chain configuration. Further, elements of a value network configuration can be recognized, with theorganization anticipating connecting clients to their social environment (relatives and friends) in order to increase clientempowerment and to support self-help. This view was supported by an insurance manager with a medical background,who stated: ‘‘Okay, which role do we play here: a supportive role or a managerial role? This also depends on the nature of the deliveryprocess. Is this process aiming at providing information? Is it consultation? Is it a medical cure such as therapy? Are we in the role of abroker?’’ In such ways, traces of various value configurations could be found in the Koala Care data (Table 3).

In reality, the delivery of customized remote solutions turned out to be difficult. Interviewees pointed to the variety andambiguity in the demands, as well as the ‘hands-on’ character of much homecare work, with activities such as cleaningwounds and applying dressings: ‘‘homecare is very diffuse and much work has a hands-on character. This makes it hard touse telecare within our setting’’ (project manager homecare).

Furthermore, the misalignment between the business domains was visible in Koala Care’s multichannel design. That is,telecare was offered alongside face-to-face and phone contacts with district nurses but without the design being based on a

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clear multichannel policy. This caused confusion and led to coordination problems. An external consultant said: ‘‘The currentorganisation of the care system is a problem. There are several call centres: the national emergency line, the GP emergency line, thehospital call centres and, on top of all that, we introduced the Koala MSC. A related problem is that the roles of various actors arenot well defined. These issues have caused much delay to the project’’.

Consequently, the scope of Koala Care in terms of services offered was unclear. Further, no clear care chain could be de-fined. Log data and evaluations of calls by telenurses and by clients show that the circumstances in which clients should con-tact the medical service centre were largely undefined. Most calls were unforeseen and unplanned, although the percentageof planned calls increased during the project. This increase could, however, be attributed to just a few clients. The search forwhat exactly to deliver to clients reflects two choices within the business strategy domain: (1) which role should clients take,and what should clients experience as added value? (or, stated differently, what is the exact nature of the telecare offering?);and (2) what IT support for strategy should be applied in terms of the degree of product customization, production volumeand degree of service differentiation? These two dimensions reflect relevant strategic decisions when implementing telecare.For this reason, we extended the business strategy domain accordingly (see Table 3).

The multiple scopes of the business strategy were also reflected in the business structure. Characteristics of the value shopbusiness structure could be traced, as well as features of the other two value configurations. For the skills dimension, we foundthat broadly educated and highly competent nurses were employed at the medical service centre. A manager from the homecareorganization explained: ‘‘A telenurse should have special skills and competencies to make Koala successful’’. These telenurses wereselected based on their experiences in nursing care, their ability to analyse questions from clients, their sensitivity in respondingto vague problems and their ability to deal with a large variety in demand. They would try to find solutions in close consultationwith their clients (a reciprocal service design) or refer to a wide range of specialized healthcare providers (a sequential custom-ized service, with a professional and broad back office). Moreover, as the homecare project manager explained, employees withdifferent skills were deliberately selected and trained. For example, the telenurses had held various former jobs such as a districtnurse, psychiatric nurse or medical nurse. This dimension corresponds with a Solution Shop configuration.

Table 3Koala Care mapped on the framework of telecare alignment configurations.

Legend: dark grey = fully applies; light grey = partially applies; white = not applicable.

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In other respects, the operation reflected the business structure of a Value-adding Process Chain. Although employees com-mented on the lack of standard procedures and protocols at the start, over time the medical service centre did increasinglydevelop administrative procedures and clinical protocols for specific client demands (a sequential standardized service de-sign). Especially during work meetings, telenurses discussed protocols and procedures that could standardize the less uniqueand analysable parts of the service processes. Further, traces were seen of a Self-Help Network to the extent that effort wasput into creating a social contact network around the clients.

Finally in this area, the lack of clarity in the business structure also became evident in coping with the existence of twoforms of client contact alongside each other, i.e. virtual and physical. In particular, district nurses and clients expressed con-fusion as to which ‘channel’ they should use in which situation. As the innovation manager of an insurance company ob-served: ‘‘a problem is that clients can use several ways to contact us, the medical service centre and the district nurse. Thisincreases the complexity for clients who tend to appreciate simplicity as they age’’. The lack of clarity also showed in coordinationproblems between the telenurses at the medical service centre and the district nurses and other service providers.

The IS Strategy at Koala Care indicates elements of a Solution Shop. Homecare clients mainly used the telecare home-videosystem for checking their adherence to medication schedules, advice, consultation and referral. As such, the IT scope was bothbroad and limited. It was broad in the sense that the home-video system was viewed by the implementers as a sophisticatedvirtual channel that facilitated the provision of a large range of advice and consultation services within the homecare setting.It was limited in the sense that clients and telenurses observed a gap between the specific and distinct character of clientdemands and the telecare system’s capabilities. For instance, there was no generic integration of the video system with othercommunication facilities for clients of Koala Care. The telenurses had access to only a short summary of their clients’ medicalhistories, and there was no automatic file updating as a result of an interaction; for example, no automatic messages weregenerated for other healthcare service providers, and no recordings made in clients’ medical files. This lack of IT support forthe chosen structure is evident in the following comment by a homecare manager: ‘‘a huge barrier is that telenurses cannotlook in a client’s nursing file. These are not available electronically’’.

Further, the system was not always able to support the delivery of specific homecare services, such as caring for wounds,or to effectively support requests for clarification. Overall, the scope of the IT system was therefore rather limited and lackedmany functionalities.

The main IT competences of the telecare system were its reliability and accessibility: the medical service centre was al-ways open, and nearly all clients agreed that the system was very easy-to-use. A major task of the medical service centrewas to refer clients to other providers, and other channels, such as telephone and fax, were needed to realize this. There wereno generic collaborative facilities available, nor could providers make use of a comprehensive shared client nursing file. TheIT organization was not prepared for the task of providing such additional IT functions or for integrating the home-videowith other communication channels or IT systems.

IT Governance was restricted to the video channel, and mainly outsourced. Further, the IS strategy did include the connectingof different members of the client system (the Self-Help Network configuration), but this application faced technical problems.

The IS Structure showed one particular feature of the Solution Shop: the service encounter had been transformed from a face-to-face contact, with a delay between expressed need and contact, into an immediate technology-facilitated encounter. However,it is noteworthy that other IT structural choices were not explicitly present in the design. The IT application infrastructure was notequipped to support collaboration, nor monitoring, nor interconnectivity, and no specific IT processes and skills were rolled out.

5.2. Conclusions on Koala Care

The Koala Care case clearly demonstrates that the value configurations introduced in Section 2 are needed to provide anadequate SAM analysis of telecare. The main conclusion from the above analysis is that the Koala Care project lacked a welldefined scope. Although the situation most closely corresponded to a Solution Shop, the Koala Care project also had featuresof the Value-adding Process Chain and of the Self-Help Network. This lack of a strategic choice for a particular configurationled to a lack of alignment in other areas.

Furthermore, as shown in Table 3, Koala Care provides evidence that the inclusion of the following dimensions enhancesthe original SAM model:

� IT support for strategy (degree of product customization, the product volume, degree of service differentiation);� IT support for structure;� a differentiation between front-office and back-office skills;� the customer role (in relation to the service offering) and created added value;� the role of telecare in the service encounter.

5.3. Telecare in a medical setting: Koala Cure

The second case concerns telecare use in cure-oriented processes (see Table 4). Here, telecare’s ability to monitor clients’chronic conditions in their own homes was seen as the distinctive advantage. Here, medical specialists selected those pa-tients with chronic heart failure or suffering from diabetes mellitus as appropriate participants for this project.

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As such, the telecare-enabled goal was clear. The telecare system would provide clients with facilities to collect their ownclinical data and transfer this information to telenurses who would then evaluate the data. The monitoring by the telenurseswas not real-time, but it was linked to automated control of the client’s condition and included protocol-based event han-dling if the monitored values deviated from the norms. Moreover, the telenurses scheduled video calls with clients to reviewtheir healing processes. From their side, clients could contact the medical service centre with questions related to their spe-cific illness. Nevertheless, in the event of an emergency, clients were still expected to call the national emergency number.

The business strategy of Koala Cure, in keeping with a Value-adding Process Chain, was to cut costs by reducing the num-ber of hospital visits and the length of stay of a clearly targeted client group. In addition, telecare provided clients with anincreased sense of wellbeing by reducing the number and length of their hospital visits. As such, Koala Cure was focused oncutting costs by remote client monitoring and process control, and the operating strategy was clearly focused on a high pro-duction volume and a low degree of customization. Within this Value-added Process Chain, the telenurses acted as gate-keeper and remained in control of interactions with clients.

With regard to business structure, strict evidence-based medical guidelines and protocols guided the operational behav-iour of the telenurses, and the processes were precisely defined, reflecting the characteristics of a Value-added Process Chain.Clients delivered data that were sequentially processed by the medical service centre (a sequential standardized service de-sign). The telenurses, and the specialized nurses in the hospitals, can be seen as employees executing front-office tasks, whilethe specialists and laboratories act as back-office service providers. Telenurses stated in interviews and in their question-naire responses that their work in the Cure project was clearly defined and described, which generated commitment andconfidence.

In terms of its IS strategy, the scope of the Koala Cure project was rather narrow, as it focused on monitoring a specificclient group. Likewise, the video interactions supported only a few distinct, standardized sequential steps in this specifiedhealthcare process to which specific patient monitoring services were added.

Table 4Koala Cure mapped on the framework of telecare alignment configurations.

Legend: dark grey = fully applies; light grey = partially applies; white = not applicable.

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As such, the competences of the IT organization in integrating video and monitoring were properly present. Accordingly,clients used standard measuring equipment that was integrated with the video technology platform. However, the requiredIT support skills were outsourced. Monitoring and video facilities were drawn from an external business partner who wasspecialized in supporting these particular monitoring processes, while providing a broadband connection and installationwere assigned to another party. In other words, the governance was dispersed over several parties. Collectively, these partiesoften failed to deliver monitoring equipment in a timely way. Clients who agreed to be monitored at home needed the equip-ment within 24 h if this was to enable significantly shorter stays in (expensive) hospital beds. This requirement was not metby the IT delivery organization in one-fifth of cases. This led to much frustration with the suppliers of medical services, asseen from the following comment by a manager from the medical service centre: ‘‘Getting ADSL in place also takes far too long– 4 to 6 weeks! This has to be accelerated, to also allow the realisation of short-term connections’’.

The IS Structure showed typical features of the value chain: the integrated platform for monitoring and video was appro-priate for the application. Although proprietary technology was used, the IT functioned in line with the requirements of themedical specialists. The IT infrastructure and skills were therefore aligned with the IS strategy. However, it is noteworthythat the broadband delivery and the installation processes were not aligned. This relates to the weak governance structurehighlighted above. The technology mediated the service encounters between telenurses and clients who were not co-located,and both made use of the same technology but without a real-time connection. Video calls from regular clients concerningtheir periodical check-ups were transferred to specialized nurses within the hospital. This created some dissatisfaction withthe role of the medical service centre in this activity. As an innovation manager from an insurance company commented: ‘‘ina manner of speaking there is no added value. It is an extra link in the chain that could, I suppose, be removed. The role of the tele-nurse in the check-up calls - that is a difficult issue’’. Having an IT-supported workflow (in line with the value chain alignmentprofile, Section 3) could have resolved this issue, but this was not in place. In terms of Fig. 1, this suggests a lack of structuralalignment.

5.4. Conclusions on Koala Cure

Koala Cure was a balanced and aligned telecare project with elements of a Value-adding Process Chain found in all fourdomains. There was a clear vision and a plan to align the business strategy of a value-added process chain with the requiredIT investments. Although there was some politicking surrounding the specific software choice, the functional requirementsseemed clear. The strategy and structure business domains were closely aligned, and both strategic and structural alignmentwere realized. However, one important failing could be distinguished: the unreliable delivery of monitoring equipment, andthis reflects a misalignment between IS strategy and structure. Further, there is, as yet, no workflow support. Overall, theKoala Cure project demonstrates the relevance of considering the following additions to the adapted SAM model:

� IT support for structure;� differentiation between front-office and back-office skills;� the role of telecare in the service encounter.

6. Cross-case analysis: alignments and performance outcomes in Koala Care and Koala Cure

6.1. Degree of business alignment

The description of the Koala Care project shows a lack of focus in setting business objectives. Both the business strategy,in terms of scope and competences, and the business structure, in terms of processes and skills, reflected a mix of objectivesthat the homecare organization was pursuing. This led to misalignments, such as the mismatch between the skills of the tele-nurses and the skills required to meet service demand. Koala Cure was evaluated as a considerably better balanced andaligned telecare project. The business strategy and structure domains showed close alignment with each other, and in linewith the principles of a value chain. The business scope (to provide medical treatment and monitor its effects remotely) waswell aligned with the organization of the operational processes, and the required competences were translated into skills.Business governance resided with medical specialists who could set up the administrative infrastructure for the whole valuechain, including the remote and the physical activities, in line with their own vision. The different alignment profiles found inKoala Care and Koala Cure were reflected in the relatively low (Care) and high (Cure) performance scores (see Table 5).

6.2. Degree of strategic alignment

In Koala Care, the IS strategy supported the main objective within the business strategy of the homecare organization: byprimarily providing a reliable system it supported the provision of a broad service package. Nevertheless, the IT system wasincapable of providing the generic collaborative facilities needed to support the referral service. Moreover, users reported amisfit between the specific characteristics of the demands of homecare clients (albeit ambiguous and vague demands) andthe shallow character of the IT system. The Koala Cure business scope was well aligned with the IT scope: the medical spe-cialists were very clear on the services required from IT, and these were properly documented. Accordingly, the competencesrequired were precisely expressed. The only issue where some misalignment could be observed was in IT governance where

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Table 5Alignments based on cross-case analysis and their relationships to performance.

Alignments Cross-case analysis Performance Strategic and design issues

Businessalignment

Care: the dominant strategic asset of ‘‘clientcomfort and intimacy’’ was not entirely andconsistently elaborated in the businessstructure: (a) back office expert support skillswere barely arranged, and (b) use was made ofstandardized work processes, which does notfit with the unique character and complexity ofthe type of work expected

Care: highly skilled telenurses felt thenature of this work was ‘too soft’ forthem; employees reported lowautonomy and medium job complexity.Calls regarding Care did not call upontheir competences, whereas Cure callsdid. They experienced Care-related callsas disturbances to their real work

Care: shows the relevance of developinga realistic operating strategy (level ofproduct customization, product volumeand product complexity), which shouldbe elaborated in a consistent way in thebusiness structure

Cure: a close fit between business strategy andelements of the business structure: (a) a staffexpert (a hospital physician) strictly organized(b) narrowly described procedures andprotocols that fit the character of the work

Care: most clients call during officehours, calls have a short duration androutine character, which shows animbalance with the round-the-clock,highly skilled, staffing

Both: relevance of clearly identifyingboth back-office and front-office skills

Care: attempt to integrate the telecare servicewithin and alongside existing services. Careclients were unsure when to use whichchannel

Cure: patients reported high trust in thedelivered service (almost 80%)

Care: no clear multichannel policydeveloped (the use of multiple channelsbased on strategic choices and clientsegments)

Cure: applied telecare in well-demarcated sub-processes for well-defined client segments

Care: less than half of calls replaced ahome visit (only 37%), and clients oftenunsubscribed from the service during thepilot period (low perceived usefulness,low frequency of use). Only a few clientsused the system sufficiently intensivelyfor savings to exceed costsCure: remote access reduced length ofhospital stays and resulted in fewerunplanned readmissions. Many clientsfavoured telecare over traditionalhospital consultations

Strategicalignment

Care: no integration of telecare facility withother communication facilities such as theelectronic patient file. This negatively affectedthe ‘‘client comfort and intimacy’’configuration. The managers interviewedmentioned the technology push; strategicalignment was not disputed

Care: high costs of coordinating withdistrict nurses and other serviceproviders. Only a few individual clientsused the system sufficiently intensivelyand effectively that cost savingsexceeded investment and operationalcosts

Cure: There was a clear vision and plan to alignthe business strategy of a value-added processchain with the IT investments required.However, governance was dispersed andtimely delivery could not always be realized

Cure: all clients became telecare userswhere the service was offered, nearly 70%of the users remarked that they used theservice intensively, and overallsatisfaction was high

Discussions on use started with asking how IToptions could support the business strategy,and subsequently moved on to how tointegrate telecare use in the business structure

However, timely delivery of medicalequipment was not always achieved,which increased hospital costs (due tolonger stays)

IS alignment Care: many video calls could have beenhandled using cheaper phone calls (79%)

Care and Cure: operational costs were toohigh

Clear identification of the use of telecarein service encounters

Cure: the use of monitoring equipmentparticularly replaced the need for hospitalvisits; again the phone could have replacedmany of the video calls (91%)

Care: clients often experienced thesystem as complex, whereas the targetedclient segments were aging andappreciative of simplicity

Care: dispersed IS strategy made it hard tomake choices in the IS structure

Cure: most clients appreciated the easyuse of the system (video connection 89%,monitoring equipment 78%) whichstimulated use, and the majority ofclients experienced the system asproviding security and increasing theirlife skills

Cure: the clear and consistent IS strategy driveschoices in the IS structure

Care and Cure: limited scalability, nosignificant economies of scale

Care: high material and operational costs perclient hindered expansionCure: use of dedicated equipment hinderedexpansion

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the medical specialists had agreed to outsource IT delivery. The different alignment profiles resulted in different performancescores for Koala Care and Koala Cure (see Table 5, third row).

6.3. Degree of IS alignment

In both Koala Care and Koala Cure, most of the content of the video calls could have been adequately conveyed in lessexpensive telephone calls (see Table 5, fourth row). This reflects a misalignment between IS strategy and IS structure, andshows the importance of giving adequate consideration to technology choice in a service encounter. Further, the IT systemcould not provide the communication services required when the homecare organization wanted to support contacts andlinks between clients and other relevant stakeholders within their own client system. Applications that would have sup-ported the value shop configuration, such as groupware and collaboration tools, document sharing facilities, search toolsfor navigating in medical databases and a shared use of client medical files, were simply not available. Accordingly, an align-ment between the IS strategy and the IS structure only existed in the short-term.

In Koala Cure, one important failing could be distinguished: the unreliable delivery of monitoring equipment. This reflectsa misalignment between IS strategy and IS structure on this important point. In both cases, scalability was limited, i.e. theability to improve margins (revenue minus variable costs) as sales volume increases. In Koala Care, the reason was the highmaterial and operational costs per client and, in Koala Cure, the use of dedicated equipment.

6.4. Degree of structural alignment

In Koala Care, the skills of the IT organization showed some misalignment as the mechanics who installed the servicefailed to communicate well with Koala Care clients. Further, the round-the-clock staffing did not fit with the pattern ofincoming calls, and telenurses also felt that they were sometimes responsible for tasks which were not well supported bythe IT system (the lack of referral facilities). Furthermore, telenurses experienced problems in combining Koala Cure mon-itoring tasks, which generated a planned and steady workload, with unplanned Koala Care calls.

In Koala Cure, the telecare delivery organization and the IT delivery organization were aligned well. This was partially dueto good personal relationships between the managements of the IT organization and of the homecare organization. Telenur-ses felt supported by the IT system when executing their tasks.

7. Conclusion

Our research has integrated Stabell and Fjeldstad’s value configurations, as applied to healthcare by Christensen et al.(2008), into the strategic alignment model. This has led to two extensions to the SAM that are not based on Porter’s ValueChain framework (1985) but, rather, on the Value Shop and on the Value Network respectively. These extensions forhealthcare services have also led to sector-specific adaptations of the model’s dimensions, such as our drawing on the workby Rivard et al. (2006) to add a resource-based view to the SAM.

For each of their value-creating configurations, namely the Value-adding Process Chain, the Solution Shop and the Self-Help Network, a telecare alignment profile has been tentatively developed, and then discussed in Section 6. These profiles aredescribed in terms of the strategic alignment model domains, namely business strategy, business structure, IS strategy and ISstructure (Table 1). In so doing, concepts from the respective literatures that are relevant for strategic IT management wereconnected within the SAM. This framework for aligning telecare technology with healthcare providers’ strategies may

Table 5 (continued)

Alignments Cross-case analysis Performance Strategic and design issues

Structuralalignment

Care: installers of the service did not alwayshave enough skills to communicate adequatelywith elderly clients

Care: increased costs because bothnurses and mechanics were involved ininstalling the service

Relevance of finding a balance betweenIT skills and the role of telecare in theservice encounter

Care: logs show a low volume of calls and alarge variety in call subjects during the day

Care: telenurses experienced Care-related calls as disturbances to theirCure-monitoring work

Cure: processed a steady workload and couldplan work

Care: employees reported low autonomyand unbalanced tasks, responsibilitiesand authorities, and poorly supportedtelecare encounters

Care: telenurses had the authority to assess aclient’s care needs but no access to electronicpatient records or any other communicationfacilities

Cure: a clear balance between tasks,authorities and responsibilities, all wellsupported by available IT systems

Cure: telenurses experienced a well-definedbalance between authorities andresponsibilities regarding monitoring tasksthat were supported by the IT system

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contribute to avoiding the lack of alignment that has been observed in the field by systematically identifying strategic designchoices and alignment issues.

As a preliminary test of this tentative framework, the design characteristics of two telecare projects were mapped ontothe alignment profiles (Tables 3 and 4). This analysis pointed towards the relevance of the proposed adaptations in terms ofthe following strategic design dimensions: IT support for structure, the determination of client roles and client added value,the identification of required front- and back-office employee skills, the role of the technology (i.e. telecare) in the serviceencounter, and the development of a consistent multichannel policy. In both projects, the importance of a balanced align-ment between the employees’ focus and skills and telecare’s role within the service encounter was acknowledged.

The central finding in the subsequent cross-case analysis (Table 5) was that the least aligned telecare project was also theleast successful in terms of client adoption. This indicates that the enhanced strategic alignment model is applicable to tele-care. The first case studied, Koala Care, suffered from a low degree of alignment between all four domains. Since no strategicalignment activities were undertaken, intermediate changes in one domain yielded, at best, ad hoc changes in other domains,and led to an unstable and indistinct telecare service. In contrast, Koala Cure benefited from the active involvement of phy-sicians who had a vision of what should be achieved. Nevertheless, political and supply issues hampered a smooth imple-mentation and sustainable adoption. Our framework-based evaluation explains the ways in which the Care project wasless aligned than the Cure project. Moreover, these theoretically underpinned conclusions are in line with the lack of align-ment experienced by interviewees in the Care project.

An alternative explanation for this significant finding could be that only a ‘value-chain-based’ business model (as in KoalaCure) can succeed, and that the other two value configurations are not viable in healthcare. This explanation seems less con-vincing considering the strong arguments put forward by Hwang and Christensen (2008) in favour of innovative e-healthbusiness models. Nevertheless, longitudinal studies to evaluate the long-term viability of each of the telecare alignment pro-files are recommended. Both the timespan (see Sabherwal et al., 2001) and the number of cases in our study were limited.

The strategic alignment model and its anticipated benefits have been well researched (Chan and Reich, 2007) and themodel has been applied in many industries. The argument presented here is not that one should replace the traditionalSAM dimensions; rather, we are suggesting additions and adaptations that broaden the SAM’s applicability to business mod-els other than ‘value-chain-based’ ones. In this instance, we have elaborated on telecare applications within the healthcaresector. The strategic challenges facing healthcare providers, in combination with the opportunities new technologies offer,question the sector’s existing value configurations. The proposed framework helps to phrase relevant questions, and drawsattention to specific design issues that have come to the surface in strategic IS (e.g. Rivard et al., 2006) and service manage-ment (e.g. Christensen et al., 2008). It is our view that expounding on and framing these questions and issues is especiallyrelevant for healthcare services. Healthcare’s ongoing reconfiguration and globalisation requires researchers to develop inte-grative frameworks that facilitate dialogue among professionals with diverse backgrounds.

Despite the contribution noted above, the proposed framework has the limitation that it focuses on strategic choices anddesign consistencies, the so-called ‘what’ of alignment. As such, it ignores the complexities of the implementation process.Implementation does, as the Koala Cure project showed, involve social, political and cultural changes, and also learning pro-cesses. Our position is that these processes, unlike consistent design options, cannot be captured in profiles. Studies adoptinga process perspective on alignment (such as Rondinelli et al., 2001) complement the design perspective adopted here.

7.1. Implications for practitioners

A coherent strategic IS alignment framework, offering generic and widely accepted theoretical concepts, may help tobridge professional and institutional differences. It would do so by offering a common terminology that outlines design op-tions and highlights alignment issues. Despite these benefits, one must accept that stakeholders may see the desirability ofeach profile differently. They may still feel tempted to emphasize different domains, or to stress different performance areas,such as accountability over innovation. Further, the ongoing changes during the duration of the telecare projects emphasizethe suggestion by Henderson and Venkatraman (1992) that there is a need for continuous re-evaluation and readjustment ofthe strategic alignment. Finally, a single healthcare providing organization may need to develop a range of telecare applica-tions for ‘client demand’ categories that require different value configurations if they are to be competitive. A hospital’s busi-ness model can be seen as a ‘Solution Shop with a broad scope’ but, at the same time, it will also refer clients to medicalservice delivery units that amount to a ‘value-chain configuration’.

7.2. Future research

From a theoretical perspective, we aimed to deliver a framework that would support the alignment of telecare technol-ogies with the strategies of healthcare providers. Although the profile descriptions are not necessarily exhaustive, theirapplication to Dutch telecare services has proved useful. The framework’s ability to align other e-health technologies re-quires further study. Such studies should measure both the degree of alignment and the effects of alignment on performanceindicators for healthcare services.

Furthermore, action-oriented research could determine whether this adapted SAM framework can also support innova-tive developments involving the reconfiguration of healthcare services, such as through multilayered networks in whichhealthcare, insurance and telecom providers cooperate.

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The starting point for this analysis was the business strategy domain. Based on Stabell and Fjeldstad (1998), this led to thedevelopment of three strategic alternatives for telecare. An alternative route is to start with the IT domain, and ask whatforms of support IT can offer. This results in a number of strategic alternatives as one can, for example, conceive of telecareapplications that fit differently-positioned value configurations. For example, we could think of a specialist rather than amore generalist Solution Shop (see Stabell and Fjeldtad, 1998, p. 427). One could also argue that even hybrid value config-urations, such as the comparison websites described by Laffey and Gandy (2009), may survive as long as crucial alignmentissues can be managed, and performance trade-offs accepted.

Acknowledgements

This paper has benefited substantially from conversations with and comments from John van Meurs and Jacob Wijngaard.We are also indebted to the clients, carers, care coordinators, managers and others who participated in the Koala projects.We thank KPN, TZG and Menzis for cooperating with us in this project.

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