INOM
EXAMENSARBETE INDUSTRIELL EKONOMI, AVANCERAD NIVÅ, 30 HP
STOCKHOLM SVERIGE 2017,
Speech therapy and digital gamification services
- Investigating the receptivity to digital
gamification services within speech therapy treatment
ISAC GUSTAFSSON ERIK EDBERG
KTH
Speech therapy and digital gamification services
- Investigating the receptivity to digital gamification services within speech therapy treatment
by
Erik Edberg Isac Gustafsson
Examensarbete INDEK 2017:110
Logopedvård och digitala gamification-tjänster
- Undersöker mottagligheten för digitala gamification-tjänster inom logopedibehandling
av
Erik Edberg Isac Gustafsson
Master of Science Thesis INDEK 2017:110 KTH Industrial Engineering and Management
Industrial Management SE-100 44 STOCKHOLM
Master of Science Thesis INDEK 2017:110
Speech therapy and digital gamification services
-
Investigating the receptivity to digital gamification services within speech therapy treatmentErik Edberg Isac Gustafsson
Approved Examiner
Johann Packendorff
Supervisor
Erika Lokatt
Commissioner
Lingo Studios
Contact person
Arthur Onoszko
Abstract
A majority of the more developed countries are struggling with healthcare costs rising faster than the country’s GDP. In a model of the Swedish healthcare by year 2025, the costs could be decreased by 25 percent if the digital techniques are being fully utilized compared to if no progress are made towards a more digitized healthcare. Simultaneously, implementations of new digital innovations and new ways of working in the healthcare system evolve slower than the evolving of new technical innovations within the area.
The prevalence of people suffering from speech impairment amongst 5-year-olds is estimated to be around 7 percent worldwide. It has been shown that people with speech impairment find it more difficult to learn, read, get a job and establish relationships with family and friends.
A main challenge within speech therapy treatment is motivating the patient to maintain long and effective practice sessions at home without the consultation of a therapist. Another is to enable wide access to professional speech therapy. Digital gamification as part of the rehabilitation process in speech therapy has shown to be advantageous because of, amongst other factors, having broad accessibility and motivating the patient in a fun way to maintaining practice sessions outside the speech therapy clinic.
This study was conducted through interviews with stakeholders in the American and Swedish speech therapy system including speech therapists, clinical managers and digitalization experts.
Findings indicated that three factors strengthen previous closely related research; regulations, culture & finance. It has been concluded that two additional factors affect the receptivity of digital gamification services within speech therapy treatment; Socio economic status &
Stakeholders and structural forces.
Keywords: Digitalization, speech therapy, treatment, healthcare, technology, barriers, innovation, receptivity
Examensarbete INDEK 2017:110
Logopedvård och digitala gamification-tjänster
-
Undersöker mottagligheten för digitala gamification- tjänster inom logopedibehandlingErik Edberg Isac Gustafsson
Godkänt Examinator
Johann Packendorff
Handledare
Erika Lokatt
Uppdragsgivare
Lingo Studios
Kontaktperson
Arthur Onoszko
Sammanfattning
I en merpart av utvecklingsländerna ökar sjukvårdskostnaderna snabbare än ländernas BNP. I en modell av det svenska sjukvårdssystemet vid år 2025 skulle kostnaderna kunna sänkas med 25 procent om digitala tekniker implementerades till fullo jämfört med om ingen utveckling mot en mer digital sjukvård skulle ske. Samtidigt så sker användandet av digital innovation och nya arbetssätt i vården långsammare än vad nya tekniska landvinningar utvecklas i samma område.
Utbredningen av människor som lider av talsvårigheter bland femåringar är uppskattat till hela 7 procent världen över. Det har visats att människor med talsvårigheter har svårare att lära sig, att läsa, få ett jobb och etablera relationer med familj och vänner.
En huvudutmaning vid behandling av talpedagogik är att motivera patienter att upprätthålla lång och effektiv övning i hemmet, utan konsultation av en talpedagog. En annan är bred tillgång till professionell talpedagogik. Digital gamification som del av rehabiliteringsprocessen vid talpedagogik har visat vara fördelaktigt av flera anledningar, bland andra då det möjliggör bred tillgång till vård samt motiverar patienten att på ett roligt sätt öva på talet utanför logopedens lokaler.
Den här studien genomfördes genom intervjuer med intressenter i det amerikanska och det svenska logopedvårdssystemet, inkluderande logopeder, verksamhetschefer och digitaliseringsexperter.
Resultaten indikerar att tre faktorer styrker tidigare nära besläktad forskning; regelsättning, kultur och finansiering. Slutsatser dras att två ytterligare faktorer påverkar mottagligheten av digitala gamification-tjänster inom talpedagogik; socio ekonomisk status samt intressenter och strukturella krafter.
Nyckelord: Digitalisering, talpedagogik, behandling, sjukvård, teknik, barriärer, innovation, mottaglighet
Table of Contents
1. Introduction ... 5
1.1 Background ... 5
1.2 Problem formulation ... 6
1.3 Purpose ... 6
1.4 Research question ... 6
1.5 Delimitations ... 7
1.6 Expected contribution ... 7
2. Theory ... 8
2.1 Literature Review ... 8
2.2 Theoretical Framework ... 11
2.2.1 Diffusion of innovation on a system level ... 11
2.2.2 Regulation and digital innovation within healthcare ... 12
2.2.3 Financing and digital innovation within healthcare ... 13
2.2.4 Culture and digital innovation within healthcare ... 15
2.2.5 Inner context and the receptivity of digital innovations in healthcare ... 16
2.2.6 Mobile devices, user experience and the receptivity of digital innovations in healthcare ... 17
3. Methodology ... 18
3.1 Methodological approach and research design ... 18
3.2 Research process ... 19
3.2.1 Pre-study ... 19
3.2.2 Empirical study ... 20
3.3 Credibility ... 21
3.4 Transferability ... 21
3.5 Ethics ... 22
4. Results & Analysis ... 24
4.1 Regulation ... 25
4.1.1 Restrictions tied to the collaboration and information spreading with adjacent institutions ... 25
4.1.2 Treatment methods ... 26
4.2 Financing ... 28
4.2.1 Compensation models effect on treatment ... 28
4.3 Culture ... 30
4.3.1 Digital gamification friendliness amongst speech therapists ... 30
4.3.2 Digital habits and demands amongst speech therapy recipients and their parents .. 32
4.3.3 Leadership sharing digital knowledge at speech therapy clinics and institutions ... 33
4.5 Stakeholders and structural forces within speech therapy ... 37
4.6 Receptivity to digital gamification in speech therapy: barriers and possibilities ... 39
5. Discussion ... 41
6. Conclusions ... 44
7. References ... 46
List of Figures
Figure 1: Advantages with digital gamification in speech therapy ... 10
Figure 2: Compensation models ... 13
Figure 3: Drivers of digital innovation in healthcare ... 16
Figure 4: receptivity of mobile devices in healthcare rehabilitation ... 17
List of Tables
Table 1: Stakeholders, country and duration ... 21Foreword
This thesis was conducted during the spring semester 2017 at the department of Industrial Economics and Management at the Royal Institute of Technology in Stockholm, Sweden, KTH.
List of central concepts
In order for the readers to get familiar with all concept used in this study, it starts with introducing central concepts that are important to understand from the very beginning. With knowledge in these concepts, the readers will be able to understand the process of thought more clearly.
- Special Language Impairment, SLI
The concept of special language impairment, SLI, is central for this study. The following definition is used for this study (Tomblin, Records, Buckwalter, Zhang, Smith, O'Brien, 1997):
SLI is defined purely in behavioral terms: there is no biological test for SLI.
There are three points that need to be met for a diagnosis of SLI
1. The child has language difficulties that interfere with daily life or academic progress
2. Performance on a standardized language test is significantly below age level
3. Children scoring in the lowest 10% on two or more composite scores are identified as having language disorder
SLI is characterized as mentioned above, not by a known neurological, intellectual, emotional or sensory deficit. SLI can affect the advancement of vocabulary, grammar and communicative skills and makes it especially hard to acquire certain morphemes such as past tense (Tomblin et al, 1997). Except the difficulties with language, children with SLI may very much be healthy and intelligent.
- Speech Therapy
Speech therapy is a professional field of expertise practiced by a clinician called a speech therapist, who specializes in the evaluation and treatment of cognition, voice disorders, communication disorders and swallowing disorders (Brady et al, 2016). A frequent misunderstanding is that speech therapy is only focused on helping speaking individuals in correcting pronunciation difficulties and to help stuttering people to become more fluent speaking. The profession does also include a broader scope of speech, swallowing, language and voice troubles that in some way involve communication. Examples of these are:
● SLI, including difficulties creating sentences that are grammatically correct and meaningful
● Difficulties in reading and writing related to the relationship of letter-to-sound, word- to-meaning and reading apprehension
● Voice troubles such as too soft, raspy or other complications that impact an individual’s professional or social performance
● Cognitive difficulties such as memory and attention, if they inhibit communicative skills
Digital gamification
The concept of gamification is a central theme in this study. Detering (2011) describes it as “the use of game design elements in non-game contexts”
and is the definition this study will use. The fundamental idea behind gamification is to use the design features or motivational elements of entertainment games in other structures to make the involvement in these systems more motivating (Zhang, 2008). Gamified systems use intrinsic motivation appealing to well known theories with the implementation of features like continuous progress feedback, success feedback, goal setting through point scores, different levels, leaderboards, badges, social feedback and similar support (Ryan & Rigby, 2011). These features provide emotional and value based rationale for a continuous use of the service. It is also characterized by the implementation of customizable avatars and user choice in activities and goals.
Digital gamification is a concept that will appear frequently in this study. It is the use of gamification on digital devices. This are devices as smartphones, computers and tablets, through which the users are subjected to the game.
1. Introduction
The chapter starts of by bringing out the background and the problem formulation leading up to the purpose and research questions. Lastly it presents and explains delimitations and expected contribution.
1.1 Background
A majority of the more developed countries are struggling with healthcare costs rising faster than the country’s GDP. The development is largely due to the fact that people live longer which increases the need of care. In a study by Mckinsey (2016) which contains a model of the Swedish healthcare by 2025, the costs could be decreased by 25 percent if the digital techniques are being fully utilized compared to if no progress are made towards a more digitized healthcare.
In year 2025, 25 percent corresponds to 180 billion SEK just for the Swedish healthcare system.
Mckinsey concludes that a more digitized healthcare would not only lower the costs but will make the system more available for the whole population.
Digitalization within healthcare is a highly researched area, however the field of speech therapy has been sparsely researched from a digital receptive perspective. The prevalence of people suffering from speech impairment amongst 5-year-olds is estimated to be around 7 percent worldwide (Johnson et al, 1999., Bishop & Edmundson, 1987). It has been shown that people with speech impairment find it more difficult to learn, read, get a job and establish relationships with family and friends (McCormack et al., 2009). Having a speech impairment also influences a person’s role in society in ways that deter them from interacting in social activities that may lead to social anguish and avoidance issues (Mcleod et al., 2013).
Although the knowledge base about communicative functions have increased rapidly, the speech therapy treatment has changed little in the last 40 years (Kumar and Cohn, 2013). The way speech therapy is provided in clinics and schools is much the same today as it was in the 1970s. In the book Telerehabilitation (2013) speech therapists from across the globe confirm that techniques and methods used for treatment are far from what to be expected in the twenty- first century. When they use digital tools in treatment, they are often comprised to merely photocopied and printed versions of drill books and worksheets.
A big challenge in speech therapy treatment today is the lack of intensive, continuous practice (Hula, 2007). One challenge is motivating the patient to maintain long and effective practice sessions at home without the consultation of a therapist. Another is to enable wide access to professional speech therapy. For people living in remote areas the cost usually is a lot higher and professional speech therapy can be highly inaccessible (Bourke et al, 2004).
The use of digital gamification services for education and health purposes is expanding as the use of digital tools increases. Compared to traditional persuasive technology, digital gamification services have proven to offer several advantages in stimulating a change in behavior for well-being (Johnson et al, 2016).
Mähring & Kjellberg (2008) investigated why the implementations of new digital innovations and new ways of working in the healthcare system evolve slower than the evolving of new technical innovations within the area. They found that focus and resources are limited when considering the specific context and receptivity that the innovations are to be used in.
1.2 Problem formulation
Considering the high prevalence of people suffering from SLT and the known troublesome effects on both society and individuals, the importance of a well functioning speech therapy healthcare is evident. Research has shown that the usage of digital gamification services within speech therapy treatment comes with positive impacts on a number of today’s challenges, such as rising costs and lack of continuous training (Piper et al, 2011), (Nikalova, 2010), (Salminen et al, 2004).
However, previous studies conducted in the area of digitalization receptivity within the healthcare system are general and not fully applicable on certain sub-areas within the healthcare system, such as the speech therapy system. This comes from fundamental differences regarding treatment, challenges and processes (Alahäivälä & Oinas-Kukkonen, 2016), (Angst et al, 2011), (Boulos et al, 2011), (Cameron et al, 2014). Moreover, there are lack of research and understanding about how the receptivity to digital gamification services within the speech therapy treatment are affected by factors related to the speech therapy system (Mähring &
Kjellberg, 2008).
1.3 Purpose
The purpose of this study is to examine factors tied to the speech therapy system that affects the receptivity to digital gamification services within speech therapy treatment.
1.4 Research question
The research questions consist of one major research question (MRQ) and two sub questions (SQ).
MRQ: How is the receptivity to digital gamification services within the speech therapy treatment affected by factors related to the speech therapy system?
SQ1: What are the major factors that affects the receptivity to digital speech therapy gamification services?
SQ2: How does these factors affect the receptivity to digital speech therapy gamification services?
1.5 Delimitations
The study examines the Swedish and the American speech therapy systems with an objective to generalize the findings making them applicable on speech therapy systems in general.
However, due to differences in national laws and structural characteristics in combination with a research method with low degree of transferability, the results are foremost delimited to the two examined countries.
The study is mapping out factors and explaining how they affect the receptivity to digital gamification services within speech therapy treatment. However, the study is delimited in describing to what extent each factor affects the receptivity. To investigate to what extent each factor contributed to the receptivity would have needed additional information gathering and a more complex analysis. This was regarded, due to the given timeframe, something that would have made the study to extensive.
1.6 Expected contribution
With this study we aim to contribute to the research area regarding the receptivity to digital gamification services within the speech therapy treatment. Previous studies conducted in the area of digitalization receptivity within the healthcare system are general and not fully applicable on certain sub-areas within the healthcare system, such as the speech therapy system.
This comes from fundamental differences regarding treatment, challenges and processes (Alahäivälä & Oinas-Kukkonen, 2016), (Angst et al, 2011), (Boulos et al, 2011), (Cameron et al, 2014), (McKinsey, 2016).
This study will have a narrower perspective, focusing on the speech therapy system. Further, the aim is to contribute with an understanding of what and how factors affect the receptivity to digital gamification services within the speech therapy treatment. This contribution could also be applicable to digital innovation research within sub-areas of the healthcare system that share the same fundamental characteristics as the speech therapy system. Moreover, this qualitative research is a contribution to previous closely related research by presenting an additional study to the field of healthcare digitalization.
This study aims to contribute to an understanding for the receptivity within the system that digital innovations and particularly digital gamification services are to be used in.
Understanding in what and how factors affect the receptivity will hopefully facilitate the implementation of digital gamification services. Thereby patients and society could be able to benefit from advantages such as increased quality and accessibility and decreased costs tied to the use of digital gamification services within speech therapy treatment.
2. Theory
This chapter presents an overview of the literature on healthcare digitalization and digital gamification services within speech therapy. The chapter begins with a literature review that presents related research and that illustrates the specific gap motivating this study. It continues with a theoretical framework, which includes relevant theories that can act as a basis to understand and analyze the empirical results later in the study.
2.1 Literature Review
The overall purpose with the literature review was to examine areas related to the research questions in order to gain understanding for the existing knowledge, in other words, identify previously conducted research in areas related to digitalization, healthcare, receptivity, digital gamification services, speech therapy treatment and the different areas combined. Previous research was used to contribute to gain a deeper understanding of existing knowledge, support in the configuration of research design, theoretical framework, data collection and analysis (Collins & Hussey, 2014).
The examined literature was collected from books and articles from journals found at the search engines ScienceDirect and Google Scholar. The search process for relevant literature initially focused on a wide range of literature and later on the search narrowed down to literature closely linked to the research questions.
The following keywords, separate and combined, were used in the search for relevant literature:
- Digitalization, speech therapy, treatment, healthcare, technology, barriers, innovation and receptivity
The literature review showed that the two fields; Receptivity to digitalization within healthcare and gamification within speech therapy have been subject for plenty of international research, yet the subject of this study; Receptivity to digital gamification services within speech therapy treatment has been sparsely researched.
There is a need of narrowing research within the area of receptivity to digitalization within healthcare mainly because previous research within healthcare digitalization tends to see the healthcare system as one entity. This leads to findings and solutions that tries to fit the whole system, despite the fact that there exist different challenges and goals that needs different solutions (Ekholm, Nilsson & Riggare, 2016)
By using the two research fields; Receptivity to digitalization within healthcare and gamification within speech therapy as a part of the theoretical framework, we aimed to reach a deeper understanding for what and how factors could affect the receptivity to digital gamification services within speech therapy treatment.
Receptivity to digitalization within healthcare
When investigating previous research within the area of receptivity to digitalization in healthcare focus was comprised to studies that target the way factors affect the receptivity of digital solutions in healthcare. By gathering existing knowledge about the healthcare system’s receptivity to digitalization as a whole, that knowledge could be used to help understand and analyze the receptivity within one of its’ subsystems, in this case the speech therapy system.
Mckinsey presented an investigative report in June 2016 where they analyzed the requirements and implications of a digital transformation of the healthcare system. The research was based on over 500 international studies where digital solutions have been tested in different care environments and produced results in terms of quality improvements and cost savings. The study reached five areas of importance when engaging in a digital transformation of a healthcare system:
● National coordination and allocation of responsibility
● Digital infrastructure and data-security
● Legislation and privacy issues
● Finance and remuneration
● Knowledge of digitalization and e-health
These findings can be compared to a research project funded by the Swedish government by the Institute for Future Studies (Ekholm, Nilsson & Riggare, 2016), which reached the following system obstacles aligned with the receptiveness of digital services within the healthcare system:
● Economy and models of remuneration
● Regulations and guidelines
● Organization and leadership
● Professional standards
● Expertise and skills
● Functionality of the digital solution
Two additional studies identified financial factors as a primary obstacle for a healthcare systems’ receptivity to digital solutions (DesRoches et al. 2008), (Jha et al, 2009). The functionality of the digital solutions is another major obstacle according to Poon et al (2004) and DesRoches et al (2008) since it can lead to resistance among users. This is also the conclusion drawn by Agarwal et al (2010) and Bhattacherjee et al (2006).
Furthermore, researchers have identified the importance of regulations, since the industry is heavily influenced by governmental decisions (Borzekowski, 2002), (Menon et al, 2000). Prior research also states that the healthcare systems’ receptivity to digitalization is influenced by social contagion, by the actions of peer institutions (Angst et al, 2011).
Digital gamification within Speech Therapy
In addition to the previous definition of gamification stated in the central concepts, this study uses the following definition of gamification for healthcare purposes (Cugelman, 2013):
Digital gamification within health is the intersection of persuasion technology, personal informatics and games
Similar to persuasive technology, it concerns the application of particular design principles or features that targets behavior and experiences. As with the concept of a game, gamification drives behavior by motivating qualities of professionally designed games. Like personal informatics, gamification involves tracking individual behaviors enrolled in progress feedback or goal-setting (Johnson et al, 2016).
This study focuses on digital gamified systems in the context of speech therapy. Digital gamification as part of the rehabilitation process in speech therapy has shown to be advantageous because of the following aspects:
Figure 1: Advantages with digital gamification in speech therapy Intristic
motivation
Gamified systems can motivate the patient to perform tasks in a fun way, like practice speaking abilities outside the therapy sessions (Deterding, 2015)
Broad accessibility
Mobile devices, tablets and computers make gamified
applications within speech therapy widely accessible and enable the use for patients regardless location (Lister et al, 2014)
Broad appeal
As wider audiences are familiar with the concept of digital games, game design elements have become more approachable and attractive to a higher number of people (King et al, 2013)
Supporting well-being
•Beyond stimulating rehabilitation, the engagement in gamified applications contributes to well- being by achieving positive experience of fundamental need-satisfaction and elements like
relationship, accomplishments and meaning (McGonical, 2011)
Broad applicability
•Gamified solutions cover all major areas within speech therapy, from grammatical
difficulties and voice troubles to cognitive difficulties that inhibit
communicative skills (Alexander, 2015)
The use of digital gamification services for health purposes is expanding as the use of digital tools increases. However, this development does not evolve in the same pace that new technical innovations within the area. The development delay is a highly present issue for the future development on the area but still a rather unexplored area (Georgiou, Schaper & Whetton, 2016).
2.2 Theoretical Framework
2.2.1 Diffusion of innovation on a system level
In this section, the field of organization-theoretical innovation research are investigated. The term receptivity is about the degree to which a system has the ability to absorb new technology or new methods. Within innovation research, a system’s absorbency is discussed as essential to receptivity. In principle, this refers to the degree to which the system can understand and translate knowledge from the outside world, and what opportunities there are to change the system in order for new solutions to be used and integrated into everyday work (Damanpour &
Gopalakrishnan, 1998).
How well innovations are being received are dependent on the innovation itself, but also of surrounding structures and competing control signals. In larger systems there are often parallel initiatives competing for the money, time and attention. Implementation strategies that, already from the design phase, considers potential conflicts and overlaps amongst different innovations, operation processes, priorities and interests are more likely to have a broad and lasting impact in practice (Damanpour & Gopalakrishnan, 1998).
Diffusion of innovations is a theory first popularized by Evertt Rogers (1962). It seeks to explain how technology is spread and defines the process by which an innovation is adapted in a social system. Rogers introduces four basic elements that affect the receptivity of a new idea:
● The innovation itself
● Communication channels
● Time
● The social system
This study focusses its theory on the fourth element, the social system, in order to align with the purpose of the research; to examine factors tied to the speech therapy system that affects the receptivity to digital gamification services within speech therapy treatment. The diffusion of innovation theory states that a social system faces complex possibilities of adoption to innovation, since it is the aggregates of its individuals and its own system (Greenhalgh et al, 2004). It is broken down to three characteristics;
● Motivation and ability - how the system can be motivated to adopt innovation
● Compatibility - how the system is fit for innovation
● Observability - how the implications can be assessed
The ambition is to find sub-factors affecting the three areas above, from closely related research fields such as healthcare, education, and digital innovation theory in general. The sub-factors that could be relevant will then be used when applying to the field of speech therapy. These sub-factors are presented below.
2.2.2 Regulation and digital innovation within healthcare
A central prerequisite to be able to utilize digitalization potential within healthcare is that legislation and other sets of regulations are developed from a user perspective. That means that all political reforms and legislations should be implemented with respect to how they are affecting the digital landscape and its’ receptivity from a user perspective (Coates, 2015).
A lot of today’s regulations does instead pose obstacles for the receptivity to digital development, especially from a user perspective. This is partly due to the fact that they were developed and implemented in a time when the society and technology were not the same as it is today (Malvey, 2016).
The high development pace of today’s technology puts a high pressure to a dynamic and ever changing legislation. Research has shown that legislation must be flexible to changing needs, possibilities and risks in order to utilize the potential that comes with digital development (Coates, 2015).
Research within the area of healthcare digitalization shows that the following characteristics are central for receptivity to digital innovations (Swedish Institution for Future Research, 2016):
- User/Individual perspective
The legislation needs to have an individual/user focus rather than the traditional organizational focus
- Regulations used as guidelines
The healthcare system is a complex system. Complex systems can not be effectively controlled or lead by highly detailed regulations. These kinds of systems shall instead be steered by general regulations without renouncement on fundamental values, such as quality, security and integrity.
- Local mandatory
The value from healthcare are created where people and organization meets. Reforms should always aim to increase that value. Hence, local organizations should have mandate to decide what should be done and with whom to cooperate with to maximize that value.
2.2.3 Financing and digital innovation within healthcare
Healthcare is increasingly determined by economic incentives. It has become common to link the payment to factors such as the operation’s resource efforts, achievements or level of attainment. The way compensation systems are designed creates different incentives for healthcare actors and influence their behavior. The systems are central for healthcare efficiency, quality and organization. The economic governance is amongst the most debated health issues (Glass et al, 1999).
- Compensation models and their receptivity to digital innovation
If the compensation is determined in advance, prospectively, the provider gets a fixed amount, without taking into account what the actual costs will be (Glass et al, 1999).
If compensation is determined in retrospect, retrospectively, the provider is paid on the invoiced, actual resource consumption. Research has shown that when implementing the prospective model, the provider has incentives to work as resource-efficient as possible whereas the retrospective model motivates the provider to produce as much as possible (Glass et al, 1999), (Jacobsson, 2008).
Compensation may be solid, the same amount regardless of how much is being done, or variable, based on the amount delivered. Research shows that when implementing variable compensation, the provider has incentives to perform as much as possible, which is not the case when the compensation is solid (Jacobsson, 2008).
The chart below describes the four main types of compensation models used in healthcare.
•The provider is compensated retrospectively for each completed action
•The provider is compensated for a defined package with a fixed price
•The amount is based on the population the provider is responsible for
•Compensation is based on a predetermined budget
Grant Capitation
Action-based compensation Compensation
per product
In addition to the four models above, there is result-based compensation, where achievements are rewarded and the compensation is combined with any of the above models. Two different approaches within result-based compensation are distinguished (Jacobsson, 2008):
1. Goal related compensation where bonuses or fines are linked to one or several measures 2. Value based compensation, that aims to stimulate increased value by linking the
compensation to health outcomes and all affecting activities
Research has shown that the various models provide different conditions for the receptivity of innovation in healthcare (Khullar et al, 2015). When utilizing goal related compensation, the bonuses is often small in comparison which limits the potential for innovation. When value based, a substantial part of the compensation is often tied to results, which increases the incentives for innovation. Action based compensation is the least favorable for innovations in healthcare that improves efficiency, since improved efficiency means less actions and lower compensation for the care-provider. Grant- and capitation-based compensation encourage innovations that reduces resource use, although it has been shown that improved efficiency can lead to smaller grants in the future to come, which in time can act as a counterforce (Khullar et al, 2015).
Bundled payment, which works as a middle ground between action based compensation and capitation, has shown to be successful in providing the care-giver with possibilities to change processes without being financially afflicted in the short term (Sutherland and Borden, 2015).
Research has shown that it gives incentives for innovation, especially if the bundle payment meets the following conditions:
● The compensation is linked to outcomes
● The financial risk in complications is linked to the performer
● The compensation model is constructed with value based principles
Studies have shown that bundled payments that meets these conditions gives strong incentives for innovation, particularly for private actors but also within public healthcare providers (Sutherland and Borden, 2015), (Khullar et al, 2015).
The capitation model has several promising features in theory. It gives the healthcare provider an overall responsibility for the patient, which means being able to adapt and organize from what the patient needs (Khullar et al, 2015). Autonomy facilitates innovative solutions such as digital services in the healthcare system, if the investment costs can be covered. In real life it is common to utilize action based compensation in addition to the capitation model, to cover up for its less attractive sides such as low incentives to activity and a lack of availability for the patients. It has shown increase the productivity but has also resulted in a landscape where it is more difficult to apply effective solutions which doesn’t involve a physician office visit (VanLare and Conway, 2012).
A more suitable solution with respect to requisites for distance care is to compensate the easier activities by the action based model, to maintain the availability, and simultaneously set a path towards value based principles with a responsibility for the general health in a population.
Conducted studies have shown that one successful way is to a greater extent link the compensation in primary and special care, where smaller costs in the latter as a consequence of more effective prevention and coordination work is transferred to successful units of primary health care (VanLare and Conway, 2012), (Sutherland and Borden, 2015).
The compensation models are not only correlated with the efficiency and receptivity to innovations, but with the quality of healthcare. Activity based compensation models are theoretically neutral in terms of quality of care (Jacobsson, 2008). Models with fixed compensation have shown to bring incentives to low activity, which in turn implicates a risk for low patient service and low quality. Compensation per product theoretically leads to a lower quality in terms of care, since the provider have incentives to keep down the resource consumption at every occurrence (Jacobsson, 2008). One important purpose with result based compensation is to compensate for the potential risks of low quality with the other models.
However, this have shown to cause other problems, such as a smaller focus on patients with diagnoses that are not covered by the result based compensation (Mold, 2017).
2.2.4 Culture and digital innovation within healthcare
In this study we define culture in an organizational context according to Needle (2004):
Collective values, beliefs and principles of organizational members that contribute to the unique psychological and social environment of the organization
Further, we define the subject of user experience on a personal context according to the International Organization for Standardization (2015):
A person's perceptions and responses that result from the use or anticipated use of a product, system or service
In this section we use this definition and target previous literature that include factors affecting the healthcare system’s receptivity to digital innovation. With this we aim to isolate subcultures within the healthcare system that we can use as theory in the empirical study and later when analysing the cultural impact on the receptivity of digital gamification services within speech therapy treatment.
Our first part of the theory section on culture target research regards the inner context as it affects the acceptance and sustainability of digital innovations in healthcare. The second part of the theory section on culture target research regards the user perception towards mobile services as it affects the receptivity of digital innovations in healthcare.
2.2.5 Inner context and the receptivity of digital innovations in healthcare
The inner context constitutes of the “hard, visible organizational structure, and the “soft”, cultural medium which both vary enormously between organizations (Gosling, 2007). In this study we are interested in previous research regarding the “soft”, cultural factor on digital innovation in healthcare. We call it the cultural assimilation for innovation - features of a healthcare organization that have been shown to influence the absorption of digital innovation and adopted by all relevant individuals.
With a review of related research, four drivers of digital innovation in healthcare are identified (Gosling, 2007), (National Health Service, 2017), (Kimberly & Cook, 2008):
Figure 3:Drivers of digital innovation in healthcare
A learning organisation al culture
That shows support for experimentation and the tolerance of failure and where risk taking is a norm
Knowledge sharing leadership
• A proactive leadership where senior staff stimulate sharing of knowledge, internally and externally
The ability to connect with new knowledge
• Members of the organization have capacity, approval and ability to horizon-scan and capture new ideas
foundation A of sound knowledge
and a competence
base
• In relation to a specific innovation, multiple members of the
organisation are familiar with basic concepts and able to apply them
2.2.6 Mobile devices, user experience and the receptivity of digital innovations in healthcare
During the past decade, mobile health systems have been rapidly increasing. This have sparked a lot of research in how the usability towards patients affect the receptivity of the mobile applications in a rehabilitation purpose. The aim is to use previous findings when analyzing the empirical results in the field of speech therapy, an area which have not been as actively researched.
Four key factors tied to the receptivity of mobile devices in healthcare rehabilitation have been identified through previous research (Demiris et al, 2008), (Koivumäki et al, 2006), (Boulos et al, 2011):
Figure 4: Receptivity of mobile devices in healthcare rehabilitation
User- friendliness
Factors dealing with hardware matters such as noise, size, obstructivity and artistic presence affect the receptivity of the product
User competence
• The users’ technology skills affect the usage for
rehabilitation purposes, where habit users are more likely to be receptive in using the devices. Higher user-familiarity of the device and higher user-skills increases positive
perceptions of the services
Usability
• Factors dealing with software matters such as device operation and interfaces affect the receptivity of the product
Confidence
• The users’ perception of their own technical knowledge affect the way mobile devices are adopted for healthcare purposes, where patients that have a higher perception of their knowledge tend to be more receptive to using products
3. Methodology
This chapter explains and motivates the chosen research approach, research design and methods for data collection and analysis.
3.1 Methodological approach and research design
The purpose of this study is to examine different healthcare systems’ receptivity to digital gamification services within speech therapy. The subject of receptivity to digital gamification services within speech therapy treatment has been sparsely researched, however the two closely related fields; healthcare digitalization and gamification has been subject for plenty of research (Alahäivälä & Oinas-Kukkonen, 2016), (Angst et al, 2011), (Johnson et al, 2016), (McKinsey
& Company, 2016), (King et al, 2013). In other words, we aim to fill a specific gap within a rather researched area.
An interpretive technique is used for this study. That is, an approach to social science where the researchers examine qualitative data, interpret it via forming an impression and study the impression in a structured form. This technique is used due to that the aim of this study is to understand rather than explain the given area, which suits the interpretive technique (Ashley &
Orenstein, 2009). Moreover, the phenomena examined in this study is highly complex and thanks to the adoption of interpretivism, areas such as cross-cultural differences in organizations, issues of ethics, culture and leadership and analysis of factors impacting those can be studied and understood in a great level of depth (Sanders, Lewis & Thornhill, 2012).
The view on knowledge for this study can be described as empirical-holistic. This enables an openness and adaptability towards the empirical data and new results, not discussed in previous research, which suits the purpose of this study. Further, this view on knowledge suits the use of qualitative data that are not limited to predetermined categories and do enable a holistic view with openness for contextual differences. Limitations of this view on knowledge are further discussed in the sections of trustworthiness and transferability, however the general limitations are tied to low degree of transferability and biases tied to the authors and respondents.
An abductive research approach is chosen, which involves gathering data and relevant previous research within the area. Next the data is analyzed in relation to previous research in order to find a better understanding of the specific phenomena. This approach is chosen due to that there are closely related research that in combination with observation could strengthen earlier, related findings and at the same time contribute to new understanding for the specific phenomena examined. The research was performed through an iterative approach, which means that the background, problem formulation, purpose, research question, method etc. was updated when new insights were acquired, according to recommendations by Blomkvist & Hallin (2015).
In social science, it is important to beware that the researchers’ owns interest and values affect the research. It is impossible to separate what happens in the social world from how the researchers interpret the research (Collins & Hussey, 2014).
To investigate how speech therapy systems affects a country’s receptivity to digital gamification services within speech therapy treatment. The methodology included gathering of qualitative data through interviews with stakeholders within the speech therapy system. The chosen methodology aims towards obtaining a better understanding of the research area, a sub- area within the healthcare system.
3.2 Research process
The research process is carved into three legs; pre-study, empirical study and analysis. To fully understand the purpose, direction and framework of the study, the first stage was a thorough pre-study. This was the section where the research area was defined and examined, leading up to the research questions and framework for the empirical study. Once this was established, the empirical-study was initiated. In this stage data was collected through semi structured interviews. The collected data was subsequently analyzed with related literature in order to answer the research questions. The literature review progressed throughout the whole research process.
3.2.1 Pre-study
A pre-study was made in order to contribute to a deeper understanding of different countries’
speech therapy systems and their characteristics before the empirical study. The pre-study was initiated with a thorough literature review on the area of speech therapy in general and the area of speech therapy treatment in specific.
Furthermore, unstructured interviews were performed with one Swedish and one American speech therapist and complemented by unstructured interview with one American and one Swedish member of the national speech therapy association. The two countries were chosen and limited to, also for the empirical study, because of:
- Limitations in number of countries examined was done due time limitations
- Structural differences within the two speech therapy systems, such as financing, organizational design and regulation, that serve different perspectives and potential contextual differences
- The access to relevant information and willingness to participate among relevant respondent groups
The unstructured interviews were done in order to explore an area of research with merely overall headings to describe the direction of the conversation. This is a useful concept in the beginning of a study, where the respondent can speak openly about a topic when the need is big to explore a specific area (Blomkvist & Hallin, 2015). This enables the researcher to get information that otherwise could been lost while discussing (Collis & Hussey, 2014).
3.2.2 Empirical study
From the pre-study a deeper understanding of the speech therapy system and its’ characteristics was acquired. This understanding was then used to decide what stakeholders to be interviewed for the two examined countries and to be able to navigate in the interviews of the empirical study, however not tied to certain categories in order to be able to adapt to where the interviews could lead. The interviews were based on barriers and possibilities tied to the receptivity to digital gamification services within the speech therapy treatment. The respondents then shared their knowledge, experience and opinions on the broad and open interview questions.
The interview results were later mapped out by the unstructured interviews. The barriers and potential shared from the respondents was then thematized in order to find potential similarities and differences with previous research on the area of healthcare digitalization as well as new findings, not earlier discussed in previous research.
Interviews
The interviews conducted were of unstructured nature with open-ended and general questions regarding barriers and potential to the receptivity to digital gamification services within speech therapy. The respondents for the empirical study were chosen in order to cover the different types of perspectives within the speech therapy system. These respondents were:
- Speech therapists - Clinical managers
- Digitalization experts within the field of speech therapy (working with governmental digitalization projects within speech therapy)
The methodology of unstructured interviews is such that interview questions are not prearranged. The interviewer has instead prepared a number of topics that the interviewer wants to cover (Klenke, 2008). In this way the interviewers are able to explore new areas that might derive from the interview (Collis & Hussey, 2014). This creates space for flexibility, where interesting information that might otherwise have gone unnoticed now can be explored. In open- ended questions the respondent is encouraged to describe the subject thoroughly rather than digital answers, “yes” or “no” (Collis & Hussey, 2014).
Stakeholder Country Duration
Speech therapist American 2 times 1 h Swedish 3 times 45 min Clinical Manager American 1 time 1,5 h
Swedish 2 times 1 h Digitalization Expert American 2 times 45 min
Swedish 2 times 45 min
Table 1: Stakeholders, country and interview duration
All respondents are anonymous, in order to get as valid answers as possible. The results from the interviews were, when viewed separately, interpreted as personal opinions and not opinions that the whole organization share.
The interviews were conducted with both researchers present in order to more likely be able to capture crucial information and steer the conversation in directions that resulted in valuable knowledge. In the analysis, the results were separately interpreted and afterwards discussed so that both researchers would be able to provide insights.
Another feature that may be considered to be a limitation is that the theoretical framework of the study encloses the healthcare system in general, not directed to any specific country. Due to lack of time, the interviews with different stakeholders had to be limited with respect to quantity and countries. The results would have been more reliable if they included stakeholders from additional countries and individuals amongst each targeted stakeholder.
3.3 Credibility
The credibility varies amongst the information sources used and the conclusions drawn. The information gathered in the literature review, the theoretical framework, statistical and regulatory information, should in general be seen as high since they derive from quality secure channels.
The credibility of interviews in general are low and since unstructured interviews are used in the pre-study and semi-structured interviews in the empirical study. To increase credibility, the following approach was used:
1. A test-group was used to calibrate the topics with respect to quality, perceptiveness and precision
2. All interviews were recorded and later written down 3. Ensured that all pre-designed topics were processed
3.4 Transferability
Transferability is the extent to which research findings can be extended to the population in
for this study, relate to the subjective nature of this approach and that it is highly sensitive to bias on behalf of the researcher (Saunders, Lewis & Thornhill, 2012). The empirical data used for this study also has a low degree of transferability since the data is heavily impacted by personal viewpoint and values, this could also be seen in the formulations from the interview extracts in chapter 4.
However, thematized results and conclusions drawn should be seen as indications that contribute to the theoretical research within the area. Since the speech therapy system have different stakeholders which may have various incentives in different countries, the unstructured interviews only capture a handful of these contextual differences.
3.5 Ethics
The study was performed in line with the Swedish Research Council’s four main ethical codes.
These codes can be summarized by (Gustafsson, Hermerén & Pettersson, 2011):
The Code of Information
- The researcher shall inform the respondents about their task in the specific research and what terms that concern their participation. They shall be informed about all elements that may affect their willingness to participate and that their participation is voluntary.
- Actions taken: An information material was produced that aimed to thoroughly describe the research purpose, the purpose with the specific information gathering and how the information was handled and processed. The information material was read by the interviewer.
The Code of Concurrence
- The researcher shall obtain the respondents concurrence. They shall own the right to decide if, for how long and on what conditions they participate.
- Actions taken: All respondents were informed that the participation was voluntary. No incentives were offered or given to the participants. Further, all participants were informed about their right to cancel the interview/survey whenever they wanted to.
The Code of Confidentiality
- All agents, involved in the research project, with access to ethical sensitive information about individual and identifiable persons shall sign a confidentially agreement regarding this information. Further, all information about identifiable respondents shall be written down, stored and presented in a way that individuals can not be identified by outsiders.
- Actions taken: Access to the information gathered from interviews and surveys was limited to the two authors of this study. A confidentially agreement with respect to this information was signed by both authors.
The Code of Good use
- Individual information, gathered for research purposes, shall not be used for commercial interest or other non-research purposes. This information shall not be used for decisions or actions that directly affects involved individuals without a separate admission.
- Actions taken: Individual information was processed in order for no outsider to be practical able to identify individual information.
4. Results & Analysis
This chapter presents the empirical data from conducted interviews. The empirical data are presented in different sections based on what receptivity factor they are referring to.
The empirical data was conducted through in-depth interviews with different stakeholders within speech therapy; digitalization experts, clinical managers and clinical active speech therapists. For the two examined countries, Sweden and the United States, there was one respondent from each of the four respondent groups.
The empirical data will be presented in sections based on the receptivity factor they are referring to; Regulation, Financing, Culture and Other factors.
Based on the conducted interviews emerged a number of key factors that affects the receptivity for digital gamified services in speech therapy. These factors will be presented as they emerged in the interviews and analyzed with respect to the previous research and the new discoveries in the particular research field.
An overview of these key factors are presented below:
1. Regulation
a. Restrictions tied to the collaboration and information spreading with adjacent institutions
b. Treatment methods
2. Compensation
a. Compensation models effect on treatment
3. Culture
a. Digital gamification friendliness amongst speech therapists
b. Digital habits and demands amongst speech therapy recipients and their parents c. Leadership sharing digital knowledge at speech therapy clinics and institutions
4. Socio economic factors
5. Stakeholders and structural forces within speech therapy
4.1 Regulation
4.1.1 Restrictions tied to the collaboration and information spreading with adjacent institutions
An overall theme when interviewing speech therapists and clinical managers from both United States and Sweden was that restrictions tied to the collaboration with adjacent institutions act as a barrier for the receptivity to digital gamification services.
From interviews with the Swedish speech therapist:
To see and understand how children with SLI act in their every-day context, a valuable method is to observe them in pre-school and search for how speech-language difficulties appears in real-life situations. However, we are not allowed to collaborate and consult with pre-school employees or parents to the extent that we want to.
The Swedish speech therapist later continued:
This possible collaboration would clearly suit a digital platform that follows the patient's development like the service you are referring to (digital gamification services). The pre-school employee can give time for the child to sit down and train and know what areas to support.
From interviews with the American clinical manager:
The non-existing and restricted phenomena of collaboration between institutions that all have some kind of interest for helping children with SLI are probably a barrier for the receptivity to digital gamification services. This kind of product would have several benefits for helping the children to get the right training and for employees within these institutions to have a suitable and accessible tool to use.
From interviews with the American speech therapist:
A digital gamification service could serve as a useful tool for the interface between speech therapists, other related workgroups and the children’s parents. One of the challenges within speech therapy is the training in-between the speech therapy sessions and this product would help others than the speech therapists to support the children in their training.
The extractions above clearly indicate that the restrictions regarding collaboration and information spreading between institutions adjacent to speech therapy clinics work as a barrier to get a holistic picture and training of children suffering from SLT. Further, these potential collaborations seem to be suitable environments for digital gamification services. The lack of these collaborations and information spreading could therefore be seen as a barrier for the receptivity to digital gamification services on a system level.
This barrier can be tied to and explained by a number of areas from the previous research regarding regulations. Firstly, the balance between possibilities coming from digitalization and risks such as risks tied to breaches of integrity is complex. This analysis is however limited to barriers for the receptivity to digital gamification services and therefore the analysis of potential effects from new regulations are excluded.
From the previous research we have that the high development pace of today’s technology puts a high pressure to a dynamic and ever changing legislation. Research has shown that legislation must be flexible to changing needs, possibilities and risks in order to utilize the potential that comes with digital development.
The responses from both Swedish and American speech therapists and clinical managers are in line with the previous research concerning regulations and digital innovation in healthcare. That is that the restrictions tied to collaboration and information-spreading contradicts, to various extent, the characteristics of regulations that are receptive to digital innovations within healthcare; User/Individual perspective, Regulations used as guidelines and Local mandatory.
Firstly, the collaboration restriction doesn’t seem to have a user perspective since the respondents point out a number of benefits tied to collaborations on the patient’s behalf. The restrictions could instead be seen to have the traditional organizational focus, easing the control and management of the speech therapy system. Further, the collaboration restriction could not be seen to characterize regulations used as guidelines or facilitate local mandatory. That is since the restrictions are no guidelines but rather detailed regulations and that there are no room for local organizations to decide with whom to cooperate with in order to maximize the value.
Previous research highlight that today’s set of regulations were developed and established in a time when the digital landscape did not exist. Regulations was established rather to protect information from other organizations than to spread information between them, which is one of the keystones in the nature of digitalization. The collaboration and information spreading barriers to digital gamification services within the speech therapy system are therefore confirming the previous research within the greater field of healthcare digitalization.
4.1.2 Treatment methods
Another factor within regulation that repeatedly was mentioned amongst the respondents corresponds to what activities that the speech therapists are able to use. Despite the fact that the American speech therapy system use a larger variety of treatment methods, the majority of treatment comes from physical treatment sessions at the clinic, as for the Swedish speech therapy system.
From interviews with the Swedish speech therapist:
As I mentioned earlier, we can only get compensated by physical treatment sessions.
That can be seen as a barrier for digital gamification services since distance treatment such as e-rehabilitation and telerehabilitation suit these kind of services better.
If we for example were able to prescribe homework tied to these digital gamification services it would imply not only that we would use it as a central tool within treatment sessions but also that the service would have a natural entry to the patient's every-day life.
From interviews with the American speech therapist:
Physical treatment sessions stand for a definitive majority of our total service delivery and this is a method where digital gamification services often are seen as just one of many tools to train children suffering from SLT.
Other treatment methods such as e-rehabilitation are under strong development and faces increased demand from the patients. This demand often comes from the patients living far from the clinic or from the patients’ whose parents have difficulties finding time to follow their children to the clinic. In those situations, digital tools become more natural and central devices in the treatment.
A barrier for these new methods is that plenty of our patients’ insurances does not cover these methods. Another, I think, is that we (speech therapists) are to passive in offering these services.
From interviews with the American digitalization expert:
As for the healthcare in general, the speech therapy system are regulated and managed by structures that was developed at a time when digital services was non-existing. This has shown to be a clear barrier for digital innovations to find it’s place in the current system, so also for the digital gamification services.
A number of countries, e.g. Australia have tried to loosen up some of the old regulations, compensation justified activities and part of the patient secrecy within healthcare that have led to positive impacts for digital innovations. This is however a long and very complex process tied to both benefits and challenges for the whole healthcare system and its surroundings.
Both the American and Swedish respondents argue that the physical treatment session has less receptivity to digital gamification services than alternative and less used methods such as telerehabilitation and e-rehabilitation. These alternative methods do however seem to become more commonly used, especially in situations that suits these kind of methods better, e.g. when the distance between the patient and the speech therapist is large.
