The emergence oftechnology-based service systemsA case study of a telehealth project in Sweden

Anna EssenStockholm University School of Business, Stockholm, Sweden

Abstract

Purpose – The purpose of this paper is to propose a framework for studying the process oftechnology-based service system innovation from a broad perspective using an approach thatelucidates the non-linear facets of this process. The framework draws on Levy-Strauss’s conceptof bricolage, which implies that individuals’ “making do with resources at hand,” as opposed tomanagerial visions, can trigger innovation. This concept is combined with the notion of technologicaldrift and with a model of emergentism.

Design/methodology/approach – The paper uses case study data from the Swedish elderlyhomecare setting.

Findings – The findings illustrate how the emergence of technology-based care services can betriggered by an injection of energy in terms of a new technological resource being made available in anorganization, proceeding as a continuous interaction between personnel repurposing and recombiningresources at hand, positive and negative feedback dynamics, institutional regulations andculture-related stabilizing mechanisms.

Research limitations/implications – New services can arise as a result of a number of efforts andevents that, in isolation, might appear insignificant. Taken together, and interacting with enabling andconstraining forces that promote the emergence of certain new services and prevent others, such actsand events generate unpredictable outcomes. The result may be incremental but by no means trivialinnovations.

Originality/value – The paper suggests an approach to innovation that complements conventionalthinking in the new service development literature. The proposed framework can help to explain howand why certain new services emerge and why others do not in unexpected and unpredictable ways.

Keywords Elder care, Sweden, Customer service management, Technology led strategy,Service systems

Paper type Research paper

1. IntroductionKnowledge about the service innovation process is important for our understanding ofthe transformation of offerings, organizations and sectors over time. However, it is stillan underexposed area in the literature (de Jong and Vermeulen, 2003; Sanden, 2007;Syson and Perks, 2004), particularly the process of innovating technology-basedservice systems (Menor et al., 2002; van Riel, 2005). Authors have recently pointed atthe complexity related to this kind of service innovation, arguing that it involves notonly technological, but also organizational development (Magli et al., 2006; Piccoli et al.,2004). It has further been suggested that the technology-based service innovationprocess encompasses many informal and iterative elements, and that it is influenced byextra-organizational factors, such as prevailing policies and cultural values (Barlowet al., 2006). These insights indicate that students of technology-based service

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Received 22 June 2007Revised 4 January 2008Accepted 3 April 2008

Journal of Service ManagementVol. 20 No. 1, 2009pp. 98-121q Emerald Group Publishing Limited1757-5818DOI 10.1108/09564230910936878

innovation should take on a broad perspective. Regrettably, the emergingtechnology-based service innovation literature does not quite respond to this call.Existing studies largely attempt to:

. model the systematic sides of technology-based service innovation; or

. investigate to what extent certain technology-based services respond to certainconsumers’ needs (Chircu et al., 2001; Dabholkar et al., 2003; Lanseng andAndreassen, 2007; Massey et al., 2007; Mørch et al., 2004; Slater and Mohr, 2006;Sung-Eui, 2005; Walker et al., 2002).

This tends to produce studies incapable of capturing the complexity oftechnology-based service innovation. The prevailing practice-oriented approachtends to generate studies that neglect the informal and unpredictable dimensions ofthe technology-based service innovation process and its sensitivity to the influence ofextra-organizational factors. This weakness applies to the new service developmentliterature in general. It is dominated by studies depicting service innovation asa well-planned, formal process, starting with a managerial vision and ending with afull-scale launch (Cooper et al., 1994; Johne and Storey, 1998; Menor et al., 2002).Although authors have criticized these models for obscuring the iterative andbottom-up sides of service innovation (Edvardsson et al., 1995, Dolfsma, 2004; Stevensand Dimitriadis, 2004; Sanden, 2007), alternative models are hard to find.

In summary, the new service development literature (including studies focusing ontechnology-based service innovation) mainly theorizes about the formal, linear andpredictable facets of the innovation process despite observations suggesting that manyinnovation processes are cyclical and that they involve unexpected, informalinteractions between factors at the individual, organizational and societal level. Thelack of theoretical understanding of the latter aspects has implications in practice.Such aspects are not considered in cost analyses or supported with tools ortechnologies (Maglio et al., 2006). As a result, informal mechanisms and ideas are notcaught up, potential innovations go unnoticed and many extra-organizational forcesthat exert a positive or negative influence on the innovation process are not dealt with,leading ultimately to a reduction in financial performance.

The present paper seeks to address the imbalance in the literature by proposing aframework for studying the process of technology-based service system innovationfrom a broad perspective using an approach that elucidates the non-linear facets of thisprocess. The paper draws on Levy-Strauss’s (1966) concept of bricolage, which impliesthat individuals’ “making do with resources at hand,” as opposed to managerialvisions, can trigger innovation. To flesh out this concept, illustrating how it isinfluenced by certain institutions, resources and events, the present paper integratesit with the notion of technological drift (Ciborra et al., 2000) and with a model ofemergentism (Chiles et al., 2004; Prigogine and Stengers, 1984).

The paper illustrates the proposed framework using empirical data on the firstphase of developing technology-based elderly care services. Hence, the paper respondsto calls for innovation research in settings other than the financial sector, which hasreceived a disproportional amount of attention in the development literature to date(Smith and Fischbacher, 2005; Stevens and Dimitriadis, 2004). The care setting isrelevant as increased healthcare spending and possibly unsustainable healthcarefunding models motivate many care providers to develop existing care services by

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using information technology (IT) or “telehealth” applications (Koch, 2006; Lansengand Andreassen, 2007; OECD, 2004). Service development in this area, however, isimmature and there are internationally few examples of telehealth services offered inroutine care service delivery (Barlow et al., 2006). This situation in particular and thepublic healthcare sector in general have received surprisingly little attention inthe service innovation literature (Smith and Fischbacher, 2005).

Drawing on the proposed emergentism framework, this paper describes thebeginning of an innovation process, which is triggered by a new technological resourcebeing made available in a care organization and proceeding as a continuous interactionbetween repurposing mechanisms, feedback mechanisms, institutional regulations andstabilization mechanisms. This way of understanding the service development processextends the concepts of bricolage and drift by revealing the enabling and constrainingdynamics that reinforce the emergence of certain services and prevent others fromemerging. The applicability of these insights goes well beyond the care setting and isrelevant to students of innovation processes in general. Overall, the paper opens upavenues for research studying how new services can arise, actualize and materialize ina non-linear and rather unpredictable way. In this way, it serves to complement thenew service development and service innovation literature, which to date has beendominated by studies outlining “success factors” and emphasizing the importance ofsystematic innovation processes (Astebro and Michela, 2005; Atuahene-Gima, 1996;Avlonitis et al., 2001; de Brentani, 2001).

The paper begins with a selective literature review and a presentation of theproposed theoretical framework, integrating insights from bricolage (Levy-Strauss,1966), technological drift (Ciborra et al., 2000) and emergentism (Chiles et al., 2004;Prigogine and Stengers, 1984). A case study from a telehealth project conducted by apublic elderly care provider in Sweden follows. The paper concludes with implications,limitations and suggestions for further research.

2. The innovation of technology-based servicesThe concern of this paper is the process of innovating new technology-based servicesystems[1]. The “new service development” literature has paid little attention to suchinnovation processes (Menor et al., 2002). A review of the nascent technology-basedservice innovation literature reveals that it largely attempts to shed light on thesystematic, ordered facets of the development process (Chircu et al., 2001; Palmer andGriffith, 1998; Passerini et al., 2007; Sung-Eui, 2005; van Riel and Lievens, 2004).For example, Piccoli et al. (2004) conceptualize the development of technology-basedservices as a migration from one discrete phase to the next that follows a predictablepattern determined by the firm’s overarching goal of maximizing its return on itstechnology investment. Many service development studies further focus on consumers’adoption of technological innovations (Dabholkar et al., 2003; Lanseng andAndreassen, 2007; Massey et al., 2007; Slater and Mohr, 2006; Walker et al., 2002;Vrechopoulos et al., 2001). This research produces important insights, but tends tobring about an understanding of the innovation process as predictable and possible tocompletely control.

A few recent studies have suggested that the process of innovatingtechnology-based services is more complex than previously thought. Barlow et al.(2006) point out that this process involves integration between the technological

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innovation and the service provision system (including authority structures). They alsosuggest that the policy context, contemporary values and cultural norms can influencethe innovation process[2]. In general, they point at a mishmash of factors, at variouslevels, that can play important roles in the process of innovating technology-basedservices. Maglio et al. (2006) similarly suggest that technology-based serviceinnovation involves not only technological relationships but also organizational andindividual relationships, i.e. that it should be understood as a matter of developing newservice systems. Their examination of IT service delivery systems suggests that suchsystems comprise a large share of non-planned tasks and negotiations performed byindividuals and that other “fuzzy” factors, which are beyond the manager’s directcontrol, influence the development of such systems.

These latter studies indicate that the technology-based service innovation process:. involves more than the ordered implementation of a new technology is;. cyclical rather than linear and that it is; and. influenced by informal and unpredictable factors, among which many are

beyond the organization’s control.

As noted above, however, such aspects have not seen much light in the new servicedevelopment literature. In their review, Johnson et al. (2000) conclude that the NSDliterature provides three types of innovation process models: models that depict a partof the process (Schostack, 1984); models based on blueprints for new productdevelopment (Bowers, 1989); and comprehensive models (Scheuing and Johnson (1989)that propose a model including 15 stages). Common for these models is their normativecharacter and their focus on intra-organizational issues and phases that the NSDprocess “should” encompass. Sanden (2007, p. 41) writes that more recent research hasconcentrated on various aspects of NSD but that few studies have examined the NSD“process”. Interestingly, Sanden (2007, p. 18) argues that NSD is often “ad hoc andbased on trial-and-error type of approach”. It is further important to note that researchon innovation systems more generally is increasingly underlining that innovation canoccur through other pathways than well-managed and systematic processes.Observations suggest that innovation trajectories are often informal, ad hoc andunpredictable and that they should be understood as cyclical, including variousfeedback loops and evolving through complex – often unexpected and even accidental– events (Consoli, 2005; Gadrey et al., 1995; Jensen et al., 2007; Metcalfe et al., 2005;Rothschild and Darr, 2005).

However, few models elucidating how trial-and-error mechanisms and other factorsinteract have been suggested. Hence, there appears to be a need for a morecomprehensive framework in the innovation process that allows for a multi-levelanalysis of the dynamics between emergent micro-processes at the individual andorganizational level, on the one hand, and structures at societal level, on the other. Inthe next section such a framework is outlined. I will start by introducing the notion ofbricolage (Levy-Strauss, 1966) and technological drift.

2.1 Bricolage and technological driftThe concept of “bricolage,” often referred to as making do with “whatever isat hand” (Levy-Strauss, 1966, p. 17; Miner et al., 2001; Weick, 1993), helpedto describe and understand the innovation process observed in this study.

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This paper draws on Baker and Nelson (2005, p. 333), who define bricolage as “makingdo by applying combinations of the resources at hand to new problems andopportunities.” Resources at hand refer to a set of pre-existing “odds and ends”(Levy-Strauss, 1966, p. 18), such as available materials (Lanzara, 1999), copingmechanisms (Hatton, 1989) and skills and ideas (Baker and Nelson, 2005). Bricolageimplies that such resources-at-hand are reused for different applications than those,which they were originally intended for or used (Garud and Karnoe, 2003; Miner et al.,2001). In other words, bricolage is the repurposing and refashioning of the old inmaking something new (Weick, 1993) and it involves recombining existing elementsrather than fabricating them from scratch (Baker and Nelson, 2005).

Bricolage contradicts the rational model of innovation as seeking means to reach agiven end. In bricolage, the ends are not clearly known at the outset and the“reasoning” process does not use logical deduction but is more of a spontaneousprocess (Innes and Booher, 1999). Bricolage is related to improvisation. To paraphraseMiner et al. (2001, p. 314):

[. . .] as improvisation permits no temporal gap between the design and execution of activities,improvisers have little opportunity to seek resources beyond those already at hand, and theytherefore typically engage in bricolage.

Hence, in contrast to conventional views on innovation, bricolage suggests thatinnovation can be understood as actors departing from the means and graduallylearning what aims are possible. It is difficult to foresee the result of such practices.Bricolage is associated with unexpected outcomes that are half-realized, hybrid andimperfect, but which do their job and can be improved (Lanzara, 1999; Miner et al.,2001). As this paper deals with technology-based services, insights on theunpredictability of outcomes in the information systems (IS) literature are relevantto consider here. The IS literature discusses this in terms of technological drift (Ciborraet al., 2000, p. 4), i.e. the tendency of technologies to deviate from their planned purposefor a variety of reasons. Technology often performs in unexpected ways and it tends toproduce unintended side effects when implemented. As a result, users often have torevise goals and intentions or try to find ways to alter or work around the technologicalproperties over time (Ciborra et al., 2000; Pickering, 1995). The affordance (Gibson,1979) of technology, i.e. users’ perception of what action is possible with thetechnology, is further highly contextual. This fact shapes the consequences of ISimplementations in unpredictable ways (Orlikowski, 1992; Feenberg, 1999; Murata,2003).

Summing up, the concepts of bricolage and technological drift complement eachother, suggesting that the innovation of technology-based services can be triggered byindividuals making do with available resources, and that the outcomes of suchpractices, i.e. the new technology-based services that actually emerge, may be differentfrom what was initially envisaged by technology designers or the user organization.These insights were valuable when analyzing the innovation process studied here.However, it soon became clear that there was more to the process studied than actors“making do with resources at hand.” Further, neither bricolage nor technological driftcould sufficiently explain why certain technology-based services emerged while otherswere prevented from being realized. Why did outcomes “drift” in one direction and notanother?

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2.2 Proposing a framework for studying the emergence of new technology-based servicesAlthough the literature applying bricolage and technological drift sheds light onthe triggering- and outcome-related elements of the innovation process, the bricolageprocess has essentially remained a black box. To open this black box, i.e. unpack theintermediate dimension of the innovation process, this paper uses insights fromcomplexity theory (McKelvey, 1999). Complexity theory is suitable for the study of hownew services can come to be as it focuses on emergence, on “becoming rather thanbeing” and on “process rather than state” (Gleick, 1987, p. 5). It can be used to explainhow and why a phenomenon evolves from the interaction of myriad events, small andlarge, spontaneous and deliberate and at multiple levels (Chiles et al., 2004). The ideathat emergent properties amount to more than the sums of the properties of their partsis central in emergentism theory (Gleick, 1987). This paper uses the dissipativestructures model (Prigogine and Stengers, 1984; Chiles et al., 2004), which posits fourinteracting mechanisms of emergence[3]:

(1) “Fluctuation” refers to injections of energy represented by new activities, eventsor resources that interrupt the existing order and catalyze the emergence of anew order.

(2) “Feedback dynamics” amplify the initial fluctuations, helping the new order totake hold and gain momentum.

(3) “Recombination dynamics” refers to how the system’s existing elements arereused, rearranged, reconstructed, re-leveraged and re-created.

(4) “Stabilization dynamics” are deep structures that shape novelties and guidechoices in a way consistent with the systems accumulated history and learning,preserving the systems identity and core behavioral patterns.

Hence, the dissipative structures model overlaps with bricolage but it also extends thisconcept by specifying the forces that enable and constrain what individuals can makeof the available technological resources. Although organizational students have usedthe dissipative structures model to explain how the evolution of organizational systemsproceed from a “punctuated emergency” to the next, i.e. from one order to another overtime (Chiles et al., 2004; Leifer, 1989), this paper uses it to explain the first phase in aservice development process, i.e. the emergence of a new service, which can beunderstood as the evolution of one new order.

The framework (Figure 1) suggests that the development of new services canbe triggered by the injection of energy in terms of a new technology resourcebeing made available in an organization. The organizational members will engagein bricolage (Levy-Strauss, 1966) by making do with the new resource, i.e. theywill repurpose it and recombine it with old resources, and as a result, they willlearn what the technology affords in context. The individual members’ acts ofmaking do should, however, not be confused with boundless freedom and endlesscreativity. Positive and negative feedback mechanisms shape their acts of makingdo. That is, the immediate responses the personnel encounter when using the newresource will amplify certain uses and prevent others from being repeated. The(unexpected) performance of the new technology, when implemented, will alsoactuate responses and developments in certain directions rather than others. Theseresponses contribute to the definition of the boundaries of the emerging service.

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The emergence of new ways of using the new resource, i.e. the birth of newtechnology-based services, is further influenced by more permanent institutionalconstraints and stabilizing mechanisms, such as organizational structure,regulations and cultural values (Chiles et al., 2004; Prigogine and Stengers,1984). The innovation process will unfold as a continuous interaction betweenthese enabling and constraining mechanisms, producing results that may driftfrom the original intention of the technology designers and the user organization(Ciborra et al., 2000). In general, it is difficult for any single actor to control theoutcome of this process because it is shaped by participants and forces at variouslevels and at different points of time.

This view of the innovation process has emerged during the process of writing thispaper (see method section) and it has guided the analysis and presentation of thepresent findings.

3. MethodThe present paper explores how the mechanisms shown in Figure 1 operate in aparticular context such as technology-based care service innovation, i.e. the purpose isto develop rather than to test theory. The study is based on a single case. This case waschosen for theoretical reasons in the sense that it could reveal an unusual phenomenon(technology-based care service innovation) and support the elaboration of the emergent

Figure 1.A framework forunpacking the concept ofbricolage in the context ofthe innovation oftechnology-based services

Feedbackmechanisms:The positive/negativeresponses personnelencounter whenintroducing noveltiesand personnelreacting tounexpectedtechnologicalperformance.

The injection of energy : Anew technologicalresource. This resource isredefined over time alongwith personnel using it andthe contextual affordancesthat emerge.

Making dowith resources at hand:The recombination, reuse andrepurposing of availableresources, including the newtechnology.

Institutional constraints &stabilization mechanisms:Personnel adjusting to institutionalconstraints, to culture and to values.

Drifting outcomes

NewServicesemerging

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theory (theoretical rather than representational sampling (Yin, 1984)). Studying thesingle case over a three-year period (2004-2007)[4] allowed me to follow the informal,gradual processes of service development over time in its real-world context and to usevarious information sources (Yin, 1984). In general, the case study approach is suitablefor longitudinal research seeking to unravel the underlying dynamics of phenomenathat play out over time (Siggelkow, 2007).

3.1 Data generationA telehealth project conducted by the community care organization in Heby, Swedenconstitutes the case studied. Heby is one of few elderly care providers engaged inthe development of IT-based services in Sweden. The author has participated in a largenumber of formal and informal meetings in Heby from 2004 to 2007. Field notes havebeen taken from these observations and home-helpers’ service documentation hasfurther been scrutinized and summarized in field notes. In 2006, 12 unstructuredinterviews were performed with home-help and managerial personnel within the Hebycommunity care organization. The interviews revolved around visions about thetelehealth technology and the actual use and development of services based on thistechnology (see Appendix). The longitudinal study allowed the researcher to askfollow-up questions (see interview guide in the Appendix) and thereby understand howone thing led to another (interactions).

Interviews were performed at the nursing home where personnel gather before theydeliver home-help services. The interviews, which lasted about 90 minutes each,included open-ended questions in order to allow for unexpected issues to emerge.The interviews were recorded, transcribed and translated (Swedish to English) by theauthor.

3.2 Data analysisFollowing the pattern for inductive research (Denzin and Lincoln, 1998; Miles andHuberman, 1994), the author worked recursively between the interview transcripts,field notes and the theory being developed. Field notes and interview transcripts wereanalyzed at two levels. The author first focused on building detailed descriptions ofparticular acts in which the individuals involved in the telehealth project created newways to use the new technology. These descriptions were then coded tentatively usingkey words that emerged from the empirical data (Miles and Huberman, 1994). Whendocumenting patterns in the data, tentative theoretical explanations were constructedbased on an initial framework. The individual-level, pragmatic, ad hoc and bottom-uptendencies ran across interview transcripts as well as observational notes. Similarly,the role of forces at the structural level was evident in several sources. The authordiscussed uncertainties in the data with two of the home-helpers on several occasions.Several working papers that attempted to explain regularities in the data were written.These papers were presented to peer scholars and critical feedback was received.During the repeated process of interrogating the data, revising the theory andreturning to the data, Levy-Strauss’s concept of bricolage was discovered as a goodcharacterization of the behaviors observed in the case. However, it became obvious thatthis concept could not explain the process alone. The dissipative structures modelemerged as relevant after some modification. After several rounds of experimentalcoding, the themes reported in the present paper emerged (Denzin and Lincoln, 2000).

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In the presentation of the results illustrative examples of the data from which theauthor drew inferences are provided (Miles and Huberman, 1994). When quotes areused, the names of the informants are coded.

3.3 The caseThe study focused on a sub-unit of the Heby community care organization (as this unitimplemented the new technology). This sub-unit employed 18 home-helpers at the timeof the study. The municipality director of Heby is ultimately in charge of the caredelivered by these home-helpers. There are also regional managers, heading overgroup leaders, who in turn lead groups of home-helpers.

In 2003-2004, the Heby municipality director and regional manager decided toinvest in an activity monitoring technology. At this time, Heby was suffering fromfinancial constraints (budget deficit). The managers used money from a temporarymunicipal development fund to cover the investment. The new technology hassimilarities with “traditional safety alarms” that are provided to seniors in thecommunity. The monitoring units are wrist-worn and include a button that seniors canmanually press when they are in an emergency situation. The new monitoring units,however, also include functionality that differs radically from the traditional alarms.Embedded sensors continuously monitor the activity level of the seniors, transmit thisinformation to service providers and present it in the form of graphical activity curvesdisplayed on a computer screen. The monitoring system also sends automatic alarms topersonnel if significant changes in activity level are detected (e.g. if a senior iscompletely inactive as this can indicate an emergency). The system thus providesinformation about subtle changes in activity patterns over time (i.e. non-emergencyinformation), but also about drastic changes in activity levels via automatic inactivityalarms (i.e. emergency information). The Heby managers bought 23 end-usermonitoring units. The technology was installed in 23 elderly households located in asub-region of Heby. They also purchased a PC with a certain application installed,which was needed in order for personnel to be able to analyze the patient activityinformation (graphical activity curves) generated by the system.

4. FindingsThe development process studied was characterized by a continuous interactionbetween the mechanisms in the proposed theoretical framework. The mechanisms areillustrated with examples from situations where they were salient.

4.1 An injection of energy: introducing a new technological resource without a clear endin sightA group of managers in the Heby community care organization initiated thedevelopment process studied. They envisioned that new technology-based servicescould contribute to a more cost-effective care service production and thus decided toinvest in a telemonitoring system. There were numerous new care technologiesavailable on the market, but few targeted the elderly homecare sector. Therefore, themanagers pragmatically “settled” with a technology that seemed to hold some promise.An important reason for the managers paying attention to this particular technologywas an informal relationship between key actors (as opposed to a systematic scanningof all technologies available). Serendipitous events, such as people being seated next to

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each other at a grand dinner, played a role here. The vendor marketed the monitoringsystem as a tool for ensuring the safety of seniors living in single households:

[. . .] The message was that the monitoring system would enhance our capacity to detectemergencies [. . .] And the extended information about the senior patient’s “general status”would enable us to “know” our seniors better [. . .] (Birgitta, Manager).

Although the managers were animated by such claims, they were uncertain aboutwhat benefits the use of the technology could produce at a more concrete level:

We found it difficult to predict [. . .] At this stage, our belief was that the advantages of themonitoring technology in practice would emerge along with the staff members starting to useit (Anna, Manager).

It was difficult for the managers to formulate a new service concept at this stage becausethey were unsure of what the new technology, in the hands of the home-helpers, could do.

4.2 Making do: “creating” the resources needed to innovate servicesThe managers saw to that the new hardware and software were paid for.Their engagement, however, was limited to the purchase of the new technology.Hence, the front-line employees (home-helpers and their group leader) faced thechallenge of installing, configuring and using the new technology without any newresources formally being allocated to this purpose. The empirical material revealedthat the personnel, “out of nothing,” created resources that, taken together, made itpossible for the technology to be used and the innovation of new services to begin.Take, for example, the issue of finding a place for the new PC (to which the monitoringinformation would be sent). The home-helpers do not have an “office” as they arealways out visiting seniors. The home-helpers, however, meet every morning at one ofthe community nursing homes for demented patients. The group leader repurposed aroom that was not occupied by any senior to create space for using the technology:

This room is rarely used, and it can be locked, which is important as the elderly [nursinghome residents suffering from dementia] may otherwise wander through the door and startplaying with the computer (Liv, Group Leader).

There was also a need to “find” time to install the new monitoring devices in the elderlyhouseholds. The group leader managed this by reallocating time from other tasks thatcould wait. As this was not always possible, the installation was sporadic and spannedover a long period. Moreover, because there were no formal resources allocated to this,the personnel were forced to “create” technical support. The group leader tookadvantage of her good relationship with an employee at the technology vendor in thiscontext:

There were a lot of unexpected problems in the beginning. I can tell you that [. . .] so I calledFredrik [employed at the technology firm] and told him that we just had to make themonitoring devices work again [. . .] Poor Fredrik I called him often, but he was alwayswilling to help. He has a hard time saying no – he’s that type of guy [. . .] Fredrik really wantsus to like the new technology [. . .] so that we can spread the gospel I guess [. . .] we don’t payfor this [. . .] (Eva, Group Leader).

Finally, there was a need to innovate some rules for how to respond to the new alarmsgenerated by the new technology. The personnel reused existing routines in

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this context. They decided to respond to the new inactivity alarms in exactly the sameway as when they are notified about the traditional manual alarms: two home-helpersworking shift at the nursing home take a community car and drive immediately to thesenior in question to check on him/her:

[. . .] we’re not sure of what kind of events would actually trigger inactivity alarms.What I mean is that these automatic alarms are totally different from the other alarms[manually triggered alarms], but it seemed reasonable to use our existing routines [. . .] thatwe are all familiar with ( Jenny, Home-helper).

Hence, by making do with the resources that are accessible, the front-line employeescreated a platform that enabled them to start using and innovating services based onthe new technology.

4.3 Feedback mechanisms during the use of the new technologyAs the personnel started using the new technology, feedback mechanisms reinforcedcertain features and affordances and impeded others. An important feedback link wasthat from the monitored senior consumers. Most of the seniors appreciated beingprovided with new, “modern” alarms with monitoring functionality. This encouragedthe personnel to keep on using and learning about the new technology. However, someof the seniors started to rely too much on the technology:

[. . .] Jim told me he’d felt really bad before my visit. But he didn’t call on us as he thought thetechnology would notice this anyway. You could see this on the computer, couldn’t you, hesaid [. . .] but we couldn’t [. . .] (Jessica, Home-helper).

This feedback taught personnel what the monitoring technology was not, i.e. a generalhealth monitor, as they had initially envisaged. Instead, the personnel started to defineit as a complementary source of information, which reflected a single and very specificaspect of the seniors’ health.

4.3.1 Redefining the automated alarms triggered by the new technology. As opposedto what was initially expected by the vendor and the care providers, none of theautomatic inactivity alarms triggered was caused by emergencies[5]. Thehome-helpers’ alarm documentation revealed that the automatic alarms were causedby various subtle changes in activity. For example, one note said:

The alarm was presumably triggered by Jeff lying still most of the day. He was tired, recentlybeing discharged from hospital. I gave Jeff a sandwich when I arrived. He appreciated this.

Another example:

Lillian confirmed she was just tired and a bit sad when I arrived. We talked for a few minutes.This made her happy. I told her I would call back in half an hour.

The personnel learned that the monitoring system could detect and notify them aboutsituations when seniors were “unusually weak.” New services emerged as thepersonnel responded to such situations. They paid the seniors, from whom alarms wereautomatically triggered, extra “support visits.” The content of these visits was deemedhighly contingent on the senior and necessary to innovate in situ. A home-helperexplains:

You have to feel what is right in these moments. The automatic alarms can be triggered forvarious reasons. Perhaps the seniors are weak and just need you to sit next to them, holding

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their hand for a minute. In other cases, making them laugh may be the recipe in making themfeel better [. . .] (Joni, Home-helper).

The seniors’ responses suggested that the new customized support visits couldproduce feelings of safety and reduce anxiety among the seniors:

[. . .] Essentially, I think these visits make the seniors feel watched over and cared for [. . .](Hannah, Home-helper).

Interviewees also reported that the new support services have preventive value:

[. . .] Visiting a senior who is merely feeling a bit tired and sad may prevent him/her fromgetting really anxious and completely passive [. . .] and if seniors feel safe at home, this mayprevent them from applying for placement at a nursing home [. . .] (Gunilla, Group Leader).

4.3.2 Redefining the patient data continuously provided by the technology. Themonitoring technology also generates real-time information about the seniors’ activitylevel over time, displayed as graphical activity curves on a computer screen.The personnel realized that this activity information allowed them to see whether theseniors wear their alarm. This is important as many seniors forget to wear their alarmsand are therefore unable to call for help in emergencies:

[. . .] I realized that I can see if seniors are wearing their alarm or not on the screen [. . .] if theline is straight, this means there is no signal, [that] the senior is not wearing the alarm [. . .] wedidn’t think of this in the beginning [. . .] (Ulla, Home-helper).

The personnel started to remind the seniors (who, according to the activity data, werenot wearing their alarm) to wear their alarms. That is, a “making-sure-that-seniors-wear-their-alarms” service started to take shape. As there were no pre-existing routinesto copy in this context, the personnel improvised when reminding the seniors about thealarms, combining the new patient data with their “old” consumer knowledge. Forexample, Jenny says:

We saw on the screen that Siv never wears her alarm during the night [. . .] I did not reallyknow how to talk to her about this though. I didn’t want to say that we “can see” if she wearsit or not [. . .] Siv would find this privacy threatening – I know her. I ended up not talkingabout the monitoring system at all. Instead, I talked about the risk of falling [. . .] and I think itworked [. . .] ( Jenny, Home-helper).

This way of using the new patient data generated the desired results:

[. . .] We’ve seen an effect on the curves. When we tell them specifically about this, more orless directly, they tend to start using their alarm. Thus, they can call on us when in danger.This provides the seniors and their relatives with a greater sense of safety [. . .] they’ve told usthis [. . .] (Maria, Home-helper).

4.4 Institutional constraints and stabilizing mechanismsThe personnel assert that they could use the monitoring system in a number ofpreventive ways beyond what has been mentioned:

[. . .] We could use it [the new patient data] to identify seniors who appear to be extremelypassive during the daytime or suffer from insomnia at night and help them become moreactive during the day: for example, [. . .] introducing targeted daily activity services could

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prevent a lot of sleeping disorders from getting worse. This could prevent fall accidents,which are more common among tired seniors [. . .] (Maria, Home-helper).

However, the home-helpers do not have the authority to make any major changes in theservices they deliver:

[. . .] The home-helpers have to stick to the service plans: they cannot just add new services[. . .] We would need to create a new role structure, where front-line employees could adjustthe content of the services they deliver on the basis of real-time information generated bytechnologies like this [. . .] (Anna, Manager).

In general, the data revealed that the reimbursement system and organization of thenational care system constrained the organization’s possibilities to realize serviceinnovations that respond to “new” needs:

Addressing seniors sleeping disorders or irregular activity patterns as a preventive measure[. . .] is beyond our public commitment [. . .] we would have to bear such production costswithout being reimbursed by the government for this [. . .] sure this could generate long-termhealth improvements and reduce costs [. . .] but there is no evidence of this. And who knows ifI’ll ever get any return on such investments as political shifts may change my budget totally[. . .] (Karin, Manager).

Privacy concerns further hampered more extended customized prevention servicesfrom being accomplished. The monitoring technology actually provides a good deal ofinformation about the seniors: when they leave the house, when they sleep, how deepthey sleep and it is possible to infer quite a lot on the basis of their general activitylevel. As a preventive measure, the home-helpers could use this information tointervene in the seniors’ behavior. However, the home-helpers did not use the data inthis way. Eva explains:

[. . .] I mean sure, we can see if the senior leaves the house and at what time. I can see that Elovleaves the house every day at about the same time and that he returns after 15 minutes.I knew this before: he likes to take a morning walk every day. But if I would see that he didn’tleave the house one day, I wouldn’t call him and tell him to take a walk, even if it is good forhis health. This would invade on his privacy! But if he would stop performing this dailyroutine completely, I would perhaps tell the girls to check on him a bit extra during theirregular visits [. . .] (Liv, Group Leader).

Similarly, Jessica says:

If an activity curve indicates that something is not OK, you feel like asking the senior aboutthis [. . .] But we cannot say to a senior that “we have seen on the curves that you are veryinactive during the days.” This might make the seniors feel they are being continuouslywatched and thus have a negative impact [. . .] (Jessica, Home-helper).

The data also indicated that the value attached to principles, such as autonomy andpluralism, impeded certain services from emerging:

[. . .] Unless there’s an alarm, we rarely do anything about the changes in activity level we seeon the screen [. . .] I mean, for how long is it normal to have a “low activity” level? In somecases low activity level can be a sign of depression or a signal that something is wronghealth-wise [. . .] something that could get worse if we do nothing about it [. . .] but seniorsmay simply need a lot of rest some days [. . .] and who are we to decide what’s “normal” andnot? [. . .] (Eva, Group leader).

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[. . .] It is a scary thought that we would use this to see that everyone has a perfectly regularpattern, i.e. sleeping during the night and being active during the day. We know that sleepingpatterns change with age. It is important to allow variation here. Some elderly may enjoystaying up until 3 am, sleeping until 6 am and then sleeping again in the afternoon [. . .](Birgitta, Manager).

Skepticism toward “high-tech business” further discouraged the personnel fromexploiting the functionality of the new technology. The monitoring system can be set totrigger various alarms (e.g. if the senior leaves the apartment). The home-helpershowever decided to keep such alarm functions latent:

We decided to only activate the inactivity emergency alarms in this first stage of use [. . .]using all the new functions seemed too demanding and complicated [. . .] We’re not in ahigh-tech business. We’re not high-tech people [. . .] ( Jenny, Home-helper).

Finally, the data indicated that the deeply rooted view of elderly care as a matter ofhuman (read: face-to-face) contact contributed to the personnel using the newinformation as a complement rather than as a replacement of face-to-face visits:

[. . .] We would never collect information about our elderly merely via computers instead ofvisiting them. This would be out of the question: care is about human contact [. . .] (Ulla,Home-helper).

4.5 InteractionsThere were numerous interactions between the mechanisms. For example, stabilizationmechanisms influenced the “energy-injection mechanism” as financial constraintsencouraged the managers to choose a relatively low-cost technology and the prevailinghealthcare culture made them inclined not to choose a too radical technology(e.g. robotics). Stabilization mechanisms in terms of prevailing values furtherinfluenced the “feedback mechanism” in terms of the positive reaction among seniors(via their high belief in the reliability of modern technology). Prevailing values alsoinfluenced how the care workers interpreted the feedback signals from the seniors andhow the care workers, as a result, redefined the purpose of the technology. There werealso interactions between the stabilization mechanisms and the “making-domechanisms” (operational employees’ acts of bricolage). Care workers were forced tomake do with available resources because of institutional constraints, such as a limitedbudget and the rigid financial structure. Cultural values further constrained their use ofthe technology. Hence, stabilization mechanisms influenced how care workers madedo with the technology, which greatly influenced how seniors reacted to thenew technology, which influenced how care workers continued to make do with thetechnology. These examples illustrate the cyclical nature of the emergence of newtechnology-based services in the case studied.

4.6 Drift: redefining the new technological resource – unexpected services emergingIn summary, as a result of the implementation of the monitoring technology, newtechnology-generated patient data entered the work-life of personnel. The new dataunexpectedly made it known that seniors often forget to wear their alarms and itoccurred to the personnel that they could use the technology to detect and respond to thisproblem. The personnel also understood that the technology could notify them whenseniors were “weak” and thus provided them with an opportunity to address these subtle

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health changes. Overall, the personnel gradually learned that the new technologyenabled various preventive services. This view differed from the technology vendor’sclaims and the managers’ initial expectations of the new technology, which revolvedmore around its role as an emergency-detector. The personnel redefined the newtechnological resource, increasingly referring to it as a complementary decision supportand an “early warning” tool. Based on this contextualized understanding of thetechnological resource, the personnel started to provide seniors with new “extra supportvisits” and “alarm-usage control services,” carefully adjusted to the individual seniorand the situation. Neither the vendor nor the managers had anticipated the emergence ofthese new services. The services are still in a beginning stage. The personnel andmanagers, however, assert that they will continue to use the technology to learn what itenables them to do for their senior consumers.

5. Conclusion, implications and further researchThe aim of this paper was to propose a theoretical framework for studyingtechnology-based service system innovation as a non-linear and emergent process.The proposed framework draws on complexity theory (the dissipative structuresmodel, Prigogine and Stengers (1984)) as well as the notion of technological drift(Ciborra et al., 2000) and bricolage (Levy-Strauss, 1966); concepts that have not beendiscussed in the NSD literature heretoforth. The paper uses empirical data from theelderly care setting to show the relevance of the enabling and constraining dynamicsincorporated in the proposed framework in the study of service innovation. Morespecifically, the paper has described the emergence of new technology-based careservices as a continuous interaction between “the injection of energy” in terms of a newtechnological resource, personnel “making do with resources at hand,” “feedbackdynamics” and “stabilizing mechanisms.” These dynamics helped to explain how andwhy certain new care services emerged and why others did not in the case studied. Forexample, the personnel started to tinker with the new technological resource in theactual context, combining it with existing resources, and various unexpected actionsmade possible by the technology, i.e. new “service affordances” emerged. Thepersonnel’s realization of these possibilities was influenced by feedback mechanismsthat attenuated certain acts and strengthened others. There were also more permanentstabilizing forces that prevented the personnel from even starting to carry out certainideas that emerged.

The proposed framework contributes to the NSD literature in several ways.Although there are many models of the service innovation process, these models arelargely normative and focused on the sequential and formal facets that the process“should” (ideally) encompass (see discussion above and in the reviews of Johne andStorey, 1998; Johnson et al., 2000; Sanden, 2007). In contrast, the framework proposedhere allows a broad analysis of the innovation process, including its non-linear,informal and unpredictable facets. The framework also highlights the influence ofindividual factors and of extra-organizational dimensions at the societal level, onthe innovation process. In general, the present paper suggests an approach thatcomplements established thinking on service innovation. Much of the serviceinnovation literature to date appears primarily interested in identifying success factorsin innovation projects. It typically underlines the importance of allocating resources tomulti-functional, autonomous development teams and engaging external parties,

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including consumers, suppliers, competitors and other stakeholders in all stages of theprocess (Alam and Perry, 2002; Astebro and Michela, 2005; de Brentani, 2001; de Jongand Vermulen, 2003; Johne and Storey, 1998; Kelly and Storey, 2000; Matear et al., 2004;Ottenbacher et al., 2006). In contrast, the present paper reports about “trivial” acts andevents, which, taken together led to the emergence of new service ideas and to theprovision of a few new services. There is reason to believe that “mundane”development processes and results such as those reported in this paper are no lesscommon than innovation processes that are aligned with the recommendations in thenew service development literature. As noted by Sundbo (1997), service industriesseldom have R&D departments. To understand how new services emerge we thereforeneed to acknowledge that services may sometimes emerge as a result of fluctuations,i.e. injections of energy, spontaneous or deliberate, that trigger more or less unexpectedresponses and in an ad hoc manner lead to incremental changes. This, too, isinnovation in services. And such innovation does most likely occur also in strictlymanaged processes, where sequential models are used and where there is adevelopment team and development budget.

5.1 Research implicationsAs Siggelkow (2007) noted, single cases can serve as counterexamples that enablethe development of existing theory by pointing to gaps and beginning to fill them. Thepresent study can be viewed as an attempt to, if not “falsify,” then at least challenge theprevailing tendency to model technology-based service innovation only as apredictable, systematic process contingent on managerial decisions (Chircu et al.,2001; Palmer and Griffith, 1998; Passerini et al., 2007; Piccoli et al., 2004; Sung-Eui,2005; van Riel and Lievens, 2004). The present study has attempted to illustrate that asan alternative, the concepts of bricolage, technological drift and complexity theory cansensitize researchers to important cyclical dynamics inherent in the emergence of newtechnology-based service systems. In general, the purpose of this explorative studywas to begin to outline a new direction in new service development research, one thatgoes beyond the interest of providing managers with unrealistic recipes for how tocreate optimal innovation processes, but instead takes on a multilevel analysis andconsiders the influence of forces at both the individual and societal level to describehow new services actually come into being. Complexity theory (McKelvey, 1999)provides opportunities for learning more about how new services can emerge in thiscontext. The service innovation literature would benefit from this theory being appliedto help crystallize how single events at the micro level can trigger changes at macrolevels, leading to the emergence of new orders and paradigm shifts in the servicesindustry, i.e. multilevel analysis (Chiles et al., 2004).

5.2 Managerial implicationsThis paper does not set out to provide managerial recipes for how to conduct optimalinnovation processes. It is descriptive rather than prescriptive. Still, the findings doprovide insights on issues that managers should recognize in their decisions about howto plan for and support the innovation process. To start with, this paper reports abouthow a service innovation process can unfold in the absence of a clear strategy,i.e. without much managerial planning. In the case studied the managers simply madea new technological resource available to front-line personnel and their idea was to see

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what new care services could emerge as a result. This is contrary to innovationprocesses beginning with the managerial definition of a “service objective” andproceeding with the formal allocation of the resources necessary to achieve thisobjective, as has been proposed (Alam and Perry, 2002; Cooper et al., 1994; Edgett,1994; Kelly and Storey, 2000). In the case studied the new technology was the onlyresource formally allocated to the service development project. There was no“development team” or “development budget” devoted to the service innovation as isoften recommended in the service innovation literature (de Jong and Vermulen, 2003;Edvardsson and Olsson, 1996; Johne and Storey, 1998; Kelly and Storey, 2000; Stevensand Dimitriadis, 2004; Syson and Perks, 2004). The present study, however, shows thatthis did not prevent innovation from happening. It rather forced front-line personnel tomake do with the resources at hand, i.e. to engage in bricolage (Levy-Strauss, 1966).In creating the prerequisites for employing the new technology, i.e. creating space forservice innovation, they reallocated time from activities that could wait and repurposedavailable resources, such as abandoned facilities, social relationships and privateexperiences. The absence of any formal allocation of resources to the innovationprocess studied may have had positive implications. For example, hidden andseemingly unrelated resources had perhaps not been put to any productive applicationif a development budget had been available. As it were, bricolage sometime createdvalue without withdrawing resources from any current use. Further, as the operationalpersonnel could not delegate tasks to some “development team,” they were forced toinfuse the new technology into their work life without disrupting their day-to-daywork. As a result, the technology was fairly integrated in the organization.

However, the lack of “new” development resources in terms not only of time, butalso of authority and competence among participants, and the reliance on obtainableresources most likely made the personnel strive for a workable rather than abreakthrough solution. The absence of an innovation strategy led to ad hoc choices thattended toward the option requiring the least cognitive effort and time (Douglas, 1987).As a result, the personnel were inclined to choose paths that avoided dramatic changes.These factors contribute to the fact that incremental rather than radical or disruptive(Christensen, 1997) innovations were produced. In general, the creative use of bits andpieces has produced a “bits and pieces” innovation, i.e. a half-realized innovation.Elements that are vital to the development of a sustainable service are still lacking.As noted by Baker and Nelson (2005), “coaxing,” a large degree of ad hoc responses andimprovisation can be anathema to the establishment of reliable impersonal routines.The provision of the new service is dependent on the employees’ capability to createspace to use the new technology as no formal roles or responsibilities have beencreated. Further, the vendor will not provide “free” support forever. It needs to be notedthough that the process is far from finished. More formalized processes and roles willmost likely emerge over time.

In general, the findings presented here are relevant to managers not only in the caresetting but also in service settings in general. This study emphasizes the complexityrelated to the innovation of technology-based service systems and the many forces thatmanagers need to take into account before and during such innovation processes.Although it is difficult for managers to control the mechanisms involved, such asindividual care workers improvisations, pragmatic acts of “making do,” institutionalconstraints and reactions among consumers, managers need to be aware of the

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significance of such forces. They should establish support systems (in terms of,e.g. rewards or other incentives) to support and encourage care workers’ tinkering withthe available resources. They should also engage in continuous follow-up meetings tocatch up emergent ideas. Finally, they should try to reflect on how institutionalregulations and cultural values may influence the innovation process.

In summary, the present study suggests that although innovation processes may bedifficult to predict and control, it is nevertheless possible to distinguish patterns and to“prepare for” certain interactions in advance. The findings elucidate how individuals’engagement in bricolage is not merely a matter of arbitrarily departing from the meansavailable; it is also shaped by attenuating and reducing feedback mechanisms.Outcomes do not drift randomly but as a result of structural and cultural factors.Institutional constraints had particular significance in the context studied. Thepersonnel could not introduce new services merely on the basis of what was technicallyafforded and what could produce values to their senior caretakers. Rather, they had tokeep their public commitment in mind, i.e. what needs they are and are not officiallyresponsible and reimbursed for responding to. Deeply rooted values (such asmaintaining privacy, autonomy and the prevailing healthcare culture where care isseen as a matter of human (face-to-face) contact) also influenced the emergence of newservices by disallowing more radical uses of the new technology.

5.3 Limitations and future research directionsThe present exploratory study is based on a single case. As noted, the publichome-help setting studied is idiosyncratic in many ways. However, the purpose wasto develop theory rather than to test theory (Eisenhardt and Graebner, 2007). Ofcourse, further research needs to validate and refine the proposed framework(Figure 1) in other settings. Explorations of how organizations can make use of newtechnologies (e.g. digital and nanotechnologies) to provide new services in complexsettings (such as healthcare) are particularly warranted. Such innovations occur ininterfirm modularity settings (Staudenmeyer et al., 2005), where it is difficult for asingle actor to develop all parts of the final offering as this requires deep insightinto what is technologically feasible as well as insight into the specific servicedelivery processes in question. Longitudinal studies, using multiple cases andcovering various actors (not only the service provider but also technology vendors,etc.) as well as combining qualitative and quantitative data generation methods,would benefit the development of the framework suggested here. This paper alsostudied the early stage of a single service innovation process. Research focusing onlater phases in such emergent processes would further our understanding of hownew services are integrated into existing service systems (Tax and Stuart, 1997),legitimized and actually become available to consumers. In general, there is reasonto believe that many new service development processes include formal as well asinformal elements. The proposed framework could be used to analyze how forces atindividual and societal level shape well-planned and strictly managed processes.Finally, this study indicates that the lack of resources in terms of authority andcompetence can hamper innovation outcomes. Although this could be expected(Vargo and Lusch, 2004) further research about how such pre-requisites can becreated in the public sector is needed.

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Notes

1. Innovation can broadly be described as an idea, artifact, or behavior that is new to orperceived as new by the organization adopting it (Daft, 1978; Zaltman et al., 1973).This paper deals with the process that generates such “outcomes.”

2. Barlow et al. (2006) write about “implementing” a technological innovation, but I believe thatit is more appropriate to talk about service innovation. The overall discourse needs to shiftfocus from technology implementation to service innovation.

3. This version of the dissipative structures model is simplified to suit the purpose of this paper(see Prigogine and Stengers (1984) for a more detailed account).

4. This study is part of an ongoing research program investigating the infusion of IT intoelderly care.

5. There were also a large number of “false” alarms that were triggered by seniors sleepingunusually deep during the study period.

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AppendixInterview guide (many of these questions were asked (in one way or another) at several times, atinformal/formal meetings and during interviews).

To managers:

How did you choose to invest in this particular technology?

(Often, follow-up questions were asked, such as: was there any other aspect thatinfluenced your decision, you think?)

Who did you engage in the decision phase?

Why?

What was problematic in this first stage?

What was your intention at this stage? Vision? (What benefits did you foresee at thisstage?)

How did the project proceed?

Has your vision been realized?

What have you learned?

If it would be up to you to decide, would you recommend a continued use of thetechnology?

Why?

To home-helpers:

What do you think of the new technology?

How many times per week have you used it, and for how long?

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How have you used it?

Why have you used it in this way?

Has it been difficult?

Did you use all functions/features possible in the application?

Why did you not/use certain features?

If it would be up to you to decide, would you recommend a continued use of thetechnology?

Why?

What benefits can the technology produce from your viewpoint?

Corresponding authorAnna Essen can be contacted at: aes@fek.su.se

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