Abstract
Currently, healthcare is worldwide one of the most critical service domains, dealing with human being health and well-being. Its importance and significance are also reflected through the Agenda 2030 and its SDGs, which point to guarantee health and well-being for all at all ages. In this sense, this article aims to better investigate if and how specific paths of value creation contribute to healthcare sustainability. The analysis has been conducted assuming a system perspective, which led to approach those dynamics, supported digital technologies and platforms, that boost the sustainability of complex service systems such as healthcare. To this end, a case study analysis has been conducted, investigating the potential of a digital platform in boosting an ongoing path of value creation able to contribute to short- and long-term sustainability of healthcare domain and of the related services. The results of this analysis pointed out that digital platforms can acts as value generation enablers, paving the way for the definition of sustainable paths of value creation.
Introduction
Even though the debate on sustainability goes back to the late ‘80s with the publication of the Brundtland report (1987), it has gained momentum in boardrooms across the world over the last two decades. This was mainly due to the growing pressures from scholars, governmental and non-governmental organization and even citizens (Komiyama & Takeuchi, 2006). It follows that sustainability issues have become significant in many sectors, such as manufacturing, agriculture, retailing, and even healthcare. However, research still approaches sustainability as a blurred and multifaceted concept, lacking a unique and well-established definition (Burger, 2006; Pearce et al., 1990). Thus, the extant literature calls for further investigations able to merge together its three dimensions, the ecological, social and economic ones. This is not an easy challenge to meet, because sustainability always matters with intricate and ‘unbalanced human-based and social interactions that affect decision-making at social, economic and environmental levels’ (Faggini et al., 2019). This complexity is particularly evident in healthcare, where it is due to the need for locally and globally ensure human beings health and well-being, as the Agenda 2030 maintains, setting healthcare as an overarching theme that highly contributes to all of three (social, economic, and environmental) spheres of sustainable development. Drawing on these considerations, a question arises, how the long-lasting sustainability of the healthcare system can be nourished?
However, some criticalities such as globalization, digital revolution, innovation, the search for efficiency and resource reduction affect healthcare globally and pressure governments towards the introduction of sustainability-oriented measures to address economic, social, and even environmental issues. These measures are globally intended to respond to citizens’ calls for greater accountability in the effectiveness and quality of health service, even though this remains a challenge that can be meet boosting an increasing citizens/patients’ engagement in health-related processes (Osborne, 2018) and in the (co)creation of value.
It is worth noting that in healthcare, value creation lies upon integrated care plans, based on the merging of clinical and not-clinical activities done by both health service providers and patients, who interact with the common goal of creating long-lasting value for themselves and others (Osei-Frimpong et al., 2015; Tanniru, 2020), able to ensure healthcare system viability in the long-run. In this sense, some authors pointed out the potentially enhancing role that digital technologies and the more recent digital platforms play in supporting value-creation processes and the interactions on which they are built (Broekhuizen et al., 2021; Meijer & Boon, 2021). In fact, digital technologies are often considered as an essential driver for creating value, even though the question of how them drive value-creation processes in healthcare needs to be further explored. This study aims to contribute to bridge this gap, deeply investigating the role of digital technologies and, in particular, of digital platforms in the generation of value able to contribute to health-related services effectiveness, cost efficiency, and quality (Saviano et al., 2017).
The article has been organized as follows. The next section describes the theoretical background of the study; then, the methodological approach and the case study are presented. Follows, the presentation and the discussion of the case study analysis results. Finally, some implications and future research paths are proposed.
Theoretical Background
Healthcare Sustainability: A System Approach
Healthcare is a complex and inherently intricate service domain, built upon an environment that asks for efficiency and equity, being focused on long-lasting and not easy to accomplish challenges, such as patient safeness and satisfaction, a fair and equitable service, and a cost-effective orientation (Salvatore & Fanelli, 2020).
According to this perspective, healthcare can be considered as made up of a dynamic configuration of people (patients, families, health providers), technologies, organizations, and shared information, able to create and deliver value for both providers and customers (Rajala et al., 2014). It follows that this domain can be approached as a complex and adaptive service system, being a value (co)creation configuration of people, technology, internal and external service systems connected by value propositions and shared information, for example, language, laws, measures and (Barile et al., 2016; Reynoso et al., 2018). The complexity of this adaptive service system is mainly due to its ‘performance and behavior changes over time and cannot be completely understood by simply knowing about the individual components’ (Braithwaite, 2018, p. 3). Thus, complexity mainly lies upon the need for merging the interactions of different actors (patients, families, health providers, institutions, other service organizations, etc.) with sometimes opposite economic, functional, emotional and ethical needs and expectations (Polese & Capunzo, 2013). This implies that the related pressures and demands are often unpredictable because performance and behaviour can highly vary over the time and cannot be understood merely approaching and analyzing the single components (Anderson et al., 2020). In fact, in healthcare, the process at the core of value (co)creation engage several different actors (included patient in her/his role of customer) and can be considered sustainable, when these actors aim to improve their current and future quality of life, thanks to better managing health-related services (Polese et al., 2016). Therefore, the assumption of a value-based perspective led to better focus on the way companies and customers (providers and customers) interact for achieving a mutual benefit (Grönroos, 2017; Kotler, 2017; Mahajan, 2016). Drawing on the healthcare complexity, some authors underlined the need for balancing traditional healthcare targets of efficiency and effectiveness with sustainability to boost the viability of the whole health service system (Lipsitz, 2012). In fact, a more valuable and sustainable resource sharing—essential to (co)create value—needs for changing health-related service providers’ mindset, which should move from the traditional doctor–patient relationship toward a provider–client relationship (Grönroos, 2017; Wood et al., 2018), in which patient and their personal network (families, peers, personal caregivers, etc.) (Ciasullo et al., 2018) plays an even more active role, which is the core element of the so-called patient-centred approach to care (Epstein et al., 2005; Forsythe et al., 2018). This approach makes also able to overcome the long-lasting information asymmetry that traditionally constrains physician–patient relationships and which is mainly due to a dissonant interpretation of events and to a different culture that can lead them to not share their personal resources and to prevent the (co)creation of value for the whole healthcare service system (Barile et al., 2014). In this sense, the extant literature pointed out that technological advancement and digital innovations can support the overcoming of these asymmetries, boosting the enactment of value (co)creation mechanisms (Vargo, 2018).
Digital Platforms for Creating Sustainable Value for Healthcare
As stated, in healthcare domain technologies can change at fast pace from cutting edge to ubiquity; thus, especially Information and Communication Technologies (ICT) and the more recent digital technologies represent a ‘key interactional resource in most healthcare value-creation systems, where there is a need to continually search for and orchestrate contextually available knowledge and institutional’ (Chaston, 2017, p. 251). Recently, the literature (Balta et al., 2021; Lee, 2019) has pointed out the benefit that ICT and digital technologies (DT) can have on value (co)creation in healthcare, enhancing interactions between actors, especially between patients and health service providers.
One of the main definitions of value approached it as ‘a contribution to a customer’s well-being, from the customer’s perspective’ (Grönroos & Gummerus, 2014, p. 222). However, it is worth noting that over the years managerial research has provided a number of different definitions of value. Mahajan (2017) considered it as ‘actions that increase the overall good and well-being’ (p. 219). In healthcare, value is often approached as the patient outcome, related to resources or costs for attaining the patients’ outcome (Porter, 2010). It is worth noting that value represents for healthcare a pivotal paradigm, which is inspiring health-related policies, the management, and the financing of health provision (Porter, 2008). In healthcare, value is also essential for technological choices, because it represents one of the drivers at the core of technology implementation. However, it must be noted that the most academic contributions are mostly focused on the influence that technologies can play on the quality of health service in terms of process efficiency (Chaudhry, et al., 2006), even though further research is still needed for better understanding their influence on effectiveness. In this sense, effectiveness is approached as coming from people interactions and their contribution to the co-production of personalized health services and their sustainability (Palumbo, 2017; Palumbo et al., 2017). In fact, due to healthcare inner complexity, each patient should be considered unique, and, for this reason, she/he should perform as an active contributor to the co-production of personalized or patient-centred health services. It follows that ICT, DT and the more recent digital platforms can support not only health service efficiency, but also its effectiveness, thanks to ongoing and massive empowerment of patients ‘who can now access, mainly via digital devices, a huge amount of information that nourishes their ability to self-manage their disease’ (Faggini et al., 2019, p. 5).
Focusing on digital platforms, it is worth noting that the general concept of ‘platform’ is not new; thus, it has been firstly used in tech sectors at the beginning of the XXI century as synonymous with ‘computer architecture’. More recently, it has been widely used also in other domains for conceptualizing those ‘digital intermediaries’ that link together individuals, information, goods, and services (Evans et al., 2006). Digital platforms, intended as an evolution of the more general platforms, are one of the most critical innovation of this century (Kim, 2018). This is due to the fact that their innovativeness lies upon the ability in creating specific arrangements between different (human and non-human) actors and information materiality (Dourish, 2017).
Digital platforms have been also defined as modular structures made up of ‘tangible and intangible components (resources) and facilitates the interaction of actors and resources (or resource bundles)’ (Lusch & Nambisan, 2015, p. 157). This implies that these digital artefacts—enhancing the access to the existing knowledge—can easily support patients/customers in improving their health-related knowledge and, consequently, the awareness about their own medical issues (Realpe & Wallace, 2010). It follows that digital platforms contribute to a sustainable value (co)creation enhancing resources’ accessibility and facilitating actors’ interactions, built upon resource sharing, cooperation, and networking (Ciasullo et al., 2017; Grunwald, 2017). Thus, these platforms represent a concrete tool for balancing efficiency (or doing things in the right way), effectiveness (or the right things that must be done) and sustainability (or the effort towards the establishment of the right relationships with other systems) (Spohrer et al., 2007), as well as adding long-term sustainability to healthcare (Palumbo et al., 2017).
Methodology
This article has been based on a qualitative analysis and in particular on the implementation of the case study method (Yin, 2003). This specific qualitative method has been used because particularly suitable for explorative research (Baxter & Jack, 2008) and for understanding complex social phenomena such as the way (or how) digital platforms contribute to (co)create sustainable value in healthcare. In particular, the case study method seems to support the investigation of the main issue at the core of this study, that is the multi-actor participation in the (co)creation of sustainable value for healthcare service system. This approach is based on ‘a research strategy focused on the comprehension of those dynamics characteristic of specific contexts’ (Eisenhardt, 1989, p. 532). Thus, this study aims to analyze a specific phenomenon within its own context, collecting data from different sources in order to provide a tentative answer to the questions at the core of the study (Baxter & Jack, 2008). For this purpose, an expressive case has been selected using a non-probabilistic technique, being the case platform, a patient-centric innovation recently developed by Capgemini. Data were retrieved from different secondary sources (e.g., reports, handbooks, papers, video-interviews, corporate blogs, and corporate social networks) as well as accessing to the platform itself. To be analyzed, data have been organized according to the following categories retrieved from the analysis of the extant literature (Faggini et al., 2019; Senbekov et al., 2020): (a) core services, (b) target, (c) connected digital apps, (d) connected actors and (e) tracking & protection.
The collected data were organized following a specific research protocol that researchers developed for the purpose of this study, and which has been based on digital worksheet that researchers could independently access for analyzing data. No time limitations were set for the analysis; thus, all the online retrievable data were considered, and no exclusion criteria were applied. When necessary, additional evidence was searched online to improve the reliability and the consistency of this research. Finally, a joined research report was arranged, which inspired the findings of this research.
The Main Characteristic of the Case Platform
This study delves into the analysis of one of the first and most advanced digital platforms dedicated to healthcare launched by Capgemini in Europe, some functions of this platform are still under testing.
Capgemini, a global company active in professional consultancy, digital transformation, technology, and engineering services which headquarter is based in Paris, has developed one this platform mainly focused on tracking and managing the personal health and health details of patients, close relatives and family members. The case company developed this platform to improve health management for both patients and service providers, in order to offer a personalized health service at lower cost and in real-time. Recently, a new partnership (between Capgemini, Sanofi, Generali and Orange) boosted the further development of this platform dedicated to the advancement of European healthcare.
Results Presentation and Discussion
The main findings of the case study analysis pointed out the importance of a patient-centred approach for designing and developing a digital platform dedicated to health-related services. In fact, this orientation opens to the achievement, the tracking, and the registering of information coming from sources other than health professional domain. In terms of core service, the analyzed platform makes possible to assess the current (and previous) health status of each patient as well as their current (and previous) prescriptions, medications and/or treatments. To this information can be also added any other available health-related information. This core service is going to be enforced with the development of a further function, which will support the registration and the analysis of health insurance information to offer a specialized service of pattern recognition and of identification of high-risk associated to a single user/patient or to a group.
This platform allows users to personally manage their own medical data, which under their authorization will be accessed by service providers (single physicians or healthcare organizations), while other companies (e.g., sponsors, pharma companies, etc.) can access them only under a previous authorization. However, users can always decide who can access their personal data, but they can also freely decide to revoke the access permission for whatever reason. Accessing these data, medical professionals can merge their examinations with patients’ health information and adapt their diagnosis and treatment accordingly.
Each action done through this platform is managed using the informed consent (IC), in order to make users always aware about the processes that have been activate. This is a way to challenge the negative influence that information asymmetries can have on patients’ engagement and, therefore, on their direct involvement in health-related service processes (Barile et al., 2014; Moro Visconti, 2017). In this sense, the CEO of Capgemini Group Aiman Ezzat stated in an online interview that ‘one of our major responsibilities for future generations is to put technology at the service of health. (…) The founding members all believe that digital technology will provide a tremendous boost; we have the ambition to quickly achieve concrete results’. One of these results is the ability of the analyzed platform to challenge the aforementioned information asymmetries also involving collective users, such as patients and their families, boosting information sharing not only between service provider and clients, but also between the first and clients’ private/personal network (Ciasullo et al., 2017; Ciasullo et al., 2018). This implies that the second investigated element—the target—merges together individual and collective users (e.g., patients’ relatives and family members). More in details, the platform supports those multi-actor interactions essential to (co)create now and in the future value for themselves and others (e.g., future generation) (Avelino & Wittmayer, 2016; Cosimato et al., 2020).
In terms of connected digital apps, the analyzed platform is characterized by a high interconnectivity with several different apps. This implies that users can access it via different apps and devices, which allows for virtual and more quickly consultations, done via videoconferencing tools or chats, reducing the waiting times and the frequency of face-to-face check-up. A mobile app is also used for making users able to decide to participate or not to test study, for example to initiatives organized by hospitals, research centres or pharmaceutical companies. In this case, through a specific mobile app, users can freely, autonomously, and anonymously decide to candidate themselves to a study test or not. The most important characteristics of these embedded apps are (a) the privacy-enhancing technology, which easily supports users in recording and sharing their personal data respecting the related standard of data privacy security and (b) the possibility to share data in real-time. This confirms that health-related platforms tend to be aimed at (a) enhancing information generativity, sharing different resources (mainly information), (b) boosting their accessibility and (c) supporting actors’ ability in accessing different and more reliable sources of knowledge (Beirão et al., 2016; Lusch & Nambisan, 2015).
As grasped from the previous statements, in terms of connected actors, the analyzed digital platform has been designed as a multi-actor digital infrastructure. Thus, even though at its centre lies the patient/user and their personal network (Palumbo et al., 2017), it also links—in a nested bundle of interactions—other single or collective actors, such as medical professionals, hospitals, pharmacies, insurance companies, and health authorities form essential components. Among these actors, it is possible to find out another focal actor (who interact with patient directly and most frequently), medical organizations. This testifies the participation and the involvement of different actors, involved into different interactions—based on resource sharing—essential to create valuable health-related services (Davey & Grönroos, 2019). This is the reason why digital platforms can be considered interactions’ enablers; thus, they activate specific and dynamic relationships between the aforementioned actors belonging to healthcare service system (Faggini et al., 2019). This open to another dynamic system configuration, the ecosystem, which recently is often used for understanding the complex interactive dynamics at the core of healthcare.
A service ecosystem has been defined as a socio-technical, complex adaptive system (Voima et al., 2011), pointing to be sustainable over the time (Trischler et al., 2020). In line with literature (Edvardsson et al., 2011; Vargo & Lusch, 2010), the achieved findings demonstrated that boosting multi-actor interactions, digital platforms can support the emergence of service ecosystems, dynamic configuration of resource that goes beyond the traditional provider/client dyad, opening to a nested network of multi-actor interactions. This also emerges from the CEO of Generali France Jean-Laurent Granier statement, who maintained that ‘Generali wishes to actively contribute to the creation and running of this unique ecosystem in France and Europe, in collaboration with other leading international companies in their sector’.
In terms of tracking and protection, the platform has improved the protection of data privacy, following the principles of General Data Protection Regulation (GDPR), for example in terms of speed and personal consent. In this sense, the integration of the most recent blockchain technologies also supported the general setup of this platform. In fact, users can share their data, and, at the same time, access data shared by others, even though blockchain technology gives the private key only to data owners, who can allow or not their accessibility. Data are stored in specific home servers to ensure a high degree of security and sovereignty. More in detail, using this platform users can personally decide to release their data, to whom, and in what format (open, anonymized, etc.). These characteristics have led to justify that some scholars approached digital platforms as interactions’ enablers (Sestino et al., 2020), which at same time ensure data protection and sharing. This protection and real-time data sharing ensure an ongoing and mutual resource exchange, essential for nourishing those (co)creation process that generates a sustainable value to healthcare service system (Barile et al., 2020). The function of the analyzed platform also supports a critical, but vital process for healthcare, the empowerment of patients, which is also based on their ability to
access to a growing and detailed amount of health-related information, which increases their knowledge about their specific disease, as well as other possible health-related issues. This implies that patients and the actors belonging to their personal network can improve their self-reliance and competence with disease, which makes them willing to participate in the provision of even more personalized health-related services. (Faggini et al., 2019, p. 12)
It follows that this process makes health actors others than physicians able to act (via digital platform) as real contributor to the production of even more specialized and personalized health-related services (Patrício et al., 2018). This is possible enacting those service-for-service exchanges that pave the way for an ongoing and, therefore, sustainable value (co)creation (Padhi, 2018), at the core health service system viability and balancing the traditional need for efficiency, reducing the time and costs of health-related processes, with the lively need for an ongoing improvement of service effectiveness.
Final Remarks
Assuming a system perspective, this article has contributed to better understand how digital platforms contribute to the generation of long-lasting or sustainable value. In doing so, results coming from both theoretical and practical analysis supports a deeper understanding of those multi-actors’ interactions, which sharing a common goal can nourish—through an ongoing value (co)creation—healthcare service system sustainability (Lipsitz, 2012). This led to advance research on healthcare sustainability and on the way, the most recent DT can support this complex service system to achieve it (Palumbo et al., 2017) as well as to address the aforementioned question, how the long-lasting sustainability of the healthcare system can be nourished? In fact, enhancing multi-actor interactions digital platforms can nourish those value generation patterns essential for improving health services and, therefore, actors’ long-lasting well-being, essential for the sustainability of the whole healthcare service systems (Cosimato et al., 2020; Faggini et al., 2019). This is mainly due to digital platform ability in boosting patient engagement and her/his gradual empowerment, essential to challenge the enduring information asymmetries typical of this service domain (Barile et al., 2014; Moro Visconti, 2017).
The analysis of the Capgemini digital platform has also opened to some implications for both public and private healthcare managers, who should support and promote a wider use of these advanced tools to combine the healthcare need for efficiency and effectiveness with its long-term viability or sustainability. In fact, the result of the analysis highlighted that the current digitalization together with the spread of advanced technologies and artefacts, such as digital platforms, facilitate the multi-actors’ interactions (e.g., patients, health employees, physicians, families, other service providers, institutions, etc.) at the core of value (co)creation and of the patient-centred healthcare. However, the actors who populate healthcare system still need to understand and familiarize themselves with the emerging digital platforms and their interactive potential. This is true for both health professional users and health customers, which according to a co-creative logic are now considered partners in the delivery of care. In fact, the implementation of digital platform represents one way for creating a value-based health system. However, further research is still needed for better understand if and how the integration of other advanced technologies (e.g., big data, data mining, artificial and/or augmented intelligence, virtual reality, etc.) positively or negatively affect the sustainability of healthcare service system. Even though this study contributes to shed further light on sustainable value (co)creation in healthcare, the implementation of qualitative methods somewhat limits it. However, further research will be intended to deeply investigate (also applying quantitative methods) the influence that actors-generated and shared data through the most advanced technologies can have on the value co-creation process that adds sustainability to complex service systems.
