Hitting a moving target: digital transformation and welfare technology in Swedish municipal eldercare

Abstract

Introduction

This article contributes to the discussion on digital transformation and welfare technology in municipal eldercare. The aim of welfare technology solutions is to exceed the current welfare system and to meet the challenges of an ageing population through technological innovations and applications that help people to better cope with health issues and strengthen their participation, activity and independence regarding their own healthcare.

Methods

First, this article outlines a number of different perspectives on technological and social change. Against this backdrop, this article portrays the challenges faced by Swedish municipal eldercare organizations due to the moving targets of digital transformation and the development of welfare technologies.

Conclusion

In this context, eldercare organizations are at risk of becoming victims of the fast pace at which technology develops and the rhetoric of technological determinism; they may try to pursue the latest technological innovation at the expense of their stakeholders’ needs. The implementation and deployment of welfare technology become a real-world social experiment. Without proper tools for evaluation, welfare technology might be implemented and deployed as an end in itself, instead of as means for better ageing or improved eldercare. This article concludes by framing a set of questions to help increase the understanding of welfare technology implementation and deployment in order to mitigate risks and improve outcomes.

IMPLICATIONS FOR REHABILITATION

• Analysis of different perspectives regarding technological and social change.

• Identification of the challenges faced by municipal eldercare organizations due to digital transformation.

• Presentation of evaluation questions to increase the understanding of welfare technology implementation and deployment in order to mitigate risks and improve outcomes.

Keywords:

• Digital transformation
• welfare technology
• Swedish municipalities
• technological change
• eldercare

Introduction

Digital technology has become a pervasive part of everyday life, both for work and leisure. Digital technologies and digitalization have transformed how most people interact and communicate, as well as the way many jobs are conducted. New roles, professions, markets and services have developed due to this digital transformation. Digital technology and digitalization are also expected to solve some of the grand challenges of our time, such as issues related to an ageing population and increasing healthcare expenditures [1].

Based on the Digital Economy and Society Index (DESI) report 2019, all EU countries have improved their digital performance [2]. Sweden, Finland, the Netherlands and Denmark have the most advanced digital economies. The vast majority of Swedes have access to the Internet at home (98%), while about 94% use the Internet [3]. Among people of the age 76 years or older, 90% have access to the Internet at home, while about 58% use the Internet, which indicates that although a majority have Internet access, not all of them use it. Among Swedes between the ages of 66 and 75, 94% use the Internet, which is very close to the average Internet usage among the whole population. The statistics indicate that young people prefer to access the Internet through their smartphones, while people over the age of 76 years prefer to access the Internet through a computer. Statistics also show that among people above the age of 76 years, only 25% access the Internet daily through their smartphones [3].

While digitalization has resulted in many benefits, it has also brought new challenges. For example, the possibilities, capabilities and hype surrounding digital technologies have increased the uncertainty regarding how elderly care organizations and healthcare providers ought to operate [4]. The Swedish government has a vision of Sweden as one of the best countries in the world in its utilization of eHealth [5]. eHealth is an all-encompassing term and relies on the use of digital technologies in healthcare to meet the needs of citizens, patients, policymakers, healthcare professionals and clinicians [6,7]. It is interesting to note that Sweden’s vision is not to be the best at providing healthcare in general but to be the best specifically at providing eHealth. This vision evokes technological determinism and accentuates the allocation of resources towards an enhanced pace of digitalization over the coming years. As such, the vision determines a performative space for municipal eldercare based on what is viewed as important, legitimate and possible, and on which activities should be chosen and targeted [8]. The basic underlying assumption and understanding are that backing the development and application of welfare technology innovations and the digital transformation of healthcare will result in prosperity and improve healthcare in general [9].

In Sweden, municipalities are responsible for home care, home help services and long-term somatic care [10]; as a result, Swedish municipalities face daunting challenges due to an ageing population and a strained economy. One projected solution to meet these challenges is welfare technology, a Scandinavian concept launched to promote digitalization. Welfare technology is a solution that aims to provide welfare services; it is defined as the knowledge and use of technology that can maintain and/or increase the feelings of safety, activity, participation and independence for a person (any age) who has or is at an increased risk of having or developing a disability [11–13].

eHealth and welfare technology are related and overlapping concepts. Both concepts are allied with promises of an improved public sector, with self-management, self-care and greater responsibility for one’s health as a focus, and with increased cost effectiveness [14,15]. Welfare technology is regarded as necessity in order to meet the future demands of home care and healthcare [16]. Welfare technologies exist in numerous forms and with various functionalities, including eating aids to replace staff who feed patients, and surveillance cameras that replace physical visits with digital surveillance. The list of potential welfare technologies continues to grow at a rapid rate (please see Table 1 for additional examples of welfare technologies).

Table 1. Examples of welfare technologies and services.

Digital locks	Caregivers can open doors to different homes with their mobile phones to save time retrieving keys if the visit schedule changes
GPS alarms	Caregivers can determine the location of a care receiver
Virtual doctor visits	Patients can get medical opinions via video links from the comfort of their home
Safety bracelets	Patients can use bracelets with sensors that analyse movement patterns and can warn carers if there is an increased risk for falls
Shower robots	Disabled people can shower on their own and control soap and shampoo with keystrokes
Mobile access	Caregivers can access patient records through smartphones so they do not have to carry documentation or bring paper lists
Digital signing	Caregivers can sign for medications and drugs on their smartphones
Incontinence detection sensor technology	Patients can have a sensor in their incontinence pads that detects daily urine patterns as well as when the incontinence protection needs to be changed
Artificial intelligence coupled with sensors	Smart home sensors analysed by AI can learn an individual’s movement patterns and alert personnel or relatives in case of deviations

Digital transformation and technological developments are considered moving targets [17,18]. The rate of change in digital technologies makes it difficult for municipal eldercare organizations to accurately predict the future needs of patients, staff and the organization itself, as well as what kind of welfare technology and digital services would best serve their needs. In municipalities where the budget and strategic planning model is set for up to several years in advance, technological changes are hard to accommodate. Often, municipalities have to wait until the next planning cycle or the new procurement period for new decisions or to change plans. However, digital transformation and digitalization do not wait for the next planning or procurement cycle, and the failure to quickly respond to technological changes may lead to missed opportunities or to procuring irrelevant technologies.

In order to develop a deeper understanding of digital transformation and the implementation and application of welfare technology innovations, this article starts with introducing the underlying assumptions and understandings of technological and social change. Second, by building on these concepts, a critical approach is introduced to identifying and discussing the challenges faced by Swedish municipal eldercare organizations. Third, a potential framework for exploring, investigating and evaluating responsible innovations in welfare technology is presented. Based on the framework, we make recommendations on how to deal with the challenges and issues related to the implementation of welfare technology solutions and digital transformations faced by municipal eldercare, which are needed for a successful transition.

Technological and social change

Digital transformation and the growth of welfare technologies may be responsible for wide-ranging changes in municipal eldercare in the near future. There are three key drivers of these changes [19]:

• Technological drive: Technology advances at a fast pace, with memory capacity, transistor density and bandwidth capacity growing at an exponential rate [20]. New generations of digital and software products, or new versions of existing products, appear frequently. This fast pace strains the relationship between technology and people’s everyday practices. People regularly abandon digital products and applications for new ones. In 2018, about 60% of Europeans used the Internet to seek health-related information [2]. In Finland, 47% of the population use eHealth services to make practitioner’s appointments, while in Denmark the number is 41% and in Sweden the number is 28% [2]. Statistics show that the rapid adoption of information and communications technology (ICT) and the increased use of the Internet have led to new routines and habits for communicating with healthcare providers and accessing health-related information [3]. Although the percentage of people making practitioner’s appointments through eHealth services in Sweden has not reached the levels in Finland and Denmark, its neighbouring countries, a rapid increase in the popularity of eHealth service use is expected due to the dramatic growth of new eHealth services and the availability of welfare technology solutions [21].

• Social drive: In Sweden, 93% of the population have access to a computer at home, 70% have access to a tablet and 90% own a smartphone [3]. In 2018, 76% of Europeans used the Internet almost daily, while 83% of Europeans used the Internet at least once a week [2]. There is increased use of mobile devices among all age groups [22], which is believed to have increased the expectation that smartphones, tablets and wearables can be used to access real-time healthcare data and information [3]. Patients search for health information, identify treatment and share experiences online [23], and it is predicted that patients will want healthcare providers to partake in online services such as digital reminders or alerts regarding long-term courses of treatment, remote monitoring of a patient’s health status and virtual meetings [21,24]. Welfare technology solutions and the digital transformation of healthcare are assumed to respond to societal needs and values, such as improving accessibility, eliminating the inconvenience of travel to healthcare providers and reducing the risk of contagion from other patients by offering smartphone apps so patients can directly connect with doctors and other healthcare professionals [21].

• Political drive: As previously mentioned, the Swedish government has a vision of Sweden becoming one of the best countries in the world with regard to the utilization of eHealth [5]. The vision is four-fold (a) make healthcare more efficient to meet the demands of an ageing population and a shortage of care professionals; (b) strengthen the resources of citizens for self-management, self-care, participation and independence [25–27]; (c) improve well-being and work environments for care staff and (d) have a positive effect on the private sector, especially in connection with the development of welfare technology products and know-how that can lead to new sales and export possibilities [28].

It is unclear whether any of the above drivers has a greater impact than the others on technological and social change in municipal eldercare. There are several different theoretical approaches to explain technology and its relationship to society [29]. Either technology is understood as shaped by society through the dominant social, economic and political values during a certain moment in history [30], or technology is seen as a determining force that shapes and constructs society [31]. In the first approach, humans play an active role in the development and application of technology: engineers and developers produce technologies, end-users interpret and make sense of technologies, and technologies then, if adopted and adapted, change the society [32]. This process is a loop in which social relations influence technological development and technology influences society [33]. Welfare technology solutions such as the social security alarm with GPS and sensors that enable care receivers to be out and about and that can analyse movement patterns, emerge from existing social security alarms that can only be used at home [26]. This represents a gradual change in the existing social security alarm systems towards new combinations of technological solutions. This change is driven by technological development and the political agenda of self-management, as well as by societal assumptions and values regarding the possibility of older people enjoying active lifestyles, participating in society and enjoying equal rights to independence [26]. In the second approach (technological determinism), humans react and change according to technology. An example of technological determinism in regard to welfare technology is the implementation of vehicle routing problem solvers in Norwegian municipal eldercare [34]. The vehicle routing problem solver aimed to calculate optimal driving routes for home care staff in order to increase their efficiency and effectiveness. As such, the welfare technology solution aimed to change the care staff’s behaviour. However, ultimately, the vehicle routing problem solver did not support the daily care work of the care workers, and they negotiated ways to work around the technological solution [34]. Consequently, the study supports the counter-argument to technological determinism: that a number of technologies fail to get adopted into society each year because they do not meet the needs of the users [35], which demonstrates that individuals and social processes influence technology adoption and usage.

The above perspectives – technological determinism and the social shaping of technology – consider technology as a tool, while another theoretical approach interprets the discourse of technology as a projection of ideas and viewpoints about what constitutes a good life and practical living [36]. In and of itself, technological discourse shapes social, economic and political values, and outlines a political ideology that may become normative in time. Katz [37] points out that all political rhetoric and technological communication involves and predicts actions and decisions, which affect human life. Katz emphasizes that the relationship between political discourse, arguments, social organization and style of thought is political and strategic [37]. In regard to welfare technology, welfare technology solutions are framed to respond to issues surrounding an ageing population and are justified in terms of the increasing costs of the welfare system [5]. The concept of welfare technology itself functions as an emotive argument: as a tool – for example, camera surveillance at night for more efficient care processes and personnel logistics – and as a means to stimulate care receivers’ wishes and needs for activity, independence, participation and security. One could regard welfare technology to be based on far-fetched speculations about an uncertain future, since, so far, the implementation of welfare technology in Swedish municipalities has been slow. However, welfare technology is portrayed as a political foundation in Swedish eldercare. As a result, the political discourse encourages caregivers and care receivers by advocating welfare technology and financing municipalities, research and development to realize its vision [38].

However, it is problematic to fund institutions and projects based on political discourse and policymakers’ needs because it might result in supporting particular developments, municipalities and individuals to the exclusion of others and to the exclusion of traditional care work. Furthermore, there is a risk that funding calls framed by political discourse might lead to normative assumptions about health, ageing and technology. A telling example is that in Swedish municipal eldercare there has been a 30% increase in office holders (i.e., quality assurance officers, human resources, organizational strategists, eHealth specialists, digital strategists, etc.), while at the same time there has been a decrease in frontline care workers [39]. Subsequently, there are more and more people working with administration and strategic planning, and fewer people than ever before working closely with patients. As such, welfare technology projects are not objective or free of values. Moreover, municipalities that support the political ideology might be promoted and, in the worst case, might reproduce the political discourse. Winner [40] argues that technology has political dimensions that can either constrain or enable practices, beliefs or social configurations. Technological rationality computes values and ideas in terms of its own technological promises and functionalities [37]. In a similar fashion, Miller [32] argues that technology can become a form of consciousness and an end in itself due to economic rationality and financial strategies. Thus, welfare technology might be initially developed as a means for better ageing or improved elderly care but becomes an end in itself; as a result, welfare technology would become an ideology of modern ageing and eHealth would become an ideology of modern healthcare.

Ways of thinking about socio-technological practices and change

There are several theories explaining why people use and accept certain technologies. These include theories that consider the individual’s agency as a determining force for technology usage and acceptance [41–44]; theories perceiving usage of technology as dependent on larger systems and socio-economic structures [45,46]; or theories understanding technology acceptance and usage as part of social practice, constituted by mutual relations between materials, social structures, agency and meanings [47,48]. Each of these theories is situated within its author’s perspective, worldview and scientific practices. The concern here is not with assessing the validity and reliability of each of these theories but rather with shifting the notion of technology acceptance and usage and how this can be understood within a municipal eldercare context.

Technology acceptance models and theories, such as the theory of reasonable action [44], the technology acceptance model [41], the unified theory of acceptance and use of technology [42], and the task-technology fit [43] perceive technology acceptance and usage as a product of the individual’s beliefs, attitudes, norms and intentions. Technology acceptance models have been successfully used to predict older adults’ acceptance of various technologies [49,50]. Associating acceptance with individual behaviour may guide a municipality to carry out actions such as education or interventions to change how care employees and care receivers understand digital transformation and welfare technologies [51]. As technology acceptance is seen as part of an individual’s behaviour and personality, unsuccessful digital transformation or failure to use welfare technologies might result in blaming the individual instead of re-evaluating the given technology.

Technological change and technology acceptance may also be explained through the perspective of socio-technological transition [46,52]. Through this lens, digital transformation and the adoption of welfare technologies are slow paced, transformative societal processes. Perspectives on these processes can be considered from three levels: (1) the landscape level, which is the macro-level and refers to the overall political, economic and cultural pattern; (2) the regime level, which is the meso-level and refers to current practices and currently used technologies and (3) the niche level, which is the micro-level and refers to radical innovations and experimentations [45]. Socio-technological transitions are explained by Geels and Schot [45] as follows:

(a) niche-innovations build up internal momentum, through learning processes, price/performance improvements, and support from powerful groups, (b) changes at the landscape level create pressure on the regime and (c) destabilisation of the regime creates windows of opportunity for niche-innovations. The alignment of these processes enables the breakthrough of novelties in mainstream markets where they compete with the existing regime.

Socio-technological transition can already be seen in Swedish healthcare. In 2016, private providers started to offer medical services online [21]. Digital medical services entail direct contact with a doctor in a digital meeting. A doctor can prescribe medication that can be picked up at a local pharmacy. All Swedish citizens can use this service by paying a small fee, as Swedish healthcare is publicly funded. The Swedish government set up general guidelines, while the county councils (n = 21) have the authority to tax citizens of their county and shape the county healthcare services. If county citizens use healthcare services from another county, the “home” county pays for the services. Digital medical services have been set up in some counties and provide care for all Swedish citizens, which results in some counties making a lot of money from the niche of digital medical services, while others have to pay those counties for medical services. The popularity of digital medical services and the increased costs created pressure on county councils to provide their own digital services. Now the landscape is changing and all county councils are in the stage of developing or launching their own digital medical services [21].

The multilevel perspective of socio-technological transition emphasizes that technological change and digital transformation are not just the result of the work of scientists or engineers but are due to multiple actors at different levels. Seeing technological change and digital transformation from a multilevel perspective enables governments to understand their potential to change current practices. Visions, such as the Swedish eHealth Vision 2025 [16], may articulate a discourse, stimulate knowledge and open pathways to digital transformation in healthcare. As an example, the Swedish government has funded selected municipalities to conduct experiments with embedding welfare technologies into eldercare practices [53]. Some of these municipalities have experimented with the use of surveillance cameras, which replace the regime of physical visits at night with the niche innovation of digital surveillance during the night, while others have experimented with GPS alarms, which allow care staff to see the location of care receivers when they are outdoors [53]. The findings of these experiments have been widely disseminated through media and at national conferences, and, as a result, the experiences and changed care practices of these municipalities have shaped actions in other locations [54]. In one sense, this shows how influence is exerted by only a few municipalities and how some practices are capable of orchestrating, constraining and shaping others [55]. A telling example is that the most commonly used welfare technologies in Swedish municipalities are the ones that the selected municipalities have tested: GPS alarms and night surveillance cameras [54]. As such, initial niche innovations like GPS alarms and night surveillance cameras have destabilized the regime of traditional social security alarms and physical night visits and, as a result, have evoked change in care practices at the landscape level.

Technology acceptance and usage can also be understood as social practices, constituted by mutual relations between materials, social structures, agency and meanings [47,48]. In this perspective, individuals are seen as carriers of practices. As such, technology acceptance and technology usage originate from interaction with other people and the structures of the practice they sustain. Practices do not change by a technology per se, but technology acceptance and usage evolve through changes, rearrangements and readjustments of the elements that hold practice together (objects, infrastructures, competences, images and meanings) [48]. This perspective emphasizes that municipalities first need to understand the practices and routine behaviours they would like to transform through digital and welfare technologies, and then address the different elements (i.e., technology, infrastructure, know-how, competence and meanings) that sustain the practice they would like to change. A recent literature review on welfare technologies shows that key factors for successful implementation in a municipal context are: (1) clear goals, incentives and strong leadership; (2) infrastructure, organizational structure and collaboration and (3) economy and resources [56]. The review highlights the importance of considering the elements of social practices and readjusting these elements in order to achieve successful deployment of welfare technologies.

There is no one correct theoretical perspective on why people use and accept certain technologies. Each theory is best suited to different forms and levels of questioning technology change, acceptance and adoption. The theories above identify different elements that characterize technology and the meaning attached to the relative importance of large socio-economic structures or social practices as opposed to the characteristics of individuals or groups.

Technology assessment

One of the problems with digital transformation for eldercare organizations in Swedish municipalities is that digital transformation is a moving target due to the fast pace at which digital technologies evolve [57]. As Downes [58] argued, “technology changes exponentially, but social, economic, and legal systems change incrementally”. The inherent uncertainty in technology, as well as the lack of suitable supporting social, economic and legal frameworks, might lead to uncertainty and hesitation, with regard to adopting new technology [59]. The fast pace at which technology develops puts municipal eldercare organizations in the middle of the Collingridge dilemma. This dilemma can be described as follows: (a) the impact of technological innovations cannot be easily predicted until the technology is extensively developed and diffused; and (b) changing and controlling the technology is difficult because although it is easy and affordable to make changes when digital innovations are in their infancy, the requirements are often unrecognizable and unpredictable; when digital innovations are more mature, the requirements and needs for change are more predictable and recognizable but are now more costly and difficult to address [60]. One suggestion for solving the Collingridge dilemma is by exercising caution: technological innovations should not be embraced until it is demonstrated that they do no harm to individuals or society [61]. The precaution principle has been criticized for hampering technological development and implementation. The principal also raises questions about what comprises “harm” to individuals and/or society, and which shared values should prevail for innovative technologies [62].

One of the large obstacles for many municipal eldercare organizations attempting to implement welfare technology is the lack of knowledge regarding technology assessment and evaluation [63]. A German study on care professionals who had the role of promoting, prescribing, consulting and coordinating the implementation of technologies for older people shows that their main source of information was from the manufacturers [64]. We have found similar results among care professionals who have the role of promoting and coordinating implementation of welfare technologies in Swedish municipalities (forthcoming article). Without and assessing or evaluating welfare technologies and their impacts on the care organization and the care receivers, but instead trusting the advice of the manufacturers, the implementation of welfare technologies becomes a real-world social experiment. Van de Poel [65] argues that introducing a new technology in society can be considered a social experiment, since (a) the experiment takes place in an uncontrolled environment rather than a laboratory or controlled space; (b) it is not only a technical operation but embeds social risks and normative dimensions; and (c) it is done by multiple actors, including those making decisions as well as the participating patients, relatives and care professionals. The advantage of these kinds of real-world experiments are both technical and institutional learning (e.g., knowledge about the long-term hazards and benefits of a new technology, answering what kind of governance is needed for embedding the technology and what is desirable). However, real-world experiments also pose ethical questions concerning the awareness and consent of participants [65].

Technology can be assessed before it is implemented to ensure that it is reliable, safe, efficient and effective while delivering the most value to the organization [66]. Health technology assessment (HTA) is a broad method of assessing the impact a technology may have in a clinical practice. HTA is used as an instrument to identify the external effects (i.e., organizational, social, economic and ethical) a well-developed healthcare technology may have in an existing situation; if used accurately, HTA enables the impacts of similar technologies in the same situations to be compared [67]. HTA has been criticized for assuming that care practices and technologies are static [67], as well as for following predefined checklists [68]. HTA evaluates the impact a well-developed technology has on a current practice and the existing norms and values; it does not consider that a technology and a practice mutually interact and co-evolve. New practices, new professional roles and new organizational forms might evolve through mutual interaction between a technology and a current practice. There have been several studies showing that welfare technology solutions become means for professional development and cross-sectoral professional cooperation [51,69–73]. These studies show how technology constructs and reconstructs professional roles and co-constitutes ways of doing care work. For example, Ertner [51] examines how project managers create “implementation agents” with the intention of using these “implementation agents” to drive technology change (i.e., to create digital older citizens) in Danish eldercare. In Ertner’s study, the “implementation agents” are responsible for making older citizens use iPads. Ertner explored the work “implementation agents” do with, around and on the iPads and the older citizens. This is not a straightforward implementation process; it involves a lot of articulation work [51,74]. Similarly, Sánchez-Criado et al. [70] demonstrate that installing telecare in the homes of elderly people is not a linear technical process of implementing technology as plug-and-play but a dynamic process of maintenance and transfiguration of both the users and the digital services. The users learn from and adapt to the telecare system, and the system developers need to learn from and adopt the telecare system to the users in order for it to be used [70]. Pols and Willems [75] also suggest that the implementation of healthcare technology is not a linear process (i.e., the implementation of technology in healthcare results in change in both the technology and in the practice for which the technology is used). Pols and Willems’ study shows that the same kind of technology can be tamed and unleashed in a number of different ways and with several unintended consequences, as users have tremendous interpretive flexibility [75]. All of the above-mentioned studies show how care practices and professional roles co-evolve with technology and thereby how norms and values are reconfigured in relation to new technology [45].

While HTA focuses on well-developed technologies, constructive technology assessment (CTA) is an iterative methodology that can be used throughout a technology’s development process, from the idea stage to the final large scale implementation [76]. CTA tries to anticipate the potential economic, social, technological, ethical and legal considerations that need to be addressed in order for a technology to be diffused. In contrast to HTA, which focuses on the impacts of existing technologies, CTA is constructive in the sense that it may help to appropriately shape technological developments, since it is meant to be used iteratively from the idea stage to the final stage [77]. CTA proposes an approach to trying out new things and learning from them [78,79]. Although assessing the impacts of a technology is not entirely straightforward, with the help of methods like HTA or CTA it may be possible to identify and reveal probabilities; however, there will still be many unknowns [65].

Responsible welfare technology

Anticipating risk is not only crucial when conducting technology assessments or real-world experiments but also when developing and designing technologies or innovations. The EU policy about innovations highlights the importance of responsible research and innovations (RRI) [80–84]. RRI has four dimensions: (1) anticipation: systematic analysis and contemplation of the known and unknown risks and benefits of an innovation; (2) reflexivity: awareness and examination of the motives behind the innovation and codes of conduct, as well as the innovation’s implications for individuals and society; (3) inclusion: public debates about the innovation and involvement of users in its development; and (4) responsiveness: the capacity to act on stakeholder and public values [81]. RRI may be interpreted as an attempt to democratize the process of research and innovation [85] and is promoted by several European initiatives [84].

Stahl and Coeckelbergh [86] have modified RRI to make it more applicable to the field of ICT and care robots by integrating the 4Ps – process, product, purpose and people – into a framework. Drawing on the principles of Stahl and Coeckelbergh’s framework of RRI in ICT [86], we modified and translated their framework in regard to welfare technology by considering a range of empirical and theoretical work [34,56,87–90]. Asking the types of questions listed in Table 2 may mitigate risks, improve outcomes and help increase the understanding of welfare technology and digital service implementation and deployment. The strengths of these questions lie in their ability to allow reflections on and considerations about a number of “big issues” to be addressed about welfare technology and digital services in municipal eldercare that may otherwise be overlooked. These questions include how a specific welfare technology fits into eldercare practices and the interpretations of a wide group of stakeholders as well as what training and infrastructure are needed for implementation. These questions offer a direct way to unpack the ethical considerations that ought to underpin the implementation of welfare technology and digital services in eldercare practices.

Table 2. Responsible welfare technology framework; modified from Stahl and Coeckelbergh [86].

	Purpose (Addresses why the product/service should be implemented at all)	Process (The activities involved in the preparation and implementation of a product/service)	People	Product Welfare technology/digital service
Prediction/anticipation (Risk analysis)	Why should this welfare technology be used and implemented? What are the benefits and the risks?	How should this welfare technology be implemented?	Who should be involved in the decision-making process? Who should be involved in the implementation?	Usability: Is the welfare technology solution useful, effective, efficient and satisfactory? Social acceptance: Is the welfare technology solution socially desirable? Budget: Is the welfare technology solution affordable?
Reflection (Contemplation of objectives for and implications of the welfare technology and its implementation)	What are the consequences of using this welfare technology? What are the consequences of the implementation?	What processes are used for decision-making? What processes are used for the implementation?	Who is affected by the welfare technology? Who is affected by the implementation?	What might be the potential usage? What do we not know about, e.g., risks and consequences? How can we ensure social desirability?
Inclusion (Initiate debates and engagement with a broad audience)	Are the purpose and risks acceptable?	How do we engage a wide group of stakeholders?	Who matters? Who prioritizes? For whom is the implementation of the specific welfare technology done?	What are the viewpoints of a wide group of stakeholders?
Responsiveness (Influence the course of actions, codes of conduct and implementation process)	How do we verify the success of the technology for end-users? How do we measure success? What kind of benchmarking or metrics are relevant? What kind of impact would we like to achieve? If it is not successful, what do we do? How do we verify that the implementation is successful? How do we measure the progress of the implementation process? What kind of benchmarking or metrics are relevant? If the implementation is not successful, what do we do?	How can the implementation structure become flexible? What training is required? What infrastructure is required?	What training is required? What infrastructure is required?	How can we modify and adapt the product to ensure usability among a wide group of end-users? How can we modify and adapt the product to ensure social desirability among a wide group of end-users? How do we achieve sustainable modification and adoption of the product?

In an ever-changing technological society, it can sometimes seem that municipal eldercare is trying to hit a moving target by fixating on the next evolution in technology rather than focusing on the goals of the organization and stakeholder values [63]. In his article “Too much technology”, Hofmann [91] describes how many health technologies are used without any evidence of their safety, efficiency or effectiveness due to the belief that new technology is better than old technology, more advanced technology is better than simpler technology and more technology is better than less technology. He argues that there needs to be greater responsibility for the development, implementation and use of healthcare technology because it is a driving force in healthcare expenditure, even more than the ageing population and increased public demand [91]. However, this does not mean that digital transformation and the development and deployment of welfare technologies should be discouraged; instead, the focus must shift from an overreliance on technology to an interest in and an understanding of its limits and benefits. Table 2 offers a framework that draws attention away from specific technologies to instead stress the needs and goals of organizations and end-users. The framework is heuristic in the sense that it is designed to guide thinking rather than be used as a model to predict outcomes of implementing welfare technology. The framework focuses on the four main influences that affect the uptake of welfare technology: the purpose, the process, the people and the product itself (i.e., welfare technology/digital service). The connections between the four main influences and the dimensions of prediction, reflection, inclusion and responsiveness are shown in Table 2. The main purpose of this framework is to provoke reflection and discussion about the deployment of welfare technologies/digital services in municipal eldercare. It addresses many of the ethical and practical issues that ought to be part of the process of determining potential welfare technology solutions. The framework might help municipal managers and leaders identify and solve issues in order to prevent adverse events or being overwhelmed by a technological tsunami.

Conclusion

The aim of this article has been to discuss technological change, digital transformation and welfare technologies, as well as the digital development challenges faced by Swedish municipal eldercare organizations. Digital transformation may be understood as driven by three key drivers: technological, social and political. These form a loop in which social processes influence technological and political processes, which in turn influence the meaning of a technology as well as the needs and usage patterns among end-users. Digital transformation and the development of welfare technologies are moving targets, and municipal eldercare organizations are facing the Collingridge dilemma: the impact of a welfare technology or digital service is difficult to predict until the welfare technology or digital service is extensively developed and implemented in its intended context. The dilemma can be addressed by focusing on the needs and goals of the organizations and end-users instead of on the continuing evolution of technology. Furthermore, if a new welfare technology or digital service is identified as adding value to care receivers and/or care staff, then municipal eldercare organizations need to be responsive and able to accommodate changing practices and technological change.

This article draws attention to a set of evaluation questions adapted from Stahl and Coeckelbergh’s framework of RRI in ICT. These questions allow reflections on and considerations about a number of ethical and practical issues to be addressed regarding welfare technology and digital services in eldercare that may otherwise be overlooked in a municipal context. These questions set the scene for future empirical and theoretical investigations.

Acknowledgements

I would like to thank Professor Britt Östlund, who has contributed by securing the funding for this research.

Disclosure statement

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Additional information

Funding

This work was supported by the Swedish Research Council for Health, Working Life and Welfare [grant numbers 01755, 2017].