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"Health care is about the relationship with the customer"

He may well be an organisational theorist, but he has no interest in how health care should be structured at national level. And despite his PhD in business administration, he doesn’t want to know about cash flows in the sector.

Instead, he specialises in the individual’s interaction with the health service.
"I’ve always been interested in how the relationship with the health care customer or patient can be organised so that the individual is visible, becomes more independent and is involved in the care process. These are the cornerstones of person-centred care," says Lars Edgren, newly appointed adjunct professor attached to the University of Gothenburg Centre for Person-Centred Care (GPCC).


Lars Edgren prefers to talk of health care customers instead of patients, as by definition the relationship with a patient is never really equal.
“The term patient is tied up with ideas of a passive recipient of care, whereas health care these days is working towards an equal and active relationship,” says Edgren, who feels that the concept of the patient is so deeply entrenched in our subconscious that it is difficult to come up with anything new.

Controversial thesis
The concept of the customer comes from service theory, which Edgren has helped to adapt and transfer over to the health care sector. Talking about customers in health care was alien to many when Edgren submitted his thesis in 1992.
“The advantage of the concept of the customer is that the person seeking health care is perceived as someone with needs that go beyond all things medical – social needs and a need for information, for example,” says Edgren.
Customers who are involved in health care decisions work actively to adapt care to meet their own particular needs. Where health care customers are passive, there is a real risk that they will be disappointed and dissatisfied.
“Private health care providers in primary care began using the term customer for their patients, and then the public sector followed suit,” says Edgren. “It’s all about building long-term relationships, and is a far cry from the cut and thrust of the business world.”

From in-patient care to primary care
Edgren spends 20% of his time as an adjunct professor of care sciences at the Sahlgrenska Academy. This will see him working at the GPCC on a heart study of how the relationship and respect between health care providers and customers can improve rehabilitation in cases of acute coronary artery disease. The project will investigate which measures can reduce the rehabilitation period from the current three to six months to around a month.
“Chronic care requires a completely different approach from health care providers,” says Edgren, who will be investigating how the transition from in-patient care to primary care can work optimally. “There are often lots of different health care providers involved, which means that communication between them has to work if we are to stop customers or patients from getting caught in the middle.”
He feels that hospitals and primary care need to create health care processes together so that health customers are not overlooked in the transition process and do not end up having to organise this themselves.

Health care – a package deal
As Edgren sees it, different types of health care offer customers different packages put together in advance by the health care provider. Information or the transfer of knowledge plays an important role here.
“The health care sector needs to adapt what it offers in line with how well-informed and well-educated patients are. The health care package goes beyond a diagnosis and treatment – it also involves a social and emotional dimension that’s important to customers,” says Edgren, highlighting the 1177 health care hotline and website as a good example of information packaged to meet customer needs.

Major advances in 30 years
Edgren is something of a pioneer in his field. In 1981 he distributed one of the first ever patient questionnaires in Sweden, which saw him asking every patient who came to the orthopaedic clinic in Lund over the course of a week for their opinions. The survey showed that although the patients had spent a long time in the waiting room, they were still happy with their visit. Patient expectations of health care were low at the time. The decision makers talked of a well-oiled machine, drawing comparisons with Volvo’s assembly line. Patients got the care they needed.
“It was controversial at the time to ask patients what they thought of the care they were getting,” says Edgren. “Since then we’ve undergone a fantastic transformation whereby the health care customer is now a person who is ill instead of an illness in a patient. The individual and the individual’s resources are the focus of the rehabilitation process.”

New technology opens doors
Technological advances have been a key driver for the activation of patients, with information on the Internet enabling them to make different demands of doctors, and there is even a smartphone app that can remind people to do the exercises that are so important for their rehabilitation.
“There are many new technological solutions that have enabled health care customers to be more involved. Of course, patients do get hold of information off the Internet that isn’t reliable, but on the whole the technological revolution has been positive and has benefited the democratisation of care.”

Developing e-health
When he is not at the Sahlgrenska Academy, Edgren works for the regional council on assessing and developing e-health, which involves liaising with technical staff to find new ways of organising care to incorporate new technology.
“This is one of the biggest challenges facing health care at the moment – trying to match the customer’s own knowledge growth and build on it, so that health care customers get better and better at taking responsibility for their own health and ill-health,” says Edgren.

New ways of working for radiologists
In his most recent study Edgren was involved in assessing an enterprise information archive for storing and distributing radiological information.
“Light boxes and X-ray plates are a thing of the past now, everything’s digital these days. This makes for a completely different way of working, where radiologists here in western Sweden can consult other radiologists in the region and the rest of Sweden, and just as easily turn to colleagues in Australia and have an answer the next day.”

Change of perspective
Instead of asking radiologists how well they thought the archive was working, Edgren came at it from a different angle: he started by investigating which doctors needed information from the archive. It turned out that other specialists such as orthopaedic surgeons and neurologists were annoyed that the archive had not been adapted to their needs. They needed to get hold of the images faster than is currently possible so that they could use them during consultations with health care customers. These customers wanted to see for themselves the impact of a specific treatment, even if they had been treated elsewhere.
“So the images act as an educational tool for consultants when dealing with health care customers, which is a great example of the new demands resulting from customer involvement in their care,” says Edgren, pointing out that health care customers are the real winners when the information can be shared simply and securely between the various players in the sector.

Selected publications:

Lars Edgren, Keith Barnard, (2012). Complex adaptive systems for management of integrated care. Leadership in Health Services, Vol. 25 Iss: 1, pp.39 – 51

Lars Edgren. The meaning of integrated care: a systems approach. Int J Integr Care. 2008 Oct-Dec; 8: e68.

Kent Fridell, Lars Edgren, Lars Lindsköld, Peter Aspelin, and Nina Lundberg. The Impact of PACS on Radiologists’ Work Practice. J Digit Imaging. 2007 December; 20(4): 411–421.

BY: Elin Lindström Claessen

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