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Influencing Practice with m-Health: Using Lewins Change

Theory to Implement the Usage of Cell Phones in the Delivery of
Health Care
by Carla L. Kennedy and Wendy Young

Memorial University of Newfoundland and Labrador

Corresponding author: youngw@mun.ca

Abstract
Over the past decade, cell phone usage has increased amongst adults with 78% of
Canadian households having active mobile phone accounts (Statistics Canada, 2011).
The increasing rise of cell phone use makes it a promising method for aspects of
health care delivery. Mobile communications or mHealth use affords new ways for
health care professionals to provide health care, inviting change in the way health
services are usually implemented (Kaminski, 2011; United Nations Foundation and
Vodafone Foundation, 2009). Mobile communications has the potential to transform
health care delivery and requires vision directed under transformational leadership for
successful implementation. In order to strategize this transformation, leaders can be
guided by the use of Lewins change theory. For the purpose of this paper, we have
developed a hypothetical scenario that advocates the implementation of mobile
communications in the delivery of health care. We use this scenario to evaluate
literature on mHealth, and argue that this form of technology can be effective in
delivering health care. In addition, we offer information on transformational leadership
and on Lewins change theory. This provides guidance about how administrators can
explore the leadership style and change processes required to integrate these
technological advancements into practice.

Keywords
Mobile communications, mHealth, cell phone usage, health care delivery, transformational leadership, Lewins
change theory

Introduction
The Canadian Nurses Association (2009) and the Canadian Federation of Nurses Union (2006) advocate that quality
health care occurs as a result of communication and collaboration between health care providers and their patients..
Current and emerging technologies enable levels of collaboration beyond traditional methods of health care delivery.
Consequently, the literature makes a strong connection between effective health care delivery and mobile
communications. Mobile communication technologies provide alternate ways to exchange information, collaborate
with health care professionals, influence health outcomes and affect the processes of care (Hodder & Frazer, 2012;
Krishna, Boren, & Balas, 2009). Mobile phones, combine phone access, text messaging, convenient Internet
access, and other apps that enable health care professionals to provide health related interventions and disease
management support to their patients from a distance (Krishna et al., 2009). Technology advances such as mHealth,
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or mobile Health, can create change in the way that health care services are traditionally conducted. Thus,
stakeholders, health administrators, and leaders should consider embracing these changes.

Although the technological advancements of cell phones have the potential of providing a successful method of
health care delivery, many health care institutions ban cell phone inhibit or even ban their use by employees. The
purpose of writing this paper is to gain insight on how mobile communications can be used in health care and to offer
a process by which health care leaders can reconsider the use of mHealth. We evaluate cell phone usage amongst
health care professionals and offer a process to implement change in a growing world of technological innovations.
This paper provides a description of a hypothetical scenario which provides a real life example to illustrate mHealth
in action and how to apply the change process to incorporate mobile communications into health care. This paper
also provides: a literature review of mHealth with a focus on cell phone use; a comparison of mHealth versus
eHealth; a description of mHealth applications; and a discussion on transformational leadership and Lewins change
theory in the context of adopting mHealth into practice.

Hypothetical Scenario
A committee at an institution in an urban area in Canada is in the process of reviewing their personal cellular
telephone use policy. Although the policy is aimed at personal cell phone use, it also restricts the usage of mobile
technology in the administration of health care. The committee has concerns about the current cell phone usage
policy, and is in the process of compiling evidence to submit a report to institutional administrators tot challenge the
current policy. The report outlines the benefits of cell phones as tools that can enhance the delivery of health care.
The committee included a review of the literature on cell phone usage within the delivery of health care as part of
this report.

Background Information
One of the challenges for health care professionals and patients living in this urban area in Canada is that residents
and communities are geographically dispersed. Also, unpredictable weather presents a potential access and
delivery challenges for both patients and health care professionals. Thus, health care accessibility can be
problematic for individuals living in this area. The use of mobile communications including technology such as cell
phones and personal digital assistants (PDAs) offers a solution since it has the potential to improve accessibility to
health services and provides health-related information to rural communities and hard-to-reach-individuals (United
Nations Foundation and Vodafone Foundation, 2009).

Literature Review
A literature search was initiated using the CINAHL and MEDLINE (PubMed) databases (Pravikoff, Levy, & Tanner,
2011). Search keywords or concepts used included cell phone, wireless communication or mobile
communication combined with health care delivery wireless communications AND rural OR remote; AND patient
care to locate recent research on cell phone use, restricted to within the last ten years. Approximately three hundred
references in the English language were identified and reviewed. Most of the results about cell phone use in the
delivery of health care were distributed equally between qualitative and quantitative research.

A report authored by the United Nations Foundation and Vodafone Foundation (2009) provided evidence of the use
of mobile communications in developed countries. Another anecdotal or commentary report on cell phone use
suggested that restrictions on the use of cellular phones in hospitals are impractical and that guidelines should be
put in place to integrate this technology in the delivery of health (Flynn-Makic, VonRueden, Rauen, & Chadwick,
2011). The literature review explored the meaning of cell phone use under the umbrella of mHealth, the comparison
of mHealth versus eHealth, and a description of mHealth applications.

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Cell Phones as a Form of mHealth
The United Nations and Vodafone Foundations (2009) defined mHealth as the use of mobile communications,
which includes technology such as mobile phones or cell phones, and personal digital assistants (PDAs). PDAs are
small hand held devices that, like mobile phones, allow the retrieval and transmission of data via the internet, and
the storage of information (Allen, Bakrim, Lacy, Boyd, & Armstrong, 2011). Mobile devices can be used to access
health information, to collect data, to collaborate with health care professionals, and gain interactive support from
friends, family, and health providers (Allen et al., 2011; Klasnja & Pratt, 2012). With mHealth technologies, health
interventions can be offered by professionals at a decreased cost while continuing to improve the health status of
individuals and groups seeking health care (United Nations Foundation and Vodafone Foundation, 2009; Guy et al.,
2012).

Mobile phones offer an effective and efficient method of enhancing health care. The increase in cell phone use
across populations provides accessible tools for delivering health interventions (Klasnja & Pratt, 2012). Individuals
tend to have their cell phones on them at all times, thus could have access to health care delivery systems in a
convenient and accessible manner (Klasnja & Pratt, 2012). Furthermore, the special features that are enabled
through mobile technology, such as personal settings, privacy protection, and the ability to download specific health
applications (or apps), create an innovative way to monitor health, to collect data on various medical conditions and
diseases, to complete research, provide education, and provide alternate ways to connect with professionals about
health (United Nations Foundation and Vodafone Foundation, 2009; Allen et al., 2011; Klasnja & Pratt, 2012).

mHealth versus eHealth

To recap, mHealth deals with the mobile technologies through which health care can be delivered. eHealth, or
electronic Health, is defined as [u]sing information and communication technology (ICT) such as computers,
mobile phones, and satellite communications for health services and information (United Nations Foundation and
Vodafone Foundation, 2009, p. 8). Both mHealth and eHealth are concerned with improving health care accessibility
and health outcomes through the use of technology (United Nations Foundation and Vodafone Foundation, 2009). In
particular, eHealth is related to point of care (POC) technology and involves the development of electronic health
records for patients receiving care within a health care system (Quinn, 2011).

POC technologies create ways to ease documentation and increase its accuracy (Quinn, 2011). The electronic
health record (EHR) is one form of eHealth that works to improve clinical processes and quality of care, it offers
efficient methods for information sharing amongst professionals, and potentially decreases the rate of medical errors
(Quinn, 2011). Other forms of eHealth include telehealth and health information technology (HIT). Telehealth consists
of telephone consultations that offer remote medical advice between a patient and a provider, and can be used for
collaboration between health care providers (Franc et al., 2011). HIT consists of specific software and computer
programs that health care organizations implement to engage in electronic administrative and clinical functions
(McHugh, 2011). For example, a computer system called Meditech is used by many organizations. eHealth and
mHealth technologies are linked since mHealth creates opportunities for health care professionals to access and
collect data that otherwise would be impossible (United Nations Foundation and Vodafone Foundation, 2009).
mHealth provides various applications that are beneficial to both recipients and providers of health care services.

mHealth Applications
The literature provides support for the benefits of mHealth, and points to its diverse functions. These functions
include: sending short message service (SMS) reminders to patients about upcoming appointments; influencing
health behaviors as a result of provider-patient intervention via mobile phones; offering education and awareness via
the internet on a PDA or phone; and the capability to track data on illness symptoms and disease (Boland, 2007;
Fjeldsoe, Marshall, & Miller, 2009; Krishna et al., 2009; United Nations Foundation and Vodafone Foundation, 2009;
Ehrenreich, Righter, Rocke, Dixon, & Himelhoch, 2011; Guy et al., 2012).
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The application of short message service (SMS), or texting, has been successful in increasing the clinical
attendance of patients with their health care provider. Thus, when patients see their providers as scheduled, health
care is not financially burdened with. In addition, patients are attending to their individual health issues;
nonattendance at outpatient clinics has been linked to adverse health outcomes. As well, SMS can offer
administrators a cost effective method of providing reminders that are automatic, thereby decreasing the human
labour cost of paying personnel to place telephone reminders (Guy et al., 2012).

Research evidence also suggests that SMS facilitates health interventions by offering education and awareness for
both those receiving care and those administering it ((Boland, 2007; Fjeldsoe et al., 2009; Krishna et al., 2009;
United Nations Foundation and Vodafone Foundation, 2009; Ehrenreich et al., 2011). SMS offers an avenue through
which health care providers can monitor chronic conditions such as diabetes, asthma, and mental health disorders,
such as anxiety, and a means to offer health-promoting advice to their patients (Boland, 2007; Fjeldsoe et al., 2009;
Krishna et al., 2009; Ehrenreich et al., 2011). SMS enables telephone-based counseling that influences health
behaviors and outcomes (Ehrenreich et al., 2011). For example, smoking cessation programs and glucose control in
diabetics have been linked to the SMS ability to provide health intervention from remote locations (Fjeldsoe et al.,
2009; Ehrenreich et al., 2011; United Nations Foundation and Vodafone Foundation, 2009). For health care
providers, SMS enables data collection technology to track patients progress and symptoms (Krishna et al., 2009; &
United Nations Foundation and Vodafone Foundation, 2009). SMS also offers an interactive tool for health care
providers in hard to reach places, to consult with other professionals and to pursue continuing education through
online learning (United Nations Foundation and Vodafone Foundation, 2009).

MHealth enables the opportunity to offer health services in unique and effective ways. These technological
advancements invite change in the way health care is accessed, offered, and delivered. Therefore, in order to
implement mHealth technology in health care, administrators must be open and ready for change. Transformational
leadership and Lewins change theory can guide health care professionals and administrators to embrace mHealth.

Transformational Leadership
Patients are the central focus and priority in the provision of health care service. If patients are to receive effective,
efficient care, health care provision must be properly organized and the professionals involved must be open to the
changes that technological advances invite (Lemin, 1978; Kaminski, 2000). In his book, Lemin (1978) illustrates a
triangulation relationship whereby interactions between multidisciplinary professionals are dependent on patient
requirements. In this schema, the patient is at the top of the triangle, and is simultaneously connected to the
physician and the nurse via the sides of the triangle. Caregivers, lab technicians, engineers, accountants,
physiotherapists, occupational therapists, and other pertinent health care professionals intercept the triangle sides.
As technology becomes a part of the health care system, one can argue that mHealth has a role within this Lemins
triangulation relationship. Roles of leaders and managers are imperative in successfully processing patients and in
addressing patient needs. Lemins illustration demonstrates that patients are the focus of care and that other
members of the health care sector enable the health process. Today, evidence suggests that mHealth also enables
this process. For favorable patient outcomes, the health care system requires management with a transformational
leadership style that embraces the vision of mHealth as a process in the delivery of care.

Transformational leadership considers the relationship between a leader and his/her followers in the context of the
organizational culture. To clearly define what is meant by transformational leadership, it is necessary to consider
transactional leadership. Marriner-Tomey (1993) wrote that transactional leadership occurs when a leader initiates a
relationship with followers based on exchange (p. 22). A desirable behavior is acquired from the follower as a result
of being motivated by the leader in exchange for some valuable resource. In transformational leadership, an
engagement process occurs whereby leaders and followers assume motivational and ethical aspirations (Marriner-
Tomey, 1993).

Currently, some organizations restrict the use of mobile phones, thereby placing limitations on new ways that can
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improve access to patient information, complete legible clinical documentation, and timely and accurate patient data
at point of service (Wise, 2011, p. 38). Mobile devices can be used by health professionals to organize data, access
information in a timely manner, and utilize interoperability functions that help numerous health care providers to work
with information at the same time (Charters & Guberski, 2011). In addition, mobile devices can be used to download
application tools that apply to clinical practices such as calendars, calculators, education on health diseases and
services, and access to professional up-to-date literature on best care practices (Charters & Guberski, 2011; &
Kaminski, 2000).

The current fiscal and human resource challenges in health care support the need for a transformational model of
leadership (Marriner-Tomey, 1993). Subsequently, advancements in technology such as mHealth offer ways to
deliver health care in a cost effective but efficient manner (Kaminski, 2000). Furthermore, [i]t is up to the leaders to
make these change initiatives tangible rather than abstract and to awaken enthusiasm and ownership of the
proposed changes within the corporate milieu (Kaminski, 2000, p. 2). Transformational leader characteristics
include proactive and visionary traits, and the ability to lead and adapt to technological changes in the delivery of
health care (Marriner-tomey, 1993; Kaminski, 2000; & United Nations Foundation and Vodafone Foundation, 2009).
The theoretical underpinnings of Lewins change theory offers guidance on how to implement change and adapt
mHealth to health care.

Application of Lewins Change Theory

Lewins change theory offers a method that leaders can use to implement change within health care systems
(Kaminski, 2011). In his theory, Lewin offers an operational framework that explains human behavior resistance to
change and provides a solution to adapt technology into health care delivery and its services (Kaminski, 2000;
Bozak, 2003; & Kaminski, 2011). His operational framework involves working through three stages: the unfreezing,
moving to a new level, and refreezing stages (Bozak, 2003; & Kaminski, 2011). Using Lewins change theory can
help administrators review their current cell phone usage policy and incorporate guidelines that work towards the
integration of mobile technology in the work place setting.

Unfreezing Stage
First, it is important that leaders recognize there is a need for change (Kaminski, 2000; Kaminski, 2011). Flynn-
Makic et al.(2011) articulated that [h]ospital policies that ban use of cellular phone devices are not only impractical to
enforce, they also exclude a key tool that is used as a vital source of information for health care providers (p.56).
Given that technology advancements are inevitable, health care administrators need to embrace the change that it
offers. If administrators do not want mobile phones to be used in the clinical setting for personal use, guidelines
should be developed that enable clinicians to still use mobile technology for clinical applications.

Policies that outline cell phone use restrictions produce a sense of discontent and frustration in employees. We live
in a technological era and use technology to connect with the world. This trend could and should apply to health care
as well. Thus, a new organizational culture surrounding the trend of implementing cell phone use in health care
must begin in the unfreezing stage of Lewins change theory if administrators are going to adjust this policy. The
preceding literature review was presented to influence driving forces and convince health care administrators to
reconsider restrictive cell phone use policies (Bozak, 2003). In this stage, it is important to identify both the driving
and restraining forces that support or impede the desired change. The driving forces in this instance include better
access to information, thereby the ability to offer better care (Charters & Guberski, 2011). If organizations do not
provide explicit rationale for enforcing the restrictions, the validity of cell phone use policies are likely to be
questioned by employees. Lewins change theory outlines that both driving and restraining forces should be
honestly and openly discussed and compared during this stage of the change process (Bozak, 2003). Otherwise,
moving forward to the next stage would be futile. Administrators should be invited to discuss their perceptions of
current cell phone use policies and weigh the pros and cons of policy change.

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Moving Stage
Once administrators have accepted that the review of this policy is necessary, stakeholders can move towards
changing policies to ones that support the integration of mobile communications. Hopefully administrators will
understand the benefits that mobile technology add to the delivery of health care. mHealth is a tool and a resource
for rural health care providers and many of its applications have its place in caring for individuals, families, and
communities in any geographic setting. Mobile technology is a promising method to care for people in hard to reach
areas, consult other health care providers, and access online education. After considering the benefits of mHealth
applications, organizational leaders might not only review their cell phone policy but also consider piloting a project
to implement a specific application offered by mHealth for example, SMS reminders for outpatient clinic
appointments.

Refreezing Stage
Once administrators have renewed their organizational culture around mobile technologies, they can develop new
guidelines to integrate permission to use these tools for clinical purposes. It is true that [t]he very culture of an
organization needs to be reshaped to properly support the new process introduced (Kaminski, 2000, p. 2). The
development of new cell phone use policies prepares employees to use their mobile phones for direct health care
applications (Kaminski, 2011). In this stage, it is important that unit managers and clinical leaders, such as the
patient care coordinators, support mobile technology in the work place (Bozak, 2003), thus, creating a new norm for
the way in which health care organizations provide services. Two examples of this improved services include: a)
permitting critical care nurses to use their smart phones to look up drug compatibilities rather than having to leave
the patients bedside and look at a chart in the medication room, or b) allowing an English speaking nurse to
communicate with a French speaking patient with the help of a language conversion application downloaded on their
phone. This allows nurses to become leaders in embracing mHealth, and offering a different avenue to deliver
health care, and improve the quality of health services.

Discussion
In Canada, there is much literature that supports eHealth, but a deficiency in discussions and research about
mHealth. For example, the Pan-Canadian Change Management Network consists of several key groups
collaborating about integrating technology within the Canadian health care system (Hodder & Frazer, 2012).
However, much of the literature examining mHealth comes from the United States. The Canadian government
places priorities on information communication technology (ICT) which produces advanced health care services
such as telehealth, the development of electronic health care records, and the accessibility of online education
(Nagle, Hannah, & Hammell, 2011). To our benefit, Canada is moving forward with ICT initiatives but eHealth
initiatives are expensive. Given that Canadian health care is a publicly funded privilege, it is challenging for
government to financially fund these technological advances and put them into practice.

On the other hand, mHealth deals with mobile technologies that are purchased by individuals. This could be
advantageous to health care administration since employees could use their personal cell phones for work purposes.
Of course for legal and ethical reasons, this would have to occur within a policy-driven collaboration between the
health care employee and employer. With this agreement, health care institutions could trial mHealth and analyze
the pros and cons within their own organization. Furthermore, research could be completed to collect data examining
the cost efficiencies of mHealth in Canada. Since the United States delivers health care under a fee-for-service
regime, US researchers and leaders are interested in saving money in order to profit in a privatized health sector.
Still, in a publicly funded system, it makes sense that the Canadian government invest in ways to save money also.
Therefore, mHealth may be an avenue to save funds yet improve care, and health authorities may be the first to
investigate its cost saving benefits.

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 Conclusion
Change is inevitable and with new advancements in technology, industries are going to have to learn to deal with
change if they are going to succeed in reaching organizational goals. Health care organizations are no exception,
and administrators must create a culture that invites change. Technology advances such as mHealth offer new ways
of delivering health care that benefit both recipients and providers of care. As a result, health outcomes are more
favorable. Thus, health care administrators must learn to embrace mHealth since the changes that it offers improve
the service provided. A small step taken to revise restrictive cell phone policies is a big step in the right direction of
embracing mHealth.

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Author Biographies

Carla L. Kennedy
Carla gradated with her bachelor of nursing in 2001. Since graduating, she has worked in an adult critical care
setting for most of her nursing career. Carla is completing her Masters in Nursing on a part-time basis while she
works full time. Her interests in nursing include quality of work life environments which enhance nurses life and the
patients they care for.

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Dr. Wendy Young
Dr. Young completed her PhD training in the Department of Health Policy, Management and Evaluation, University of
Toronto and a CHSRF/CIHR Post Doctoral Fellowship at the University of Toronto and York University. Her research
focuses on what makes for healthy aging in the community, and on reducing the effects of common age-related
chronic diseases such as diabetes, and cardiac disease. Currently, she holds a Canada Research Chair in Healthy
Aging at Memorial University of Newfoundland.

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