Ebook: Information Technology in Health Care 2007

It is hard to overstate the importance of an international forum which brings together leading researchers studying how information and communication technologies (ICT) can be safely and effectively designed, implemented and used within the health system. The ICT research enterprise has increased substantially in the last decade.

Alongside the research interest, investments in clinical systems have grown and their sophistication and capacity to contribute to health sector improvement continues at a rapid pace. Yet, amongst this growth, evidence regarding the benefits of system introduction remains limited and has not kept pace. For example, good studies of benefits realization remain sporadic, and large scale system failures occur all too frequently. Early studies of health information system failures identified the central role of the human, social and organizational contexts in which information systems operate. They set the challenge for researchers to understand how to obtain the best fit between the technical systems (e.g. the information systems and associated work practices) and the social systems (e.g. organisational culture, social practices and behaviours, and political mileu).

The origins of socio-technical theory can be traced to different strands, one of which is the seminal work undertaken by organizational researchers Trist and Bamforth who originally studied British coal miners in the 1940s and 1950s. Another important strand is the work of Bruno Latour and Steve Woolger who in the 1970s examined how scientific facts are constructed in a laboratory. Since this time many health informatics researchers have adapted this theoretical approach implicitly or explicitly, and have framed their research within a socio-technical perspective.

This has resulted in a new and exciting body of work embracing a socio-technical perspective of health information system design, implementation and evaluation contributed to by researchers from many countries. In 2001 the 1st International Conference on Technology in Health Care: Socio-technical Approaches was held in Rotterdam, The Netherlands. It brought together academics to discuss their research under the common theme of socio-technical approaches. This conference was important in identifying an international community of scholars from a broad range of disciplines. The research discussed revealed aspects of the complexity involved in studying the implementation and impact of clinical information systems within health care organisations. In particular, the research highlighted the value in harnessing a multi-disciplinary and multi-method approach to this topic. In 2004 the 2^nd International Conference on Technology in Health Care: Socio-technical Approaches was held in Oregon, USA. This showed how innovative researchers were extending the reach and relevance of their research contributions.

This volume presents the papers from the 3^rd International Conference on Technology in Health Care: Socio-technical Approaches held in Sydney, Australia in 2007. Six years on from the first conference in Rotterdam the quality of the research papers has continued to improve as have the theoretical sophistication and empirical methodologies. Considerable advances are evident, though many of the underlying challenges, such as our ability to design, implement and evaluate safe, useable and effective systems within complex health care organisations, remain. Several researchers at the original Socio-technical conference present papers in the current volume and the continued development and contribution of their work can be seen. Importantly, there is also a contingent of newer researchers who present papers which bring new insights. Our field is dynamic, and growing, and is a platform for some of the finest research and researchers in any discipline. These contributions demonstrate the vital role that the socio-technical health informatics research community has in fostering greater research capacity, and translating research findings to improve health care service delivery, health policy and outcomes. We are grateful for the support and conference sponsorship provided by the NSW Health Department and Intel Australia. Continued collaborations between researchers and industry are vital in moving this important research agenda forward.

Johanna I Westbrook, Enrico W Coiera, Joanne L Callen, Jos Aarts

Many healthcare ICT innovations fail in practice because of a failure to take into account user needs. User needs should be identified broadly, encompassing different levels of organization of the healthcare system and different stakeholder concerns. Full-scale simulators are starting to be used to help in the design and evaluation of novel biomedical devices and displays. Although promising, simulators have significant technical and operational limitations for this purpose and they do not address important aspects of the sociotechnical systems context in which healthcare ICT will be embedded. This argument is illustrated with a case study in which advanced auditory displays for patient monitoring were successfully evaluated in a full-scale patient simulator, but many further questions remain prior to successful translation to practice.

The development of assisted living technology today lies within the realm of ambient computing, making assistance automatic and the systems invisible. Unfortunately, this invisibility is also the reason why the users of these systems have no means to remedy even very simple fault situations. By focusing on the needed complementarities between user control and automation, we identify three main issues which are critical when introducing new technology in the homes of older people: Individual need for representation of data, the need for the user to construct a conceptual model of the system and the need for systems to change over time.

Papua New Guinean primary health care workers describe their Standard Treatment Manuals as like “a teacher” or “a doctor”. This paper explores this glowing reference, looking at how Standard Treatment Manuals are utilised, through data collected in a study which identifies what influences primary health care workers in Papua New Guinea to access and utilise information for diagnostic and treatment decisions. In addition to presenting a unique perspective on this method for transferring information to health workers across the world, this paper presents an opportunity to consider some of the factors which both enable and inhibit the process of providing information to health workers in a non western culture.

The National Programme for IT in England is an ambitious programme comprising a variety of systems from the tried and tested to the new based on new government policy that is being implemented at the same time. For such a large and complex programme, it is not surprising that there are a variety of outcomes emerging. While there are many successes, there are also delays and concerns. This paper looks at two very different systems in the programme (Choose and Book and PACS). It compares and contrasts their implementation within a health community and identifies implications, based on complexity theory, this has for the choice of approach to implementation of associated change.

This paper will describe two alternate conceptual frameworks (i.e. Structuration and Sensemaking) that will help to describe and provide insight into how best to implement health information systems in ICUs throughout the globe. Structuration and sensemaking are two competing ways to view the social world within hospitals. To examine the impact of information technology in health care organizations, it is important to explore the dynamic interplay between clinical decisionmaking, outcomes of HIT implementation, and individual characteristics of the organizational setting. The adaptation of information technology within health care organizations is by its very nature quite complex. The recursive pattern of social interactions that shape the implementation of technologies within that setting is key. Structuration theory provides an understanding of human work as social interaction within that organizational culture, mediated by artifacts such as tools, language, rules and procedures, and open to change. The ICU provides multiple opportunities for sensemaking. It involves caring for multiple patients simultaneously; is subject to high levels of uncertainty and is provided under significant time constraints. It is highly interdependent work, necessitating shared sensemaking as well as individual sensemaking. Sensemaking is made partially visible in this context as clinicians communicate to each other what they think is the cause of the patient's symptoms and how to treat them in the form of discussions about patient care, consultation requests, ancillary testing, and the electronic medical record. The collaborative nature of work in the ICU lends itself to the application of sensemaking and structuration theories.

An electronic triaging system was introduced into a busy children's hospital emergency department. Within 18 months of its introduction, amidst complaints from staff about patient safety related to work slow downs, a decision was made to stop using the system. In this paper we examine issues that arose with the introduction of the electronic triaging system, and discuss these in relation to decision making in complex systems. We suggest that difficulties with the triage system resulted partly because data resulting from the triage encounter are used in several domains including the care domain, the access domain, the federal equity and accountability domain, the local accounting and quality domain and the research domain, each of which has different primary stakeholders, with varying needs. Greater attention to identification of data requirements for each of these domains and acknowledgement of varied stakeholder interests prior to software selection and implementation may improve future implementations.

A study at the urology clinic, Frederiksberg Hospital Denmark, the clinicians working procedures, when prescribing, dispensing and administrating drugs using a computerized physician order entry system (CPOE) showed an overwhelming majority of the clinicians who believed it does support the patient safety and quality of treatment despite the CPOE was not used to the expected degre.

The aim of this paper is to describe the effect on the clinical cooperation when introducing video consultations in the home of the patient. The study was conducted as a Participatory Design process containing workshops, field studies, clinical experiments and pilot tests involving participants from the Danish primary and secondary care sectors as well as patients and relatives. The video consultation set-up constitutes a new organisational way of working, described as “a new triangle”, based on immediate inter-individual cooperation and team-work. In the triangle, competences were combined which led to a more holistic treatment and a more active role of the patient. Furthermore, a spreading of knowledge between all participants was seen, resulting in an upgrading of the competences of especially the visiting nurse. The introduction of a real-time, on-line link between hospital and home constitutes the basis for simultaneous communication between all participants, resulting in a “witnessing” situation potentially securing or even enhancing quality of treatment.

The research reported in this paper describes the development, empirical validation and analysis of a model of technology acceptance by Australian occupational therapists. The study described involved the collection of quantitative data through a national survey. The theoretical significance of this work is that it uses a thoroughly constructed research model, with one of the largest sample sizes ever tested (n=1605), to extend technology acceptance research into the health sector. Results provide strong support for the model. This work reveals the complexity of the constructs and relationships that influence technology acceptance and highlights the need to include sociotechnical and system issues in studies of technology acceptance in healthcare to improve information system implementation success in this arena. The results of this study have practical and theoretical implications for health informaticians and researchers in the field of health informatics and information systems, tertiary educators, Commonwealth and State Governments and the allied health professions.

The healthcare environment has been characterized as interrupt-driven with medical doctors (MDs) and registered nurses (RNs) receiving many interruptions during a shift. Previous research studies have focused on the recipient because of the negative impact on task performance. It is equally important to understand the initiator of an interruption to help design strategies to lessen the number of interruptions and the possible negatives consequences. The purpose of this instrumental study was to examine MDs and RNs as initiators of interruptions. Results of this study indicate that MDs and RNs initiate interruptions most often through face-to-face situations and use of the telephone. Strategies to successfully manage interruptions must consider both the role of initiator as well as the recipient in an interruption event.

In this paper, we discuss how profiles of communicative behaviour can be used to present and analyse information about role activity recorded through structured observation of specific situations. The role activities are encoded as distinctive speech acts. Example profiles resulting from the analysis of three clinicians' communicative behaviour during pre-rounds meetings and ward rounds are given. The examples are based on an observational study performed at a Norwegian university hospital. One fifth-year medical student spent 20 days in two different hospital wards, following 7 physicians from one to seven days each. The observer recorded data from several ward situations such as pre-rounds meetings, ward rounds, and discharge situations. The data was recorded by means of an observation form consisting of a mixture of codes and free-text fields. The data has been post-processed by associating each event with one communicative act. The approach is an efficient and useful means for studying clinicians' information and communication patterns in hospital wards, which can serve as an important tool in the design of new clinical information systems.

Socio-technical approaches to health information systems evaluation are particularly relevant to the study of Computerised Provider Order Entry (CPOE) systems. Pathology services are made up of a number of departments each with unique and complex tasks and requirements. These different components of pathology have received very little research attention. This study used qualitative methods to identify key organisational and work process along with repercussions of the implementation of CPOE through a comparison of the Haematology and Clinical Chemistry departments of a hospital pathology service. The results focus attention on areas where the departments face similar challenges along with those areas where work practices diverged. This underlined the key importance of understanding the context and setting of pathology laboratories. The study also draws attention to the importance of cross departmental and multi-disciplinary negotiation in the implementation process and highlights the potential for technology to affect and be affected by the organisational context in which it is placed.

Clinical networks are being increasingly employed to drive innovation in health services by encouraging multi-disciplinary clinical engagement in management processes. The effectiveness of a network, however, depends critically on the ability of its leader to coordinate group interactions. This paper discusses leadership of clinical networks, and in this context reviews technologies for analyzing the way team members interact in group conversations. This review will form the foundation for ongoing research to develop the profile of an effective clinical network leader, along with techniques and tools for evaluation and professional development.

Investigating two longitudinal ethnographic studies of managing gradual adaptation of electronic patient records in Canada and Norway, we conduct a cross-case analysis of the enabling factors that support a continuous transformation of technology and health care practices. In line with previous research, our study shows that large-scale information systems adaptation in health care should be managed by a project-group including not only IT-developers, but also representatives of future users and management. While we also argue for the importance of these meetings, we complement and expand the notion of project meetings by providing a conceptualization of the essential aspects of these meetings. Our conceptualization is composed of continuous reflection-on-practice activities to construct technology-in-use practices. Reflection-on-action activities are internally initiated, and comprise critical reflections by the participants, who continuously evaluate and question work practices in relation to technology.

A substantial proportion of nurses' work consists of medication related tasks undertaken in a current environment of high medication error rates. Electronic medication management systems (EMMS) are anticipated to address many of the factors which contribute to errors. These factors, for example illegible hand-written drug orders, reputedly require nurses to spend additional time in clarification and discussion. We report an observational modified time and motion study of 44 registered nurses (215 hours of observation) in a major academic hospital to quantify the time nurses spend in medication related tasks prior to EMMS introduction. On average nurses spent seven minutes in an 8.75 hour shift clarifying or discussing medication issues. The majority of this time (5.4mins) was spent talking with other nurses. Only 1.6 minutes was spent clarifying or discussing medication with doctors. Our results call into question some of the predicted efficiency benefits to nurses' work following EMMS introduction.

While identifying reasons for the failure of information communication technology (ICT) to transform the healthcare system and constructing models of better designed technology with socio-technical integration is relatively straightforward, implementing these solutions into the rapidly changing medical world has proven considerably more difficult. From a technologist's perspective, the promise of technology remains powerful. New technologies, with high level of socio-technical integration have long been considered as one of the most important factors to transform the medical world in order to deliver better and safer care. From the socio-cultural perspective, however, there is an equally powerful force, which has largely been ignored by the greater community: the entry of generation Y into the healthcare system. Generation Y has generated significant changes in many other industries. This powerful socio-cultural change within the healthcare system needs to be more clearly investigated to guide the design and implementation of sociotechnical integrated ICT solutions. This research-in -progress paper presents a methodological approach that both generates an in-depth understanding of generation Y and illuminates criteria that can be used to meaningfully identify the guiding principles for future socio-technical integrated ICT design and implementation. It aims to make a significant contribution to the field of socio-technical approach to ICT design by alluding the audience to this new generation Y phenomenon in healthcare. It provides some preliminary data to support the need to consider generation Y in future ICT design in healthcare.

We report from a longitudinal laboratory-based usability evaluation of a health care information system. A usability evaluation was conducted with novice users when an electronic patient record system was being deployed in a large hospital. After the nurses had used the system in their daily work for 15 months, we repeated the evaluation. Our aim was to inquire into the nature of usability problems experienced by novice and expert users, and to see to what extend usability problems of a health care information system may or may not disappear over time, as the nurses get more familiar with it – if time heals poor design. On the basis of our study, we present findings on the usability of the electronic patient system as experienced by the nurses at these two different points in time and discuss implications for evaluating usability in health care.

Blogs, short for “web logs,” together with podcasts and wikis are currently important foci of general internet research. These three applications are part of the larger body of next-generation communication applications that comprises “Web 2.0.” Within the specific area of health care, however, little attention has been devoted to understanding these technologies and how they are being used by lay health publics. In this article, I will discuss the emergent findings from a new project that looks at blogging interfaces as potential tools for disease prevention and health promotion. I use a literature review combined with “front stage” web analyses of two cases and interviews with the supporting institutions for these sites to discuss the relevant informatics questions that arise with respect to these applications. I further introduce the idea of “goal-oriented” blogging that is found in the first case study. Because this research project is still in preliminary phases, this should be viewed as an exploration into the topic and work in progress. In addition to raising questions, I will outline the important subsequent research steps.

Heuristic evaluation is a usability testing method aiming to improve the user interface design. Traditionally, a panel of experts in usability and human factor issues evaluate and judge the compliance of computer software according to recognized usability principles, the heuristics. In this paper, we investigate clinicians' attitudes towards learning and performing a heuristic evaluation and present the procedure of educating the healthcare staff and their accomplishment of the evaluation. 18 clinicians were recruited for a 2-hours education and filled in a post-education questionnaire regarding their opinions of the evaluation method when applied by clinicians. Six of the clinicians participated later in a heuristic evaluation of a web-based virtual health record,Their time spent for evaluation and analysis of results was approximately four hours each. Opinions from the six “clinical evaluators” were gathered in an post-evaluation form and compared to the post-education questionnaire. The results of 18 clinicians indicate that there is an interest in learning and participating in such evaluations. Our interpretation is that it is feasible to educate healthcare staff to perform rapid usability inspections to locate usability defects and additionally emphasize the domain specific problems residing in health information systems.

Electronic medication systems may impact communication in hospital wards. To identify the ways in which communication patterns may be altered it is necessary to compare processes both before and after system introduction. This paper reports the use of a social network approach to examine the medication advice-seeking network of an Australian hospital renal ward before the introduction of an electronic medication management system. A social network questionnaire was completed by 96% of staff members (doctors, nurses, allied health professionals and administrative staff) on the ward (n=45). Survey data were analysed to produce a sociogram to display the medication advice-seeking network of the staff in the ward. The results showed that there was a relatively low level of advice-seeking about medication-related decisions and tasks. Most communication occurred within professional groups. Several key individuals were pivotal in providing advice both within and across professional groups.

Shared home care is increasingly common, and in order to develop ICT that support such complex cooperative work it is crucial obtain an understanding of the work routines, information demands, and other central preconditions at the clinical level before the development is initiated. Scenarios are proposed as a technique that can be useful for capturing work processes in shared home care and experiences from the Old@Home project are presented. The scenarios are useful not only in the initial phases of the development project but throughout the development process, improving the accessibility of end user requirements and usability issues for the design team, and as a basis for use cases and further design.

Introducing an innovative, multidisciplinary concept of care means the change of existing structures both in work and communication flows which often involves problems. In this paper we describe exemplary the communication problems which arose during the introduction of the multidisciplinary concept of Family-Centred, Individualized Developmental Care of Premature Infants and Newborns at the Children's Hospital Heidelberg. We suggest workflow adaptations to achieve timeliness of information and present ideas to prevent communication problems e.g. caused by inadequate knowledge of staff. We used interviews, analyzed video-recordings and modified the Communication Observation Method [7] to analyze the present state of communication flows and structures.

This paper demonstrates how qualitative System Dynamics methodology can be used to provide a better understanding of health systems thus facilitating better development and design of computer-based health information systems. In an earlier paper by the same authors, system dynamics modeling and field study research methods are used to capture the complex and dynamic nature of the immunization process, to enhance the understanding of the immunization health care problems and to generate insights that may increase the immunization coverage effectiveness. Through qualitative modeling, causal loop diagrams which are used to show the key issues that need to be addressed when developing health information systems are drawn with the aim of improving the immunization services. The paper shows the benefits of using System Dynamics to understand systems with complex interactions thus facilitating the development of information systems that meet the stakeholder requirements.