-
journal homepage: www.e
Available online at www.sciencedirect.com
nsystems Mirroring a wide spectrum
$
Ulf Melinn, Karin Axe
Department of Management and ELinkoping, SwedenAvailable online
13 November 2013
KEYWORDSHealthcare
on and use. This istation is linked to
healthcare organizations as professional bureaucracies, being
highly politicized and institutionalizedso discussed in this
reserved.
s (cf. [26]) of anof technologicalprocess are also
in managing healthcare costs and in improving the quality ofSafe
public e-services an issue of trust and organization,
Health Policy and Technology (2014) 3, 26352211-8837/$ - see
front matter & 2013 Fellowship of Postgraduate Medicine.
Published by Elsevier Ltd. All rights reserved.care [9].
Simultaneously, HIS implementation processeshave been evaluated by
many IS researchers. Heeks [12]indicates that a majority of these
studies highlights success-ful implementation processes, while
failures to implement
http://dx.doi.org/10.1016/j.hlpt.2013.11.001
nanced by: Swedish Civil Contingencies Agency.nCorresponding
author. Tel.: +46 13 28 44 37.E-mail addresses: [email protected]
(U. Melin),
[email protected] (K. Axelsson).that can be related to the
implementation of a healthcare illustrated. Integrated HIS are
increasingly implementedglobally in the care sector [27,32] and
have much to offerand to the IT artefact as an integrated HIS.
Viewing images as rational myths is alpaper as an original approach
to understand HIS implementation.& 2013 Fellowship of
Postgraduate Medicine. Published by Elsevier Ltd. All rights
Introduction
This paper deals with the spectrum of interpretations
information system (HIS). Different imageimplementation project
as well as imagesand organizational changes in a complexillustrates
several images of HIS implementation and use. Highlighting images
is onreluctance, support, complexity and power that are present in
HIS implementatione important contribution from this article. The
complexity in the implemenrelation between IS and organization.
This challenge literature on critical success factors. This studye
way to illustrateinformation system;Structuration
theory;Implementation;IT project;Resistance;Imageslsson
ngineering, Information Systems, Linkoping University, SE-581
83
AbstractThe main purpose of this paper is to discuss the
spectrum of interpretations that can be related to
theimplementation and use of a healthcare information system (HIS).
The empirical part of this paper isbased on a qualitative case
study of a Swedish healthcare provider, called Alpha, where a HIS
wasimplemented. By studying how different actors interpret
technological and organizational changes ina healthcare case, we
mirror different images of the implementation project. Put
together, thisdiversity of images provides an illustration of the
complexity associated with the process ofimplementing a HIS. We
apply an adjusted version of Orlikowski's practice lens, with its
roots inStructuration Theory, in order to study technology in
organizations (focusing inertia, application andchange). The
implementation process of a HIS is much too complex to be judged as
being eitherentirely positive or negative; instead it offers an
illustration of the multi-faceted and reciprocalof images of an IT
projectImplementing healthcare ilsevier.com/locate/hlpt
formation
-
27Images of HIS implementation and useHIS are rarely discussed,
even though HIS implementationcan be perceived by [] change
resistant stakeholdersas disruptive or even potentially life
threatening. ([1],p. 177). By analyzing previous HIS studies from a
failure (andsuccess) perspective, Heeks [12] explores a gap
betweendesign of a new HIS and reality (present state) at a
careunit. The gap can relate to different aspects; e.g.
informa-tion, technology, processes, objectives and values,
stafngand skills, management systems and structures. How thisgap is
handled seems to be a parameter that implies thelevel of success or
failure in the implementation process(ibid.). This gap is therefore
relevant to study how it isshaped in terms of images of a HIS
before, during and afterimplementation and use. This is the point
of departure forthis paper. A HIS has several characteristics in
common withenterprise systems (ES) in general (cf. [21]). An ES is,
like aHIS, an answer to several problems with ordinary infor-mation
systems (IS), such as low level of integration,disparate data
formats and separated databases (cf. [7]).A HIS is also often
standardised and provided by a supplieron a market. In HIS, like
other packaged IS, it is obvious thatactions that constitute the IS
are consequently separatedfrom the actions that are constituted by
the system [28].HIS contains more or less standardized processes
offered asbest practice and a high degree of integration (cf.
[40]).Existing nuances in a healthcare context also provide a
richenvironment from which to learn more of existing IStheories and
their application [5,32]. The healthcare con-text, being highly
politicized and institutionalized [27],is also considered to be
particularly problematic in termsof realizing the benets of IS
(ibid.) and still struggling withall kinds of development on a
structural level (cf. [37]). Thisdimensions of the area makes it
even more interesting tostudy the spectrum of interpretations that
can be related tothe implementation of a HIS outlined above.
In order to capture different images of the implementa-tion and
use of an HIS in this paper, the subjective andobjective aspects of
social structures, human actions, and IS[28] will be used as a
point of departure to analyze the HIScase in a Swedish public
health provider (called Alpha).Following this view, an IS is a
social product of subjectivehuman interpretation [3] and action,
and they have aconstitutive role. An IS embodies interpretative
schemes,provides coordination facilities and is deeply implicated
inlinking social action, structure and interaction. By using
agenerative practice lens for studying technology in Alpha,we will
examine the institutional, interpretive, and tech-nological
conditions which shape the on-going constitutionof different
structures and vice versa [28]. Using thepractice lens, with its
roots in Structuration Theory (ST)make it possible to capture the
dimensions of institutiona-lization, interpretation and interaction
characterizing thespecic empirical domain [3,27,37].
The purpose of this paper is to discuss the spectrum
ofinterpretations that can be related to the implementationand use
of a HIS. By studying how different actors interprettechnological
and organizational changes in a healthcare case,we mirror different
images of the studied implementationproject. Put together, this
diversity of images provides anillustration of the complexity
associated with the process ofimplementing a HIS. The paper
contributes with understandingof HIS complexity by discussing these
simultaneous images usingthe structuration theory. Increased
understanding of HIS com-plexity has both theoretical and practical
implications, asdiscussed in the concluding section of the
paper.
The paper is arranged in the following sections; wediscuss the
theoretical background in section two. We dothis by viewing HIS as
a special case of ES. We also discussresearch on IS implementation
and change. In the thirdsection we describe the research approach,
followed by thecase description in section four. The case is
analyzed anddiscussed in the fth section, where we draw attention
toimages of the project and the HIS. The paper is concludedwith
contributions and further research.
Theoretical background
Here HIS are introduced together with implementationand change
in a general IS context, and a practice lens oftechnology.
Health Information Systems
The strategic importance of integrated HIS, as introducedabove,
is obvious since it is used as a tool to improveservices and
decrease medical mistakes [22]. Simulta-neously, HIS implementation
processes have been evaluatedas such in many recent studies (e.g.
[14,18,35,38]) and alsoearlier studies on e.g. computer tomography
(CT) scanners[3]. Heeks [12] indicates that a majority of case
studiesabout HIS implementations highlights successful
implemen-tation processes, while failures to implement HIS are
rarelydiscussed. By analyzing previous HIS studies, Heeks exploresa
knowledge gap regarding what we can learn from failures(ibid.).
Evaluating success is a challenging activity in this con-text.
There are many authors suggesting and discussingcritical success
factors (CSFs) (e.g. [11,44]). Berg [4] claimssuch CSF lists to be
problematic since success can be judgedin many dimensions; such as
effectiveness, efciency,organizational attitudes and commitment,
employee andpatient satisfaction. This makes the situation very
complexand CSF lists often offer a more simplied solution. In
orderto illustrate the complexities of HIS implementation
pro-cesses, Berg (ibid.) investigates three myths related to
suchprocesses; implying that HIS implementation is a
technicalrealization of a planned system in an organization, that
itcan be left to the IS department, and that the implementa-tion
including the required organizational redesign can beplanned
(ibid.). By scrutinizing these myths, he concludesthat HIS
implementation instead is a mutual process whereorganization and
technology inuence each other (furtherelaborated below). The
management of a HIS implementa-tion process also implies a
balancing act between organiza-tional change and using the HIS as a
change agent (ibid.).Identifying and discussing the spectrum of
interpretationsthat can be related to the implementation and use of
a HIS,as in this paper, is one way of trying to broaden the
scoperegarding simplied sets of CSF and investigate
situationalaspects further.
An important aspect when discussing HIS implementa-tion is to
acknowledge the involved actors' expecta-tions and perceptions. It
is not feasible to announce an
-
success or failure of an HIS depends on whether physicians
U. Melin, K. Axelsson28accept or resist its implementation
(ibid). Sallas et al. [35]present an assessment approach that
focuses on users incontext. The study indicates that focusing on
users incontext is a way to avoid or minimize negative
reactionsupon IS implementation among highly skilled
professionalslike physicians (ibid.). Jensen and Aanestad [15] use
asense-making perspective to study how professionals reactupon
implementation of new HIS. They argue that managersmust clarify the
needs, values, and preferences of the usersin order to understand
how professionals interpret andrespond to HIS implementation. This
is line with a widenedperspective on the reluctance to use HIS
among medicalprofessionals reported by e.g. Lapointe and Rivard
[17]. Thepresent study follows the perspective on resistance
high-lighted by Lapointe and Rivard [19,20], that resistance
isinteresting and useful in order to understand implementa-tion of
HIS and its reciprocal relationship with actors andstructure. A
systematic analysis of different models ofresistance is elaborated
on by Lapointe and Rivard [19]. Inthe images highlighted below,
resistance is one dimensionamong others.
Enterprise systems are enterprise-wide application pack-ages
that tightly integrate enterprise functions [7]. Suchsystems have
some aspects in common with integrated HISlike the one studied in
this article. Khoumbati et al. [16]argue for the healthcare
sector's need to integrate applica-tions organizational-wide, which
is in line with our view ofintegrated HIS. ES, as well as HIS, are
created in differentsteps: the development of the system, the
modication ofthe system, and the use of it. The point, partially
followingOrlikowski [28], is that the ES is constituted in at least
twosteps: by the supplier and by the system implementer,followed by
constituting user action.
Information systems implementation, change andstructures
The relation between IS and organization is full of nuances
andcontradictions. We investigate the multi-faceted and
reciprocalrelation in line with Barley [3], Howcroft et al. [13]
andOrlikowski [28], moving away from an over-simplied
under-standing of it [23,34]. The role and inuence of IS in
organiza-tions [30,41] and the emergence and improvisation is
importantto investigate when trying to understand IS
implementation.Exploring the institutional context is also
important when tryingto understand HIS and its relation to
organizational structures,processes and outcomes (cf. [4]). There
can be many reasonsimplementation a success without stating from
whoseperspective it is successful, cf. Berg [4]. Actors can
belongto a certain profession; e.g. physicians, nurses,
medicalsecretaries or an organizational unit; e.g. a hospital ward
ora health center. It is, thus, important to identify
involvedactors in the beginning of an implementation project
[22]and also to assure that the actors are involved and infor-med
[18]. A professional group's reaction upon the imple-mented HIS is,
among other things, inuenced by the waythe HIS is perceived to
improve work situations or whetherthe HIS is interpreted as a
control system (ibid., [14]). Therole of medical professions is
also highlighted in a study ofthree implementation processes [20].
They claim that thefor implementing an HIS, not only to improve
medical carequality. To gain and retain legitimacy can be even more
impor-tant (cf. [25]). Structurational perspectives focus on
humanaction and have a potential to help us understand emergenceand
change in technologies and the use of it (cf. [3]). IS, as
atechnology, is developed through a social and political
processresulting in structures embedded in the present
technology.Following that, the use of technology is heavily
inuenced bythe users' interpretation of the functionality and by:
[]images, descriptions, rhetorics, ideologies, and
demonstrationspresented by intermediaries such as vendors,
journalists,consultants, champions, trainers, managers, and
powerusers. ([28], p. 409).
The images mentioned above can be regarded as ratio-nalized
myths (cf. [25]). Claims put forward from inter-mediaries (e.g.
journalists and consultants) are oftenpersuasive and users tend to
take them for granted [29].Technologies never become complete or
fully stabilized(ibid.) and identical technologies can lead to
differentconsequences [3]. We analytically regard technology
asbeing possible to redene and modify meaning of. Proper-ties and
application of technology can also be modied afterinitial
development. It is usually common that users thathave similar work,
common training, shared socialization,and on-the-job experiences,
enact similar technologies inpractice. That
technologies-in-practice may become insti-tutionalized and tends to
predetermine prescriptions foraction. Technologies-in-practice may
also impede change(ibid.). Different images (cf. [26]) of an
implementationproject as well as images of technological and
organiza-tional changes can be regarded as a connection
betweenthinking and action within organizations.
Understandingimages carried by members of an organization can be
aplatform to help us nd new ways of organizing, to under-stand and
change perspectives and create shared under-standing (ibid.).
Images is also linked to metaphors byMorgan (ibid.) and used to
create powerful illustrations ofe.g. organizations as machines.
Metaphors can also be a wayof not seeing since they are based on
certain ways ofthinking.
By using a practice lens for studying technology in thecase
study, we examine the institutional, interpretive, andtechnological
conditions which shape the on-going constitu-tion of different
structures within Alpha. This lens, and theadherent perspective, is
primarily based on Giddens's [10]ST. Structuration is viewed as a
social process that involvesthe reciprocal interaction of human
actors and structuralcharacteristics of organizations. Structures
are viewed ashaving two sides (the duality of structure), enabling
andconstraining human action. At the same time structures
areproducts of human action. When humans act in organiza-tions,
they also create and recreate the elements of socialinteraction:
meaning, power, and norms. Power is linked tostructures of
domination by resources. Moral sanction islinked to structures of
legitimation by norms. Interpretiveschemes are stocks of knowledge
and form the core ofmutual knowledge in the production and
reproduction ofinteraction. Interpretive schemes also serve as a
constraint.Meaning, power, and norms are dependent on
technology.Elements from ST enactment (cf. [43]) will be
discussedin terms of using three different types [29]; (1)
inertia(no evident change in process, technology or structure
-
occurred), (2) application (some change has occurred in oneor
more of process, technology and structure), and (3)change (change
in one or more of process, technology andstructure occurred)
(ibid.). The three types of enactmentare based on the conditions,
actions and consequences.
Research approach
The empirical part of this paper is based on a case study
ofAlpha where a HIS was implemented. The case study wasconducted
during 20082011. We had the opportunity to studythree care units on
site which had recently got the HISimplemented; two public health
centers (one located in acity center [C] and the other located in a
suburb [S]) and ahospital clinic. We also studied the Care Process
Center (CPC)which managed the project. CPC is Alpha's central,
strategic,resource for organizational, quality and IS development
andmaintenance of care supporting processes. The case study isbased
on 26 interviews within Alpha as well as studies ofdocuments.
Examples of documents are Alpha's website
mentioned before). Some of the interviews also consisted
ofsystem studies (Table 1), when the interviewee/system
userdemonstrated a certain characteristic or pattern of use
linkedto their work in the system.
This work corresponds to central concepts and ideals
ininterpretive and qualitative research, such as interpreta-tion,
pre-understanding and the use of multiple methods fordata
generation [42]. The interpretative tradition in the ISeld is
suitable here because of the kind of researchpurpose and questions
raised; e.g. how the actors in Alphastruggle, both strategically
and in daily work, with the HISand how they enact and interpret the
system and theorganizational change. Orlikowski's framework has
beenused as a guide for analyzing the interviewees'
interpreta-tions of the HIS and as a part of an iterative process
of datacollection and analysis [42].
The case of an integrated health informationsystem
ata
teryste
ter
Medical secretary
teryste
29Images of HIS implementation and useInterview andsystem
study
Healthcenter [S]
Nurse, responsible for rstpatient contacts
Ins
Medical secretaryinformation to patients, internal project
documentation,budgets, external evaluation reports, and media's
coverageof the project. The different, multiple, sources of
empiricaldata as well as the data collection techniques were used
inorder to get a more varied and truthful view of
actors'perspectives, the implementation and use of the HIS. Dataand
method triangulation [17] is used as an attempt togenerate a rich
picture of descriptions and impressions ofthe implementation
process, its institutional context andtechnology in practice. Two
interview rounds were done,one initial and one with follow-up
interviews. The interviews(Table 1) were audio recorded and the
average interview lastedfor 1 h. Additional notes were also taken
covering impressionsand opinions of the studied actors. Qualitative
interview guideswere used, with a mix of pre-dened open and
open-endedquestions, topics and informal communication [31].
On-going,upcoming, themes generated by the context and by
theinterviewees were also included (e.g. when an
intervieweementioned new dimensions in the implementation process,
not
Table 1 Interview/respondent information.
Data collection Unit Role D
Interview CPC Organization developer Ins
Project leaderCPC manager
Interview andsystem study
Clinic/surgery
Physician 1 and 2 InAssistant nurse andadministrative
coordinatorview andm study
Health center[C]
NursePhysicianAssistant nurse 1 and 2Medical secretary;
nurse,health center managerDistrict nurse; nurse; healthcenter
manager
view Clinic/ward Assistant nurse and admin.coordinator;
nurse
Physician, assistant nurse andadmin. coordinator
view andm study
Health center[S] (cont.)
Physician, health centermanagerNurse, health
centercoordinatorThe HIS implementation is studied in a large
Swedishorganization providing medical care. Alpha is a
democrati-cally run organization and their task is to promote
publichealth according to the needs of the population in theregion.
Local healthcare is organized into three geographi-cal areas.
Specialist healthcare operates from ten centerspositioned county
wide. Alpha has 11.000 employees. Alphaoperates 40 care centers and
four hospitals, which includeshighly specialized medical
healthcare.
The Swedish IS vendor Cambio has developed the HIS Cosmicthat is
marketed as a fully integrated and organizational-widesystem under
the slogan One journal one system for allhealthcare. Cosmic has
about 10,000 users in Alpha, reachingfrom four different hospitals,
regional and local healthcareunits, administration, etc. Cosmic
includes both a back-ofcesystem (e.g. supporting the storing of
medical drugs prescribed,laboratory test results, and statistics)
and a present artefact, atdesktops, when patients are meeting
physicians, nurses andsecretaries (e.g. having a dialog of medical
records in care
collection Unit Role
-
situations). Alpha purchased the HIS, consisting of
severalapplication modules for healthcare, e.g. patient
administrationand clinical care support, from Cambio. An important
function-ality in Cosmic is the integrated Electronic Medical
Record(EMR) built around a common database (cf. [21]). Alpha
hadearlier bought other applications from Cambio, which was areason
for choosing this vendor again. The project was initiatedin October
2005. After a planning and preparation phase, a pilotstudy started
in February 2007, which was followed by a roll-outphase in 2008.
The implementation project, ofcially, ended inDecember 2008 when
all care units within Alpha had imple-mented the HIS. The project
was run by CPC which completedthe project on time and below budget.
The implementationproject's purpose was to dene and implement new
processesand corresponding system support. Key aspects in the
projectwere accessibility, security and efciency. The HIS comprises
awidely integrated EMR for all care units in Alpha which impliedan
important change compared to the prior situation. The
been in the HIS implementation project, in project manage-ment,
in CPC, or in organizational development activities ingeneral at
Alpha. The meanings also depend on eachrespondent's personal
associations and experiences of IS ingeneral and EMRs in
particular.
Several of the images (i.e. a way of thinking and seeing,cf.
[26]) (summarized in Figure 1) relates to the project inthe role of
image-builder for the organization and signi-cant actors in it.
Prexes such as visionary, impress,and paradigm shift indicate
intentions of wanting to be aforward-looking, modern organization
supported by a mod-ern HIS and processes (cf. [2]). Image-building
processes areimportant for the self-image within the organization
as wellas in situations where there is a need to reposition
Alphaagainst other public or healthcare organizations.
Severalaspects also affect the scope, i.e. the volume, of
theproject. This concerns the entire range from being a huge(the
largest) project in Alpha's history to what, from an
of past actions (such as previous decisions to implement
ges
U. Melin, K. Axelsson30project was characterized as the largest
change project thatAlpha had ever initiated. For the local
healthcare centers theintegrated HIS replaced existing local IS
solutions for medicalrecords. The centers located at the hospitals
in the region didnot have any EMR before, so digitalized medical
records werenew for them. They have had disparate IS before,
handlinge.g. schedules and lab results, but no integrated IS.
Analysis and discussion
In the two sections below we analyze and discuss theempirical
ndings in order to mirror various images of thestudied
implementation project. The explored diversity ofimages provides an
illustration of the complexity associatedwith the HIS
implementation process. Then we apply anadjusted version of
Orlikowski's [29] practice lens for study-ing technology in
organizations.
Images of the project and the HIS
The studied project and HIS implementation were givenmany
different meanings by the actors we have been incontact with. In
what way the meanings differ, partlydepends on how closely involved
the individual actor has
Figure 1 The many imaseveral modules from the same vendor).
Thus, earlier madeIS implementation choices have already mapped out
thedirection for this implementation and alternative routes, tothe
one now chosen, were few, if existing at all. Alpha hasalso stated
that they are not willing or even capable ofacting in the role of a
system architect or integrator.
[] and we cannot pay the wages and we are not sentto keep on
with it. This is what software vendors aregood at and get to work.
[Interview, CPC Manager,January, 2009]
The choice of a standard solution from one or a fewvendors is
based on the above intentions. The choice toproceed with several
HIS modules from the same vendor asearlier implemented modules,
rather than choosing othersolutions, is also motivated by
education, skills and resourcereasons.
of the studied project.individual employee's and HIS user's
perspective, can beseen as yet another change of IS. At the same
time as theproject is considered to be forward-looking and
proactive bysome respondents, it is also interpreted as an
imposedproject or a consequential project by others.
It is seen as an imposed decision made as a consequence
-
31Images of HIS implementation and useThe implementation of
Cosmic is also justied by theneed for employees to be able to move
from old, paper-based routines to the integrated use of IS for
multipletasks. Remarkable many of the images above also touchupon
the organizational dimension of the HIS implementa-tion in terms of
management, standardization and rationa-lization (i.e. to reduce
costs, save time, etc.). Suchincreased opportunities for
administrative functions withinAlpha to plan, coordinate and
follow-up healthcare activ-ities are possible thanks to the HIS
implementation (includ-ing increased information access, measure
data, etc.).These opportunities are expressed in many of the
identiedproject prexes. This is a reason for the expressed image
ofthe project as being a civil servant project. Concerns
arereported by medical staff that the control over healthcarewill
increase due to the HIS. Explicit health related aspects(e.g.
increased quality of healthcare) have not been ascommon as the
organization related images in our empiricaldata. In contrast,
expected negative effects on quality ofhealthcare have frequently
occurred. The project and thesystem have been given the role as
scapegoat not leastin media coverage of the process. It seems less
delicate toassign an artefact negative attributes and to be an
excusefor weak administrative processes or lack of leadership
thanto criticize the organization of care processes, actors
andadministrative processes. If we look at the non-project
label(Figure 1) this aspect represents an image of the project as
yetanother change of IS as one nurse at a health center
expressesand interprets the implementation. For her it was the
third EMRthat was implemented in a rather short time. This time
moreintegrated and complex but still another system. This
imagechallenges the view of the project as a huge project from
anoverall organizational perspective and a CPC project manage-ment
perspective.
Types of enactment and institutional aspects
In the analysis of types of enactment and institutionalaspects
of the implementation process and the HIS as such,we illustrate our
analysis by giving examples of the differentdimensions based on
Orlikowski [29]. We use the main typesof enactment (inertia,
application and change) as a basiswhen structuring our analysis. If
we take a look at thedifferent types of consequences (processual,
technologicaland structural) (ibid.) we refer to the different
changes (ifany) that is a result of the technology-in-practice.
Theprocessual consequences refer to changes in performanceand
outcome of work practices; the technological conse-quences refer to
changes in the technology available to theusers; and the structural
consequences refer to changes instructures of a larger social
system. The technical condi-tions are the same for every type of
enactment in ouranalysis. We have therefore omitted this in Table
2. Tech-nical conditions are the HIS available for all users in
Alpha.
In the case we have identied inertia as one type ofenactment.
There is a limited technical knowledge amongdifferent professionals
(assistant nurses, nurses and physicians);even if physicians tend
to express their norms and values moreoften regarding the HIS in
use based on medical competence.
Somebody should measure the time we spend in frontof the
hourglass everyday it must be 15 minutes eachday, for each
physician in the organization. [Interview,Physician, September,
2009]
The far-reaching role of medical professions highlightedby
Lapointe and Rivard [19,20] is echoed also in thisimplementation
study. The HIS role in physicians spendingmore time managing
patient records in front of the compu-ter is also present in the
study by Lapointe and Rivard [20].The images of the success or
failure of the present HISdepends on strong professional groups and
e.g. whetherphysicians support or resist its implementation
(ibid.;[14,15]) and which rationalized myths that are spread inthe
organization and its environment.
Several running commentaries in the regional media havealso been
published, exposed for and discussed by personnelat the different
healthcare units at Alpha.
Cosmic is dangerous for the patients and Cosmic jeo-pardizes the
patients security and creates a bad workingenvironment (Regional
Newspaper, October, 2008)
This is an illustration of the HIS as potentially life
threat-ening (cf. [1,20]). This is also an example of external
actors(journalists) that have an inuence on the users
norms,interpretation and use ([29], p. 409f.) of the present HIS.We
can also see that strong stakeholders use media as theirmouthpiece
when expressing their views and thoughts ofCosmic, putting pressure
on the project management team.These images are as a part of the
rationalized myths [25,33]and also a question of power
distribution. Such myths arepersuasive and users tend to take them
for granted. Theimmediate interpretation of Cosmic has often been
that thesystem is slow and complex, containing too many clicks;but
when we continued the dialog a more multi-facetedview emerged. The
overall picture is that the system isquite usable. Shared meanings
(rationalized myths) are inline with a sociological understanding
of institutions and therelation to IS use. What is interesting in
the present case isalso that comments like this and rationalized
myths startedeven before the HIS was rolled-out in the
organization.It started already in the pre-implementations phase
basedon limited pilot testing. In some sense the resistance
startedbefore the real implementation project begun, and
alsopartially in media. This is a complementary results com-pared
for example with Lapointe and Rivard [19] thatidenties that the
resistance starts when an implementationstarts. If we take a look
at the technology-in-practicecategory within inertia we have
identied, in some sense,a limited use of the HIS. Our identication
is that:
[] users choose to use their new tool rarely andperfunctorily,
and show little or no interest in integrat-ing its use into their
ongoing work practices ([29],p. 421).
Perfunctorily use was identied in the case study con-cerning
handling letters of referral where users use thesystem, but use the
old paper based routines in paralleleven one year after system
implementation. This is moti-vated by the users (assistant nurses)
as a way of keepingtrack of the referral ow, in order to physically
identify theletters in the mailbox to construct personal security
andhandle stress. The use of the HIS in terms of frequency is
not
-
d c
chrac
imiterfot rf th
ollaolleroblvidivrodroc
ollandroblvidivrodrocpr
U. Melin, K. Axelsson32Table 2 Case analysis enactment
conditions, actions an
Type ofenactment
Interest inusing thetechnology
Interpretiveconditions
Institutionalconditions
Tep
Inertia Low Limited technicalknowledge
amongdifferentprofessionalgroups
Hierarchical L(pno
Individualistic
Application Moderateto high
Moderatetechnicalknowledge (users)
Hierarchical CIndividualistic C
psoMore detailed
technicalknowledge (super[power] users)
CollaborativeInpP
Change Moderateto high
Moderatetechnicalknowledge (users)technicalknowledge
(superusers)
Collaborative CapsoInpPImlimited; the use is mandatory regarding
basic functionality(e.g. using the note function in the medical
record).
The institutional conditions, within the inertia
category,surrounding the HIS are rather regulated and work tasks
arerelated to professional groups. In line with Orlikowski's
[29]experiences we have identied a rigid career hierarchyhaving an
inuence on the user of the HIS in the daily work.Hospitals have
strong technical and strong institutionalcontrols [36] which
explain this situation as well as thedivision of labor. Some
changes in division of labor occurredwhen physicians use the note
tool in order to (very brief)document diagnoses in the EMR modules,
instead of voicedictation and handing over transcription to medical
secre-taries. However, this change in division of labor is not
anorganizational phenomenon; it is more up to the
individualphysician to decide. It is also a question of norms,
aquestion of age and a question of how one interprets one'sroles in
Alpha (valid both for the physicians and the
medicalsecretaries).
In the case study we have identied IS use providingrenement of
existing actions. Examples are: to schedulepatient-physician
meetings, to issue letters of referral, toprescribe medical drugs,
and to document in a medicalrecord. The application of the HIS
provides an overallprocess support across unit borders not provided
beforeand a workow based functionality. The overall interpreta-tion
of the case is that the interest in using the technology ismoderate
to high. It is moderate among most of the usersinterviewed. They
usually regard Cosmic as yet anothertool but more complicated.
Several users identify thestructural potential in the system. The
interest in using theonsequences.
nology-in-tice
Processualconsequences
Technologicalconsequences
Structuralconsequences
edunctorily;arely) usee HIS
Minor(duplication ofwork occurs)
None Reinforce andpreserve statusquo concerningsome routines
boration Increasedeffectiveness incommunicationand care
Adaptationsto the tool
Reinforce andenhance statusquo
ctivelemng Change in the
toolidualuctivity
Improvedcollaboration
ess support Increasedeffectiveness inproblem solving
borationcollectivelemng
Redened workdistribution
Change in thetool
Transformstatus quo
Shift in type ofcollaboration
Adaptationsto the tool
idualuctivityess supportovisationtechnology is higher among the
super users. They aretrained to be ambassadors and to support early
and dailyuse with a more detailed technical knowledge compared
tothe average user.
The institutional conditions are identied in the hier-archical,
individualistic and collaborate level. The hierarch-ical and
control dimensions are commented above regard-ing inertia. Personal
(individualistic) productivity gains areidentied e.g. regarding the
fact that several people do nothave to search, or even hunt, for
the paper based medicalrecord anymore. However, the opposite is
also identied(productivity loss) regarding e.g. physicians
searching forinformation and getting an overview of a lot of
material inthe HIS (compared to the earlier fast dip into the
paperbased le containing a certain patient's medical record).The
HIS implementation, as analyzed above, also have anoverall efciency
intention (in terms of direct medical care,administration of
medical care and overall management ofthe healthcare units). The
collaborative dimension is pre-sent in the integrated character of
the HIS. The systemprovides the opportunity to work over healthcare
unitboundaries (e.g. to solve problems together) that have notbeen
the case before (without the EMR) (i.e. a processualconsequence).
This has proven to make communication andcollaboration among actors
easier (in terms of providingpatients with e.g. medical care
overviews, previous appoint-ments, letters of referrals, and lab
tests).
Changes in the HIS (a technological consequence) has alsobeen
made during upgrades of the system. This has beenpartially based on
comments and requests from users andsuper users within the
organization and also based on the
-
tional one. Using Orlikowski's terms (2000) it is considered
stating that new HIS are considered as supporting for
33Images of HIS implementation and useto be more reinforcement,
or modest transformation, thansubstantial transformation.
Alpha has the interpretation of the HIS as a technologythat
never becomes complete or fully stabilized, even ifthey choose to
treat the system as temporary stabilizedwhen nishing the
implementation project. The projectmanagement team at CPC launches
an initiative labeled as asecond wave that is supposed to deal with
modicationsof the system after initial development [29] in order
tochange processes and activities connected to the use of
thesystem. This is made in order to achieve
substantialorganizational change. Challenges connected to the
socalled second wave can be that the technology-in-practice (ibid.)
has become institutionalized and tends topredetermine prescriptions
for action in the organization.Technology-in-practice may impede
change (ibid.) and theobjectives from CPC associated with the
initiative cancreate a new wave of inertia or even resistance
tochange. These challenges are in line with a view of
amulti-faceted and reciprocal relation between IS and orga-nization
[13,42].
The third type of enactment (ibid.) is labeled change.Here
people choose to use new technology to [] sub-stantially alter
their existing way of doing things. Suchenactment results in
transformation of the structural statusquo, and signicant
modications to users' work practices aswell as the technological
artefact. ([29], p. 423). The factthat Cosmic is a standardised HIS
leaves not much space forimprovisation, emergence or customization
(cf. [30,42]) ofthe system as such, for most users in Alpha. The
strongtechnical and institutional controls present at hospitals
andcare centers can also impede change (cf. [36]). New
ordeveloped/changed ways of working have, however, beenidentied.
Some of these new ways of working are relatedto the functionality
concerning the EMR.
It is so easy to do the same action as before [when youhave all
the history and information available in theHIS]; when you actually
need to do a new examination ofthe patient. It should not be too
easy [Interview,Physician, September, 2009]
The balance between routine and reection is an impor-tant aspect
in the expression above. The physician thinksthat it is too easy to
take certain actions when the HIS is inuse. The physician takes one
example when the systemdeals with this complexity in a proper way;
every medicaldrug is prescribed separately from a list of a
patientsearlier use it is not possible to prescribe more than
onedrug without signing each time. This creates time forvaluable
reection rather than to get into a rut.vendor's knowledge and
general ES development process. Atthe same time, users have adapted
to the HIS regarding forexample the language used for several
functions androutines implemented in Cosmic. Even if some changes
areidentied in the processual and structural consequencecategory
(application and change enactment below), theoverall impression is
that Cosmic reinforces and enhancesstatus quo. It is, so far (also
in follow-up interviews from2010), more a technological innovation
than an organiza-administrative activities like monitoring and
potentiallythreatening the power of the medical professional
groups[14,15,39]. We have also commented upon the fact
thatcollaboration among different units has been facilitated bythe
HIS. It is hard to classify if this is an example ofincreased
collaboration (application) or a shift in type ofcollaboration
(change), though.
Conclusions, limitations and further research
An enterprise-wide HIS implementation engages and some-times
provokes. But there also supporters. This is illustratedin the
present case study. Different actors have theirinterpretations,
images and opinions about both the IS,organizational changes to
come and the results of it onseveral levels (their own work
practice, their organizationalunit, Alpha as an entire organization
and e.g. the patient).Some express positive interpretations and
expectations,based on individual or group values and norms; the
health-care practice will be more effective, more accessible
andsafer. Other actors or groups of actors fear the
systemimplementation, the system as an artefact and the
organi-zational changes it will bring and are reluctant.
Profes-sionals and groups have their attitudes, media providesother
views of the process, and patients might have yetother
interpretations. The present HIS is interpreted aseverything from a
scapegoat to a savior for healthcare, anda way of being modern (cf.
[2]) on an organizational level.The spectrum of interpretations and
images that can berelated to the implementation and use of a HIS
has been amain theme in this paper, and is an important
contribu-tion from this research. The case study analysis
illust-rates several images that can be regarded as
rationalizedmyths (cf. [25]). Such images are important expression
ofRedened work distribution has been identied to someextent between
physicians and medical secretaries (men-tioned above). We have also
identied that particularhealthcare units needs to document e.g.
patients' medicalstatus thinking of the fact that everyone in Alpha
can getaccess to it, read it and even base their decisions on
thatpiece of information. This means that documentation by acertain
unit is done for the benet of other units. This alsomeans that
there is a distribution of (documentation) workamong units.
Achieving change can also be restrained by theimages of the project
with prexes as measurement,management control, standardization or
rationaliza-tion expressing resistance from medical professionals
[20].These interpretations exist among nursing staff within
Alphaand create a gap between administrators and
medicalprofessionals concerning motives, objectives and
normssurrounding the implementation, use and effects of Cosmic.This
is also a question of power between medical profes-sionals and
administrators identied also by e.g. Lapointeand Rivard [16];
administrators threatening the power ofmedical professionals though
the new integrated HIS withall possibilities to monitor, control,
and manage resources(like with any integrated IS, such as
enterprise systems). Ingeneral our case study also identies that
administrators aremore positive towards the new HIS than medical
profes-sionals. This is in line with previous studies (e.g.
[39])
-
U. Melin, K. Axelsson34the medical professions' [20] view of the
HIS and its imple-mentation. Such images heavily inuence the
success or failureof an HIS (ibid). The results from the case study
conrmsconclusions from previous HIS studies like Lapointe and
Rivard[19,20] and [14,15], but also expand the body of
knowledgethrough the focus on discussing images from a
structurationtheory perspective. The present study also shows that
theresistance and the rationalized myths starts even before the
fullscale implementation process begun, which for example not
ishighlighted in the study by Lapointe and Rivard [19].
The case study is also an illustration and analysis of
thecomplexity in HIS implementation linked to
healthcareorganizations as professional bureaucracies, being
highlypoliticized and institutionalized (cf. [27]). At the same
timeelements and pockets of diversity in healthcare processesare
present in the organization regarding patients, disci-plines,
treatment options, and delivery processes [9] chal-lenging a
standardized HIS. The tension between theroutinized work and the
need for exibility magnies thecomplexity surrounding HIS
implementation and use and thesituational nature of it (ibid.).
This tension is also high-lighted in general IS studies and studies
focusing integratedIS in terms of enterprise systems and labeled as
anorganization's administrative paradox [24].
In this article we have used the main types of
enactment(inertia, application and change) as a basis when
structuringour analysis and illustrated the different types of
conse-quences (processual, technological and structural) based
onOrlikowski [29]. By providing multiple images of the
imple-mentation process, the project and the artefact, we haveaimed
to focus the challenges that a large-scale implemen-tation process
in the healthcare sector has to manage.Identifying and
acknowledging images can be a way tohandle the gap between design
and reality in HIS imple-mentation projects, mentioned by Heeks
[12]. This has severalpractical and theoretical implications. These
diverse imageshave to be identied, acknowledged and constructively
dealtwith from a practical perspective and not dismissed
asdysfunctional and destructive [19,20]. Jensen and Aanestad[15]
also argue that it is important clarify the needs, values,and
preferences of the users in order to understand howprofessionals
interpret and respond to HIS implementation.However this is a
challenge on a strategic level, as well on atactic and operative
level of an organization. The challengeconcerns implementation
strategy and pace, information andcommunication, norms and values
within groups and indivi-duals, of conditions and expected
consequences, as well as therelation between organizational and IS
change. Theoreticallywe need to identify and use perspectives,
frameworks and waysof being sensitive in order to capture multiple
and temporalimages of implementation processes, artefacts and
structures.Our use of structuration theory as a meta-theory is an
attemptto focus such dimensions that are well known and reported in
ISliterature [28,30]. When identifying diverse images, theinvolved
actors are focused. In order to succeed with this kindof
implementation projects, concerned professionals have to beinvolved
([22]) and informed [18]. By acknowledging variousimages of the HIS
implementation actor awareness is alsoreached, which is an
important aspect according to otherstudies in the HIS eld
[14,15,35].
The implementation process of a HIS is much too complexto be
judged as being either positive or negative it is anillustration of
the multi-faceted and reciprocal, complexrelation between IS and
organization (cf. [13,42]) which isillustrated through the images
in the present article. Ourndings show that the images of the
implementationprocess and the HIS depend on what dimensions that
arein focus, which professionals that are interviewed, andwhen (cf.
[4]). Our results therefore challenge the norma-tive denitions of
standardised IS providing a kind ofshortcut to operational
excellence (cf. [40]). Multipleimages of the project as well as the
artefact as such (e.g. asa scapegoat and a savior) show the span of
interpretationsin Alpha. This challenge presentation of CSF's, the
reasoningof what best practice design is (ibid.) and
rationalapproaches towards system implementation and change
ingeneral, based on e.g. a technological imperative [23].These
ndings also have managerial implications; from aproject management
perspective it is important to acknowl-edge different images of a
project, discussing e.g. impres-sions of shortcuts vs. long-term
change. Time is animportant factor challenging the norms of trying
to realizeshort term benets of HIS (cf. [27]). In the case study
thereis also evidence that more radical change on a structurallevel
[37] is not a result of the HIS implementation so far.
This paper uses a single case study approach in order toin-depth
explore a HIS implementation process. This is aresearch design
decision that of course has both pros andcons. We have been able to
follow this implementation caseclosely and longitudinally and,
thus, gained good access toAlpha. However, further case studies
will be performed inorder to validate our ndings. A possible next
step is toanalyze the links from this project to the national
policylevel; a Swedish action plan for e-health has been
launchedrecently. To focus on the institutional logics [6] and
thepolicy implementation from a national level to a regionaland
local level can also be rewarding. Analytically, institu-tional
theory [25,33] can be used as a more distinct plat-form to further
analyze the empirical data or adaptivestructuration theory (AST)
[8] as a way to be even morespecic about technology changes, for
whom and for whichprocess this makes a difference. There are also
severaldimensions of resistance in the empirical data that can
behighlighted and studies more carefully in line for examplewith
Lapointe and Rivard [19]. In the present analysis theinterpretation
of empirical data is guided by a particulartheoretical lens, with
its merits and shortcomings.
Acknowledgments
The authors would like to thank PhLic Ester Andrasson forher
cooperation when performing the interviews in the casestudy. This
study is funded by the Swedish Civil ContingencyAgency and a part
of the "Safe Public e-services - an issue oftrust and organization"
project at the Department ofmanagment and engineering, Linkping
University, Sweden.
References
[1] Abraham C, Junglas I. From cacophony to harmony: a casestudy
about the IS implementation process as an opportunityfor
organizational transformation at Sentara Healthcare. JStrateg Inf
Syst 2011;20(2):17797.
-
[2] Abrahamson E. Management Fashion. Acad Manag Rev
1996;21(1):25485.
[24] Melin U. The enterprise system as a part of an
organization'sadministrative paradox. J Enterprise Inf Manag
2010;23(2):181200.
[25] Meyer JW, Rowan B. Institutionalized organizations:
formalstructure as myth and ceremony. Am J Sociol
1977;83:34063.
[27] Newell S. Editorial: special section on healthcare
informationsystems. J Strateg Inf Syst 2011;20(2):15860.
[28] Orlikowski W, Baroudi J. Studying information technology
in
35Images of HIS implementation and usezations: myths and
challenges. Int J Med Inf 2001;64:14356.[5] Chiasson MW, Davidson
E. Pushing the contextual envelope:
developing and diffusing IS theory for health informationsystems
research. Inf Organ 2004;14(3):15588.
[6] Currie WL, Guah MW. Conicting institutional logics: a
nationalprogramme for IT in the organisational eld of healthcare.
JInf Technol 2007;22(3):23547.
[7] Davenport TH. Putting the enterprise into the
enterprisesystem. Harv Bus Rev 1998;76(4):12131.
[8] DeSanctis G, Poole MS. Capturing the complexity in
advancedtechnology use: adaptive structuration theory. Organ
Sci1994;5(2):12146.
[9] Fichman RG, Kohli R, Krishan R. The role of
informationsystems in healthcare: current research and future
trends.Inf Syst Res 2011;22(3):41928.
[10] Giddens A. The constitution of society: outline of the
theory ofstructuration. Polity Pr., Cam; 1984.
[11] Gil-Garca JR, Pardo TA. E-government success factors:
map-ping practical tools to theoretical foundations. Gov Inf
Quart2005;22(2):187216.
[12] Heeks R. Health information systems: failure, success
andimprovisation. Int J Med Inf 2006;75:12537.
[13] Howcroft D, Newell S, Wagner E. Understanding the
contextualinuences on enterprise system design, implementation,
useand evaluation (Editorial). J Strateg Inf Syst
2004;13(4):2717.
[14] Jensen TB, Aanestad M. Hospitality and hostility in
hospitals: acase study of an EPR adoption among surgeons. Eur J Inf
Syst2007;16(6):67280.
[15] Jensen TB, Aanestad M. How healthcare professionals
makesense of an EPR adoption. Inf Syst Manag 2007;24:2942.
[16] Khoumbati K, Themistocleous M, Irani Z. Evaluating
theadoption of enterprise application integration in
health-careorganizations. J Manag Inf Syst 2006;22(4):69108.
[17] Klein HK, Myers MD. A set of principles for conducting
andevaluating interpretive eld studies in information systems.Manag
Inf Syst Quart 1999;23(1):6794.
[18] Kohli R, Kettinger WJ. Informating the clan:
controllingphysicians costs and outcomes. MIS Quart
2004;28(3):36394.
[19] Lapointe L, Rivard S. A multilevel model of resistance
toinformation technology implementation. Manag Inf Syst
Quart2005;29(3):46191.
[20] Lapointe L, Rivard S. Getting physicians to accept
newinformation technology: insights from case studies. Can MedAssoc
J 2006;174(11):15738.
[21] MacKinnon W, Wasserman M. Integrated electronic
medicalrecord systems: critical success factors for implementation.
In:Hawaii international conference on information
systems(HICSS-42), IEEE Computer Society, January 58, Big
Island,HI, USA, http://10.1109/HICSS.2009.264; 2009.
[22] Mantzana V, Themistocleous M, Irani Z, Morabito V.
Identifyinghealthcare actors involved in the adoption of
informationsystems. Eur J Inf Syst 2007;16(1):91102.
[23] Markus ML, Robey D. Information technology and
organiza-tional change: casual structure in theory and research.
ManagSci 1988;34(5):58398.organizations: research approaches and
assumptions. Inf SystRes 1991;2(1):128.
[29] Orlikowski WJ. Using technology and constituting
structures: apractice lens for studying technology in
organizations. OrganSci 2000;11(4):40428.
[30] Orlikowski WJ, Robey D. Information technology and
thestructuring of organizations. Inf Syst Res 1991;2(2):14369.
[31] Patton MQ. Qualitative evaluation methods. Beverly
Hills,California: Sage Publications; 1980.
[32] Payton FC, Pare G, Le Rouge CM, Reddy M. Health care
IT:process, people, patients and interdisciplinary considerations.J
Assoc Inf Syst 2011;12(2/3):ixiii.
[33] Powell W, DiMaggio P. The new institutionalism in
organiza-tional analysis. Chicago: University of Chicago; 1991.
[34] Robey D, Boudreau M. Accounting for the
contradictoryorganizational consequences of information technology:
theo-retical directions and methodological implication. Inf Syst
Res1999;10:16785.
[35] Sallas B, Lane S, Mathews R, Watkins T, Wiley-Patton S.
Aniterative assessment approach to improve technology adoptionand
implementation decisions by healthcare managers. Inf SystManag
2007;24:4357.
[36] Scott WR. Organizations rational, natural, and open
sys-tems.4th ed. N.J: Prentice Hall; 1998.
[37] Spil TAM, Stegwee RA. Strategies for healthcare systems.
In:Stegwee RA, Spil TAM, editors. Strategies for healthcaresystems.
Idea Group Publishing; 2001. p. 111.
[38] Sunyoung C, Mathiassen L, Nilsson A. Contextual
dynamicsduring health information systems implementation: an
event-based actor-network approach. Eur J Inf Syst
2008;17(6):61430.
[39] Venkatesh V, Xiaojun Z, Sykes TA. Doctors do too
littletechnology: a longitudinal eld study of an electronic
health-care system implementation. Inf Syst Res
2011;22(3):52346.
[40] Wagner EL, Newell S. Best for whom?: the tension
betweenbest practice ERP packages and diverse epistemic cultures
ina university context J Strateg Inf Syst 2004;13(4):30528.
[41] Walsham G. Interpreting information systems in
organizations.Chichester: John Wiley; 1993.
[42] Walsham G. Interpretive case studies in IS research:
natureand method. Eur J Inf Syst 1995;4:7481.
[43] Weick KE. The social psychology of organising.
Addison-Wesley;1969. (Reading Mass).
[44] vretveit J, Scott T, Rundall TG, Shortell SM, Brommels
M.Improving quality through effective implementation of
infor-mation technology in healthcare. Int J Qual Health
Care2007:18.[4] Berg M. Implementing information systems in health
care organi- [26] Morgan G. Images of organizations. Newbury Park:
SagePublications; 1986.[3] Barley SR. Technology as an occasion for
structuring: evidencefrom observations of ct scanners and the
social order ofradiology departments. Adm Sci Quart
1986;31(1):78108.
Implementing healthcare information systems Mirroring a wide
spectrum of images of an IT projectIntroductionTheoretical
backgroundHealth Information SystemsInformation systems
implementation, change and structures
Research approachThe case of an integrated health information
systemAnalysis and discussionImages of the project and the HISTypes
of enactment and institutional aspects
Conclusions, limitations and further
researchAcknowledgmentsReferences