A Theory of Organization-EHR Affordance Actualization

While organizations implement information technology (IT) to effect change, current theories of IT-associated organizational change pay insufficient attention to the change goals, the role of IT in organizational change, and the multilevel nature of change processes. We take a fresh look at IT-associated organizational change using grounded theory methods. Our longitudinal study of an electronic health record (EHR) system implementation in a multi-site medical group found user behaviors that did not fit well with existing theories. Instead, we found that they fit better with the concept of affordances from ecological psychology. In developing our affordance-based theory of IT-associated organizational change from our field data, we discovered three gaps in the affordance literature; namely, the lack of theory for (1) the process of actualizing an affordance’s potential, (2) affordances in an organizational context, and (3) bundles of interrelated affordances. This paper extends the theory of affordances to handle these three gaps and, in doing so, develops a mid-range theory for EHR-associated organizational change in a healthcare organization. While the resulting theory is specific to EHR implementations, it offers a template for other mid-range affordance-actualization theories and a more general affordance-actualization lens. Our affordance-actualization lens considers the materiality of the IT artifact, the non-deterministic process by which IT leads to organizational effects, the multilevel nature of IT-associated change processes, and the intentionality of managers and users as agents of change, and thus addresses important criteria for theories of IT effects in organizations. The paper also provides practical guidance for implementing EHR systems and other organizational systems

A Theory of Clinic-EHR Affordance Actualization

To build theory about how to achieve expected benefits from a system implementation, we conducted a longitudinal study of the implementation of an electronic health record (EHR) system at a multi-site clinic using grounded theory methods and a critical realist perspective. We developed a mid-level process theory of how clinics actualize affordances arising from the implementation of an EHR. In so doing we complement the work of Markus and Silver (2008) in their application of Gibson’s Affordance Theory to the understanding of IT effects on organizations. Specifically, we replace the DeSanctis and Poole (1994) concept of appropriation with a new concept, actualization, and show how the individual level journeys of users as they actualize affordances as perceived from their various personal perspectives result in the organizational level outcomes. In building this mid-level theory, we identify the central affordances pertaining to the clinic-EHR relation and in so doing, provide an example of how to define affordances and how to conduct empirical studies using an Affordance Theory lens. Our theory should prove useful to practitioners implementing such systems

Information Quality in Secondary Use of EHR Data : A Case Study of Quality Management in a Norwegian Hospital

The motivation for undertaking this study relates to my experiences from practice in a public hospital, where I have observed variations in reaching organizational goals of quality management informed by electronic health records (EHR) data. For example, while some departments and units have long-time traditions in meeting the quality goals that are set locally, regionally, or nationally, other departments and units struggle to meet the same quality goals. Thus, generating actionable information by reusing routinely collected EHR data does not necessary lead to action in response to the information. This process of generating information from existing EHR data, and communicating and using such information for organizational purposes, may be challenging in a highly complex environment such as health care organizations. Within this process, information quality (IQ) may influence actors’ perceptions of action possibilities the information offers, thus influencing the actual use of the information required to reach organizational goals. EHR data can be used for clinical purposes at the point-of-care (i.e., primary use) and reused for purposes that do not involve patient treatment directly (i.e., secondary use). Examples of such secondary use includes quality management, research, and policy development. Though it is widely accepted that IQ influences the use of EHR systems and the information generated by EHR systems, research on the implications of IQ on health care processes is limited: the focus of the current literature is concerned with defining and assessing IQ in primary use of EHR data, whereas the role of IQ in secondary use of EHR data remains unclear. Thus, this dissertation investigates the role of IQ in secondary use of EHR data in an organizational context. This dissertation addresses this practical and theoretical challenge by focusing on the overall research objective of understanding the role of IQ in secondary use of EHR data. To address this research objective, this dissertation explores the following research questions: RQ1. How do human actors influence in transformation of IQ while generating, communicating, and using information in secondary use of EHR data? RQ2. What are the underlying generative mechanisms through which IQ transforms in the process of secondary use of EHR data?publishedVersio

Challenges of Mainstreaming Telecare. Exploring Actualization of Telecare Affordances in Home Care Services

Application of telecare has received increased attention as a means to address the future care needs in home care services. However, the uptake of telecare has been slow and fewer solutions than expected have been implemented. Healthcare employees’ perspectives on telecare and organizational issues have not received appropriate attention in earlier research. There is a need to understand the challenges related to telecare services. Through the lens of affordance theory, the present study aims to explore municipal employees` experiences of TCS. The study contributes to affordance theory by developing an understanding of the collective actualization process. Focus group interviews were conducted with 26 employees involved in telecare services in eight municipalities in Southern Norway. Findings reveal that successful actualization of the seven perceived telecare affordances required involvement of several actors, new ways of working and close cooperation within the municipalities across units and disciplines. Furthermore, the actualization process was strongly influenced by contextual factors. The most prominent factors included anchoring and cooperation, competence and knowledge, and routines and follow-up. Findings indicate that specific focus on these factors is needed in order to succeed with mainstreaming of telecare in home care services

The influence of electronic health record use on collaboration among medical specialties

Background: One of the main objectives of Electronic Health Records (EHRs) is to enhance collaboration among healthcare professionals. However, our knowledge of how EHRs actually affect collaborative practices is limited. This study examines how an EHR facilitates and constrains collaboration in five outpatient clinics. Methods: We conducted an embedded case study at five outpatient clinics of a Dutch hospital that had implemented an organization-wide EHR. Data were collected through interviews with representatives of medical specialties, administration, nursing, and management. Documents were analyzed to contextualize these data. We examined the following collaborative affordances of EHRs: (1) portability, (2) co-located access, (3) shared overviews, (4) mutual awareness, (5) messaging, and (6) orchestrating. Results: Our findings demonstrate how an EHR will both facilitate and constrain collaboration among specialties and disciplines. Affordances that were inscribed in the system for collaboration purposes were not fully actualized in the hospital because: (a) The EHR helps health professionals coordinate patient care on an informed basis at any time and in any place but only allows asynchronous patient record use. (b) The comprehensive patient file affords joint clinical decision-making based on shared data, but specialty- and discipline-specific user-interfaces constrain mutual understanding of that data. Moreover, not all relevant information can be easily shared across specialties and outside the hospital. (c) The reduced necessity for face-to-face communication saves time but is experienced as hindering collective responsibility for a smooth workflow. (d) The EHR affords registration at the source and registration of activities through orders, but the heightened administrative burden for physicians and the strict authorization rules on inputting data constrain the flexible, multidisciplinary collaboration. (e) While the EHR affords a complete overview, information overload occurs due to the parallel generation of individually owned notes and the high frequency of asynchronous communication through messages of varying clinical priority. Conclusions: For the optimal actualization of EHRs' collaborative affordances in hospitals, coordinated use of these affordances by health professionals is a prerequisite. Such coordinated use requires organizational, technical, and behavioral adaptations. Suggestions for hospital-wide policies to enhance trust in both the EHR and in its coordinated use for effective collaboration are offered

How can we develop contextualized theories of effective use? A demonstration in the context of community-care electronic health records

We contribute to the shifting discourse in the literature on information system use, towards context-specific (rather than general) theories and effective use (rather than just use). Organizations are under great pressure to use information systems effectively but they have few theories to turn to for insights. Motivated by this need, we propose an approach for developing context-specific theories of effective use. The approach suggests that effective use can be theorized by: (1) understanding how a network of affordances supports the achievement of organizational goals, (2) understanding how the affordances are actualized, and (3) using inductive theorizing to elaborate these principles in a given context. We demonstrate the approach in the context of a Canadian health authority’s use of a community-care electronic healthcare record (EHR). We discovered that effective use in this context can be viewed at a high level as the accuracy and consistency with which users work with the EHR, and how they engage in reflection-in-action across a network of nine affordances. The key, however, is understanding how those elements interact with the multiple levels of data needed to achieve the organization’s various goals. Overall, we contribute by offering an approach for developing context-specific theories of effective use, demonstrating its usefulness in an important context, and discovering the importance of understanding in a new way the multilevel nature of information systems

Differences in Physician Use of Electronic Health Records: Development of a Scale Assessing Individual Factors Influencing Physician Actualization

Electronic health records (EHRs) are one of the most talked about topics within and surrounding health care organizations and the health care system in the United States; however, the U.S. has been slow to implement these computerized medical record systems into their organizations. One of the factors often overlooked regarding the implementation of EHRs, is the role of individual health care professionals and the effects produced by their interactions with the EHR as they perform their job duties throughout the day. Using a Theory of Organization-EHR Affordance Actualization as a guiding framework, the focus of this dissertation is to examine the factors that influence how physicians use the EHR at the individual-level during clinical interactions by analyzing physician perceptions of their interaction with the EHR while providing patient care in the exam room and how it influences their work process. A mixed methods approach was used to identify the affordances, EHR features, factors that influence EHR use, and individual physician characteristics that produce the visible effects of EHR use during the clinical encounter when individual physicians interact with the EHR. The findings of this study confirm the identification of individual level affordances proposed by Strong and colleagues and propose three additional affordances. This study also identified additional features that should be taken into consideration when investigating individual level affordance actualization. Finally, this study provides a survey tool for practice managers, health care executives, trainers, and vendors to use in order to better understand the individual user characteristics of their physicians, predict their patterns of use based on these user characteristics, and thus tailor their training to enhance affordance actualization and organizational goal attainment

The Role of Mediators in Transforming and Translating Information Quality: A Case of Quality Assurance in a Norwegian Hospital Trust

The existing literature on information quality (IQ) provides limited understanding of how roles influence IQ in healthcare. The traditional way of understanding roles such as collectors, custodians, and consumers assumes that data are simply transformed into information and subsequently used by consumers. However, this does not explain how interpersonal communication influences IQ. In reality, the actors involved can actively change the quality of healthcare information through transformation, translation, or distortion. Latour’s idea of intermediaries and mediators can be an appropriate lens for understanding these roles. Latour defined intermediaries as socio-technical actors who simply transport information, whereas mediators can transform, translate, distort, and change the meaning of information. Following Latour’s idea, we conducted a qualitative case study of quality assurance in a Norwegian healthcare organization. In doing so, we illustrated how IQ mediators can distort or create shared understanding of quality assurance information, which further influences enactment

Advancing Digital Collaboration: Barriers to Enterprise Social Media Adoption and how to Overcome them

Advancing digital collaboration and fostering effective communication among a widespread workforce continues to be a perpetual challenge for companies. Organizations are progressively turning to Enterprise Social Media (ESM) because they promise new avenues for collaborative working. However, most ESMs fail to reach a wider adoption by the workforce, owing to an underutilization by the employees. To enhance the understanding of the underutilization phenomenon, we use affordance actualization theory as our theoretical lens to critically study the challenges employees face in their attempt to actualize respective ESM affordances. By analyzing comments from 992 frequent, infrequent, and discontinued ESM users from a large multinational company, we uncover four major challenges. By enhancing our understanding of ESM affordances and by incorporating the full spectrum from problem identification to solution, we provide practical advice for digital leaders and meaningful theoretical implications for the IS community

A conceptual model of feedback mechanisms in adjusted affordances – Insights from usage of a mental mobile health application

Affordance theory provides one of the most prominent lenses through which the socio-technical aspects of a system’s use can be investigated and understood. In this context, the literature has proposed that perceived and actualized affordances may be adjusted over time. Yet, how the adjustment of affordances occurs has not been explained in detail. Thus, in this article, we develop a conceptual model of feedback mechanisms that includes a more explicit description of how affordances are perceived by users, whether actualized and adjusted. With the model, we introduce the central concept of a generative base, out of which affordance perceptions emerge and which can be updated through affordance actualizations. With this base, we integrate mental model (MM) theory to explain better the differing perceptions before and after actor–artifact interactions. Our conceptual model is illustrated and specified using an empirical case of the mental mobile health (mHealth) app “Between The Lines” in Germany. In this study, we conducted 40 interviews in two rounds with 20 teenage app users. Our results show that the users’ perceptions of mHealth affordances become adjusted and hence change over time due to experiencing the actualization process, which may lead to an update of the generative base, including the user’s MM