An Exploration of Heterogeneity in Electronic Medical Record Use: Information Technology Use as Emergent and Driven by Values and Expertise

We explore heterogeneity in the use of an organization-wide information technology (IT) by both individuals and groups in a professional organization. We study electronic medical record use by physicians and clinic work groups in two medical practices operating within one multi-specialty health care clinic. Data collection methods include interviews, non-participant observations, and questionnaires. Drawing on theories of professional organizations and complex adaptive systems, we offer as an explanation of heterogeneity in IT use by individuals that IT use is a function of professional values and expertise and of heterogeneity of IT use in groups the insight that IT use at a collective level is an emergent property arising from the interactions of diverse, learning agents. This study contributes to information systems research by enriching current understandings of IT use and by providing new insights about heterogeneous IT use in professional organizations

Are We Putting the Cart Before the Horse? A Microcosm of Intended and Unintended Outcomes of Electronic Medical Record Implementation

Leaders in health care are calling for the implementation of electronic medical records (EMR) systems to help alleviate high costs of care delivery, high error rates, and uneven access to care. However, many of these leaders seem to be overlooking unintended outcomes of EMR implementation. Specifically, they may be overlooking the critical role physician beliefs and relationships play in the use of EMRs and in generating both intended and unintended outcomes. We studied a microcosm of the health care system through a qualitative field study examining EMR use in four clinics operating within a multi-specialty medical organization. We found that beliefs held by physicians about medical practice and the patterns of relationships in clinics influence EMR use behaviors in both expected and unexpected ways. Our contribution is to call attention to unintended outcomes of EMR implementation and to suggest that EMRs can be used as artifacts for learning

The role of conversation in health care interventions: enabling sensemaking and learning

<p>Abstract</p> <p>Background</p> <p>Those attempting to implement changes in health care settings often find that intervention efforts do not progress as expected. Unexpected outcomes are often attributed to variation and/or error in implementation processes. We argue that some unanticipated variation in intervention outcomes arises because unexpected conversations emerge during intervention attempts. The purpose of this paper is to discuss the role of conversation in shaping interventions and to explain why conversation is important in intervention efforts in health care organizations. We draw on literature from sociolinguistics and complex adaptive systems theory to create an interpretive framework and develop our theory. We use insights from a fourteen-year program of research, including both descriptive and intervention studies undertaken to understand and assist primary care practices in making sustainable changes. We enfold these literatures and these insights to articulate a common failure of overlooking the role of conversation in intervention success, and to develop a theoretical argument for the importance of paying attention to the role of conversation in health care interventions.</p> <p>Discussion</p> <p>Conversation between organizational members plays an important role in the success of interventions aimed at improving health care delivery. Conversation can facilitate intervention success because interventions often rely on new sensemaking and learning, and these are accomplished through conversation. Conversely, conversation can block the success of an intervention by inhibiting sensemaking and learning. Furthermore, the existing relationship contexts of an organization can influence these conversational possibilities. We argue that the likelihood of intervention success will increase if the role of conversation is considered in the intervention process.</p> <p>Summary</p> <p>The generation of productive conversation should be considered as one of the foundations of intervention efforts. We suggest that intervention facilitators consider the following actions as strategies for reducing the barriers that conversation can present and for using conversation to leverage improvement change: evaluate existing conversation and relationship systems, look for and leverage unexpected conversation, create time and space where conversation can unfold, use conversation to help people manage uncertainty, use conversation to help reorganize relationships, and build social interaction competence.</p

Hospital boards and hospital strategic focus: The impact of board involvement in strategic decision making

Background: Despite pressures to change the role of hospital boards, hospitals have made few changes in board composition or director selection criteria. Hospital boards have often continued to operate in their traditional roles as either “monitors” or “advisors.” More attention to the direct involvement of hospital boards in the strategic decision-making process of the organizations they serve, the timing and circumstances under which board involvement occurs, and the board composition that enhances their abilities to participate fully is needed. Purposes: We investigated the relationship between broader expertise among hospital board members, board involvement in the stages of strategic decision making, and the hospital’s strategic focus. Methodology/Approach: We surveyed top management team members of 72 nonacademic hospitals to explore the participation of critical stakeholder groups such as the board of directors in the strategic decision-making process. We used hierarchical regression analysis to explore our hypotheses that there is a relationship between both the nature and involvement of the board and the hospital’s strategic orientation. Findings: Hospitals with broader expertise on their boards reported an external focus. For some of their externally- oriented goals, hospitals also reported that their boards were involved earlier in the stages of decision making. Practice Implications: In light of the complex and dynamic environment of hospitals today, those charged with developing hospital boards should match the variety in the external issues that the hospital faces with more variety in board makeup. By developing a board with greater breadth of expertise, the hospital responds to its complex environment by absorbing that complexity, enabling a greater potential for sensemaking and learning. Rather than acting only as monitors and advisors, boards impact their hospitals’ strategic focus through their participation in the strategic decision-making process

A Field Study of the Effect of Interpersonal Trust on Virtual Collaborative Relationship Performance

This article examines the relationship between interpersonal trust and virtual collaborative relationship (VCR) performance. Findings from a study of 10 operational telemedicine projects in health care delivery systems are presented. The results presented here confirm, extend, and apparently contradict prior studies of interpersonal trust. Four types of interpersonal trust—calculative, competence, relational, and integrated—are identified and operationalized as a single construct. We found support for an association between calculative, competence, and relational interpersonal trust and performance. Our finding of a positive association between integrated interpersonal trust and performance not only yields the strongest support for a relationship between trust and VCR performance but also contradicts prior research. Our findings indicate that the different types of trust are interrelated in that positive assessments of all three types of trust are necessary if VCRs are to have strongly positive performance. The study also established that if any one type of trust is negative, then it is very likely that VCR performance will not be positive. Our findings indicate that integrated types of interpersonal trust are interdependent, and the various patterns of interaction among them are such that they are mutually reinforcing. These interrelationships and interdependencies of the different types of interpersonal trust must be taken into account by researchers as they attempt to understand the impact of trust on virtual collaborative relationship performance

What a Mess! Participation as a Simple Managerial Rule to “Complexify” Organizations

This paper adopts a view of organizations as complex adaptive systems and makes a case for making organizations more complex internally through the use of a fairly simple managerial rule—using participative decision making. Participation in decision making enhances connectivity in organizations, which in turn, gives the organization the opportunity to self-organize and co-evolve in more effective ways than when there is minimal connectivity (i.e., autocracy). The paper uses a specific body of research to support the arguments about why participation can benefit the practice of management in modern organizations

How Complexity Science Can Inform a Reflective Process for Improvement in Primary Care Practices.

BACKGROUND: Quality improvement processes have sometimes met with limited success in small, independent primary care settings. The theoretical framework for these processes uses an implied understanding of organizations as predictable with potentially controllable components. However, most organizations are not accurately described using this framework. Complexity science provides a better fit for understanding small primary care practices. METHODS: The Multimethod Assessment Process (MAP)/Reflective Adaptive Process (RAP) is informed by complexity science. This process was developed in a series of studies designed to understand and improve primary care practice. A case example illustrates the application and impact of the MAP/RAP process. RESULTS: Guiding principles for a reflective change process include the following: an understanding of practices\u27 vision and mission is useful in guiding change, learning and reflection helps organizations adapt to and plan change, tension and discomfort are essential and normal during change, and diverse perspectives foster adaptability and new insights for positive change. DISCUSSION: A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements

Understanding Organizational Designs of Primary Care Practices.

During the past decade, many hospitals experienced difficulty integrating primary care practices into their health systems. We hypothesized that this difficulty may be, in part, a result of limited understanding of practice organizational designs. The structure and function of practices have not been well studied. In this article, we answer the following questions: Are practices all the same, or do variations in their organizational design exist? Do hospital designs predict the designs of affiliated practices? If variation exists, what are the management implications? Eighteen family practices, including nine affiliated with five separate hospital systems, were studied using an in-depth comparative case study design. A content analysis of the rich descriptive data from these cases indicates that a great variety exists in the organizational design of primary care practices, and this variety appears to be influenced by the initial conditions under which the practice was organized. Hospital system design in and of itself did not predict the design of affiliated practices. In fact, both affiliated and independent practices exhibited a range of design characteristics, some of which did not fit traditional models. Hospital systems that allowed greater flexibility of practice organizational designs were more effective at integrating and managing practices. Practices response to environmental change was greater when practice autonomy was highest. These findings suggest that a science of practice organizational design separate from that of hospitals is needed to help explain the success and failure of practices within health systems and to provide information for planning practice change