Abstract
Implementation of large Health Information Technology (HIT) systems is critical to healthcare organizations and has seen heavy investment. However, research has not fully explored the adaptation of HIT systems, particularly the tensions between individual flexibility and organizational needs in the adaptation process. This study analyzes how Emergency Department (ED) clinicians adapted to a new hospital-wide Electronic Medical Records (EMR) system. We present four adaptation cases revealing two interrelated types of adaptations—technical and organizational—as responses to the new system in use. First, individual clinicians respond to the immediate alteration in workflows caused by the EMR, while the organizational adaptations later mitigate the changes in healthcare quality control resulting from the clinicians’ initial adaptation. Our analysis reflects the critical nature and value of both adaptation types, with an emphasis on the triggers and process of organizational adaptation, for the successful implementation of a socio-technical-political system in a healthcare organization.
- C. Argyris and D. Schon. 1978. Organizational Learning: A Theory of Action Perspective. Addison-Wesley, Reading, MA.Google Scholar
- D. Armijo, C. McDonnell, and K. Werner. 2009. Electronic health record usability: Evaluation and use case framework. Agency for Healthcare Research and Quality, Rockville, MD.Google Scholar
- J. S. Ash, M. Berg, and E. Coiera. 2004. Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. J. Am. Med. Inform. Assoc. 11 (2004), 104--112.Google ScholarCross Ref
- B. Azad and N. King. 2008. Enacting computer workaround practices within a medication dispensing system. Eur. J. Inform. Syst. 17, 3 (2008), 264--278.Google ScholarCross Ref
- S. R. Barley. 1996. Technology as an occasion for structuring: Evidence from observations of CT scanners and the social order of radiology departments. Admin. Sci. Quart. (JSTOR) 31 (1986), 78--108.Google Scholar
- H. Beyer and K. Holtzblatt. 1997. Contextual Design: Defining Customer-Centered Systems. Morgan Kaufmann, San Francisco, CA, 1997. Google ScholarDigital Library
- A. D. Black, J. Car, C. Pagliari, C. Anandan, K. Cresswell, T. Bokun, B. McKinstry, R. Procter, A. Majeed, and A. Sheikh. 2011. The impact of ehealth on the quality and safety of health care: A systematic overview. PLoS Med. 8, 1 (2011), e1000387.Google ScholarCross Ref
- M. C. Boudreau and D. Robey. 2005. Enacting integrated information technology: A human agency perspective. Org. Sci. 16, 1, 3--18. Google ScholarDigital Library
- N. Boulus and P. Bjorn. 2010. A cross-case analysis of technology-in-use practices: EPR-adaptation in Canada and Norway. Int. J. Med. Inf. 79, 6 (2010), e97--e108.Google ScholarCross Ref
- G. Convertino, T. P. Moran, and B. A. Smith. 2007. Studying activity patterns in CSCW. In Proc. CHI2007, ACM, New York, NY, 2339--2344. Google ScholarDigital Library
- R. M. Cyert and J. G. March. 1963. A Behavioral Theory of the Firm. Prentice-Hall, Englewood Cliffs, NJ, 1963.Google Scholar
- C. M. DesRoches, E. G. Campbell, S. R. Rao, K. Donelan, T. G. Ferris, and A. Jha, et al. 2008. Electronic health records in ambulatory care—A national survey of physicians. New Engl. J. Med. 359, 1, 50--60.Google ScholarCross Ref
- John M. Dutton and Annie Thomas. 1985. Relating technological change and learning by doing. In Research on Technological Innovation, Management and Policy, Richard S. Rosenbloom (Ed.), 2, 187--224.Google Scholar
- G. Fitzpatrick and G. A. Ellingsen. 2012. Review of 25 years of CSCW research in healthcare: Contributions, challenges and future agendas. Computer Supported Cooperative Work (CSCW). 22, 4--6, 609--665. Google ScholarDigital Library
- M. E. Flanagan, J. J. Saleem, L. G. Millitello, A. L. Russ, and B. N. Doebbeling. 2013. Paper-and computer-based workarounds to electronic health record use at three benchmark institutions. J. Am. Med. Inf. Assoc. 20, e1, e59--e66.Google ScholarCross Ref
- B. G. Glaser and A. L. Strauss. 1967. The Discovery of Grounded Theory: Strategies for Qualitative Research. Aldine Transaction, New York, NY, 1967.Google Scholar
- S. W. Glickman, K. A. Baggett, C. G. Krubert, E. D. Peterson, and K. A. Schulman. 2007. Promoting quality: The health-care organization from a management perspective. Int. J. Quality Health Care 19, 6 (2007), 341--348.Google ScholarCross Ref
- J. M. Goh, G. Gao, and R. Agarwal. 2011. Evolving work routines: Adaptive routinization of information technology in healthcare. Inf. Syst. Res. 22, 3 (2011), 565--585. Google ScholarDigital Library
- E. Goorman and M. Berg. 2000. Modeling nursing activities: Electronic patient recrods and their discontents. Nurs. Inq. 7 (March 2000), 3--9.Google Scholar
- J. Grudin and L. Palen. 1997. Emerging groupware successes in major corporations: Studies of adoption and adaptation. Worldwide Computing and Its Applications, Lecture Notes in Computer Science Volume 1274. Springer-Verlag, New York, 142--153. Google ScholarDigital Library
- Y. Y. Han, J. A. Carcillo, S. T. Venkataraman, R. S. B. Clark, S. Watson, T. C. Nguyen, H. Bayir, and R. A. Orr. 2005. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 116 (2005), 1506--1512.Google ScholarCross Ref
- J. R. B. Halbesleben, G. T. Savage, D. S. Wakefield, and B. J. Wakefield. 2010. Rework and workarounds in nurse medication administration process: Implications for work processes and patient safety. Health Care Manage. Rev. 35, 2 (2010), 124--133.Google Scholar
- W. R. Hersh. 1999. The electronic medical record: Promises and problems. J. Am. Soc. Inf. Sci. 46, 10 (1999), 772--776.Google ScholarCross Ref
- R. Hillestad, J. Bigelow, A. Bower, F. Girosi, R. Meili, R. Scoville, and R. Taylor. 2005. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Affairs 24, 5 (2005), 1103--1117.Google ScholarCross Ref
- G. P. Huber. 1990. A theory of the effects of advanced information technologies on organizational design, intelligence, and decision making. Acad. Manag. Rev. 15, 1 (1990), 47--71Google ScholarCross Ref
- A. K. Jha, C. M. DesRoches, E. G. K. Campbell Donelan, S. R. Rao, and T. G. Ferris, et al. 2009. Use of electronic health records in U.S. hospitals. New Engl. J. Med. 360, 16 (2009), 1628--1638.Google ScholarCross Ref
- J. M. Juran, A. B. Godfrey, R. E. Hoogstoel, and E. G. Schilling. 1999. Juran's Quality Handbook (5th ed.). McGraw-Hill, New York, NY.Google Scholar
- V. Kaptelinin and B. A. Nardi. 2006. Acting with Technology: Activity Theory and Interaction Design. MIT Press, Cambridge, MA. Google ScholarDigital Library
- C. H. Kepner and B. B. Tregoe. 1976. The Rational Manager: A Systematic Approach to Problem Solving and Decision Making (2nd ed.). Kepner-Tregoe, Inc., Princeton, NJ.Google Scholar
- H. Klein and M. Myers. 1999. A set of principles for conducting and evaluating interpretive field studies in information systems. MIS Quarterly, 23, 1 (1999), 67--93. Google ScholarDigital Library
- M. Kobayashi, S. R. Fussell, Y. Xiao, and F. J. Seagull. 2005. Work coordination, workflow, and workarounds in a medical context. In Proc. CHI 2005, 1561--1564. Google ScholarDigital Library
- R. Koppel, J. P. Metlay, A. Cohen, B. Abaluck, A. R. Localio, S. E. Kimmel, and B. L. Strom. 2005. Role of computerized physician order entry systems in facilitating medication errors. J. Am. Med. Assoc. 293 (2005), 1197--1203.Google ScholarCross Ref
- R. Koppel, T. Wetterneck, J. L. Telles, and B. T. Karsh. 2008. Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association 15, 4 (2008), 408--423.Google ScholarCross Ref
- B. Latour. 2004. Nonhumans. In Patterned Ground: Entanglements of Nature and Culture. 224--227.Google Scholar
- D. Leonard-Barton. 1988. Implementation as mutual adaptation of technology and organization. Res. Policy 17, 5 (1988), 251--267.Google ScholarCross Ref
- P. M. Leonardi. 2011. When flexible routines meet flexible technologies: Affordance, constraint, and the imbrication of human and material agencies. MIS Quart. 35, 1 (2011). Google ScholarDigital Library
- J. Locke and A. Lowe. 2007. A Biography: Fabrications in the life of an ERP package. Organization 14, 6 (2007), 793--814.Google ScholarCross Ref
- C. V. Lukas, S. K. Holmes, and A. B. Cohen, et al. 2007. Transformational change in health care systems: An organizational model. Health Care Manag. Rev. 32, 4 (2007), 309--320.Google ScholarCross Ref
- A. Majchrzak, R. E. Rice, A. Malhotra, N. King, and S. Ba. 2000. Technology adaptation: The case of a computer-supported inter-organizational virtual team. MIS Quart. 24, 4 (2000), 569--600. Google ScholarDigital Library
- Z. Niazkhani, H. Pirnejad, H. van der Sijs, and J. Aarts. 2011. Evaluating the medication process in the context of CPOE use: The significance of working around the system. Int. J. Med. Inf. 80, 7 (2011), 490--506.Google ScholarCross Ref
- L. L. Novak, J. Brooks, S. Anders, N. Lorenzi, and C. S. Gadd. 2012. Mediating the intersections of organizational routines during the introduction of health IT systems. Eur. J. Inf. Syst. 21 (2012), 552--569.Google ScholarCross Ref
- L. L. Novak, R. J. Holden, S. H. Anders, J. Y. Hong, and B.-T Karsh. 2013. Using a sociotechnical framework to understand adaptations in health IT implementation. Int. J. Med. Inf. 82, 12 (2013) e331--e344.Google ScholarCross Ref
- W. J. Orlikowski and J. D. Hofman. 1997. An improvisational model for change management: The case of groupware technologies. Sloan Manag. Rev. 38, 2 (1997).Google Scholar
- W. J. Orlikowski and S. V. Scott. 2008. 10 Sociomateriality: Challenging the separation of technology, work and organization. Acad. Manag. Annals 2, 1 (2008), 433--474.Google ScholarCross Ref
- W. J. Orlikowski. 2009. The sociomateriality of organisational life: Considering technology in management research. Cambridge Journal of Economics.Google Scholar
- S. Y. Park and Y. Chen. 2012. Adaptation as design: Learning from an EMR deployment study. In Proc. CHI 2012. ACM, New York, NY, 2097--2106. Google ScholarDigital Library
- E. S. Patterson, M. L. Rogers, R. J. Chapman, and M. L. Render. 2006. Compliance with intended use of bar code medication administration in acute and long-term care: An observational study. Hum. Factors Ergon. Soc. 48, 1 (2006), 15--22.Google ScholarCross Ref
- L. Poissant, J. Pereira, R. Tamblyn, and Y. Kawasumi. 2005. The impact of electronic health records on time efficiency of physicians and nurses: A systematic review. J. Am. Med. Inform. Assoc. 12 (2005), 505--516.Google ScholarCross Ref
- J. Richardson and J. Ash. 2008. The effects of hands free communication devices on clinical communication: Balancing communication access needs with user control. In Proc. AMIA Annual Symposium, Washington, DC, 621--625.Google Scholar
- N. Rosenberg. 1982. Inside the Black Box. Cambridge University Press, Cambridge, UK.Google Scholar
- J. J. Saleem, A. L. Russ, A. Neddo, P. T. Blades, B. N. Doebbeling, and B. H. Foresman. 2011. Paper persistence, workarounds, and communication breakdowns in computerized consultation management. Int. J. Med. Inf. 80, 7 (2011), 466--479.Google ScholarCross Ref
- A. Tucker and A. Edmondson. 2002. Managing routine exceptions: A model of nurse problem solving behavior. Adv. Health Care Manag. 3 (2002), 87--113.Google ScholarCross Ref
- M. J. Tyre and W. J. Orlikowski. 1994. Windows of opportunity: Temporal patterns of technological adaptation in organizations. Organ. Sci. (1994), 5, 1 (1994), 98--118.Google Scholar
- A. A. Vogelsmeier, J. R. B. Halbesleben, and J. R. Scott-Cawiezell. 2008. Technology implementation and workarounds in the nursing home. J. Am. Med. Inform. Assoc. 15, 1 (2008), 114--119.Google ScholarCross Ref
- S. Wang. 2003. A cost-benefit analysis of electronic medical records in primary care. Am. J. Med. 114, 5 (2003), 397--403.Google ScholarCross Ref
- B. J. Weiner, S. M. Shortell, and J. Alexander. 1997. Promoting clinical involvement in hospital quality improvement efforts: The effects of top management, board, and physician leadership. Health Serv. Res. 32 (1997), 491--510.Google Scholar
- X. Zhou, M. Ackerman, and K. Zheng. 2011. CPOE workarounds, boundary objects, and assemblages. In Proc. CHI 2011. ACM, New York, NY, 3353--3362. Google ScholarDigital Library
Index Terms
- Technological and Organizational Adaptation of EMR Implementation in an Emergency Department
Recommendations
Adaptation as design: learning from an EMR deployment study
CHI '12: Proceedings of the SIGCHI Conference on Human Factors in Computing SystemsWe conducted an observational study in an Emergency Department (ED) to examine the adaptation process after deploying an Electronic Medical Records (EMR) system. We investigated how EMR was adapted to the complex clinical work environment and how ...
Organizational and Environmental Determinants of Hospital EMR Adoption: A National Study
The recent focus on health care quality improvement and cost containment has led some policymakers and practitioners to advocate the adoption of health information technology. One such technology is the Electronic Medical Record (EMR), which is ...
The effect of electronic medical record application on the length of stay in a Chinese general hospital: a department- and disease-focused interrupted time-series study
A key purpose of electronic medical records (EMR) introduced in medical institutions is to improve work efficiency. The average length of stay (LOS) is just an important indicator to evaluate work efficiency of medical care in hospitals. Recently, there ...
Comments