A cross-case analysis of technology-in-use practices: EPR-adaptation in Canada and Norway

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Abstract

Purpose

To identify and characterize enabling factors that support a continuous adaptation of technology and work practices in the health care sector.

Methods

Cross-case analysis of two longitudinal ethnographic studies of managing the gradual adaptation of electronic patient records, one in Canada and one Norway.

Results

The cross-case analysis revealed that technology-in-use practices developed more rapidly in one of the cases, and one of the major driving forces was the establishment of a special committee and the associated project meetings. Based on the literature and grounded in the empirical observations, we complement and expand the notion of project meetings as composed of continuous reflection-on-practice activities to construct technology-in-use practices.

Conclusion

We characterize reflection-on-practice activities as frequent encounters of negotiations of work practices and technology use, providing internal actors a space for systematic evaluation of suggested changes. Further we argue that representatives of the affected professions should not only participate, but also have a mandate to make and evaluate decisions of the technology-in-use practices of the particular group.

Introduction

“The electronic medical record has been pursued as an ideal by so many, for so long, that some suggest that it has become the Holy Grail of Medical Informatics” [1, p. 73].

Health care practitioners spend considerable time on activities such as documenting, archiving, retrieving, distributing, and reporting medical data. Medical data is used by clinicians to get an overview of patients’ medical histories to determine their medical status, and serves as a basis for future treatments and interventions. Patient data have a long history of being written on paper, collected in physical folders and stored in archives [1], [2]. The idea of computerized patient records emerged in the 1960s and 1970s [3], and many attempts have been made with various degrees of success and failures.1 For the last couple of decades, the adaptation of electronic patient records (EPRs2) has been viewed as an immensely important, although highly challenging, task.

Among the prevailing visions for the role of EPRs are goals to use them as management tools that will support care logistics, to redesign work processes, and to improve quality of care [7]. However, the transition to EPRs has turned out to be an unexpectedly long and complex process where many goals have not yet been met [8]. There are many examples of technology adaptation within the health care sector that have fallen victim to myths [4], and underestimate the complexity of implementing such systems [9], [10], [11]. Additionally, the governments of industrial countries such as Canada, the Netherlands, the United Kingdom, and Scandinavian countries use extensive amounts of resources on the implementation of information systems. There is, therefore, an increasing need for more research on the adaptation of technologies in the health care sector. More specifically, there is a need for investigating the great variation of adaptations and changes of work practices within real-life case studies, because these studies can enable rethinking of alternative approaches for managing the complexities of information systems in the health care sector [12].

Embedding technology in a context requires knowledge and understanding of the situated work practices [13]. Situated actions are the actual practices, which are dependent upon the social circumstances. Plans, on the other hand, are representations of actions used as resources for formal description of processes. The situated actions are influenced by, but not equal to, the formal plans. Instead situated actions emerge from the actual situation. Plans and situated actions are highly interlinked; however, when identifying structures of organizations in the process of embedding technology, one should assume that organizational structures are located in the situated actions rather than in the formal plans [13]. Making situated action visible in the process of adapting technology is thus an essential activity. Initial planning of the adaptation process is important; however, one must recognize that it is impossible to predict and fully plan the socio-technical changes and the overall effect of the technology [4], [7], [10]. This unpredictability is due to the emergence of new possibilities and unanticipated patterns of use that are brought along by the new technology [14], [15]. Thus, the impact of a new technology emerges only in use [10], [16].

Adaptation of technology is highly influenced by peoples’ perceptions [6]. Technology-in-use practices comprise people's understandings of the technology-use on a daily basis and the consequences of such use [16]. In adapting technology, people have to reconsider their context-dependent and invisible work practices, since context is highly dynamic and continuously changing, which might lead to success or failure of adaptation [17]. This is a dynamic and reflexive process where the technology is locally shaped and re-invented through situated use; it is an ongoing learning process where people try to configure ways of utilizing the technology [18]. For technology adaptation in the health care context this implies that clinicians should create and continuously renegotiate technology-in-use practices, re-aligning technology and situated actions. Renegotiating technology-in-use practices requires space for reflection-on-action activities. Reflection-on-action refers to the activity in which health care practitioners explicitly reflect on implicit experienced problems and articulate new strategies for actions [19]. Enacting the space for reflection-on-action activities requires health care practitioners to step back from their situated practices and to critically evaluate and reflect upon their technology-in-use practices and, on this basis, construct new technology-in-use practices.

Having access to rich empirical material from two longitudinal ethnographic field studies of managing gradual adaptation of EPRs, one in Canada and one in Norway, we had the unique opportunity to investigate various aspects of technology adaptation in the health sector. Previously we had argued that providing a space for constructing technology-in-use practices is essential for developing and strengthening the interrelations between technology and work practices [20]. Here we will extend this argument by characterizing this important space for continuous reflection-on-action activities. Grounded in empirical observations, we characterize reflection-on-action activities as being ongoing, frequent encounters of negotiations of work practices and technology-use providing internal actors a space for systematic evaluation of suggested changes.

We begin by presenting the method, including research design, empirical cases, data sources, collection, and analysis. This is followed by the results and discussion section, which includes three main subsections building up our argument. Finally, we describe limitations of the study and offer our conclusions.

Section snippets

Research design

The data collection method applied to both research projects was longitudinal ethnography. Ethnographic research seeks to place the phenomenon studied in a wider social context [21], with the primary focus on acquiring rich insights and in-depth understanding of human, social and organizational aspects of the phenomenon [22, p. 4]. Moreover, ethnographic research seeks to develop an understanding of how various aspects influence, and are influenced by, the context [23]. This method is

Identifying technology-in-use practices

We will now describe the adaptation process of the EPR as it proceeded in Case A and Case B, providing in-depth descriptions from our empirical material as to how the technology-in-use patterns developed over time. It is not our intention to determine which case was more successful, after all, the EPR is still in use in both cases. Our intention, rather, is to articulate the initial and emergent technology-in-use practices while identifying the role of the reflection-on-action activities in the

Conclusion

Previous research found that large-scale information systems adaptation in health care should be managed by a project-group including not only IT-developers, but also representatives of future users and management [e.g., 14]. They also found that negotiations of system specifications, as well as organizational changes, should be discussed frequently at project-group meetings [4]. While we also argue for the importance of these meetings, we additionally complement and expand the notion of

Acknowledgements

We are grateful to the Social Sciences and Humanities Research Council of Canada, for their support of the ACTION for Health Research Program, Grant #512-2003-1017, funded through the Initiative for a New Economy Collaborative Research Initiative.

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