Implementing information systems in health care organizations: myths and challenges

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Abstract

Successfully implementing patient care information systems (PCIS) in health care organizations appears to be a difficult task. After critically examining the very notions of ‘success’ and ‘failure’, and after discussing the problematic nature of lists of ‘critical success- or failure factors’, this paper discusses three myths that often hamper implementation processes. Alternative insights are presented, and illustrated with concrete examples. First of all, the implementation of a PCIS is a process of mutual transformation; the organization and the technology transform each other during the implementation process. When this is foreseen, PCIS implementations can be intended strategically to help transform the organization. Second, such a process can only get off the ground when properly supported by both central management and future users. A top down framework for the implementation is crucial to turn user-input into a coherent steering force, creating a solid basis for organizational transformation. Finally, the management of IS implementation processes is a careful balancing act between initiating organizational change, and drawing upon IS as a change agent, without attempting to pre-specify and control this process. Accepting, and even drawing upon, this inevitable uncertainty might be the hardest lesson to learn.

Introduction

The implementation of comprehensive information systems in health care practices has proved to be a path ridden with risks and dangers. It has become evident that there are many more failure stories to tell than there are success stories—and the more comprehensive the technology, or the wider the span of the implementation, the more difficult it appears to achieve success [1], [2], [3]. It has become equally evident that organizational issues account for many of these difficulties, and that the social sciences have an important contribution to make [4], [5]. It is obvious that inadequate design of an information system (e.g. an inadequate user-interface) or its poor performance (e.g. slow response times) will reduce its chances of being implemented successfully. Yet even in cases of clear-cut technical difficulties, the question whether the implementation is seen as a success or a failure is ultimately not a mere technical matter. In the end, this final decision is about the attachment of the label ‘success’ or ‘failure’ (or anything in-between) to a particular situation. Some health care organizations might decide to muddle through with a given system, or to invest more resources so as to improve the problems perceived to be most problematic; other organizations might, in similar situations, decide to abort the project, and accept their losses. In the end, then, the question whether an implementation has been successful or not is socially negotiated [6], [7], [8].

In addition, organizational issues are key because technical difficulties can be the result of poorly managed development processes. When users are not sufficiently involved in the design process, the user-interface may become illogical from the users’ point of view, for example, or the sequence of actions prescribed by the system may run against the users’ working routines [9]. Or, likewise, some groups of users might have a political agenda embedded in the new system—insight in the working patterns of other groups, for example, or access to another group's information resources. Such agenda's might lead to open conflict with other groups, thus leading to non-use of the system [10], [11]. These small examples illustrate the deep interrelation of technical and social aspects in systems development. Technical problems may have organizational roots, and result in organizational conflicts; a well-functioning system exemplifies a match between the functionalities of the system and the needs and working patterns of the organization.

It is this interrelation that is put central in the sociotechnical approach [4]. In this paper, the issue of successful implementation will be addressed from this perspective. Three myths will be introduced that often underlie implementation failure, but that still seem to be surprisingly alive. Concurrently, alternative and more fruitful viewpoints will be introduced, drawn from the scientific literature on organizational change and technology development, and where possible illustrated with concrete examples. The focus here is on systems that are to be used by health care professionals in the primary care process. Such systems could aim at supporting that process (such as decision support systems), and/or they could aim to ensure a more optimal fit between the primary care process and the secondary work processes that support, manage, investigate, or control it (such as management information systems, resource planning systems, electronic patient records). As a general and admittedly imperfect overall term to address such systems, I will refer to them as patient care information systems (PCIS).

Section snippets

What is a ‘successful’ implementation?

When is a PCIS implementation successful? As stated, in real-life projects, whether an information system is ‘successful’ or not is decided on the workfloor, by the middle management, by top managers—and it is the outcome of all these interactions that in the end settles the system's fate. It is of course also possible to be less relativistic, and to set a success measure outside of an organization's own deliberations (for example, ‘the percentage of professionals using the system for the

Myth 1: PCIS implementation is the technical realization of a planned system in an organization

Overlooking the fact that PCIS implementation will fundamentally affect the health care organization's structures and processes is one core reason for implementation failure [20], [26]. All too often, still, we can hear authors, project leaders or IS professionals speaking about ‘rolling out’ a system, or planning its ‘diffusion’ [3]. Such terminology underestimates that whether it is anticipated as such or not, the implementation of an information system in an organization involves the mutual

Striving for synergy: successful implementation revisited

A proper implementation process, then, attempts to reach a situation as described in Fig. 1. The primary work processes denote all the work that is directly linked to patient care (the central work tasks of doctors, nurses, and other health care professionals). The secondary work tasks consist of the work processes that support, complement and steer the primary care process. This includes the whole gamut ranging from resource management, management of medical equipment, food services, billing,

Conclusion: the challenge

In this paper, it is described how the implementation of a PCIS in health care organizations is a process of mutual transformation. The organization is affected by the coming of this new technology, but the technology is in its turn inevitably affected by the specific organizational dynamics of which it becomes a part. This empirical fact can become highly problematic when IS implementation is seen as a mere matter of ‘diffusing’ a technology, or of merely ‘rolling out’ a technical fix. In such

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