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Ripple effect of technological change in organizations
Source publication
The paper reports on the preliminary findings of an in-depth case
study of the implementation of a computerized order entry (COE) system
at a medium sized, acute care hospital. We propose a theoretically
grounded framework, based on work by S.R. Barley (1986; 1990), for
analyzing organizational changes that may result from COE introduction
and use...
Contexts in source publication
Context 1
... changes in the organization occur if changes in social networks and roles are sustained in day-to-day interactions over time. Figure 1 depicts a simplified schematic of what Barley [9] terms a ripple effect of technological change through levels of analysis. ...
Context 2
... changes resulting from COE use [(1) in Figure 1]: Barley [9] posits that organizational roles are bundles of nonrelational and relational tasks and skills, and that changes in technology directly affect nonrelational aspects of roles. New technologies may alter required skills and knowledge, decision-making capabilities and autonomy, or productivity [3] [16], and specific design characteristics of the technology may affect the extent and type of changes that occur. ...
Context 3
... in social networks of roles [(3) in Figure 1]: Technology-triggered changes in interactions at the dyadic level may propagate in shifting patterns of interactions among role sets, for example, when cliques reform, boundaries between sectors of the organization are decreased or increased, or hierarchical status become more or less differentiated [9]. Such shifts are likely when technological change reduces or creates dependencies and alters patterns of supervision in a social network [9]. ...
Context 4
... in organizational structures and institutions [(4) in Figure 1]: Shifts in social networks may sustain existing institutions or modify them, affecting organizational structures such as the degree of centralized or decentralized control or the formality of rules and processes [9]. Introduction of information technology may also heighten the level of organizational control when various forms of control mechanisms (e.g., professional, technological, behavioral, structural) are intertwined in the design and use of an information system [18]. ...
Citations
... [9] Published studies regarding pharmacist workflow change following implementation of CPOE have shown varying and conflicting results. [10][11][12][13][14][15][16][17][18] A literature review of 51 publications regarding the implementation of CPOE found that two articles indicated a decrease in interruptions due to clarifying ineligible orders after implementing a CPOE system, and six studies indicated turnaround time on drug orders was significantly decreased. [10] However, several studies reported workflow interruptions including CPOE system availability, such as system malfunction or system overload during peak times, and numerous issues with human-computer interactions. ...
Objective: Computerized Provider Order Entry (CPOE) is a system that enables physicians to send medication orders electronically rather than physically writing out the order. CPOE can reduce handwriting and transcription related medication errors and has been a major implementation goal for health systems. The objective of this study was to quantify and examine differences seen in the workflow of pharmacists at hospitals, with different levels of CPOE implementation.Methods: An observational, prospective time and motion study was conducted among three hospitals within the same health system: one classified as a non-CPOE system, one as short-term CPOE, and one as long-term CPOE. Pharmacists were observed in one-hour blocks, in which a data instrument was used to record 38 different tasks, which were grouped into four activities: clinical, distributive, administrative, and miscellaneous. The distributive category was further divided into three sub-categories. The average time associated with performing activities across the three hospitals was compared by descriptive and comparative analyses using ANOVAs and the post-hoc Tukey’s range test.Results: A total of 252 hours were collected and 235 met the inclusion criteria. The significant differences in time spent on task categories among hospitals were as follows: Non-CPOE vs. short term CPOE vs. long-term CPOE (mean ± SD in min/h) clinical tasks: (6.55 ± 6.40) vs. (4.95 ± 4.15) vs. (3.79 ± 4.91), respectively, (p < .05); order entry tasks: (29.62 ± 11.24) vs. (17.44 ± 10.73) vs. (10.27 ± 8.88) respectively, (p < .05); order verification tasks: (0.88 ± 1.77) vs. (13.93 ± 8.50) vs. (16.60 ± 9.63) respectively, (p < .05); other distributive tasks: (13.60 ± 10.04) vs. (15.86 ± 8.38) vs. (19.66 ± 8.42) respectively, (p < .05); and miscellaneous: (3.78 ± 4.64) vs. (1.54 ± 3.20) vs. (2.23 ± 3.51) respectively, (p < .05).Conclusions: The presence of a CPOE system could affect pharmacists’ workflow and time allotment on different types of pharmacy activities. Further, the time spent on certain activities was associated with the amount of time the CPOE system was implemented.
... This is particularly relevant for research involving health information systems which have a disruptive ability to change the role communication plays in organisationally linking people and activities across space and time [35]. In this way we believe that organisational communications perspectives can complement, underpin and build on some of the better known approaches such as socio-technical [36, 37] , work- flow [38, 39] and system approaches404142. EEOC draws on rich sources of organisational communication scholarship which have been iteratively assessed and applied to empirical data to establish a novel innovative theoretical tool to inform future research . ...
The purpose of this paper is to illustrate the Elementally Entangled Organisational Communication (EEOC) framework by drawing on a set of three case studies which assessed the impact of new Health Information Technology (HIT) on a pathology service. The EEOC framework was empirically developed as a tool to tackle organisational communication challenges in the implementation and evaluation of health information systems.
The framework was synthesised from multiple research studies undertaken across a major metropolitan hospital pathology service during the period 2005 to 2008. These studies evaluated the impact of new HIT systems in pathology departments (Laboratory Information System) and an Emergency Department (Computerised Provider Order Entry) located in Sydney, Australia.
Key dimensions of EEOC are illustrated by the following case studies: 1) the communication infrastructure between the Blood Bank and the ward for the coordination and distribution of blood products; 2) the organisational environment in the Clinical Chemistry and Haematology departments and their attempts to organise, plan and control the processing of laboratory specimens; and 3) the temporal make up of the organisation as revealed in changes to the way the Central Specimen Reception allocated, sequenced and synchronised work tasks.
The case studies not only highlight the pre-existing communication architecture within the organisation but also the constitutive role communication plays in the way organisations go about addressing their requirements. HIT implementation involves a mutual transformation of the organisation and the technology. This is a vital consideration because of the dangers associated with poor organisational planning and implementation of HIT, and the potential for unintended adverse consequences, workarounds and risks to the quality and safety of patient care. The EEOC framework aims to account for the complex range of contextual factors and triggers that play a role in the success or otherwise of new HITs, and in the realisation of their innovation potential.
... [38] Processes of planning and implementation of CPOE systems need to take into account how the technology will both affect and be affected by the organization in which it is being installed. [39] The formalization of data in ICT systems like CPOE may also create ambiguity and uncertainty [40] because it can dramatically change the information environment in which people work. [41] Data are always produced with a particular purpose, and their specificity and flexibility is likewise customized to suit that purpose. ...
Information and communication technologies (ICT) are contributing to major changes taking place in pathology and within health services more generally. In this article, we draw on our research experience for over 7 years investigating the implementation and diffusion of computerized provider order entry (CPOE) systems to articulate some of the key informatics challenges confronting pathology laboratories. The implementation of these systems, with their improved information management and decision support structures, provides the potential for enhancing the role that pathology services play in patient care pathways. Beyond eliminating legibility problems, CPOE systems can also contribute to the efficiency and safety of healthcare, reducing the duplication of test orders and diminishing the risk of misidentification of patient samples and orders. However, despite the enthusiasm for CPOE systems, their diffusion across healthcare settings remains variable and is often beset by implementation problems. Information systems like CPOE may have the ability to integrate work, departments and organizations, but unfortunately, health professionals, departments and organizations do not always want to be integrated in ways that information systems allow. A persistent theme that emerges from the research evidence is that one size does not fit all, and system success or otherwise is reliant on the conditions and circumstances in which they are located. These conditions and circumstances are part of what is negotiated in the complex, messy and challenging area of ICT implementation. The solution is not likely to be simple and easy, but current evidence suggests that a combination of concerted efforts, better research designs, more sophisticated theories and hypotheses as well as more skilled, multidisciplinary research teams, tackling this area of study will bring substantial benefits, improving the effectiveness of pathology services, and, as a direct corollary, the quality of patient care.
... Various opinions were given by doctors regarding the effect of computerized DOE for instance task alteration performed by physicians to issue medical orders slower than handwriting orders (Cusack, 2008), on the other hand, Foster and Connelli (2002) cited that the reduction in time of retrieving information. Another opinion is that the use of the system tends to limit and direct physician's choice of medication and procedure (Davidson, 1999). Thus, there are pros and cons situation regarding the implementation of computerized DOE. ...
Drug Order Entry (DOE) is one of the most important components in Electronic Medical Records System (EMR). Doctor's appropriate order of drugs via DOE is very important to reduce consultation hour per patient and medical errors. Keystroke-Level Model (KLM) was employed to estimate the doctor's quickness and effort while performing DOE at two public hospitals in Malaysia. Observation method was used in this study. The results showed that the proposed scenario represents the DOE behaviours well, and confines to the doctor's workflow, easy to be understood and navigated, hence increases the efficiency of the EMR, reduce medical errors, and increases the acceptance level of the system.
... This finding reinforces that of other researchers in this field who have described the multilayered and collaborative character of the ordering process 11 and have strongly recommended that new information systems be designed to facilitate these collaborative relationships and be supported by negotiation between different hospital departments. 12 Three areas are highlighted where CPOE's role can affect (either positively or negatively) the blood bank's contribution to the safety and effectiveness of patient care. These are (1) information storage and retrieval; (2) robust communication channels; and (3) safety and quality of patient care. ...
The introduction of computerized provider order entry (CPOE) systems is associated with major changes in work processes. Implementation strategies need to consider how the technology will affect and be affected by the organization in which it is being installed. The aim of this study was to examine the potential effect of the introduction of a CPOE system on key work processes in a hospital blood bank by using qualitative data from focus groups, interviews, and participant observation and quantitative data of telephone communication. We found that work practices in the blood bank are made up of a mosaic of collaborative processes underpinned by communication channels to facilitate safe and efficient work practices. The introduction of CPOE systems requires consideration of these channels and of the ways that CPOE may disrupt existing communication processes. There needs to be high levels of staff preparedness to minimize patient risk and optimize performance.
... However, the rise in the volume of telephone calls beginning with the introduction of the new results reporting system (November 2005) followed by the new order entry system (January 2006) suggests that the phone was used heavily by clinicians as a means of monitoring the status of test requests. This may have been a transitory phenomenon associated with unfamiliarity of the new system [7]. Regular monitoring of the situation using the metrics outlined in this study can answer this question. ...
Organisational communication perspectives provide a framework for examining the impact of new Computerised Physician Order Entry (CPOE) systems on health care organisations. The aim of this study was to utilise performance metrics (volume of telephone/fax calls and the management of unfulfilled test requests) as a way of monitoring the impact of a new CPOE system on the communication (synchronous and asynchronous) interface in the Central Specimen Reception (CSR) area of a pathology laboratory service. The total number of outgoing and incoming calls rose considerably after the implementation of the new system. The number of unfulfilled test requests initially increased in the implementation period and thereafter fell to below pre-implementation levels. There were significant differences in the relative proportion of duplicate (69%-35%) and rescheduled requests (4%-24%) between the pre- and post-periods. Performance metrics, can be relevant for measuring and monitoring changes in communication processes. This is important with CPOE systems whose introduction can have unexpected consequences requiring early detection and action.
... This is because they confront, on a smaller scale, many of the same data-handling questions faced in the hospital-wide setting [17,18]. Some early work in the area of Information and Communications Technologies (ICT) evaluation focused on ancillary hospital departments like pathology laboratories or radiology to explore how computer systems can be catalysts for new interactions between departments and healthcare organizations [17,192021. These approaches were strongly motivated by a concern about the lack of research into how computer systems affect the nature and definition of jobs and the work process [17,22,23]. ...
... Change in how departments deal with issues is to be expected. Previous studies have noted that problems confronted by CPOE can be transitory and may decrease with greater experience and knowledge202122. Time is also a crucial element in user acceptability. ...
... It also threatened the boundaries between different occupational communities and contributed to dysfunctions and altered work practices and relationships. Several researchers have emphasized the ability of CPOE systems to replace previous communication channels with new, often poorly understood channels, in some cases creating ambiguity and uncertainty about order information [21,43,50] . Recent trends expressed within international informatics literature point to the potential value of numerous electronic tools including mobile computing devices, such as Personal Digital Assistants (PDAs) [51] , and silicon chip technol- ogy [52] to better manage labelling and time stamping procedures within hospitals, possibly overcoming the dysfunctions reported in this study. ...
The purpose of this study was to identify the key implications of the implementation of a computerized physician order entry (CPOE) system on pathology laboratory services.
An in-depth qualitative study using observation, focus groups and interviews with pathology staff, managers, clinicians and information systems staff during implementation of a CPOE system in 2004 at a major Australian teaching hospital.
Pathology laboratories experienced a shift in their work roles resulting in altered work practices, responsibilities and procedures. These changes were marked by terminological and procedural changes in the test order process from when clinicians issued a request for a test, to the new system that established clinical orders at the point of care. This change was accompanied by some organizational dysfunctions including the emergence of a new category of "frustrated" orders without specimens; problems with the procedure of adding tests to previously existing specimens; the appearance of discrepancies in the recorded time of specimen collection. In response to these changes, hospital and pathology staff adopted a variety of means to cope with their changed circumstances. These ranged from efforts to increase clinical awareness to compensatory laboratory workarounds and enforced rule changes.
CPOE systems can have a major impact on the nature of the work of pathology laboratories. Understanding how and why these changes occur can be enhanced through considering the organizational and social contexts involved. The effectiveness of CPOE systems will rely on how administrators and staff approach and deal with these challenges.
... If realised, these benefits would logically lead to improvements in patient outcomes, as well as major cost efficiencies. CPOE systems are an integral part of hospital information systems and constitute an important building block for the establishment of the electronic medical record [2,7,15]. For these reasons, CPOE systems have been strongly promoted in the United States, Europe and Australia as a means of improving the quality of care, reducing errors and increasing efficiency in health care delivery16171819202122. ...
... In today's environment, it is the " off the shelf " system that has the potential for wide application [66]. This is particularly as CPOE is more than just a niche computer system replacing handwritten orders, but has direct impact on the entire hospital-wide process of order management [3,16] and is a critical component of the electronic medical record [15]. This review found a number of areas of impact studied across the different stages of the pathology process. ...
Computerised physician order entry (CPOE) systems hold the promise of significant improvements to health care delivery and patient care. The implementation of such systems is costly and complex. The purpose of this paper is to review current evidence of the impact of CPOE on hospital pathology services.
This paper presents a review of the literature (1990-August 2004) about CPOE systems and identifies indicators for measuring the impact of CPOE on pathology services.
Nineteen studies which contained some form of 'control' group, were identified. They featured a variety of designs including randomised controlled trials, quasi-experimental and before and after studies. We categorised these into three groups: studies comparing pathology CPOE systems (with no decision support) to paper systems; pathology CPOE systems (with decision support) to paper systems; and pathology CPOE systems with specific pathology features compared to systems without those features. We identified 10 areas of impact assessment and 39 indicators used to measure the impact of CPOE on different stages of the pathology test ordering and reporting process.
We conclude that while some data suggest that CPOE systems are beneficial for clinical and laboratory work processes, these data are limited, and further research is needed. Few data are available regarding the impact of CPOE on patient outcomes.
... Computerised Provider Order Entry (CPOE) systems pose major challenges for hospital pathology laboratories [1], with important implications for a range of laboratory processes including inter-department functions, work organisation and laboratory effectiveness [2][3][4][5]. CPOE systems provide clinicians with the ability to enter orders directly into a computer [6]. ...
The aim of this multi-method study based at a microbiology department in a major Sydney metropolitan teaching hospital was to: i) identify the role that information and communication processes play in a paper-based test request system, and ii) examine how these processes may affect the implementation and design of Computerised Provider Order Entry (CPOE) systems. Participants in this study reported that clinical information can impact on the urgency and type of tests undertaken and affect the interpretation of test results. An audit of 1051 microbiology test request forms collected over a three-day period showed that 47% of request forms included clinical notes which provide a variety of information often vital to the test analysis and reporting process. This transfer of information plays an important role in the communication relationship between the ward and the laboratory. The introduction of new CPOE systems can help to increase the efficiency of this process but for that to be achieved research attention needs to be given to enhancing the provision and communication of clinical information.
... One misconception is that IT expenditure drives successful healthcare operations. (Davidson andChismar 1999, Davidson 2000). A higher intensity of IT usage may require a radical change in organization (Scott Morton 1991). ...
... One misconception is that IT expenditure drives successful healthcare operations. (Davidson andChismar 1999, Davidson 2000). A higher intensity of IT usage may require a radical change in organization (Scott Morton 1991). ...
Information Technology (IT) is an important enabler in supporting the growing demand for healthcare services and the growing complexity of healthcare services. IT is also a cost driver of importance in healthcare services; hospitals spend an estimated 3% of their annual revenues on IT. These factors make that IT expenditure is of strategic importance to local and national healthcare policy makers. This paper addresses the question often raised by hospital management; how much do we spend on IT and on what do we spend it? An analysis of the expenditure of IT of a Dutch hospital (1996-2005) gives an insight usable as a reference for other hospital management and Information System researchers on how to approach IT expenditure evaluation. The discussion generates important issues for further research in IT expenditure in healthcare services.
