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Justifying Health IT Investments:
A Process Model of Framing Practices and Reputational Value
Stavros Polykarpou*
Judge Business School, University of Cambridge, Cambridge CB1 2AG, United Kingdom
Corresponding author: sp745@jbs.cam.ac.uk
Michael Barrett
Judge Business School, University of Cambridge, Cambridge CB1 2AG, United Kingdom
m.barrett@jbs.cam.ac.uk
Eivor Oborn
Warwick Business School, University of Warwick, Coventry CV4 7AL, United Kingdom
eivor.oborn@wbs.ac.uk
Torsten Oliver Salge
School of Business and Economics, RWTH Aachen University, Aachen 52072, Germany
salge@time.rwth-aachen.de
David Antons
School of Business and Economics, RWTH Aachen University, Aachen 52072, Germany
antons@time.rwth-aachen.de
Rajiv Kohli
Raymond A. Mason School of Business, The College of William and Mary, VA 23187-8795,
U.S.A.
rajiv.kohli@mason.wm.edu
Highlights
● We develop a performative framing framework to unpack how temporally oriented
practices are consequential in performing different health IT value possibilities.
● We study how practitioners at two hospital organizations facing different reputational
circumstances justified HIT reputational value.
● We highlight how reputational value is performed in different ways, through the
ongoing process of justifying HIT investments.
● We contribute a process model of how value justifications are enacted through
temporally oriented framing practices informed by the past, but also oriented toward
the future and the present.
Abstract
Despite important research contributions on the financial and operational dimensions of
information technology (IT) value, justifying health IT (HIT) investments remains a difficult
and enduring issue for IT managers. Recent work has expanded our understanding of HIT
value, by focusing on the initial resource allocation stage, and through conceptualizations of
value across multiple dimensions. Building on these developments, we adopt a performative
perspective to examine the research question of how practitioners justify early stage HIT
investments, with a focus on reputational value. We explored this question through a
comparative field study of two hospital organizations in the English National Health Service
(NHS). We found that practitioners’ temporally orientated framing practices matter in
justifying HIT investments, enacting different possibilities for reputational value. We develop
a process model to explain these dynamics and highlight the mutability of reputational value,
which can lead to different possibilities for restoring, enhancing, or maintaining reputation. We
conclude by discussing the implications for justifying HIT investments.
Keywords: IT business value; IT investments, Health IT; health care; value; case study;
reputation; framing practices; performativity
1. Introduction
For more than two decades, information technology (IT) value research has made important
contributions to a fundamental topic in our field, namely how organizations justify and create
value from IT investments (Agarwal & Lucas, 2005; Kohli & Grover, 2008). The dominant
and enduring stream of literature in this domain has focused primarily on justifying value
through a one-off and largely static outcome, by explicating and measuring operational and
financial value dimensions of IT (Melville, Kraemer, & Gurbaxani, 2004). Further, the
approach taken has been predominantly to assess the value of IT investments post hoc - in other
words, after the investments have been made. In healthcare this is problematic as practitioners
have historically faced great pressures in justifying health IT (HIT) investments, where
institutional pressures are at work. For example, research in the UK’s National Health Service
(NHS) has highlighted institutional pressures associated with the introduction of a national
program for IT between 2002 and 2012 in the UK’s NHS (Currie 2012; Currie & Guah, 2007;
Mark, 2007). While there are indications that HIT investments pay off (Ayabakan, Bardhan &
Zheng, 2017; Lin, Chen, Brown, Li, & Yang, 2017) this is neither certain (Davidson &
Chiasson, 2005) nor short-term (Schryen, 2013), thus making HIT investments hard to justify
and to appropriately assess.
Recent work has emphasized the need to expand our understanding of the HIT investment
process by focusing on the initial resource allocation stage (Salge, Kohli, & Barrett, 2015) and
by exploring and the multidimensional nature of IT value (Barrett, Oborn, & Orlikowski, 2016;
Tempini, 2017) as an important complement to the dominant view of value. In particular,
relating economic and operational notions of value to other dimensions has formed a stronger
basis for understanding the importance of value as a concept (Stark, 2009). We know, for
example, that HIT investments can provide multiple forms of value for different stakeholders,
such as reputational, epistemic and platform value among others (Barrett et al., 2016) and that
these develop in a nonlinear and contingent trajectory (Tempini, 2017). Yet, while these studies
have provided important contributions, by examining how HIT investments provide
opportunities for value creation along multiple dimensions, our understanding of how
investments are justified in practice during the allocation stage is largely an incomplete task.
The purpose of this paper is therefore to respond to a call for a broader HIT research agenda
that moves beyond examining operational and financial performance post-hoc, towards
exploring how HIT investments can enhance social goals, such as reputation – an intangible
asset reflecting multidimensional evaluations held among stakeholders (Ravasi, Rindova, Etter
& Cornelissen, 2018), at the allocation stage (Salge et al., 2015). Healthcare practitioners are
justifying HIT investments for reputational value that arises from the general social approval
of various stakeholder groups (Rindova, Williamson, Petkova, & Sever, 2005), which in turn can
influence operating autonomy, access to financial resources, and help in securing future patient
referrals (Scott et al., 2000). For these reasons, we shift to a proactive approach to examine
how healthcare practitioners are framing and evaluating HIT investments with a broader social
focus on reputational value. We therefore examine the research question how do practitioners
justify HIT investments, and how are these justifications consequential for enacting
reputational value?
To address our research question, we present findings of two case studies at hospital
organizations facing different reputational circumstances. The first hospital provided the
opportunity of studying how practitioners were restoring reputation with HIT, following a
regulatory inspection failure. In contrast, the second hospital enjoys a leading reputation both
nationally and internationally for high quality patient care, which practitioners were aiming to
reproduce and enhance going forward. Our paper makes two key contributions. First, we
develop a process model that unpacks how practitioners justify HIT investments through
framing practices. Responding to Davidson’s (2006) call, we develop a performative
perspective on framing practices, by which justification of HIT investments is accomplished.
We find that temporally oriented framing practices in terms of time horizon (short or long term)
and value seeking approach (reactive or proactive), enact different possibilities for reputational
value. We conceptualize framing practices as performative in that they involve both the
creation and emergence of different aspects of value, informed by the past, but also oriented
toward the future and the present. Second, we highlight how the justifying of HIT investments
is an ongoing process which enacts reputational value that is nevertheless mutable over time, with
implications for how reputation is restored, enhanced, or maintained. In the following section, we
review different perspectives on justifying IT investments, such as the initial IT allocation stage,
and motivate our theoretical and empirical focus on reputational value. This is followed by our
theoretical basis which develops a performative HIT value perspective.
2. Perspectives on justifying HIT investments
2.1. Examining the initial IT allocation stage
There is considerable literature in general IT and HIT (Grover & Kohli, 2012; Kohli & Devaraj,
2003; Melville et al., 2004) that focuses on the importance of examining the process of investing
in IT. Scholars have examined, for example, IT adoption (Agarwal et al., 2010; Jha et al., 2009),
IT usage (Devaraj & Kohli, 2003; Melville et al., 2004), and IT value appropriation (Davidson &
Chismar, 2007; Oborn, Barrett, & Davidson, 2011), thereby justifying the value of IT investments.
However, studies in this research stream tend to treat IT investments as “given”, unitary and
unchanging, with the primary emphasis placed on evaluating the consequences of IT investments.
Recent work by Salge et al., (2015) has expanded the process spectrum of IT investment research
to encompass the initial allocation stage, during which senior managers decide how and how much
of the organization’s scarce financial resources may be allocated to the IT function, in the face of
competing priorities (Xue, Liang, & Boulton, 2008). Their study reveals that intended performance
improvements are only just one of several reasons why hospitals invest in HIT. They conclude by
calling for a broader HIT research agenda that moves beyond examining clinical and economic
performance as important dimensions, towards exploring how HIT investments can enhance social
goals such as reputation (Bitektine, 2011).
Reputation has been defined as an impression widely received, which represents public cumulative
judgments over time (Fombrun, 1996; Hall, 1992; Rao, 1994). Organizational reputation is an
important form of social approval and a critical intangible resource of competitive advantage that
can facilitate access to customers, employees, suppliers, or finance (Deephouse, 2000; Fombrun &
Shanley, 1990; Lange, Lee, & Dai, 2011; Ravasi et al., 2018). Multiple studies show the importance
of reputation for organizations as a valuable strategic resource, leading to positive economic
outcomes such as financial performance (Roberts & Dowling, 2002) and the ability to charge
premium prices (Fombrun & Shanley, 1990; Rindova et al., 2015). Reputation is critically
important for organizations in general (Podolny, 2005) and hospitals in particular (Scott et al.,
2000). For example, hospitals today operate in a highly regulated field (Agarwal, Gao, DesRoches
& Jha, 2010; Scott, Ruef, Mendel, & Caronna, 2000) and rely on the endorsement of multiple
external stakeholders, including the Department of Health, regulatory bodies such as the Care
Quality Commission, patient advocate groups and the media to operate. All these stakeholders are
constantly assessing hospitals and HIT enabled care in the form of patient feedback, national audits,
quality inspections and news stories, respectively (Ruef & Scott, 1998). Therefore, reputation is
essential for hospitals in our digital era. Overall, the IT resource allocation decisions and their
underpinning justifications are a crucial and emerging area of research for holistically
understanding the value of HIT across a wide range of economic and social goals, especially
reputation.
2.2. Realizing multiple value dimensions
The broadening of the HIT value literature aligns with key themes in the emerging stream of
information systems research that examines multiple dimensions of value. For example, Barrett,
Oborn, & Orlikowski (2016) examine multiple forms of value being enacted in an online healthcare
community. Drawing from the sociology of worth literature (Boltanski & Thévenot, 2006; Stark,
2009), they conceptualize valuation processes as shaped by encompassing regimes of worth that
enact multiple kinds of value such as financial, epistemic, ethical, service and reputational value.
Similarly, Tempini (2017) builds on and develops a multidimensional value framework to examine
business value, scientific value, community value and individual value, all of which had different
informational value depending on situated use.
By taking these insights into account, we are interested in elaborating theory as to how practitioners
justify and enact multiple dimensions of reputational value. Reputational research shows that IT
can provide other value, such as organizational survival and social fitness (Lim, Stratopoulos, &
Wirjanto, 2013). For instance, Wang (2010) found that following IT fashions – “the transitory
collective belief that an IT is new, efficient, and at the forefront of practice” (p.64), can improve
organizational reputation, even in the absence of performance improvement. Although these studies
have crucially expanded our understanding of value that IT investments can provide, they largely
view value as a one-off, static outcome. That is, reputational value is conceptualized as either the
intrinsic property of IT, or the preferences of the evaluative audiences. This is problematic because
reputation is a multi-dimensional concept (Boutinot, Ansari, Belkhouja, & Mangematin, 2015;
Lange et al., 2011) and multiple reputational assessments may change over time. In this paper we
unpack how senior healthcare practitioners allocate various possible forms of reputational value
into their HIT investment justifications. We do so by considering how the various stakeholders are
framing HIT investments.
3. Theoretical framework: Towards a performative perspective of framing HIT investments
We devise a theoretical framework that conceptualizes HIT value as performed through framing
practices. As such, in examining how HIT investments are justified, we pay attention to the way in
which justifications are accomplished, and how HIT value is constituted through framing practices.
We identify the practices that are constitutive of, and implicated in, performing shared
understandings of justifying HIT investments. In so doing, we conceptualize the phenomenon of
value as fluid and enacted in the doings of organizational actors (Feldman & Orlikowski, 2011).
The performativity turn is comprised of a diverse body of foundational approaches and generative
theories for studying diverse phenomena across disciplines. The performative turn is unified in
arguing that realities (including objects/subjects) and representations of these realities are being
enacted or performed simultaneously. In other words, and to paraphrase Strum & Latour (1987),
phenomena (in our case reputational value) are continuously constructed through the heterogeneous
efforts to define them in practice.
3.1. Framing HIT Value
Organizational members’ frames “concern the assumptions, expectations, and knowledge they use
to understand technology in organizations” (Orlikowski & Gash, 1994, p. 178). More broadly,
scholarship on framing (Barrett, Heracleous, & Walsham, 2013) has identified several aspects of
framing practices that are important, based on the literature on social movements (Benford & Snow,
2000) and computerization movements (Iacono & Kling, 2001; Kling & Iacono, 1995). These and
other studies have highlighted the importance of a processual view of technological framing. For
instance, Davidson (2002) developed business value of IT frame domains which were concerned
with members’ understanding of how IT could be used to alter business processes and relationships.
By doing so, Davidson contributed by providing a process model that draws attention to the
dynamics and possible consequences of frame shifts.
Our perspective uses framing practices, which concern the material and discursive manner by
which justifications are accomplished, with an orientation of accounting for how justification is
done in practice. This implies framing practices are routinely made and remade in practice and are
consequential to shared understandings of reputational value. The concept of performative framing
is related to Davidson’s (2006) call to IT researchers to focus on the dynamic aspects of the framing
process. That is, framing practices are performative in that they involve both the creation and
emergence of different aspects of value. In our case this helps us unpack the multiplicity of how
reputational value can be enacted, rather than assuming a priori value singularity. For instance,
ongoing framing practices may make evident the diverse aspects of reputational value.
3.2. Temporally Performing HIT Justifications
Further, our performative perspective allows us to take seriously the role of temporality (Emirbayer
& Mische, 1998; Langley, Smallman, Tsoukas & Van de Ven, 2013; Reinecke & Ansari, 2017) in
the process of justifying HIT investments. As Emirbayer & Mishe argue (1998), agency is a
temporally embedded process informed by the past, but also oriented toward the future and toward
the present. In other words, acting in the present is extended and overlapping with our ability to
imaginatively construct a sense of the past and the future. Following these process insights
(Langley & Tsoukas, 2017), our framework examines how temporal orientations – the
interpretations and invocations of time horizons (short or long term) and value seeking approaches
(reactive or proactive) - influence how reputational value is framed in the process of justifying HIT
investments. Specifically, we link the reactive value seeking approach to the short-term time
horizon, which tends to be focused more towards the past and the present. On the other hand, a
proactive value seeking approach tends to be focused on the future and the present. However, these
are not universal truths and do not preclude the potential for a temporal orientation having a broader
focus at particular times and situations.
As illustrated by Kaplan & Orlikowski (2012), people are engaging in multiple interpretations that
help constitute projections into the future, such as the short term or long term, and we draw on this
to suggest how these might link to reputation. In other words, we pay attention to how healthcare
practitioners are justifying HIT investments and what difference the time horizon and value seeking
approach have in framing reputational value. Finally, and relatedly, we conceptualize reputational
value as not a one-off outcome; rather, value dimensions are viewed to be mutable over time.
In summary, we develop a performative understanding of the framing practices used to justify HIT
reputational value, in that we theorize how temporal orientations grounded in value seeking
approaches (reactive or proactive) and time horizons (short or long term) were continually
performing multiple aspects of HIT reputational value.
4. Methods and data sources
We followed an inductive research design and adopted an interpretive approach (Golden-Biddle &
Locke, 2007; Walsham, 1993), starting from an interest in how organizational participants engaged
in framing practices when justifying HIT reputational value. Informed by a process approach
(Langley, 1999), we collected data at two different hospitals, which are both members of a common
health group we call Alpha Health Partners (AHP).
4.1. Research context
Our two cases offer different dynamics in relation to our research question, which provided fertile
ground for examining framing practices for justifying HIT investments. AHP1 provides mental
health and specialist community services to more than 755,000 people across the country. With
annual income of more than £150 million, AHP1 employ 2,500 people across 75 sites. They service
children, adolescents, adults, older people, as well as provide specialist forensic and learning
disability services. AHP1 provided the opportunity of studying how the hospital organization was
restoring reputation with HIT, following a regulatory inspection failure. During their usual hospital
regulatory audit, the regulators issued a warning which placed the hospital under pressure to restore
and repair their reputation. In contrast, AHP2 enjoys a leading reputation both nationally and
internationally for its services and for high quality patient care. AHP2 is a specialist hospital that
provides care to approximately 3 million people. During the time of our study, AHP2 was justifying
HIT investments as part of major move to a new hospital site, to replace their outdated building
and infrastructure, which was constricting their ability to grow and develop the way they
envisioned. A major part of this move was a business transformation program they called eHospital,
which is a combination of IT infrastructure, handheld devices and a fully integrated electronic
medical record system (EMR), defined as the digital repository of patient data that is shareable
across stakeholders (Angst et al., 2010).
4.2. Data collection
We collected data from a variety of sources over a period of 3 years, including site visits,
observations during meetings, formal interviews, informal discussions, and publicly available
documents. First, we engaged with AHP1 before, during and after their regulatory inspection by
the care quality commission (CQC). We conducted 14 semi-structured interviews to better
understand a) the situation they were facing, b) the future requirements of mental health, as part of
their digital strategy, and c) how they were justifying HIT investments and implementing these
investments in practice. The interviews were conducted on-site in 2014, with participants from a
diverse range of backgrounds, different hierarchical levels and service provisions (chief executive
officer, chief nursing officer, chief pharmacist, nursing, medical and finance directors, nursing
manager, patient lead, nurse matron, deputy finance executive, clinical psychologist, consultant
psychiatrist, psychology lecturer, audit and governance manager). Subsequently, we had the
opportunity to engage with the technology director at AHP2, who was keen to collaborate with us.
Similar to AHP1, we conducted 13 semi-structured interviews on-site between 2015 and 2016, with
participants from a diverse range of backgrounds (operations and service improvement directors,
senior level managers of communications, change, IT and radiology, transplant consultant,
consultant cardiologist, consultant physician, consultant anesthetic, transplant matron, clinical lead
for eHospital, and a nurse lead - eHospital coordinator). Across both cases, our interviews provided
multiple understandings and accounts of the framing practices used and allowed us to examine not
only how management were framing HIT investments, but also how HIT was implemented by staff
on the ground. The interviews varied in length, ranging from 35 to 120 minutes. All interviews
were digitally recorded and subsequently professionally transcribed, verbatim.
Our interview questions focused on understanding the practices through which our organizational
participants were justifying HIT investments and how they were implemented, given their
circumstances in the context of their work. For example, we asked how they were using different
types of HIT to complete their work, how they envisioned HIT would provide value in the work
setting. In addition, we collected and analyzed secondary data sources. These included informal
chats, internal documents (e.g. operational, strategy and annual reports, presentations, newsletters,
images,) as well as archival and documentary data (e.g. healthcare commissioning guidelines,
regulator reports including hospital performance intelligence monitoring guidelines, and hospital
rankings), leading to a database of 85 documents.
4.3. Data analysis
Our analysis followed the general procedures of process analysis (Langley, 1999) to expand our
understanding of how healthcare practitioners were justifying HIT investments. Throughout all the
different stages of analysis, we used Atlas.ti, a qualitative data analysis software package, to create
an integrated database. This facilitated the generation of rich memos and open codes across the two
cases, as well as the development and tracking of coding categories.
The first cycle of analysis involved a narrative strategy, where we constructed a detailed narrative
for each case based on our interview transcripts, hospital annual and regulator reports and internal
documents (Langley, 1999). Subsequently, we performed open coding (Charmaz, 2014) to unpack
the framing practices used in justifying HIT investments. To do so, we engaged in within-case
analysis to become familiar with each case, enabling us to write further detailed narratives for each
case, based on extensive theoretical memos on our emerging findings. To keep track of the
unfolding analysis, we compiled an event-history database in Atlas.ti throughout the fieldwork.
This enabled the unique patterns of each case to emerge in terms of temporal framing practices,
before we attempted to apply insights across the cases, facilitating familiarity and accelerating the
cross-case comparison. It is important to note that the importance of framing practices emerged as
a key theme in justifying HIT investments across both our cases, and this reinforces the significance
of our research design in studying both cases.
In a second cycle of analysis, we identified how these framing practices, within and across our
cases, were performing shared understandings of HIT value, with a focus on our inductive data
around reputational value. In this round of analysis, we iterated among the in-depth analysis of each
case, comparing across cases, and connections to the literature (Barrett et al., 2016; Kornberger,
2017; Tempini, 2017), which drew our attention to other salient issues emerging from the data that
were unexplored. For example, while we connected the framing practices to HIT reputational value,
we also realized the importance of different temporal orientations found within each case, in terms
of the time horizon.
Having recognized this opportunity, and during a third round of analysis, we examined the temporal
orientation of each of the practices we identified in round two, following our theoretical framework.
While our sensitivity around time horizon was theoretically driven, the analysis of the framing
practices in terms of reactive or proactive value seeking approach was grounded in our data. In
this round of analysis, we traced and explained the performative dynamics of how temporal
orientations mattered when enacting framing practices in the ongoing justifying of HIT
investments. This allowed us to categorize the framing practices practitioners used at AHP1 and
AHP2 as helping to overcome issues of the past, resolving present issues, whilst being oriented
towards the future. For example, the aggregate dimension of “overcoming the past” refers to the
practices anchored in solving past problems, “present issues” provides the tactical practices
anchored in short-term horizons, and finally, we categorized strategic practices anchored in long-
term horizons under the dimension of “towards the future”. Figure 1 shows how we categorize the
practices under the temporal aggregate dimensions and according to short/long term horizon as
well as reactive/proactive value seeking approach.
------------------------------Insert Figure 1------------------------------
Additionally, we paid attention to how framing practices were invoking multiple value aspects and
stakeholders, such as convincing regulators during inspections, improving relations with
commissioners, hospital staff, general practitioners (GPs), patients and other referring hospitals.
This allowed us to develop a performative understanding (MacKenzie & Millo, 2003) of how
practitioners were using framing practices in the process of justifying HIT reputational value at
AHP1 and AHP2. We theorize how temporally oriented framing practices informed by the past but
also oriented toward the present and future issues were justifying multiple HIT reputational value
aspects, invoking different stakeholder groups.
5. Findings and Analysis
We present our findings for each case separately. We begin by describing the circumstances facing
each of our hospital organizations, which are consequential for the temporally oriented framing
practices performed by the senior managers and practitioners. We then show how framing practices
at AHP1 and AHP2 were used in performing different justifications of HIT reputational value.
Finally, drawing on these empirical findings across our cases, we conclude our empirical analysis
by synthesizing our findings in a general process model of framing practices and reputational value
in justifying HIT investments in healthcare.
5.1. AHP1: Restoring reputation through HIT
To understand how practitioners at AHP1 enacted their temporally oriented framing practices for
reputational value, it is necessary to examine the pressures they faced and their ensuing temporal
orientation. In 2011, the care quality commission (CQC)– the independent regulator of health and
social care in England, found AHP1 to be failing to meet the five essential standards during its
annual compliance review process. CQC inspects hospitals to establish whether their services are
safe, effective, well led, responsive to people’s needs, as well as whether staff is caring. By
exercising its legal right, the regulator demanded action from AHP1 to conform to effective care
quality and patient safety standards. Following the specification of this major organizational failing,
AHP1 practitioners were justifying HIT investments using both short-term and long-term time
horizons, as well as reactive and proactive value seeking approaches, to quickly implement HIT
that would help them restore their reputation, but also help them proactively appeal to different
stakeholder groups, respectively. Figure 2 summarizes our empirical findings and structures our
analysis, while table 1 provides additional evidence for the time horizon and value seeking
approach of the temporally oriented framing practices.
-------------------------------Insert Figure 2------------------------------
------------------------------ Insert Table 1 ------------------------------
5.1.1. Overcoming the past: Crafting urgency for restoring reputation with HIT
The failure to meet the regulatory compliance standards by CQC, led AHP1 senior managers and
directors to justify HIT investments as urgently needed for collecting, storing, and visualizing data
to CQC in an accessible manner. Their aim was to improve the quality, safety and effectiveness at
the point of care delivery. A nurse matron responsible for implementing this HIT reflected on this
process:
“There was just this mad rush for everything, everything you know to do with IT, where we can
make these dashboards, make everything very visual so it is at a glance, everything was red, green
or amber, nobody wanted to attract a red. Red was like blood, animal pack attack. You know not a
pretty picture”.
Furthermore, AHP1 executives framed HIT investments as helping the hospital devise an internal
quality assurance framework, that would allow clinical teams to self-assess against CQC measures
of compliance, at the point of delivery. The aim of this strategy was to restore their reputation in
the CQC rankings. Each clinical team was required to maintain a portfolio of evidence provided by
HIT dashboards, which would support CQC compliance measurements. With this framing practice,
the practitioners argued HIT would help them rigorously test and review local evidence of how
each compliance measure was being assessed. By identifying the problem as needing immediate
evidence of CQC compliance, while reflecting on a reactive temporal orientation, their framing
practice introduced a sense of urgency for restoring reputation with HIT.
5.1.2. Present issues: Investing in HIT to display professional information handling processes
AHP1 practitioners also sought to legitimize the use of EMR information as beneficial in
quantifying the metrics CQC is seeking during their inspection process. As such, HIT was framed
as helping them restore their reputation by articulating solutions and action plans. For instance, the
director of finance highlighted the importance of storing and presenting EMR patient information
for enhancing regulatory compliance, by giving the impression that they are “more professional
than just rooting around for the odd note”:
“CQC like to come and visit, review and you log onto the [EMR] system and see how information
is stored and kept, it is important that whatever system we use complies with the appropriate
governance, that we store all the information we need on the system, so when they turn up it is all
very clear and they are not having to go to this drawer for that piece of information… the benefit
of the EMR, then, is that they can come in, log onto a patient’s record and see patients’ physical
health, their daily actions, their drugs, they can just see it on one screen… the EMR helps us prove
that quicker and we are more professional than just rooting around for the odd note”.
Although EMR information was crucial, AHP1 were also framing mobile applications as important
in helping them convince CQC of their compliance, by enabling the monthly tracking and
evaluation of compliance targets through real time digital scores:
“There is a range of CQC compliance standards that we have to comply… we have created an
iPad assessment tool that all of our teams have to complete monthly and every question then is
allocated to an outcome, a CQC standard”.
In addition, AHP1 practitioners were invoking other stakeholder groups in their justifications of
HIT investments. For instance, they framed the use of EMR information as helping them convince
commissioners of increased health care service activity levels, gain access to further funding and
improve their overall negotiating position with them. In this way, the use of EMR information was
framed as providing reputational value through the power of commanding resources, such as
funding with commissioners. As reflected in the quote below by the CEO of AHP1, EMR
information was framed as being a “weapon in the armory” for contract negotiation with
commissioners:
“It is not just commissioning in terms of the financial elements […], it is also about the information
as a weapon in our armory around contract negotiation. This is an important element of what we
would use an information system for”.
The CEO of the organization framed EMR use as affording information that could provide a better
negotiating position with commissioner groups. HIT was crucial for AHP1, especially in the
context of mental healthcare, as hospitals receive funding under block contracting. In this contract
type, commissioners pay mental health service providers an annual fee in instalments, in return for
providing a defined range of services over a fixed period. However, AHP1 had been spending more
money than provided by the fixed contract amount due to increased patient activity. The CEO of
the hospital shared that the only way they could access further funding was by evidencing this
increase in activity through information, something they have had real difficulties doing so in the
past, therefore leaving the hospital financially strapped. Through several discussions with the
commissioner groups, the hospital senior management team were aware that commissioners get
frustrated and remain skeptical with the lack of information, because then they think the hospital is
trying to hide something just to take their money. In short, senior managers were invoking the
importance of the mental healthcare funding context, to justify investing in HIT to display
professional information handling processes. This was to motivate their framing practice in terms
of lack of transparency for the commissioners, which made their funding evaluations more difficult
– hence making the collecting, storing and using of information as a signal of good decision
making.
5.1.3. Towards the future: Investing in HIT to improve relationships with key stakeholders
On the other hand, during the period of the CQC crisis, contrary to their primary temporal focus, a
more future oriented dimension was also noted. For example, HIT was framed as having
“substantial benefits to stakeholder relations”, such as improving existing relationships with CQC,
GPs, research organizations and their own research staff. For instance, the CEO argued that
utilizing EMR anonymized patient information would help AHP1 engage with other key research
hospitals in the wider ecosystem:
“We have got a very strong research base in the [hospital]… we use information a lot and we have
been able to produce some very striking insights about death rates amongst people with
schizophrenia by looking at meta data [‘data about data’]. What we would be able to do is enhance
our reputation there is no doubt about it”.
More specifically, senior managers at AHP1 stressed the importance of ‘granular’ information for
building better relationships with their GP stakeholders. For example, the COO commented on how
information can improve relationships with GPs:
“The other thing for me is the type of information that I would have to share with stakeholders…
obviously with the GPs, I would have had a good understanding of market analysis, where, what
sort of market share I had, I’d be able to go and target GPs who stopped referring [patients] to my
organization, and so actually the information in itself, takes you out of the organization, and starts
a really intelligent conversation with the GPs”.
The above quote demonstrates the importance of GPs for hospitals. GPs increasingly have greater
involvement and influence when referring patients to hospitals. Investing in HIT was framed as a
way to better engage with this stakeholder group through the provision of granular level patient
data instantly and remotely. This was an issue which many practitioners at AHP1 thought was
crucial for reputation. The chief pharmacist commented that “in terms of reputation…GPs value
clear and quick information from us at the time of discharge”. Similarly, the deputy director of
finance noted that GPs tend to seek “micro [detailed] data about patients from their micro
perspective”. This was very important for AHP1, given the “poor relations mental health hospitals
have with GPs”, often on the bases of the “lack of professional information” and their “inability to
access patient data remotely during meetings” (Deputy Finance Director).
Relatedly, they framed HIT as a potentially attracting and retaining factor for hospital staff. The
chief pharmacist emphasized that “if people are seen to be embracing new technology, then you
are seen as a forward-thinking organization and people want to work for you”. In this way, AHP1
practitioners framed HIT investments as improving relations with key stakeholders relatively
quickly, enabling them to restore their reputation by invoking other stakeholder groups. Their
temporal orientation influenced their framing practices such that HIT was a means to an end; a way
to convince their stakeholders of the rationality of their decision making and to impress with visual
dashboards, irrespective of actual decision improvements. Through their framing practices, they
were performing new justifications of HIT value for diverse aspects of reputational HIT value for
different stakeholders.
5.1.4. Restoring HIT reputational value
The temporally-oriented framing practices were key at AHP1, as they helped the hospital mobilize
after the critical CQC inspection and eventually to restore their reputation with the regulator.
Through their framing practices, their ongoing justifications for using and investing in HIT
were framing different aspects of reputational value for diverse stakeholders. For example, the
short-term, reactive value seeking practices justified the urgent need for AHP1 to develop their
own mobile applications to enable the monthly tracking and evaluation of CQC compliance
targets, through real time digital scores. More specifically, they created a tablet-based
assessment tool that all their care teams had to complete monthly were based on questions
allocated to CQC outcomes and standards. All the data collected were fed into a governance
dashboard that produced visual charts around a wide range of CQC outcomes. Throughout a
period of rapid changes in relation to IT based mechanisms for assuring quality, they convinced
the CQC that they met the standards and restored their reputation. In their inspection report in
2013, CQC praised patient care at AHP1 for being “fully compliant in key CQC areas” and
lifted the ‘special measures’ the hospital had been facing.
5.2. AHP: Enhancing and maintaining reputation through HIT
AHP2 is a leading hospital that enjoys an international reputation for clinical excellence and
innovation. Practitioners at AHP2 had an overall orientation towards the future, by using mostly
long-term and proactive value seeking approaches with a view of investing in HIT to maintain and
enhance their reputation. As such, the framing practices used were concerned with reimagining
their future as a “digital hospital without walls”. Their vision, articulated in their HIT strategy
document, was as follows:
“Our vision is to deliver a ‘hospital without walls’. Where world renowned, specialist care can be
provided at the right time in the right location enabled by high quality, flexible HIT that provides
a single source of clinical information, supports patient choice and empowerment and enables staff
to do exceptional work through access to the right technology and information”.
Although AHP2 were subject to audits, inspections, assessments, and rankings from regulators,
similar to AHP1, they were not bounded by their present concerns and pressure in justifying HIT
investments. Therefore, their proactive temporal orientation influenced their framing practices by
giving them open time horizons to appeal to the future needs of the hospital. We summarize our
case findings in figure 3. Table 2 provides supporting evidence for the framing practices enhancing
reputational value at AHP2.
------------------------------Insert Figure 3-----------------------------
------------------------------ Insert Table 2 -----------------------------
5.2.1. Towards the future: Envisioning national and local strategies
AHP2 practitioners were framing key contributions that HIT investments would make to enable
the hospital to respond to local and national strategic drivers. First, they were envisioning a future
where they would appeal to the national strategic context of the UK by investing in HIT. For
instance, they were invoking the National Information Board’s framework for action (2014), which
was providing details as to how data and technology will support the delivery of the Five Year
Forward View (NHS England, 2014). As such, they appealed to the technology-focused national
healthcare strategy to proactively identify their present situation and envisioned a future where HIT
is key to their success, as communicated in their HIT strategy:
“HIT needs to support the hospital in responding to national strategic initiatives through delivering
systems and infrastructure that directly support the delivery of high quality care at every stage of
the patient journey regardless of location, as well as the creation of open, transparent, accessible
data that can be used intelligently to become proactive, not reactive, and drive accurate business
decisions based on integrated real-time information”.
Second, by reimagining the future through responding to the local strategic context, they framed
investing in HIT as supporting them in maintaining and building further their worldwide
recognition for care, training, and research. Relatedly, leaders at AHP2 were framing HIT
investments in the present as supporting the future vision of their “digital hospital without walls”.
As part of their framing, they highlighted the importance of moving to a new hospital site:
“The move to [the new hospital site] is a once in a lifetime opportunity for the hospital to create a
truly digital hospital that delivers exceptional patient care and staff experience”
To do so, they framed HIT investments as supporting personalized, patient centered healthcare and
the provision of integrated systems that would provide fast, reliable information and data for both
management and research purposes. Additionally, they highlighted the importance of how HIT
would support them in providing safe and high-quality care, by enabling them to capture, monitor
and audit clinical information electronically. Overall, their proactive, long term temporal
orientation influenced their framing practices by helping in justifying and identifying long term
benefits from HIT investments.
5.2.2. Towards the future: Investing in HIT to create strong business partnerships and relationships
As part of their framing practices, AHP2 justified HIT investments as the way to create strong
business partnerships and relationships with their key stakeholders. The technology director
explained:
“So one of the golden threads in realizing the HIT strategy is we can’t do it on our own, we don’t
have the knowledge, the expertise, […] what we have is our reputation for clinical excellence and
innovation, so one of the things that I’m keen to build is that we bring the two parties together and
we form strategic partnerships to do the clever stuff”.
Apart from helping them engage in strategic partnerships, AHP2 practitioners enrolled diverse
stakeholders whom HIT would allow them to connect with. One of these groups is the funding
commissioners, as explained by the technology director:
“Technology may help us with commissioners too, because we’ll have more granular information
about all of our interventions, how much they cost and how long they take, so the data that we can
extract from our technical solutions become a selling mechanism in themselves”.
In addition to commissioners, another key stakeholder group enrolled in their framing practices
were other referring hospitals. They framed HIT as helping them improve their waiting lists for
patients and delivery care, which they envisioned would influence hospital referrers. In the words
of the technology director:
“One of the expectations we have is that technology will help us to work the usual faster, smarter,
better. If we don’t have waitlists, then we become an attractive place for hospital referrers to send
patients. One of the stressful things for lots of patients is waiting to get seen, so if you don’t have a
wait to get seen then not only is that better patient experience, but also the delivery of care has got
to be improved. So that may influence referrers’ behaviors”.
5.2.3. Towards the future: Investing in HIT to improve clinical research and patient recruitment
The third framing practice they used in the ongoing process of justifying HIT investments was
framing HIT as improving their clinical research, and hence as a way of maintaining and enhancing
their international reputation. The HIT and technology director highlighted the importance of data
as “the most important asset” after patients and staff:
“The progression towards digital data now means it is possible to record, access and analyze data
in much larger amounts. The acquisition, curation, management, analysis and exploration of data
drive the medical research industry and is increasingly seen as the most important asset after
patients and staff”.
Not only did they envision HIT as improving clinical research, but also as improving their ability
to recruit patients for scientific trials. A consultant physician at AHP2 explained that sharing patient
anonymized data through EMRs could help them “obtain target patient sample sizes for scientific
trials”. The consultant physician emphasized the importance of recruiting patients for such
scientific trials:
“An essential part of our research work is commercial trials and the ability to recruit appropriate
patients speedily and rapidly and then follow them up and use the various systems that they require
us to do so, is also very important as well… leveraging IT is a brilliant way of doing that”.
Overall, this framing strategy helped AHP2 frame HIT as fully supporting the hospital in its
research and development vision, by creating a robust environment for research to enable clinical
staff to compete in the national and international research market. This framing practice justified
HIT investments as a way of providing accessible, automated performance dashboards for
performance monitoring; forecasting and modelling of data and the production of real-time reports
and dashboards.
5.2.4. Maintaining HIT reputational value
However, although AHP2 envisioned enhancing their reputation through long-term, proactive
value seeking framing practices explored above, they did not draw on stable conceptions of value,
but rather framed HIT reputational value as mutable, something they had to continuously engage
with to secure, not a one-off outcome of HIT investments. This involves justifying actions such as
the “maintenance” work of value over time, reputation vulnerability and HIT as threat to reputation,
all of which emphasized the mutable nature of value and show the diverse generative opportunities
for performing reputational value. AHP2 practitioners were framing HIT as a threat to their
reputation, where HIT implementation could disrupt established healthcare practices, highlighting
the mutable nature of HIT value. A business change manager at AHP2 commented on this:
“… when an organization has introduced technology based projects they typically are not normally
going to work right first time […] there is a whole variety of issues that falls out of that project that
can impact straightaway hospital reputation […] in some of my past activity I have seen some
major implementation of IT based projects and really the reputation of the hospital has fallen in
most instances almost straightaway on that”.
At the heart of these issues, according to the clinical lead of intensive care at AHP2, is the way HIT
can come in conflict with the already established healthcare care practices. For example:
“Any IT implementation may crystallize problems […] what you are not taking into account are
the unconscious, not recognized, mechanisms that have been put in place by people to support
actions, and when you put the technology in place […] any problem becomes the fault of the
technology, even if it has nothing to do with it”.
Relatedly, another important aspect of justifying HIT investment was reputational value
maintenance, where practitioners at AHP2 emphasized that maintaining their international
reputation was a continuous process rather than a static one. As a transplant consultant explained:
“Our reputation is enormously important and in order to maintain that reputation we need to keep
delivering every single day of every single week or every single month of the year, you cannot rest
on your laurels because you will be moving behind”.
Finally, AHP2 practitioners recognized that even the most favorable and established reputations,
including theirs, cannot be taken for granted. In justifying HIT investments, the service
improvement program director noted how reputational value is vulnerable:
“… [reputation represents] both sides of the same coin in my view, so good reputation, bad
reputation have different consequences, but you cannot consider one without considering the
other, so they’re just two sides of the same coin… the time and effort that goes into building
and establishing a good reputation and the ease at which that can be flipped […] and then the
time and effort that goes into trying to recover it […] for me it’s two sides of the same coin”.
Through the framing practice of maintaining HIT reputational value, AHP2 practitioners were
conceptualizing the contingent status of HIT reputational value as both generative (forming as a
prerequisite for further benefits to come, such as enhancing their reputation with different
stakeholders), but also as vulnerable (forming as a hindering factor bearing negative consequences
for hospitals).
In summary, the framing practice of maintaining HIT reputational value continuously points to the
importance of continually engaging in framing practices for HIT value, as a consequence of
ongoing evaluation, where hospitals need to engage in a continued investment of effort to sustain
favorable reputational value from their stakeholders. In other words, even though HIT reputational
value may appear lasting and enduring at one point in time, it cannot be taken for granted, as it can
also be depleted temporally; stakeholders can change their perspective quite significantly, based on
the threat HIT poses. Hence, the process of justifying HIT investments may be conceptualized as
an ongoing evaluating process that relevant hospital stakeholders are constantly framing HIT value.
5.3. A process model of framing practices and reputational value in healthcare
As shown on figures 2 and 3, we identified framing practices that senior managers and other
practitioners used to perform justifications of HIT investments, generating potential for multiple
facets of HIT reputational value for diverse stakeholders (such as restoring, enhancing, and
maintaining reputation). We synthesize our findings across the two cases into a general process
model (shown in Figure 4 below), which facilitates cross comparison of the temporally oriented
framing practices performed at our case hospitals.
------------------------------Insert Figure 4-----------------------------
First, we find that practitioners used temporally orientated framing practices to justify HIT
investments for overcoming issues of the past, addressing present issues, and finally, projecting
towards the future. Our model highlights that the time horizon (short or long term) and value
seeking approach (reactive or proactive) matter for justifying HIT investments. For example, in the
case of AHP1, the short-term, reactive temporal orientation of their “crafting urgency” framing
practice was key for helping the hospital mobilize after the very critical CQC inspection and in
devising a framework for quality improvement using different HIT. At the same time, they were
also using framing practices to address present issues. For example, the short-term, reactive
temporal orientation of the tactical framing of “displaying professional practices” justified the
urgent need for AHP1 to develop their own mobile applications to enable the monthly tracking and
evaluation of CQC compliance targets, through real time digital scores. In addition, they justified
investing in HIT as providing EMR information that can act as a “weapon for contract negotiation”
with commissioner groups and make them seem more “professional than rooting around for the
odd note”. As we show in section 5.1.4, they eventually convinced CQC they met the regulatory
standards and eventually restored their reputation.
However, despite crafting urgency and addressing present issues, practitioners at AHP1 also used
framing practices oriented towards the future. Their framing practice of “improving relationships
with key stakeholders” envisioned reputational value for other stakeholders beyond CQC, such as
improving the negotiating position with commissioners, GPs and by potentially attracting hospital
staff. This suggests that temporally orientated framing practices can be overlapping with different
time horizons and value seeking approaches simultaneously. Even with a major organizational
failing and a sense of urgency to act and overcome the past and address present issues, temporally
oriented framing practices can also stretch towards the future.
Second, in contrast to AHP1, practitioners at AHP2 were oriented towards the future and mostly
used long-term horizons and a proactive value seeking approach. For example, the framing practice
of “envisioning national and local strategies” was centered on their vision of delivering a “digital
hospital without walls” and was used to justify HIT investments as an opportunity for maintaining,
enhancing and reproducing their reputation in the future. Also, their framing practice of “creating
strong business partnerships” with commissioners, GPs and other referring hospitals, helped them
in justifying HIT investments as providing reputational value for the hospital. This framing practice
is similar to AHP1’s practice of “improving relationships”, where practitioners at both hospitals
used a long-term time horizon and a proactive value seeking approach. Similarly, AHP2’s framing
practice of “improving clinical research and patient recruitment” allowed them to justify HIT
investments as providing reputational value from improved outreach to patients, and to clinical
stuff from exploiting data for medical purposes. As the model demonstrates, in both cases,
practitioners were performing framing practices that appealed to different stakeholders, unpacking
multiple facets of reputational value, rather than a singular notion of reputation.
Third, our model emphasizes the mutable nature of value, which we summarize as HIT value
dynamics, by showing the diverse generative opportunities for reputational value. For instance, in
the case of AHP2, practitioners used the framing practice of “maintaining HIT reputational value”,
recognizing that HIT can threaten reputation. Taken together, our findings show the process and
practices through which practitioners are justifying HIT investments in an ongoing manner. Our
model highlights that the framing of value is an ongoing process, and reputational value mutable.
Further, we unpack the multiple facets and possibilities for performing HIT reputational value.
6. Discussion
In this paper, we have addressed the question of how healthcare practitioners enacted framing
practices for justifying HIT value, with a focus on reputational value. Through a cross-comparative
case study, our study elaborates theory on the role of temporally oriented framing practices which
perform multiple justifications of HIT reputational value, leading to different possibilities by which
reputation is restored, enhanced or maintained. Our analysis suggests a re-orientation of value, from
being a singular, one-off outcome, to a process understanding of how value (in our case reputational
value) may be mutable. We synthesize our empirical findings in a process model of framing
practices and reputational value which contributes an understanding of the process of justifying
HIT investments for multiple facets of reputational value. This process is dynamic and ongoing.
Such a view highlights our understanding of value as being enacted through framing practices
which invokes multiple stakeholders. Below, we describe how our findings contribute to the
literature on HIT investments. Further, we develop the concept of value mutability as an important
elaboration of enacting HIT value, with specific reference to reputational value.
6.1. Implications for HIT value literature
Our study suggests a number of implications for the business value of IT (Kohli & Grover, 2008;
Melville et al., 2004) and for HIT (Devaraj & Kohli, 2003). Previous work has conceptualized HIT
value as either the intrinsic property of IT, or the subjective preferences of the evaluative audiences
shaping IT value. On the other hand, scholars argue that pre-existing categories exercise
disciplinary effects on organizations, which leaves organizational actors and IT strategists with
little room to maneuver (Meyer & Rowan, 1977). As Kornberger (2017, p.1766) argues, we
encounter a not unusual impasse: an essentialist approach to technology which clashes with an
“over-structuralized, sociological account of the conditions of the (im-) possibility of agency”.
First, our performative framing perspective contributes an alternative view bringing into focus
agency, while keeping an eye on structural constraints. This is a “bottom-up” approach that shows
practitioners can and do enact new value understandings through temporally oriented framing
practices, rather than acting on already imposed categorizations by intermediaries that are frame-
making. Related to our “bottom-up” view, we also contribute by showing the mutability of IT value,
that is, HIT reputational value as a dynamic, ongoing process, continually unfolding and constituted
by ongoing reconfiguration. Previous work has emphasized IT value in terms of new organizational
processes that produce specific, relatively stable value outcomes, such as financial (Menachemi,
Burkhardt, Shewchuk, Burke, & Brooks, 2006) or operational value (DesRoches et al., 2008).
These value outcomes are usually examined in isolation (see Schryen, 2013 for a recent review).
Our study challenges this assumption by viewing the justifying of HIT investments and performing
of value as an ongoing accomplishment, defined by maintenance work and the possibility of having
to either restore, maintain or enhance reputation.
Second, our findings have implications for the recent stream of research that examines value as
articulated in multiple dimensions (Barrett et al., 2016; Tempini 2017). Our process model connects
with previous findings on the creation and making of value in practice, contingent value dynamics
(Tempini, 2017) and valuation processes as shaped by encompassing regimes of worth that create
multiple kinds of value (Barrett et al., 2016). However, it differs in providing insights into the
performative mechanisms through which justifications of value are performed and “brought into
being”, as well as by unpacking multiple facets of the same reputational value. We confirm
Tempini’s (2017) nonlinear, contingent value dynamics that warn against eventual interpretations
of value creation as a linear accretion trajectory, but at the same time, extend these findings by
showing the process and mechanisms through which these dynamics are performed. For instance,
our performative framing model shows that temporal orientation is an important aspect of the IT
investment justifying process, which influences framing practices in the enactment of HIT value.
As such, we show how these contingent value dynamics may play out, and the mutable, tenuous
forms of HIT value that can lead to both favorable (restoring, enhancing) and unfavorable
(threatening reputation) value at different points in time.
Moreover, we build on Barrett et al., (2016) who examine how the use of the platform and
stakeholder participation led to different values being enacted, such as reputational, financial,
service, and epistemic. We extend this line of research by problematizing further the nature of the
phenomenon of value, by showing the mechanisms through which reputational value can be
enacted in different ways. Framing practices may lead to favorable reputational value being enacted
for commissioners, regulators and hospital staff, yet negative assessment of new clinical practices,
such as from unplanned disruptions during IT implementation, can enact negative reputational
value from the perspective of patients. This insight, coupled with our findings of the ongoing need
for maintaining reputational value, suggest organizations need to engage in continuous efforts for
enacting aspects of the same value differently for different stakeholders. At the same time however,
our findings emphasize that such value is neither certain, nor a final outcome, but rather implicated
in a continuous process of justifying and framing HIT.
Third, and relatedly, we contribute by responding to the call made by Salge et al., (2015) for
exploring how HIT can enhance organizational reputation among other social goals. Although
previous research illustrates that organizations following IT fashions tend to have better reputation
regardless of performance improvement (Wang, 2010), it falls short of demonstrating the process
through which this happens. By adopting a “bottom-up” view of how practitioners enacted framing
practices at the initial resource allocation stage, our model conceptualizes HIT reputational value
benefits for different stakeholders, addressing the missing interrelations of value between
healthcare stakeholders. At the same time, we suggest that framing value is distributed across
different intermediary stakeholders. This relates to the valuation literature (cf. Kornberger, 2017),
which argues that valuation practices involved a series of different intermediary actors, such as
critics, credit scoring agencies or investment bankers, who shape preferences and act as guideposts
for others’ deliberations and decisions. In other words, these are “frame-makers” (Beunza & Garud,
2007) that define conventions and structure the understanding of value. In our cases, the healthcare
practitioners were invoking multiple other stakeholders, such as commissioners, GPs, patients and
regulators in their framing practices for reputational value through HIT. As such, our model points
to the distributed agency of value (Kornberger, 2017).
6.2. Implications for practice
Our study also has practical implications. First, we emphasize the importance of temporally
orientated framing practices in understanding the process of justifying HIT investments and
performing reputational value. Practitioners can be mindful of how short/long term time horizons
and the reactive/proactive value seeking approaches they use can influence their justifying of HIT
investments and eventually enact different value possibilities. In addition, as our cross-case
comparison suggests, temporally orientated framing practices can be overlapping with different
time horizons and value seeking approaches simultaneously. Even though our two hospital cases
were facing contrasting pressures, practitioners used both a reactive and proactive value seeking
approach where necessary. For instance, a short-term/reactive temporal orientation might be useful
for hospital staff to take actions that produce tangible results and overcome HIT disruptions to
practices, whereas using only long-term/proactive framing practices might be too visionary so that
hospital staff may get discouraged or lost in the day-to-day struggles with HIT (in relation to HIT
risks). At the same time, our insights around value mutability suggest practitioners can transition
from one set of temporally oriented practices to another, as external situations change.
Second, the multiple stakeholders our case organizations invoked in their framing practices suggest
that hospital managers and IT professionals should focus not only on stakeholders they believe to
be the most strategic, such as regulators or funding commissioners, but also to a wider range of
stakeholders, including patients, GPs and their own hospital staff. Beyond healthcare, managers
need to be mindful of reputation multiplicity (Boutinot et al., 2015; Carter & Deephouse, 1999;
Mishina, Block, & Mannor, 2012), that is, having reputation in various domains. For example,
having a favorable reputation with regulators might not necessarily ensure a favorable reputation
with clinical staff or commissioners. Therefore, practitioners might be framing HIT investments
broadly, to incorporate different stakeholders. We suggest that managers might strategically appeal
to a plurality of stakeholders (e.g. clinical staff, regulators, commissioners, GPs, other referring
hospitals).
Third, our insights around value mutability and the ongoing process of justifying HIT investments
can help practitioners better understand the dynamic nature of mutable reputational value. Our
findings suggest that even though it is widely recognized that reputation takes significant time and
effort to develop (Fombrun, 1996), forming based on past actions (Balmer, 2003; Barney, 1991)
and becoming an enduring and “sticky” resource (Ang & Wight, 2009; Fombrun & Van Riel, 2004;
Schultz et al., 2001), reputational value is neither certain, nor a one-off outcome, as illustrated by
our process model.
7. Conclusion
In this paper, we studied how practitioners justified HIT investment at two UK hospitals, with a
focus on reputational value. We have developed a process model of framing practices and
reputational value, which provides an understanding of the dynamic way in which reputational
value is performed through the ongoing process of justifying HIT investments, which is influenced
by the temporal orientation of individuals’ framing practices. Further, our study provides an
enhanced appreciation of value mutability; value as not a finalized outcome, but rather, mutable in
its enactment through framing practices that are temporally oriented.
The limitations of this study offer opportunities for future research in this area. Although focusing
on reputational value allowed us to elaborate theory and provide a more granular understanding of
the dynamics and mechanisms in the process of justifying HIT investments, future research can
extend our findings to other dimensions of value reported in the literature, such as epistemic,
platform, scientific and service values. For example, are aspects of the aforementioned values
enacted in the same way as reputational value? Are they as mutable as reputational value? These
questions can help shed more light on the phenomenon of HIT value.
Relatedly, although our study examined the orientation of framing practices towards time, future
studies can study the performativity of value over time, in relation to value fragility. As argued by
other scholars, performativity is never a settled state of affairs, but must instead be considered as
an ongoing journey (Garud, Gehman and Tharchen, 2017). Even if a constitutive order of value is
reached, it is “fragile” (Callon, 2010), as the unravelling of felicitous conditions underlying such
constitution will de-constitute the original order. Our findings on the framing practice of
“maintaining HIT reputational value” allow us to speculate on the fragility and tenuous nature of
reputational value. For example, even though HIT reputational value may appear lasting and
enduring at one point in time, it cannot be taken for granted, as it can also be depleted temporally;
stakeholders can change their perspective quite significantly, based on the threats HIT poses.
Therefore, while we did not observe value fragility in our cases, we anticipate this is a possible and
important topic that future studies can build on and shed light on the process through which
reputational value, and other types of value identified in the literature, are performed on an ongoing
basis.
Second, scholars can pay more attention to the multiple ways different materialities, other than
HIT, may perform value differently, by enabling and constraining framing practices. This is an
important area for future work given the increasingly established view that material artifacts and
materiality more broadly are fundamental components of practices (Bechky, 2003; Carlile, 2002;
Feldman & Orlikowski, 2011; Leonardi & Barley, 2008), or constitutive of phenomena (Orlikowski
& Scott, 2008). Relatedly, future studies can pay attention to distributed agency of valuation
practices by paying closer attention to non-human actor agency in defining value (Kornberger,
2017). Experts, critics, but also non-human agents, such as algorithms, are involved in practices of
valuation. Analytically, this focus on distributed agency suggests understanding valuation practices
not as static information on, and assessment of objects, but as a dynamic, ongoing process flowing
through networks of people, intermediaries, and non-human actors.
Third, our findings are limited to the extent that we focused on the hospital organizations’
perspective and framing practices. Future research can further enrichen data collection at the field
level, enabling a more holistic understanding of the ongoing process of justifying HIT investments
for different stakeholders. For example, research could more closely observe and conduct
interviews with evaluating stakeholders, such as inspection teams of regulators, healthcare
commissioners, media journalists, patient advocate group leaders, patients, and GPs. Nevertheless,
despite these limitations, we believe our theoretical insights on reputational value and mutability
can be analytically generalizable to other relevant contexts beyond health care.
Funding
Stavros was supported by a scholarship from the Economic and Social Research Council (Grant
Number: 1491536). Eivor Oborn was supported by the National Institute for Health Research
(NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands. This
paper presents independent research and the views expressed are those of the authors and not
necessarily those of the funders the NIHR.
Acknowledgments
The paper has benefited from the constructive feedback of audiences at the Cambridge Judge
Business School Paper Development Sessions and the Workshop on Organizing for Digital
Innovation at KIN, Vrije University in Amsterdam. A previous version of the paper won a best
paper proceedings award at the 76th Academy of Management Annual Meeting. We want to
especially thank Karla Sayegh for her insightful comments and support. We would also like to
thank the editorial team and especially the editor in chief at Information and Organization,
Elizabeth Davidson, for their valuable, thorough feedback and continuous support. Last, but not
least, we thank the participants in this study who generously provided their time and insights.
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Fig. 1. Categorizing Temporal Framing Practices across Case Studies
Fig. 2. Summary of Findings at AHP1
Table 1
Temporally-oriented Framing Practices for Restoring Reputational Value at AHP1
Aggregate
Dimension
Temporal
Orientation
Framing
Practices
Justifying
Actions
Exemplary Quotes
Overcoming the Past
(Practices anchored in solving past problems)
Short-term
horizon
Reactive
Value
seeking
approach
Crafting
urgency for
restoring
reputation
with HIT
Investing in
HIT urgently to
collect, store
and visualize
data to CQC in
an accessible
manner
“The framework focuses around a
self-assessment approach
undertaken by clinical team
through HIT. This assessment
measures local compliance against
a wide range of standards derived
from the CQC” (AHP1 Annual
Strategy Document)
“We will develop an internal
quality assurance framework that
underpins improvements in
quality, safety and effectiveness at
the point of care delivery through
HIT” (AHP1 Annual Strategy
Document)
Investing in
HIT will help
us devise a
framework of
action
“CQC quite rightly picked us up
on it and so we said right okay
we’ll put in an improvement plan
through HIT and then we will
monitor it”
(Chief Pharmacist)
Present Issues
(Tactical practices anchored in short-term horizons)
Short-term
horizon
Reactive
Value
seeking
approach
Investing in
HIT to
display
professional
information
handling
processes
Using EMR
makes us seem
more
professional
than rooting
around for the
odd note with
our
stakeholders
“If regulators know your record
keeping systems are robust… then
they will have more confidence in
what you are doing” (Consultant
Physician)
“I think at a sort of very basic
level, if an organization can’t in 24
hours produce reasonable
information in response to a public
Freedom of Information request, a
local health organization ringing
up and asking to know stuff and
regulators, they are not very good.
We have had immense difficulties
with our purchases of one sort or
another when we can’t provide
them with information they believe
we ought to be collecting and
having electronic form” (Medical
Director)
Using apps to
collect
information
helps us
convince CQC
of our
compliance
with standards
“CQC need assurance that we are
being mindful of any aspect of
assessment that may impact upon
the patients’ outcome” (Nurse
Matron)
Using EMR
information as
weapon for
“We have a block contract which
means that we don't automatically
get paid if we see more people… so
we have to negotiate [funding] at
contract
negotiation
with
Commissioning
Groups by
monitoring
safety of
services
the end of each year [with
commissioners]. So being clear
about what that increase is and
which teams have experienced
what increase and what the impact
of that was, so other bits of
information like the acuity of the
patients who are being cared for,
that's all vital to the case we make.
As well as understanding what's
going on in the service” (CEO)
“Technology helps us with
commissioners because we have
more granular information about
all of our interventions, how much
they cost and how long they take,
so… the data that we can extract
from our technical solutions
become a selling mechanism in
themselves”(Chief Operating
Officer)
Toward the Future
(Strategic practices anchored in
long-term horizons)
Long-term
horizon
Proactive
Value
Seeking
Approach
Investing in
HIT to
improve
relationships
with key
stakeholders
HIT can
improve
stakeholder
relationships
by providing
detailed
information
“Good IT systems have substantial
benefits to the stakeholder
relations… an organization that
has immediate access to its data is
one that’s impressive to work
with” (Clinical Psychologist)
HIT can help
us by attracting
and retaining
hospital staff
“HIT allows you to attract staff
more easily at all levels… it is
easier to recruit people”
(Consultant Anesthetist)
Fig. 3. Summary of Findings at AHP2
Table 2
Temporally-oriented Framing practices for Enhancing Reputational Value at AHP2
Aggregate
Dimension
Temporal
Orientation
Framing
Practices
Justifying
Actions
Exemplary Quotes
Toward the Future
(Strategic practices anchored in long-term horizons)
Long-term
horizon
Proactive
Value
Seeking
Approach
Envisioning
national and
local
strategies
Reimagining the
future by
responding to
national strategic
context
“HIT needs to support the
hospital in responding to
national strategic initiatives,
through delivering systems and
infrastructure that directly
support the delivery of high
quality care at every stage of
the patient journey regardless
of location (HIT strategy
document)
Reimagining the
future by
responding to
local strategic
context
“HIT needs to support the
hospital in responding to local
strategic initiatives through
enabling us to maintain and
build further worldwide
recognition for our care,
training and research” (HIT
Strategy Document)
HIT can support
and future proof
our hospital
“From a HIT perspective, the
challenge is one of creating a
strategic HIT service that can
support and future proof the
hospital whilst bringing
business-as-usual practices
into an age of rapidly
advancing technological
change” (HIT Strategy
Document)
Toward the Future
(Strategic practices anchored in long-term horizons)
Long-term
horizon
Proactive
Value
Seeking
Approach
Investing in
HIT to
create
strong
business
partnerships
and
relationships
Investing in HIT
to create strong
business
partnerships and
relationships
● With
commissioners
● With other
referring
hospital
It is recommended that the
hospital invest in HIT to create
a strong business partnership
that will enable us to meet and
exceed both local and national
expectations and implement a
truly digital hospital” (HIT
Strategy Document).
“By using HIT we can negotiate
with commissioners in terms of
the levels of activity that we do”
(Medical Director)
“We can use HIT as an
influencer with referrers. So by
way of example, if we can
manage our waiting lists more
efficiently, more effectively
using E-Hospital, if I’m a
referring district general
hospital I may look around and
say, so who can do that
radiology test for me, I may
choose to send my patient to
our hospital because we don’t
have a waiting list, because its
managing its patient flows so
much better with the use of
technology as well” (HIT &
Technology Director)
Toward the Future
(Strategic practices anchored in long-term
horizons)
Long-term
horizon
Proactive
Value
Seeking
Approach
Investing in
HIT can
help us
improve
clinical
research
and patient
recruitment
Investing in HIT
to improve
clinical research
“I think the use of an EMR
facilitates recruitment to
clinical trials that will be
hugely important… being able
to ask a database who’s got this
condition, who’s got this bug
and who’s not is hugely
important for reputation…
which would mean a lot of
money for the hospital”
(Consultant Physician)
Investing in HIT
to improve ability
to recruit patients
for scientific trials
“An essential part of our
research work is commercial
trials and the ability to recruit
appropriate patients speedily
and rapidly and then follow
them up and use the various
systems that they require us to
do so, is also very important as
well… leveraging IT is a
brilliant way of doing that”
(Medical Director).
Toward the Future
(Strategic practices anchored in long-term horizons)
Long-term
horizon
Reactive
Value
Seeking
Approach
Maintaining
HIT
reputational
value
Threat-to-
reputation: HIT
can disrupt care
pathways when
implemented
“The problem with HIT is that
they will, depending on
implementation, affect some of
your pathways, and you try to
decrease that, [but] it will still
disrupt some of the pathways.
So, you need to be careful for
that […] in fact, it can disrupt
pathways so much that […]
there can be an increase in
death” (Medical Director)
Maintaining
reputation on an
ongoing basis
“We need to maintain our
reputation in research circles
as well, an important part of
our research work, well an
essential part of our research
work really is commercial trials
and the ability to recruit
appropriate patients to them
speedily and rapidly and then
follow them up and use the
various systems that they
require us to do so” (Nurse
Lead – eHospital Coordinator)
Our reputation is
vulnerable
“We have a lot of transplant
patients around the country
because we are a centre… so
we are using more
technology [like skype] for
their follow up
assessments… they don’t
want to travel all the way
here… but we have to be
careful because sometimes
you can miss things on video
calls with patients that you
would catch when seeing
them [face to face]… we
have to get it right and make
sure the patient gets the
best care… otherwise [it can
damage] our reputation and
harm the patient”
(Senior Transplant Nurse
Lead)
Fig. 4. A Process Model of Framing Practices and Reputational Value in Justifying Health IT
Investments
