CONTRADICTIONS IN ELECTRONIC HEALTHCARE RECORD IMPLEMENTATION
University of Groningen Faculty of Economics & Business
Msc Business Administration - Change Management
June 2014
Tom van Duijn Jan van Goyenstraat 2a
9718NX Groningen
Tel: +31 (0)6-29026408 E-mail: T.van.duijn@student.rug.nl
Student number: 1627864
Supervisor:
Prof. Dr. A. Boonstra (University of Groningen)
Co-assessor:
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INTRODUCTION
Electronic Health Records (EHR) are increasingly implemented around the globe (e.g. Anderson, 1997; Abrahamson et al., 2011, Jaana et al., 2012). They form: “a repository of information regarding the health status of a subject of care, in computer processable form” (ISO, 2004, p.13) directed to increase healthcare’s safety, quality and efficiency (Grimson et al., 2000; Hartswood et al., 2003; Glasgow et al., 2010; Jensen & Aanestad, 2007; Bates & Gawande, 2003). Hence, they are often depicted as the cornerstone of modernised healthcare service (Greenhalgh, et al., 2009).
However, despite their potential benefits, implementing EHR is a complex endeavour and often leads to failure (Jensen & Aanestad, 2007; Berg, 2001; Lorenzi & Riley, 2003; Aarts et al., 1998; Dick et al., 1997; Aarts & Berg, 2006). Factors that contribute to the complexity of EHR implementation include: costs, technical issues, systems interoperability, concerns about privacy and confidentiality and lack of a well-trained clinician informatics workforce to lead the process (Hersh, 2004; Heeks, 2006; Boonstra & Broekhuis, 2010). Because of such factors, EHR implementations’ complexity exceeds that of ordinary Information Technology (IT) implementations (Grimson et al., 2000)
The complexity of EHR implementation further increases due to different perspectives of the stakeholders involved in the EHR implementation process. Inconsistencies between these perspectives lead to the creation of contradictions (Benson, 1977; Carlo et al., 2012; Van de Ven & Poole, 1995). For example, an EHR implementation forces a clinician to replace his home grown and refined patient file that is fully adapted to his working practices by a generic hospital wide system that does not acknowledge the specifics of his medical specialism. Contradictions exist out of two poles, which are contradictory yet represent important aspects of healthcare operations. In case of the example above: flexibility and control. Choosing between one of them has consequences for the other, because their relationship is mutually implicating (Bosserman, 1995). Namely, raising control of healthcare may have negative consequences for the flexibility of care processes. However, despite their difficulties, contradictions also point out new ways to enhance EHR implementation success. They indicate innovative ways that enable organisations to increase their performance (Evans, 1999).
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Instead, change is recognized as the result of contradictory forces and managing change involves managing their underlying competing demands and expectations (Lewis, 2000; Smith & Graetz, 2011; Smith & Lewis, 2011). This perspective recognizes the dynamic, complex and contradictory nature of organisations, and the diversity of people, since each has their own interests and idiosyncrasies (Smith & Graetz, 2011, Handy, 1994; Eisenhardt, 2000; Lewis, 2000). Dialectical theory is an example of a change management theory that explains change as the result of contradictions. It provides a general view of the way social processes forge change as the result of conflict between opposing values, forces or events (Van de Ven & Poole, 1995). It has been used to study the complex dynamics of change in society, institutions and organisations (e.g. Benson, 1977; Chae & Bloodgood, 2006; Das & Kumar 2010), for understanding the organisational consequences of Information Systems (IS) (DeLuca et al., 2008; Robey and Boudreau, 1999) and for examining the dynamic action of systems development and implementation (e.g. Sabherwal & Newman, 2003; Cho, Mathiassen & Robey, 2007; Carlo, Lyytinen & Boland, 2012). However, it has not yet been applied to the context of EHR implementation.
This research adopts a dialectical perspective in order to identify and analyse contradictions within EHR implementation and to increase our understanding of their effects on the implementation process. This research assumes that dialectical theory will reveal the contradictions involved in the EHR implementation process, which can lead to understanding of the present situation and the future trajectory of EHR implementation. The research question of this research is: How can we understand the EHR implementation process by identifying and analysing emerging contradictions?
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LITERATURE REVIEW
This section reviews dialectical theory in more detail and explains their capabilities for analysing and identifying contradictions within EHR implementation.
Dialectical theory draws on a general view of social life that originates form the work of philosophers (e.g. Mao, Hegel, and Marx) who explained reality as being a construct of multiple actors’ goals and actions. Their ideas support a pluriform perspective on reality; they recognize reality as a product of social construction related to the interaction of multiple actors’ actions and their consecutive goals, values and ideas. Today, dialectical theory is used to examine the complex dynamics of change in social systems. According to Benson (1977) the key principles of dialectical theory consist of: social construction; totality and contradictions.
First, social construction refers to the interaction between relevant actors. These interactions, influenced by actors’ histories, interests, power bases and environmental constraints jointly create the social system (Benson, 1977). During EHR implementation these social processes arise due to interactions of actors (e.g. managers, physicians and nurses) that continue to shape the implementation process. Second, totality refers to the interconnectedness of these social processes on multiple interpenetrating levels (Carlo et al., 2012). This represents the enclosure of all relevant processes of social construction within one social system, for example in the context of a single hospital.Third, contradictions refer to the various ruptures and inconsistencies within the established social arrangements (Carlo et al., 2012). The word contradiction origins from the Latin expression “contra dicere” which means speak against. This illustrates that contradictions are a product of different perspectives of actors within the social system (Benson, 1977).
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produced (i.e. synthesis). Figure 1 shows the dialectical theory of organisational change of Van de Ven and Poole (1995).
FIGURE 1
Dialectical theory of organisational change
(Source: Van de Ven & Poole, 1995)
Figure 1 illustrates that dialectical theory for organisational change represents a process that continues to evolve as the synthesis eventually becomes the new thesis, which is again confronted with an antithesis and so on. The notion that change is a process is important because it states that organisations are in a continuous state of change. This increases the importance for understanding the contradictions in organisations as they are the driving factors of change (Cawsey et al., 2012) The dialectical theory of Van de Ven and Poole (1995) is established according to three characteristics: unit of change, motor and mode of change (table 1).
TABLE 1
Characteristics of dialectical theory of organisational change
Unit of change Motor Mode of change
multiple: there must
exist at least two entities that oppose or contradict one
another.
conflict: opposing entities must
confront each other and engage in a conflict or struggle through some physical or social venue, in which the opposition plays itself out.
constructive: the outcome of the conflict
must consist either of a new entity that is different from the previous two, or the defeat of one entity by the other, or a stalemate among the entities.
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The characteristics mentioned in table 1 show that a contradiction must include at least two different poles. These poles conflict through physical or social events from which a new construct emerges. This synthesis signifies a constructive mode of change: “a departure from the past and produces a new entity that is an original rather than the reproduction of some prior state” (Van de Ven & Poole, 1995, p. 524). However, sometimes synthesis is not realized (Van de Ven & Poole, 1995). For instance when the antithesis overthrows the status quo or when it is not strong enough to challenge the existing thesis. Nonetheless, the common understanding of this theory is that a synthesis is the result of a combination between the two poles that form a contradiction.
8 Identification of Contradictions
In order to analyse emerging contradictions within the context of EHR implementation process, first contradictions need to be identified. Bjerkness (1991) suggests that contradictions can be identified according to two essential qualities of a contradiction: struggle and identity. The struggle resembles to “what we often connect to ‘contradiction’ in everyday language” (Bjerkness, 1991, p. 64). These represent the inconsistencies and ruptures within the social system which create the existence of organizational tensions. The identity of a contradiction refers to the contradiction as a whole and points the interconnection between the poles (Bjerkness, 1991). With other words, a struggle is the easier-to-identify aspect that resides on the surface and together multiple struggles can be related to one identity as illustrated by figure 2. Both essential qualities together form a contradiction.
FIGURE 2
Essential qualities of contradictions
9 TABLE 2 Categories of tensions
Category Tensions DESCRIPTION
Performing Plurality of goals What are we going to do?
Organising Structuring and Leading How are we going to operate? Belonging Individual and Collective Who is going to do what?
Learning Past and Future What can be improved?
(Source: Smith & Lewis, 2011)
These categories all represent different, yet interrelated aspects of organisational life (Smith & Lewis, 2011). Within EHR implementation this interrelatedness can be distinguished as follows. The remainder of this section will explain the four types of contradictions in detail and provide examples in relation to EHR implementation context.
Performing. Performing tensions arise as the organisation is trying to define what they are going to do with the implementation by highlighting goals and strategies. Contradictions arise when these goals are not congruent with those of other stakeholders involved in the process (Lüscher & Lewis, 2008). These different goals arise as stakeholders seek divergent organisational success, which has implications for the EHR system. For example physicians and administrative workers both demand different features of the EHR system. Struggles within this category arise because of different in perspectives of users in relation to their respective roles within the EHR implementation process. Conflicts within this category arise, for example, because of different goals concerning efficiency and quality. For example, some stakeholders (e.g. administrative workers, physicians or nurses) think the EHR system must raise the efficiency of operations, while others believe it must focus on increasing the quality of healthcare.
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Belonging. Eventually the EHR implementation requires defining who is going to do what highlighting conflicting identities, roles and values creation belonging tensions (Smith & Lewis, 2011). For example, belonging contradictions may revolve around ways by which individuals seek homogeneity with certain groups, while simultaneously searching for ways to distinct themselves from others. As table 2 illustrates, belonging contradictions revolve around tensions between the individual or group and the collective. In EHR implementation, these contradictions may arise as different occupational groups or departments seek different ways by which they establish integration of their different identities with those of others. For example when one department wants to realize more integration of functions, while other departments want to remain to their distinct and differentiated position.
Learning. Eventually as the EHR implementation evolves tensions of learning will arise. These tensions revolve around letting go of the past in order to create the future. Contradictions in this category emerge concerning different beliefs about which aspects of the implementation need to be replaced to create the future (Smith & Lewis, 2011). This encompasses all efforts by which individuals, groups or departments try to handle changes in their current operations as a direct result of the implementation of the EHR. These contradictions arise, for example, when actors in the implementation process are struggling to let go of the past, seeking the security of their current practices in favour of changes imposed by the EHR implementation process.
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METHODS
This study adopts a dialectical perspective to identify and analyse emerging contradictions in the context of EHR implementation. The goal of this research is to increase the understanding of which contradictions have emerged, why they have emerged and by whom. This raises the understanding of contradictions in EHR implementation and enables EHR implementers deal with competing demands and expectations. This section provides justification for the choices of the research design, data collection and data analysis. Furthermore this section reviews the methods for quality assurance.
Case Study Approach
This research focuses on promoting the understanding of contradictions in EHR implementation. This demands interpretation of different meanings and behaviours of people within the context of EHR implementation. This interpretative approach is well supported by choosing a case study approach (Lee, 1991).
12 Data Collection
The type of data used within this research was qualitative, which was collected by individual interviews within a single case. Interviews allow to capture and reflect on select details of experience of individuals (Schultz, 1967; Seidman, 2006). Two researchers, in agreement with the project team, conducted all interviews. These interviews were semi-structured and covered the characteristics of the participants’ departments and occupation, their involvement in the change, the expected future impact of the EHR, the support, resistance and the tensions they had experienced during the process. The interview also contained the participant’s view on the implementation process, the cooperation between the departments and the project team, and their suggestion for future interventions. Together these questions provide rich insights about areas of tensions within the pre-implementation phase from which emergent contradictions could be deducted. The duration of the interview lasted 60 to 90 minutes. The collection of the data was held between mid-2012 and mid-2013. Each interview was recorded and subsequently transformed into verbatim transcripts. Feedback sessions with the participants and some of their colleagues were held in order to verify correctness and accuracy (Johnston, Leach & Liu, 1999).
Table 3 shows an overview of the participants who were interviewed for this study. A total of fifteen interviews where held within this case. From each selected department three respondents were interviewed. These respondents each represent one occupational group (managers, physicians and nurses), which were equally distributed among the four departments. From the project team also three respondents were interviewed. Table 3 provides an overview of the different respondents and their codes.
TABLE 3 Overview of respondents
Department A Department B Department C Department D
Managers Respondent A1 Respondent B1 Respondent C1 Respondent D1
Physicians Respondent A2 Respondent B2 Respondent C2 Respondent D2
Nurses Respondent A3 Respondent B3 Respondent C3 Respondent D3
Project Team
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Respondents within departments were selected based on future use and availability of the EHR system. The project members were selected because of their high degree of involvement with this specific pre-implementation phase. The multiple insights form the different interviews increased the richness due to the different and complementary views which enhances the construct validity of this research (Yin, 2014). To ensure external validity the theory used for this research is based on existing literature from peer-reviewed academic sources.
The departments, which were selected for this case study, represent different characteristics. Table 4 shows these different characteristics (digitalization and interdependence) are distributed across each department. This selection of departments with different characteristics promotes the transparency of the process of interests (Pettigrew, 1988). In addition to these characteristics each department is functionally different from each other.
TABLE 4
Departments’ characteristics
Department Digitalization Interdependence
A Low High B High High C Low Low D High High Data Analysis
For identifying and analysing the emergent contradictions within the context of this single case study of EHR implementation the steps of Bjerkness (1991) where adopted. These steps suggest to identify contradictions by focussing on conflicts and to analyse each contradictions by their identity and struggles. This process was guided by the suggestions of that contradictions exist among different stakeholder groups (Robey & Boudreau, 1999; Robey et al. 2002).
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By adopting the conceptual framework of Smith and Lewis (2011) the case study data could be reduced to four categories of tensions. Reducing the data into smaller categories is important to allow comparison of the data (Miles & Huberman, 1994, Glaser & Straus, 1967). This deductive coding process was guided by the coding schema which was constructed according to the conceptual framework of Smith and Lewis (2011), as described within the theory section. Appendix I provides the coding schema containing these codes. The coding process was an iterative process whereby the data was continuously consulted in order to refine these four categories. Field notes were taken to promote the transparency of this process (Eisenhardt, 1989).
Codes represent the four categories of tensions where carefully collected for each respondent. Together these quotes were captured in a table to support comparison (Miles & Huberman, 1994; Hennink, Hutter & Bailey, 2011). The total of codes was 300. These codes where distributed across the different categories: organising (103); performing (122); belonging (25) and learning (50). Comparison of these quotes demonstrated conflicts within each category of tensions. From these conflicts struggles could be derived (Bjerkness, 1991). By comparing the struggles they could be conceptualised into a more abstract category: the identity. This process was supported by discussions between researcher and the first supervisor. This approach for identifying contradictions is similar to that of Cho et al., 2007. Eventually four contradictions where identified as represented in table 5.
Analysing these contradictions across organisational levels occurred through comparing the quotes relevant to each of these contradictions by all members of departments and the project team. This facilitated an analysis of their different perspectives in order to promote the understanding of the influence of contradictions on this level of the EHR implementation process. Analysing the emerged contradictions across departments was accomplished by comparing the quotes of all departmental members. For analysis on occupational group level this comparison was conducted by comparison relevant quotes for each occupational group.
Quality Criteria
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limits the extent of the generalizability of the results of this research across cases. However since this study is part of a longitudinal research, generalizability across cases is less important given that further research within the context of this case will evaluate the results of this research on different points in time.
During data collection measures were taken to promote the reliability of this research (Yin, 2014). In order to enhance reliability and minimize researcher bias the interviews were carried out by two researchers simultaneously (Van Aken et al., 2012). This form of investigator triangulation (Stake, 1995) is used to decrease the effect of individual sensemaking frameworks for interpreting the interviews (Weick, 1979).
RESULTS
Within this section the results of this research will be presented. First a case description is provided to increase information about the context where this research has taken place. Furthermore the emerged contradictions identified within this research will be explained and the results of the analysis among organisational levels, departments and occupational groups will be provided.
The case study context contained a Large Teaching Hospital in the Netherlands (LTHN). This hospital wishes to implement their EHR system in the near future. During the moment of research, they remain in the pre-implementation phase. This phase involves making a broad inventory of the organisational needs and goals for the EHR system. This inventory process provides the basis for hospital-wide implementation. The main rationale for this EHR implementation is to overcome the problems based on the multiplicity of different systems that each support different functions require to be linked together via a complex network. This network has demonstrated its vulnerability and is in need of replacement.
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Emerged contradictions in EHR implementation
Category Contradiction Identity Struggle
Performing Uniformity and
Flexibility
The effectiveness of the EHR system relies on providing uniformity and allowing flexibility.
Finding a balance between uniformity and flexibility within a single EHR system is difficult.
Organising Top-down and Bottom-up
The success of the EHR
implementation process relies on both a top-down approach and bottom-up support.
The top-down and bottom-up approaches are not supportive of one another.
Belonging Integration and Differentiation
The EHR implementation process relies on the differentiation of their members and their integration with each other.
Organisational members seek ways for integration with others, while trying to remain unique through differentiation Learning Stability and
Change
The EHR implementation process is depending on both change and stability.
EHR implementation causes change that interferes with the stability of the current system.
Within this section each of these emerged contradictions will be explained in detail. Furthermore this section describes the different perspectives of stakeholders across organisational levels, among departments and within occupational groups. These perspectives will be compared and analysed at the end of this section.
Uniformity and Flexibility
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processes stimulated by the EHR system. Flexibility revolves around providing exceptions to the EHR system; allowing the existence of specific systems within the EHR system. Table 5 shows that the main struggle of this contradiction revolves around finding a right balance between uniformity and flexibility. The definition of how this balance must be achieved differs across the organisation as the following analysis will show. Struggles arise because the EHR system depends on both poles of this contradiction, hence the identity. For example, the system can support the decrease of manual errors by increasing uniformity. However, when uniformity rises, it can lead to rigidity of the operational practices. This impedes the flexibility, which is necessary to deal with the complex nature of the healthcare operations. The following section shows the analysis of this contradiction for the different organisational levels, across departments and among occupational groups.
Organisational level. The contradiction between uniformity and flexibility is clearly present between both organisational levels of this case study. The perspective of the project team is that the EHR system must guarantee more uniformity. They believe the multiplicity of different systems must take place for generic processes integrated within one system: “A lot of departments still have their own applications, sometimes completely tailor-made. Those are private designs and must be removed. Departments need to move towards generic processes, which make it accessible to everyone” (T1).
Departments acknowledge the potential of a uniform EHR system to support their operations, however they do not believe that uniformity must be an end in itself: “It (EHR system) must also be flexible. The organisational goal must not be overlooked by focusing only on uniformity” (A3). Other departments support this by stating that promoting uniformity though the EHR could also have negative effects on the quality of their operations: “There are concerns being expressed about the quality of healthcare and the EHR system” (B1). Departments fear that increasing the uniformity would impede their capability to achieve their operations. As such, departments advocate for a customized EHR; a single system equipped with their specific demands: “That would be nice, customized EHR” (A1) or “An EHR can be implemented on all departments, but each departments must be capable of designing their own records” (D1).
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However, multidisciplinary work becomes more ordinary, and there is where you see increased needs for digitalization”(T3).
Departments. Figure 4 shows the different meanings of the uniformity and flexibility contradiction for each department. It shows that each department recognizes differences because they possess different perspectives about the balance between the two poles of this contradiction. One respondent explains the existence of these different perspectives: “I think that each department hopes that their specific demands are granted. So, each receives the most workable EHR system. Only these are contradictory interests, because you also want a generic EHR, one that works quick and so you don’t want to incorporate all wishes because you end up with an opaque whole”(A2).
FIGURE 4
Departments’ perspectives on uniformity and flexibility
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Occupational groups. In this section the different perspectives with regard to this contradiction will be analysed across three occupational groups. First, managers express an ambiguous perception of this contradiction one the one hand they feel that the EHR system must facilitate flexibility, allowing their departments’ specific needs: “It would be annoying if we had to work with an imposed system” (D1) or “Basically, I think that the system needs to have a supportive role and not directing” (A1). However, on the other hand, they support the increase of uniformity because of its potential to stimulate the efficiency of control and lowering their administrative burden: “If you increase the uniformity everything become much more efficient. This also applies for controlling. We only have to control one procedure” (B1).
Physicians express fear that the increasing uniformity will have consequences on their capability for providing healthcare: “That you are less concerned with the provision of healthcare and more with the administration” (D2). This feeling is enforced by previous negative experiences with IS systems for increasing uniformity. One physician noticed: “Healthcare is going mad. The EHR off course is not the cause of this, but it requires that all of these things must be recorded. The more you must register the better; however, people seem to forget that there are also other things to do than registering” (B2). Nonetheless, physicians do recognize the potential for adopting EHR system and increase uniformity. However, they advocate for a significant lower level of uniformity than other occupational groups and demand a low degree of involvement of the system in their operations: “If the EHR system is easy to handle, I will not complain; however, if we cannot perform well because of the time the system demand physicians feel hindered by this (A2)”.
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Top-down and Bottom-up
The dominant organising contradiction revolves around directing the change process from the top-down, providing centralized direction and control and enabling bottom-up support. The latter contains a decentralized process where decisions are made through bargaining and people have the opportunity to contribute to and take responsibility for the implementation process. Table 5 shows that the struggles of this contradiction are related to the difficulties of establishing a supportive relationship between the two poles. The implementation process struggles with establishing a way that encompasses the benefits of both approaches. However, as the identity demonstrates, the success of the EHR implementation relies on both approaches. This is because although the top-down approach is effective in constructing a framework for the implementation. However it is not an effective approach to stimulate adoption of the EHR system and enable empowerment among its users. The following analysis shows how this contradiction manifests itself differently across the organisational levels among departments and across occupational groups.
Organisational levels. The project team acknowledge that the process is directed from the top-down. One respondent noticed: “The decision that “we” are going to change things is established from the top” (T2). However; they increasingly recognize the need for bottom-up support to create a working system: “It should now be more bottoms-up in order to get the 'hordes' along” (T2). Although the recognition that both approaches are important for realizing the EHR implementation process. The project team leans more towards a top-down approach. This perspective is enforced by previous negative experiences whereby bottom-up support has created a complex process, shaped by a web of compromise which ultimately resulted in: “Something no one within the entire hospital was completely pleased with”. (T1). The fact that a likewise EHR implementation process in a German hospital has outperformed Dutch achievements contributes to this conviction: “In Germany, the process went fluently. Here it is rather participative. We’re busy with generic processes, but some want to work differently? Are we going to allow that or not? These discussions will start next period” (T1).
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departments is that they need to “defend their own boundaries” (B1) against the current dominant top-down approach of the EHR implementation process.
Departments. Analysing the data for the different departments within this case study showed different perspectives about the relationship between the two poles of this contradiction. Figure 5 provides an overview of these different perspectives.
FIGURE 5
Departments’ perspectives on top-down and bottom-up
The content of figure 5 shows that each department is struggling to provide bottom-up support within the context of the top-down approach of the implementation process. Although, each department expresses different involvement with bottom-up support, they all recognize its importance. They acknowledge that the top-down approach needs decentralization of decision making in order to achieve alignment with the specific characteristics of their departments. They suggest the top-down approach is essential to provide the framework of action but is must not dominant their capability to contribute to the EHR implementation process.
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illustrates this by stating: “They (dep. C) are autonomously working to create an EHR system based on their views on how they think the system must be established.”(T3).
Occupational groups. Analysing this contradiction across occupational groups shows different perspectives about this contradiction. Managers indicate that a top-down approach is necessary for realizing a consistent EHR implementation across the organisation. However, they denote that each individual has the responsibility to support this process from the bottom-up: “I think that we all are responsible for the progress of the implementation process, you cannot leave everything for the EHR project team” (B1). They recognize that everyone has to take this responsibility in order to make sure that the quality of the EHR implementation reaches its full potential.
Physicians notice that a top-down approach is not a constructive approach for the EHR implementation process, especially when this approach ignores their role for providing bottom-up support. As such they demonstrate not so much confidence in those who represent them during the implementation process: “You can formulate all kinds of things, but eventually we do not have any influence on what is decided. We’ll see. I do not expect much of it” (B2). Physicians expect that the will be involved in the process, however they do not express assertiveness to realize this. Instead they believe that those responsible for the implementation process (project team) must facilitate ways by which those responsible for the operational process can provide bottom-up support: “The pitfall of this kind of organisations is that al lot of people not involved with the operational process, think of all sorts of things directed at this process… Instead they need to involve the users more” (D2).
Nurses’ dominant feeling with regard to this contradiction is that they feel that the top-down approach is dominating their capability for providing input: “Sometimes that is a shame, because more has to be decided by the use” (A3). They support the perception of physicians about the negative balance between their capability of providing bottom-up support and the level they demand.
Integration and Differentiation
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for more integration and those that demand to refrain from more integration of identities and relationships. The identity explains that both poles of this contradiction are necessary aspects for the EHR implementation. For example, integration contributes to ways by which the implementation processes can realize cohesion and synergy to support the implementation process. Differentiation on the other hand is required to allow specialization within the organisation. This enables organisational members to develop their unique capabilities by which they in return can contribute to implementation process.
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Departments. Figure 6 shows how the different departments react to the effects of the EHR implementation process on their identity and the relationships between departments.
FIGURE 6
Departments’ perspectives on integration and differentiation
Figure 6 shows that there are differences between the departments in regard to the belonging contradiction of integration and differentiation. Departments A and D demonstrate are in favour of integration. Department C, favours its distinct character and does not demand more integration. However, they recognize the contribution to multidisciplinary work; they think their identity must remain unique of those of others to support their function. Department B also favours differentiation. They express that integration within their organisation is not beneficial to their operations. Although they recognize that integration outside the boundaries of their organisations would be an improvement to provide better healthcare to patients: “We’d hoped that all clinics would participate” (B1).
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have to perform; a lot of administrative activities are now performed by physicians.”(B2). This quote demonstrates that increasingly administrative roles are becoming integrated within the functions of physicians. Another example of the belonging contradictions among occupational groups is the notion of a nurse: “A lot is coming our way at the moment. What exactly remains our work these days?”(B3). This struggle relates to the increasing ambiguity of nurses’ identities. Their activities shift more towards administrative tasks. This creates a struggle of coexisting roles with those of administrative workers. Stability and Change
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Organisational levels. The project team advocates that change is necessary for the organisation to adjust to future demands. They see the implementing the EHR process of paramount importance and achieving this requires letting go of past practices. Their experiences with the ‘improved’ operations concerning the EHR implementation support their belief: At one department we have designed a framework for multidisciplinary consultation. We presented this at another department. They responded: “We thought that we were performing really well but this is a lot better. This needs to be the new standard for the whole hospital” (T1). The project team therefore stimulates ways by which departments can embrace the changes and build on their past practices in order to build the future: “We provide lessons, e-learning. And make sure that there is always someone they can call”. Departments are less enthusiastic to embrace the changes imposed by the EHR project team. They feel threatened by the changes and in response they cling on their current level of stability: “People dread the period of transition. You have to imagine that when you are working on the clinic and you cannot reach your record that’s a bad and embarrassing. I have my doubts if that is well organised” (A2). However, all departments do demand changes to their current process. They feel that the EHR implementation can support their operations in order to provide better healthcare to patients.
27 FIGURE 7
Departments’ perspectives on stability and change
Figure 7 shows that department C is not yet willing to let go of current practices in order to establish a future concerning the EHR implementation. They demonstrates active involvement in the EHR system, however they need more convincing before engage with departing from their current system and adapt to the imposed future. Department B also demonstrate to apprehension to converge from their current level of stability. This perspective derives from their disbelief about the benefits of the EHR system to their operations. Other departments are willing to diverge from their current stability and engage with the changes of the EHR implementation in order to establish a break from the past.
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their current operations: “The medical staff has previous experience with applications within the hospital, therefore they are more sceptical”(C3) or: “The promise is that things will improve; however I don’t believe any of it because experiences has learned that you’ll only receive more work” (D2). As such they are not declaring effort to move beyond their current level of stability and invest in building upon their current practices in order to establish a future. More research is required to analyse the existence of learning contradictions within each occupational groups. Although the data did reveal some insights into the different perspectives of occupational groups on this contradiction. There was few consistency between their answers which limited the analysis of common perspectives.
Result Analysis
The results of showed that there exist different perspectives on the emerged contradictions within the EHR implementation process. This section provides reflection of the results by explaining why these different perspectives exist among organisational levels, across departments and between occupational groups.
Table 6 illustrates the distribution of the different perspectives towards the emerged contradictions for both the project team and for all departments. This table summarizes the findings of the results and the differences of interpretation will be discussed in the following of this section.
TABLE 6
Perspectives on the emerged contradictions for project team and departments Uniformity and flexibility Top-down and bottom-up Integration and differentiation Change and stability
Project team Uniformity Top-down Integration Change
D ep a rt m en ts
A Uniformity Bottom-up Integration Change
B Uniformity Bottom-up Differentiation Stability
C Flexibility Bottom-up Differentiation Stability
D Uniformity Bottom-up Integration Change
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“Department D closely cooperates with department X. This must have influence of the EHR implementation process” (T3). Department C, on the other hand, is not involved with others: “Department C is working actively for themselves. They are explicit in what they want and what not. They think they are highly special because their work is rather different from other departments… they operate independently” (T3). As the results show both departments A and B both differ according their interaction with other departments; whereas department A is involved with other departments department B is not. However department B does support uniformity. This again can be explained by the level of multidisciplinary work which differentiates department B from department C. Multidisciplinary work involves inter-organisational collaboration. The project team explains in the results that they experience similar perspectives of this contradiction with those departments involved with multidisciplinary work. This is supported by the results in table 6.
The similarity of perspectives among departments for the contradiction of top-down and bottom-up can be explained as a reaction to the approach of the project team: “The process is rather prescriptive, rational and analytical, which collided with the world of healthcare” (T2). As the results showed departments demand an increase of bottom-up support to supplement the EHR implementation where they believe is necessary. Another explanation derived from the results directly relates to the different organisational levels where both groups operate. This influences the perspective of both groups about the scope of the EHR implementation process. The project team is more focused the organisation as a whole and departments are more focussed on their own operational processes. This is illustrated by the notice of one project team member who explains that the proactive bottom-up support of department C is not beneficial to the total implementation process because they seem to overlook the fact that: “They are part of a larger whole” (T3).
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The differences between departments in relation to the stability and change contradiction can be explained according their different nature of their operations. A project team member explained that those departments involved with analysing and research are less willing to let go of the past and invest efforts in engaging with the change. Departments, who are more practically involved within the healthcare operations are more willing to engage with the changes: “It is typically for this department to highlight challenges. That is because of their nature. Others are more practical, they act first” (T1). However in the case of department C this does not explain much. This department however is clinging on to their current system because they demand different types of change than imposed by the EHR implementation. They represent mistrust in the organisation-wide efforts to realize changes directed to their operational practices through which they cling on to their current system.
In the following section the differences of perspectives across occupational groups will be explained according the results. Table 7 shows these different perspectives about the contradictions within the EHR implementation process across occupational groups. This table shows that not for all contradictions perspectives of occupational groups could be distinguished. In the case of the managers perspectives on integration and differentiation this was not possible because the data did not contain explicit information about their perspectives. In case of the contradiction of change and stability again no distinguishing of perspectives could be derived from the data for each occupational group. This was because of lack of inconsistency between the answers of group members and the fact that they based their answers on mere speculations.
TABLE 7
Perspectives on the emerged contradictions for occupational groups
The analysis of the contradiction of uniformity and flexibility shows that each occupational group expresses different perspectives towards this contradiction. Managers demonstrate a mixed perception as the results shows their perspectives towards this contradiction are ambiguous. Physicians support Occupational groups Uniformity and flexibility Top-down and bottom-up Integration and differentiation Change and stability
Managers Mixed Mixed - -
Physicians Flexibility Bottom-up Differentiation -
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flexibility. This can be explained because of their specialistic working practices. The results indicate that physicians fear the implications for uniformity on their operational practices. Nurses are involved with more generic processes and therefore are more capable of recognizing the benefits of increased uniformity.
The differences within the contradiction of top-down and bottom-up can be explained by the different roles of each occupational group within the organisation. Managers again display a mixed perception towards both poles of this contradiction. This can be explained by their position; they are responsible for both facilitating the needs of their department and to the organisational as a whole. Physicians and nurses are both more involved with their own operations and such they demand bottom-up support to instruct the EHR implementation with their knowledge and specific demands.
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DISCUSSION AND CONCLUSION
This paper has addressed the question How can we understand EHR implementation by identifying and analysing emerging contradictions? A dialectical perspective was adopted according the assumption that this perspective would enable to identify and analyse emerging contradictions in EHR implementation. Indeed taking this perspective allowed to identify four types contradictions and analyse them according the different perspectives of stakeholders across organizational level, among departments and across occupational groups. The identification of the emerged contradictions was guided by the conceptual framework of organizational tensions of Smith and Lewis (2011) which was not yet applied to EHR implementation. These categories of tensions all represent different aspects of organizational life which are all represented within EHR implementation. The analysis of the different perspectives of stakeholders of different groups in the organization provided deep understanding of the different expectations and demands involved in EHR implementation. This promotes the understanding of contradictions in EHR implementation and their influence on the implementation process. EHR implementers can benefit from this by choosing ways to deal more with these contradictions effectively. Together the identification and analysis of contradictions by though a dialectical perspective promoted the understanding of which contradictions emerged and why and among whom these exist within the context of EHR implementation.
In the following part of this section the findings of this research will be discussed and compared with existing literature and other relevant studies to support the empirical evidence. Furthermore, this section describes the limitations of this research and possibilities for future research. Finally, the theoretical and managerial implications will be explained.
Uniformity and Flexibility
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involvement with multidisciplinary work. Departments that support the increase of multidisciplinary work embrace uniformity in contrary to those that demand a department specific design. However even though all departments would eventually be involved with this type of work the contradiction between uniformity and flexibility will continue. This is given that fact that different departments in hospitals have different needs and need different ways of managing their information (Grimson, 2001). Therefore, an EHR system must enable diversity and be adaptable to specific needs. EHR implementers must be aware of the consequences of the adoption of a uniform system to the specialist practices of hospitals. The different perspectives of occupational groups indicate that not all groups support the creation of generic processes. This draws on the level of specialization of practices for each occupational group. The higher the level of specialization the more difficult it is to integrate them within a uniform system (Jones, 2007).
Top-down and Bottom-up
The contradiction between top-down and bottom-up emerged due to different perspectives about organising the implementation process. The results of this research indicate the differences between perspectives of this contradiction are the result ofcontextual factors and the change context (Long & Franklin, 2004; Ripley & Franklin, 1982). Contextual factors (e.g. dispersed medical world) create the existence of divergent perspectives that casue the existence of this contradiction. A bottom-up approach can mitigate the influence of contextual factors by promoting inter-subjective agreement among important stakeholders (Hjern & Porter, 1981; Sabatier, 1986). However the change context of a hospital, characterized by its pluralistic nature (Denis, Langley & Boudreau, 1999), demands a top-down approach for realizing a consistent and effective implementation process (Burnes, 2009). This shows that although both approaches are contradictory yet complementary to one another. This is supported in existing literature (Long & Franklin, 2004; Thompson, 2000). Both approaches co-determine whether the implementation is to achieve its indeed outcome (Long & Franklin, 2004; Pressman & Wildavsky, 1984) and therefore both are necessary for achieving successful implementation (Sabatier, 1986). EHR implementers must learn to balance between both approaches in order to benefit from their contributions to the implementation process.
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is undermined. This declares why they demand to be involved, yet express an inactive attitude towards the process.
Integration and Differentiation
The contradiction of integration and differentiation relates to the changing roles and identities according the EHR implementation process. This contradiction is already described in literature of innovation that mentions contradictions of complementarity and contrast (Conway & Steward, 2009). The results show that this contradiction exists because the EHR implementation demands more integration of roles and identities to support the reciprocal interactions among departments, which is not supported by all departments and its inherent occupational groups. According the results homogeneity of departments can explain the differences between their perspectives towards this contradiction. Departmetns which are more heterogeneous demand more integration than those with high homogenteity. From a cultural perspecitve homogeneity can be explained by a high degree of shared values and beliefs demonstrated through a strong culture (e.g. Kilman et al., 1985; Hofstede et al., 1990). A strong culture limits the flexibility of departmetns for integration of identities (Smith & Graetz, 2011; Cawsey et al., 2012). The difference between occupational groups and their department can also be explained by culture. In this case, the shared values of occupational groups resist the integration of roles and identities.
Stability and Change
35 Contradictions
36 Further Research and Limitations
This research showed that during the pre-implementation process of EHR implementation contradictions about the plurality of goals and about structuring and leading the process are most prevalent. This seems logical as the purpose of the pre-implementation phase is to make an assessment of the what (i.e. goals and strategies) and the how (i.e. structuring and leading) of the process. Bjerkness (1991) suggests that during the implementation process contradictions can evolve and others may become more evident. This suggests that during the EHR implementation process tension of learning and belonging can become more evident. Van Fenema et al. (2007) supports this by stating that most conflicts arise during the translation phase where the software is implemented. So further research is required to research the development of these contradictions and how they remain influencing to the EHR implementation process. This will promote the understanding of how contradictions evolve during the EHR implementation process and if the assumption is right about the shifting emphasis of organizational tensions during the implementation process.
The four categories of tensions that form the basis for the identification process of this research are presented individually they are undoubtedly interrelated and influential to one another (Smith & Lewis, 2011). Understanding how these contradictions relate to one another may increase the understanding of their existence on a deeper level. Such analysis may reveal new dynamics between these contradictions which further support promoting the understanding of their influential capacity to the implementation process. Also testing the emergence of the contradictions within these research into multiple context will add to the generalizability of this research. Different contexts cause the emergence of different contradictions (Bjerkness, 1991). This implies that contextual factors play an important role in the creation of contradictions. Comparing the contradictions across multiple cases would substantiate the research findings. This also allows investigating of contradictions that are expressed on an inter-organisational level.
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interviews is that they were conducted in the native language of the interviewees: Dutch. Therefore, the researcher had to translate quotes. This has potential consequences for the objectivity of the interpretations of the data and the increase of researcher bias.
Theoretical Implications
This research has shown that the use of a dialectical perspective in EHR implementation context can promote the understanding of contradictions inherent to this process. This perspective has not yet been applied within the context of EHR implementation. A dialectical perspective contributes to the interpretivist approach in EHR implementation (Greenhalgh et al., 2009). This approach recognizes the implementation process containing multiple realities that are socially constructed and were individuals’ different meanings, frames of references or processes of sensemaking cause contradictions. Though increased understanding about the different perspectives of stakeholders within the process this research moves away from positivist and engineering perspectives on EHR implementation. The adoption of the conceptual framework of Smith & Lewis (2011) showed its applicability for identifying contradiction in EHR implementation context. The adoption of this framework allowed to identify contradictions of different aspects of the implementation process. Analysing the different stakeholder perspectives provides understanding of the complexity of EHR implementation as well as the dynamic struggle between both poles of a single contradiction. Together they provide rich insight in the different perspectives of stakeholders within EHR implementation and increase the understanding how these influence the EHR implementation process.
Managerial Implications
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