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The influence of Electronic Health Records on the
collaboration in and between medical-specialties of a
Dutch teaching hospital.
Master Thesis
MSc BA Change Management University of Groningen Faculty of Economics and Business Nettelbosje 2, 9700 AV Groningen.
February 4th, 2019
Word count: 14048 (introduction – conclusion)
Thesis supervisor: J.F.J. Vos Second Assessor: I.M. de Bresser
Arjen Kooistra
A.kooistra.7@student.rug.nl
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Table of contents
1. INTRODUCTION ... 4
2. THEORETICAL BACKGROUND ... 6
2.1 Electronic Health Records ... 6
2.2 Collaboration in Healthcare ... 7 2.3 Representational theory ... 7 2.4 Theory of affordances ... 9 3. METHOD ... 11 3.1 Research approach ... 11 3.1 Research site ... 11 3.2 Data gathering ... 12 3.4 Data analysis ... 13 4. RESULTS ... 14 4.1 Within-case analysis ... 14 Outpatient clinic A ... 14 Outpatient clinic D ... 17 Outpatient clinic E ... 20 4.2 Cross-case analysis ... 23
DISCUSSION & CONCLUSION ... 30
Implications for research ... 33
Practical implications ... 35
Limitations and opportunities for further research ... 35
REFERENCE LIST ... 37
APPENDIX ... 42
Appendix A: Interview protocols ... 42
Overall interview protocol ... 42
Adapted interview-protocol ... 45
Appendix B: Example of the collected data per outpatient clinic ... 48
Appendix C: Codebook ... 49
Appendix D: Results of the remaining within-case analyses ... 58
Outpatient clinic B... 58
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ABSTRACT
With increasing investments in healthcare information systems, interprofessional collaboration seems to be more and more forthcoming in hospitals. As a result, organizational processes change and consequently, these may alter how healthcare professionals interact and communicate, and eventually collaborate. Electronic health records (EHRs) have been introduced in the 1960s, however, to date only a few studies specify how the introduction of an EHR affects collaboration between collaborating healthcare professionals. Therefore, this study aimed to discover how collaboration between healthcare professionals is affected by professionals’ use of an EHR. By the use of certain collaborative affordances, a qualitative analysis was performed on five outpatient clinics of a Dutch teaching hospital. This study shows that the introduction of an EHR does not change the nature of the collaboration between medical-specialties. However, professional identities of actors from certain function-groups of these medical-specialties do change. As a result, their collaboration with other function-groups was interfered. Interestingly, achieving collaborative advantages of using EHRs in hospitals depends on professionals’ uniform use of collaborative affordances. For this reason, this study argues that healthcare professionals use’ of EHRs should be guided by hospital-wide policies that steer healthcare professionals to use an EHR in uniform manners.
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1.
INTRODUCTION
Healthcare evolves worldwide and “the foundational realities driving the revolution are similar throughout the world: the growing costs of care, aging and growing populations, and the emergence of worldwide epidemic conditions, such as obesity, diabetes, heart disease, Alzheimer’s disease, and cancer” (Edelstein, 2017; McKinsey & Company, 2013). Interprofessional collaboration is seen as a key factor for the achievement of better effectiveness in health services and may therefore be a solution to address the changing demands of healthcare (D’Amour, Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005; Edelstein, 2017; Oandasan et al., 2006). Moreover, with increasing investments in information systems, more collaborative and integrated teams seems to be more and more forthcoming (Green & Johnson, 2015).
Collaborative care is assumed to have a higher quality of live in palliative care (Ferrell et al., 2015), better understandings in patients’ needs by pooling knowledge from different medical domains (Abramson & Mizrahi, 1996; Jessup, 2007) and is generally seen to improve healthcare processes (Zaharatos, 2006). Symptoms of today’s patients are often more complex, therefore, their treatment generally require several specialties to collaborate (Lumague et al., 2006). In order to collaborate efficiently, different specialties have to share expertise, knowledge and skills, integrate information, and work as a team (Lumague et al., 2006; Nancarrow et al., 2013). Interestingly, Medical specialists of intensive care units appreciate the potentials of an electronic health record (EHR) to increase common ground of patients’ plans of care (Collins et al, 2011), but contrarily is observed that interdisciplinary communication is currently poorly supported (Jiang, 2017).
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2013, p. 663). Affordances are potentials for behaviours that arise from the relationship between an artefact (e.g. an EHR) and goal-oriented actors (e.g. Medical specialists) to achieve immediate concrete outcomes (e.g. interprofessional collaboration) (Strong et al., 2014). As healthcare professionals’ goals can be divergent (Boonstra, van Offenbeek, & Vos, 2017), it must be clear from what perspective the use of an certain information system is analysed (Burton-Jones & Volkoff, 2017).
Recently, Bardram & Houben (2018) show that EHRs consists of four collaborative affordances, namely: Portability, Collocated access, Shared overview and Mutual awareness. Collaborative affordances are potentials for action that enable collaborative action and workflow among actors. This research elaborates how professionals’ use of collaborative affordances affects the collaboration of healthcare professionals in five outpatient clinics of a Dutch teaching hospital. Therefore, the aim of this study is to explore how the use of collaborative affordances of an EHR affects (supports or impedes)
collaboration in and between specialties of outpatient clinics.
Several gaps exist in the theory of effective use. Recent studies on this theory take an individual- Jones & Grange, 2013), organizational- (Strong et al., 2014) or multilevel approach (Burton-Jones & Volkoff, 2017). Literature gaps exist in the departmental level of analysis (Burton-(Burton-Jones & Grange, 2013; Strong et al., 2014; Volkoff & Strong, 2018) because affordance actualization by groups may differ since groups of individuals are more likely to be affected by social forces that may affect how well, or even whether affordances will be actualized (Bloomfield, Latham, & Vurdubakis, 2010; Thapa & Sein, 2018; Volkoff & Strong, 2018). This study extends the research of Strong et al. (2014) on affordance actualization by analysing how collaborative affordances are actualized in and between departments. Moreover, it extends the literature on collaborative affordances of Bardram & Houben (2018) by showing that EHRs consist of two other collaborative affordances. To do this, a case study approach is used since this is an effective method for theory development (Aken, Berendsen, & Van der Bij, 2012; Blumberg, Cooper, & Schindler, 2011).
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Finally, results are compared with current literature in the discussion and conclusion with implications for further research.
2.
THEORETICAL BACKGROUND
How the use of an EHR may lead to organizational benefits depends on various factors. One of these factors is how actors use an EHR. Therefore, the theory of effective use is developed to gain better understanding in actors’ use of information systems. Burton-Jones & Grange indicate (2013, p. 635) that theory of effective use is underdeveloped and describe effective use in general. They clearly indicate the difference between use and effective use: when actors “use” a system they “perform an goal-directed
activity” (Burton-Jones & Straub, 2006, p. 235) and when actors “effective use” a system they “use a system in a way that helps attain the relevant goal” (Burton-Jones & Grange, 2013, p. 663). To date,
research has not yet determined how effective use is realized by groups of individuals (Burton-Jones & Grange, 2013; Strong et al., 2014; Volkoff & Strong, 2018). Therefore, this study aims to describe how effective use of certain collaborative affordances is realized in and between (different) healthcare departments. To do this, first brief introductions on the history of EHRs and collaboration in healthcare are provided. Hereafter, the theoretical underpinnings of the theory of effective use are discussed.
2.1 Electronic Health Records
EHRs are introduced in the 1960s and provide “a documented record of care that supports present and
future care by the same or other clinicians” (International Organization for Standardization, 2005, p.
15). The contained data in EHR provide “a means of communication among clinicians contributing to
the patient's care” (International Organization for Standardization, 2005, p. 5). EHRs have been
introduced to improve clinical documentation, shared decision making, coordinate and monitor care, save healthcare costs and are a mean to deliver high-value care (Hillestad et al., 2005; Kuhn et al., 2015; Nguyen, Bellucci, & Nguyen, 2014; Strong et al., 2014; Walker et al., 2005). Moreover, EHRs can enlarge the common ground between Medical specialists (Collins et al., 2011; Olson & Olson, 2000). Interestingly, Olson & Olson (2000) indicate that common ground between professionals is an important component for good communication and collaboration. However, little is known how professionals’ use of an EHR actually affects professionals’ common ground and how this consequently affects collaboration in hospitals (Chase, 2015).
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component for efficient collaboration. Accordingly, the manner how healthcare professionals interact and eventually collaborate may change. To understand what collaboration in healthcare constitutes, first more theory is provided on collaboration in healthcare.
2.2 Collaboration in Healthcare
The relevance of collaboration in healthcare is growing and visions for more collaborative care seem to be more forthcoming in both academic literature (Fewster-Thuente, 2008; Oandasan et al., 2006; Romanow, 2002) as in today’s practise (Elsevier, 2013). To describe collaboration in healthcare, this study adopts the following working definition: collaboration is “a complex phenomenon that brings
together two or more individuals, often from different professional disciplines, who work to achieve shared aims and objectives” (Houldin, Naylor, & Haller, 2004, p. 41). This definition includes different
healthcare professionals who try to reach a common goal (Fewster-Thuente, 2008) and has in that sense common ground with the theory of effective use.
Distinctions can be made in the degree of collaboration. Firstly, multidisciplinary collaboration points to departments that utilize “skills and experience of individuals from different disciplines, with each discipline approaching the patient from their own perspective” (Jessup, 2007, p. 1). These disciplines work independently on disciplines-specific care plans that are implemented together, but are not an integrated approach to care (Department of Health & Human Services, 2003). Secondly, interdisciplinary collaboration integrates separate discipline approaches into a single consultation (Jessup, 2007). Stated differently, healthcare professionals that work interdisciplinary build on each other’s expertise and skills to attain mutually defined goals (Fewster-Thuente, 2008). However, how healthcare professionals collaborate effectively depends on several conditions. For instance, the development of clear goals and rules, respect and trust between actors, clear organizational structures, and organizational support may help groups to work collaborate more effectively (Youngwerth & Twaddle, 2011).
Recent evidence show that healthcare professionals’ goals can be divergent (Boonstra et al., 2017). Consequently, collaborating actors can have divergent goals to use an EHR and can accordingly have different patterns of use. As a result, particular actors and/or departments may use an EHR less extensively that could possibly decrease the quality of their documentation (Chase, 2015). Accordingly, a lowered quality in documentation may decrease healthcare professionals common ground. Therefore, the representational theory is adopted as a theoretical lens to assess how the quality of the documentation in EHR affects collaboration between different healthcare professionals.
2.3 Representational theory
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structures and surface structures. Physical structures are the physical objects actors can touch (e.g. physical computer devices), deep structures are the scripts of a system (e.g. scripts in an EHR that determine how patient data is being processed) and surface structures enable actors to work with the system (e.g. the dashboard that actors use to interact with the system).
Burton-Jones and Grange (2013) argue that information systems are used to create representations of the world that are easier and better to obtain than without the information system. The world is represented in information systems by means of system representations. A requirement for system representations is that they need to faithfully track the real-world domain it is intended to model (Wand & Weber, 1990). In actual practice, actors use system representations to generate changes in the real-world domain more easily (Burton-Jones & Grange, 2013). For example, patient-related data can be shared more easily between locations in an EHR compared to paper-based health records: paper-based health records are bound to a certain physical area, the data of an EHR is not restricted to a physical area since it can be shared through the system. As a result, healthcare professionals are better supported to assess health-related information from remote locations and may accordingly be better supported to provide care.
As an EHR often contains data of different specialties, it provides the potential to increase the common ground between different healthcare professionals. Nevertheless, common ground between different specialties might only increase when an EHR faithfully represents the real-world domain. Therefore, Burton-Jones & Grange (2013) define the following requirements for system representations in order to be able to effectively use an information system: system representations need to be truthful and faithful (e.g. EHR-data is consistent with reality), and understandable (e.g. the EHR must consist of a structured lay-out).
Interestingly, an EHR can be classified as an information system that is used as resource to support other work (Gasser, 1986). Burton-Jones & Grange (2013) proposed two goals to use information systems: lower-level goals (realizing effective use) and higher-level goals (realizing performance). Accordingly, actors’ performance can be measured by analysing to which degree actors, departments and/or organizations achieved their desired goals by means of the information system (Burton-Jones & Grange, 2013). Since an EHR is seen as a resource to complete other work, is an EHR not the only factor that determines whether healthcare professionals may use an EHR as a tool to collaborate.
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2.4 Theory of affordances
A well-built system does not guarantee the benefits that are initially designed by developers and can therefore not be taken for granted (Soh & Sia, 2005). Therefore, the theory of affordances is developed as a theoretical lens to understand the relationship between actors and information systems (Leonardi, 2011). The basic principle of this theory is that information systems provide affordances for action-possibilities. Subsequently, actors first have to perceive and then actualize these affordances in order to be able to effectively use an information system. Gibson, the founder of the theory, argues (1979, p. 127), “perhaps the composition and layout of surfaces constitute what they afford. If so, to perceive
them is to perceive what they afford”.
The theory of affordances recognizes the influence of actors and looks to an information system in terms of what it affords or constrains actors to do (Leonardi, 2012; Majchrzak & Markus, 2012; Zammuto et al., 2007). As Gibson argues (1979, p. 127): “affordances of the environment are what it offers the
animal, what it provides or furnishes, either for good or ill. The verb to afford is found in the dictionary, the noun affordance is not. I have made it up. I mean by it something that refers to both the environment and the animal in a way that no existing term does. It implies the complementarity of the animal and the environment.”. Thereby, Strong et al. (2014) show that affordances are potentials for behaviours that
arise from the relationship between an artefact (e.g. an EHR) and goal-oriented actors (e.g. Medical specialists) to achieve immediate concrete outcomes (e.g. interprofessional collaboration).
The theory takes the material in consideration but also recognizes the influences of actors: what opportunities do actors get from an information system in relation to the goals of the actors themselves. Leonardi (2011) considers this relationship between human and material agencies as an “imbrication”. Imbrications are the ongoing interactions between actors and technologies and are expressed in the form of organizational routines that actors use to fulfil their job (Leonardi, 2011). Strong et al. (2014) show that EHRs provide affordances to coordinate, monitor, standardize and integrate care, capture, access and use data about patients, substitute healthcare professionals, swift work across roles, and use more information in clinical decision making. More recently, Bardram & Houben (2018) show that EHRs also consist of collaborative affordances that enable collaborative action and workflow among different actors. In their study, Bardram & Houben (2018, p. 8) define collaborative affordances as “a relation
between a [physical and/or digital] artifact and a set of human actors, that affords the opportunity for these actors to perform a collaborative action within a specific social context”.
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mutual awareness (see Table 1) and argue that their concept might be broaden by identifying other collaborative affordances.
As stated earlier, affordances can also exist without being perceived by actors (Gaver, 1991). Affordances are in that sense primarily useful when actors recognize them as useful (Gibson, 1979; Volkoff & Strong, 2018). Stated differently, EHRs provide certain affordances that are built into the system by an EHR-provider with certain actors in mind. However, advantages of the use of these affordances depends on how actors perceive and actualise these affordances (Strong et al., 2014). Therefore, it is more likely that actors’ use of an information system is more effective when affordances are perceived as useful and actors thereupon mindful actualise these affordances (Volkoff & Strong, 2018).
Table 1: The earlier found collaborative affordances by Bardram & Houben (2018)
Burton-Jones and Volkoff (2017) indicate that the effectiveness of actor’s system-use is ultimately dependent on the actions that actors take and the subsequent consequences of those actions. Moreover, Volkoff & Strong (2018) show that the affordances are not actualized in a vacuum. That is, contextual factors may influence how actors perceive and/or actualise affordances. For example, strong et al. (2014) indicate the role facilitating conditions of the organizational context in actualising affordances of an EHR. They show how a hospital that implemented an EHR convened improvements meetings to share affordance actualization ideas across different departments. As a result, ideas to actualise certain affordances emerged across departments. More recently, Thapa & Sein (2018) supported this finding by showing that certain facilitating conditions (personal, social and cultural arrangements) were needed to actualise certain affordances in a remote telemedicine project in Nepal.
By the use of a “Trajectory of affordances”, Thapa and Sein (2018) demonstrate how affordances are first perceived, then actualized and later aggregated to form a bundle of affordances. Moreover, the authors show that interrelations can exists between different affordances. For example, they show how actors actualise certain affordances and how this may lead to outcomes in which new affordances
Affordance Affords the ability to
Portability Carry, manoeuvre and navigate health records among locations.
Collocated access To support quick and flexible navigation and simultaneous access to update multiple documents.
Shared overview Collective build and share an overview of information.
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emerge. As EHRs consists of multiple collaborative affordances, this study makes use of these findings to elaborate if such interrelations also exist between collaborative affordances.
3.
METHOD
3.1 Research approach
A multi-case-study is adopted to elaborate how actors’ use of collaborative affordances of an EHR influences collaboration in and between outpatient clinics. This approach offered the opportunity to conduct five within-case analyses. Moreover, it offered the second advantage to conduct an overarching cross-case analysis. The research is conducted in five outpatient clinics that all consist of multiple specialties. This research approach has been taken since there is currently no existing theory that offers comprehensive answers on the quest how the use of EHRs influences collaboration between healthcare professionals in different organizational settings. By the use of a multiple-case perspective, the study is able to create an understanding in how an EHR influences collaboration in two contexts: in departments and between departments. Therefore, this theory-building approach is embedded in empirical data and is likely to deliver theory that is accurate, interesting and testable (Eisenhardt & Graebner, 2007). In this way, the study contributes to the development of contextualized theories of effective use (Burton-Jones & Volkoff, 2017).
3.1 Research site
This study is conducted in a large teaching hospital in the Netherlands in which the EHR was implemented organization-wide approximately a year before this study was carried out. Before the implementation of the EHR, departments had their own applications to support their healthcare processes. After go-live of the EHR, several hospital-wide policies were developed for the use of certain functionalities of the EHR, however, sanctions for using the EHR inconsistently to this policy were lacking. In particular, guidelines for the use of two specific functionalities (Medical history and actual Problem-lists) were still being developed at the time that the study was carried out.
The research site was useful as it consists of many outpatient clinics that differed in the degree of interdependence, number of specialties and type of care. Interestingly, each department had its own management board. This resulted in clear differences how the EHR was implemented in each outpatient clinic. Therefore, this research site was suitable for a multiple-case-study. Moreover, the structural characteristics of each outpatient clinic provided an interesting opportunity to analyse how these (e.g. degree of interdependence) possibly affected collaborative affordance actualization.
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internal documents of the hospital showed later that in most outpatient clinics specialties were incorporated that had no medical overlap. Consequently, opportunities to work in a more multidisciplinary manner were not truly increased in most of the outpatient clinics. Below a general overview of the outpatient clinics is to be found (see Table 2).
Table 2: Description of the selected outpatient clinics in a Dutch teaching hospital
MA: Head of the Medical administration, MS: Medical specialist, NS: Nursing specialist, MI: Medical-Intern, MM: Medical manager, BM: business manager
3.2 Data gathering
Four function-groups were selected based on three perspectives on collaboration. That is, from medical perspectives, managerial perspectives, and supportive, administrative points of view. At least one Medical specialist was interviewed per outpatient clinic as Medical specialists were the only fully-authorized function-group in the EHR. In particular, Heads of the Medical administration and Medical specialists were chosen since the administrative burden was moved from the Medical administration to the Medical specialists with the implementation of the EHR. Hereby, their professional identities were possibly challenged with possible consequences for their mutual collaboration.
Interviewees were selected with help of two managers highly involved in the EHR-implementation. Initially, only function-groups were selected who had a function in the delivery of care or who had a management function. Therefore, Heads of the Medical administration (MA), Medical specialists (MS), Medical managers of the outpatient clinics (MM) and Business managers of outpatient clinics (BM) were selected. Interviewees were contacted by mail to get approval. Thereafter, appointments were scheduled. After several interviews, two more function-groups were selected on the advice of several interviewees, which were Nursing specialists (NS) and Medical-interns (MI). These function-groups were recommended by several Medical specialists as they argued that much of their collaboration took place with Nursing specialists and Medical interns. Table 2 provides an overview of the selected interviewees.
In total, 29 interviewees were interviewed. 24 interviews were conducted at the focal hospital together with another researcher who had a similar research focus. Three interviewees indicated that they preferred an EHR-expert during their interview, which resulted in three dual-interviews. Moreover, two extra interviews with Nursing specialists of a second Dutch teaching hospital were taken by phone after
Outpatient clinic Number of specialties
Medical overlap of specialties
Interviewed professionals (n)
A 3 Medium MS, MM, BM
B 2 Low MS (2), MM, NS, BM, MA, EHR-expert
C 3 Low MS, MM, BM, EHR-expert
D 4 Medium MS (3), NS, BM, MA
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several interviewees argued that the interview-results were possibly negatively biased since the focal hospital was still in the post-implementation phase. The second hospital had already been working with the same EHR for five years, therefore, it was less plausible that the results of these interviews were negatively biased. The outcomes of the second hospital were used to verify, substantiate and broaden the interviews of the focal hospital.
Data was gathered by means of semi-structured interviews as these leave more room for probing. Two interview protocols were used. Initially, one overall interview-protocol was used to interview all function-groups. During the study-period, a second general interview-protocol was developed after it turned out that Business managers and the Heads of the medical administration had less substantive in-depth knowledge of the EHR. Therefore, one Head of the Medical administration was interviewed by means of the overall interview-protocol. Hereafter, the adapted-interview protocol was developed. Both interview-protocols were composed deductively based on four collaborative affordances (Portability, Collocated access, Shared overview, and Mutual awareness) and are to be found in Appendix A. During the research two other collaborative affordances (Messenger and Orchestrator) came forward. Accordingly, questions were also raised about these affordances. Medically-schooled interviewees were interviewed by means of the overall interview-protocol. Therefore, the interviews with Business managers and Heads of the Medical administration were conducted by means of the adapted interview-protocol.
The research started in September 2018 and was finished in February 2019. The actual data collection started October and the last interview was held in December. All interviews were held in Dutch and lasted on average 25-45 minutes. Interviews of the focal hospital were conducted face-to-face together with another researcher and were all voice recorded with the exception of one interview. All participants of the focal hospital were asked to sign an informed consent and are informed about the dissemination of the results. Hereafter, the recorded interviews were transcribed in Dutch.
3.4 Data analysis
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The coding procedure was both inductive as deductive. The deductive coding process was based on four collaborative affordances (Portability, Collocated access, Shared overview and Mutual awareness). The inductive coding procedure was different in nature and codes were generalized from the data (Gephart, 2004). Firstly, emerging themes were described by using a first-order code. Secondly, the first-order codes were classified into groups by the use of a second-order code. Finally, second order codes were aggregated into two collaborative affordances (a Messenger and an Orchestrator) and contextual factors on affordance actualization. The used codebook is to be found in Appendix C. At last, aggregated themes and enclosed first-order and second-order codes were generalized among the cases by using a cross-case table (see table 3, p. 26). The benefit of this approach was that interview-constructs could be grouped. Hereby, opportunities were provided to find other collaborative affordances when data could not be grouped into the deductively derived codes.
4.
RESULTS
This section outlines how the introduction of an EHR can both support as impede collaboration between healthcare professionals. It was found that the EHR was used differently in most cases, this resulted in clear differences how the use of six collaborative affordances (Portability, Collocated access, Shared overview, Mutual awareness, Messenger and Orchestrator) affected collaboration in and between specialties. After it was found that the collaborative affordances were interrelated, the within-case analyses were structured as follows: supporting aspects on collaboration, impeding aspects on collaboration, and contextual factors on affordance actualization. Afterwards, a cross-case analysis is used to show overarching themes that were found by the use of Table 3 (see p. 27).
4.1 Within-case analysis
Since it differed per case to what extent the specialties collaborated, three representative cases are included in the within-case analysis. The included cases were (i) outpatient clinic A, that consists of three specialties that have some medical-overlap and accordingly also collaborate, (ii) outpatient clinic D that consists of three specialties that have no medical-overlap, and therefore, very little collaboration takes place between these specialties and finally (iii) outpatient clinic E that consists of two specialties that work in the same medical-field and accordingly experience their patients as a joint patient. The results of outpatient clinic B and C are to be found in Appendix D.
Outpatient clinic A
Description of the outpatient clinic
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of the patients are clinical complex patients. Interestingly, all these multidisciplinary consultations are provided by the three incorporated specialties.
Supportive aspects on collaboration
Firstly, the Mutual awareness between the three specialties was heavily supported since all function-groups made use of two specific collaborative affordances, namely the Orchestrator and the
Messenger. The Orchestrator is a tool of the EHR to give orders to other healthcare professionals, plan
multidisciplinary meetings and consultations, and so on. In other words, it’s a tool that ensures that the right healthcare professional(s) is (are) doing the right thing at the right time. The Messenger is a tool to send messages (e.g. laboratory results, internal EHR emails, notifications of unfinished letters) to other healthcare professionals by means of the EHR. By the use of these collaborative affordances, Medical specialists were better supported in their collaboration since it was uniformly agreed in this outpatient clinic that these affordances should be used to arrange patient-related affairs. As argued by the Medical manager:
"That is a nice development. We also agreed that we use the messenger as the only means to discuss patient-related affairs. That works really well.” - [A-MM1]
Despite that work-related processes became more efficient, the introduction of the Orchestrator and the Messenger did also ensure that verbal communication between different function-groups was marginalized, as stated by the Business manager:
"I think there is less verbal communication. Also, because we now have the messenger, so they [Medical administrators] see the doctors less in person." - [A-BM1].
Each interviewee expressed that the EHR afforded Portability. Hereby, all interviewees were supported to open health records at different locations by means of a desktop. However, it was expressed that portable health records did not change the nature of collaboration between distinct specialties. One Medical specialist voiced that the nature of collaboration between different specialties might change when the EHR could be opened with other devices such as tablets and smartphones. All interviewees argued that the data (notes, letters, etc.) of each specialty of the hospital was to be found in the Shared
overview, as argued by a Medical specialist:
“There are various specialties that provide information, for example, lab results and photos, that is
now all integrated into the EHR, which is therefore positive." - [A-MS1]
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Impeding aspects on collaboration
A variety of interviewees expressed that the data of different specialties was sorted on priority and not on the chronology of medical interventions. As a result, Medical specialists were impeded to efficiently gain a Mutual awareness in what other specialties were involved in the patient’s treatment. Some negative comments were expressed that the EHR impeded Medical specialists to import photos in the EHR. Accordingly, this interfered them to quickly discuss photos during a meeting. Therefore, photos were not Portable.
Moreover, two interviewees argued that the EHR impeded Collocated access to adapt a single health record what impeded them to collaborate efficiently. Medical specialists were as well obstructed to simultaneously work in a single note during meetings. This negatively affected them to build a clear
Shared overview. As a consequence, the Mutual awareness between different Medical specialists was
decreased, as argued by a Medical manager:
"We are not able to write in each other's notes when we are together with different specialists. We sometimes run into that and that’s really annoying. You always have to create a new note. In the end,
you get hundreds of notes. [..]. That is unstructured and unclear." - [A-MM1] Contextual factors on collaborative affordance actualization
Different system representations, strict role authorizations, and a low involvement of the EHR-provider and the Board of the hospital influenced to what extent collaborative affordances could be actualized. Firstly, only Medical specialists were authorized to adapt health records. As a result, only Medical specialists were able to process the administrative burden, as argued by the Business manager:
"There are really some acts that Medical administrators can do that are now tasks of doctors: such as preparing the letters and completing finances. These are all small actions that take a lot of time of the
doctor." - [A-BM1]
Since Medical administrators were authorized to process the administrative burden before the introduction of the EHR, it was also voiced that “expert-administrators” were looking for other jobs since they did not like their job anymore. The Business manager voiced that this could be detrimental for healthcare since these Medical administrators were an important part of the team.
Secondly, another reported problem was that the EHR had different system representations per medical-context and function-group. Therefore, it was hard for different function-groups to gain a Mutual
awareness during their collaboration. Lastly, it was voiced by the Business manager and the Medical
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disappointed that no response was given by the EHR-provider and the hospital’s board to solve these problems:
"What I am very dissatisfied about - and we already have been talking about that for a year - is that we as a department are turned away like we are a non-problem in a hospital that has a very complex patient population. [..]. We are not helped by the EHR-provider and also not that much by the Board. [..]. It is not only in my department, but also in the [specific speciality], [specific speciality] and some
other specialties. So, it's a really a big problem." – [A-MM1]
Outpatient clinic D
Description of the outpatient clinic
Outpatient clinic D consists of three different specialties. Moreover, it has a separate department where Medical specialists from different specialties highly collaborate to treat patients that have a long medical history. Therefore, the EHR is a critical tool for these Medical specialists to be able to understand the medical-timeline of their patients. Interestingly, the Business manager argued that the three incorporated specialties of this case hardly collaborate:
“We have [mentions three specialties]. Between the [department A] and [department B], we hardly
have any collaboration as these specialisms have no medical interface. [Department C] has more collaboration with [another specialty] for [a specific disease], however, this specialism is not integrated in our department” - [D-BM1].
Supportive aspects on collaboration
Firstly, because health records were Portable in the EHR, Medical specialists were better able to support meetings with other specialties and meetings with neighbouring-hospitals. Secondly, collaboration between different specialties was better supported since data all specialties of the hospital was integrated in the EHR, as argued by the Medical manager:
“We all look at the same screen and go through the same processes. [..]. Previously, a lot of specialties had different types of files that no one could access.” - [D-MM1]
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Impeding aspects on collaboration
The EHR indirectly interfered collaboration during meetings since it lacked to provide a clear Shared
overview. Hereby, Medical specialists had to search for the right information during multidisciplinary
meetings with other Medical specialists that indirectly impeded their collaboration:
“What currently happens at our meeting is that we constantly switch between the different scans,
[specific] results and that kind of things [..]. This has an influence on our process, because when you look at those (shifting) results, you just forget what patient was being discussed.” - [D-MS1].
The same interviewee suggested that this problem could be remedied by using two desktops. Hereby, Medical specialists did not have to switch between different notes and medical-results what positively influenced their Mutual awareness. Secondly, Collocated access to place orders for a single patient or updating a single health record was impeded for all function-groups. This was called into question by a Medical specialist: he argued that he and his (collaborating) colleague worked in a different part of the EHR’s database. Therefore, he could not understand why the hospital, or the EHR-provider chose to impede all function-groups in having simultaneously access to a single health record. Since data was sorted on priority and not on the chronology of events, did the Shared Overview indirectly impede Medical specialists to efficiently gain a Mutual awareness with other specialities:
“It is all in one system, but it is still specialism-specific. [..]. Moreover, it categorizes on priority and not on chronology. Doctors want to see that chronology. This makes working with multiple
specialisms more difficult." - [D-MS1]
It became clear that the hospital did have some policies that prescribed how certain affordances should be used, however, many specialties did not work according this policy. As a result, data was entered differently per speciality what negatively affected the quality of the Shared overview. Therefore, Medical specialists were impeded to efficiently gain a Mutual awareness in the results of other specialties.
Although it was found that multidisciplinary consultations could be planned by means of the
Orchestrator, it was also argued by a Medical specialist that still too little collaboration took place
between different specialties. However, he also argued that it was currently difficult to invite other Medical specialists into multidisciplinary consultations. Therefore, this Medical specialist voiced that this could be seen as a potential improvement for the EHR to further support collaboration between different specialties:
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Moreover, it was mentioned by a Medical specialist that the use of the Messenger and the Orchestrator also led in this outpatient clinic to a more electronic form of collaboration. This was experienced as a negative development since verbal communication between healthcare professionals was seen as more useful to discuss patient-related affairs. A crucial example was voiced by a Medical specialist:
“Certain lab results are so life-threatening that I need a phone call right away. However, currently I get these results in my Messenger with two exclamation points behind it. That's not the problem of the EHR, but a problem of how this hospital organises its processes. [..]. In the past, you were called and
now you just have to find out... Life-dangerous!” - [D-MS3] Contextual factors on affordance actualization
The role of Medical administrators was heavily changed due to strict role authorizations in the EHR. As a consequence, the administrative burden was heavily increased for Medical specialists. Interestingly, both function-groups of this outpatient clinic started to examine what tasks and orders could be returned to the Medical administration, as argued by Business manager:
Well, in the beginning our administrators could not place any order at all, but that is slowly recovering. [..]. I think it's a great thing that when a doctor places an order that this order is processed right after. However, if something goes wrong, then the Medical administration should play
an important role. This is currently not the case.” – [D-BM1]
Secondly, it was clearly indicated by several interviewees that different system-representations per function-group directly impeded their collaboration as it was harder to develop a Mutual awareness, as stated by the Medical specialists:
"A major disadvantage what I notice is that all professional-groups have their own screens. [...]. Therefore, the mutual communication between people who experience a problem in the use of the EHR
is very difficult." – [D-MS1]
It was argued that an effective organizational policy was lacking for the use of the EHR. Consequently, most specialties entered patient-related data in different manners what decreased the quality of the
Shared overview. Therefore, it was hard for Medical specialists to efficiently actualize this affordance
in order to gain a Mutual Awareness in what other specialties did, with negative consequences for their collaboration:
"Colleague x sees a patient of another colleague and is consequently not able to read what happened to the patient. That is friction: “you can refer this patient to me, but first make sure that its’ health
record is documented well." - [D-MS3]
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with the development of an hospital-wide policy for the use of the Medical history and the Problem-lists:
"Together with two other colleagues, I currently write a working method for the Problem-lists and the Medical history. In this policy, we describe how specialties should enter patient-data in a uniform
manner across the whole hospital." - [D-MS2]
Outpatient clinic E
Description of the outpatient clinic
Outpatient clinic E consists of two specialties that focus on the same organ. The specialties do have medical overlap and consequently, their patients are experienced as a joint patient. As argued by the Business manager, only patients with complex syndromes are treated. Before the introduction of the EHR the clinic integrated all administrative processes of both specialties in the legacy system. It was striking to discover that the EHR led to a negative development, as the administrative processes of both specialties were non-integrated again in the EHR.
Supportive aspects on collaboration
It was argued by several Medical specialists and Medical interns that the EHR could support collaboration with other specialties since health records were Portable in the EHR. As a result, both specialties were better able to find specific results (such as notes) of other specialties, thereby increasing the Mutual awareness between these specialties. Although it was argued that a Shared overview of information could facilitate collaboration between different specialties, was it strongly dependent on how other Medical specialists used the EHR, as argued by a Medical intern:
“Basically, it should improve collaboration as long as the information is correct! The information is correct in the notes, however, this is not always the case in the Problem-lists. [..]. I think that many patients that had a surgery have an incomplete health record. So, in terms of shared information, yeah that's a plus, however, not all the information contained in the EHR is necessarily correct.” - [E-MI1].
Several interviewees indicated how the Shared overview could be improved: 1) notes need to be arranged per speciality, 2) information need to be chronologically arranged, 3) it should be more easy to enter data in the Problem-lists and Medical history as actors were currently bounded to certain codes that were developed by the EHR-provider and 4) Medical specialists should to be obligated to enter data or the administrative burden should be returned back to the Medical administration.
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Impeding aspects on collaboration
Firstly, several interviewees indicated that Collocated access was impeded since they were obstructed to work simultaneously in a health record. Although it was not found that this actually impeded collaboration between different specialties, was it found that collaboration between different function-groups was interfered. For example, a Medical intern argued that he was obstructed in his work when he had a joint consultation with Nursing specialists. In that case, the Nursing specialist was already working in the patient’s health record what consequently obstructed the Medical intern to progress the right orders in the Orchestrator. Each Medical specialist and Medical Intern stated that professionals’ current use of the EHR negatively influenced the Shared overview, as stated by a Medical specialist:
“You could hear in the hallway that a number of specialties said: 'were not going to do that [entering
the medical history and problem-lists] anymore' - I will not mention any names. Coincidentally, one of these departments generates half of my patients. So, if they decide to not enter the medical history
anymore, then I'm not going to spend half an hour per patient on it.” – [E-MS1]
As a result, several interviewees argued that they could not trust the contained data of the Shared
overview. Therefore, the Mutual awareness of healthcare professionals from different specialties
decreased due to missing medical-results. Secondly, it was voiced by Medical specialists and Medical interns that photos of two specific specialties could not be opened in the EHR as these specialties did not provide the right authorizations to other specialties. Accordingly, several Medical specialists were interfered to efficiently develop a Mutual awareness when patients were referred from these specialties:
"It is really annoying that in particular photos of [specific department] or [specific department] are not yet visible in the EHR. They have blocked them for us, which is really irritating. Sometimes
patients are referred, but only [the two departments] can see those photos." – [E-MS3]
The use of the Messenger and the Orchestrator was divided. Although most interviewees saw the advantage to use the Messenger between different specialties, did one Medical specialist also express the disadvantage of having to many communication devices during collaboration:
“You have to make choices, you should abolish certain things. It is conceptually very good that the EHR has a communication channel like that, but in practice it is really dramatic. I work with [names a
specialty], who do everything with the Messenger, I work with [names another specialty], who do everything by email. 80% of my direct colleagues do everything by mail, but the other 20% use the
Messenger. I find that really confusing.” - [E-MS1]
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introduction of the Orchestrator and the Messenger. Contrarily, several Medical specialists did argue that verbal communication between different function-groups was decreased:
“The only collaboration consists of the medical spam box (Messenger). [..]. I find that a wondrous
form of communication. A simple call also worked, the collaboration is actually very abstract now.” –
[E-MS2]
Lastly, another Medical specialist argued that he did not make use of the Messenger since it led to an information-overload, what possibly impeded collaboration with other specialties when patients were referred by means of the Messenger.
Contextual factors on affordance actualization
Surprisingly, employees of the Medical administration saw the strict role authorizations of the EHR not as a threat, but as a chance. The Business manager argued that her team was characterized by team members who search for new opportunities what positively influenced how the group actualized the EHR. Moreover, the Medical administrator expressed that she experienced an increase in respect between different function-groups:
"I think that the Medical administration, and certainly how we work here ... other function-groups show more respect! They are like: 'wow they (Medical administrators) can really do something." –
[E-MA1]
On the other hand, both interviewees also argued that they did not understand why the administrative burden was removed from the Medical administration to the Medical specialists. As argued by the Medical administrator:
"At the moment we have the following question: What is registration at the source (enter relevant patient-data in the EHR)? Is that really the Medical specialist or is it also the Medical administrator?
The Board clearly said: 'Only doctors have the understanding to registrate', but we know better than anyone else that doctors don’t always have the right administrative understanding. [..]. I think the
boundary has not yet been determined.” – [E-MA1]
Each Medical specialist argued consistently with this statement and voiced that they were better supported in their job before the introduction of the EHR:
"That is a foul of the EHR! The hospital did some financial cutbacks at the same time: the disappearance of the entire administrative staff [..]! It is a huge difference if you compare that with
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Lastly, several interviewees argued that different system representations impeded different function-groups to collaborate well. Moreover, the effects of a lacking organizational policy are sufficiently covered in the impeding aspects on collaboration.
4.2 Cross-case analysis
Several similarities and contradictions were found how the use of collaborative affordances affected the collaboration in and between specialties of five outpatient clinics. For example, some indications showed that Medical specialists were better supported to create a Mutual awareness by means of the EHR. Therefore, collaboration between different specialties was better supported. Table 3 shows how six collaborative affordances of the EHR affected (supported or impeded) collaboration in and between (different) specialties. The third column, influence on collaboration, is derived from overarching themes that were found in each outpatient clinic. After highlighting how each collaborative affordance affected collaboration, more details are provided about contextual factors that played an important role in the actualization of each collaborative affordance.
Portability
A common view among the cases was that information of each specialty was integrated in the EHR. The legacy system already provided this functionality for health records, however, the EHR ensured that personal notes of Medical specialists were now also integrated. Several function-groups voiced the importance to collect data of all specialties since it led to an increased Shared overview of information. Based on the Shared overview, Medical specialists were better enabled to efficiently gain a Mutual awareness. Therefore, collaboration between different specialties was better supported since Medical specialists had more sufficient information to act on. This was mainly expressed in outpatient clinics (A, C, D) that consists of highly collaborative specialties. However, although access to more integrated information facilitated collaboration between different specialties, did it not change the nature of the collaboration.
In three cases, Medical specialists argued that imported photos in the EHR were sometimes still bounded to certain specialties. Through this, Medical specialists of outpatient clinic A, C and E could less efficiently gain a Mutual awareness with departments that provided these photos. As a result, Medical specialists were not able to discuss these photos during meetings. This was experienced by several Medical specialists as a negative influence on collaboration. Moreover, it was argued in all cases that health records of hospitalized patients were still bounded to certain medical-domains. Therefore, Medical specialists could only access these health records when they logged into the right domain. However, no evidence was found that collaboration was affected.
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was interfered what negatively affected several Medical specialists to efficiently gain a Mutual awareness. Accordingly, the efficiency of their collaboration was decreased. Lastly, outpatient clinic B has many collaborations with external parties such as research institutions. Therefore, the Business manager indicated the difficulty to share relevant EHR-data with these parties:
“I find it a big disadvantage that we can’t easily get reports from the EHR. We can’t do that ourselves: we are constantly dependent on others! [..]. But, we as [specific speciality] have to share
lots of data with external agencies and we struggle with that for a long time.” - [B-BM1] Collocated access
Firstly, it was voiced in all cases that the EHR impeded actors to simultaneously adapt health records. Interestingly, most interviewees argued that the collaboration between different specialties was not interfered since “patients could only be at one location at a time”. However, multiple Medical specialists of all outpatient clinics argued that they were frequently impeded to place orders when another colleague already worked in the same health record. Hereby, the collaboration between professionals that worked at a different location was not actually interfered, however, it did not contribute to efficient healthcare processes as some actors were sometimes interfered in their job. Secondly, it was striking to discover that several function-groups were frequently obstructed when they collaborated in the same office or clinic. For example, three Medical specialists and Medical interns of outpatient clinic E argued that they were temporality disabled to complete their work during joint consultations with Nursing specialists. In those situations, only one actor had access to the health record. Hereby, the other actor was not able to progress orders or relevant-data in the EHR. This was called into question by a Medical specialist because he was convinced that actors often worked in a different part of the EHR’s database. Therefore, this Medical specialist could not imagine why it was obstructed to simultaneously work in one health record. Moreover, he argued that it would only make sense to impede Collocated access when professionals worked in the same part of the EHR’s database.
Thirdly, an exceptional number of notes were created in the EHR as notes could only be adapted by the owner of the note. Accordingly, concerns were expressed in outpatient clinic A, C, D and E about the quality of the Shared overview since it was tangled up by dozens of notes of various specialties. Lastly, Medical specialists were impeded to collaborate well during Multidisciplinary meetings when they only had access to one desktop. In that case, Medical specialists had to switch between medical-results and the notes of the meeting what made it difficult to remember what patient was discussed. Interestingly, it was also voiced that this could be solved by using a second desktop.
Shared overview
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priority and not on the chronology of events, Medical specialists of all cases were impeded to easily understand what happened in the medical-timeline of their patients. Interestingly, interviewees of outpatient clinic B, D and E expressed that hand-written notes were a thing of the past because notes were now entered digitally in the EHR. Therefore, Medical specialists were “finally” able to read and understand the notes of their colleagues.
In each outpatient clinic, Medical specialists voiced that the Medical history and Problem-lists of patients were not useful to gain a Mutual awareness with other specialties. Two causes were found. Firstly, specialties had different preferences in what information was important for providing care. Therefore, most specialties entered data in different manners. Therefore, the contained data was still specific per specialty, making it less useful for other specialties. Secondly, it was even argued that some specialties did not make use of the Medical history and Problem-lists. Accordingly, friction arose between specialties when patients were referred with an empty health record. Interestingly, (some specialties of) outpatient clinic A and C developed a uniform policy for the use of the Medical history and Problem-lists. As a result, all Medical specialists of these specialties entered the required data. The importance of having an integrated information-resource in order to provide high-quality care was expressed by many Medical specialists. For example, for some outpatient clinics (D & E) the Medical history and Problem-lists was of high importance since these clinics often treat patients with an extensive medical history. However, as stated earlier, concerns were raised about the quality of the contained data. Therefore, interviewees of outpatient clinic D and E voiced that they did not make use of the Medical history for their medical-consults and surgeries because they simply did not trust the stored data. To be more specific, several Medical specialists and Medical interns voiced that important information was missing occasionally in the Medical history and Problem-lists. Consequently, these interviewees explicitly read letters (contained in the EHR) to develop a Mutual awareness with other Medical specialists.
Thirdly, data of the Medical-history and Problem-lists were bounded to certain codes of the EHR’s vocabulary. As a result, symptoms that were not included in the EHR’s vocabulary or symptoms that were misspelled could not be added. Thereby, several Medical specialists of outpatient clinic E argued that the EHR did not consists of a proper search-functionality what impeded them to link the right diagnose to the right code. Consequently, the quality of the Shared overview was decreased.
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Table 3: Influence of collaborative affordances on collaboration between healthcare professionals.
Collaborative affordance
Descriptive code As voiced by interviewees Influence on collaboration (+, -, +/- or *) per outpatient clinic (A, B, C, D, E)
Portability The EHR integrates health records The EHR is bounded to certain locations
All specialties are integrated
Data is bounded to departments Data is bounded to a medical-context
Impeded to share data with neighbouring hospitals A+, B+, C+, D+, E+ A-, C-, E- A*, B*, C*, E*, D* B-, D-, E- Collocated access EHR (cannot) be updated simultaneously Mutual understanding
EHR impedes simultaneously access to health records EHR impedes simultaneously access to notes
A-, B-, C-, D-, E- A-, B*, C*, D-, E-
Current collaboration lacks when having access to one desktop Advantage of two desktops
B-, C-, D- C+, D+ Shared overview Mutual awareness Messenger Information overview is unclear Medical history is unreliable
All working processes are digital Improves collaboration Overview of information Overview of planned consultations Information is integrated Discuss patients without referring them
Swift from Outlook to Messenger Less verbal communication Use of Messenger between Medical specialists Information is polluted by excessive amount of results
A-, C-, D-, E-
Entered data is specific per speciality and not based on chronology of events
A-, B-, C-, D-, E-
No hand-written notes
Shared information is a necessity for collaboration
B+, D+, E+
A+, B+, C+, D+, E+
Information overview is polluted by excessive amount of information Working processes are uniform, Integrated agenda
Information is bounded to a certain specialty
Health record is attached to messages
Outlook is not being used anymore for patient-related affairs
Function-groups don’t meet in person (also due to the Orchestrator).
Medical specialists’ uniform use
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+: supportive effect on collaboration, -: adverse effect on collaboration, +/-: ambivalent, *: no effects on collaboration were found
Mutual awareness
In each outpatient clinic, it was argued that Medical specialists were impeded to easily develop a Mutual awareness between different specialties because information was not clearly represented in the EHR. Two causes were found. Firstly, the Shared overview was not clear since each specialty entered the data differently what negatively influenced the Mutual awareness between Medical specialists of different specialties. Secondly, EHR-data was sorted on priority what impeded specialists to figure out what happened in the medical-timeline of their patients. As stated earlier, the Mutual awareness of (some) Medical specialists of outpatient clinic A, C and E was decreased because photos were still bounded to certain departments.
On the other hand, it was voiced that the EHR supported Medical specialists to improve their Mutual awareness in the medical time-lime of patients since this process was more transparent. Moreover, the Mutual awareness between Medical specialists was increased due to Portable notes. Because all specialties of the hospital were integrated in the EHR, it was argued in four outpatient clinics (B, C, D, E) that patients could be referred more easily between different specialties by means of the Orchestrator. Lastly, the use of the Messenger was also seen as an important component to support the Mutual awareness between Medical specialists.
Interestingly, not a single EHR-functionality could be directly related to the Mutual awareness of healthcare professionals. However, all other collaborative affordances had a primary influence on actors’ Mutual awareness. Thereby, the Mutual awareness between different healthcare professionals was seen by many interviewees as a highly important factor for collaboration. However, it was also
Orchestrator Use of Messenger between different function-groups Receive results Overload of Information Efficient work processes
Less efficient work processes
Multidisciplinary consultations Multidisciplinary meetings
Irritations between function-groups
Notification of results Overload of messages
Healthcare processes are digitalized
Employees don’t work without orders
Not able to work organically with different function-groups
Multidisciplinary consultations are not supported by EHR
Results are better registered
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voiced that the Mutual awareness between Medical specialists was merely dependent on professionals’ uniformly use of the EHR.
Messenger
Advantages of the use of the Messenger were experienced differently. Firstly, interviewees of all cases appreciated the benefit to have the possibility to attach health records to messages. In the previous situation, patient-related affairs were discussed by means of Outlook. This frequently led to misunderstandings between Medical specialists because health records could not be attached to their email. In three outpatient clinics (A, C and D), it was argued that some specialties developed a policy that obligated the use the Messenger. Therefore, different function-groups of these specialties were assured that the “receiver” actually read their message. Accordingly, healthcare professionals of these specialties were better facilitated to gain a Mutual awareness. Interestingly, a shift from Outlook to the Messenger was noted in these specialties.
Contrarily, no shift to the Messenger was noted in outpatient clinics B and E that did not adopt a uniform policy for the use of the Messenger. Interestingly, (departmental) collaborative advantages were in these cases strongly dependent on Medical specialists’ use of the Messenger. For example, some Medical specialists of outpatient clinic E did not made use of the Messenger. This possibly led to negative consequences when other specialties tried to discuss a patient with these actors by means of the Messenger. Secondly, interviewees of both outpatient clinics expressed that (some) Medical administrators did use Messenger, but that Medical specialists did not make use of it. Accordingly, Medical administrators were annoyed because their messages did not get answered.
Therefore, collaborative advantages of the Messenger were strongly dependent on uniformly use in and across departments. Strikingly, in all cases it was argued that the Messenger currently led to an information-overload mostly due to non-informative medical-results or letters. Accordingly, a decrease in the use of the Messenger was noted in outpatient clinic B and E. Thereby, side effects of the Messenger were also expressed. For example, verbal communication between collaborating function-groups was lost in most cases. Accordingly, interviewees voiced how this negatively impacted collaborating function-groups. Remarkably, less verbal communication could also decrease the quality of healthcare.
Orchestrator
