Contextual influences on technology use mediation: a comparative analysis of electronic medical record systems

Overcoming institutionalised barriers to digital health systems: an autoethnographic case study of the judicialization of a digital health tool

BACKGROUND

The deployment of digital health systems may be impeded by barriers that are, or are linked to underlying enduring institutions. Attempting to challenge the barriers without addressing the underpinning institution may be ineffective. This study reflects on ways actors may surmount institutionalised barriers to the uptake of digital tools in health systems.

METHODS

I applied Institutional theory concepts to an autoethnographic case study of efforts to introduce a digital tool to provide citizens with medicines information.

RESULTS

The tool's uptake was impeded because of state regulators' institutionalised interpretation of pharmaceutical advertising laws, which rendered the tool illegal. I, along with allies beyond the health sector, successfully challenged the regulators' institutionalised interpretation of pharmaceutical advertising laws through various actions. These actions included: framing the tool as legal and constitutional, litigation, and redefining these concepts: 'advertising', 'health institution', and the role of regulatory bodies vis a vis innovation.

CONCLUSION

After identifying a barrier as being institutionalised or linked to an institution, actors might challenge such barriers by engaging in institutional work; i.e. deliberate efforts to challenge the relevant institution (e.g. a law, norm or shared belief). Institutional work may require the actions of multiple actors within and beyond the health sector, including judicial actors. Such cross-sectoral alliances are efficacious because they provide institutional workers with a broader range of strategies, framings, concepts and forums with which to challenge institutionalised barriers. However, actors beyond the health system (e.g. the judiciary) must be inquisitive about the potential implications of the digital health interventions they champion. This case justifies recent calls for more deliberate explorations within global health scholarships and practice, of synergies between law and health.

Enabling adoption and use of new health information technology during implementation: Roles and strategies for internal and external support personnel

OBJECTIVE

Successful technological implementations frequently involve individuals who serve as mediators between end users, management, and technology developers. The goal for this project was to evaluate the structure and activities of such mediators in a large-scale electronic health record implementation.

MATERIALS AND METHODS

Field notes from observations taken during implementation beginning in November 2017 were analyzed qualitatively using a thematic analysis framework to examine the relationship between specific types of mediators and the type and level of support to end users.

RESULTS

We found that support personnel possessing both contextual knowledge of the institution's workflow and training in the new technology were the most successful in mediation of adoption and use. Those that lacked context of either technology or institutional workflow often displayed barriers in communication, trust, and active problem solving.

CONCLUSIONS

These findings suggest that institutional investment in technology training and explicit programs to foster skills in mediation, including roles for professionals with career development opportunities, prior to implementation can be beneficial in easing the pain of system transition.

Infrastructuring Public Consultation in Town Planning— How Town Planners Translate Public Consultation into a Socio-Technical Support System

For public consultation in town planning, town planners can employ various software systems to improve the dialogue with citizens. This article looks at attempts to do so by following the work of a team of municipal town planners across four stages of public consultation held between 2012 and 2015. The study is based on detailed semi-structured interviews, field notes from regular visits to the planners’ office, and a database of public consultation comments and attendance at consultation events across the stages. Using an approach that considers planners’ work in the selection and implementation of software within institutional objectives and constraints as “infrastructure” work, we examine the joint deployment, use and effects of nine software tools and arising practices for public consultations. Our findings demonstrate how the infrastructure work of planners involved numerous interpretations about the possibilities for software adaptation and the effects of software use, which were enabled and constrained by consultation and planning requirements. The results also indicate a role for researchers in helping planners mediate between formal processes and public concerns, and illustrates how this technological-institutional struggle in infrastructuring work forms an essential part of town planners’ practice.

The negotiated order and electronic patient records: A sociomaterial perspective

In this article, we consider how the notion of the negotiated order can be reinterpreted by drawing on ideas from sociomateriality. We argue that the negotiated order is an ongoing accomplishment in which a heterogeneous set of situated sociomaterial practices (or actors) are implicated. To do this, we draw upon an in-depth study of the use of a computerised physician order entry system in a hospital in Saudi Arabia. We explore how a computerised physician order entry system, as a new sociomaterial actor, performatively repositions the actors involved and hence offers the conditions of possibility for medical work practices to be renegotiated. We show that it is often contingent, mundane, situated sociomaterial practices that enact the conditions under which the negotiated order becomes re-established in terms of division of labour, legitimacy, collaboration, and social capital. We argue that as the social and material are co-constitutive, or intra-actional, it makes more sense to talk about the negotiated intra-actional order rather than the negotiated order. Importantly, such a change in conceptual vocabulary reveals the empirical and ontological issues at stake; essential for a more nuanced understanding of change/becoming.

Investigating Knowledge Flows between Information Systems and Other Disciplines:

Information systems (IS) is one of the most rapidly changing disciplines in the social science field, and it is currently facing a new academic shift. The prevailing concepts, such as big data and Internet of things (IoT), imply that there is a plethora of research opportunities for IS researchers. Since these opportunities lie mostly in conjunction with other disciplines closely related to IS, it is essential to identify the interaction between IS and those disciplines. A few studies using bibliometric analysis have been published regarding this topic. However, we have identified several limitations in them: (i) inclusion of only a small journal basket, (ii) focus on a very restricted area of discipline, and (iii) a methodological limitation that can lead to the failure to capture the authentic knowledge flow between IS and other disciplines. We attempt to extend previous studies by proposing a comprehensive analysis model with the largest journal basket and areas of disciplines. As a result of our analysis, a knowledge flow structure different from that of past research is identified. In addition, through the discussion on emerging reference disciplines, we discover new research opportunities into which IS researchers can delve.

Patients' intention to use online postings of ED wait times: A modified UTAUT model

BACKGROUND

As health care becomes more reliant on technology, a better understanding of the factors that contribute to acceptance and use of technology is now critical. The Unified Theory of Acceptance and Use of Technology (UTAUT) has been applied to study a variety of technologies in different settings, and it is one of the most cited theories in Information Systems (IS) research. However, there has been limited application of UTAUT to health IT and, in particular, to patients' IT use.

OBJECTIVES

The aim of this study is to adapt UTAUT to the context of patient acceptance and use of an Emergency Department (ED) wait-times website, and to empirically test the modified model and compare the results to those of the original UTAUT model. Specifically, it is proposed that there will be a significant relationship between facilitating conditions and behavioral intention.

METHODS

A survey of patients in the ED of a Canadian hospital was conducted, yielding 118 completed surveys, and subsequently analyzed using Partial least squares (PLS).

RESULTS

This study found that the modified UTAUT produced a substantial improvement in variance explained in behavioral intention compared to the original UTAUT (66% versus 46%). The modified-UTAUT model showed significant effects in performance expectancy (r = 0.302, p < 0.01) and facilitating conditions (r = 0.539, p < 0.001) on behavioral intention to use the website, while the effort expectancy impact was not significant.

CONCLUSIONS

This study provides empirical support for the modified-UTAUT in the context of patients' intention to use an ED wait times website. Some results of this study support prior research, while some differ, such as the non-significant relationship between effort expectancy and behavioral intention and the finding that performance expectancy is not the main driver of intention to use. As proposed, facilitating conditions - having the resources necessary to view the website and having the ability to find the website - were the most important factors influencing behavioral intention. UTAUT is a key theoretical advance in IS research and by modifying it to the context of patient use, we contribute to both IS and health research.

Mediating the intersections of organizational routines during the introduction of a health IT system

Public interest in the quality and safety of health care has spurred examination of specific organizational routines believed to yield risk in health care work. Medication administration routines, in particular, have been the subject of numerous improvement projects involving information technology development, and other forms of research and regulation. This study draws from ethnographic observation to examine how the common routine of medication administration intersects with other organizational routines, and why understanding such intersections is important. We present three cases describing intersections between medication administration and other routines, including a pharmacy routine, medication administration on the next shift and management reporting. We found that each intersection had ostensive and performative dimensions; and furthermore, that IT-enabled changes to one routine led to unintended consequences in its intersection with others, resulting in misalignment of ostensive and performative aspects of the intersection. Our analysis focused on the activities of a group of nurses who provide technology use mediation (TUM) before and after the rollout of a new health IT system. This research offers new insights on the intersection of organizational routines, demonstrates the value of analyzing TUM activities to better understand the relationship between IT introduction and changes in routines, and has practical implications for the implementation of technology in complex practice settings.

Theorizing the configuration of modifiable off-the-shelf software

Purpose

The purpose of this paper is to theorize the social dynamics of modifiable off-the-shelf software (MOTS) configuration process. The authors do so by formulating theoretical propositions about the configuration process.

Design/methodology/approach

The authors have conducted a comprehensive review of the literature on MOTS configuration and the associated challenges to draw on the properties of MOTS. The authors then examined these properties through the lens of social construction of technology to formulate the authors’ theoretical propositions.

Findings

The authors formulate theoretical propositions about the configuration process. The authors also develop four scenarios based on the authors’ theoretical propositions for managing the configuration process of MOTS. These scenarios categorize the difficulty level of the configuration by two theoretical groups: malleability and interpretive flexibility.

Practical implications

The findings especially the scenarios can guide practitioners when managing configuration processes.

Originality/value

The authors synthesize the literature on MOTS. The theoretical contributions emphasize the social dynamics in configuring this type of software which is an angle that has not been developed in previous literature.

Evaluation of health information systems research in information systems research: A meta-analysis

Given the importance of the health-care industry and the promise of health information systems, researchers are encouraged to build on the shoulders of giants as the saying goes. The health information systems field has a unique opportunity to learn from and extend the work that has already been done by the highly correlated information systems field. As a result, this research article presents a past, present and future meta-analysis of health information systems research in information systems journals over the 2000–2015 time period. Our analysis reviewed 126 articles on a variety of topics related to health information systems research published in the “Senior Scholars” list of the top eight ranked information systems academic journals. Across the selected information systems academic journals, our findings compare research methodologies applied, health information systems topic areas investigated and research trends. Interesting results emerge in the range and evolution of health information systems research and opportunities for health information systems researchers and practitioners to consider moving forward.

Radio frequency identification-enabled capabilities in a healthcare context: An exploratory study

Increasingly, the adoption and use of radio frequency identification systems in hospital settings is gaining prominence. However, despite the transformative impact that radio frequency identification has in healthcare settings, few studies have examined how and why this change may occur. The purpose of this study is to systematically understand how radio frequency identification can transform work practices in an operational process that directly impacts cost and operational efficiency and indirectly contributes to impacting patient safety and quality of care. We leverage an interdisciplinary framework to explore the contextual characteristics that shape the assimilation of radio frequency identification in healthcare settings. By linking the use of radio frequency identification with specific contextual dimensions in healthcare settings, we provide a data-driven account of how and why radio frequency identification can be useful in inventory management in this setting. In doing so, we also contribute to recent work by information systems scholars who argue for a reconfiguration of conventional assumptions regarding the role of technology in contemporary organizations.

Beyond technology acceptance to effective technology use: a parsimonious and actionable model

OBJECTIVE

To develop and test a parsimonious and actionable model of effective technology use (ETU).

DESIGN

Cross-sectional survey of primary care providers (n = 53) in a large integrated health care organization that recently implemented new medication reconciliation technology.

METHODS

Surveys assessed 5 technology-related perceptions (compatibility with work values, implementation climate, compatibility with work processes, perceived usefulness, and ease of use) and 1 outcome variable, ETU. ETU was measured as both consistency and quality of technology use.

RESULTS

Compatibility with work values and implementation climate were found to have differential effects on consistency and quality of use. When implementation climate was strong, consistency of technology use was high. However, quality of technology use was high only when implementation climate was strong and values compatibility was high. This is an important finding and highlights the importance of users' workplace values as a key determinant of quality of use.

CONCLUSIONS

To extend our effectiveness in implementing new health care information technology, we need parsimonious models that include actionable determinants of ETU and account for the differential effects of these determinants on the multiple dimensions of ETU.

Hybridity as a process of technology's 'translation': customizing a national Electronic Patient Record

This paper explores how national Electronic Patient Record (EPR) systems are customized in local settings and, in particular, how the context of their origin plays out with the context of their use. It shows how representations of healthcare organizations and of local clinical practice are built into EPR systems within a complex context whereby different stakeholder groups negotiate to produce an EPR package that aims to meet both local and generic needs. The paper draws from research into the implementation of the National Care Record Service, a part of the National Programme for Information Technology (NPfIT), in the English National Health Service (NHS). The paper makes two arguments. First, customization of national EPR is a distributed process that involves cycles of 'translation', which span across geographical, cultural and professional boundaries. Second, 'translation' is an inherently political process during which hybrid technology gets consolidated. The paper concludes, that hybrid technology opens up possibilities for standardization of healthcare.

Organizational learning in the implementation and adoption of national electronic health records: Case studies of two hospitals participating in the National Programme for Information Technology in England

Objective:

To explore the role of organizational learning in enabling implementation and supporting adoption of electronic health record systems into two English hospitals.

Methods and setting:

In the course of conducting our prospective and sociotechnical evaluation of the implementation and adoption of electronic health record into 12 “early adopter” hospitals across England, we identified two hospitals implementing virtually identical versions of the same “off-the-shelf” software (Millennium) within a comparable timeframe. We undertook a longitudinal qualitative case study–based analysis of these two hospitals (referred to hereafter as Alpha and Omega) and their implementation experiences. Data included the following: 63 in-depth interviews with various groups of internal and external stakeholders; 41-h on-site observation; and content analysis of 218 documents of various types. Analysis was both inductive and deductive, the latter being informed by the “sociotechnical changing” theoretical perspective.

Results:

Although Alpha and Omega shared a number of contextual similarities, our evaluation revealed fundamental differences in visions of electronic health record and the implementation strategy between the hospitals, which resulted in distinct local consequences of electronic health record implementation and impacted adoption. Both hospitals did not, during our evaluation, see the hoped-for benefits to the organization as a result of the introduction of electronic health record, such as speeding-up tasks. Nonetheless, the Millennium software worked out to be easier to use at Omega. Interorganizational learning was at the heart of this difference.

Conclusion:

Despite the turbulent overall national “roll out” of electronic health record systems into the English hospitals, considerable opportunities for organizational learning were offered by sequential delivery of the electronic health record software into “early adopter” hospitals. We argue that understanding the process of organizational learning and its enabling factors has the potential to support efforts at implementing national electronic health record implementation endeavors.

Changes in healthcare professional work afforded by technology: The introduction of a national electronic patient record in an English hospital

This article considers changes in healthcare professional work afforded by technology. It uses the sociology of professionals’ literature together with a theory of affordances to examine how and when technology allows change in healthcare professional work. The study draws from research into the introduction of a national electronic patient record in an English hospital. We argue that electronic patient record affords changes through its materiality as it interacts with healthcare professional practice. Its affordances entail some level of standardisation of healthcare professional conduct and practice, curtailment of professional autonomy, enlargement of nurses’ roles and redistribution of clinical work within and across professional boundaries. The article makes a contribution to the growing literature advocating a cultural approach to the study of technological affordances in organisations and to studies that explore healthcare professional practice in conjunction with the materiality of technology. Two main lines of argument are developed here. First, that technological affordances do not solely lie with the materiality of technology nor with individual perceptions, but are cultivated and nurtured within a broader cultural–institutional context, in our case a professional context of use. Second, that technological affordance of change is realised when healthcare professionals’ (individual and collective) perceptions of technology (and of its materiality) fit with their sense of (professional) self. In this respect, the article shows the extent to which the materiality of technology plays out with professional identity and frames the level and extent to which technology can and cannot afford restructuring of work and redistribution of power across professional groups.

Interpretive flexibility in mobile health: lessons from a government-sponsored home care program

Background

Mobile technologies have emerged as important tools that health care personnel can use to gain easy access to client data anywhere. This is particularly useful for nurses and care workers in home health care as they provide services to clients in many different settings. Although a growing body of evidence supports the use of mobile technologies, the diverse implications of mobile health have yet to be fully documented.

Objective

Our objective was to examine a large-scale government-sponsored mobile health implementation program in the Danish home care sector and to understand how the technology was used differently across home care agencies.

Methods

We chose to perform a longitudinal case study with embedded units of analysis. We included multiple data sources, such as written materials, a survey to managers across all 98 Danish municipalities, and semistructured interviews with managers, care workers, and nurses in three selected home care agencies. We used process models of change to help analyze the overall implementation process from a longitudinal perspective and to identify antecedent conditions, key events, and practical outcomes.

Results

Strong collaboration between major stakeholders in the Danish home care sector (government bodies, vendors, consultants, interest organizations, and managers) helped initiate and energize the change process, and government funding supported quick and widespread technology adoption. However, although supported by the same government-sponsored program, mobile technology proved to have considerable interpretive flexibility with variation in perceived nature of technology, technology strategy, and technology use between agencies. What was first seen as a very promising innovation across the Danish home care sector subsequently became the topic of debate as technology use arrangements ran counter to existing norms and values in individual agencies.

Conclusions

Government-sponsored programs can have both positive and negative results, and managers need to be aware of this and the interpretive flexibility of mobile technology. Mobile technology implementation is a complex process that is best studied by combining organization-level analysis with features of the wider sociopolitical and interorganizational environment.

Ten key considerations for the successful implementation and adoption of large-scale health information technology

The implementation of health information technology interventions is at the forefront of most policy agendas internationally. However, such undertakings are often far from straightforward as they require complex strategic planning accompanying the systemic organizational changes associated with such programs. Building on our experiences of designing and evaluating the implementation of large-scale health information technology interventions in the USA and the UK, we highlight key lessons learned in the hope of informing the on-going international efforts of policymakers, health directorates, healthcare management, and senior clinicians.

We are bitter, but we are better off: case study of the implementation of an electronic health record system into a mental health hospital in England

BACKGROUND

In contrast to the acute hospital sector, there have been relatively few implementations of integrated electronic health record (EHR) systems into specialist mental health settings. The National Programme for Information Technology (NPfIT) in England was the most expensive IT-based transformation of public services ever undertaken, which aimed amongst other things, to implement integrated EHR systems into mental health hospitals. This paper describes the arrival, the process of implementation, stakeholders' experiences and the local consequences of the implementation of an EHR system into a mental health hospital.

METHODS

Longitudinal, real-time, case study-based evaluation of the implementation and adoption of an EHR software (RiO) into an English mental health hospital known here as Beta. We conducted 48 in-depth interviews with a wide range of internal and external stakeholders, undertook 26 hours of on-site observations, and obtained 65 sets of relevant documents from various types relating to Beta. Analysis was both inductive and deductive, the latter being informed by the 'sociotechnical changing' theoretical framework.

RESULTS

Many interviewees perceived the implementation of the EHR system as challenging and cumbersome. During the early stages of the implementation, some clinicians felt that using the software was time-consuming leading to the conclusion that the EHR was not fit for purpose. Most interviewees considered the chain of deployment of the EHR-which was imposed by NPfIT-as bureaucratic and obstructive, which restricted customization and as a result limited adoption and use. The low IT literacy among users at Beta was a further barrier to the implementation of the EHR. This along with inadequate training in using the EHR software led to resistance to the significant cultural and work environment changes initiated by EHR. Despite the many challenges, Beta achieved some early positive results. These included: the ability to check progress notes and monitor staff activities; improving quality of care as a result of real-time, more accurate and shared patient records across the hospital; and potentially improving the safety of care through increasing the legibility of the clinical record.

CONCLUSIONS

Notwithstanding what was seen as a turbulent, painful and troublesome implementation of the EHR system, Beta achieved some early clinical and managerial benefits from implementing EHRs. The 'sociotechnical changing' framework helped us go beyond the dichotomy of success versus failure, when conducting the evaluation and interpreting findings. Given the scope for continued development, there are good reasons, we argue, to scale up the intake of EHR systems by mental health care settings. Software customization and appropriate support are essential to work EHR out in such organizations.

Comparative case study investigating sociotechnical processes of change in the context of a national electronic health record implementation

The introduction of electronic health records (EHRs) lies at the heart of many international efforts to improve the safety and quality of healthcare. England has attempted to introduce nationally procured EHR software--the first country in the world to do so. In this qualitative comparative case study tracing local developments over time we sought to generate a detailed picture of the implementation landscape characterising this first attempt at implementing nationally procured software through studying three purposefully selected hospitals. Despite differences in relation to demographic considerations and local implementation strategies, implementing hospitals faced similar technical and political challenges. These were coped with differently by the various organisations and individual stakeholders, their responses being shaped by contextual contingencies. We conclude that national implementation efforts need to allow effective technology adoption to occur locally before considering larger-scale interoperability. This should involve the allocation of sufficient time for individual users and organisations to adjust to the complex changes that often accompany such service re-design initiatives.

Mediation of adoption and use: a key strategy for mitigating unintended consequences of health IT implementation

OBJECTIVE

Without careful attention to the work of users, implementation of health IT can produce new risks and inefficiencies in care. This paper uses the technology use mediation framework to examine the work of a group of nurses who serve as mediators of the adoption and use of a barcode medication administration (BCMA) system in an inpatient setting.

MATERIALS AND METHODS

The study uses ethnographic methods to explore the mediators' work. Data included field notes from observations, documents, and email communications. This variety of sources enabled triangulation of findings between activities observed, discussed in meetings, and reported in emails.

RESULTS

Mediation work integrated the BCMA tool with nursing practice, anticipating and solving implementation problems. Three themes of mediation work include: resolving challenges related to coordination, integrating the physical aspects of BCMA into everyday practice, and advocacy work.

DISCUSSION

Previous work suggests the following factors impact mediation effectiveness: proximity to the context of use, understanding of users' practices and norms, credibility with users, and knowledge of the technology and users' technical abilities. We describe three additional factors observed in this case: 'influence on system developers,' 'influence on institutional authorities,' and 'understanding the network of organizational relationships that shape the users' work.'

CONCLUSION

Institutionally supported clinicians who facilitate adoption and use of health IT systems can improve the safety and effectiveness of implementation through the management of unintended consequences. Additional research on technology use mediation can advance the science of implementation by providing decision-makers with theoretically durable, empirically grounded evidence for designing implementations.

Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems

BACKGROUND

A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments' healthcare reform strategies. The resulting politically-initiated large-scale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money.

METHODS

Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England's National Health Service's Care Records Service (NHS CRS).

RESULTS/DISCUSSION

We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations → intervention → changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions.

SUMMARY

New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.

Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

CONTEXT

The extensive research literature on electronic patient records (EPRs) presents challenges to systematic reviewers because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches.

METHODS

Using the meta-narrative method and searching beyond the Medline-indexed literature, this review used "conflicting" findings to address higher-order questions about how researchers had differently conceptualized and studied the EPR and its implementation.

FINDINGS

Twenty-four previous systematic reviews and ninety-four further primary studies were considered. Key tensions in the literature centered on (1) the EPR ("container" or "itinerary"); (2) the EPR user ("information-processer" or "member of socio-technical network"); (3) organizational context ("the setting within which the EPR is implemented" or "the EPR-in-use"); (4) clinical work ("decision making" or "situated practice"); (5) the process of change ("the logic of determinism" or "the logic of opposition"); (6) implementation success ("objectively defined" or "socially negotiated"); and (7) complexity and scale ("the bigger the better" or "small is beautiful").

CONCLUSIONS

The findings suggest that EPR use will always require human input to recontextualize knowledge; that even though secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper may offer a unique degree of ecological flexibility; and that smaller EPR systems may sometimes be more efficient and effective than larger ones. We suggest an agenda for further research.

Expanding multi-disciplinary approaches to healthcare information technologies: what does information systems offer medical informatics?

The effective use of information technology (IT) is a crucial component for the delivery of effective services in health care. Current approaches to medical informatics (MI) research have significantly contributed to the success of IT use in health care but important challenges remain to be addressed. We believe that expanding the multi-disciplinary basis for MI research is important to meeting these research challenges. In this paper, we outline theories and methods used in information systems (IS) research that we believe can inform our understanding of health care IT applications and outcomes. To do so, we discuss some general differences in the focus and methods of MI and IS research to identify broad opportunities. We then review conceptual and methodological approaches in IS that have been applied in health care IT research. These include: technology-use mediation, collaborative work, genre theory, interpretive research, action research, and modeling. Examples of these theories and methods in healthcare IS research are illustrated.

Extending the Research Agenda on Diffusion: The Case of Public Program Interventions for the Adoption of E-business Systems in SMEs

Given the importance of contextual influences on the diffusion of innovations, the theories and methodologies that take context into account are increasingly relevant to research and practice. One such approach, the systems of innovation approach, considers context to be a cascading set of effects arising from various participants and innovations surrounding the production and diffusion of a focal innovation. Based on this approach, we focus on a public program involved in the diffusion of e-business systems to small and medium-sized enterprises (SMEs). E-business systems are complex innovations, and the contextual influences are particularly important here, because SMEs often lack the knowledge and resources to strategically adopt, modify, and use these innovations. Using the systems of innovation approach, we examined the contexts around public program interventions with an SME in order to explain their form and influence on e-business adoption processes. The empirical findings suggest that many public programs fail to effectively deliver interventions because program contexts restrict program personnel's ability to completely assess and respond to the range of adopter needs. While some aspects of the program contexts can be altered by the program directors, others are further removed and are currently beyond our collective control at this point-in-time. The implications for diffusion research and practice are discussed.

Toward an effective strategy for the diffusion and use of clinical information systems

The full impact of IT in health care has not been realized because of the failure to recognize that (1) the path from availability of applications to the anticipated benefits passes through a series of steps; and (2) progress can be stopped at any one of those steps. As a result, strategies for diffusion, adoption, and use have been incomplete and have produced disappointing results. In this paper, we present a comprehensive framework for identifying factors that affect the spread, use, and effects of IT in the U.S. health care sector. The framework can be used by researchers to focus their efforts on unanswered questions, by practitioners considering IT adoption, and by policymakers searching for ways to spread IT throughout the system.