heath information technology ( hit ) will play a key role in facilitating healthcare delivery to meet these objectives .
studies have described positive outcomes from hit , including support for the management of chronic diseases , facilitation of communication as part of care transitions , and improvements in patient safety by providing necessary information to all providers .
there is also a wide body of research that describes numerous challenges to implementing hit in organizations , including workflow , communication and cognitive issues , and medical errors that are mitigated by the use of hit .
further , studies have reported that hit adoption has had minimal impact on the quality of care , measured by patient mortality , adverse drug events , and readmission rates . yet , despite the implementation issues , governments continue to spend large amounts of money on the adoption of hit . organizational and social issues ( osis ) contribute to hit implementation issues . while some studies have explicitly studied or discussed osis in hit , much of the research on osis has been imbedded in studies of post - implementation issues , such as unintended consequences and adverse events .
one essential point that needs to be made is that even if the hit in question adequately automates the task it was designed for ( e.g. , order entry ) , unintended consequences may still occur due to conflicts between the hit and the context of how and where the system is used .
overall , there is a need for better understanding of the organizational issues surrounding hit implementation .
one of the biggest challenges in studying osis is what can be referred to as ' bounding ' .
such a wide range of studies have reported on osis that it becomes challenging to identify what elements should be studied and how studies should be conducted .
healthcare systems continue to focus on goals such as patient safety , collaborative care delivery , and patient centered care , yet an often overlooked fact is that these goals are bound within the organizational and social web that exists in healthcare settings .
there is a need for a paper that reviews the wide body of literature on osis in hit to provide some bounding for how to think about and study these issues .
this paper addresses that need by reviewing the literature on osis in hit to identify themes that can be used to provide bounding for future research .
the papers reviewed included explicit studies about osis in hit ( e.g. , review articles ) as well as papers that referred to osis in hit in the context of other studies ( e.g. , unintended consequences , medical errors , collaborative care delivery ) . in reviewing the papers , five overarching themes around osis in hit
were identified : scope and frameworks for defining osis in hit , context matters , process immaturity and complexity , trade - offs will happen and need to be openly discussed , and means of studying osis in hit . to provide some framing for the discussion , each theme is discussed from the perspective of micro and macro aspects of osis .
macro aspects include organizational structure , leadership , incentives , training , and organizational structure ( e.g. , facility size , it spending ) .
micro aspects include front - line care delivery issues , such as communication , collaboration or training for hit usage .
as stated in the introduction , a significant challenge in studying osis in hit is defining them , given the range of studies that have reported on osis .
on one hand , osis have been studied using broad approaches or frameworks , such as those from classic studies of information technology in organizations .
an interpretive review by cresswell and sheikh   points out the range of models used to study osis in hit , such as the technology adoption model ( tam ) , the diffusion of innovation model , and organizational psychology models .
other models from the information systems literature that have been used to evaluate hit include the delone and mclean information system success model . a literature review by lluch   identified and classified organizational barriers and hit under five main headings : structure of healthcare organizations , tasks , people policies , incentives , and information and decision processes .
it was proposed that the five categories be used as a starting point for policy interventions .
while the above reviews and models are good at identifying the broader structural or macro aspects of hit in osis , they do not provide as much insight into the behavioral or micro aspects of osis , yet behavioral issues are a major cause of hit issues and often span across individual , group , and organizational levels .
a significant amount of research has looked at micro - level intricacies between hit and the organizations where they are used .
while studies may not be explicitly labeled as studies on osis in hit , many of their findings refer to aspects of osis . a seminal work by ash et al
the plethora of studies on the unintended consequences of hit implementation emphasizes that even a well - designed system can be influenced by organizational culture and issues , such as power struggles .
research drawing upon socio - technical theory has been used to study hit for some time and has provided valuable insight on hit in osis .
a sociotechnical framework was developed by sittig and singh   that articulates eight dimensions for studying the safety and effectiveness of hit , including organizational policies and procedures .
others have suggested that while organizational structure and leadership are important for hit success , it is equally important that culture , workflow , and productivity be studied .
developed the ' triangle evaluation model ' , which incorporates the organizational structure , processes pertaining to organizational implementation of technology , and organizational policies affecting providers .
macro - level solutions are impacted by the micro - level context where they are implemented . a systematic review of hit implementation identified better reporting of context as the biggest need in hit evaluation .
provide a good perspective on the importance of context by differentiating the ideal or abstract description ( the ostensive dimension ) of how hit should be used and how it is actually used in real clinical settings ( the performance dimension ) .
the performance dimension is defined by context , and failure to account for the ostensive - performance gap can lead to unintended consequences , such as communication , coordination , and patient safety issues . a key part of understanding the performance dimension is understanding the intersection of organizational routines and technology . while evaluation approaches , such as usability testing , can identify individual variations or contexts , it is equally important to understand organizational contexts , such as leadership , culture , and workflow , as they can impact hit usage
one context is the type of organization , as hit implementation can vary according to the size and type of organization where hit is being implemented .
while training on the specific features of the hit being used is obviously important , it is equally important that organizations invest in training on technical skill sets ( e.g. , information management skills , such as data entry and retrieval ) that are necessary for effective interaction with hit .
a shortcoming of many of the it adoption frameworks described in the previous section , such as tam , is that they focus on behavior related to the technology and not the organizational or clinical context where the technology is used . to address this shortcoming , models of hit implementation
have been developed that attempt to incorporate the macro ( organizational ) and micro ( clinical ) context .
one such model is the contextual implementation model ( cim ) , which looks at hit usage from organizational , clinical unit , and individual contexts . hit implementation is often compared to other industries , such as finance , aviation , or manufacturing . while it has been able to improve supply chain efficiency in companies like wal - mart , and it has enabled courier companies to develop online customer package tracking systems , a key difference between these domains and healthcare is that supply chain management and parcel delivery are mature processes ; therefore , the technology was used to automate well - defined processes .
a major challenge is that many of the healthcare organizational processes we are trying to automate lack maturity .
for example , while numerous interventions have been proposed to improve team - based care delivery , including training and the use of technologies such as electronic health records , these macro - level interventions have not resulted in improved outcomes .
it has been stated that if a care team lacks team characteristics ( e.g. , shared objectives and processes ) than they exist as teamwork in name only .
poorly defined teams provide less than ideal team - based care delivery , leading to adverse events , such as communication issues and medical errors . while there have been mixed reports about the ability of hit to support teamwork , hit on its own will not enhance team - based care delivery ; rather , we need a better definition of the rules of engagement and the relationship between teamwork and individual provider work routines .
handovers are another example of processes that can be classified as evolving . a lack of standardized handover processes has been cited as a reason for errors and other quality issues related to handovers .
essential elements for handoffs , such as common ground amongst providers , are still a work in progress . poorly defined handover processes and measures make it challenging to develop hit to support handovers .
while hit may be designed to automate a specific task , it will impact and be impacted by other organizational and clinical tasks . a well acknowledged shortcoming in how we design hit
is a focus on " tidy use cases of predictable orderliness " which fail to describe the complex interrelated manner in which hit is used . rather than considering hit as isolated events or activities , we need to draw upon systems theory and consider hit and the processes it supports as complex entities .
hit is more likely to introduce unintended consequences if it designed to support specific tasks while ignoring other tasks or routines that interact with it .
tenets of complexity theory , such as emergence , non - linearity , and self - organization can help us understand the inter - relatedness between hit and the processes , policies , and other system components that interact with a hit .
hit implementation often necessitates trade - offs between how people currently work and how their work routines change because of hit .
however , providers may be unwilling to make trade - offs , or they may find trade - offs problematic to their work practices , and as a result develop workarounds to mitigate hit - mediated changes .
a significant trade - off is the individual - collaborative interchange . while systems may be designed to support individual or organizational tasks , designing for groups is a different challenge .
macro - level objectives , such as collaborative care delivery , necessitate trade - offs at the individual - collaborative interchange and across clinical units , change individual roles in the context of working in a team , and may require the development of awareness or rules of engagement for social or group dynamics . while standardization of data and processes is required for interoperability to support inter- and intra - organizational care delivery
standardized data may lead to increased charting for providers , which can require a workflow trade - off with respect to patient care delivery .
tasks such as communication , information retrieval , or decision - making may become more challenging because of hit . at times , it may not be possible to perform tasks in the same manner with hit , and providers may be forced to learn new variations on tasks .
in addition to the need to understand hit mediated trade - offs , there is the need to effectively manage them
. some of the changes may be flexible and can be negotiated as part of hit design , whereas others ( e.g. , data standards or organizational policy ) are more permanent .
failure to discuss hit - induced changes can result in adverse events and other unintended consequences because of individual variations on processes .
the nature of trade - offs and/or losses to work practices from hit need to be discussed and , if applicable , negotiated with providers .
kaplan has advocated for methodological pluralism , emphasizing the need for broad approaches to hit evaluation that study social , cultural , organizational , cognitive , and other contextual concerns . both qualitative and
such studies have included the use of markov models , simulation , and multi - agent models .
quantitative studies can also be used to define structural aspects of work processes , such as communication flows or patterns , to model how things should work .
while quantitative studies are helpful for providing bounding or structure regarding osis in hit , a shortcoming of quantitative approaches is that they decontextualize situations and thus may not sufficiently explain why things happen . as described above , a lack of rules of engagement for team - based care delivery may cause a seemingly ideal collaboration structure to work in unintended ways .
qualitative approaches , such as non - participant observations , interviews , and focus groups , have been valuable for studying and providing explanations about the organizational context of osis in hit .
an advantage of qualitative studies is their ability to provide rich descriptions of situation , particularly the micro aspects regarding why things happen . although there has been a wide variety of approaches to studying hit that have come directly from the medical informatics community , we need to remember that the broader discipline of information systems also offers many approaches and frameworks that can be used in studying osis in hit .
furthermore , fields peripheral to medical informatics , such as computer - supported cooperative work ( cscw ) , have also made significant contributions to our understanding of the relationship between osis in hit .
regardless of the type of approach used , an iterative approach that engages users will increase the chance of understanding osis as a precursor to successful hit design and implementation .
methods such as design science and participatory design provide ways to engage users in the understanding of problems and the design of hit solutions to these problems .
as stated in the introduction , a significant challenge in studying osis in hit is defining them , given the range of studies that have reported on osis .
on one hand , osis have been studied using broad approaches or frameworks , such as those from classic studies of information technology in organizations .
an interpretive review by cresswell and sheikh   points out the range of models used to study osis in hit , such as the technology adoption model ( tam ) , the diffusion of innovation model , and organizational psychology models .
other models from the information systems literature that have been used to evaluate hit include the delone and mclean information system success model . a literature review by lluch   identified and classified organizational barriers and hit under five main headings : structure of healthcare organizations , tasks , people policies , incentives , and information and decision processes .
it was proposed that the five categories be used as a starting point for policy interventions .
while the above reviews and models are good at identifying the broader structural or macro aspects of hit in osis , they do not provide as much insight into the behavioral or micro aspects of osis , yet behavioral issues are a major cause of hit issues and often span across individual , group , and organizational levels .
a significant amount of research has looked at micro - level intricacies between hit and the organizations where they are used .
while studies may not be explicitly labeled as studies on osis in hit , many of their findings refer to aspects of osis . a seminal work by ash et al
the plethora of studies on the unintended consequences of hit implementation emphasizes that even a well - designed system can be influenced by organizational culture and issues , such as power struggles .
research drawing upon socio - technical theory has been used to study hit for some time and has provided valuable insight on hit in osis .
a sociotechnical framework was developed by sittig and singh   that articulates eight dimensions for studying the safety and effectiveness of hit , including organizational policies and procedures .
others have suggested that while organizational structure and leadership are important for hit success , it is equally important that culture , workflow , and productivity be studied .
developed the ' triangle evaluation model ' , which incorporates the organizational structure , processes pertaining to organizational implementation of technology , and organizational policies affecting providers .
macro - level solutions are impacted by the micro - level context where they are implemented . a systematic review of hit implementation identified better reporting of context as the biggest need in hit evaluation .
provide a good perspective on the importance of context by differentiating the ideal or abstract description ( the ostensive dimension ) of how hit should be used and how it is actually used in real clinical settings ( the performance dimension ) .
the performance dimension is defined by context , and failure to account for the ostensive - performance gap can lead to unintended consequences , such as communication , coordination , and patient safety issues . a key part of understanding the performance dimension is understanding the intersection of organizational routines and technology . while evaluation approaches , such as usability testing , can identify individual variations or contexts , it is equally important to understand organizational contexts , such as leadership , culture , and workflow , as they can impact hit usage
one context is the type of organization , as hit implementation can vary according to the size and type of organization where hit is being implemented .
while training on the specific features of the hit being used is obviously important , it is equally important that organizations invest in training on technical skill sets ( e.g. , information management skills , such as data entry and retrieval ) that are necessary for effective interaction with hit .
a shortcoming of many of the it adoption frameworks described in the previous section , such as tam , is that they focus on behavior related to the technology and not the organizational or clinical context where the technology is used . to address this shortcoming , models of hit implementation
have been developed that attempt to incorporate the macro ( organizational ) and micro ( clinical ) context .
one such model is the contextual implementation model ( cim ) , which looks at hit usage from organizational , clinical unit , and individual contexts .
hit implementation is often compared to other industries , such as finance , aviation , or manufacturing . while it has been able to improve supply chain efficiency in companies like wal - mart , and it has enabled courier companies to develop online customer package tracking systems , a key difference between these domains and healthcare is that supply chain management and parcel delivery are mature processes ; therefore , the technology was used to automate well - defined processes .
a major challenge is that many of the healthcare organizational processes we are trying to automate lack maturity .
for example , while numerous interventions have been proposed to improve team - based care delivery , including training and the use of technologies such as electronic health records , these macro - level interventions have not resulted in improved outcomes .
it has been stated that if a care team lacks team characteristics ( e.g. , shared objectives and processes ) than they exist as teamwork in name only .
poorly defined teams provide less than ideal team - based care delivery , leading to adverse events , such as communication issues and medical errors . while there have been mixed reports about the ability of hit to support teamwork , hit on its own will not enhance team - based care delivery ; rather , we need a better definition of the rules of engagement and the relationship between teamwork and individual provider work routines .
handovers are another example of processes that can be classified as evolving . a lack of standardized handover processes has been cited as a reason for errors and other quality issues related to handovers .
essential elements for handoffs , such as common ground amongst providers , are still a work in progress . poorly defined handover processes and measures make it challenging to develop hit to support handovers .
while hit may be designed to automate a specific task , it will impact and be impacted by other organizational and clinical tasks .
a well acknowledged shortcoming in how we design hit is a focus on " tidy use cases of predictable orderliness " which fail to describe the complex interrelated manner in which hit is used . rather than considering hit as isolated events or activities ,
we need to draw upon systems theory and consider hit and the processes it supports as complex entities .
hit is more likely to introduce unintended consequences if it designed to support specific tasks while ignoring other tasks or routines that interact with it .
tenets of complexity theory , such as emergence , non - linearity , and self - organization can help us understand the inter - relatedness between hit and the processes , policies , and other system components that interact with a hit .
hit implementation often necessitates trade - offs between how people currently work and how their work routines change because of hit .
however , providers may be unwilling to make trade - offs , or they may find trade - offs problematic to their work practices , and as a result develop workarounds to mitigate hit - mediated changes .
a significant trade - off is the individual - collaborative interchange . while systems may be designed to support individual or organizational tasks , designing for groups is a different challenge .
macro - level objectives , such as collaborative care delivery , necessitate trade - offs at the individual - collaborative interchange and across clinical units , change individual roles in the context of working in a team , and may require the development of awareness or rules of engagement for social or group dynamics . while standardization of data and processes is required for interoperability to support inter- and intra - organizational care delivery
standardized data may lead to increased charting for providers , which can require a workflow trade - off with respect to patient care delivery .
tasks such as communication , information retrieval , or decision - making may become more challenging because of hit . at times
, it may not be possible to perform tasks in the same manner with hit , and providers may be forced to learn new variations on tasks .
in addition to the need to understand hit mediated trade - offs , there is the need to effectively manage them
. some of the changes may be flexible and can be negotiated as part of hit design , whereas others ( e.g. , data standards or organizational policy ) are more permanent .
failure to discuss hit - induced changes can result in adverse events and other unintended consequences because of individual variations on processes .
the nature of trade - offs and/or losses to work practices from hit need to be discussed and , if applicable , negotiated with providers .
kaplan has advocated for methodological pluralism , emphasizing the need for broad approaches to hit evaluation that study social , cultural , organizational , cognitive , and other contextual concerns .
such studies have included the use of markov models , simulation , and multi - agent models .
quantitative studies can also be used to define structural aspects of work processes , such as communication flows or patterns , to model how things should work .
while quantitative studies are helpful for providing bounding or structure regarding osis in hit , a shortcoming of quantitative approaches is that they decontextualize situations and thus may not sufficiently explain why things happen . as described above , a lack of rules of engagement for team - based care delivery may cause a seemingly ideal collaboration structure to work in unintended ways .
qualitative approaches , such as non - participant observations , interviews , and focus groups , have been valuable for studying and providing explanations about the organizational context of osis in hit .
an advantage of qualitative studies is their ability to provide rich descriptions of situation , particularly the micro aspects regarding why things happen .
although there has been a wide variety of approaches to studying hit that have come directly from the medical informatics community , we need to remember that the broader discipline of information systems also offers many approaches and frameworks that can be used in studying osis in hit .
furthermore , fields peripheral to medical informatics , such as computer - supported cooperative work ( cscw ) , have also made significant contributions to our understanding of the relationship between osis in hit .
regardless of the type of approach used , an iterative approach that engages users will increase the chance of understanding osis as a precursor to successful hit design and implementation .
methods such as design science and participatory design provide ways to engage users in the understanding of problems and the design of hit solutions to these problems .
although hit continues to play a vital role in healthcare delivery , successful implementation of hit remains a challenge .
this paper reviewed osis in hit and identified five themes to help us better understand and study osis in hit .
one overall finding is that , while organizations frequently have strategies for macro - level objectives , such as patient safety , systems integration , collaborative care delivery , and chronic disease management , these efforts need to be studied and integrated with the underlying micro processes that operationalize the objectives .
one of the key issues identified in this paper is the need to account for immature or evolving processes .
while hit introduces a sudden and often substantial change to how work is done , the processes being automated by hit may not evolve as quickly . as a result
, unintended consequences occur because of the gap between the level of automation and the people and processes using the automation .
defining rules of engagement for tasks such as collaborative care delivery , or handovers , needs to be done prior to automation of these tasks . while we need to continue research on macro - level osis , such as leadership , funding , and organizational structure , these studies need to be complemented by research on osis at the micro level . organizational strategy and policy
may define the framework of healthcare delivery , but it is the social and behavioral aspects at the micro level that will define the activities within the framework .
we also need to move away from studies that look broadly at osis ; rather , we need to focus our research efforts on specific contexts of osis .
for example , dorr et al .   pointed out that hit is often not designed to explicitly support collaboration .
therefore , there is a specific research need to define the collaborative behaviors and rules of engagement that hit needs to support .
another context is the organizational setting or type . as more healthcare delivery , and subsequently more hit
, occurs outside traditional healthcare settings ( e.g. , in patient homes , long - term care centers ) we need better evidence on how to design and evaluate hit to support care delivery in these contexts .
it shows how osis need to be studied from micro and macro perspectives , both upstream and downstream , as part of hit implementation .
macro considerations include the funding , incentives , leadership , organizational structure , and process or care delivery objectives .
micro considerations include the context and complexity of hit usage , rules of engagement , and training and trade - offs . '
upstream ' refers to hit design and development prior to the actual implementation of hit . '
downstream ' refers to the operations and maintenance that take place after hit is implemented .
it is essential that both micro and macro perspectives are studied upstream ( i.e. , pre - implementation ) as well as downstream ( i.e. , post - implementation ) because of the dynamic and evolving nature of healthcare processes .
further , hit users need to be involved as much as possible to enable to them to understand the nature of hit - induced changes and how it will impact their work routines .
one of the other conclusions from this work is that osis can not be studied from the perspective of linear modeling of ideal scenarios ; rather , they must be studied from the perspective of the messy and complex reality in which hit is situated . in that context
in addition to the frameworks and methods from medical informatics , insights may be gained through a wide array of approaches from the information systems discipline , such as peter checkland 's soft systems methodology   and the technological frames approach of orlikowski and gash , and approaches from the social sciences , such as activity theory and actor network theory .
as hit is more widely implemented in healthcare settings , it is essential that we ensure hit is a fit in the organizational setting where it will be used .
this paper reviewed osis in hit and identified five themes to provide guidance and bounding for future research .
echoing other studies , the findings from this paper suggest that there is a key need for more explicit and theoretical studies of osis in hit .
more research on integrating micro and macro perspectives of hit use in organizations is also a priority need .
 objectivesthis paper reviews organizational and social issues ( osis ) in health information technology ( hit).methodsa review and synthesis of the literature on osis in hit was conducted.resultsfive overarching themes with respect to osis in hit were identified and discussed : scope and frameworks for defining osis in hit , context matters , process immaturity and complexity , trade - offs will happen and need to be discussed openly , and means of studying osis in hit.conclusionsthere is a wide body of literature that provides insight into osis in hit , even if many of the studies are not explicitly labelled as such . 
 the two biggest research needs are more explicit and theoretical studies of osi in hits and more research on integrating micro and macro perspectives of hit use in organizations . 
I. Introduction
II. Methodology
III. Results
1. Theme One - Scope and Frameworks for Defining OSIs in HIT
2. Theme Two - Context Matters
3. Theme Three - Process Immaturity and Complexity
4. Theme Four - Trade-offs Will Happen and Need to Be Openly Discussed
5. Theme Five - Means of Studying OSIs in HIT
IV. Discussion
V. Conclusion