Adopting the Talk? Drifting Visions of the Electronic Health Record

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1 Adopting the Talk? Drifting Visions of the Electronic Health Record Akbar Saeed, Ivey School of Business, UWO Supervisor: Dr. Abhijit Gopal Started research 2007, currently completing 4 th.year Status: Full-time student For: Doctoral Colloquium, CMS 5, Manchester, UK When confronted with the challenge of adopting an IT-based innovation, managers must first develop a conceptual understanding of how that innovation might benefit their organization. This conceptual framework, or vision of the future, plays an important role in the way innovations are applied and diffused. However, in many cases, building a credible and useful vision becomes highly problematic as the innovation itself is often immature, illdefined and poorly understood. In this document, I use the perspective of Actor-Network Theory (ANT) to theorize how the vision of the innovation comes to be and how this vision consequently influences the way that the innovation is put into play. I suggest that the vision, a socio-technical construction, possibly emerges from the reconciliation of multiple visions of the innovation that are put forth by various interested parties in the wider stakeholder community. Furthermore, I posit that visions continually drift as these various parties, including adopting organizations, struggle to make sense of their ongoing experiences with the emerging and evolving innovation. I intend to illustrate such theorizations with an analysis of the ongoing pan- Canadian Electronic Health Record initiative. I conclude by suggesting that the vision or talk of the innovation, over and beyond the innovation itself, may have a fundamental and ongoing influence on the adoption, diffusion and production of any IT-based innovation. Such thinking has profound implications for the way that we currently approach adoption research.

2 Many organizations invest heavily in Information Technology (IT) based innovations with the hope of supporting both operational processes and long term strategic objectives. When faced with novel technologies, managers must develop a conceptual understanding of how that innovation might benefit their organization. This conceptual framework, or organizing vision, plays an instrumental role in the way innovations are applied and diffused as the vision influences how managers approach and deal with the innovation (Ramiller & Swanson, 2003; Swanson & Ramiller, 1997). However, building a credible and useful vision is usually quite problematic as the innovation itself is often immature, ill-defined and poorly understood. Adding to the confusion is that multiple visions of the innovation seem to originate from a variety of stakeholders in the inter-organizational community with often conflicting interests. These visions seem to continually drift as various stakeholders, including adopting organizations, struggle to make sense of their ongoing experiences with the emerging and evolving innovation. As a result, implementing and assimilating IT based innovation into organizational practice can pose significant technical and social challenges (Chiasson & Davidson, 2004) In this document, I attempt to scope out a possible research agenda. I begin by suggesting that the case of the pan-canadian Electronic Health Record initiative may be a fruitful site in which to study the interplay of multiple visions. I then briefly discuss the approach of Actor-Network Theory (ANT) and the contribution it makes to the way that we understand multiple and drifting visions. I conclude by suggesting that the vision or talk of the innovation, over and beyond the innovation itself, may have a fundamental and ongoing influence on the adoption, diffusion and production of any IT-based innovation. I discuss some of the implications of such thinking for the way that we currently approach adoption research. Pan-Canadian EHR

3 For this research project, I have identified the pan-canadian Electronic Health Record (EHR) initiative as a possible site in which to study the interplay of multiple visions of an innovation. Besides the easier access to public documentation, this project is particularly appealing due to the multiple and varied stakeholders that have a vested interest in the EHR. Several visions of the EHR have been already put forth. For instance, Infoway (a non-profit organization that consists of the Deputy Health Ministers of the provinces and the Federal Deputy Health Minister) has developed a somewhat detailed vision of what the future of healthcare in Canada will look like, as a result of the implementation of the EHR and other associated IT-based innovations. Interestingly, they have used various material means to promote their vision, including conference presentations, brochures, software standards and videos. The overall project has a 10 year projected total cost of ownership of approximately $22 billion with expected benefits to include improved quality, greater access to healthcare services, increased informational availability for public health initiatives and improved cost control (Infoway, 2005). Also, the Ministry of Health and Long-Term Care has put forth a vision (which I will not describe here): The EHR requires a considerable shift in thinking, on behalf of the users (healthcare professionals and administrators) as it not only supports medical work but also structures and transforms it in highly complex ways (Berg & Bowker, 1997). Also, an interesting adoption problem has surfaced as reflected in the low adoption rates of electronic patient records among physicians (around 10% in the U.S. and similar in Canada), possibly due to cultural and work process differences among various specialists (Hoffman, 2007). This research

4 project has the potential to gain a much richer understanding of some of these issues and challenges than extant research has provided to date. Boeing 747s do not fly, airlines fly' (Latour, 1999) Actor-Network Theory For this research project, I will employ the theoretical and methodological approach of Actor-Network Theory (ANT) (Latour, 1999; Law & Hassard, 1999). ANT forces us to shift our natural frame of reference, in order to allow us to perceive those networks of relations that constitute our world. For instance, with this approach, we can sense that it is not the Boeing 747 that flies us but the airline itself, with its entire ensemble of aligned human and nonhuman actants. Purposeful action becomes the property of institutions and not of objects or humans (Latour, 1999). ANT allows us to bring technical objects and people into a process of reciprocal definition in which objects are defined by subjects and subjects defined by those objects with which they have relations (Akrich, 1992). The social and the technical are therefore established simultaneously, mutually constituting each other (Bijker & Law, 1992). It is through such movement that the network emerges; it is not given a priori (Law, 1992). Using this relational perspective, I can focus on the emergence, construction and maintenance of the EHR vision. Visions of the EHR, as forms of discourse, could also be seen as one of many socio-technical ordering attempts that are performed, embodied and told in different materials. I can get a sense of how the EHR vision emerges through the interplay of several actants, not in the mind of any one individual (Cordella & Shaikh, 2006). I can also become more attuned to how particular visions compete with other visions and how some visions become more durable over time. I could use ANT to understand the process through which this happens and the various ways in which these visions interact, change, or indeed face extinction (Law, 1994). Rather than focusing on the innovation itself as a static entity

5 that gets adopted or not, as has been the approach of the dominant paradigm in adoption research, the focus is shifted to the visions that surround the innovation and the attempts by multiple stakeholders to enroll others by promoting particular visions. This research will try to understand how this happens. Multiple Visions When confronted with the prospect of trying to implement an IT-based innovation, managers try to understand how that innovation could benefit their organization, in their unique context. Invariably, they look to various sources inside and outside the organization to get a better sense of what those possibilities may be. The range of possibilities represents multiple visions. Consequently, research on such visions requires a shift in focus away from the traditional approach of adoption studies that focus on the adoption practices of individual organizations to trying to gain an understanding of the evolving text and institutional presence of the various visions that develop in the inter-organizational community. Therefore, this approach calls for process-oriented, historical studies (Swanson et al., 1997). Institutional Level Organizational Level Vision of Innovation Vision of Innovation Vision of Innovation Vision of Innovation Vision of? Innovation? Vision of Innovation? Multiple Stakeholders Innovation Possible sources of Visions of the EHR Infoway Canada

6 Ontario Ministry of Health and Long-Term Care Local Health Integration Networks (LHIN) Other government agencies Technology (hardware and software) vendors e.g. IBM, Sierra Systems, Cerner Professional Associations e.g. Physicians, Pharmacists, Nurses, Health Records Consultants Individual adopting Healthcare institutions Individual users: Physicians, Pharmacists, Nurses Drifting Visions If we understand being to be strictly composed of fluid, discontinuous and everchanging processes, then entities are nothing but arrested movement (Bergson, 1998). Accordingly, drift can be thought of as a central rather than an aberrant phenomenon and one that perhaps needs a much more nuanced consideration by both scholars and practitioners. The more that systems and applications are distributed, multifaceted, and a-centred (as in the case of the Internet), the more this phenomenon [drift] will be ubiquitous and momentous (Ciborra, 2002: 89). From the perspective of ANT, drift is brought about from the necessary unfolding of systems as they emerge from the interaction of the designers intentions and the users enactment into practice (Quattrone & Hopper, 2006). Accordingly, a vision can be considered to be only one particular understanding of the innovation among many possible ones. A particular vision may emerge and become privileged through various methods. However, as managers gain experience with the innovation, they may develop new perspectives that cause them to re-orient their vision towards what the reality of the ongoing situation has revealed. Accordingly, the vision drifts. Research Questions Based on the previous discussions, I will be guided by, but not limited to, the following research questions: How is the EHR being put into play? Who are the multiple stakeholders? Do these stakeholders have particular interests?

7 If so, by what material means (e.g. documents, practices, technologies and events) do these stakeholders advance their interests? Is there a common vision that emerges from the multiplicity? If so, how? Do managers come to realize that the vision is indeed drifting? If so, how do they account for drift in their managerial practices? Implications for Adoption Research The vast majority of the research in this area has been conducted using survey methods, where the adopter or adopting organization serves as the focal concern. Relatively less attention has been paid to the rich web of cultural, political and technological influences that serve as context (Marcon & Compeau, 2003). Due to methodological bias, much of the work has been fixated on identifying potential antecedents that will increase innovation adoption, assuming that only the most appropriate innovations will be adopted by rational users (Jeyaraj, Rottman, & Lacity, 2006). In contrast to extant research, my research takes a broadly interpretive perspective in which it is assumed that reality can only be accessed through social constructions such as language, consciousness and shared meanings (Prasad & Prasad, 2002). In this way, I see the representation of the innovation (the vision) as being perhaps more consequential than the innovation itself. Overall, there has been a paucity of research on visions of innovations, with little attention paid to how visions both succeed and fail in supporting the innovations that they describe (Swanson et al., 1997). Through such understanding, organizations may begin to engage the institutional creation of the visions upon which they must fundamentally rely. My research, uniquely addresses questions that cannot be adequately answered by traditional survey methods and enhances our understanding of, among other things, the symbolic dimensions of organizational life (Prasad et al., 2002). Future Research Agenda The historical course of an organizing vision leaves a substantial trace in the public as well as private record. Its imprints may be followed (Swanson et al., 1997). Multiple

8 stakeholders (e.g. Government representatives, Industry Associations, IT vendors) will be interviewed to get an understanding of the various kinds of visions of the EHR that have been put forth. Hospital administrators (e.g. physicians, nurses and professional) will also be interviewed to understand how they have made sense of the EHR through its various organizing visions. In general, interviewees will be asked about how they understand the EHR in the context of medical work. Interviews will be open ended and semi-structured, beginning with open ended and general questions that allow for the exploration of relevant issues. In addition, they will be asked to identify relevant documents and sources that might inform this research. Consequently, such documents and sources will be analyzed for evidence of visions. Also, I will gather information from non-traditional sources as researchers should probe the larger community terrain over which the vision has ranged. They should venture out, to practitioner conferences, exhibitions and the like. They should also engage the relevant practitioner publications (Swanson et al., 1997). At these venues I will observe, record and gather relevant documentation. An ANT approach is especially well suited to achieving the stated objectives of this research and the stated weaknesses of research in this area. ANT is historical and process-oriented. The principal limitation of this approach is that it relies on documentary sources and retrospective interviews with multiple stakeholders. Texts are not necessarily equivalent to what managers and hospital workers would actually do everyday in organizations or representative of all possible ways in which they may make sense of the EHR. A focus on discourse as inscribed in texts cannot therefore account for the totality of all that is understood about the EHR. Without wishing to make a claim to totality, such an examination is still useful in providing an overarching view of generally held ideas and practices about the EHR. Such ideas and practices are an integral part of how the reality of the EHR is constructed. They have material effects on the lives of people in organizations, at times shaping human action as well as our understanding of the world and being shaped by such actions and

9 understandings in turn. Investigating ideas and practices inscribed in texts can provide a means to understand the present in its connection to the past and in the context of historically contingent ways of conceiving of the world that construct the reality of the EHR along particular lines. I intend to gather data from three main sources: interviews with multiple stakeholders, relevant documentation and observation notes of conferences/meetings. Everything will be transcribed into a textual format for analysis purposes. The approach to textual analysis is broadly hermeneutic. The principle of the hermeneutic circle guides interpretation through iterative consideration of the whole and the parts, emphasizing understanding in context (Prasad et al., 2002). It entails a constant movement from consideration of individual elements or parts to consideration of the whole, and vice versa. Elements or parts can be words in a sentence, or sentences in a paragraph, paragraphs in a text, etc. The whole can be a sentence, a paragraph, a text or a collection of texts, etc. Whole and parts must be understood iteratively in relation to each other. A broadly hermeneutic orientation also entails a deeply reflexive stance: a constant awareness of the researcher s own location in history and the attempt to suspend unexamined beliefs or prejudices (Prasad et al., 2002). Conducting this research will necessitate the successive analysis of multiple texts. To provide a useful structure for this process, I intend to routinely synthesize analytical findings in the form of summaries and notes that will be compiled separately for each document. Such analyses, together with other notes or reflections on the findings or progress of the research that may be compiled at various times, will form the basis for constructing a rich description of the multiple visions of the EHR. Such a description does not attempt to integrate and reconcile the analytical findings but rather to shape them into an ensemble or a collage, constructing a complex web of intelligibility around a phenomenon that makes visible the process through which it has come into being in the present.

10 I anticipate that I will need to gather information from a variety of sources which will likely include research participants in the following types of organizations: Hospital Administrators, Physician Administrators, Nurse Administrators, Electronic records standards organizations, Professional organizations, IT vendors, Government representatives. The interviews will cover topics related to the understanding of the EHR with particular emphasis on aspects most relevant to the participants as representatives of specific organizations. Follow-up interviews may be needed in some cases where particular points need to be clarified. Topics may include some or all of the following: Their understanding of what the EHR means to medical work, their particular interest in the EHR, identification of other stakeholders in the discourse community, their understanding of the roles and interests of other stakeholders and identification of relevant textual materials that could further the research agenda. Conclusion In this research, I take the view that managerialism becomes a way of making objects fit to be known by social scientists (Law 2005:333). If we are to accept that our methods do not just describe realities but are also involved in creating them (Latour, 2004), then the understanding of an IT-based innovation as an object can be seen as a necessity precursor for those who espouse traditional methods of research. On the other hand, I will be sensitive to the way that the multiple visions of the EHR slip and slide imperceptibly into other and different objects. By understanding vision drift as an inevitable result when systems are put into play, I hope to open up a free space for alternate visions and consequently alternate innovations to emerge. Managers may learn that rather than trying to impose your will on the system, you try to balance the right kinds of control with the right kinds of letting go. (p.154: Malone- The Future of Work). This would involve a special sensitivity to the unfolding sociotechnical system being managed. In particular, such research may cause stakeholders to

11 reflect upon their role in influencing the way that the EHR is put into play. As a result, alternative conceptualizations of the EHR may emerge that are perhaps more sensitive to existing ways of doing medical work and therefore may have the potential to benefit society at large.

12 References: Akrich, M The De-Scription of Technical Objects, Shaping Technology/Building Society: Studies in Sociotechnical change: Berg, M., & Bowker, G The multiple bodies of the Medical Record. The Sociological Quarterly, 38(3): Bergson, H Creative Evolution (A. Mitchell, Trans.). New York: Dover Publications. Bijker, W. E., & Law, J. (Eds.) Shaping Technology/Building Society: Studies in Sociotechnological Change. Chiasson, M., & Davidson, E Pushing the contextual envelope: developing and diffusing IS theory for health information systems research. Information and Organization, 14: Ciborra, C The Labyrinths of Information: Challenging the Wisdom of Systems: Oxford University Press. Cordella, A., & Shaikh, M From Epistemology to Ontology: Challenging the Constructed "truth" of ANT. Working Paper. Hoffman, T What's plaguing E-health?, Computerworld, Vol. 41. Infoway Executive Summary, Canada Health Infoway's 10-year investment strategy. Jeyaraj, A., Rottman, J. W., & Lacity, M. C A review of the predictors, linkages, and biases in IT innovation adoption research. Journal of Information Technology, 21(1): 1. Latour, B Pandora's Hope. Cambridge: Harvard University Press. Law, J Notes on the Theory of the Actor-Network: Ordering, Strategy and Heterogeneity. Systems Practice, 5(4): Law, J Organizing Modernity. Oxford: Blackwell. Law, J., & Hassard, J Actor Network Theory and after: Blackwell. Marcon, T., & Compeau, D Information systems research on Individual IT adoption: Time for a Change. Paper presented at the ASAC, Nova Scotia. Prasad, A., & Prasad, P The coming of age of interpretive organizational research. Organizational Research Methods, 5(1): Quattrone, P., & Hopper, T What is IT? SAP, accounting, and visibility in a multinational organisation. Information and Organization, 16: Ramiller, N. C., & Swanson, E. B Organizing visions for information technology and the information systems executive response. Journal of Management Information Systems, 20(1): 13. Swanson, E. B., & Ramiller, N. C The organizing vision in information systems innovation. Organization Science, 8(5): 458.

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