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Understanding the context and nuances of clinical performance at the front-line can provide valuable insights into why the effects of Health Information Technology implementation might differ across sites. It also helps to inform the design of systems that support performance flexibility as clinicians respond to the changing demands of the clinical environment. This study explored the use of an electronic result acknowledgement (eRA) system by physicians at two Emergency Departments (EDs) at Australian metropolitan teaching hospitals to understand how electronic result acknowledgement is managed differently in response to varying environmental demands. Semi-structured, in-depth interviews relating to physician electronic test result acknowledgement processes were conducted with 21 emergency physicians. Physician use of the eRA system differed in four aspects: i) responsibility (i.e. who acknowledges test results); ii) types of tests acknowledged; iii) coordination and synchronisation (i.e. when acknowledgement occurred); and iv) documentation of follow-up actions. [ABSTRACT FROM AUTHOR]

Electronic medical record-based test results management interventions hold the potential to reduce errors in the test result follow-up process. However, ensuring the adaptability of such systems to the clinical environment has proven challenging. The aim of this study was to explore how contextual factors can influence senior emergency physicians' experience and perceived impacts of an electronic result acknowledgement system across two Emergency Departments. Semi-structured, in-depth interviews relating to physician test result acknowledgement processes before and after system implementation were conducted with 14 senior Emergency Physicians across two Australian metropolitan teaching hospitals. Perceived impacts of the electronic test result acknowledgement system on test result endorsement varied in terms of: changes to workflow, impacts on patient safety; and changes to documentation practices. Existing work practices and the departmental staffing mix and roles play a part in determining the nature of change that an electronic result acknowledgement system is likely to produce. [ABSTRACT FROM AUTHOR]

Socio-technical approaches to health information systems evaluation are particularly relevant to the study of Computerised Provider Order Entry (CPOE) systems. Pathology services are made up of a number of departments each with unique and complex tasks and requirements. These different components of pathology have received very little research attention. This study used qualitative methods to identify key organisational and work process along with repercussions of the implementation of CPOE through a comparison of the Haematology and Clinical Chemistry departments of a hospital pathology service. The results focus attention on areas where the departments face similar challenges along with those areas where work practices diverged. This underlined the key importance of understanding the context and setting of pathology laboratories. The study also draws attention to the importance of cross departmental and multi-disciplinary negotiation in the implementation process and highlights the potential for technology to affect and be affected by the organisational context in which it is placed. [ABSTRACT FROM AUTHOR]

Follow-up of abnormal test results for discharged Emergency Department (ED) patients is a critical safety issue. This study aimed to explore ED physicians' perceptions, practices, and suggestions for improvements of test result follow-up when using an electronic provider order entry system to order all laboratory and radiology tests and view results. Interviews were conducted with seven ED physicians and one clinical information system support person. Interviews were analyzed to elicit key concepts relating to physicians' perceptions of test result follow-up and how the process could be improved. Results described the current electronic test result follow-up system with two paper-based manual back-up systems for microbiology and radiology results. The key issues for physicians were: responsibility for test follow-up; the unique ED environment and time pressures, and the role of the family physician in test result follow-up. The key suggestion for improvement was a complete integrated electronic information system with on-line result endorsement. The study highlighted the complexity of the test result follow-up process and the importance of engaging clinicians in devising solutions for improvements. [ABSTRACT FROM AUTHOR]

A major focus of nurses is to improve patient outcomes, and any introduction of technology into their work environment should add value through enhancing patient care and contributing to the development of nursing intelligence. This study addressed whether nurses working in an emergency department (ED) perceived a relationship between using an emergency department information system (EDIS) and patient outcomes. A cross-sectional survey design was used, with data collected from the population (n=168) of nurses from five Australian metropolitan public hospital emergency departments (EDs). The questionnaire collected information on how EDIS impacted on patient outcomes in terms of waiting times, triage process, departmental accountability, documentation focus, computer interaction, and system purpose. Nurses acknowledged the value of an information system in improving the triage process and increasing the accountability of the ED, however failed to identify any impact on reducing overall ED waiting times or its relationship to improved care delivery. Over half the respondents could not identify negative effects such as compelling nurses to focus on documentation details or ‘treat the computer’ rather than the patient. The use of technology in this study evoked optimistic responses, however results indicated a lack of clarity about the impact of EDIS on patient outcomes. [ABSTRACT FROM AUTHOR]

The organisational culture of a health facility has been identified as a significant factor for successful implementation of clinical information systems. There have been no reported studies exploring the link between sub-cultures and the use of information systems. This study utilises cross sectional surveys to measure doctors' and nurses' perceptions of organisational culture and relate this to their use of a hospital-wide mandatory computerised pathology order entry (CPOE) system. Data were collected by administering an organisational culture survey (Organisational Culture Inventory, OCI) along with a user-satisfaction survey to a population of 103 doctors and nurses from two clinical units in an Australian metropolitan teaching hospital. We identified subcultures based on professional divisions where doctors perceived an aggressive/defensive culture (mean percentile score = 43.8) whereas nurses perceived a constructive culture (mean percentile score = 61.5). There were significant differences between doctors and nurses on three of the attitude variables with nurses expressing more positive views towards CPOE than doctors. The manifestation of subcultures within hospitals and the impact this has on attitudes towards clinical information systems should be recognized and addressed when planning for system implementation. [ABSTRACT FROM AUTHOR]

The aim of this paper is to describe the effect on the clinical cooperation when introducing video consultations in the home of the patient. The study was conducted as a Participatory Design process containing workshops, field studies, clinical experiments and pilot tests involving participants from the Danish primary and secondary care sectors as well as patients and relatives. The video consultation set-up constitutes a new organisational way of working, described as “a new triangle”, based on immediate inter-individual cooperation and team-work. In the triangle, competences were combined which led to a more holistic treatment and a more active role of the patient. Furthermore, a spreading of knowledge between all participants was seen, resulting in an upgrading of the competences of especially the visiting nurse. The introduction of a real-time, on-line link between hospital and home constitutes the basis for simultaneous communication between all participants, resulting in a “witnessing” situation potentially securing or even enhancing quality of treatment. [ABSTRACT FROM AUTHOR]

Many healthcare ICT innovations fail in practice because of a failure to take into account user needs. User needs should be identified broadly, encompassing different levels of organization of the healthcare system and different stakeholder concerns. Full-scale simulators are starting to be used to help in the design and evaluation of novel biomedical devices and displays. Although promising, simulators have significant technical and operational limitations for this purpose and they do not address important aspects of the sociotechnical systems context in which healthcare ICT will be embedded. This argument is illustrated with a case study in which advanced auditory displays for patient monitoring were successfully evaluated in a full-scale patient simulator, but many further questions remain prior to successful translation to practice. [ABSTRACT FROM AUTHOR]

Papua New Guinean primary health care workers describe their Standard Treatment Manuals as like “a teacher” or “a doctor”. This paper explores this glowing reference, looking at how Standard Treatment Manuals are utilised, through data collected in a study which identifies what influences primary health care workers in Papua New Guinea to access and utilise information for diagnostic and treatment decisions. In addition to presenting a unique perspective on this method for transferring information to health workers across the world, this paper presents an opportunity to consider some of the factors which both enable and inhibit the process of providing information to health workers in a non western culture. [ABSTRACT FROM AUTHOR]

The development of assisted living technology today lies within the realm of ambient computing, making assistance automatic and the systems invisible. Unfortunately, this invisibility is also the reason why the users of these systems have no means to remedy even very simple fault situations. By focusing on the needed complementarities between user control and automation, we identify three main issues which are critical when introducing new technology in the homes of older people: Individual need for representation of data, the need for the user to construct a conceptual model of the system and the need for systems to change over time. [ABSTRACT FROM AUTHOR]

This paper will describe two alternate conceptual frameworks (i.e. Structuration and Sensemaking) that will help to describe and provide insight into how best to implement health information systems in ICUs throughout the globe. Structuration and sensemaking are two competing ways to view the social world within hospitals. To examine the impact of information technology in health care organizations, it is important to explore the dynamic interplay between clinical decisionmaking, outcomes of HIT implementation, and individual characteristics of the organizational setting. The adaptation of information technology within health care organizations is by its very nature quite complex. The recursive pattern of social interactions that shape the implementation of technologies within that setting is key. Structuration theory provides an understanding of human work as social interaction within that organizational culture, mediated by artifacts such as tools, language, rules and procedures, and open to change. The ICU provides multiple opportunities for sensemaking. It involves caring for multiple patients simultaneously; is subject to high levels of uncertainty and is provided under significant time constraints. It is highly interdependent work, necessitating shared sensemaking as well as individual sensemaking. Sensemaking is made partially visible in this context as clinicians communicate to each other what they think is the cause of the patient's symptoms and how to treat them in the form of discussions about patient care, consultation requests, ancillary testing, and the electronic medical record. The collaborative nature of work in the ICU lends itself to the application of sensemaking and structuration theories. [ABSTRACT FROM AUTHOR]

The National Programme for IT in England is an ambitious programme comprising a variety of systems from the tried and tested to the new based on new government policy that is being implemented at the same time. For such a large and complex programme, it is not surprising that there are a variety of outcomes emerging. While there are many successes, there are also delays and concerns. This paper looks at two very different systems in the programme (Choose and Book and PACS). It compares and contrasts their implementation within a health community and identifies implications, based on complexity theory, this has for the choice of approach to implementation of associated change. [ABSTRACT FROM AUTHOR]

An electronic triaging system was introduced into a busy children's hospital emergency department. Within 18 months of its introduction, amidst complaints from staff about patient safety related to work slow downs, a decision was made to stop using the system. In this paper we examine issues that arose with the introduction of the electronic triaging system, and discuss these in relation to decision making in complex systems. We suggest that difficulties with the triage system resulted partly because data resulting from the triage encounter are used in several domains including the care domain, the access domain, the federal equity and accountability domain, the local accounting and quality domain and the research domain, each of which has different primary stakeholders, with varying needs. Greater attention to identification of data requirements for each of these domains and acknowledgement of varied stakeholder interests prior to software selection and implementation may improve future implementations. [ABSTRACT FROM AUTHOR]

A study at the urology clinic, Frederiksberg Hospital Denmark, the clinicians working procedures, when prescribing, dispensing and administrating drugs using a computerized physician order entry system (CPOE) showed an overwhelming majority of the clinicians who believed it does support the patient safety and quality of treatment despite the CPOE was not used to the expected degre. [ABSTRACT FROM AUTHOR]

The research reported in this paper describes the development, empirical validation and analysis of a model of technology acceptance by Australian occupational therapists. The study described involved the collection of quantitative data through a national survey. The theoretical significance of this work is that it uses a thoroughly constructed research model, with one of the largest sample sizes ever tested (n=1605), to extend technology acceptance research into the health sector. Results provide strong support for the model. This work reveals the complexity of the constructs and relationships that influence technology acceptance and highlights the need to include sociotechnical and system issues in studies of technology acceptance in healthcare to improve information system implementation success in this arena. The results of this study have practical and theoretical implications for health informaticians and researchers in the field of health informatics and information systems, tertiary educators, Commonwealth and State Governments and the allied health professions. [ABSTRACT FROM AUTHOR]

The healthcare environment has been characterized as interrupt-driven with medical doctors (MDs) and registered nurses (RNs) receiving many interruptions during a shift. Previous research studies have focused on the recipient because of the negative impact on task performance. It is equally important to understand the initiator of an interruption to help design strategies to lessen the number of interruptions and the possible negatives consequences. The purpose of this instrumental study was to examine MDs and RNs as initiators of interruptions. Results of this study indicate that MDs and RNs initiate interruptions most often through face-to-face situations and use of the telephone. Strategies to successfully manage interruptions must consider both the role of initiator as well as the recipient in an interruption event. [ABSTRACT FROM AUTHOR]

In this paper, we discuss how profiles of communicative behaviour can be used to present and analyse information about role activity recorded through structured observation of specific situations. The role activities are encoded as distinctive speech acts. Example profiles resulting from the analysis of three clinicians' communicative behaviour during pre-rounds meetings and ward rounds are given. The examples are based on an observational study performed at a Norwegian university hospital. One fifth-year medical student spent 20 days in two different hospital wards, following 7 physicians from one to seven days each. The observer recorded data from several ward situations such as pre-rounds meetings, ward rounds, and discharge situations. The data was recorded by means of an observation form consisting of a mixture of codes and free-text fields. The data has been post-processed by associating each event with one communicative act. The approach is an efficient and useful means for studying clinicians' information and communication patterns in hospital wards, which can serve as an important tool in the design of new clinical information systems. [ABSTRACT FROM AUTHOR]

Investigating two longitudinal ethnographic studies of managing gradual adaptation of electronic patient records in Canada and Norway, we conduct a cross-case analysis of the enabling factors that support a continuous transformation of technology and health care practices. In line with previous research, our study shows that large-scale information systems adaptation in health care should be managed by a project-group including not only IT-developers, but also representatives of future users and management. While we also argue for the importance of these meetings, we complement and expand the notion of project meetings by providing a conceptualization of the essential aspects of these meetings. Our conceptualization is composed of continuous reflection-on-practice activities to construct technology-in-use practices. Reflection-on-action activities are internally initiated, and comprise critical reflections by the participants, who continuously evaluate and question work practices in relation to technology. [ABSTRACT FROM AUTHOR]

A substantial proportion of nurses' work consists of medication related tasks undertaken in a current environment of high medication error rates. Electronic medication management systems (EMMS) are anticipated to address many of the factors which contribute to errors. These factors, for example illegible hand-written drug orders, reputedly require nurses to spend additional time in clarification and discussion. We report an observational modified time and motion study of 44 registered nurses (215 hours of observation) in a major academic hospital to quantify the time nurses spend in medication related tasks prior to EMMS introduction. On average nurses spent seven minutes in an 8.75 hour shift clarifying or discussing medication issues. The majority of this time (5.4mins) was spent talking with other nurses. Only 1.6 minutes was spent clarifying or discussing medication with doctors. Our results call into question some of the predicted efficiency benefits to nurses' work following EMMS introduction. [ABSTRACT FROM AUTHOR]

We report from a longitudinal laboratory-based usability evaluation of a health care information system. A usability evaluation was conducted with novice users when an electronic patient record system was being deployed in a large hospital. After the nurses had used the system in their daily work for 15 months, we repeated the evaluation. Our aim was to inquire into the nature of usability problems experienced by novice and expert users, and to see to what extend usability problems of a health care information system may or may not disappear over time, as the nurses get more familiar with it – if time heals poor design. On the basis of our study, we present findings on the usability of the electronic patient system as experienced by the nurses at these two different points in time and discuss implications for evaluating usability in health care. [ABSTRACT FROM AUTHOR]

Clinical networks are being increasingly employed to drive innovation in health services by encouraging multi-disciplinary clinical engagement in management processes. The effectiveness of a network, however, depends critically on the ability of its leader to coordinate group interactions. This paper discusses leadership of clinical networks, and in this context reviews technologies for analyzing the way team members interact in group conversations. This review will form the foundation for ongoing research to develop the profile of an effective clinical network leader, along with techniques and tools for evaluation and professional development. [ABSTRACT FROM AUTHOR]

While identifying reasons for the failure of information communication technology (ICT) to transform the healthcare system and constructing models of better designed technology with socio-technical integration is relatively straightforward, implementing these solutions into the rapidly changing medical world has proven considerably more difficult. From a technologist's perspective, the promise of technology remains powerful. New technologies, with high level of socio-technical integration have long been considered as one of the most important factors to transform the medical world in order to deliver better and safer care. From the socio-cultural perspective, however, there is an equally powerful force, which has largely been ignored by the greater community: the entry of generation Y into the healthcare system. Generation Y has generated significant changes in many other industries. This powerful socio-cultural change within the healthcare system needs to be more clearly investigated to guide the design and implementation of sociotechnical integrated ICT solutions. This research-in -progress paper presents a methodological approach that both generates an in-depth understanding of generation Y and illuminates criteria that can be used to meaningfully identify the guiding principles for future socio-technical integrated ICT design and implementation. It aims to make a significant contribution to the field of socio-technical approach to ICT design by alluding the audience to this new generation Y phenomenon in healthcare. It provides some preliminary data to support the need to consider generation Y in future ICT design in healthcare. [ABSTRACT FROM AUTHOR]

Blogs, short for “web logs,” together with podcasts and wikis are currently important foci of general internet research. These three applications are part of the larger body of next-generation communication applications that comprises “Web 2.0.” Within the specific area of health care, however, little attention has been devoted to understanding these technologies and how they are being used by lay health publics. In this article, I will discuss the emergent findings from a new project that looks at blogging interfaces as potential tools for disease prevention and health promotion. I use a literature review combined with “front stage” web analyses of two cases and interviews with the supporting institutions for these sites to discuss the relevant informatics questions that arise with respect to these applications. I further introduce the idea of “goal-oriented” blogging that is found in the first case study. Because this research project is still in preliminary phases, this should be viewed as an exploration into the topic and work in progress. In addition to raising questions, I will outline the important subsequent research steps. [ABSTRACT FROM AUTHOR]

Heuristic evaluation is a usability testing method aiming to improve the user interface design. Traditionally, a panel of experts in usability and human factor issues evaluate and judge the compliance of computer software according to recognized usability principles, the heuristics. In this paper, we investigate clinicians' attitudes towards learning and performing a heuristic evaluation and present the procedure of educating the healthcare staff and their accomplishment of the evaluation. 18 clinicians were recruited for a 2-hours education and filled in a post-education questionnaire regarding their opinions of the evaluation method when applied by clinicians. Six of the clinicians participated later in a heuristic evaluation of a web-based virtual health record,Their time spent for evaluation and analysis of results was approximately four hours each. Opinions from the six “clinical evaluators” were gathered in an post-evaluation form and compared to the post-education questionnaire. The results of 18 clinicians indicate that there is an interest in learning and participating in such evaluations. Our interpretation is that it is feasible to educate healthcare staff to perform rapid usability inspections to locate usability defects and additionally emphasize the domain specific problems residing in health information systems. [ABSTRACT FROM AUTHOR]

Electronic medication systems may impact communication in hospital wards. To identify the ways in which communication patterns may be altered it is necessary to compare processes both before and after system introduction. This paper reports the use of a social network approach to examine the medication advice-seeking network of an Australian hospital renal ward before the introduction of an electronic medication management system. A social network questionnaire was completed by 96% of staff members (doctors, nurses, allied health professionals and administrative staff) on the ward (n=45). Survey data were analysed to produce a sociogram to display the medication advice-seeking network of the staff in the ward. The results showed that there was a relatively low level of advice-seeking about medication-related decisions and tasks. Most communication occurred within professional groups. Several key individuals were pivotal in providing advice both within and across professional groups. [ABSTRACT FROM AUTHOR]

Shared home care is increasingly common, and in order to develop ICT that support such complex cooperative work it is crucial obtain an understanding of the work routines, information demands, and other central preconditions at the clinical level before the development is initiated. Scenarios are proposed as a technique that can be useful for capturing work processes in shared home care and experiences from the Old@Home project are presented. The scenarios are useful not only in the initial phases of the development project but throughout the development process, improving the accessibility of end user requirements and usability issues for the design team, and as a basis for use cases and further design. [ABSTRACT FROM AUTHOR]

Introducing an innovative, multidisciplinary concept of care means the change of existing structures both in work and communication flows which often involves problems. In this paper we describe exemplary the communication problems which arose during the introduction of the multidisciplinary concept of Family-Centred, Individualized Developmental Care of Premature Infants and Newborns at the Children's Hospital Heidelberg. We suggest workflow adaptations to achieve timeliness of information and present ideas to prevent communication problems e.g. caused by inadequate knowledge of staff. We used interviews, analyzed video-recordings and modified the Communication Observation Method [7] to analyze the present state of communication flows and structures. [ABSTRACT FROM AUTHOR]

This paper demonstrates how qualitative System Dynamics methodology can be used to provide a better understanding of health systems thus facilitating better development and design of computer-based health information systems. In an earlier paper by the same authors, system dynamics modeling and field study research methods are used to capture the complex and dynamic nature of the immunization process, to enhance the understanding of the immunization health care problems and to generate insights that may increase the immunization coverage effectiveness. Through qualitative modeling, causal loop diagrams which are used to show the key issues that need to be addressed when developing health information systems are drawn with the aim of improving the immunization services. The paper shows the benefits of using System Dynamics to understand systems with complex interactions thus facilitating the development of information systems that meet the stakeholder requirements. [ABSTRACT FROM AUTHOR]

Telemedicine is the use of communication networks to exchange medical information for providing healthcare services and medical education from one site to another. The application of telemedicine is more promising in economically developing countries with agrarian societies. The American Telemedicine Association (ATA) identifies three healthcare services: clinical medical services, health and medical education, and consumer health information. However, it is not clear how these services can be adopted by different sectors: public and private. This paper looks at four Indian case studies, two each in public and private sectors to understand two research questions: Are there differences in telemedicine adoption between public and private hospitals. If there are differences: What are the differences in telemedicine adoption between public and private sectors? Authors have used the extant literature in telemedicine and healthcare to frame theoretical background, describe the research setting, present the case studies, and provide discussion and conclusions about their findings. Authors believe that as India continues to develop its telemedicine infrastructures, especially with continued government support through subsidies to private telemedicine initiatives, its upward trend in healthcare will continue. This is expected to put India on the path to increase its life expectancy rates, especially for it rural community which constitute over 70% of its populace. [ABSTRACT FROM AUTHOR]

Medical errors are common, especially within the acute healthcare delivery. The identification of systemic factors associated with adverse events and the construction of models to improve the safety of the healthcare system seems straightforward, this process has been proven to be much more difficult in the realism of medical practice due to the failure of the incident reporting system to capture the essential information, especially from the perspective of junior doctors. The failure of incidence reporting system has been related to the lack of socio-technical consideration for both system designs and system implementations. The main reason of non-reporting can be conceptualised through the motivation psychology model: Maslow's hierarchy of needs; in order to achieve a change in the socio-cultural domain for incident reporting. This paper presents a qualitative research methodology approach to generate contextual-rich insights into the socio-cultural and technological factors of incident reporting among junior doctors. The research illuminates the guiding principles for future socio-technical integrated information communication technology designs and implementations. Using Maslow's hierarchy of needs as the conceptual framework, the guiding principles aim to design electronic incident reporting systems which will motivate junior doctors to participate in the process. This research paper aims to make a significant contribution to the fields of socio-technical systems and medical errors management. The design and implementation of the new incident reporting system has great potential to motivate junior doctors to change the culture of incident reporting and to work towards a safer future healthcare system. [ABSTRACT FROM AUTHOR]

This paper describes a case study into the development of an electronic support tool for clinical handover conducted in the Royal Hobart Hospital's Department of General Internal Medicine. By directly involving clinicians as co-participants in the development, and by conceptualising the system to be built as a support tool rather than as a 'total solution' this case study outlines the practical experience of dealing with a diversity of user requirements. The approach involved in-depth fieldwork to understand the factors and their inter-relationships in clinical handover processes. From an analysis of the data generated key issues relating to work processes and potential impacts on patient safety were identified and discussed with clinicians. A support tool incorporating a series of design features aimed at improving patient safety and supporting existing work processes identified as important by the clinicians was developed. Through early and continual involvement of clinicians in the project, this case study highlights how socio-cultural analysis can be translated meaningfully (in terms of the end-users) into systems design. The paper aims to contribute to a stronger recognition within the domain of eHealth of user-centred approach to systems development for patient safety. [ABSTRACT FROM AUTHOR]

Prior to developing and implementing health informatics systems it is essential to acquire information about the work practice. Interviews are often used but they don't always capture important details. In this project we used video cameras to observe the work practice of two medical secretaries at Department of Urology at Århus University Hospital, Skejby. The project was carried out with a clear user influence in all phases of the project. The observation and the analysis focused on interruptions of the work processes, of which we found numerous that we categorized in three different types. The use of video and audio proved to be powerful tools for analysis of work practice, although it is very labor intensive method. [ABSTRACT FROM AUTHOR]

A conceptual model of computerised hospital information system (CHIS) use has been developed, based on the results of case studies in four South African regional (level 2) hospitals, interviews with local experts, and related work on modelling and evaluation of health information systems. In addition to factors within hospitals, factors which reflect the decisionmaking and resource allocation processes at provincial level have also been included in the model. The applicability of the model is demonstrated through an analysis of the effects of limited or vulnerable resources on CHIS implementation and use at hospital level. Some potential approaches to overcoming these effects are suggested. [ABSTRACT FROM AUTHOR]

It is hard to overstate the importance of an international forum which brings together leading researchers studying how information and communication technologies (ICT) can be safely and effectively designed, implemented and used within the health system. The ICT research enterprise has increased substantially in the last decade. Alongside the research interest, investments in clinical systems have grown and their sophistication and capacity to contribute to health sector improvement continues at a rapid pace. Yet, amongst this growth, evidence regarding the benefits of system introduction remains limited and has not kept pace. For example, good studies of benefits realization remain sporadic, and large scale system failures occur all too frequently. Early studies of health information system failures identified the central role of the human, social and organizational contexts in which information systems operate. They set the challenge for researchers to understand how to obtain the best fit between the technical systems (e.g. the information systems and associated work practices) and the social systems (e.g. organisational culture, social practices and behaviours, and political mileu). The origins of socio-technical theory can be traced to different strands, one of which is the seminal work undertaken by organizational researchers Trist and Bamforth who originally studied British coal miners in the 1940s and 1950s. Another important strand is the work of Bruno Latour and Steve Woolger who in the 1970s examined how scientific facts are constructed in a laboratory. Since this time many health informatics researchers have adapted this theoretical approach implicitly or explicitly, and have framed their research within a socio-technical perspective. This has resulted in a new and exciting body of work embracing a socio-technical perspective of health information system design, implementation and evaluation contributed to by researchers from many countries. In 2001 the 1st International Conference on Technology in Health Care: Socio-technical Approaches was held in Rotterdam, The Netherlands. It brought together academics to discuss their research under the common theme of socio-technical approaches. This conference was important in identifying an international community of scholars from a broad range of disciplines... [ABSTRACT FROM AUTHOR]

The aim of this multi-method study based at a microbiology department in a major Sydney metropolitan teaching hospital was to: i) identify the role that information and communication processes play in a paper-based test request system, and ii) examine how these processes may affect the implementation and design of Computerised Provider Order Entry (CPOE) systems. Participants in this study reported that clinical information can impact on the urgency and type of tests undertaken and affect the interpretation of test results. An audit of 1051 microbiology test request forms collected over a three-day period showed that 47% of request forms included clinical notes which provide a variety of information often vital to the test analysis and reporting process. This transfer of information plays an important role in the communication relationship between the ward and the laboratory. The introduction of new CPOE systems can help to increase the efficiency of this process but for that to be achieved research attention needs to be given to enhancing the provision and communication of clinical information. [ABSTRACT FROM AUTHOR]

Evaluating and optimising 'fit' between technology and clinical work is critical to ensure the intended benefits of technology implementations are achieved. Using a mixed method approach (structured observation, interviews, field notes) we collected data regarding users, tasks, technology, and factors impeding technology use from a sample of 38 clinicians on two wards at an Australian hospital. We used the FITT framework to assess the relationships between users, tasks, and technology. Our findings showed that even when adequate fit between users, tasks, and technology was attained additional factors related to the environment (including the temporal rhythms of a ward, infection control rooms, or space limitations) ultimately affected technology use. Thus, we propose the fit between individuals, task, technology and environment (FITTE) framework as a means to evaluate and optimise technology use by explicating the relationships between users, tasks, technology, and the environment in which they operate.

Understanding the context and nuances of clinical performance at the front-line can provide valuable insights into why the effects of Health Information Technology implementation might differ across sites. It also helps to inform the design of systems that support performance flexibility as clinicians respond to the changing demands of the clinical environment. This study explored the use of an electronic result acknowledgement (eRA) system by physicians at two Emergency Departments (EDs) at Australian metropolitan teaching hospitals to understand how electronic result acknowledgement is managed differently in response to varying environmental demands. Semi-structured, in-depth interviews relating to physician electronic test result acknowledgement processes were conducted with 21 emergency physicians. Physician use of the eRA system differed in four aspects: i) responsibility (i.e. who acknowledges test results); ii) types of tests acknowledged; iii) coordination and synchronisation (i.e. when acknowledgement occurred); and iv) documentation of follow-up actions.

Medication monitoring of ambulatory rheumatology patients on Disease Modifying Anti-Rheumatic Drugs (DMARDS) is time consuming and complex, with possibilities for error. Electronic systems have the potential to improve the process. The aim of this study was to evaluate the impact of an electronic Drug Monitoring System (eDMS) on the time nurses' spent on clinical documentation associated with monitoring. The study was conducted with all nurses (n=4) in the Rheumatology Department of a large metropolitan Australian teaching hospital. The eDMS was designed as a module of the Hospital Clinical Information System (HCIS) to assist clinicians in monitoring rheumatology patients on DMARDS. Timing data were collected using a modified time and motion work measurement technique using software on a handheld computer. Data included the time nurses spent on documentation regarding medication monitoring before and after the implementation of the eDMS. Results showed that following implementation of the eDMS nurses spent significantly less time documenting medication monitoring information (13.6% to 7.2%, P<.0001). The cumbersome paper-based Drug Monitoring Patient List was replaced entirely by the eDMS. Consequently, there was a significant decrease in the time nurses spent using the HCIS (13.01% to 2.8%, p<.0001) for monitoring and the use of loose-leaf paper also decreased (7.6% to 5.0%, p = 0.002). The eDMS made the process of drug monitoring quicker and simpler for nurses and thus permitted them to increase their time spent in direct patient care.

Follow-up of abnormal test results for discharged Emergency Department (ED) patients is a critical safety issue. This study aimed to explore ED physicians' perceptions, practices, and suggestions for improvements of test result follow-up when using an electronic provider order entry system to order all laboratory and radiology tests and view results. Interviews were conducted with seven ED physicians and one clinical information system support person. Interviews were analyzed to elicit key concepts relating to physicians' perceptions of test result follow-up and how the process could be improved. Results described the current electronic test result follow-up system with two paper-based manual back-up systems for microbiology and radiology results. The key issues for physicians were: responsibility for test follow-up; the unique ED environment and time pressures, and the role of the family physician in test result follow-up. The key suggestion for improvement was a complete integrated electronic information system with on-line result endorsement. The study highlighted the complexity of the test result follow-up process and the importance of engaging clinicians in devising solutions for improvements.

A major focus of nurses is to improve patient outcomes, and any introduction of technology into their work environment should add value through enhancing patient care and contributing to the development of nursing intelligence. This study addressed whether nurses working in an emergency department (ED) perceived a relationship between using an emergency department information system (EDIS) and patient outcomes. A cross-sectional survey design was used, with data collected from the population (n=168) of nurses from five Australian metropolitan public hospital emergency departments (EDs). The questionnaire collected information on how EDIS impacted on patient outcomes in terms of waiting times, triage process, departmental accountability, documentation focus, computer interaction, and system purpose. Nurses acknowledged the value of an information system in improving the triage process and increasing the accountability of the ED, however failed to identify any impact on reducing overall ED waiting times or its relationship to improved care delivery. Over half the respondents could not identify negative effects such as compelling nurses to focus on documentation details or 'treat the computer' rather than the patient. The use of technology in this study evoked optimistic responses, however results indicated a lack of clarity about the impact of EDIS on patient outcomes.

The organisational culture of a health facility has been identified as a significant factor for successful implementation of clinical information systems. There have been no reported studies exploring the link between sub-cultures and the use of information systems. This study utilises cross sectional surveys to measure doctors' and nurses' perceptions of organisational culture and relate this to their use of a hospital-wide mandatory computerised pathology order entry (CPOE) system. Data were collected by administering an organisational culture survey (Organisational Culture Inventory, OCI) along with a user-satisfaction survey to a population of 103 doctors and nurses from two clinical units in an Australian metropolitan teaching hospital. We identified subcultures based on professional divisions where doctors perceived an aggressive/defensive culture (mean percentile score = 43.8) whereas nurses perceived a constructive culture (mean percentile score = 61.5). There were significant differences between doctors and nurses on three of the attitude variables with nurses expressing more positive views towards CPOE than doctors. The manifestation of subcultures within hospitals and the impact this has on attitudes towards clinical information systems should be recognized and addressed when planning for system implementation.

The aim of this multi-method study based at a microbiology department in a major Sydney metropolitan teaching hospital was to: i) identify the role that information and communication processes play in a paper-based test request system, and ii) examine how these processes may affect the implementation and design of Computerised Provider Order Entry (CPOE) systems. Participants in this study reported that clinical information can impact on the urgency and type of tests undertaken and affect the interpretation of test results. An audit of 1051 microbiology test request forms collected over a three-day period showed that 47% of request forms included clinical notes which provide a variety of information often vital to the test analysis and reporting process. This transfer of information plays an important role in the communication relationship between the ward and the laboratory. The introduction of new CPOE systems can help to increase the efficiency of this process but for that to be achieved research attention needs to be given to enhancing the provision and communication of clinical information.

Socio-technical approaches to health information systems evaluation are particularly relevant to the study of Computerised Provider Order Entry (CPOE) systems. Pathology services are made up of a number of departments each with unique and complex tasks and requirements. These different components of pathology have received very little research attention. This study used qualitative methods to identify key organisational and work process along with repercussions of the implementation of CPOE through a comparison of the Haematology and Clinical Chemistry departments of a hospital pathology service. The results focus attention on areas where the departments face similar challenges along with those areas where work practices diverged. This underlined the key importance of understanding the context and setting of pathology laboratories. The study also draws attention to the importance of cross departmental and multi-disciplinary negotiation in the implementation process and highlights the potential for technology to affect and be affected by the organisational context in which it is placed.