Action design research for creating value through healthcare information technology

Health Information System

Promoting Action Design Research to create value in healthcare through IT

Recently there has been varying proof showing that health IT reduces costs while improving the standard of care offered. The same factors that had caused delays in reaping benefits from IT investment made in other sectors (i.e. time consuming procedural change) are also very common within the healthcare sector. Due to the current transitive nature of the Healthcare sector, new IT investment is likely not going to provide maximum value unless this new investment is backed up with a total reform of healthcare delivery. The overall ability of healthcare IT value researchers to add value to practice will be severely limited as a result of the traditional ex-post approach to measuring IT and the fact that government spurs significant investment. It may be risky to generalize or compare results from traditional IT value research with those from healthcare due to the difference between them. It is broadly accepted that the key to improved healthcare quality and reduced cost is Healthcare Information Technology (HIT) (Sherer, 2014). The idea of Knowledge Management (KM) as a probable solution to most of the problems confronting the U.S. And international healthcare systems has emerged. Safety concerns and quality of patient care, serious ineffectiveness, contrasting information principles technologies, rapidly growing costs and clinical information overload are some of these problems (Wills et al. 2010). Although still in its infancy and quite far from providing meaningful use, the potential of IT in healthcare is increasing. Subsequently, healthcare stakeholders like hospitals, medical practitioners, physicians, and consumers are faced with a myriad of concerns associated with IT use in healthcare. Thus, its enactment is a constant challenge for the healthcare sector (Palvia et al. 2012). I propose an action design research that uses existing theories as a base, but is adapted to fit the specific characteristics of the healthcare industry. By actively partaking in the design and appraisal of these new socio-technical systems, IT value researchers can generate sound theories to explain value creation in healthcare so that practice can be influenced (Sherer, 2014).

Introduction

The results reported by various industries such as banking and finance indicate that digitally automated client transaction and processing decades ago are very similar to those being reported today in healthcare. Several years were spent by IT researchers to determine how, why, and when value is generated from investments made in IT. This allowed IT researchers not to only have a firm grasp on how to properly study IT value, but to also have a solid body of knowledge about the dynamics that generate it (Kohli & Grover, 2008), especially the time-intensive process changes that are required. This extensive body of knowledge can therefore be of significance to IT value researchers who are well situated to use it to clarify how IT can be of value to the healthcare industry. However, there is a possibility that industry differences will influence how IT value is taken in the healthcare, this is because industry is a significant differentiator in IT research. Furthermore, the relevance of research approaches that focus on post-hoc analysis of former IT investments can neither be timely nor be able to influence healthcare now, when extensive investment incentives are stimulating adoption and industry change. Using traditional IT as a base, strategically positioned IT researchers studying the generation of value in healthcare can adapt it as necessary to account for the dissimilarities it has with the health industry. I argue that IT researchers must actively be involved in the design and assessment of the innovation that is currently underway in IT and multi-organizations. In order to proffer answers to the questions of how and what IT interventions can do to increase value to healthcare, it is necessary for researchers to adopt action design research approaches. (Sherer, 2014).

Statement and Analysis

Traditional IT Value Research and the Healthcare Industry

Under certain circumstances, research on IT value has shown that IT creates value, and firms do not appropriate all the generated value. This value manifests in various ways and at several organizational levels. A multiplicity of balancing organizational investments influence IT value. In Healthcare, there are a number of distinct differences that can influence conditions to drive value, the complementing elements, the mechanisms, which allow the value to be added, and the methods used to measure the value. Healthcare characterizes a remarkably different socio-technical context when compared with several industries where IT research is being conducted, and IS theories developed (e.g. transportation, manufacturing, financial services). Healthcare benefits through societal values like; improved living standard, public health, and lack of disease. In addition, traditional benefits like costs, choice, customer satisfaction, profitability still exist. Although the outcome sought after by healthcare's numerous and diverse stakeholders are different, traditional IT value research has concentrated on its economic impact). As an illustration, nurses and physicians will emphasize on healthcare quality, while directors and managers are more concerned about efficiency. Social, economic, environmental and behavioral factors influence the value of healthcare among stakeholders who belong to identical groups. Some values are personal, thus cannot be expressed by numbers and formulas i.e. quality of life. Regular IT business value research does not usually distinguish performance and its possibly different values to each individual interpretation of dissimilar stakeholders. Healthcare IT's most prominent issue is to improve societal value. This is a more complex variable, as it may have diverse meanings to various stakeholders. Whereas, Regular IT value research is concerned with multiplying firm value. Traditional IT value research is yet to thoroughly explain the casual relationship that exists between IT investment and value. The mechanism via which value is generated is believed to be influenced by multifaceted interactions and dependences of all healthcare participant's goals. The heterogeneity among healthcare providers, patients, and the functionality of their applications (e.g. electronic healthcare records) is becoming increasingly challenging to control. The role of IT in increasing value to healthcare through regular mechanisms like system and work process standardization is brought about by a realignment of business processes and organizational change, this is complicated by the complexity of each patient's unique circumstance.

The distinct requirements of various healthcare stakeholders and settings makes it hard to control the interdependence between applications like basic electronic healthcare records and decision support components that leverage these records (Sherer, 2014). The interactions and complementarities between IT assets and their complex social relations are yet to be addressed by traditional IT value research. The success of IT implementation is directly linked to the workflow of existing professionals who are a powerful force in healthcare (Goh, Gao, & Agarwal, 2011). Also, additional factors impact the value of healthcare. These factors such as risk to life, quality, and privacy concerns of the patient. Similarly, for healthcare delivery to become more integrated (i.e. medical conditions oriented) rather than organized around separate specialists, delivery of quality care has to be the joint responsibility of several providers and a single organization can no longer control various processes. Therefore, complementary changes within an organization alone are not enough to effect value realization, rather a wave of change across several organizations is required.

Healthcare is not a self-contained institute, rather a complicated combination of diverse organizational forms that is subject to several market and regulatory structures. Unlike other sectors where partners join forces to produce a service, the mechanism via which care value can be achieved is different from other industries. This is evident in interactions where participants like insurers, influence prices but do not partake in care delivery.

A possible drawback lies in costly and negative effect on care quality brought about by workarounds which may result from the implemented changes which are actually supposed to encourage value realization via information sharing. As an example, insurers and providers share data to improve care quality for certain patients, healthcare patient data security was unintentionally compromised by members sharing spreadsheets and databases in order to bypass difficult-to-use enterprise information systems (Sherer, 2014). Initial research in healthcare did not specify which complementary elements are important to the creation of value in this sector, neither did it specify the mechanisms by which these elements influence value realization. It is expected that the difference between healthcare and other industries will impact value and its mode of creation, there is an opening to contextualize assumptions which reflect the institutional environment and material resources of the industry and consider how they affect value and its creation in healthcare. Although we can use traditional IT theories as foundations, the results cannot be applied so simply; rather, special attention has to be paid to the social context whereby existing theories will be verified (Sherer, 2014).

Position

Action Design Research for Healthcare IT Value

Econometric, empirical, variance theories, the ex-post perspective, firm-level perspective, and complementary effect of lag and contextual elements have been dominant in Traditional IT business value research (Schryen, 2013). Industry dissimilarities that impedes application of traditional IT value research results, combined with time struggles to effect change, has influenced me to promote for an action design research approach to study IT value. Most traditional IT value research studies are results of bygone IT investments through post-hoc analysis (Kohli & Grover, 2008). Traditional approaches check validity by replicability or extensive elimination of substitute explanations. In the case of the health industry, it will require time to gather additional granular data than is currently available in other to investigate process changes that are starting to complement the application of new IT systems and care delivery models. Due to the significant time lags expected before value can be demonstrated (Schryen, 2013), I anticipate that traditional econometric and ex-post empirical approaches will not be able to deliver timely results. By the time we have sufficient data to perform post-hoc analyses, ample effort and cost would have been exhausted (and possibly fruitless). Thus, now is the time for IS researchers to employ their IT value knowledge so as to influence practice, and not when the investments have been made. Action design research (ADR) is sufficiently appropriate for our needs: it pools together design research DR and action research AR to produce prescriptive knowledge. ADR concurrently builds and (or) implements inventive IT artifacts in an organizational context and learns from the involvement while at the same time addressing problematic situations. ADR explicitly identifies research continuums that integrates organization dominant and IS dominant innovation. Although IS innovation is going to become quite useful, mostly in developing new patient-oriented applications, IS dominant innovation alone will be of limited use since most care providers who lack required resources needed to develop bespoke innovative applications are progressively turning to commercially-off-the-shelf (COTS) applications. Due to fundamental and structural change in healthcare industry, IT value research has to consider not only change within an organization, but also value creation and multi-organizational change across many participants (providers, pharmaceuticals, device manufacturers, insurers) in the newly restructured inter-organizational value chain. Both simultaneous multi-organizational and IT change will be necessary. Traditional IT value research approaches that use variance theories may limit the capability to introduce the effect of definite contextual differences in the healthcare industry, which requires more process-oriented analysis (Sherer, 2014). By placing restrictions on how IT can be used within organizations, regulations can constrain realization of IT value. The financial service industry is perhaps, the only industry aside healthcare that has such complex regulations, in addition to regulations by different international organizations. Through consolidation and standardization, financial service firms have been able to manage this regulatory complexity. Although these mechanisms are available to the healthcare industry, it has not been effectively used. ADR will be beneficial to IT care value researcher due to the fact that it can test and evaluate interaction between contradicting institutional objectives and different care delivery structures for value creation. Using existing theories, we can support the development of processes and systems that balance the evolving mode of care delivery. As an example, co-creating value is in itself not fully understood in other industries (Kohli & Grover, 2008); it is composed of four primary components: knowledge-sharing routines, relationship-specific assets, effective governance, and complementary capabilities and resources (Sherer, 2014). I emphasize on how ADR research might be used, even though there are several other evolving modes of care delivery.

Using this framework, we can co-create value in other to establish basic guidelines regarding the process and system types that can support various structures for an accountable care organization (ACO). We would estimate how each partner's goal will affect value and its generation. As an example, shared analytical abilities, like clinical data and integrated claims, risk scoring, and predictive modeling amount to relationship-specific assets. Efficient use of these assets to produce value for an ACO which is organized as cooperation between a physician provider institution and another private insurer will require implementation of certain complementary and collaborative processes and also the creation of new relationships among these partners. These changes may seem different from that mandated by an ACO designed with a secondary governance mechanism, such as a public insurance with an integrated health network. At the local, state, and national levels, Government regulation and competitive context for the payers and providers could affect these relationship structures. ADR can be employed to provide support to care participants who are involved in the structuring of different networks by inputs they provide to the types of IS, information sharing, and the complementary abilities they can build in various governance structures. We can gauge the value of these interventions by estimating the degree at which complementary process, information, and relationship change positively address the issue of value realization for various participants as well as healthcare outcomes for the populace. By implementing organizational designs and innovative IT, IT researchers can capitalize on analytical capabilities and information, rather than waiting to contrast outcomes from emerging models. This will provide much needed support to ACO creators (Sherer, 2014).

Support

Information Asymmetry

There exists a steep knowledge curve among the stakeholders in the healthcare industry. Shareable and understandable Outcome metrics of patients are unavailable. Moreover, there are presently very limited incentives for knowledge interpreters or patient advisors. Several environmental and social factors can influence the interpretations and outcomes of benefits. There are interpretable metrics in the delivery, supply, and costing in the supply chain of manufacturing. Others in this chain use these metrics to analyze and evaluate events in real time by making use of the monitoring capabilities of IT. By making real-time prices openly available to customers, IS has reduced information asymmetry concerning current prices in financial services. Nevertheless, the information used to assess the consequences of pricing various savings and investment options, like historical projections and trends, may still be challenging for a novice investor to understand. The health industry is akin to the financial industry in that its consumers i.e. The patients, regularly find it trying to deduce meaning from their care information. Several health experts suppose that patient do not have the expertise and knowledge to read data such as a physician notes. Therefore, patients do not presently have the devices required to monitor their health, neither has this type of information been made readily "digestible" for them. (Sherer, 2014).

Kelley et al. (2011) offered an example of an ADR project that modified theories of IT implementation for factors that influence healthcare behaviors and environment. It was recognized that enabling, predisposing, and reinforcing situations have to be aligned in other to influence behavior. ADR was used to control the design process of a Web-based system, this system was studied to determine the affected condition of a chronic patient populace. It is this type of pro-active research that is being proposed. Evaluation tests a design that was influenced by theory. Therefore, to fill theoretical gaps, these evaluations will be helpful to us in healthcare, predominantly those that are influenced by compounded environmental and social factors. Presently, health advisors are starting to be situated in new healthcare-delivery models to be able to handle information asymmetry in the healthcare industry. While IS intellectuals cannot address all concerns associated with information asymmetry in health, ADR can be used to help implement suitable IT that helps these advisors influence behavioral change and hence health outcomes. Research has revealed the significance of strategic position between customer necessities and supply-chain partners. In health, partner goals might not be so well aligned (Sherer, 2014).

Future Concerns

Failure Impact and Privacy Concerns

The dissimilarity between risk of IT failure in health and other industries is the fact that the possibility of failure affecting loss of life or reduced quality of life is normally greater in care. In health, dangers that can amount to loss of life or reduced quality of life exist for countless every day activities, making it far more challenging to build-in subordinate processes. As organizations concerned with healthcare digitize their clinical archives and depend further on IS to deliver care, flawed information processing will be able to influence life-threatening choices on an everyday basis. Therefore, there is a higher possibility of IT failure causing loss of life than in any other industries. This intensely affects the outcome variable in IT value research in health. Effective and cost efficient systems which do not help reduce this serious failure risk have no value (Sherer, 2014).

ADR can become very useful in addressing this high IT failure risk in health by designing the resilience theory. Resilience engineering does not focus only on recognition, but rather absorption of and adaptation to changes, variations, disruptions, disturbances, and surprises, particularly those that fall outside the scope of disturbances that the designed system is able to handle (Hoffnagel et al., 2006). Resilience refers to a system's or organization's quick recovery ability, and keeping a stable state, permitting it to operate through and after an accident or in the continuous occurrence of significant stresses. Because the risk of IT failure is serious in healthcare, it can be assumed that additional effort needs to be put into the safe design of proper systems backup in the industry. To build resilient organizations and systems, it requires developing performance indicators that will deliver existing information on data analysis linked to safety climate and culture, safety performance, explanations of how work should be carried out, and the extent and timing of resources crucial for the absorption of harm that might occur. It requires better understanding of the decision making process, specifically, how human behavior and work processes can become potential source of failure and how to make safety better. We need to ensure that these systems cannot overload personnel. In fact, least information systems that require additional staff to authenticate processes will probably be far more resilient than complex systems that overwork personnel. Building on the resilience theory, ADR can help support the implementation and/or design of a robust information system alongside an organizational process that offers resilience. Alternate organizational and system designs have to be assessed to define their influence on value, measured not only economically, but also its potential to reduce risk of loss of life and increase resilience (or quality of life) (Sherer, 2014).

Health information is extremely personal, there are serious concerns about this personal information being accessible by the wrong individual (Fichman, Kohli, & Krishnan, 2011). Privacy concerns, both real and factual, exist in the financial service industry, but perhaps is greater in healthcare. There are several risks integral in the breach of critical health information and people are highly emotional about details of their health history and its usage (Sherer, 2014).

Conclusion

Delivery of healthcare is presently undergoing considerable innovation stimulated by efforts from the government. New techniques of delivering healthcare are undergoing trials. New systems, usually COTS, are being implemented as a result of government incentives. All this is happening presently. If we attempt to wait and make use of traditional ex-post research procedures so as to understand creation of IT value in this industry, the opportunity to influence and cause change in practice now will be missed. ADR allows researchers in IT to adjust existing theories in a distinctive industry. In the future, we have to ensure we do not apply traditional IT value research results generated from another industry due to obvious industry dissimilarities that can and will affect how value is achieved and measured. Moreover, if we choose to wait until all changes are effected and then ex-post study the factors which led to increased value, we would have missed the chance to impact practice. I propose the use of kernel theories that are used in existing research, adapting them to suit this industry, influencing the design of social and/or technical processes by modifying these theories, and assessing its effect on value creation. Even though the industry differences cannot be resolved through improved design alone, we can make use of existing theories developed by/for other industries to recommend alternate socio-technical designs which might lead to more value for this industry. In the future, ADR can permit researchers to dynamically partake in the implementation and/or Design and evaluation of innovative socio-technical systems so as to generate a new theory. This task will not be easy, IT value researchers will have to team up with others to carry out this research. They will have to partner with authorities/specialists in health management, informatics, and economics, who are able to comprehend processes, relationships, and other social issues within the industry and their influence on value. A partnership with both delivery providers and healthcare IT will also be required. I suggest IT value researchers do not design the organizational innovations or IT artifacts but rather provide guidance to the designers who by drawing from fundamental IT theories design, implement and then assess the impact it has on value. IT theory is far-off to almost all researchers and practitioners in healthcare profession, there exists the need to seek out these relationships and make evident the applicability of these theories. Health providers are accustomed to clinical research as well as evidence-based medicine, which is akin to ADR, efforts to decide efficiency of practice, we can anticipate that this method will be enabled through the active participation of the provider by testing new organizational and IT models, determining benefits as well as better health outcomes and lower costs. In the meantime, the IT value researchers will concentrate on the development of a theory founded on the evaluation. The research will be time demanding as proper design, evaluation, and implementation can run into years. On the other hand, choosing to wait until all the innovations are effected and then using ex-post analysis will take an even longer period of time.