Information Systems in Healthcare

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

Professional Control

Traditionally, the health industry has been organized around the profession as the primary source of control instead of the bureaucracy or market. Professionalism which has been a firm tradition in medicine is presently under attack. Information processing tasks that bureaucratic or market influenced industries used middle level managers for are now carried out by information systems, this has contributed to the flattening out of hierarchies. Instead of being monitored by mid-level managers, front-line employees using discretion and information provided by IT, can now operate based on parameters set forth by the firm's officials and institutionalized information systems. The growth of these types of businesses typically involves either employing more client facing employees like financial advisors and salesmen, or taking advantage of IS to control and support their client facing employees rather than hiring more mid-level managers. Whereas, in the healthcare industry heavy reliance is placed on front-line professionals who through extensive training have acquired highly specialized knowledge. The rate of expansion in the number of certain front-line professionals, particularly physicians is limited as it would be in other industries due to significant training requirements and cost. The combination of socials and technological skills needed by healthcare is therefore difficult to reproduce.

However, in a similar way the industry reacted to care cost pressures, significant growth has seen physician extenders such as nurse practitioners, medical assistants, and physician assistants moving physicians into mid-level management supervisory duties. While in non-healthcare industries mid-level management employees have reduced as more front-line employees are being controlled and monitored with IS; in health, the physicians who are the source of control, have mostly taken on more mid-level management functions, this moves towards more bureaucratic and less professional logic. By implementing externalization of knowledge so as to allow other less skilled employees perform the task can be risky as the work becomes less competently handled, specifically since the intricacy of any clinical setting regularly requires specific IS artifacts that must be modified to fit or manage individual differences. Consequently, physicians will still retain a considerable level of power by virtue of the professional expertise they possess. This power can have an effect on complementary change and IT value realization (Sherer, 2014). Systems designed to provide support to professionals can vary in respect to their benefits from the value adding ones in market or bureaucratic systems. As an example, communication, internal expertise development, and knowledge generation systems are aligned more with the needs of professionals than with monitoring systems. The systems that are recently being developed to match the evolving needs of healthcare organizations do not necessarily consider the present professional shortage of physicians. As an example, one of the main complaints physicians have while working with current electronic healthcare records systems indicate that more administrative work has to be done as compared to when they used paper, i.e. assigning procedure and billing codes. Most systems that are being introduced today in order to increase productivity, like electronic healthcare record systems, affect clinical functions that have always been in the control of professionals. But several commercial IS have generally poor interfaces; user-centered design approaches that are not widely implemented by commercial healthcare IT vendors (Jones et al., 2012). Predefined functionality might not be compatible with the current practices of the professionals who are predominant. When the characteristics of the system is not consistent with the user's philosophy and values, the process of implementation is hindered. Process reengineering has to be given a high priority because commercial applications, and not customized systems, will be mainstream focus of HIT acceptance in the next couple of years. Nonetheless, how reengineering impacts realization of value will be determined by the tension introduced with trained control (Sherer, 2014).

ADR may be useful in testing the effect of various types of systems and corresponding changes on value as their consolidating logic changes. In acknowledgment of the professionals control requirements, Decision making processes or organizational changes that amount to value in other sectors will need to be modified. Fundamental guidelines that may be changed by studying the impact of professional control on value realization can be provided by IT value research. By expanding already existing theories, we will be able to suggest suitable mechanisms for the coordination and management of the work done by the physicians, while at the same time allowing them to progressively handle new extenders, so as to increase value. Although traditional complementary and fit theories may provide guidelines needed for process and system development, they have to be modified in order to account for the values and needs of the experts as they transit into their new roles. Processes and/or systems that take into account the tension that exists between changing institutional logic and the practice of skilled control in healthcare have to be designed and evaluated in the process of developing features that can improve acceptance and usage. Kohl and Kettinger (2004) developed an example ADR that has addressed this conflict with professional logic. This study together with the theory of how to get benefits out of control systems among experts. The authors discovered that experts value particular control mechanisms, mostly those that focus on legitimacy of both information and the source. They recognized features that enhanced value by either improving outcome and/or lowering costs (Sherer, 2014).

Recommendation

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).