Mediating the intersections of organizational routines during the introduction of a health IT system

Abstract

Public interest in the quality and safety of health care has spurred examination of specific organizational routines believed to yield risk in health care work. Medication administration routines, in particular, have been the subject of numerous improvement projects involving information technology development, and other forms of research and regulation. This study draws from ethnographic observation to examine how the common routine of medication administration intersects with other organizational routines, and why understanding such intersections is important. We present three cases describing intersections between medication administration and other routines, including a pharmacy routine, medication administration on the next shift and management reporting. We found that each intersection had ostensive and performative dimensions; and furthermore, that IT-enabled changes to one routine led to unintended consequences in its intersection with others, resulting in misalignment of ostensive and performative aspects of the intersection. Our analysis focused on the activities of a group of nurses who provide technology use mediation (TUM) before and after the rollout of a new health IT system. This research offers new insights on the intersection of organizational routines, demonstrates the value of analyzing TUM activities to better understand the relationship between IT introduction and changes in routines, and has practical implications for the implementation of technology in complex practice settings.

Keywords:

• organizational routines
• unintended consequences
• technology use mediation
• electronic health records

Acknowledgements

The work reported here was supported by grants 2-T15LM007450-06 and 1K99LM-010038-01 from the U.S. National Library of Medicine. The authors acknowledge the valuable insights and enthusiastic cooperation of the study participants. Dr. Timothy Vogus is acknowledged for his insights regarding managers’ inattention to the embeddedness of organizational routines. Thanks also to the EJIS Associate Editor and anonymous reviewers for their valuable insights and critiques.

Additional information

Notes on contributors

Laurie Novak

About the authors

Dr. Laurie Novak is Assistant Professor of Biomedical Informatics at Vanderbilt University School of Medicine. She holds a Ph.D. in Medical and Business Anthropology from Wayne State University, and a Masters in Health Services Management and Policy from the University of Michigan. Her research interests include technology-in-use in the everyday management of chronic illness, and organizational perspectives on strategies employed by clinicians and patients to create safety during transitions to new systems of care. She is a member of the Implementation Sciences Laboratory at Vanderbilt.

JoAnn Brooks

Dr. JoAnn Brooks is a Postdoctoral Research Associate at Syracuse University's School of Information Studies. Her Ph.D. is from the University of Michigan in Public Policy Studies and she holds an MS in Computer and Information Science from University of Massachusetts at Amherst. Her research focuses on organizing practices in work environments, especially as they involve the use of IT.

Cynthia Gadd

Dr. Cynthia Gadd is Professor of Biomedical Informatics and Director of Educational Programs at Vanderbilt University. Her research interests include the evaluation of integrated clinical information systems and the development and evaluation of innovative approaches for biomedical informatics education and training to meet the needs of health care in the U.S. and globally. She is a member of the Implementation Sciences Laboratory at Vanderbilt.

Shilo Anders

Dr. Shilo Anders is Research Assistant Professor in the Center for Research and Innovation in Systems Safety at Vanderbilt University. She received her doctoral degree in Industrial and Systems Engineering from the Ohio State University. Dr. Anders's research focuses on using Cognitive Systems Engineering principles investigate problems in information analysis, data overload, predictive analysis, information visualization and adaptive capacity in both military and health care domains. She is interested in research on system design, individual and team performance issues, and improvements in patient safety and quality.

Nancy Lorenzi

Dr. Nancy Lorenzi is Assistant Vice Chancellor for Health Affairs, Professor of Biomedical Informatics and Clinical Professor in Nursing at Vanderbilt University. She is an internationally recognized expert on change management related to information technology, with particular focus on organizational and personnel issues related to automation in the health care industry. She is the Director of the Implementation Sciences Laboratory at Vanderbilt.