MEDINFO 2001 V. Patel et al. (Eds) Amsterdam: IOS Press © 2001 IMIA. All rights reserved
Economic Motives to Use a Participatory Design Approach in the Development of Public-Health Information Systems Vivian Vimarlund, Henrik Eriksson, Toomas Timpka MDA, Departments of Computer Science and Social Medicine, Linköping University, Lilnköping, Sweden
shortcomings in the processes and practices used to gather, document, agree on and alter the product requirements [3].
Abstract Within public health, there is a tradition of co-operation between researchers and communities in planning and implementation of health promotion programs. As a consequence, public-health organizations are characterized by having complex multidisciplinary structure and dynamic organizational goals. In this paper, we discuss the economic impacts from the use of Participatory Design for development of public-health information systems. Creation of systems that have both utility and usability is suggested to be highlighted as the central goal. The identified prerequisites for a positive impact are that the new system should be of high quality, appropriate to the nature of the health promotion tasks, and to how activities are coordinated and integrated both between and within the stakeholder groups involved. We argue further that a method that minimizes the information asymmetry in the development process is necessary for avoiding market failures1. The conclusion is that participatory design will diminish transaction costs, will help to avoid sunk costs, and will contribute to rich efficient use of human and economic resources in public-health organizations.
In the Scandinavian countries, it has long been a tradition to incorporate end-users not only as experimental subjects but also as key members of technical design teams [4,5] emphasizing their participation and collaboration in the entire information system development process. Increased participation and collaboration between end-users and technicians is considered to be the appropriate way of linking the emerging innovation (e.g., information systems) with the existing environment (i.e., public-health organizations). Further, the design of health information systems is considered a distinctly human activity involving communication and creative thought among a group of participants. Design methods that focus on the relationship between technology and human activity; that are concerned with the way in which current technologies support work activities and with the internal structure of the organizations involved and that focus on how people create, distribute, understand and use information [6,7], are considered to be a determinant factor for the final quality and costeffectiveness of any health information systems [7,8]. Today there exists a general societal rationale for increasing end-user participation in public-health information system design. A fundamental characteristic of the post-industrial society is the preoccupation with issues of health, social welfare and personal development. In parallel, there is an increasing interest in the connection between enterprise effectiveness and democratization [9]. Within public health, in particular, there is a strong incentive for co-operation between researchers and communities in planning and implementation of health promotion [10,11]. Public-health organizations are correspondingly also characterized by having a complex multidisciplinary structure and dynamic organizational goals. In this paper we discuss the use of Participatory Design for development of public-health information systems. The specific aim is to analyze the economic motives that make participation particularly interesting when developing information systems for publichealth organizations.
Keywords: Participatory Design; information asymmetry; intellectual capital; economic impacts.
Introduction The development of information systems is concerned with the identification and satisfaction of end-users' needs, and with the design of effective systems in terms of organizational goals [1]. However, several authors have noted that current methods for the development of information systems, are based on a “computer artefact preoccupation,” and are not suitable for the needs and goals of the public-health organizations [2]. Many of the difficulties encountered have been attributable to 1
Failure of the unregulated market system to achieve optimal allocative efficiency or social goals because of externalities, markets impediments, or market imperfections.
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What is the Participatory Design Approach?
Economics Impacts of Participatory Design
Originally, Participatory Design was introduced to increase the democratization of working-life through the active incorporation and participation of the employees (workers/users) in the design process [5,6]. It prescribes discussion, criticism and compromise between end-users and system developers. The earlier projects were more directed at acquiring knowledge about the technologies and about their possible consequences for the workplace, whereas the later projects more have addressed the identification of organizational changes related to the use of new systems. Further, users are to redesign and evaluate their work routines by applying the experience obtained during the participation process, but also as a manner of being provided with an opportunity to improve their understanding of computers [12]. Crucial for Participatory Design however, is the relationship between technological and organizational flexibility. Through participation, endusers are expected to become skilled in formulating an independent vision of the new information system and to be able to formulate demands in terms of technical and organizational requirements [13]. Moreover, end-users are expected to be more willing to accept the system, by enabling people to develop realistic expectations, and reducing resistance to change. Another objective for participating in the process of Participatory Design is based on the recognition of the fact that it gives the designers new and better ways of gaining an understanding of the enduser's everyday working practices, a critical success factor for any project [3]. The final overall effect of this participation can consequently be considered to be the improvement of work efficiency and productivity. The original motivation of Participatory Design was hence ideological but its has later been claimed to bring other benefits to the design process, such as increased costefficiency, better design decisions and better disposition to adapt to the organizational changes that any new system require [14]. This is also a consequence of that since the late-1980s, Participatory Design has been influenced by management theories such as Total Quality Management (TQM) and Business Process Reengineering (BPR)
Avoiding Information Asymmetry An asymmetry of available information between customers and suppliers is always a source of failure and one, which in any market processes can cause unexpected costs. When that happens, government intervention in the market can usually correct the informational asymmetries and induce a nearly optimal exchange [15]. The market for pharmaceuticals provides an example. The information asymmetry in this case can be corrected by requiring suppliers to disclose knowledge of any latent defect to prospective purchasers. If the suppliers do not make this disclosure, they may be made responsible for correcting these defects with large economic compensation. But unfortunately, this is not the situation in the market for “information system development” where every upgrade or service has to be paid at market price with its additional taxes, giving rise to opportunistic behaviour if the customer does not know when “enough is enough”. Moreover, large expensive items such as health information systems for public-health organizations, which have not been produced in large quantities previously, can give rise to cost-plus variety [16]. This situation is due to the fact that when the customer (e.g., public-health providers) and the supplier (e.g., the system development team) have different knowledge of different pieces of relevant information at the time of the contract, the contract is incomplete (e.g., poor estimation of the final quality of the system). Thus the resulting information system can be unsatisfactory at least for one of the parties. Difficulties in communication or the asymmetric information created between the customers and suppliers usually imply further costs for co-ordination that obviously grow as the number of participants involved increases. Another problem when one party in a potential transaction is ex-ante (in advance) better informed about a relevant variable in the transaction than the other party, is how to determine the factual risk level of doing business. In the specific case of a system development process, the problem for the supplier is how to determine the actual risk that the potential clients represent. The suppliers usually do not know how accurate the requirements they get at the moment of the contract are to the reality of the organization. The supplier can of course use any means to find out this information without the co-operation of the potential client. However, many sources of private observation, for instance public-health organization’s unofficial information channels, are basically not available to the other party and this situation constitutes the essence of the information problem. The solution in this case, is to reflect this risk in the price and thus charge more for the final price of the new information system.
However, while TQM promotes the conception of a customer-centred business organization, subjected to intense control and measurement, BRP suggests a radical re-organization of the entire company. U.S. businesses have reported that the use of Participatory Design principles and practices in North America has allowed to produce products that satisfy the customer and at the same time promote empowering human values, such as job satisfaction, diversity of experience, skill appreciation personal autonomy and educational development.
Fortunately, in many cases there are some other solutions to the problems of hidden information, both for suppliers and public-health organizations. Since the essential problem is one of “un-observability” or information asymmetry, one
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Scandinavian countries, due to current work-legislation. Additionally, to employ the “correct staff” involves advertising costs, costs for selection procedures, costs for checking references and costs for introducing the individuals into the idiosyncrasy of the organization. The result can be similar to the systems used in sports teams where millions of dollars are spent on searching for new talent to lead them to victory, with the risk that investment in free individuals often does not win championships in sports for which teamwork is required [22].
manner of decreasing this market imperfection is by cooperation (share information). Therefore, if the two parties 2 are risk averse they prefer to “pool” the risk [17] of the final outcome and be sure that they will not be burdened alone with the whole responsibility for the final product when it is finally implemented. Impacts on Health Promotion Routines Economic efficiency presupposes technological efficiency. This fact implies that efficiency in public-health organizations much depends upon the acquisition of an appropriate information system that does not alter the existing health promotion routines, and that allows the new ones to be formatted efficiently. Further, everyday habits as well as work-routines arise in repetitive situations and can store experience in a form that allows people to rapidly transfer that experience to new situations [18,19,20]. Consequently, even if some habits become obsolete as a consequence of a change. For instance after the introduction of a new information system, participation makes it possible for the new everyday work-routine to be formed in a rational manner. Under such circumstances, the direct economic benefit of participation in the process of an information system development is the formation of appropriate habits. The indirect consequences of such a situation is a saving in all the costs associated with the decision-making and or trial and error, which would or might occur if the individual in an organization does not dominate the new system or does not understand the new work-routines. Because the introduction of information systems are tools of change that affect large number of individuals in different organizations, the importance of participation resides in its positive externalities (a benefit that falls on people who are not necessarily directly involved in an activity) and its contribution to avoid sunk costs. Anything that makes it easier to adapt the new system to the dynamic nature of public-health organization’s workflow and that is in accordance with communities’ request of health promotion will improve the situation and lead to substantial improvements in organizational efficiency and effectively than can finally be translated into improving populations’ health [21].
Several authors agree that there is a general lack of receiver competence in a system development process [3]. New competence cannot be communicated artificially; it is embodied (tacitly) in individuals or teams of people. Disseminating the new competence throughout the systems development teams (supplier and customer) is therefore a matter for the organizational technique of allocating knowledge through participation [23]. Additionally, participation in a process gives individuals the chance to acquire comparative specific knowledge advantages (the value derived from such an investment is embodied in an individual) that remain with the organization, at least for a time, inducing the public-health organization to achieve a more rapid growth in the short-run. On the other hand, employees with specific training also have less incentive to leave, and firms have less incentive to fire them [24]. Consequently, if the implementation of any innovation such as an information system downgrades the economic value of competence or knowledge capital, the prime task of the organization has always to be to organise workers' intellectual capital. It is therefore vital to recognise the importance of the acquisition of “on the job knowledge training” as the most important source of investment in intellectual capital [22,24,25]. Normally, this training can be achieved through suitable internal conditions that steadily upgrade the current workforces' competence base, making it stronger and better and also more learning oriented. Due to the fact that much of the intellectual capital existing before a new information system is implemented will be redundant in a few days, even the best worker, who does not retool intellectually, will be displaced eventually. For this reason, if the expected output of the participation (knowledge capital) increases during the participation process, this side effect could be an incentive to create participation during the development process of a public-health information system. This is especially because for this kind of organization to transfer acquired knowledge and skills across different organizations are one of the most important components of organizational learning and competitiveness [11].
Intellectual Capital: The Acquisition of Knowledge and Skills in Informatics There are several mechanisms for acquiring intellectual capital in an organization (e.g., by acquiring experience through participation in an external process, or by buying competence). It can be argued that as a consequence of the implementation of a new information system, public-health workers with the “appropriate” abilities in informatics could be considered to replace part of the staff. However, this situation could lead to incalculable costs, at least in the
Discussion Organizations that develop effective information systems can enjoy multiple benefits but also reduce rework after implementation. Due to that public-health organizations are multidisciplinary with multiple goals, the possibilities of
2
An economics agent is said to be risk averse if she/he considers the utility of a certain prospect of money income to be higher than the expected utility of an uncertain prospect of equal expected monetary value.
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more utility to an individual). Unreflected forms of enforced democracy can also cause a loss of profits to any organization.
making effective decisions and buying the appropriate system are closely related to the transaction costs for acquiring information about the system’s functionality, learning about the technical characteristics of the system and capturing users’ requirements in the context of use [26,27]. This fact implies that in order to use scarce resources optimally, effective communication becomes even more important as the size of the design group grows. Any method for designing and developing public-health information systems has therefore to be chosen to distribute risk-bearing factors and minimize any additional costs that can affect the total production of public-health services and indirectly a third party (i.e., patients).
Conclusions Public-health activities are complex, performed by groups rather than individuals that perform collaborative work within different organizations and environments [28]. In such organizations, the inter-organizational business relationship is regulated by contracts, and the strategic relationship is related to the activities that several organizations have in common, such as urban planning or other areas with considerable popular and democratic interest involved. The prevailing goal in the design of a public-health information system should therefore be to create systems that not only have utility but also usability. A pre-requisite if it is to have any impact, is therefore that any new system should be appropriate to the nature of the work tasks, and to how different activities are co-ordinated and integrated, for instance, how health promotion is thought and practised [29]. When public-health managers fear any negative consequence for their organizations with regard to the new information system and its impacts on the workflow, and if they can find a possibility of shifting these risks, they will always prefer to engage in activities that allow to them be sure that the system will be adapted to the specific needs of their organizations.
Our theoretical analysis suggests further that shared investments during participatory design processes are particularly beneficial for the public-health organizations involved in information system development processes by (i) increasing knowledge capital, (ii) decreasing in information asymmetry, (iii) updating habits and work routines in a "natural “manner”, (iv) avoiding risk for nonacceptance of the final system, (v) avoiding unnecessary sunk-costs, and (vi) contributing to the efficient use of human and economic resources. The most important reason for introduction of Participatory Design in information system development in public-health, from an economic point of view, is that efficiency requires the use of physical and human capital. Every new system or methodology that ignores this relevant relationship runs a risk for long-term effects; e.g., a decrease of the expected profit due to high costs for re-educating or replacing personnel once an information system has been implemented. It has therefore gradually become clear that in the process of the development of an information system, we cannot focus only on the organization as such. We must regard the internal and external environment as a set of explicit circumstances. Moreover, a method that allows joint ownership of the development process through collaboration can also modify previously proposed solutions. Both developers and the users can benefit from knowledge of the other's experience [7,8] contributing in this manner to a successful design. Creating dependency through participation will not only induce a better understanding of the public-health organizations needs. It also will increase the understanding of organizational and social issues, stimulate efficiency, and permit a better disposition for adapting the situation to today's higher flexible work in public-health organizations. However, any collective, which has an economic goal, must find a means to control individual’s efficiency in participation. This implies that the resources devoted to participation must contribute to the economic optimization of these. To include too many parties in participatory design process have costs of initial investment, which are irreversible. It would seem necessary to continue a discussion of by whom and when participation is economically optimal. To generalize participation and have it as a standardized solution for all kinds of problems is a contradiction of democratic principles (e.g., liberty to choose what bring
Acknowledgments This work was supported by the Swedish Board for Technical and Industrial Development, NUTEK, trough the MTO program.
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Vivian Vimarlund, Ph.D. Department of Computer and Information Science
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Linköping University
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Phone: +46 13 28 44 73
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Telefax: +46 13 14 22 31. E-mail:
[email protected]
URL:http://www.ida.liu.se/ ¨vivvi
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