Learning from Computer Workarounds Practices - Semantic Scholar

AOM 2008 Paper Number: 15251

Situated Practices of Computer Workarounds in a Hospital Medication System: A Case Study

Bijan Azad, Ph.D. Assistant Professor Business Information & Decision Systems Olayan School of Business American University of Beirut Bliss Street, 11-0236, Beirut, Lebanon Tel: +961-1-374-374, x3745 Fax: +961-1-750214 e-Mail: [email protected] and Nelson King, Ph.D. Assistant Professor Business Information & Decision Systems Olayan School of Business American University of Beirut Bliss Street,11-0236, Beirut, Lebanon Tel: +961-1-340460/350000 X3731 Fax: +961-1-750214 e-Mail: [email protected]

Awarded Best Paper 2nd Runner Up at the Academy of Management, Organizational Communication & Information Systems Division, Anaheim California, USA, 2008.

Submission Number: 15251

Situated Practices of Computer Workarounds in a Hospital Medication System: A Case Study

ABSTRACT Are computer workarounds temporary or routine, sign of resistance or acceptance, harmful or benign? The extant literature says they can be any of these. We surmise that this ambiguity reflects the modus operandi that content and processes of computer workarounds are under-theorized as post IT implementation phenomena. Recent research, though insightful, still casts computer workarounds as nominal and aggregate phenomena analyzing their antecedent conditions and their impact. This paper is an attempt to disentangle the black-box of computer workarounds focusing on their contents and processes as situated work practices using negotiated order as a conceptual framework. By making the workaround practices as well as their immediate upstream and downstream activities the focal unit of analysis, we disentangle the enactment of a computer workaround. Specifically we propose that some workarounds are based on an alternate negotiated order and may entail coordinated action. Thus, we extend the literature by positing that computer workarounds are social practices going beyond prior formulations of workarounds as “hacks” or “tweaks” by individual computer users. Our findings are based on a non-participant observer case study of a medication dispensing system in a teaching hospital. Keywords: Computer workarounds, situated practices, hospital medication systems, negotiated social order, process analysis

1


INTRODUCTION Although information systems (IS) researchers have acknowledged the existence of computer workarounds for over two decades (Markus, 1984; Gasser, 1986; Gerson and Star, 1986), research on workarounds remains nascent (Ciborra, 2000, 2002). The extant IS research literature acknowledges that in a significant number of cases the users create workarounds which are non-compliant with the system’s requirements specifications and design (Boudreau and Robey, 2005; Markus and Robey, 2004). In some cases, designers regard workarounds as nonuse, mis-use or abuse of the intended system functionality (McAfee, 2003). In other instances workarounds are treated as harmless or more positively as improvisations (Ciborra, 2000, 2002; Pollack and Cornford, 2004). Although workarounds have been largely regarded as anomalies, however, increasingly authors are calling for their more systematic treatment (Wagner and Newell, 2006). In particular, Orlikowski and Iacono, (2001) have called on IS researchers to focus on and provide a better understanding of workaround practices. We concur with this view. We argue that, in actual work settings (Barley and Kunda, 2001), workarounds appear to have a taken-for-granted status, especially in hospitals (Spear, 2005). As a result it is important for workarounds along with their contextual and embedded dependencies be considered as a focal unit of analysis (Suchman, 1995, 1996). Ostensibly, if a workaround is more than an individual computer hack or tweak, as it is our contention, it can be a form of coordinated action within an enacted social order (Button and Sharrock, 1998; Star and Strauss, 1999). As such, it will exhibit distinct social order properties (Corbin and Strauss, 1993) in an organizational context. Thus, successful completion of a workaround requires coordination with other social actors who may be involved in the enactment of the workaround beyond its core boundary. This situated practice view of workarounds

2


promises to enhance our understanding of its underlying dynamics and hence contribute to both IT design science (Hevner et al., 2004) and IT implementation research. We will disentangle the contents, artifacts, and processes of computer workarounds and analyze the underlying practices of their enactment using a case study of a hospital medication dispensing system in a leading teaching hospital located in the Mediterranean. The case study is part of a larger effort where an observational study is being conducted in this teaching hospital to identify workflows amenable to computerization (for additional information see Chedid, 2007). The contributions of this paper are twofold. First, it makes the workaround itself the focal unit of analysis casting them as situated work practices. Second, it proposes that some computer workarounds, are enacted through distinct social mechanisms which exhibit alternate social order properties—e.g., involving negotiations and coordination among social actors. THEORETICAL FOUNDATION Computer Workarounds and of Hospital Information Systems Koopman and Hoffman (2003) define Computer workarounds as problematic IT phenomena in organizations, because they imply non-compliant user behaviors contrary to the intended system design or bypassing systems. Workarounds are in theory supposed to be fixed which then alleviates the need for them. The roots of the extant literature can be seen in this definition. Indeed, the practitioner literature often regards workarounds as non-compliant use of systems, e.g., non-use, misuse and abuse (McAfee, 2003). The pioneering study of Gasser (1986) and Gerson and Star (1986) on how users appear to not use systems as intended by the designers put workarounds on the IS research map. Since then, IS and hospital information systems (HIS) research, have worked along two streams which touch upon the notion of workarounds. One stream views workarounds as either system failures or dissatisfied users both of which are

3


attributed to user resistance (e.g., Lapointe and Rivard, 2006). Another stream of research views workarounds as benign improvisations which are brought about in practice as users begin interacting with systems and appropriating select system features in their task environments (e.g., Ciborra, 2002). However, regardless of the users’ intentions, the pervasiveness of workarounds has been rarely acknowledged in the IS literature until fairly recently (for exceptions see Boudreau and Robey, 2005; Orlikowski and Iacono, 2001; Orlikowski and Yates, 2006; Wagner and Newell, 2006). In the context of health care, the workaround phenomenon has become a focus of attention with the increasing use of medication ordering systems (Wears and Berg, 2005). In particular, hospitals have a mission critical emphasis both on fast response and on minimizing potential errors associated with manual medication orders. As a result, the computerized systems are often deployed to help minimize the potential for such errors (Bates, 2005). However, workarounds are increasingly viewed as critical issues to be reckoned with in the design and deployment of medication ordering systems (Koppel et al., 2005). In an interesting nuance, select studies of workarounds point to the fact that they customarily take place within specific medication contingencies in practice. For example, in a major North American long-term care facility a fairly involved pharmacist-intern real time routine was devised—such as printing a form and signing it, rather than resetting a flag on the computer—to implement a workaround (Rochon et al., 2005). Also, the institutional health care research has singled out workarounds as the Achilles heel of medication ordering systems (Murray, 2001, p. 114). In general, it is fair to say that workarounds take place regularly and are recognized as a fundamental issue facing HIS researchers and practitioners alike (Murray, 2000; Hurley et al., 2006). Disentangling Computer Workarounds as Practices Since the work done by Gasser (1986) and Gerson and Star (1986), calls have been made 4


for the IS scholars to produce “more research on the kinds of workarounds” (Orlikowski and Iacono, 2001, p. 132). Workarounds have begun to be recognized as an important area of research capable of providing fresh insight into IS design and implementation (Boudreau and Robey, 2005; Wagner and Newell, 2006; Ferneley and Sobreperez, 2006). For example, the post implementation non-use and under-use of an ERP in a major university is said by Wagner and Newell to “involve substantial employee workarounds.” (2006, p. 64) Similarly, according to Boudreau and Robey, an ERP implementation in another large university has resulted in workarounds which the users employ to “circumvent the rigid work processes embedded in the software” (2005, p. 13). However, the fundamental conceptual framework of the underlying research treats workarounds as black-boxes, i.e., they are analyzed in terms of their effects or as nominal phenomena (Orlikowski and Iacono, 2001). Therefore, our point of departure is to open this black box (Suchman, 1995; Star and Strauss, 1999) of computer workarounds in order to untangle them to make visible their workings and underlying social mechanisms. Our de-black-boxing metaphor is akin to tracing the wires to see where the signals go. We aim to achieve this by casting workarounds as situated work practices. We look at three aspects of situated practices within workarounds: (1) the processes of articulation work employed to enact a workaround; and (2) the implied negotiated order which the latter may be predicated upon; and (3) the practices whose enactments embody the workarounds. First, we define a computer workaround process as involving a fair amount of articulation work, i.e., it is the interactional process of doing whatever is necessary to bring an intended outcome to fruition in the context of a problematic situation regardless of work contingencies that arise in practice (e.g., Star and Strauss, 1999). Second, at least initially in the hospital setting we have studied, we propose that a computer workaround involves working 5


things out or negotiations (Corbin and Strauss, 1993). In other words, a workaround to be actually enacted needs the explicit or implicit agreement (equivalent to a tacit approval) among multiple occupational roles in the work practice setting. Third, as a result of the latter we suggest that, a computer workaround can be considered a form of coordinated action with its commensurate negotiated social order (Button and Sharrock, 1998). Specifically, this outcome is contrasted with the traditional view of a workaround as a tweak or kluge as being performed independently without the necessity of coordinated action. RESEARCH METHODOLOGY Case Background The observational study supporting our research is conducted at a teaching hospital and is focused initially on three open surgical units (e.g., 12th floor North). The study is being conducted with the permission of both the hospital administration and the institutional review board of the university’s faculty of medicine. The protocol allows the researchers to shadow anyone in a public area of the hospital excluding rooms where a patient has an expectation of privacy unless the patient grants permission. Over 250 researcher hours has been spent in the hospital to date. The majority of the time was spent on the day shift when most activities take place. However, a significant amount of time was spent on the evening and night shifts because the tasks are different and there are fewer personnel on the floor which results in different task allocations and modifications to the daytime workflow. The activities within a unit (nurses, physicians, clerks) and peripheral to the unit (messengers, transports, pharmacy technicians) were observed. The “fill form” process was one of the observed workflows and deserved further study especially as this hospital is developing a computerized order entry system to be integrated with

6


the Pharmacy Dispensing System (interchangeably also referred to as System). An additional impetus to further explore the fill form process was the insider author needing to provide a continuing education workshop on “process mapping” to a dozen nursing administrators of this hospital in December 2006. The participants expressed no disagreements on the characterization of the fill form process included in this paper, and in fact they provided additional history and process details. Research Method Given our interest in contemporary events, interpretations, and up close examination of workaround contents and processes which were at work in the medication dispensing situated practices, a qualitative case study method was considered a suitable choice (Yin, 2003; Lee, 1989; Benbasat et al., 1987). The case study was conducted by the two authors were part of an insider-outsider research team as recommended by Eisenhardt (1989) and successfully employed in IS research (Paré, 2004). The “insider” researcher has intimate knowledge of the medication dispensing system and the associated work processes gained through the observation study. Because of direct involvement in the events being analyzed, this researcher was uniquely sensitive to workaround practices which they key actors were engaged in. The “outsider” researcher had no involvement with the project other than a few of the interviews and the conduct of research. The researchers spent enough time with the hospital staff on these units so that they were comfortable providing a commentary while they were working. The observations of the researchers were supplemented by real-time clarification of why a task was being done in a particular manner (e.g., mini-interview). These mini-interviews took place several times during a shift. The primary observer gained enough familiarity with the tasks that exceptions could be pointed out to nurses (e.g., did you write instruction on the proper line). 7


The primary sources of information for the case study were shadow work conducted in the summer of 2006 and complemented with key actor interview data and various forms as well as official policy documents. The shadow work data were used to uncover the details of workaround adjustments and their types as well as the social mechanisms that appeared to have been at work to enact these workarounds. The interviews extended both upstream and downstream of the nurse (e.g., pharmacist). In parallel, other interview information were used to corroborate these adjustments and workaround data. The interviews were conducted from October 2006 through April 2007. The interviews were a combination of face-to-face and e-mail questions and responses. The actor groups interviewed were nursing, physicians, and the pharmacy. This type of case study research is subject to criticisms of potential researcher familiarity bias. However, a series of safeguards were worked out to reduce this potential impact. First, the insider-outsider team, can function to reduce familiarity bias—e.g., as proposed by Eisenhardt (1989) and similar to Montealegre and Keil (2000)—where the outsider researcher serves also in a “devil’s advocate” role. Second, in practical terms, to reduce retrospective bias the outsider researcher was an active participant in some of the interviews conducted. Third, as a control, a detailed description of the workarounds were prepared and shown to a nursing graduate student who had an intimate knowledge of the workaround process and her comments were incorporated to reduce researcher bias. Data Collection and Data Analysis Protocols Our research was guided by the following high level research questions. First, what are the elements of computer workarounds in practice versus what is mandated by the hospital in terms of formal rules? Through this research question we aimed to make visible the process steps, temporal order of execution, and the variety of occupational roles who are involved in 8


enacting a computer workaround. Second, what kind of adjustments or adaptations does a computer workaround entail for it to be enacted in practice and are they consistent with previous research findings? This question meant to uncover the collective actions (and interactions) to alter the hospital formal requirement that the System flag be set to its “sanctioned” value before restricted medication is dispensed to a target patient. The action and interaction are defined broadly and are explained below. Third, given that a workaround is effectively going “against the rules”, were there any trace of negotiations involved among the occupational groups in the hospital to enact a workaround? We wanted to use this question as a preliminary window into our exploration of both whether an alternate social order exists to enable the computer workaround and is it also coordinated action? The theoretical focus and the categorization of data that results from the above-mentioned questions is based on the following logic. We surmise that, the process of a computer workaround as it unfolds in practice consists of interactions off-line and on-line as carried out by different roles to bring about the intended result. We consider the core boundary of a workaround to include input from upstream activities and output to downstream activities. This formulation of a workaround boundary is used to help us detect major dependencies with activities: (a) that trigger inputs to the computer workaround; and (b) that are triggered by the output from the computer workaround. In addition, the temporal trajectory of a workaround is also traced. The temporal dimension allows us to see whether there are multiple paths which workarounds traverse depending on different contingencies in practice. First, our category development to detect the existence of workarounds began with the notions presented in Gerson and Star (1986) and Gasser (1986). However, we had to augment these categories during the shadow work to correspond to the range of workarounds which we came across. In particular, we encountered the following range of actions: an adjustment to the IS; an 9


adjustment to the procedural business rules; an adjustment to the roles associated with the procedures within the boundary; and use of an alternative or parallel approach. More specifically, the concept of role adjustment was added based on our shadow observations of workarounds. Also the business rule and IS adjustment are expanded categories based on the procedure amendment and data entry change proposed by Gasser. In any specific workaround situation, these adjustments may be observed alone or in combination. Second, in the sense of “going against the rules” a workaround reflects an effort to constitute an alternate social order (Strauss, 1993). From this social order perspective, a computer workaround implies ensuring that the “alternate route” taken to the “intended computer route” results in an identical or similar organizational outcome, which is quintessential definition of articulation work (Strauss, 1988). Furthermore, casting of the computer workarounds as articulation work helps us focus on the underlying activities in establishing and maintaining this social order as a practical accomplishment (Lynch, 2001). In addition, focusing on the performance of the articulation work to enact workarounds is important because it foregrounds the existence of negotiations to arrive at any particular agreement or arrangement (explicit or tacit) to affect the workaround or keep it going (Strauss, 1979). Third, as a multi-party social activity, the enactment of any workaround outcome can be presumed to reflect coordinated action. Coordination in this context is based on the existence of interdependence (Thompson, 1967) among social actors to affect the workaround. FINDINGS After the initial observation period, the research team was trying to understand the so called fill-form usage and nuances within the execution of these procedures. In the early follow up interviews, the facial expressions in reaction to our first questions told us a lot. They were

10


either dismissive or passionate so it was clear that something was amiss. What follows is the disentangling of the computer workaround black box called the fill-form process. We present our findings through the description of four workaround practices that tells us what takes place in the black box. These findings are preceded by a pre-amble which sets the stage and provides background details on the workaround practices. Preamble to Workaround Practices Our description of the workaround process centers on completing the form “Request for a ‘Restricted’ Antimicrobial Agent” which is the approval by a specialist physician in infectious medicine for ordering and dispensing a restricted medication to a patient. Multiple actors are engaged in collecting information and pushing the form through the approval process. These restricted medications are powerful antibiotics that when used inappropriately can result in antibiotic-resistant bacteria. Hospital personnel simply call this artifact the “fill form”. The computer is the Pharmacy Dispensing System (PDS) which processes the order for all medications, including restricted ones, and gives permission for the pharmacist to dispense. The patient is also billed by the PDS for the doses dispensed. The fill form process begins with the physician writing an order for a restricted medication and a bacteria culture if needed. The physician also fills out the order portion of the fill form. The infectious specialist is called to evaluate the patient. The nurse transcribes the order to the medication sheet and a carbon copy (“profile) is delivered to the pharmacy by messenger. The culture goes to the bacteria lab which must then report the results back to the physician and infectious specialist. Only then can the fill form be signed and must then be delivered to the pharmacy. The pharmacist dispenses the restricted medication which is delivered to the unit and received by a nurse who administers a dose to the patient. These activities are shown on the left side of Figure 1. Those in white are carried out by the nurses, physicians, and 11


clerks on the unit. The shaded boxes (dotted borders) represent pharmacy activities which are carried out in a different part of the hospital. The sub-process arrows represent a summarized set of tasks that collectively carry out the indicated task (e.g., “Complete FF”) so the overall process can be shown on the figure. The sub-process to complete the fill form involves numerous actors and steps as outlined below. •

Whoever initiates the fill form a) fills in information on the form for the benefit of the infectious medicine specialist (InfMD), and b) contacts the InfMD

•

InfMD arrives at a later time, evaluates patient, reads the lab results, signs the form

•

Gives to someone on unit who sends to pharmacy (if in a rush via a messenger)

The temporal sequence of the fill form is important to gain an in-depth understanding of workaround practices. The sequence begins with the initial order of a restricted medication whose initial 24 hour supply is dispensed (T1) and ends at the dispensing of the second 24 hour supply (T2). The dispensing of the first 24 hour supply occurs despite the absence of a signed fill form due to the realities of working in a situation where the patient health is at stake. The more critical point is the second dispensing when either the fill form has been completed by this point or the fill form approval process has failed which blocks the dispensing of restricted medications past the first 24 hours.

12


Evaluate Patient

Administer for T1

T1

T0 Submit order

Pharmacy Process Order

Complete FF

Fill Form OK?

Restricted Medication Ordered Yes Fill Form Initiated?

No No

T2

Deliver 1st 24hr doses Complete FF

Fill Form OK? No

Yes

Deliver next 24hr doses

Do not Dispense

Legend Tasks by Nurse or Physician

Pharmacy Process Next 24hr

Yes

Don’t Know Initiate FF

Administer for T2

Sub-process

Tasks by Pharmacy

T1 and T2 represent time of dispensing

Figure 1. Sequence of “Fill Form” Activities

Meta-Workaround The fill form process initially observed seemed straightforward enough. The physician ordered a restricted medication which the nurse transcribed to the medication sheet and sent a copy to the pharmacy. The pharmacy then processed the order and dispensed the restricted medication. Then the nurses talked about the restricted medications not showing up and the pharmacists talked about so many phone calls asking about the “fill form”. What became clear after several rounds of discussion is that on the back of the fill form are rules governing the use of restricted medications. Rule #2 required the pre-approval of any restricted medication by an infectious specialist but was in practice temporarily bypassed by invoking the “in case of an emergency” clause in Rule #3. This is why the early observations, from the ordering by the physician to the dispensing of the first 24 hour supply of medication, found nothing unusual. The rules were being interpreted in a way that “put the patient’s immediate need for the restricted medication before the official procedures”. Once the patient’s

13


immediate need was met there was time for the fill form approval process to catch up with the conditions in the workplace. This meant that subsequent doses would be delayed if a signed fill form had not been submitted in time. The research team quickly discovered the sensitivity of the actual practice when trying to obtain a copy of the procedure governing the ongoing practice. The supervisor “got worried” and needed to “ask her boss” who did not call back. The practice observed with respect to interpreting the rules is called the meta-workaround because it governs the behavior within other workarounds in the fill form process. From a theoretical perspective the practice of this meta-workaround is instructional in several respects. Does the routinized functioning of this workaround reflect a tacit agreement among the actor role groupings to enact the meta-workaround and does its enactment imply some interdependence among these roles? Our shadowing observations and our difficulties in obtaining a written policy of the informal practice are indicative that indeed the enactment of this metaworkaround points to an alternate social order which is tacitly agreed upon by the parties who enact it. Furthermore, without all of the roles implicitly honoring this agreement, “it would fall apart” quickly, this signifies a form of interdependence. Therefore, we propose that this workaround constitutes an alternate social order predicated on negotiated agreements and achievement of coordinated action. The meta-workaround is unique in that there is no tweak or adjustment to the computer system. It is neither temporary nor on the surface harmful. This is the essential workaround that has become routinized in the work practice. The invisible influence of the meta-workaround becomes apparent in the workarounds that follow. Habitual Emergency Workaround Upon receipt of the initial order for a restricted medication without a fill form at time T1, the pharmacist sets the status flag on the Pharmacy Dispensing System (PDS) to “FORM” 14


(meaning no fill form) and then dispenses the restricted medication despite the absence of a fill form. These adjustments are enacted by the pharmacist repeatedly many times a day as a matter of practice without an explicit approval from any other actor for each adjustment. However, each instance of the adjustment is in effect a different occurrence of the same workaround. Based on our observations the actors appear to have reached an implicit agreement, that is then extended to cover multiple cases. It is almost as if this workaround, as a social order, is considered an extension of the meta-workaround described above. These adjustments made to the PDS by the pharmacist appear to be considered harmless. Furthermore, the typed text is merely in a comment field so there is no computational impact to the PDS. This is perhaps more benign than the quintessential “tweak” if viewed solely by the keystrokes of the pharmacist. To the casual observer looking only at the adjustments made by the pharmacist at time T1, they would appear to be done in violation of the official policy. However, performing these adjustments many times a day with no involvement from other actors means that this portion of the process is habitually enacted as a matter of situated practice. The multi-role interactions may figure into this but it is also clear that it is governed implicitly by prior “invisible” agreement of all parties who share a common understanding of its intent rendering it an alternate social order. Furthermore, the agreements point to interdependence and thus coordinated action for the alternative social order to be practically accomplished. However, the habitual appearance of this practice often hides the fragility of this agreement which is applicable only at time T1. But this fragile social order becomes more visible when attempts are made to apply these same adjustments at time T2 as shown in the following workaround. Verbal Signature Workaround For this computer workaround, the upstream actors recognize that the Pharmacy Dispensing System has or will block the dispensing of the second 24 hour supply at time T2 15


because of the expiration of the grace period and absence of a signed fill form. Often, the infectious specialist is contacted by a nurse or physician to act on behalf of the patient to override the block on dispensing. Subsequently, the infectious specialist calls the pharmacist and negotiates an override (via the alternate social order) with the promise to submit the signed fill form as soon as practical (e.g., during rounds next morning). Upon agreeing to institute the workaround, the pharmacist adjusts the fill form flag (IS adjustment) and dispenses the restricted medication (rule adjustment) despite the absence of a signed fill form. The acceptance of a “verbal signature” invokes the use of an alternative or parallel but temporary “system” to accommodate this virtual artifact. The sanctioned role of the infectious specialist is to authorize the proper restricted medication ordered for the patient. The fact that the infectious specialist calls the pharmacists means that the fill form process has been initiated and far enough towards completion to justify a call—this is how the interdependence underlying this workaround is managed. This means that sometime during the conversation the infectious specialist will explicitly direct the pharmacist to accept a verbal signature in lieu of a signed fill form. This workaround is not automatic and confrontations can occur at times especially if the phone call is perceived as an attempt to get around the absence of a fill form. The following physician’s comment on this workaround is instructive: “…sometimes doctor orders by phone and sometimes he gets into fights with the pharmacist. The pharmacist is under rules so we can’t fault her”.

The fact that a phone call is necessary means that somewhere in the upstream process something has gone amiss. One of the pharmacists interviewed confirmed this perspective: “When all these reminders fail and the patient misses his dose we accept to take the order of resuming antibiotic by the phone from the infectious disease doctor directly. This will cover the patient for 24-48 hours till the infectious disease doctor signs it.” 16


Negotiation is required because the pharmacist effectively has also taken on the enforcer role for this policy (as well as being a pharmacist) while the caregivers perceive their role to get the restricted medication to the patient. A physician, especially an infectious medicine specialist, has formal power granted to him in this culture by virtue of his occupational role and the restricted medication policy of this hospital. However, this power is sometimes mediated as is the case within this workaround by the pharmacist invoking the formal policy on restricted medications. The difference in occupational roles and powers is evident and illustrates more tenuous status of the social order beyond the implicitly agreed upon boundaries of the metaworkaround. In practice, such negotiations entail an interactional process during which the pharmacist ascertains that there has been compliance in the upstream activities to complete the fill form and that the only thing missing is the signature. The adjustments now take on more significance. The IS adjustment is real as a coded procedure is overridden (i.e., indicating fill form received). The override allows the doses to be released and billed to the patient. The adjustments can be perceived to be harmful in the sense that the established process is bypassed and indicates to other physicians that a phone call can be accepted at least temporarily in lieu of the fill form. Fail-Safe Switch Workaround When the fill form is still absent at time T2, the Pharmacy Dispensing System blocks the dispensing of restricted medications without a signed fill form. There are a variety of reminders, which warns of this impending event. The final reminder is that the nurse notices the absence of the next dose of this restricted medication. This discovery triggers a frantic chain of activities to obtain a dose for the patient—albeit in an ad hoc fashion—which signify interdependencies and thus coordinated action. These activities range from finishing the fill form if nearly complete,

17


getting an infectious specialist to call the pharmacy (see Verbal Signature workaround), borrow a spare dose or order an alternate medication to the patient. These are enacted as a last resort. The role stature of the nurse temporarily increases to explore with the physician the available options. Based on our shadowing work and observations, the physician is usually an intern with no knowledge of what options exist. The negotiation determines the most suitable approach given the time of day (e.g., pharmacy open), availability of actors (e.g., infectious specialist) and ease of carrying on with the resources available. Our initial data suggests that the rationale for this workaround, aside from patient no longer needing a restricted medication, is that the switch to an oral medication generally does not require a fill form. When asked why there was a negative perception to the fill form, a nurse responded: “That is true. Because it is time consuming to get them, the contacts the procedure to fill out the fill form … The doctor, the infectious doctor, …”.

A senior physician’s comment was generally supportive of this as a widespread notion among the physician staff in the hospital, noting that the “Fill form process is extremely restrictive and dysfunctional”. While there are no physical adjustments to get around the block placed by the Pharmacy Dispensing System, there is an implied IS adjustment. When the physician orders a different medication (e.g., an oral form) to replace the existing restricted medication, this new order effectively closes out the existing order. The physician becomes the one who makes a de-facto adjustment to the Pharmacy Dispensing System. Both medicines would not be administered at the same time so the fill form for the original order is no longer necessary. The practical effect is that the existing order remains in the Pharmacy Dispensing System until the expiration date even though nothing can be dispensed for this order. 18


The execution of the fill form has not materialized and the social order associated with the meta-workaround is on the verge of breaking down in this workaround. The implicit negotiated agreement that allowed multiple actors to operate toward a practical shared outcome worked well at time T1, and to some degree at time T2 for the verbal signature. Looking at the practices which enact this workaround, it is apparent that the actors are working near the edge or outside the informal boundaries delineated by the meta-workaround social order once time T2 has passed. Summary of Workaround Practices Each of the above computer workarounds are situated practices that represent a subset of workaround practices. These situated practices lead to a workaround that is enacted through an alternate social order, which in these four examples also implies coordinated action. Key attributes of these computer workarounds are found in Table 1. The social order of the meta-workaround that regulates role boundaries and what can be negotiated guides the extent of adjustments that can be enacted within specific workarounds. The meta-workaround strikes a balance between strictly adhering to formal rules #1 (pre-approval) and #3 (dispense without fill form only on emergency basis) and constraining the ongoing practice. Although these rules are the official policy, the organization has institutionalized distinctly different practices and thus enacted an alternate social order that regulates dispensing practices. Based on our observations, the adjustments related directly to computer tasks on the System are performed by a single person and limited in the keyboard steps taken. The information system adjustment sets a flag condition in the comment field indicating the status of the fill form. Once the fill form status is set the business rule is adjusted to allow the dispensing of a restricted medication without the fill form. However, the underlying social order which provides a mechanism for the enactment of these adjustments is anything but simple. 19


Adjustments in roles were prominent in our findings. The pharmacist role shifts from just a being pharmacist at time T1 (i.e., Habitual Emergency workaround) to both pharmacist and enforcer of the fill form policy at time T2 (i.e., Verbal Signature workaround). The pharmacist is effectively bypassed when the Fail-Safe Switch workaround results in a physician ordering a different medication. The nurse temporarily gains additional occupational stature within this situated practice when helping the physician find an alternate means of getting medication. The negotiations to enable an alternate social order enacted by these care-givers are guided by the meta-workaround. Interestingly, given their enacted roles, those of lower social order are temporarily empowered to negotiate directly with physicians. The pharmacist could choose to withhold a verbal signature. A nurse could stand her ground if the physician proposes an option beyond the commonly understood boundaries. A variety of mechanisms constituted the underpinning of coordinated action in the overall fill form process. Some are implicit and almost routine such as the habitual emergency workaround. Others occur less frequently and explicitly coordinated when the need arises as in the verbal signature and fail-safe switch workaround. Nevertheless, almost all workarounds imply interdependence leading to a form of coordinated action.

Table 1. Computer Workarounds Practices Workaround Label

Adjustment to

Indications of Alternate Social Order

Roles

Rules

“IS”

(Negotiation Traces)

Habitual Emergency

N/A

Allow initial dispensing

By Pharmacist

Pharmacist does it by agreement of others (implicit)

Verbal Signature

Pharmacist enforcer of policy

Verbal approval for dispensing

By Pharmacist

Infectious MD gets pharmacist to do it (explicit)

Fail-Safe Switch

Nurse collaborates

Physician switches

By Physician

Finding fastest and easiest approach (mix of tacit and explicit)

20


with physician

MetaWorkaround

Delineates role boundaries

medication

(de-facto)

Some dispensing without fill form

Institutes rule in PDS

Sets parameters for what can be practiced (“prenegotiated” tacit)

DISCUSSION Based on an in-depth non-participant observer case study of a hospital electronic medication dispensing process, we have provided a rich description of the related computer workarounds and how they are enacted in practice based on explicit or tacit agreements among the key actors who engage in articulation work in support of the workarounds. Through the detailed analysis of the workaround process, we have found evidence of certain workaround adjustment mechanisms at work—business rules adjustment, IS adjustment, role adjustment, and use of alternative approach—which are obtained based on negotiations among the key actors. These adjustments were found to be in existence commensurate with the enactment of an alternate negotiated social order among the key actors which also implied interdependence thereby constituting a form of coordinated action in practice. Our findings extend and enrich previous findings of IS workaround research. Fundamentally, we respond to various calls for studying the contents of workarounds (e.g., Orlikowski and Iacono, 2001) as well as calls for exploring how workaround processes are enacted in practice (e.g., Orlikowski and Yates, 2006). However, the case presented here is unique in other ways as well. First, the contextual environment is a hospital, i.e., a fast response organizational setting, where the challenge of attending to the patient safety and health comes before other priorities. Thus the study of workarounds in this setting can produce qualitatively

21


different type of insight than say from studying ERPs in manufacturing firms. Indeed, the focus on computer workarounds by the research team had a lot to do with the concerns of the hospital who had asked one of the authors to advise on ways of improving the work processes. This includes processes associated with medication ordering and dispensing regardless of whether an information system is used or not. A second unique aspect of the case is its reliance on an insider-outsider research team. Researchers with insufficient engagement with the site are often unable to comprehend the richness of experiences, dilemmas, struggles, and complex interactions that characterize unfolding work practices (see Barley and Kunda, 2001). For example, much richness was gained from using a combination of research perspectives as the observer’s deep knowledge of events and situated activity is matched with the outsider’s focus on the theoretical understanding of workaround practices in situ. Indeed, during the conceptual development of the paper, the ability of the inside researcher to stay focused on the process view and trajectories of distinct workarounds combined with the articulation work and situated practices perspectives of the outsider researcher helped generate a richer set of findings than would have been the case if either of the two authors had done the research individually. Our findings reach beyond acknowledging that workarounds are important phenomena through a singular focus on the contents and processes of their enactment. Prior workaround research has focused more on the nominal aspects of workarounds (Boudreau and Robey, 2005; Wagner and Newell, 2006; Ferneley and Sobreperez, 2006), while we disentangled this blackbox. By content we mean specific properties of workarounds that were found to be enacted in the case—adjustments to IS, adjustment to business rules, adjustment to roles and use of an alternative approach. The role adjustment, e.g., negotiating with other key actors (within different occupational categories) to act on one’s behalf as well as the business rule adjustment are 22


additional and refined workaround categories to those proposed in earlier research (Gasser, 1986). By process we denote the multi-step procedure which extends beyond the core boundary of a workaround per se as it unfolds in practice and leading to its enactment. The process also entails enumerating multiple contingencies which are essentially variations on the theme of a basic workaround—i.e., meta-workaround, routine emergency, verbal signature, and fail-safe switch. Seen in isolation, the adjustments to the IS made by the pharmacist could be construed as a tweak or workaround done independently. It is in the presence of the other adjustments and negotiated outcome that the coordinated action nature of workaround practices become apparent. Our findings also extend the research on workarounds by focusing on their inner workings. Taking our cue from the recent push in organizational science to engage in social mechanisms theorizing (Davis and Marquis, 2005), we have asked: What happens when we make explicit the social mechanisms that are implicit in the enactment of computer workarounds? We have shown that, the workarounds are commensurately enacted via an alternate negotiated social order among the four key occupationally distinct group of actors: the infectious physician specialist, the physician, the nurse, and the pharmacist. The enactment of workarounds in practice was dependent on these actors either explicitly or tacitly having agreed among each other that an instance of a workaround was a valid practical response to situational contingencies. These contributory social mechanisms give us a richer understanding of workarounds as form of social action not just individuals acting on their own. Thus, our findings have extended the research by pointing out the existence of specific social mechanisms surrounding workarounds. The findings also extend the research on hospital-related contextual workarounds with a counter-intuitive result that they can be habitual and routine. The computer workarounds sometimes are classified as temporary responses to situational contingencies (Kobayashi et al., 2005). However, our findings point to the repetitive nature of computer workarounds. Indeed, 23


the key actors who are part of the four occupational categories have developed routine responses which are almost standard operating procedures in and of themselves—e.g., the habitual emergency workaround where the “emergency” term in the underlying rules is employed with significant “interpretive flexibility” to suit the specific workaround situation in practice. However, we also think there are conceptual differences in our formulation of underlying activities constituting a workaround. Others have used the articulation work framework to analyze workarounds in the past but have limited its focus to the “responses to on the fly events”. Our findings based on taking a slice of the process and bounding it by the immediate activities linked to the workaround (both upstream and downstream) and adding a (situated practice) time window of approximately 48 hours after the initial triggering event, extends the current understanding of workarounds beyond merely temporary articulation work to incorporate routine coordinated social action. In particular, this picture of routine workarounds constituted via an alternate social order and leading to coordinated action based on the involvement of multiple professional occupations in the hospital, points to a further extension of the literature as follows. The prior research implicitly assumes the majority of workarounds are temporary (Boudreau and Robey, 2005; Hurley et al., 2006; Rochon et al., 2005). By looking at workarounds as routines, and as coordinated action, we will be able to tap into recent theorizing in organizational science which has put forward routines as a source of both stability and change in organizations (Feldman and Pentland, 2003; and Pentland and Feldman, 2005). In particular, Feldman and Pentland’s formulation that routines consist of ostensive and performative aspects and are coupled with certain artifacts in their everyday organizational enactments, offers an interesting and potentially fruitful avenues for further analysis of workarounds as routines—e.g., our routine emergency workaround. 24


This study has limitations that must be recognized and addressed in future work. The insights gained are from a single case in an open surgical unit and thus may be limited (e.g., fewer adjustments needed in an infectious unit). The practices have been found to be slightly different from unit to unit but the essence of the four identified workarounds hold. Our primary goal was to understand in detail the contents of the workarounds and their unfolding process in practice. Additional research is needed to corroborate the extent to which the specific adjustment mechanisms are used in other settings and also to what extent the social mechanisms which operated to produce an alternate negotiated order for the enactment of workarounds are generalizable to both other IS and HIS contexts.

CONCLUSIONS This paper contributes to the theoretical understanding of computer workarounds as a common post implementation occurrence in most organizations. The prevailing theorizing on computer workarounds treats them as nominal or aggregate phenomena and focuses on the antecedent conditions as well as their impact. Although these insights are useful, the contents and processes of enacting computer workarounds and the commensurate social mechanisms which enable them are still effectively a black box from a theoretical perspective. Therefore, we propose to disentangle this black box and analyze the types of changes that computer workarounds encompass as situated work practices. Furthermore, we suggest that, save for the most trivial kinds of workarounds, a social order understanding of computer workarounds is essential to provide richer theoretical explanations of their existence and inner workings.

25


Our analysis is grounded in the articulation work and negotiated social order theories as explanatory frameworks to provide a better understanding of the observed computer workarounds and the types of adjustments (to the intended computer-based procedure) which they encompassed. We analyzed a case, involving a medication dispensing system in a hospital, where the organizational dynamic is characterized by fast response and a shared practical concern for patient health and safety. This is a very different and more urgent dynamic than say workarounds in manufacturing firms implementing ERPs. Because of the latter emphasis, this case allows us to use the situated work practices as a base for theoretical understanding of the contents and processes of workarounds. This in turn enables us to theorize on the social mechanisms which underpin this interactional articulation work in the enactment of these workarounds. These enactments are predicated on negotiating an alternate social order (to the official rule) as a practical accomplishment in the process of effecting the workaround. In both cases, our research underscores that computer workarounds are similar in their form to coordinated social action. This is a further insight that extends the literature which has often regarded workarounds as “hacks” or “tweaks” by individual computer users. We conclude by suggesting the following: First, we have attempted to disentangle computer workarounds so as to de-black-box their inner dynamics, and thus we have shown that an alternate negotiated social order is an accurate reflection of the underlying practices—at least in the context of a hospital medication dispensing system. Second, by de-black-boxing computer workarounds, we believe a fruitful area of investigation is opened up whereby a richer understanding of workarounds can aid in the upstream IS research on design science and implementation. REFERENCES Barley, S. R., & Kunda, G. 2001. Bringing Work Back in. Organization Science, 12 (1): 76-95.

26


Bates, D. W. 2005. Computerized Physician Order Entry and Medication Errors: Finding a Balance. Journal of Biomedical Informatics, 38(4): 259-261. Benbasat, I., Goldstein, D. K., & Mead, M. 1987. The Case Research Strategy in Studies of Information Systems. MIS Quarterly, 11(3): 369-386. Boudreau, M. C., & Robey, D. 2005. Enacting Integrated Information Technology: A Human Agency Perspective. Organization Science, 16(1): 3-18. Button, G., & Sharrock, W. 1998. The Organizational Accountability of Technological Work. Social Studies of Science, 28(1): 73-102. Chehid, R. 2007. PDA Use in Nursing Documentation. Unpublished Project, American University of Beirut, School of Nursing, Lebanon. Ciborra, C. U. 2000. From Alignment to Loose Coupling: From MedNet to www.Roche.Com. In Ciborra, C. U. and associates (Eds.), From Control to Drift: 15-40. Oxford, England: Oxford University Press. Ciborra, C. U. 2000. The Labyrinth of Information. Oxford, England: Oxford University Press. Corbin, J. M., & Strauss, A. L. 1993. The Articulation of Work Through Interaction. The Sociological Quarterly, 34(1): 71-83. Davis, G. F., & Marquis, C. 2005. Prospects for Organization Theory in the Early Twenty-First Century: Institutional Fields and Mechanisms. Organization Science 16(4): 332-343. Eisenhardt, K. M. 1989. Building Theories from Case Study Research. Academy of Management Review, 14(4): 532-550. Feldman, M. S., & Pentland, B. T. 2003. Reconceptualizing Organizational Routines as a Source of Flexibility and Change. Administrative Science Quarterly 48(1): 94-118. Ferneley, E. H., & Sobreperez, P. 2006. Resist, Comply or Workaround? An Examination of Different Facets of User Engagement with Information Systems. European Journal of Information Systems, 15(4): 345-356. Gasser, L. 1986. The Integration of Computing and Routine Work. ACM Transactions on Office Information Systems, 4(3): 205-225. Gerson, E., & Star, S. L. 1986. Analyzing Due Process in the Workplace. ACM Transactions on Office Information Systems, 4(3): 257-270. Hevner, A. R., March, S. T., Park, J., & Sudha, R. 2004. Design Science in Information Systems Research. MIS Quarterly 28(1). Hurley, A. C., Lancaster, D., Hayes, J., Wilson-Chase, C., Bane, A., Griffin, M., Warden, V., Duffy, M. E., Poon, E. G., & Gandhi, T. K. 2006. The Medication Administration System—Nurses Assessment of Satisfaction (MAS-NAS) Scale. Journal of Nursing Scholarship, 38(3): 298-300. Jargon File. Work-around. (n.d.). Jargon File 4.2.0. Retrieved April 24, 2007, from Dictionary.com website: http://dictionary.reference.com/browse/work-around Kobayashi, I. M., Fussell, S. R., Xiao, Y., & Seagull, F. J. 2005. Work Coordination, Workflow, and Workarounds in a Medical Context, CHI, Portland, Oregon, USA. Koopman, P. and Hoffman R.R. 2003. Work-arounds, Make-work, and Kludges. IEEE Transaction on Intelligent Systems 18(6), 70- 75. Koppel, R., Metlay, J., Cohen, A., Abaluck, B., Localio, A. R., Kimmel, S. E., & Strom, B. L. 2005. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. Journal of American Medical Association 293(10): 1197-1203. Lapointe, L., & Rivard, S. 2006. Getting Physicians to Accept New Information Technology: Insights from Case Studies. Canadian Medical Association Journal, 174(11): 1573-1578.

27


Lee, A. S. 1989. A Scientific Methodology for MIS Case Studies. Management Information Systems Quarterly, 13(1): 33-50. Lynch, M. 2001. Ethnomethodology and the Logic of Practice. In Schatzki, T. R., KnorrCetina, K., & Savigny, E. (Eds.), The Practice Turn in Contemporary Theory: 131148. London: Routledge. Markus, M. L. 1984. Systems in Organizations, Pitman, Boston. Markus, M. L., & Robey, D. 2004. Why Stuff Happens: Explaining the Unintended Consequences of Using Information Technology. In Vendelo, M. T., and Andersen, K. V. (Eds.), The Past and Future of Information Systems: 61-93. Oxford: Elsevier Butterworth-Heinemann. McAfee, A. 2003. When too much IT Knowledge, is a Dangerous Thing. MIT Sloan Management Review 44(2): 83-89. Montealegre, R., & Keil, M. 2000. De-Escalating Information Technology Projects: Lessons from the Denver International Airport. Management Information Systems Quarterly, 24(3): 417-447. Murray, M. D. 2000. Information Technology: The Infrastructure for Improvements to the Medication-Use Process. American Journal of Health- Systems and Pharmacy, 57(6): 565-571. Murray, M. D. 2001. Automated Medication Dispensing Devices. In Shojania, K., Duncan, B., McDonald, K., & Wachter, R. (Eds.), Making Health Care Safer: A Critical Analysis of Patient Safety Practices: 111-117. AHRQ, Rockville, MD. Orlikowski, W. J., & Iacono, C. Z. 2001. Research Commentary: Desperately Seeking the “IT” in IT Research—A Call to Theorizing the IT Artifact. Information Systems Research, 12(2): 121-134. Orlikowski, W. J. & Yates, J. 2006. ICT and Organizational Change: A Commentary. The Journal of Applied Behavioral Science, 42(1): 127-134. Orlikowski, W. J. 1996. Improvising Organizational Transformation Over Time: A Situated Change Perspective. Information Systems Research, 7(1): 63-92. Paré, G. 2004. Investigating Information Systems with Positivist Case Study Research. Communications of the Association for Information Systems 13(1): 233-264. Pentland, B. T. & Feldman M. S. 2005. Organizational Routines as a Unit of Analysis. Industrial and Corporate Change 14(5): 793-815. Pollock, N. & Cornford, J. 2004. ERP Systems and the University as a ‘Unique Organisation’. Information Technology & People, 17(1): 31-52. Rochon, P. A., Field, T. S., Bates, D. W., Lee, Z. M., Gavendo, L., Erramuspe-Mainard, J., Judge, J., & Gurwitz, J. H. 2005. Computerized Physician Order Entry with Clinical Decision Support in the Long-Term Care Setting: Insights from the Baycrest Centre for Geriatric Care. Journal of American Geriatric Society, 53(10): 1780-1789. Schatzki, T. R., Knorr-Cetina, K., & Savigny, E. 2001. The Practice Turn in Contemporary Theory, New York: Routledge. Spear, S. J. 1999. Fixing Health Care from the Inside, Today. Harvard Business Review, 83(9): 78-91. Star, S. L. and Strauss, A. “Layers of Silence, Arenas of Voice: The Ecology of Visible and Invisible Work,” Computer Supported Cooperative Work (8:1-2), 1999, pp. 9-30. Strauss, A. L. 1993. Continual Permutations of Action, New York: Aldine De Guyter. Strauss, A. L. 1988. The Articulation of Project Work: An Organizational Process. The Sociological Quarterly, 29(2): 163-178. 28


Suchman, L. 1995. Making Work Visible. Communications of the ACM 38(9): 56-64. Suchman, L. 1996. Supporting Articulation Work. In Kling R. (Ed.), Computerization and Controversy: Value Conflicts and Social Choices: 407-423. Academic Press, CA. Thompson, J. 1967. Organizations in Action: Social Science Bases of Administrative Theory, New York : McGraw Hill. Wagner, E. L., & Newell, S. 2006. Repairing ERP: Producing Social Order to Create a Working Information System. The Journal of Applied Behavioral Science, 42(1): 40-57. Wears, R. L., & Berg, M. 2005. Computer Technology and Clinical Work, Still Waiting for Godot. Journal of American Medical Association, 293(10): 1261-1263. Yin, R. K. 2003. Case Study Research, Design and Methods, Beverly Hills, CA : Sage Publications.

29

Learning from Computer Workarounds Practices - Semantic Scholar

Learning from Computer Workarounds Practices - Semantic Scholar

Suggest Documents