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Proceedings of the 34th Hawaii International Conference on System Sciences - 2001

Investigating Integrated Socio-technical Approaches To Health Informatics Chris Atkinson, Tillal Eldabi, Ray J. Paul and Athanasia Pouloudi Center for Health Informatics and Computing, Department of Information Systems and Computing, Brunel University, Uxbridge, Middlesex UB8 3PH, United Kingdom [email protected], [email protected], [email protected], [email protected]

University. Its emergent socio-technical research and development agenda lies in how to undertake participative, multi-stakeholder problem solving within a healthcare context. In this context it is essential to address complex problems through integrated approaches, that incorporate both systemic and traditional IS tools and techniques, with approaches to organisational, professional, process, and political change. Approaches and frameworks that go some way towards achieving this are explored in the next sections. In the conclusion it will be argued that healthcare constitutes an environment that is markedly different from business and therefore demands an identifiable discipline, ‘Health Informatics’. A discipline based on socio-technical approaches. What then is this unique context in which CHIC’s agenda has been formed and in which it seeks to intervene and from which it seeks to learn?

Abstract This paper explores the socio-technical approaches being developed in the Center for Health Informatics and Computing [CHIC] for addressing issues within healthcare that necessitate the integration of information systems with clinical and managerial development. A brief description of the health provision in the UK is given as a background to understanding the need for integrated interventions and approaches in health informatics. Three interlinked approaches are discussed: The Soft Information Systems and Technologies Methodology [SISTeM], Participative Simulation Modeling and Stakeholder Analysis. A discussion is then provided of how they relate to each other and potential synergies. How they form part of the current and future research agenda within CHIC is then presented. The paper concludes with the argument that, as a result of the nature healthcare, any health informatics intervention, if it is to be effective, has to be based on integrated sociotechnical approaches.

2. The Research Context

Key words: Health Informatics, Simulation, SISTeM, Stakeholders, Information Systems, ANT

The healthcare system within the UK [7][8][9] is one of socialized medicine, unlike the USA or the rest of Europe, where governments set overall policy and provide a regulatory framework, in which healthcare is then delivered mainly by private sector and voluntary providers. In the UK the government does this but, through the National Health Service [NHS], it also delivers the healthcare. This is achieved through a complex network of primary, community, secondary hospital and tertiary services. These are strategically ‘steered’ by the NHS Executive, both centrally and locally through its Regions, District Health Authorities [DHAs], and more recently Primary Care Trusts [PCTs]. It is funded by the Treasury to the tune of $75 billion per annum, around 6% of gross domestic product [GDP]. All citizens in the UK who work or are self-employed, together with their employers, pay a National Insurance contribution to the government for their health and social care. Healthcare in the UK is virtually free at the point of delivery. Care is generally of good quality, though it can take an inordinately long time to receive treatment in hospitals for other than emergencies. Also there are marked demographic differences in patient morbidity,

1. Introduction Despite over half a century of socio-technical research and organisational interventions, information systems development [ISD] is still dominated by data driven methodologies, tools and techniques that produce technical solutions to organisational problems. In this paradigm the human is present, not in its all its messy, Shakespearean, multidimensional complexity, but in the technocentric term ‘user’. In both the private and public sectors this has been a major contributory factor to a deficiency [1] in ISD to produce any real enhancement in organisational performance or transformation [2][3]. In business this may result in the failure of a company to survive, in healthcare it can ultimately lead to the failure of the patient to survive. The latter not necessarily from inadequate IS&T functionality [4][5] but from the vast sums of money spent [6]on ineffective health informatics projects that could have gone directly into patient care. This paper sets out to describe the work of the Center for Health Informatics and Computing [CHIC] at Brunel

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and effectiveness of these links at a national level may be debatable. A recent government white paper [8], however, has set out a strategy for improving services and professional practices. This is to be achieved through clinical governance and evidence based medicine, in the form of care protocols, pathways, patient care plans and local Health Improvement Plans, set by PCTs. A major component of this is a new national IS strategy [7] encompasses the Electronic Patient Record [EPR], Life-long Patient Health Records [HRs] and clinically based systems linking across every healthcare sector via the NHSnet. From these all managerial and performance data will be captured. Funding for IS&T projects, internal IS professional and organisational change expertise, national and local politics, management to clinical profession demarcation and sometimes antagonism and a generally conservative supplier industry are inhibitors to realizing the strategy. It is within this unique imbroglio [5] of healthcare within the UK that CHIC has set out to undertake both theoretical and action research into effective ways of problem solving of which IS&T are major components. This has revealed the need for integrating ISD and organisational change. CHIC’s research is both substantive and methodological, including tools and techniques, within a socio-technical framework. These approaches are explored in the following sections.

mortality and healthcare performance. All citizens have a personal general practitioner [GP], through whom they gain access to secondary care. GPs are generally in partnerships and work in practices, which many of them own. Unlike hospital clinicians they are self-employed and have contracts with the government to deliver primary care. They and their practices are currently being formed into Primary Care Trust (PCTs) covering 100,000 patient. As well as delivering primary and community services PCTs, along with DHAs, will be responsible for planning and commissioning hospital services and monitoring quality of service delivered. Successive governments since the NHS’ establishment in 1948 have incessantly restructured the organisation and delivery of care. PCTs are the latest manifestation. Despite the socialized nature of healthcare and the National Health Service it would be wrong to think of UK healthcare as being delivered by a single organisation. Rather, UK healthcare is better conceived of as an organizational heterogeneity, consisting of a number of self-demarcating, culturally different, yet interdependent, sectors, with a variety of legal, formal and informal powers and capacities to direct or influence each other. Threading through this are the clinical professions, with their powerful Royal Colleges and the British Medical Association. These are capable of appealing directly to the nation as a whole. In the past they have been subversive of any attempts at line management or governmental control [the current government is challenging this through clinical governance and accountability] or information initiatives that is seen as being based on a purely managerial agenda. In addition there are sections of the media, the multinational pharmaceutical, the medical equipment industry, healthcare information systems supplier industry and private medical laboratories actively involved in UK healthcare. Finally, the UK population is increasingly accessing the Internet as a source of medical information. The NHS has a recent history of very public failures [4][5] [6] in information systems develop both centrally and locally. This has lead to conservative, long-winded, procurement procedures as well as attempts at establishing public-private sector IS funding initiatives. Until recently information systems applications procured within secondary and community care were primarily directed at capturing patient episode data for performance monitoring by the NHS and government. Other IS, for example, laboratory and specialized renal clinical systems have often been stand-alone and clinician ‘owned’. In some cases IS are also developed by clinicians. The latter are used primarily for clinical audit and research. GP systems have better served clinical practice and are ubiquitous in primary care. These are now being linked together within PCTs and to hospitals and other healthcare organisations even though the nature

3. The Soft Information Systems and Technologies Methodology [SISTeM] One of the approaches capable of facilitating interventions as well as underpinning research within the field of health informatics is the Soft Information Systems and Technologies Methodology [SISTeM] [10][11]. This approach has been developed through a series of participative multidisciplinary projects within healthcare settings that incorporated and integrated IS and organisational development. SISTeM is a secondgeneration soft methodology, driven by the contingencies of problem situations in which an explicit need arose to deal with issues, opportunities and processes in which technologies, especially information systems [IS], were paramount. It is based upon the underpinning concept of the human/machine activity’. This enables technological activity to be represented within the soft modeling tools and techniques, on an equal basis, as Callon [12] and Latour [13][14] would advocate, to that of the human and also to integrate them directly with traditional ISD tools and techniques.

3.1 SISTeM’s Cycles SISTeM is similar to that of SSM [15], however it has two Cycles [see Figure 1]. The first follows the

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requirements, informational and organisational benefits/risks, and organisational location. The model defines a strategic human/machine maturation pathway for the organisation, including its IS&IT. Cycle 2 deploys the same tools as Cycle 1 but here their status is ‘developmental’ rather than ‘strategic’ or high level. From the human/activity conceptual and expressive models in Cycle 2, data flow diagrams, entity diagrams, use-cases, as well as process redesign and organisational development can be directly derived [11]. SISTeM’s models have be used [16][17][18] to define a strategic multistage IS maturation pathways and underpin applications procurement output based specifications [17]. Work is currently underway exploring the factors that have to be incorporated in SISTeM modeling to enable technical architectures to be identified and whole process screen dialogues specified. The importance of stakeholder identification, involvement and analysis within SISTeM is evident from the previous discussion. Linking SISTeM modeling explicitly to stakeholder analysis and exploring its role in supporting healthcare simulation modeling research is an emergent area of research and methodological development within CHIC that will be discussed later in this paper.

traditional soft cycle culminating in a debate and a high level ‘strategic’ decision to act based on robust accommodations amongst multiple stakeholders. The second cycle takes this high level decision and seeks to realize it through operational decision making, based on an overt [often contractual] commitment amongst relevant stakeholders, followed by actual integrated IS and organisational design, development and realization of benefits. In both cycles the decision criteria deployed are: systematic desirability, cultural feasibility, value adding, technical feasibility & ethical defensibility. These stem from both SSM and actual practice.

SISTeM Cycle 1 Inquiry & Strategic Decision Making

SISTeM’s Learning Cycle

SISTeM Cycle 2 Operational Decision Making Development & Realisation

IS&T Strategy, Design and Development Cycle

3.2 SISTeM, A Contingency Methodology SISTeM as it has been described here may be considered, in Avison and Fitzgerald's [15] terms, a contingency methodology. This is based on its ‘adaptability’, ‘integration’, ‘multidisciplinarity’ and ‘containing competing paradigms’. Firstly, it’s adaptability. SISTeM, as its soft systems heritage implies, and as witnessed in practice [10][11][17][18] is adaptable too and adapted by those who use it and by the circumstances of its use. Through reflective action research and learning that takes place in each intervention it is also developed further - mutated. Its very emergence was as an adaptation of SSM, stemming from its progenitor’s incapacity to deal with real-world contingencies in which technologies required an overt ‘voice’ [12][13][14]. SISTeM’s cycles, stages and tools can and have been followed slavishly (Mode 1). Other times, in Mode 2 they have been omitted, carried out in different sequences. Some times they have even been used unconsciously. Secondly, SISTeM actively seeks, through combining organisational and information systems development to integrate human and technological development. Thirdly the approach actively merges with other disciplines and the tools within them, ISD [11] and OD approaches, as well real world craft knowledge and practices, to address the contingencies of the problem situation. Fourth and finally SISTeM encompasses within it competing paradigms. These range from the formal/rational in its

Figure 1, SISTeM's Cycles and IS &T Development The twin cycles form a potentially never ending process of inquiry, decision making and action in the real world, from which comes the possibility for learning.

3.2 SISTeM’s Tools and Techniques Both cycles contain soft tools. Cycle 1, has the traditional, but in this case, human/machine conceptual models derived from relevant systems and based on root definitions and CATWOE. In addition there are expressive models – stakeholders define models of existing or possible activities that they populate with information machine activities - and strategic matrix models. The latter consists of a multi-dimensional human/machine activity matrix covering all or part of an organisation or across organisations. On one axis are problematical and/or strategically important organisational competencies, in the form of, stakeholder identified, relevant systems and on the other, a series of stages of IS&IT development. Each cell formed by the intersection of two axes incorporates within it IS&IT functionality and output, business processes, OD

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with similar illness may follow certain patterns of care but it is usually the case that data is not available to clearly define these patterns and treatments. This means that decision-makers may not have enough understanding about the specific healthcare system to devise suitable policies. Another problem associated with healthcare systems is that usually there is more than one stakeholder involved in setting up policies and decision-making [20]. In such cases different stakeholders may have different views about the problem, expecting different outcomes. Sometimes the problem may arise as a result of lack of communication One way to assist in making effective decisions is the employment of modeling techniques. Modeling is needed to enable stakeholders understand the problem without the need to experiment with the real system itself as it costs money and lives in the case of healthcare system. One of the main limitations associated with the modeling techniques applied in healthcare systems is their static behaviors and a high level of data dependency [21]. Given the ever-changing nature of healthcare systems, having historical data may not always reflect the prospects of the current situation and the impacts any decisions might have on future situations. In this section we propose simulation as a modeling technique that has the ability to enable stakeholders to increase their understanding of their problem and enhance their intercommunication with less dependency on actual data collection.

conceptual modeling, IS&IT and process development, business cases and output based specifications in Cycle 2, interpretivism [15] in its rich picture building and its actor developed ‘expressive’ and matrix models and the social/political aspects of decision making and organisational transformation. Action learning is also itself a paradigm. SISTeM seeks to accommodate the incommensurablities and complementarities of these paradigms within the analytic domain, its real world practices and especially through the human/machine activity system of its underpinning framework. SISTeM, in its multiple philosophies, its stages, its modes, its incorporation of tools is it can be argued an example of a ‘contingency methodology’ [15].

3.3 Applications of SISTeM SISTeM, though until only recently published [10][11], has been used to support the development of information systems and business processes associated with clinical care in areas such as the surgical treatment of breast cancer, [18] radiotherapy and cystic fibrosis and care for stroke patients and children’s services [16]. It has also been used to design clinical audit and governance processes at the service level and hospital wide [18][19]. Within the managerial arena SISTeM has, in the past, been deployed to create development pathways for linking clinical activity monitoring, to contracting and resource management within a hospital. A further development area has been that of IS strategy at the regional [16] and organisational levels. Application selection and evaluation within procurement has also been a major area in which the approach has been seen to add value. Working with the NHS to develop the Electronic Patient Record [EPR] was an important area, not the least for the development of SISTeM itself [10][11], for it was from this that the concept of the human/machine activity system was derived. All the projects identified here have been participative and multiprofessional including IS&T professionals. Their disparate views and interests of these stakeholders are accommodated and addressed in many ways throughout SISTeM’s cycles, stages, deriving and incorporating all aspects of the various forms of modeling, agenda forming and decision making, whether strategic or operational. Last but not least, SISTeM facilitates the realization of the change itself often within multi-organisational and multi-stakeholder contexts.

4.1 Simulation in Healthcare: Background. It is worth noting that by Simulation here we mean Discrete Event Simulation [DES]. Simulation as a modeling technique has been widely used as an aid for decision-making in healthcare [23] [24] [25]. It has been used in diverse healthcare application areas, from predicting the increase or decrease of certain illnesses then making decisions about their corresponding treatments [25], through understanding the appointment systems in outpatients clinics in order to make decisions about scheduling strategies [26], to supporting strategic planning given the limited resources available. A growing use of simulation in healthcare is in supporting economic evaluation [27]. Where simulation is employed, a common objective is to use the models to provide some answers about the problem in hand. This reflects a tendency to see simulation as a way of deriving future outcomes and determining the effect of different model configurations on system behaviors, thus subsequently enabling decision makers to appraise the implications of their decisions. The main purpose of modeling is to present an abstract picture of the real system and examine the system’s responses to different levels of inputs without risking the real system including

4. Participative Simulation Modeling One of the main problems that face decision-makers in healthcare systems is the complexity and lack of a well-defined shape for their system [20]. Patterns of care for patients represent a good example for such complexity of healthcare systems. In general, patients

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people and resources [22]. One of the main reasons that simulation is becoming a popular technique in healthcare problem solving is because it is able to cope with some of the problems faced when using decision trees and Markov modeling techniques – representing traditional modeling techniques used in healthcare systems [27].

4.4 An Example of PSM in Healthcare We present a brief example of PSM. It portrays the use of simulation for enhancing stakeholders’ understanding and intercommunication. This case discusses the use of simulation in an evaluative study for the technology of liver transplantation from a cost-effectiveness point of view. This study is conducted where there are no set rules for the prioritization of patients waiting for transplantation. Another objective of the simulation model is to enable health economists to understand the technology of liver transplantation and evaluate alternative waiting list policies for prioritizing patients. The main objective here revolves around finding an optimum strategy for selecting patients on the waiting list for liver transplantation. Selection could be based on a number of criteria, such as age, waiting time, and level of sickness [30]. One of the main difficulties in problems like this is that there is no specific measurement. For example, health economists may look at the cost-effectiveness of the process regardless, while clinicians may consider provision of care to all patients is more important than anything else. This represents an example of how simulation may be used to enhance stakeholders’ intercommunication and convey their understanding to each other. The model [LiverSim] was developed with the participation of health economists and clinicians using a simulation package to build the structure and the interface for enabling the stakeholders to deal with the model in a way that is convenient to them. The interface consists of inputs facilities and output representations. The interface also includes different selection criteria to choose from for experimentation to examine which one is optimal. Given the fact that simulation is a dynamic process and presents individual and aggregate levels, all stakeholders involved could present their views about the system through the model in a more realistic setting. Simulation is a tool that enables the various stakeholders, clinicians and managers to argue their case through participation in the modeling process and subsequently to arrive at robust decisions, designs and development that will improve clinical care and process as well as organisational management

4.2 Simulation: How it may help? There are two main reasons for the use of simulation for supporting problem understanding [28] and communication. Firstly, simulation provides a systematic debating vehicle between the different stakeholders who will contribute to decision making in the healthcare system. Secondly, simulation offers the flexibility to accommodate as many changes as possible in the system model, either in aggregate or individually, to enhance the understanding of the system. For example, a simulation model allows entities to experience events at any point of time after the previous event without being restricted to fixed time intervals. In addition, the model has the ability to record and retain the entity’s history throughout the course of the model, and then this history can be used to influence the entity’s future levels and pathways throughout the model. Other information about entities may be needed individually, such as, costs and quality of life effects associated with the events undergone. In general, simulation could be used to improve the understanding about the system and capture the relevant elements to the problem, without going into unnecessary details. Also it could be used to enable stakeholders to understand the system under study and reconsider this understanding while communicating with each other by using the model. That is, the model may be considered as a systematic debating vehicle rather than as a calculator.

4.3 Participative Simulation Modeling Process For the purpose of achieving a high level of understanding and intercommunication the participative simulation modeling [PSM] process should provide some facilities. One important factor is to involve the stakeholders in the modeling process from the early stages. The traditional modeling approaches are based on sequential or logical steps for building and using the model. The main problem faced here is that stakeholders have to wait for the model’s output to gain an understanding. We believe that understanding should not be restricted to the model’s results rather it should be generated alongside the process. This can be done through an iterative process. It is possible that an acceptable level of understanding amongst the stakeholders could be reached without necessarily the need to go for data collection.

5. Stakeholder Representation in Healthcare Problem Solving The presentation of both SISTeM and participative simulation modeling in the previous paragraphs indicated the importance of recognising the role of multiple stakeholders. It follows that in health informatics the inclusion of these stakeholders, of multiprofessional working practices, multiple political

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information systems research where there is often the assumption that a discussion on users, developers and managers can provide a comprehensive discussion of stakeholder issues [34]. However, the increasing complexity of the information systems context points to different conclusions [37]. In order to provide a systematic tool for the identification of stakeholders in this complex context Pouloudi [35][36] has suggested a set of principles of stakeholder behavior that guide stakeholder identification and analysis (See Table 1) This work has provided a rich insight in the study of interorganisational systems and new organisational forms [37] as it lead to the identification of non-obvious interested parties.

interests and agendas and a multiplicity of information systems and technologies are not only important but also necessary features of effective interventions and research. In health informatics, stakeholders are present in many forms: as active participants in the problem solving process itself, as components within the models, tools and techniques, as decision-makers and as a necessary constituent of any resulting interventions. A third research direction within CHIC complements the previous two as it aims to systematically identify and record the perceptions of relevant stakeholders. Relevant work in strategic management [31] [32] has failed for the most part to provide a systematic method for the identification of stakeholders. This is also the case in

Table 1- Propositions for stakeholder identification and analysis [Source: Pouloudi, [36] ] Principles of stakeholder behavior 1. The set and number of stakeholders are context and time dependent 2. Stakeholders cannot be viewed in isolation 3. A stakeholder’s role may change over time 4. Stakeholders may have multiple roles 5. Different stakeholders may have different perspectives and wishes 6. The viewpoints and wishes of stakeholders may change over time 7. Stakeholders may be unable to serve their interests or realize their wishes

• • • • • • •

Implications for stakeholder identification and analysis Stakeholder map should reflect the context stakeholder map should be reviewed over time Consider how stakeholders are ‘linked’ Adopt a long-term perspective: study how perceptions change There are different versions of the stakeholder map to be drawn for different perspectives These different versions of the stakeholder map should be reviewed over time Need to consider political issues (as well as technical, economic or other)

been used by different stakeholders as an opportunity to present and support diverse, even conflicting interests [35]. In Donaldson and Preston’s [32] terms, this means that stakeholder analysis can be descriptive, i.e., facilitating the description of the various, often conflicting interests and providing a richer understanding of who the relevant stakeholders are. Also, stakeholder analysis is instrumental, in that it can be used by the stakeholders to achieve a particular goal. In information systems research this usually accounts to either assisting in planning and strategy formulation or assisting with information systems development and implementation [36]. Donaldson and Preston [33] argue, however, that the core of stakeholder theory is normative. This implies that stakeholder analysis should be driven by the understanding that “the interests of all stakeholders are of intrinsic value”. In the context of healthcare, this calls for a stakeholder analysis approach that is not prejudiced and strives to ‘give voice’ to all relevant stakeholders. Indeed, the use of the principles presented above aims to facilitate this process. Furthermore, the normative aspect points out the importance of ethical issues. In the case of the NHSnet such issues stem from a discussion on confidentiality [35]. More generally, the use of information systems can create several dilemmas

5.1 Using stakeholder analysis in healthcare research In healthcare, the identification of stakeholders has been particularly interesting in the case of the NHSnet [35][38]. This is a nation-wide network that has been recently introduced in the UK to enhance communication and information exchange between various health care providers and administrators. Despite its technological success, the network’s adoption has been problematic because key stakeholders, namely the medical profession, ‘have not been convinced’ that it meets (or that it will ever meet) the necessary guidelines for safeguarding the confidentiality of patient data. Using a stakeholder analysis perspective, however, we have been able to study the various interests, power and access [34] of the stakeholders to this information system or the information that it carries. The result has been to unveil a much broader and complex picture that can be used by the stakeholders who wish to understand or improve their position as well as by decision makers who can learn from this implementation experience for future action. Furthermore, through the interactions of the human stakeholders, the network, a non-human stakeholder – in the sense that it inscribes human interests and values [12] – has changed shape and direction and has

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and ethical challenges that need to be investigated. Often, these concern the use of advanced, intelligent technology where the synergy between the technical expert and the medical expert is crucial for identifying ethical concerns and can be facilitated with the use of a stakeholder analysis approach that can be used systematically to this end [38]. Such normative debates are fundamental for stakeholder analysis. In healthcare particularly, the insights of this debate can be used to strengthen the understanding of the complexities and ethical dilemmas that may arise in the use of SISTeM and simulation modeling. SISTeM considers the ethical defensibility of the socio-technical solutions as critical. However, the experience of using stakeholder analysis in the NHSnet context suggests that what constitutes an ethical choice may not always be agreed amongst all stakeholders. This signifies that the normative aspect of stakeholder analysis can provide useful insights to SISTeM. At the same time both the descriptive and instrumental aspects indicate that despite the differences, stakeholder analysis can be integrated with SISTeM and participative simulation modeling. On the one hand the previous sections of the paper recognized the relevance of stakeholder debates for both approaches. This suggests that the synergy between the three approaches would be useful. On the other hand stakeholder analysis, unlike SISTeM and simulation modeling, does not guide the analyst or the decision maker towards a model that can then be implemented. This implies that stakeholder analysis can also benefit from integration with SISTeM and simulation modeling. The next section explores the importance of such integration and explores how it can be realized within the research agenda of CHIC and the British Healthcare Context

Methodology

Modeling Tools

Simulation Modeling

Stochastic Modeling Discrete Event Modeling Dynamic Modeling

Soft Information Systems and Technologies Methodology (SISTeM)

Stakeholder Analysis

Rich Pictures Root definitions and CATWOE Analysis Relevant systems and Schematics Modeling Conceptual Expressive Matrix Hybrids Organisational/ IS schematics IT architectures Developmental Models Project Planning Models Stakeholder Modeling and Analysis of interests, powers and impact

Healthcare Focus & Use Problem situation description Problem analysis IS&T Clinical/Managerial Future options appraisal of clinical/managerial process reconfiguration Organisational Understanding of decision options Stakeholder Decision Making - Process and IS improvement Problem situation expression and analysis Situation Relevant Systems Models Clinical/Managerial/IT processes development Strategic Organisational/IT maturation pathways Healthcare high level/strategic decisions Developmental models for operational decision making and change clinical, managerial, organisational IS&T Stakeholder Inclusion in the Normative Analysis of IS & organisational Development Instrumental stakeholder management

6. SISTeM, Simulation and Stakeholders

Table 2. Methodologies, Modeling and Health Focus

Currently research and development is being undertaken within CHIC in Health Informatics into how synergies may be created, tested and exploited from the complementarities in the approaches discussed above. To further support integrated ISD and organisational development within healthcare. For example simulation models, as has been demonstrated in elsewhere [40], may be derived directly from soft systems models. SISTeM’s conceptual and expressive models assist in identifying not only human processes but also machine enabled data requirements and flows. The inadequacies, or for that matter effective provision of which in may turn inhibit or enhance what results from the participate simulation modeling process. SISTeM has the capacity to capture stakeholder multiple world-views that could be represented within one or a series of simulations to aid stakeholder decision-making within Eldabi’s [21][28] and Paul’s [26] work.

Conversely simulation modeling is a powerful tool to aid decision-making within problem situations addressed using SISTeM. It could effectively be deployed in a number of ways within the approach’s Cycle’s 1and 2. For example it could be deployed as part of analyzing the problem situation and building up the relevant rich picture. Additionally a ‘conceptual or an expressive simulation model’ based upon a root definition and CATWOE could be built against a particular issue or failing process identified within SISTeM’s analysis stage. When compared with a problem situation an agenda for debate could be formed. As part of the debate stages – either strategic or operational – amongst stakeholders a simulation has the capacity to reveal the ramifications of ‘what if’ questions posed by stakeholders. This would powerfully inform any decision. Simulations also have the potential to facilitate process (re)design as part of realizing the

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problem solving and decision making within and between healthcare organisations in both the clinical and managerial arenas and IS&T. Out of CHIC’s work to date have arisen definitions of health informatics as both a practice and as a discipline. Their purpose has been to act as guides to its current and future socio-technical research and development: The Practice of Health Informatics

operational decision’s emanating from SISTeM’s Cycle2. Simulations, using spreadsheets have already been used in a recent project to explore cost, market and income projections. This was done as part of a business case and scoping study for a new tele-health informatics and medical education Internet start up in the Far East. This in turn was based on an organisational/IS expressive model and maturation pathway. These were built up from discussions and interviews with multiple stakeholders. Within CHIC, Pouloudi, in her co-operation with Whitley[37][38], draw on the Actor Network Theory [ANT] [14] of Latour [13] and Callon [12] for their own conceptual and analytic work on human and none-human stakeholder networks. Their work focuses on actor involvement in and political impact upon health informatics projects and problem solving action research. They emphasize the ubiquitous presence of multiple stakeholders within all health informatics problem situations and projects. Describing how they both impact upon the problem solving process and the necessity for them to be incorporated within it and any resulting interventions. They also argue for them to be involved in the problem solving process not just as ‘users’, sources of data, nor simply instrumentally as a means of realizing a decision, but ‘normatively’ in the forming and shaping of the decision and the way forward. Their work on stakeholders and ANT has been incorporated throughout SISTeM and PSM and their application. In SISTeM multiple-stakeholders are captured within the problem situation analysis, rich pictures and especially in matrix modeling. They also make the decisions and realize change. ANT has also been used to analyze methodologies [11] such as SISTeM and their use as none-human actors capable of being enrolled with problem solving actor networks. The three approaches SISTeM, Participative Simulation Modeling and Stakeholder Analysis form a complementary triumvirate. One capable of analyzing and addressing the need for integrated ISD and organisational solutions within the complex multi-organisational situations that constitutes healthcare in the UK. This is the focus for the discipline of health informatics practiced by CHIC. Table 2 above summaries these approaches, their tools, techniques and use. The next section explores CHIC’s current and future research agendas.

h The cost effective integration of information systems and technologies with organisational development to enhance health policy making, research, commissioning, management and the delivery of care to the individual, their families and populations.

The Discipline of Health Informatics The creation, dissemination and application of theoretical and pragmatic knowledge, through the undertaking of multidisciplinary research and engagement in the practice of Health Informatics

From these definitions it can be seen that Health Informatics demarcates itself as a pluralistic discipline. One that of necessity integrates both ‘Social\Human’ and ‘Scientific/Technical’ disciplines, as shown below: Human \ Social Health and clinical care SISTeM/PSM/Stakeholders Management science IS design, HCI Organisational theory, change and transformation Politics & economics Participative practices Policy impact analysis Psychology, sociology Socio-tech benefits analysis Qualitative methods

Scientific\Technical Medicine and bio sciences Computer sciences Communications and Information technology Data base design Ergonomics Systems engineering Engineering sciences Process Simulations Mathematics and physics Biology/clinical chemistry Scientific/Statistical methods

As to the future agenda for CHIC, building on the above descriptions of health informatics as well as current research and development to date a number of areas arise: (i) The continued practice based evolution of problem solving methodology, tools and techniques, in health informatics development within and across healthcare organisations. Exploiting the synergies between SISTeM, PSM and Stakeholder studies and other disciplines to support integrated information systems development and organisational transformation. (ii) Researches into clinical decision-making and patient care, by improving information, Artificial Intelligence and care management systems. (iii) The development of IS&T, HCI, databases and mining tools, to support clinical practice, audit, governance, and the electronic patient and health records. (iv) Research and development into distributed IT interorganisational architectures, the Internet and Intranets, as part of Health Informatics solutions.

7. Current and Future Research Agendas The current research agenda within CHIC has centered on the evolution of methodologies, tools and techniques for integrating information systems and organisational development. Addressing both clinical and managerial issues in supporting clinical and managerial practitioners carrying out their work has been its focus underpinned by an emergent socio-technical framework. This framework centers on a pluralistic, multi-stakeholder approach to

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Senior clinicians (consultants) are more powerful than managers in clinical matters, as well as in their capacity to influence the success or failure any IS development. These conditions make the allocation of resources, specifying, designing/procuring and the implementation of information systems and any subsequent accrual of organisational or patient care benefits not impossible but fraught with difficulties. Fourthly, whilst a process of patient care may well traverse several organisational boundaries, departments, and be provided by multiple professionals, with distinctly differing world-views, information systems (including clinical paper records and notes) and technologies finish at organisational, departmental and professional boundaries. Fifthly the complexity of healthcare makes demands of IS&T development in excess of those found within most businesses. These include supporting the complex, rapidly changing, potentially life-dependant clinical practices and processes that form the contingent nature of each episode of patient care. It also encompasses arcane ever-changing clinical terminology, standards, and protocols, professional accountability, litigation, ethico/legal requirements, confidentiality and security, and a multi-professional, multi-organisational delivery system. Finally, health informatics has to support management and administrative functions typical of businesses, driven however not by the market but by ever-changing government edict and clinical demands. The structured data-driven approaches [15] that currently dominate IS development have little in the way of processes, tools or techniques capable of accommodating the socio-technical complexities of healthcare. A managerial business model underpins those that do, such as RAD or Information Engineering. The three approaches explored in this paper, SISTeM, PSM and Stakeholder analysis, their potential synergies, have emerged from research and interventions tested within the rigorous of this context. As has those who have developed them and CHIC’s present and continuing agenda. In doing so they have come about to address the complexities of that arena through, what of necessity are integrated socio-technical approaches to health informatics. In this they exemplify Health Informatics as a discipline in its own right.

(v)

The development and application of evaluatory frameworks and tools, to study the impact of health informatics decision making and interventions, encompassing patient care outcomes, clinical and managerial practices, technical functionality and cost effectiveness and security and confidentiality. (vi) Include multiple stakeholders throughout the agenda; ethically, normatively and instrumentally and the creation of stakeholder management tools. (vii) Exploring the further potential of Actor Network Theory, within the above and in turn contributing to ANT’s further development. (viii) Continued work on health informatics education and health policy making in telehealth. The concluding discussion, that follows, explores the question ‘Is Health Informatics a special case?’

8. Concluding Discussion: ‘Is Health Informatics a Special Case?’ In the concluding discussion we wish to argue that Health Informatics (HI) is a special case1, for the following reasons. Firstly the wider context of healthcare in which HI takes place has features that make unique demands upon IS practitioners and researchers. In particular the fact that the government both provides the legislative and regulatory frameworks as well as the delivery of care. The latter includes the constant restructuring of the NHS that in turn has driven the shape of IS applications development by suppliers and the information required to be captured by clinical professionals. This, until recently has been dominated by administration and central returns, rather than clinical practice – this is changing [7][8]. Leading on from this, secondly, there is no market or business drivers to shape IS development within healthcare organisations or by the suppliers. Strategically IS&T in health is not driven by the need to enhance profit or market share. Rather there is a prerogative for strategic health IS to be ‘politically aligned’, with the priorities and financing set by the government of the day. Thirdly, the particular social, professional and cultural context in healthcare is a major factor that dominates health informatics. Within and between health organisations, and within and between the clinical professions and managers are fracture lines, demarcations of power, interests and agendas. The ‘patient’ is an icon that not only underpins healthcare, but one that all appeal to justify their own position in any argument. There are no hierarchical managerial lines of accountability running right through the organisation.

We wish to acknowledge the work of all the members of CHIC and of Prof. Denise Protii in defining Health Informatics.

REFERENCES [1] K. Lyttinen and R. Hirscheim, "Information systems failures - a survey and classification of the empirical literature," in Oxford Surveys in Information Technology, Vol.4, 1987, pp. 257-309. [2] L. Willcocks and S. Lester, Evaluating the feasibility of Information Technology Investments, Oxford Institute of Information Management, Research and Discussion Papers, RDP93/1, 1993.

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A comparison of the integrated socio-technical approaches in Health Infromatics with standard ISD approaches exploring how they might be used to address more effectively problems in business and other public sector organisations will be the subject of another paper. However we do believe these approaches have a capacity for adding value in other sectors, but further research and development is needed to validate this.

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[3] B. Hochstrasser and C. Griffiths, Controlling IT Investments. Strategy and Management, Chapman & Hall, 1991. [4] Beynon-Davies, P. Information systems ‘failure’: the case of the London Ambulance Service’s Computer Aided Dispatch Project. EJIS, 4, 171-184. 1995. [5] Introna L.D. ‘Management, Information and Power’ Macmillan, London 1997 [6] Anderson, R. NHS-wide networking and patient confidentiality: Britain seems headed for a poor solution. British Medical Journal, 311 (1 July), 1995 pp.5-6. [7] NHS Executive. ‘Information for Health - An Information Strategy for the Modern NHS 1998-2005:A national strategy for local implementation,’ HMSO London 1998. [8] Department of Health White Paper The New NHS Modern Dependable HMSO, London 1997 [9] NHS Handbook 1999/2000 Birmingham NAHAT1999. [10] Atkinson CJ Soft Information Systems and Technologies Methodology, SISTeM: A Case Study of the Electronic Patient Record, Requirements Eng. 1997 2: 1997, pp1-22 [11] Atkinson C. J. The ‘Soft Information Systems and Technologies Methodology: an Actor Network Contingency Approach to Integrated Development’ EJIS 9, 2000 pp. 104-123 [12] Callon, M., Techno-Economic Networks and Irreversibility in Law J (ed.) A Sociology of Monsters: Essays on Power, Technology and Domination, Routledge London, 1991 [13] Latour, B. Science in Action, Harvard, 1987. [14] Walsham G. Actor-Network theory and IS Research: Current Status and Future Prospects. Information Systems and Quality Research Proceedings of the IFIP TC WG 8.2 International Conference on Information Systems and Quality Research, Philadelphia PA. USA, 1997 [15] Avison D. E. and Fitzgerald ‘Information Systems Development: Methodologies, Tools and Techniques’ McGrawHill London 1995 [16] N Ireland HPSS ‘Scenarios for growing not building the Systems of the future: Strategic Framework for information Services in the HPSS Acute Sector 1997-2002’ HPSS, 1999 [17] Atkinson C J & Dunlop E, 'A Scoping Study of the Maturation Pathway for the CCSIS Information System' West Berkshire Priority Care Services, Internal Document, 1998 [18] Warrington NHS Trust 'A Project to Support the Combined Development of The Integrated Patient Management System (IPMS) and Clinical Practice in Warrington NHS Trust.' Report to the NHS Executive Information Management Group of the NHS and Hospital Chief Executive, 1997. [19] Atkinson C J & Peel 'Transforming a Hospital by Growing not Building an Electronic Patient Record' in Methods of Information in Medicine; 37: 1998, pp. 285-93 [20] Delesie, L. Bridging the Gap between Clinicians and Health Managers, European Journal of Operational Research, vol. 105(2) 1998 pp. 248 – 256. [21] Eldabi, T., Paul, R. J., and Taylor, S. J., Simulating Economic Factors in Adjuvant Breast Cancer Treatment, Journal of the Operational Research Society, vol. 51 (4) 2000 pp. 465 – 475. [22] Pidd, M. Tools for Thinking: Modeling in Management Science, John Wiley & Sons Chichester, 1996. [23] Roberts, M. S. Markov Process-Based Monte Carlo simulation: A Tool for Modeling Complex Disease and its Application to the Timing of Liver Transplantation, In Proceedings of the Winter Simulation Conference, Virginia, Eds: Swain, J., Goldsman, D., Crain, R. C., and Wilson, J. R.,

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