Working papers in
Information Systems
HOW TECHNOLOGY ORGANIZES LEARNING
Margunn Aanestad
WP 7/2006
Copyright © with the author(s). The content of this material is to be considered preliminary and are not to
be quoted without the author(s)'s permission.
Globally Scalable Information Infrastructures Group
Department of Informatics
University of Oslo
Gaustadalléen 23
P.O.Box 1080 Blindern
N-0316 Oslo
Norway
http://www.ifi.uio.no/forskning/grupper/is/GI
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Copyright © with the author(s). The content of this material is to be considered
preliminary and are not to be quoted without the author(s)'s permission.
How technology organizes learning
Margunn Aanestad
Dept. of informatics
University of Oslo
P.O. Box 1080 Blindern
0316 Oslo
Norway
<margunn@ifi.uio.no>
+47 2285 2410 (phone)
+47 2285 2401 (fax)
Abstract:
This paper offers an empirical study of the role of technology in an organisational change and
learning process. My focus is on the learning that occurred as the workers decided how to
integrate the technology in question (a digital patient record system) into a department’s work
practices. In particular I examine how the characteristics of the technology contributed to shaping
and organising the process of inquiry, and consequently the change process. I draw upon insights
from information infrastructure theory that conceptualise of ICTs as interconnected, layered and
extended webs of computerised systems, work practices and regulatory measures. Such
information infrastructures are complex assemblages beyond the control of a single actor, and
they gradually evolve and extend through time (see e.g. Ciborra et al., 2000; Hanseth and
Monteiro, 1997). I combine this theoretical perspective with Karin Knorr Cetina’s concept of
“epistemic objects” in knowledge practices (Knorr Cetina, 2001). She describes the objects’ “lack
in completeness of being” (ibid., p. 181), their capacity to continuously unfold and point towards
further explorations. This perspective allows an emphasis on the evolving and emergent nature of
technology-in-context and how it impacts learning. Information infrastructures are gradually and
slowly realised, and they are implemented and linked up with existing work practices and with
other computer systems through long and cumbersome processes. In settings where infrastructural
information technologies are our “epistemic objects” we will see that change and learning are
shaped by these two characteristics, first, the unfinished and evolving nature of the technology,
and second, the degree to which it is part of an interlinked assemblage and not solitary systems.
A better understanding of the character of information and communication technologies is crucial
for understanding their role in organisational change.
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1.
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Introduction
Within the Information Systems research field information and communication technologies are
recognized as important components of organisational change (Zuboff, 1988, Barley 1986,
Walsham, 1993). In organisational theory technology has not been given an equally prominent
position, however, there are some attempts at theorizing its role, perhaps the first one being
contingency theory (Woordward, 1958), which sought to determine causal relations between type
of technology and organisational structure. Following Orlikowski and Barley’s (2001) account,
subsequent conceptualisations would draw more on strategic choice theory and emphasise the
possibility for human decision and intervention, although confined to the decision to adopt or not
adopt the technology. The assumptions of technology as a given entity with definite impacts or
effects were still prevalent, and technology was seen as an outer force that determines or strongly
constrains the behaviour of individuals and organisations (Markus and Robey, 1988. p.585).
Despite this prevalent view, empirical studies presented findings that the effects of implementing
information technologies in organisations were widely divergent (Orlikowski, 1991; Robey and
Boudreau, 1999); even the effects of identical technologies in similar settings could be different
(Barley, 1986).
Later, socio-technical systems theory argued that social and technical systems reciprocally
constitute each other, and hence that their match should be optimised (Trist and Bamforth, 1951).
However, Orlikowski and Barley (2001) claim that socio-technical systems theory shares with the
other perspectives a tendency to reduce technology to an abstract, material cause, where the
specifics of technology is deleted, and where the role of human agency is limited. Markus and
Robey (1988) terms this the “technological imperative” perspective, and also identifies an
“organisational imperative” line of thought, where for example studies within the social
constructionist tradition will emphasise human agency. Usually, however, these studies are
limited to describing the processes through which technologies are designed, rather than the
stages of deployment and use of technology, which is what we are interested in here. Empirical
studies of implementation and use of information systems in organisations often describe them as
“complex and messy” (Walsham, 1993: p. 53). Rather than witnessing a straightforward
execution of implementation plans we see that ”plans keep being diverted, surprises arise
constantly, opportunistic adjustments must be carried out on the spur of the moment” (Ciborra,
1997: p. 72).
Orlikowski and Barley (2001) hold that technologies are simultaneously social and physical
artefacts. Consequently, “neither a strictly constructionist nor a strictly materialist stance are
adequate for studying technologies in the workplace” (ibid, p.149) and “adequate accounts of
technological change require hybrid explanations that weave together human action and choice,
the functions and features of specific technologies, and the context of a technology’s use” (ibid,
p.150-151). Within Information Systems research what Markus and Robey (1988) term the
emergent perspective has gained ground. This perspective holds that uses and consequences of
information technologies emerge unpredictably from complex social interactions (ibid p.588), and
thus this perspective is less normative and predictive than the other two. Organisational and
technological change and development is depicted as open-ended socio-technical negotiation
processes (Monteiro, 2000), and adaptations and re-adaptations occur in relation to people’s
ongoing sensemaking activities (Henfridsson, 1999). Well-known IS studies that may be grouped
within this perspective are e.g. (Kling, 1987; Kling and Scacchi, 1982; Gasser, 1986; Barley,
1986).
Recognising the “recursive” role of information and communication technologies in processes of
organisational change does not imply that we know enough of how this interplay actually
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happens. There is still work to do in applying this insight to studies of learning and change around
ICT, and not the least in bridging empirical studies of “technologies in action” with more
mainstream Organization Science literature on learning, which has not paid special attention to
technology’s specificities. The effect of this neglect is that technology, rather than being
examined as such, is naively conceptualised as a tool, as a given, as available and ready to hand.
It would be foolhardy to pretend to be able to review the vast and diverse literature on
organisational learning; however, as a broad trend it seems that a cognitive perspective on
learning did long dominate the discourse. Several of its main assumptions have been challenged
(Lave 1988; Brown et. al. 1989), and a “situated” or “practice-based” approach has emerged as a
critique of this perspective, emphasizing the need to integrate also the historical, political and
social conditions of learning processes. In the communities of practice perspective (Lave and
Wenger, 1991; Brown and Duguid, 1991; 2001; Wenger, 1998; 2000) learning is conceived as
“an integral part of generative social practice in the lived world” (Lave and Wenger, 1991: p. 35).
Still, the specifics of the relevant technologies are not central topics in OS. Huysman (2000)
describes mainstream research literature on organisational learning as having a predominantly
managerial bias, and being more interested in how to improve and facilitate learning than in
outcome of accidental, unintended and problematic learning processes. The literature on
limitations to organisational learning, where we might expect some attention to the role of
technology, is rather concerned mainly with issues such as the adverse effect of organisational
politics, defensive routines and vicious circles (Argyris and Schön, 1996), cognitive limitations,
learning ‘myopia’ (Levinthal and March, 1993), or competence traps (Leavitt and March, 1988).
Empirical research from the Information Systems field has studied such actual learning processes
and has emphasised the unpredictability and non-controllability emerging from the complex
nature of the socio-technical assemblage. Different alternative metaphors have been suggested,
such as improvisation (Orlikowski, 1996; Orlikowski and Hofman, 1997), drift (Ciborra, 1996),
or cultivation (Dahlbom and Mathiassen, 1993). The conceptualisation of the change processes
have developed from Lewin’s unfreeze-change-refreeze model, for instance Orlikowski and
Hofman (1997) propose the improvisational model for change management: “an alternative
model of managing technological change, one that reflects the dynamic and variable nature of
contemporary organizations and technologies, and which accommodates iterative
experimentation, use, and learning over time”.
This stream of conceptualisations in the Information Systems research field takes as a given that
technological processes are turbulent, uncertain and flexibly handled. However, Orlikowski and
Iacono (2001) found that also within the IS field the core subject matter; the IT artefact was
under-theorized. In a review of 188 IS articles in one of the top IS journals, Information Systems
Research, they found that IS researchers tended to focus on the effects, the context or the
capabilities of the technologies, with the result being that IT artefacts were conceptualised in
commonplace ways, as stable, discrete, independent and fixed. They conclude that this lack of
theories is a key unresolved issue for the research field. This exhortation is also shared by other
IS researchers. As argued by Monteiro and Hanseth (1995): “As an information system (IS)
consists of a large number of modules and inter-connections, it may be approached with a varying
degree of granularity. We cannot indiscriminatingly refer to it as IS, IT or computer systems.
Monteiro and Hanseth also cite Rob Kling (1991, p. 356), who characterises this lack of precision
as a ‘convenient fiction’ which ‘deletes nuances of technical differences’.”
I attempt to address the call for theorising the IT artefact through examining an empirical study. I
will do so using the analytic lenses of information infrastructure theory, which is an attempt at
theorising one class of phenomena; large, interconnected ensembles of technological and
organisational systems, including practices, skills, regulations, etc. With this paper I intend to
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explore the impact on organisational learning processes of what I term “infrastructural
technologies”, although limited to a single organization (a corporate information infrastructure).
The literature often emphasise the size and complexity of Information Infrastructures, and show
how they are beyond a single actor’s control. However, I am also intrigued by the role of the
temporal aspects, on how the slowly emerging infrastructural technologies are partly historical
and current realities and partly future imageries. To discuss these aspects I also draw upon Karin
Knorr Cetina’s concept of “epistemic objects”.
The purpose of this paper is to address the conceptualisations about technology-related
organisational change, through offering an empirical study of the role of technology in an
organisational change and learning process. The empirical material is drawn from a project called
the” scanning project”. While initially perceived as a minor, problem-solving, and temporary
activity to last for about six months, the scanning project soon became an organisational
development project, which was not finished two years later. Digitising the paper documents
affected the work flows and the distribution of work tasks and responsibilities and features of the
technology directly impact the scope for and type of learning and change that happened. The
empirical account try to “weave together human action and choice, the functions and features of
specific technologies, and the context of a technology’s use in a way that attends to the microdynamics of situated practice” (Orlikowski and Barley, 2001). In line with Orlikowski and Barley
who claim that “Organisational change and learning occurs as an interaction between “human
agency, material constraints/affordances and institutional dynamics” (ibid. p. 159), I have
formulated my research question as follows: How do the characteristics of the technology in
question impact and shape the processes of inquiry (learning)?
2.
Theoretical Framework
2.1
Information Infrastructures
Network technologies have attributes that make them different from traditional, standalone IT
systems. They are connected into large and complex networks based on standardized
communication protocols and formats for information exchange. Drawing on the work of for
instance Star and Ruhleder (1996) and Hanseth and Monteiro (1997) we may characterise
information infrastructures as follows:
•
Information infrastructures are shared, common resources for the community. They
support and enable a wide variety of activities and are not especially tailored to just one
or a few. They reach beyond the individual user, single event, specific application or local
site. They are also not just a collection of bilateral links, but a network, and the essential
feature that allows this reach is standardised interfaces.
•
Information infrastructures are fundamentally (i.e. in principle) open with regard to the
number of potential users, use areas, nodes in the network, and the boundaries of the
infrastructure. The boundaries will be pragmatically and temporarily defined, not a priori.
There will always be nodes that have connections with other nodes from the “outside”
world, which someone might want to include in the infrastructure.
•
An information infrastructure is a heterogeneous socio-technical network, not just a
technical communication network. The physical connections and equipment, the technical
standards, the conventions of use, the technical and organisational support structures (e.g.
from local user support to the global standardisation bodies), the organisation of work
and cooperation and so on are parts of the infrastructure. Such complex networks emerge
only over time, not as the result of a decision or proclamation only.
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•
The role of the ‘installed base’, what already exists and is implemented, is crucial
(Hanseth, 1996). An II is never built from scratch; rather in a process of building upon
what already exists. As the installed base grows it becomes increasingly more difficult to
change it. Large networks extend far beyond what can be planned and consciously
designed; rather the network is designed through the activities of all its users.
The term “information infrastructure” has often been used in contrast to that of “information
system”, in order to emphasise the differences between these large-scale networks and ordinary
information systems. There is no hard-and-fast borderline between what is called an information
system and what is seen as an information infrastructure. Depending on the researcher’s
perspective a large corporate information system may exhibit strong infrastructural
characteristics. Choosing to analyse it as an information infrastructure would help emphasising
the challenges that arise when we cannot assume that the technology is just used within defined
and fixed boundaries for specific purposes.
Large and complex projects pose several challenges to information systems designers. However,
these challenges become more pronounced when it concerns information infrastructures, as the
fundamental openness of the information infrastructures makes them inherently uncontrollable.
Usually there is simply no actor with the mandate to instruct all the partners involved, like there
(at least in theory) may be within an organisation. The openness and integration with other
networks introduce dependencies and side effects, which make the effects of actions hard, if not
impossible, to predict. As the information infrastructure grows, it acquires momentum (Hughes,
1983) and may become increasingly entrenched and irreversible. Self-reinforcing effects, path
dependence and lock-ins are other terms from the field of network economy used to describe this
(Arthur, 1988; David, 1986). Therefore, when concerned with information infrastructures it seems
appropriate to talk about technology as an actor, because it may appear to be beyond human
control (Braa and Hanseth, 2000). Information infrastructures make up much of the current
organisational environment (see e.g. Ciborra et al., 2000; Hanseth and Monteiro, 1997). These
information infrastructures are complex assemblages that may be beyond the control of a single
actor, and they gradually evolve and extend through time.
The role of the installed base and the understanding of the limited scope for traditional controloriented strategies call for different approaches to design. Also, in their seminal article on
information infrastructures, Star and Ruhleder emphasises the relational nature of information
infrastructures, as they focus on the intimate bond between infrastructural technologies and work
practices: “Infrastructure is something that emerges for people in practice, connected to activities
and structures” (Star and Ruhleder, 1996, p. 112). This perspective emphasises that an
information infrastructure is not just a thing with pre-given attributes, but that “analytically,
infrastructures appear only as a relational property, not as a thing stripped of use”. Star and
Ruhleder’s conceptualisation of infrastructural technologies emphasises these aspects:
Embeddedness, transparency, reach or scope, learned as part of membership, links with
conventions of practice, embodiment of standards, built on an installed base, and becomes visible
upon breakdown.
2.2
Epistemic Objects and Object-centred knowledge production practices
While the practice concept has often been used to signify habitual and rule-governed activities,
Karin Knorr-Cetina has studied knowledge practices that are creative and constructive, such as
scientific inquiry (Knorr-Cetina, 2001). She has focused on the “epistemic cultures”, on the ways
of proceeding, the setup of the material environment, and the practical understanding that exist in
scientific activities (Knorr-Cetina, 1999). The notions of epistemic machineries and cultures bring
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our attention to the machineries which are involved in the production of knowledge within
various communities and the culture of the communities producing and sharing the knowledge.
Epistemic culture are defined as “those amalgams of arrangements and mechanisms – bonded
through affinity, necessity, and historical coincidence – which, in a given field, make up how we
know what we know” Knorr-Cetina, 1999, p.1). Epistemic machinery defines those more specific
methodologies, techniques, and tools and instruments we use in our knowledge production and
distribution. Culture, as she uses the term, refers to the aggregate patterns and dynamics that are
on display in expert practice and that vary in different settings of expertise. She complements the
“practice-centred” accounts with “object-centred” accounts, and shows how different the
epistemic cultures and machineries of these communities are and how these cultures and
machineries are results of the differences in the objects of study in these fields and the historical
evolution of the communities. These studies display different architectures of empirical
approaches, specific constructions of the referent, particular ontologies of instruments, and
different social machines. Of specific interest to us is the ontology of the objects. She uses the
concept of “epistemic objects” to denote how the objects of knowledge work, specifically of
scientific inquiry, are in a specific relation to the subject. A particular intriguing aspect of such
knowledge objects is their “lack in completeness of being” (Knorr-Cetina 2001, p. 181). The
elusive objects have a capacity to continuously unfold and point towards further explorations, as
they are not static, fixed, given, they can not be fully grasped. Through the work of knowing in
the process of inquiry, the objects are being defined, they are acquiring and changing their
properties. The objects do have some material instantiations, but are also defined by what they are
not, by their absences. Their ontology is unfolding. This perspective allows an emphasis on the
evolving and emergent nature of technology-in-context and how it impacted learning. In the
words of Adrian Mackenzie (2003) “both normative and generative capacities of technologies can
be understood as a process of individuation, as an ontogenetic process which results in
individuated things” (Mackenzie, 2003). I aim at exploring the process of learning through which
the infrastructural technologies are realised, their ontogenesis, their individuation. My empirical
material is not from scientific practices specifically aimed at exploring objects, as Knorr-Cetina
has studied, but from everyday work where this inquiry is just about coping, solving the
immediate and non-routine problems in order to make work life go on.
3.
Method
The empirical material comes from a longitudinal study of the introduction of an electronic
patient record (EPR) system in a major Norwegian hospital. Collaboration between the research
group at the university and the IT department was initiated in 1996, when the transition to the
Electronic Patient Record system started. Initially, a few pilot departments used the system, but in
2001 the EPR system was introduced to all relevant departments, albeit with limited functionality.
Later additional functionality has been continuously developed and new versions of the software
have been installed. The author started to collect empirical material from this project in 2002 with
the intention of analysing the transition process in general (see e.g. Aanestad et al., 2002; Hanseth
et al. 2006). However, the main body of empirical material reported in this paper is drawn from a
particular sub-project; namely the so-called “scanning project”. Since computerisation was only
partial, the scanning project was initiated to scan the remaining paper documents. When initiated
by the IT department and the paper record archive department in the spring of 2003 it was
perceived as a minor project, mainly aimed at solving the problem of too much paper that were
still used and archived. The scanning project was selected for in-depth study because I expected it
to generate several significant changes in work routines that would be interesting to study. The
implementation of this project in one of the largest departments at the hospital has been studied,
because it was one of four pilot departments and the largest user of the archive services in the
hospital.
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This focused study entailed 7 formal semi-structured interviews with project management staff
from the IT and the archive department, conducted at various points in time since autumn 2003.
These interviews lasted for about one hour in average, and concerned the current status and
progress of the project. A major source of information has been participation in 6 meetings at the
pilot department; some of them were project meetings where IT staff was present, some were
internal meetings with only staff from the department. The author has also worked together with
the secretarial staff in this department, e.g. to compile detailed information about document flows
in the department, and document the actual scanning work (through time studies, documentation
of errors and problems). In total 17 hours of participant observation were conducted, and during
this work a number of informal conversations were carried out; these added to the background
perception of the process.
During the process of interpretation and analysis of this material I have come to focus on the role
of the technology itself in this learning and reorganisation process. Consequently, my interest is
not so much in describing how this process was initiated (by management decree), where it was
anchored (in the IT department and the archive department), or in how it was managed (as a
loosely coordinated, distributed project). My focus is rather on an empirical examination of the
socio-material realities that were involved in this change process in this single pilot department.
The process in this department was not very efficient, well managed or quick. On the contrary,
the department was seen as lagging somewhat behind the other pilot departments. My fieldwork,
which was intercepted by teaching duties and a maternity leave, has resulted in empirical material
that represents snapshots from different stages in the process rather than a continuous and
“complete” account. Initially, this was a source of frustrations for me, but I believe the slow
process also offers a particular opportunity to look in detail into the struggles that people had in
relating to this partly real, partly future changes. The frustrated and problematic learning process
also offer hints at what I focus on, i.e. how technological characteristics impact or shapes
learning, which would not be visible in the same way if the process was smooth and swift.
4.
Case Description
4.1
Project Overview
An Electronic Patient Record (EPR) system was introduced across the whole hospital in 2001,
and all users were expected to use the system for specified tasks. The Electronic Patient Record
system was not yet a complete record; for instance it did not include all the relevant documents
that were in use, and in addition several other information systems would contain other relevant
information. Consequently, only the paper record had the possibility to be complete, and it served
as the legally valid record. Thus all notes, discharge letters and reports that were entered in the
electronic patient record system would subsequently be printed and put in the paper patient
record. Hence, the resulting changes of work practices were not radical. For instance, the doctors
would continue to dictate their notes, reports and letters, and the secretaries would type them,
only that the document would no longer be saved as a Word document in an ad hoc file structure
before it was printed and stored. Now it was archived in the EPR system, and then printed and
stored in the paper-based record.
In the Archive Department the ever-increasing amount of paper-based patient records soon started
to pose a problem. In 2000 the hospital had moved into new facilities that were designed based on
the expectation that the hospital would have an electronic patient record and would not need
much storage space for paper records. However, the volume of paper for archiving actually
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increased after the introduction of the EPR system, and soon the crisis was impending. An
obvious solution was to abolish the printing and storing of digital documents, and a recent change
of the law allowed the record to be in digital format. But before the double record keeping could
be implemented, the Director General of the National Archival Services had to accredit the EPR
system. This accreditation concerned the technical solutions for long term storage of digital data,
and it was dependent on the software vendor implementing specific measures and releasing a new
version of the system. While the hospital awaited this, the scanning project was initiated to reduce
the paper flow to the archive.
Thus the scanning project was initially perceived as a problem solving project aimed at improving
the immediate archive crisis. Simultaneously it would address the situation where communication
within the health sector was predominantly paper-based, a situation that was expected to last for
the foreseeable future. The scanning project was initially expected to be a minor and
straightforward project of technology implementation. In an interview with the project leader she
tells that:
“The order I had when I was asked to take on this project was that this was a 50 % position that
was going to start in the middle of March. They had probably planned to start even earlier, but
hadn’t managed to find a project leader, so when I started it was already March/April. The
project should be finished by Christmas in 2003; at that point there should be full scanning in the
whole hospital. Everything should be scanned on active patients. Much was decided, what should
be scanned. We should develop a strategy, because that hadn’t been done. Due to the time
pressure, the money had been allocated for 2003, so we had to do many things in parallel. We
focused on writing a strategy for scanning and on acquiring technology in parallel. […] Many of
those in the pilot study are people that I trust and regard, so I was in good faith, I guess, and I
thought that this is probably going all right. But we’ve had some discussions later on ‘How could
you estimate 50 % over just above half a year?’ and they were just smiling, because I think it also
has to do with getting things going. If you in advance realises the whole concept and sees how
intricate it is, it is maybe more difficult to get started also.”(Project leader for the scanning
project interviewed in March 2004)
Thus, the scanning project started in the spring of 2003 with a bid for tender on scanners and
software that would import the scanned documents into the EPR system. During the summer the
chosen solution was to be tested and finalised, and actual scanning was planned to start in the
early autumn. The strategy that was developed concerned issues like division of work between a
central scanning unit located in the archive department and decentralised scanning that was to be
done in each of the clinical departments. There a number of small scanners would be installed and
used to scan documents that arrived in the ordinary mail and documents that were produced
locally at the department during the patient’s stay. The central scanning unit would be equipped
with large scanners and would then scan documents that were not A4, as well as complete paper
record files. Usually, archived documents would not be scanned, but for some patient groups with
a long-term and continued relationship, such as patients with chronic diseases or e.g. posttransplantation follow-ups, the old paper records was planned to be scanned. An alternative that
was considered was to scan the record for patients that were going to come in the next days, since
the hospital mainly offers elective as opposed to emergency treatment. In addition the strategy
should lay down hospital-wide instructions on which documents should be scanned and which
not. In particular the borderline was to be drawn between the documents that had clinical
relevance and those which was just “work process support” type of documents, where the latter
should not be archived or scanned. Also policies on temporary storage of scanned documents and
eventual maculation of the scanned documents had to be planned, in light of the not-yetaccredited EPR system and the need of still maintaining a paper record.
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Problems with the delivery of scanner technology led to some delays in this process. In particular
the central scanning unit were delayed, since the software had not previously been customised to
run on an NT local area network and it didn’t work well. Contrary to the initial strategy, the
decentralised scanning work started before the central scanning. In December 2004, the scanners
were installed in four pilot departments, where the secretaries started testing of the scanners and
software. Throughout the next weeks bugs were identified and fixed and the departments were
developing routines for the scanning. After the pilot implementation the involved parties started
to see the magnitude of organisational change that was required. The project was split up and
sequenced into phases. In the first phase of the scanning only the incoming ‘referral letters’ were
targeted. A referral letter arrives with the ordinary mail from general practitioners, specialists or
other hospitals, requesting the transfer of one of their patients to the hospital. After evaluation and
decision on admittance at the clinical departments, the referral letters would be sent to the archive
until the patient arrived. Due to substantial backlog of archiving the letters very often were not yet
archived when the patient arrived, and consequently they were not found. Digitising these letters
would thus eliminate a large work burden for the archive (archiving and retrieving the letters
within a short time period) and a problem for the user departments (missing letters).
The actual decisions concerning for instance when and by whom the referral letters would be
scanned and the design of these new local work procedures were left to the individual
departments. The hospital is a professional bureaucracy where the individual departments and
employees have traditionally enjoyed a high degree of autonomy. This necessitated a
decentralised approach to redesign; as no-one in the administration had detailed and extensive
knowledge about the idiosyncrasies of documentation practices and work patterns. However,
during the first period of pilot site usage (spring 2004), the project management realised the need
for assisting the departments with organisational development, a task they were not initially
prepared for. Several workshops were conducted by the project management staff, in which the
practices around handling incoming mail, distributing it, registration, and evaluation of referrals
were collectively charted. The aim was explicitly to detect overlaps, gaps and potentials for
simplification and in this way to stimulate the clinical departments to take on the required change
work.
Another related mechanism to concretise these learning needs was through requesting the
departments to develop procedures within given time frames. The project management asked each
department to draft procedures, e.g. for incoming mail handling, for evaluation of referral letters,
or for detailed instructions as to which documents should be scanned and which not. These
procedures were formally part of the organisations’ quality assurance system, and thus this
request had some legitimacy and became a rather well-working way to get the departments to
actually design and implement changes. These procedures also served the need to standardise
learning. The new routines in individual departments had to be coordinated with what other
departments chose to do. The work routines in a hospital make up a complex mesh or grid of
routines, where several personnel groups and departments are linked in multiple and complex
ways. Any local changes in work practices thus need to be negotiated and coordinated with other
actors. The organisation had shared representations only to a limited degree, as ad hoc and
idiosyncratic procedures had emerged through the past years. Various paper forms existed,
handling practices varied, and while the term ‘referral letter’ was commonly used, you might also
find departments which classified these letters as ‘applications’.
The work of redesigning work routines continued as the pilot departments gradually expanded
their scanning activities to also encompass other incoming (external) documents as well as
internal documents. Hospital-level general procedures were drafted, based on these experiences,
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and each department was required to adapt these procedures to their own needs. Gradually, the
scanning took off, but the paper documents were still used for a long time. A year beyond the
intended deadline, the amount of paper sent to the archive was finally starting to decrease.
5.
Learning and Infrastructure Technologies
In this section I present some material from my field work that illustrates what the involved
persons (including myself) in the pilot department perceived the learning needs to be as the
project progressed. Initially, our focus was on the practicalities of scanning itself, such as: What
are the appropriate scanner settings? Which documents should be scanned, and which not? In
which location in the EPR system should the documents be stored? Below is an excerpt from my
notes during the first day of observations of test scanning, where I sat with one of the secretaries
and we scanned 17 different documents:
•
•
•
•
•
•
•
[…]
An internal referral letter (form B2.0), a white sheet with a red logo. We try both
black/white, greyscale and colour. Black/white is best, except one detail: the referring
department’s telephone number is written with pencil, it doesn’t show on black/white,
only on the other two. A date is also written with pencil, harder, it shows on all of them
An official referral form, the old type from 1995: we try black/white, but it isn’t very
good, the folds in the paper results in thick black lines. We tried to fold the paper the
opposite way and repeat, but just ended up with even more ‘muddy’ image. We tried to
adjust brightness and contrast, and found that the folds are less visible if we set
brightness to -10%.
Another internal referral letter, printed on a green sheet from PAS. We try black/white,
then the “green paper” setting, then colour. Black/white is best, colour is OK, but with
the “green paper” setting all the text written with a blue pen disappears. Is it necessary
to continue printing these sheets on coloured paper?
A form from semen examination (it is from the In Vitro Fertilisation Clinic, referral plus
results), green sheets with white name tags. Black/white is good, and we save under D6
“Results reproduction”, but should it be saved in both the man’s and the woman’s (who’s
under treatment) record?
Examination results from the A hospital, the hormone laboratory, one page, white sheet
with a blue border and coloured logo. OK in black/white, but where to put this in the
EPR? What kind of test is this? “Clinical Chemistry” or is it to go under D6 “Results
reproduction”? Is hormone tests necessarily connected with reproduction?
Examination results from the F Laboratory, a one-page sheet with a light blue
background colour. We scan with black/white; it isn’t very good, rather blurry, so that it
might (hypothetically) create problems in reading single numbers. Colour is also not too
good, and with the “blue paper” setting all of the logo and company information
disappear. On the sheet a doctor has signed that he has seen the results – that is an issue
to be discussed more generally whether it is important to scan this signature, whether it
has a legal or only process-oriented function. And we need to decide whether to scan
results when the department receives them, or only after the doctor has signed, or both
(i.e. the same document twice).
After this testing period and the bug-fixing, discussions, and clarifications that it stimulated, real
scanning of incoming referral letter started. Real scanning uncovered even more issues that had to
be resolved. For instance, the incoming referral letters could be several pages long, as further
information and results of examinations were attached. Usually, all of the pages were scanned and
saved as one document in the appropriate folder, and within the folder the documents were
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organised according to the documents’ dates. In some instances the referral letter would state that
additional examinations had been performed and that the results would be forwarded to the
hospital when they were ready. In such cases, the forwarded documents would logically belong to
the same referral letter, as they would provide additional information required for the evaluation
and future treatment. However, it was not technically possible to append the after-sent documents
to the previously scanned referral letter. The scanner software generated images using the TIFF
file format, and in order to create one file, the different pages had to be scanned at the same time
and joined before exporting it to the EPR system. Thus a new file had to be generated for the
separate documents, and there was no way to link these documents in the EPR, except for the
decision to use the referral letters date to store also the after-sent letter. To do this properly, the
person who scanned the documents had to find out which referral this document belong to and
use the same date for storing it.
The scanning activities required cooperation between three different software systems, the
scanning software, the EPR and the Patient Administrative System (PAS). Before a document
could be scanned, a digital record (in the EPR system) had to be created on the patient’s name so
that the scanned file could be saved where it belonged. Before the record could be created in the
EPR, the patient information had to be entered into the patient administrative system (PAS),
which supplied demographic and logistic information to the EPR. With respect to time, a process
where the time delay between PAS registration and scanning was minimised would be optimal,
i.e. that the same person were responsible for all the steps. However, the PAS application which
was used by nearly all secretaries in the hospital was running on the hospital’s Windows NT
network. The scanning software required Windows 2000 and was installed on separate machines.
Thus these two systems were running on different machines in different work places, and at least
two persons had to be involved in the task. Thus the redesign of work routines did not happen
freely, “from scratch” but had to start from the given constraints, in this case constraints posed by
the software and operating systems.
The outcome of the redesign workshops in the pilot department that I studied were not major
changes. After the first months, new procedures for handling of incoming mail were in place,
mainly centred on how to sort the mail so that the right sections within the department got their
mail. The referral letters were still received on paper, and after they had been scanned the paper
documents were put back into the workflow process, which continued as before. If the paper letter
should have been removed from the work flow after scanning, a way to notify the responsible
doctor that the letter existed and was awaiting evaluation was required. In order to locate the
patient in the EPR the name and birth date was also required. A notification feature in the EPR
system that could have solved this was supposed to be implemented in the next release of the EPR
software. Throughout the time I studied the pilot department, this feature was referred to as
‘coming soon’.
The project meetings often seemed rather disorderly to me, without a strict agenda and without
much tangible results. Various pressing issues and proposed changes were discussed, and the
participants would ask or comment on them in an ad hoc, non-systematic way. It seems as if the
participants were trying to sort out the pre-conditions for the planned or wished-for changes,
predicting the consequences of them, and devising the appropriate actions to be taken. Let us look
at one excerpt:
Brigitte: If we proceed to discussing the evaluation for delivery admittances, why can not
Ellen also use the electronic referral letter? After it has been scanned?
Susanne: But consider all of those who don’t get admitted.
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Researcher: Yes, because you have to create an EPR file for all those who are to be
scanned, don’t you?
Brigitte: Yes, we should not make routines that we afterwards have to reverse.
Susanne: But why do the papers continue to Anna and Ruth?
Mary: They register in the PAS and schedule the ultrasound examination.
Ellen: They could have been registered in PAS before I get them
Susanne: Are the rejections also in PAS?
Ellen: Yes, the rejections also.
The delivery admittance issue is a special case for this department. Contrary to the general
situation for most other services within the hospital, the Delivery section cannot admit all who
apply. Approximately half of the yearly 5000 applications are rejected and the referral letters are
forwarded to other hospitals. Following the hospital’s general policy to scan incoming referral
letters (“applications”) at once (before admittance or not are decided) would not be appropriate
here. It would necessitate the unnecessary creation of around 2500 EPR files for people who are
them not admitted after all. Making exceptions for these kinds of situations was one of the issues
discussed in the meetings. The possibility to detect such kinds of dependencies and possible
consequences of actions and decisions during the process redesign process was important. These
meetings served as the way to collectively discuss it, but successful meetings depend on the
presence of the relevant persons. Nobody knew it all, not even the Head of the secretaries or the
most experienced persons. This redesign process had low organizational priority and visibility.
The meetings I attended were dominated by the secretarial staff, at one occasion a midwife was
there and also once a doctor. The participants were with no exception females, also from the IT
department and the Archive department. Cross-disciplinary groups were created in each of the
pilot departments, but the doctors in particular did never manage to find the time to attend the
meetings. As the project progressed, their absence was becoming a problem, since many of the
decisions that had to be made required their participation.
I attended only one meeting in this pilot department where a medical doctor (Jane) joined the
group. I have included an excerpt from the meeting at some length, since it shows several issues. 1
Jane: The problem is that Obstetrix and DocuLive2 don’t communicate, that link doesn’t
work anymore.
Brigitte: It is supposed to be fixed in the next version.
Jane: This is important, it is a prerequisite that the link works. By the way, both doctors
and midwives at the Delivery have to get into and learn to use DocuLive. The doctors at
the Delivery almost never use DocuLive. The barrier is even higher among the midwives.
Brigitte: It is sad that the doctors at Delivery don’t feel that DocuLive is their work tool
anymore.
Jane: It is just that it’s so much extra, you have to log in and…
Brigitte: But Obstetrix patients can be converted into DocuLive patients without
forewarning, so then must we have it in.
Ellen: Why doesn’t the link work anymore? It was super!
Brigitte: It will come back in the next version.
1
The excerpt is not truly verbatim, as the meeting was not tape recorded. It is based on extensive notes that
were written out afterwards.
2
Obstetrix is a specialized record used only in the Women’s clinic and it was implemented approximately a
year before the scanning project started. During normal deliveries information is registered only in
Obstetrix for both the mother and the baby/babies. DocuLive is the name of the general, hospital-wide EPR
system.
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Ellen: When is that?
Brigitte: There are new releases all the time.
Jane: When it comes, will it work for only new or also old patients?
Brigitte: I don’t know, it should be for all Obstetrix patients. We will have to ask the IT
department, when we meet them on Wednesday […]. If it is scanned into DocuLive, what
then about Obstetrix?
[…]
Ellen: The midwives need a refresher, to be shown what it is good for. […] We need to
have a change of attitude; everybody has to use this eventually, so a refresher is
important.
Brigitte: Yes, we should do that, it is a good suggestion, a refresher meeting, where the
DocuLive helper can come and demonstrate this, how to use it. So we can have a change
of attitude.
Researcher: What kind of knowledge is it that they need? Is it where they can find the
electronic documents, where in DocuLive they are located for example?
Jane: Yes, where things are and how you use it.
Susanne: And there is this attitude that you are not supposed to do a lot of IT things. They
at least don’t want to have to relate to a lot of programs at the same time. When they
received Obstetrix, they stopped using the other programs. Now they want their
secretaries to do all the rest. But it is also a problem with the PC’s up there, that you
cannot have both PAS, Obstetrix and DocuLive open at the same time. You are thrown
out.
Brigitte: Do you remember the small laminated user manuals for DocuLive? A5, which
we could distribute and hang? They were very useful, we could make something like that
and distribute.
Susanne: There is a barrier for daring to go in and using a program, so we must show
them the use value so that they understand why.
Brigitte: And if it is a machine problem, we have to upgrade them.
Susanne: It is not just that, it is not just old PCs; Obstetrix takes a lot of space.
Brigitte: It will be solved when the portal is there.
Jane: We should observe when and how big a problem this machine thing is.
Ellen: When is the portal coming?
Brigitte: When I asked last, I should have it for Christmas. Now things are slower
because they lack funding, but it will come.
Susanne: When we migrate to XP it will help.
Brigitte: I believe XP will come before the portal.
Jane: Where in DocuLive are the scanned referral letters? I have seen some before, but
have forgotten how I find them. Such things at least the doctors have to be informed
about.
Ellen: In the lower part, together with the doctors’ notes, under “external
correspondence”.
Susanne: Perhaps you can make an overview and email it to the doctors?
Brigitte: We have been thinking to have the outpatient clinic no. 1 without paper records
in May, to work only electronically with for instance those patients who come in before
lunch. They have done something similar in the Dermatology Department. It would be an
important motivational factor if we succeeded and could tell about that.
Jane: That works on the Delivery section, but DocuLive is more comprehensive, and
there are many who don’t even manage to work with the internal referral letters. And
nobody uses the prescription templates and sick leave certificates
Susanne: But that is a responsibility of the leadership also, our Head must say that
‘things should be done in this way’.
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Jane: But then the care personnel say that they don’t have access to DocuLive or don’t
have PC because it isn’t enough. That means that the preparatory work which could have
been done by them, is not done, and more is transferred to the doctors. For instance there
is the midwives report without PC and then we have the meeting before the ward round
and they haven’t seen something before, only then do they see it. That creates an extra
burden on the doctors. I talk generally about the doctors’ point of view.
Susanne: You have to ask from them that they prepare, you have to create change
through asking for it. [..] It is important that people have an interest to find out things on
their own as well. And we have to show that it is a simple system. But that is a leadership
issue. We have to remove the paper record and then we will have to sort it out.
Brigitte: Yes, that’s what we will do in the outpatient clinic. Besides, there is always one
or another free PC around.
Researcher: I just want to ask Jane whether it is realistic to remove the referral letters
from the work flow and just send the evaluation form to the doctors? So that they are
notified about it, but will have to open the referral itself from DocuLive.
Jane: I believe there will be an outcry. They find this in their mail shelf and then they are
on their way to the outpatient clinic or the ward round and then they cannot finish this
off.
Researcher: Does that mean that they are standing in the mail room and evaluate the
referrals at once and put them back into the mail shelf?
Jane: Yes.
Karen: We should have had such shared PC stations where you can log in, like it is in the
delivery ward. It should be standing and not sitting. What about removing the TV in the
mailroom and put a PC there?
Susanne: Such terminals that are around, in shopping malls and things like that, where
you have your own booth.
While nobody challenged the fact that this was a “scanning meeting” we do not find a lot of
explicit discussion of scanning issues, only a brief question as to where the scanned referral
letters are found in the EPR system. Instead the discussion touches a link that allows export of
data from the specialised EPR system Obstetrix to the general EPR system, Doculive, attitudes
and usage, as well as what to do to increase the usage of the EPR system, and then finally, the
work routines around referral letters. Let us consider more in depth the last issue of the referral
letters. These letters were registered in the Patient Administrative System before the scanning,
and from this system a sheet of paper, known as the “Evaluation Form” was printed. This sheet
accompanied the referral letter, and the doctor who evaluated the request, would note the decision
on this form, e.g. whether the patient should be admitted, what kind of procedure(s) and
examinations that were required, and whether the case was urgent or not. This form would then
guide the secretaries who scheduled the appointment and informed the patient. Early in the
scanning process it was decided that this form should not be scanned, as it did not contain clinical
information, just “process information”. Because the notifying feature in the EPR system was not
yet there, the paper letters were still put in the mail shelf of the doctors for them to evaluate them.
I had raised the question of whether only the evaluation form could be used, and not the actual
referral letter. However, in the previous meetings where no doctors were present these objections
were not voiced. While secretaries usually have a good understanding of the information flow and
routines in a department, this incidence indicated to me that they do not know it all, and that the
lack of participation from the other professional groups contributed to slow and inefficient
learning and change.
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6.
How Technology Shapes Learning
I perceived the learning process in the department to be “orphaned” and “frustrated”. The
scanning project was not a high visibility change project which was supported with adequate
resources and managed by people with change management competence. On the contrary, in
terms of organisational awareness, it occurred almost at the “subconscious level”. There was not a
“change culture” in place in the organisation, and the department that I studied was not very
efficient and quick in changing their work practices. Still change occurred slowly and gradually,
and (as is my main aim to show) this change was shaped by the characteristics of the technologies
in question. I want to emphasise two aspects of this influence which I believe characterises
infrastructural information technologies: the role of links and interdependencies and the partly
real, partly future character of the technology.
6.1
Preconditions, links, interdependencies
Information infrastructures consist of multiple software applications, varieties of hardware, work
practices and skills, among other things. Depending on its size also different operating systems
and networks could be connected. In such a situation it is not straightforward to achieve easy
interplay and seamless integration. This case shows how technicalities of the infrastructure
restricted the possible changes: It was impossible to integrate the registration in the Patient
Administrative System and the scanning of the referral letters because the two software
applications required different operating systems. After the hospital network operating system
was changed it became possible to run these applications on the same computer, but at that time
the “window of opportunity” was closed, and work routines were settled.
The preconditions and consequences of the complex socio-technical assemblage were often not
predicted and only became perceptible and “real” as a post-hoc fact. From the initial scanning
observation we see that only as we actually tried to scan and import documents did we encounter
problems. For instance, that the TIFF file format would exclude appending the test results to a
referral letter could easily have been foreseen if anyone had asked the question, but the issue was
not considered initially. Only as the first after-sent test result should be scanned and saved was
the consequences of choosing this file format detected. The challenge is not that the problems in
principle are so complex and intractable, but that there are so many of them and that they may
interact in unpredictable ways.
This I believe is a fundamental challenge of infrastructural information technologies, and a
challenge that is not easy to deal with, as we do not have adequate “methodologies” for predicting
and sorting out such preconditions and consequences. The main method applied in the pilot
department was to establish cross-disciplinary groups representing the widest variety of
personnel, and conduct meetings. The discussions in the meetings would seem arbitrary, such as
the above excerpt where a discussion (without conclusion) around the link between Obstetrix and
Doculive, before touching on the midwives’ attitudes and computer usage, and then the work
routines around referral letters. Such discussions of “related topics” occurred all the time in the
project meetings. Probably part of the explanation is perhaps that the meetings were just not
strictly managed, but I will also argue that this illustrates the way such a process necessarily must
be. It is not just about discussions that drifts off topic, but these loosely structured discussions did
sometimes bring very relevant information to the group from individuals. The relevance can not
be predicted a priori, in that case there would not be the need for a meeting. Seen from one
perspective the actual work performed in these meetings could be characterised as “unravelling”.
It consists of sorting out pre-conditions for the planned or wished-for changes, predicting
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consequences of the changes, and devising the appropriate actions to be taken. The discussions in
the meetings did not only concern predictions and consequences. Since the need to sustain the
ongoing everyday work processes was of paramount importance, also work of “weaving” had to
be done. While changes were intended, these were not allowed to disrupt today’s work; the
existing processes would need to ‘hold together’ during the change period. Hospitals have very
low tolerance for unnecessary disturbances, and change could not be radical, abrupt and largescale. Partial and gradual changing of single elements in the work flow was the only option, and
this required careful consideration. And in order to plan minimal disruptive changes, as many as
possible of the persons involved should be present. When the doctors did not show up,
compensatory strategies were employed: for instance a secretary would prepare a list of
remaining questions that no-one else could answer, or decisions to make, and then approach the
individual doctor. This was however not an optimal strategy: issues might have been overlooked,
and it often happened during the larger EPR implementation project that doctors would protest
only after the changes became effective.
6.2
Partly real, partly future
The links and interdependencies that I describe above have an impact on learning in the project:
they make the problem definition difficult and slow down learning and change; they almost create
a “learning paralysis”. However, there is another aspect of the technologies that affects the
learning process even more strongly: the fact that a lot of the expected benefits is not yet realised
and the planned functionality is not yet available. When needed features and fixes are requested,
the workers may hear that they are “coming soon”, that this particular feature will be included or
the problem solved in a later release of the software. This projects the actual change into the
future, delays actions and dissipates the change momentum in the organization. To a certain
degree this orientation towards future time horizons and scenarios is an inherent part of
imaginative design activities such as prototyping of IT systems (Bødker, 1991), since iterations
between the context of use and the context of design are necessary for the models and the reality
to be matched. However, this case was not (understood as) a design project, just a temporally
stretched-out finalising of a system roll-out, although with continuing updating and extension of
functionality for each new version of the software. To my inquiry on the progress of providing a
feature that the users had requested one of the project members replied: “No, we haven’t fixed
that and we will not do that for the time being. Remember, we’re trying to eat an elephant here.
We cannot take it all at once”. The delays in learning were not intended or planned, but were just
a consequence of the nature of the task. This was not about imaginative iterations between current
and future scenarios, and it did not serve to generate insight for the continuing design process. It
occurred because infrastructural technologies are too large to manage in an easy way. They grow
gradually, over time, through planned and unplanned extensions and modifications, and their
trajectory is open to shaping by powerful, persistent or lucky actors. While this characteristic
contributed to delaying learning, at the same time it also draws on the future. The “incomplete
utopian project” (Gregory, 2000) links itself to unrealized desires, wants and ongoing quests that
may energize the project. These kinds of projects may serve as valuable tools in social innovation
processes as they keeps spaces and parallel vistas open for the actors. The learning is organised
and shaped by the iterations between visions and images of new “forms of life” and the durable,
historic realities. Time frames are stretched, likely vistas are closing down, while other emerge as
the complex assemblages gradually realises itself and finds it form(s).
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18
Concluding Remarks
These empirical examples point to issues that I believe are crucial for the dilemmas of ICT for
organisational change. We are increasingly dealing with large-scale, interconnected assemblages
of technologies, where reduction into manageable sub-units as a strategy is often not an option. I
argue that these examples show fundamental characteristics of infrastructural technologies, that
they are 1) interlinked, connected and dependent, as well as 2) partly realized, partly imagined
and unrealized. These phenomena fall between our traditional disciplines, and consequently we
are yet too ignorant. An adequate understanding of how technologies and organizations are
interlinked must come to terms with how these aspects are resolved in practice.
The significant role of links, and interdependencies, and the ever-evolving nature of technology
are particularly challenging aspects of leveraging infrastructural technologies to achieve
organisational change. The uncertainty, ambiguity, complexity, and discontinuity that are and will
be the givens of most technology-related organizational change processes, is magnified when the
technology in question has a strong infrastructural character. The fact that infrastructural
technologies are not standalone entities, but elements in larger assemblages has the effect that
their deployment, and consequently learning and organisational change, can not happen freely. It
will be constrained and shaped by what is possible to achieve. The gradual evolving nature of
infrastructural technologies, a consequence of their size and complexity, further shapes the
process of learning by postponing action to the future, but also by drawing on the power of future
visions.
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