1) Introduction
The contribution focuses the
management of the organizational impact of Information and
Communication Technologies (ICT) in hospitals.
ICT, particularly because of the
innovations in the last decade, is more and more a key lever for the
organizational development of hospitals. The management of the
organizational impact of the evolution of the computerized information
system, based on the joint analysis of technological and
organizational variables, is therefore a crucial lever for performance
improvement. The evaluation of the effects of ICT on the performances
of an institution includes a wide range of aspects in addition to the
organizational ones; anyway, organizational aspects have a central
importance in the contribution of ICT to the improvement of
performances.
In this scenario, it is of growing
relevance the joint planning and management of the organizational
interventions, on the one hand, and the ICT applications selection and
implementation, on the other hand. To support it, a model for the
evaluation of the organizational impact of ICT is proposed and applied
to the case of the Polyclinic of Milan (hereafter Polyclinic) during
the ‘90s.
The
experience of the Polyclinic indicates that the joint presence of
three factors is crucial for the exploitation of ICT potentials: 1)
the application of process analysis and reengineering methods and
techniques, if they are carefully integrated with the systematic
evaluation of the organizational impact of ICT and they are considered
globally as a method of organizational development and not only as a
method for the definition of the requirements of ICT applications, 2)
the definition at the top level of an ICT strategy, and 3) the
systematic attention of the top management to ICT projects.
Parameters considered for the evaluation of the organizational impact
of ICT are described as a first step. Then, the evolution of the
literature on Business Process Reengineering (BPR) and ICT is briefly
recalled (section 2).
The
model defined in section 2 is employed in the case study. The case of
the Polyclinic is developed focusing the organizational impact in
different phases during the ‘90s, taking into account the evolution of
the IT architecture, the approaches used in the introduction of
technological innovations, the strategic and organizational context
(section 3).
In
section 4, it is examined the use of the evaluation model for the
management of the development of the computerized information system.
A relevant improvement in the organizational impact was found in the
two cases of the computerization of the outpatients’ department and
the central laboratory. Both were characterized by the joint presence
of the three factors identified as especially relevant for the
exploitation of the ICT potentials. Basing on the results of the case
study, the application of process analysis and reengineering methods
and techniques, and the role of the top management strategy and
systematic attention to ICT interventions in hospitals are discussed.
In the end, some considerations
about the growing importance of process analysis for the exploitation
of ICT are discussed particularly in the light of the recent diffusion
of technologies such as the Entreprise Resource Planning (ERP)
in the healthcare sector (section 5).
2. A model of evaluation of the organizational
impact of ICT in hospitals
In the present section, the model
employed to evaluate the organizational impact of ICT in the case of
the Polyclinic is illustrated. Then, the evolution of literature on
BPR with regard to the topic of the exploitation of the ICT potentials
is summarised. The relevance of the case study is discussed.
A model for the evaluation of the
organizational impact of ICT
The model proposed combines
descriptive parameters with a schematisation and operationalization of
some relevant aspects of the organizational implications of ICT
applications. The main purpose of the model, which is intended as a
first approximation model, is to provide the management of an hospital
with an easy-to-use tool.
Four relevant parameters have been
defined for the analysis of the organizational impact of ICT:
1.
areas of activities computerized and
functions activated;
2.
degree and modality in the use of
ICT;
3.
nature and degree of technological
and organizational integration;
4.
nature and sources of inertia and
resistance to the use of ICT.
The identification of the areas of
activities computerized and functions activated has mainly a
descriptive purpose, since the introduction of ICT systems may have
different organizational implications according to the areas involved
and the type of functions activated.
The
analysis of degree and modality in the use of ICT is the main aspect
of the organizational impact considered by the model. Real use of
applications and modalities are central to evaluate the impact of ICT.
It is the effectual use of ICT that makes an organization capable of
elaborating more information, thus meeting the informative intensity
of the organization. We follow the analysis of Galbraith (1971 and
1977) in identifying the informative intensity (the need of
elaborating information) in an organization as a function of task
uncertainty and task complexity. To meet its informative intensity, an
organization may activate interventions in order to reduce it
(relevant indications are in Galbraith, 1977) or increase its capacity
of elaborating information. Within this second line of intervention,
ICT is one of the relevant levers; its effectiveness depends on the
one hand on the inherent features of the ICT systems introduced; on
the other hand, it depends on the degree and modality in the use of
ICT.
It may
be noted, also by employing the analysis of Porter and Millar (1985),
which assess the overall informative intensity of an organization by
using a “high-low” matrix that considers the informative intensity of
processes on the one hand and of products on the other one, that
healthcare organizations may be classified as organisations that have
to elaborate a “high” quantity of information.
In the
organization design, with regard to the basic issue of the management
of interdependencies (Thompson, 1967), ICT can provide a relevant
contribution, considering that a major feature of ICT evolution in
recent years has been its integration potential. Organizational
integration is a key aspect of ICT impact, since it may be considered
as an index of organizational “effectiveness” of technological
integration. A high, integrated and uniform use of ICT resources
increases the organizational integration. The degree of enhancement of
the organizational integration made possible by technological
integration may be considered as the outcome of the use in an
integrated way of the integration potential of ICT resources.
The
analysis of the sources of resistance and inertia is instrumental to
the understanding of the causes of the trends of the variables defined
and for the activation of suitable practices in order to improve the
organizational impact.
Areas of activities computerized
and functions activated
This
parameter is mainly descriptive. Since there may be relevant
differences in the organizational impact according to the nature of
the activities examined and the staff performing them, such
differences have been taken into account. A very schematic
classification identifies four categories of operational activities:
-
resource management:
including all activities concerning procurement, asset management,
human resource management;
-
service delivery:
outpatients’, day hospital, hospitalization, also including reporting
to the region for DRG-related
grants and tickets collection;
-
support services:
diagnostic and therapeutic activities supporting service delivery;
-
research and
teaching: all
activities related to research and teaching.
For each
group of activities, in the case study, the specific ICT functions
activated have been described. In parallel, managerial activities -
involving in particular planning, budgeting and management control and
influencing all operational activities - have been analysed.
Degree and modality in the use
of ICT
It is the first relevant measure of
the impact of ICT. For each group of activities, degree and modality
of use are detected. With regard to the degree of use, three
possible values have been defined:
-
minimal use:
situations in which
potentials of ICT to change the way work is done and/or service are
delivered are not used in a substantial way;
-
high but not
integrated use:
situations in which the functions of an application are used, but not
in an integrated way;
-
high and integrated
use: situations in
which the potentials of an application are used also by making data
and information produced available for other applications, while at
the same time using data and information produced by other
applications.
With regard to the modality of
use, the key point is about the uniform or
differentiated use of ICT.
Considering the different organizational categories of actors
(doctors, nurses, administrative staff, technical staff), the
following cases may be considered:
-
a uniform or a different use of the
same application (although in general for different purposes)
according to the category of users: in fact doctors, or academics, or
nurses, etc., may have a completely different attitude towards the use
of an application;
-
within the same category of users, a
different use of the same application in different organizational
units.
So, the use of an application may be
uniform or differentiated according to the typology of organizational
actors, on the one hand, or to the organizational unit, on the other
hand. In the first case it is more a matter of different attitudes of
the different categories of professionals.
In the second case, it is more a
matter of managing organizations where usually each unit (department)
has a relevant degree of autonomy.
Both
degree and modality of use have to be assessed in dynamic terms. The
time since the introduction of the ICT application/system is a key
aspect: an integrated and uniform use achieved in a “long” time
reveals a low organizational impact of ICT.
Degree
and modality of use are the effect of a wide set of factors, ranging
from technical and interface characteristics of the application to
broadly organizational characteristics. The analysis of these factors
leads to the consideration of the causes of inertia and resistance to
the use of ICT. Preliminarily, the issue of integration has to be
deepened.
Nature and degree of
technological and organizational integration
Late ICT evolution is very much
oriented towards increasing systems integration (Austin and Trimm,
1995 - see section 5). The key question is whether this technological
integration may be used to achieve a higher degree of organizational
integration. For this reason, it is important to distinguish between:
-
technological
integration: it is
a technical characteristic of the computerized information system
adopted; and the related
-
organizational
integration: it
may be defined as the result of the actual exploitation of integration
modules; it is an organizational aspect determined by organizational
factors.
In this approach, technological
integration is a pre-condition for the management of change towards a
more integrated organization.
The
evaluation of the degree of technological integration is easier. With
regard to the experience analysed in the present contribution, the
following modalities of integration are considered:
-
EDI (electronic data interchange)
techniques, using specific healthcare standards (HL7, DICOM, etc.); it
can be applied also in presence of heterogeneous IT systems based on
different platforms;
-
RDBMS view; it can be applied in presence of IT
solutions based on different SQL databases; integration consists in
the generation of specific source codes (middleware, e.g. DLL) that
can be used from different applications to interface databases;
-
Native integration, which can be
applied when different software applications are based on a unique
database.
The high and integrated degree, and
the uniformity in the modality of use of the integration modules allow
the achievement of a higher level of organizational integration.
The
evaluation of the degree of organizational integration is much more
difficult. In the present contribution, it is considered the
organizational integration caused by, and related to, technological
integration; the aspect focused is the diffusion and share of
information, considered as a critical organizational need in order to
manage task uncertainty (Galbraith, 1971 and 1977).
The evaluation of the organizational
integration entails the use of indirect estimations and of qualitative
measures, to put together the different degrees and modalities of use
observed in the different areas of activities (see section 3, table 3
in particular) and achieve a comprehensive evaluation.
Nature and sources of inertia
and resistance to the use of ICT
The
analysis of the causes of low degrees of use of ICT, or of a
differentiated use of ICT, and of limited organizational integration
in front of technological innovations oriented to integration, leads
to the topic of the nature and sources of organizational inertia and
resistance.
The following, wide and commonly
used, definitions have been adopted:
-
resistance:
active attitude of opposition to the introduction/development of an
application; it may be generated by a variety of causes, some of
technical nature and related to an inadequate correspondence of
identified requirements of the application to the organizational
needs, others related to organizational causes, mainly connected to
the shift of power due to the organizational implications of the
technological innovation;
-
inertia:
passive attitude towards the new application, connected to work
habits, which, if not contrasted, generates a sort of “resilience” in
the organization: partial use of the new technologies at the
beginning, subsequent relinquish of them after a few time, with, in
the end, limited or no use of the new technologies.
Some of the most frequent causes of
resistance and inertia are summarized in table 1. Causes more peculiar
of the healthcare sector are examined also in the light of the results
of the case study (end of section 3).
The
causes of resistance or inertia have been classified into three
typologies: a) related to the ICT infrastructure or the specific
solution, b) related to the modification in the job description and c)
related to the organizational context, with a further distinction in
the last one between those more straightforward to generalise and
those more peculiar of the specific organizational context of a
university hospital.
Cross-cutting the scheme, there is
the issue of the relations between ICT personnel and end-users
(Foster, 1995), which may play a relevant role not only in the
management of the causes of resistance and inertia, but also,
“upstream”, in co-determining them.
|
Cause
|
Description
|
Typology |
|
|
|
|
|
Related to ICT
infrastructures |
|
Difficulties of use
|
Inadequacy of
data-entry methods, interfaces etc. |
Related to the
specific ICT solution |
|
Absence of
technological integration |
Inadequacy of
technical/functional design |
Related to the
specific ICT solution |
|
Technological and
functional immaturity of the ICT solution adopted |
Inadequacy of the
ICT solution in supporting the organizational tasks to be
performed |
|
|
Introduction of II^
generation ICT solutions (i.e.: package vs ad hoc systems) |
Users unwilling to
revisit their job description |
|
|
Perception of an
organizational gap between the organizational structure and
procedures, and the ICT solution |
Introduction of
adequate ICT solution, but without an overhaul of organizational
processes |
Related to the
organisational context |
|
Rejection of the ICT
solution connected with the perception of the role played into the
ward |
Cases when
professionals refuse to perform ‘administrative’ tasks |
Related to
modifications in the job description |
|
Modifications in
power distribution
|
Usually the critical
factor for effective organisational integration |
Related to the
organisational context |
Inertia
|
|
|
|
Absence of attention
by ward or hospital direction |
ICT introduction is
not considered a strategic priority |
Related to the
peculiar features of organizational context |
|
|
Career paths
developing mainly outside the organization (e.g.: university
personnel) |
Related to the
peculiar organizational context |
|
Absence of monetary
incentives |
Cases when ICT
innovations have for a long time been introduced by giving
monetary incentives to personnel |
Related to the
peculiar organizational context |
Table 1:
typologies of resistance and inertia in using ICT solutions
ICT and process analysis
Since
its definition in the classical works of Hammer (1990) and Davenport
and Short (1990), BPR is deeply linked to the issue of the
exploitation of ICT potentials; as reported in Halachmi (1995): “if
nothing else, IT should be used in any business process to provide all
members of the organization with easy access to a common database
bringing ‘downstream’ information upstream, thus allowing: the
elimination of unnecessary steps or repetition of activities (Linden,
1993), consistent decision making throughout the process, real time
measurement system that enables employees to inspect and understand
their performance (Champy, 1995)”.
In the early literature (Hammer,
1990, Davenport and Short, 1990), the conception of the relation
between ICT and organizational structure seems to be based on two key
notions:
-
the exploitation of ICT requires a
new and different approach to organization analysis and redesign; only
by using process-based approaches to the analysis of the functioning
of an organization, ICT potentials can be effectively exploited;
however,
-
by using such new approaches,
performance improvement can quite easily be achieved.
In later literature, emphasis on ICT
is reduced (Venkatraman 1994). Relations among the introduction of
information technology, organization restructuring and performance
improvement appears to be much more complex. Process analysis seems to
be particularly relevant exactly because the definition of
organizational solutions suitable for the exploitation of the
potentials of new technologies is an issue that does not have any
univocal answers, nor solutions are uniform in their implementation.
Process-based approaches have been
used also in healthcare and the public sector
for the exploitation of ICT potentials (Saxena and Amal 1995, Saxena
1995). The use of process-based approaches in these sectors requires
anyway a specific care for the characteristics of the organizations
involved (Packwood, Pollitt and Roberts, 1998, Willcocks, Curries and
Kackson, 1997).
Relevance of the case study
The relevance of the case study is
due to:
-
the high organizational complexity,
-
the importance of the ICT
investments, and
-
the evolution, during the period of
observation, in the approach used to manage the organizational impact
of the introduction of ICT innovations.
The high organizational complexity
is related to a plurality of aspects: the variety and high
specialization of services delivered; the presence, in addition to
hospital activities, of research and teaching activities; the system
of inter-institutional relations; and dimensions, in terms of human,
technological and financial resources.
The Polyclinic is a top level centre
for research in many fields of diseases and is able to deliver highly
specialized treatments. Therefore, the set of outputs of the
Polyclinic is made up of a variety of highly specialized cures,
research publications and lectures. Personnel are in part completely
dependent on the hospital, in part academics, whose career paths are
deeply related to their scientific activity and to their relation with
the university. In fact, with regard to inter-institutional relations,
the Polyclinic is linked to the faculty of medicine of the University
of Milan, with a specific convention signed to regulate relations.
Being a research centre, it is also related directly to the healthcare
ministry (while in general hospitals in Italy depend entirely on
regions - Lombardy region provides in fact financial support for most
activities), which appoints the top management and funds part of
research activity.
With regard to the dimensions,
expenses are about 130 million euro per year, there are more than 400
doctors and about 130 academics, about 800 nurses, a limited number of
administrative personnel (less than 10% of total). In addition, there
is a high number of young scholars payed with grants and of doctors
getting their specialisation degree; they constitute a relevant
resource for the hospital.
With regard to the importance of the
ICT investments carried through, in the first half of the ‘90s
investments were more than 2 million euro per year, lower in the
second half (about 1.5 million euro per year), while new relevant
investments in ERP technologies have been started in 2001 (ERP
representing a growing share of the ICT investments, amounting to
about 5 million euro of disbursement over the years 2002-2004).
Last, and most important, the
relevance of the case is due to the evolution, during the period of
observation, in the approach used to manage the organizational impact
of the introduction of ICT innovations.
3. ICT innovation and organizational impact at
the Polyclinic of Milan in the ‘90s
In the period considered, it is
possible to identify three main phases (corresponding to the years
before 1995, the phase 1995-98, and after 1998). This classification
fits well both with major changes occurring in the external
environment and with changes in the strategic and organizational
priorities; furthermore, it fits well with changes in the approach
used to manage the introduction or development of the new ICT systems.
Relevant factors in the evolution of the computerized information
system of the Polyclinic are summarized in table 2. The information
system of the Polyclinic is illustrated in figure 2.
In the first period, the most
important change in the external environment concerns the transfer of
many relevant functions in healthcare from the central government to
the regions. At the same time, a strong impulse to introduce a
complete revolution in the management of hospitals is given by reform
laws of 1992-93, which make hospitals more autonomous and evaluated on
performance results.
There is only a feeble reaction in
the different components of the Polyclinic, with administrative staff
still much focused on compliance to formal procedures and rules, more
than on the new orientation to performances, and clinicians not much
affected by the new organizational responsibilities. On the
technological side (see table 3), ad hoc solutions are still
prevailing. Only one case, the package for a unified booking centre,
highlighted the necessity of a deep overhaul of processes,
particularly in the interconnections between clinical and
administrative activities. Resistances caused under-use of the
package; only eight years after, a reorganization of outpatients’
department processes has made the full exploitation of the package
possible.
In the second phase, a prominent
change in the context is determined by the introduction of DRG as the
basic criterion in the funding of hospitals. The reaction of the
Polyclinic is well explained by a model proposed by Taroni (1997 – see
fig. 1). At first, interventions are focused on the operational
mechanisms concerning documentation to provide to the Region to get
the grants and on the criteria adopted in the administrative
management of patients. Then, interventions for organization
restructuring are planned (they start in the following phase).
On the technological side, for
administrative activities, both in resource management and in support
services, there is a move from ad hoc to package solutions, based on a
relational database. In clinical activities, instead, ad hoc solutions
are still prevailing. There is much more consciousness of the deep
relation between technological innovation and organizational redesign.
The necessity to involve the top management in ICT projects, because
of their organizational relevance, is clearly perceived.
In the
third phase, competition among public and private hospitals is
enhanced. The Polyclinic starts a deep reorganization. In some
relevant cases a radically different approach to computerization is
used, based on project teams to co-ordinate organizational and
technological interventions, and on users involvement.
Two
relevant principles are established:
-
different phases of the same process have
to be supported by the same application or by applications based on
the native integration of data;
-
distinct but interconnected processes may
be supported by distinct applications, but they must be integrated (by
middleware, if they are highly interconnected, by EDI, if they are
limitedly interconnected or they can anyway be interconnected in
batch).
|
FACTORS |
PHASES
|
|
before 1995 |
1995-98 |
after 1998 |
|
Characteristics of the context
|
Transfer of functions from the Healthcare
Ministry to the Regions |
Introduction of the Diagnostic Related
Groups (DRG) financial system |
Enhanced competition |
|
Strategic priorities and organizational
solutions
|
Limited emphasis on organizational issues
|
Focus on organizational restructuring,
especially in administrative sectors. Redefinition of relations
with the university.
|
Start-up of the new departmental organization
(grouping wards). Definition of the future model of the hospital:
agreement with Healthcare Ministry, Lombardy Region, Milan
Municipality and the University
|
|
Focus of ICT interventions
|
Focus on resource management activities and
support services.
Start-up of the LAN.
|
Focus on resource management activities,
especially on administrative systems (accounting and the operating
mechanisms related to the financial system).
Downsizing to open systems based on RDBMS –
first attempts of integration, but with no strategic view on the
integration issue.
|
Focus on service delivery and support
services.
Shift to web-based technologies.
Project of an integrated platform. |
|
Approaches to the introduction of ICT
|
Mainly a reactive approach, giving solutions
in response to the practitioners’ specific requests. Interventions
usually limited to the specific organizational unit involved.
|
Emphasis on the inter-operability (at
departmental level) of the applications and on the technological
integration. |
Development of the use of process analysis
(systematically applied in the case of the outpatients’ clinic).
Emphasis on inter-departmental
inter-operability.
|
|
Role of the organizational unit
responsible for the information system
|
Internal development of ad hoc applications;
subsequent increased use of standardised packages. |
Requirement analysis and increasing
organizational support in the introduction of packages.
Internal development only of clinical
applications (often not available on the market).
|
Leading role in the integration of systems
with a process-focused approach.
Start-up of the organizational analysis for
the introduction of the ERP. |
Table 2: overview of the relevant
factors in the development of the computerized information system at
the Polyclinic of Milan (1990-2000)
Figure
1: reaction of hospitals to the introduction of the DRG financial
system (adapted from Taroni 1997
Figure
2: frame of the information system of the Polyclinic (phase 3)
