Introduction
Evaluation can be defined as the systematic determination of the quality, value or importance of, for example, programs, projects or institutions [
1]. Although evaluations are generally conducted to identify areas for improvement or provide an overall assessment, they (like any evaluand) are susceptible to failure [
2]. Evaluations may ask the wrong question, adopt an inappropriate method or paradigm [
3] or even just fail to notice “the elephant in the living room.” [
4] There is no perfect or singular evaluation approach. Evaluation of health information technology (HIT) is particularly challenging. HIT is inherently disruptive and has the capacity to transform the organisational landscape and impact on professional responsibilities and roles [
5]. Systematic reviews of HIT studies continue to highlight the complex, variable and fragmented nature of evidence in this field [
6‐
9].
The HIT challenge underscores the importance of employing theory-based approaches that can help to integrate and highlight the significance of findings and improve our understanding of how and why things happen [
10‐
13]. As an example of this, consider the results of studies suggesting that a Computerised Provider Order Entry (CPOE) system has attained its goal and is deemed to be working successfully [
14‐
16]. Such findings are valuable for many purposes, but they may not necessarily explain what it is about the system within its defined context that made it work. In order to appreciate the innovative potential of HIT more fully we need to look beyond its technological features and incorporate the organisational communication structures and social-material setting within which the technology is embedded and enmeshed [
17]. In the end, it is not programs (or technologies) in and of themselves that work, but the resources they offer to enable people to make them work within a complex, adaptive environment exhibiting multi-faceted cultural features [
12]. Evaluating what works, for whom and in what circumstances, as Pawson and Tilley [
18] suggest, can help fill in the broader research jigsaw puzzle that can contribute to an understanding of the HIT and the role it can play as part of an organisation’s “innovation journey” [
19,
20].
Organisational communication and health informatics
While Pawson and Tilley [
18] encourage a focus on context, mechanisms and outcome (CMO) we wish also to highlight the role of approaches that consider the constitutive function that communication plays in organisational processes [
21,
22]. Early organisational communication studies, prominent in the US during the mid-part of the last century, emphasised the importance of channels of information which incorporated clear lines of accountability and responsibility and their role in ensuring effectiveness, efficiency and output [
23‐
25]. More recent scholarship has presented organisations as highly complex, adaptive and emergent organisms where communication is seen more as a
multi-transactional process incorporating reverberating feedback and iterative confirmation involving two or more people within a multi-faceted environment [
22]. From this perspective, communication processes can be seen as part of the
social glue facilitating organisational functioning [
26,
27]. These processes are
elemental because they undergird the way that organisations operate, but also deeply
entangled as interrelated components of the way that organisations make sense of their environment, coordinate their activities and make decisions about their future. In essence, communication processes need to be studied because they are the sociological and organisational DNA that make things work [
28]. We label initiatives which attempt to investigate this phenomenon the
Elementally Entangled Organisation Communication (EEOC) approach.
Organisational communication approaches in the way described have yet to be widely utilised by the health informatics community, at least explicitly [
29]. Giuse and Kuhn’s outline of the challenges identified by the Heidelberg Health Information Systems Working Group conference in 2002 drew attention to an apparent disregard for communication among clinical users [
30]. Moreover, as Kuziemsky et al. highlight, existing research often fails to consider the role of communication in the context of specific team structures, processes and outcomes [
31]. Communication failures, problems or misalignments are widely seen to be a central reason for poor quality health care today, but understanding the dynamics of these failures and their complex connection with hierarchy, social roles and organisational structures are not so well understood [
32]. The obvious implication of this is the need for theoretical approaches which can be employed to deepen our understanding of what is happening and why it is happening [
11].
Previous research approaches have tended to describe organisations as fixed entities or containers through which information is transmitted and communicated to internal and external audiences [
33]. However, as per Weick, organisations are more than this: they are dynamic entities comprising people enmeshed in the processes of sense making, organising and interpreting their environment [
34,
35]. Communication process are therefore an essential part of the process of establishing and maintaining the ongoing, interconnected behaviours that contribute to the makeup of an organisation [
33]. This is particularly relevant for research involving health information systems which have a
disruptive ability to change the role communication plays in organisationally linking people and activities across space and time [
35]. In this way we believe that organisational communications perspectives can complement, underpin and build on some of the better known approaches such as socio-technical [
36,
37], workflow [
38,
39] and system approaches [
40‐
42].
EEOC draws on rich sources of organisational communication scholarship which have been iteratively assessed and applied to empirical data to establish a novel innovative theoretical tool to inform future research. There are compelling reasons for the development of EEOC as a theoretical lens for HIT research. Firstly, health care itself is essentially an embedded, collaboratively-oriented set of organisational activities which rely on communication within and between groups to coordinate care [
29,
43]. Poor coordination of care is often cited as one of the main causes of inadequate services and adverse patient events [
44,
45]. Secondly, new technologies disrupt communication activities and influence the organisational structure and process [
46]. This can involve role changes [
47], transformations in the way that departments interact with each other [
43,
48,
49], altered cultural constraints and enablers [
50], adaption to changing social networks [
51‐
53] and modified infrastructure configurations [
54]. Thirdly, EEOC implicitly requires attention to the socio-material and temporal-spatial requirements of HIT implementation particularly as regards how and where work is allocated, coordinated, enacted and synchronised [
55]. This is because new technologies can affect the way that clinical work is carried out, the speed with which it is undertaken and even the setting (e.g., point of care or tele-health) in which it is performed [
56].