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01.12.2012 | Research article | Ausgabe 1/2012 Open Access

BMC Medical Informatics and Decision Making 1/2012

Tool, weapon, or white elephant? A realist analysis of the five phases of a twenty-year programme of occupational health information system implementation in the health sector

BMC Medical Informatics and Decision Making > Ausgabe 1/2012
Jerry M Spiegel, Karen Lockhart, Carmen Dyck, Andrea Wilson, Lyndsay O’Hara, Annalee Yassi
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1472-6947-12-84) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no financial competing interests. The information systems reported herein are non-commercial, and the source code for the Occupational Health And Safety Information System (OHASIS) is freely available.

Authors' contributions

JS is the principal investigator of the “Tool, Weapon or White Elephant” study funded by the Canadian Institutes of Health Research, which helped form the conceptual basis of this article. He led in the conceptualization and writing of this manuscript, along with AY. He also personally did the final editing and preparation for submission. KL conducted a literature review to support the article, assisted in the initial drafting and contributed her observations from years of working with the information system in British Columbia. LO assisted with the drafting of the article based on her involvement with the system development and implementation in South Africa. AW assisted with the drafting of the article, as well as drafting and conducting the survey of system users in South Africa noted in this article, along with the collation and interpretation of the results; she also interviewed system users in British Columbia and incorporated these observations into the article. CD also assisted with the drafting of the article, as well as drafting and conducting the survey of system users in South Africa. She also conducted interviews of system users in South Africa and contributed these observations to the article. AY, the senior author on this manuscript, played the lead role in developing, adapting and implementing the systems described in all five settings, as well as conducting research related to system use in all five settings. She wrote the first draft of this article, and worked closely with Dr. Spiegel on the final draft. All authors read and approved the final manuscript.



Although information systems (IS) have been extensively applied in the health sector worldwide, few initiatives have addressed the health and safety of health workers, a group acknowledged to be at high risk of injury and illness, as well as in great shortage globally, particularly in low and middle-income countries.


Adapting a context-mechanism-outcome case study design, we analyze our team’s own experience over two decades to address this gap: in two different Canadian provinces; and two distinct South African settings. Applying a realist analysis within an adapted structuration theory framing sensitive to power relations, we explore contextual (socio-political and technological) characteristics and mechanisms affecting outcomes at micro, meso and macro levels.


Technological limitations hindered IS usefulness in the initial Canadian locale, while staffing inadequacies amid pronounced power imbalances affecting governance restricted IS usefulness in the subsequent Canadian application. Implementation in South Africa highlighted the special care needed to address power dynamics regarding both worker-employer relations (relevant to all occupational health settings) and North–south imbalances (common to all international interactions). Researchers, managers and front-line workers all view IS implementation differently; relationships amongst the workplace parties and between community and academic partners have been pivotal in determining outcome in all circumstances. Capacity building and applying creative commons and open source solutions are showing promise, as is international collaboration.


There is worldwide consensus on the need for IS use to protect the health workforce. However, IS implementation is a resource-intensive undertaking; regardless of how carefully designed the software, contextual factors and the mechanisms adopted to address these are critical to mitigate threats and achieve outcomes of interest to all parties. Issues specific to IS development, including technological support and software licensing models, can also affect outcome and sustainability – especially in the North–south context. Careful attention must be given to power relations between the various stakeholders at macro, meso and micro levels when implementing IS. North–South-South collaborations should be encouraged. Governance as well as technological issues are crucial determinants of IS application, and ultimately whether the system is seen as a tool, weapon, or white elephant by the various involved parties.
"You may call me a fool, But was there a rule The weapon should be turned into a tool? And what do we see? The first tool I step on Turned into a weapon. - Robert Frost "
"White (albino) elephants were regarded as holy in ancient times in Thailand and other Asian countries. Keeping a white elephant was a very expensive undertaking, since the owner had to provide the elephant with special food and provide access for people who wanted to worship it. If a Thai King became dissatisfied with a subordinate, he would give him a white elephant. The gift would, in most cases, ruin the recipient. - The Phrase Finder "
Authors’ original file for figure 1
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