The promise
Health systems globally are facing increasing demands for highly sophisticated services, yet they have limited resources and current and projected shortages of health professionals[
1]. In OECD[
2] countries the costs of healthcare delivery are rising, fuelled by ageing populations, more complex care and new medical technologies. In Australia, for example, health is already one of the most expensive sectors of the economy, at 9.3% of GDP;[
3,
4] and by 2045 this allocation is predicted to rise to at least 16%[
5] One of the single most important challenges for health systems, then, is to establish new models of service delivery which increase capacity and provide rapid, safe, effective and affordable health care,[
6,
7] and do so sustainably, within health workforce and resource constraints. A key strategy being advanced to meet this challenge is increased use of information and communication technologies (ICT)[
6].
Global expenditure on ICT across all sectors exceeds $US3.5 trillion[
8] (2007 estimates) and is being driven by the desire for improvements in productivity, work practices and service outcomes [
9‐
12]. Seeking the productivity gains and improved service outcomes evident in other industries, developed health systems such as those of the US, Canada and Australia are increasingly investing in ICT [
13‐
15].
The reality
Studies have shown that the use of ICT in the health sector is capable of increasing efficiency, reducing errors, supporting more team-based care, improving integration of best practice into routine care, enabling consumers to engage more actively in their care, and producing more efficient services through changes in professional roles and responsibilities[
16,
17]. However, this has been demonstrated only in exemplar organisations and isolated projects [
16‐
18]. Evidence of large-scale changes in work practices, supported by ICT use, is lacking[
16]. Information to date suggests that despite the rapid increase in ICT investment, uptake has been slow and the benefits fewer than expected[
2,
19]. Further, cases have emerged in which ICT has produced unexpected and negative effects in efficiency and safety [
20‐
22].
Approaches to ICT implementation used in other industries have had limited success in the health sector. This is due in part to the sector's unique organisational and workforce characteristics. Healthcare organisations are complex[
23]. The major professional groups have high levels of autonomy[
24,
25], are tribal in their behaviours[
26] and operate in hierarchical structures[
26]. Work is highly specialised and work processes non-linear[
27,
28]. Yet safe and effective work is dependent upon horizontal work co-ordination, particularly strong collaborations between professional groups; thus effective inter-professional and organisational communication is vital[
29]. Furthermore, unlike in some industries, ICT in health seems to lead to an
increase in the complexity and intellectual content of work, rather than to the simplification or removal of complex tasks[
30,
31]. The business process reengineering[
32] approaches to work practice change that have been prominent in health ICT projects are, in contrast, usually based on top-down linear workflow models[
30] and are often inadequate for dealing with the complex collaborative nature of medical work. The limitation of these traditional approaches to ICT work practice reform is evidenced in the large number of reported failures of large health IT projects [
33‐
35]. Constant changes in the systems used cause additional problems. For example, a survey of over 800 participants at an annual electronic medical record (EMR) trade fair in the US in 2007 found that 19% of respondents reported that they had or were in the process of de-installing an EMR system[
36].
These failures have led to a search for approaches that place greater emphasis on the interconnectedness between the social (people, values, norms, culture) and technical (tools, hardware, equipment, processes) aspects of organisations[
37,
38]. For example, Computer-Supported Cooperative Work (CSCW) studies have investigated the ways in which individuals and teams interact with technologies such as flight simulators[
39,
40]. But one problem with human-technology interaction studies is that they are based largely on a theory of command and control[
41]. For example, in the cockpit a small team conducts a sequence of tasks in accordance with explicit rules and regulations. This workplace is clearly defined and relatively isolated. Studies focussed on such bounded organisational structures are of questionable relevance to more intricate and fragmented work settings. The health sector, with its many professional subgroups, complex work processes and power structures, represents a much more fluid and dynamic context with fewer formalised control mechanisms[
42].
Gaps in knowledge
Although it is recognised that the benefits of ICT will not be realised without considerable changes in work processes and structures,[
19] there is a critical absence of research-based, empirically-tested models for achieving this on a large-scale in the health sector[
43,
44]. Instead, single site, short-term, primarily descriptive studies have dominated research in the field internationally. Also, researchers have focussed almost exclusively on studying organisations that have developed their own ICT systems. In a systematic review of the impact of ICT use in health, nearly 25% of studies were conducted in one of four US medical centres, all with home-grown systems[
16]. In only 9% of 257 studies were commercial systems examined. Yet in Australia, as in other countries, it is commercial systems that are implemented by the vast majority of organisations. Most of these systems are developed in the United States and thus are designed for health delivery models that may not hold in other health jurisdictions. As such, they create particular challenges for predominantly publicly-funded health systems and may create barriers to their use in supporting effective work practice change[
45,
46]. In summary, there is poor understanding of why some organisations are able to achieve significant work practice change, yet others using the same ICT systems are not[
46]. This raises questions about which factors enable or inhibit ICT-supported work innovation. In previous studies we have shown that characteristics of team[
47] and organisational[
48] cultures are associated with effective ICT use, but there are likely to be other significant factors.
Thus the evidence of how ICT can support and drive innovative work practice change is generally weak and comes largely from non-transferable case studies of single organisations[
16,
21,
49]. Large-scale multi-site studies are now needed. This is crucial not only to achieve the productivity improvements required, but to create safer health systems[
50]. One in ten patients is harmed as a result of care received, and studies have shown overwhelmingly that poor communication and lack of teamwork are major causes[
51], Runciman, 2007 #1852] ICT is central to improving communication and teamwork to deliver a safer health system.
The aim of this research is to conduct a large-scale, multi-site study to measure current ICT impact on workforce practices. It will also develop and test new models of ICT use which support innovations in work practice.