DOI: 10.4018/IJSODIT.2017010104
Copyright©2017,IGIGlobal.CopyingordistributinginprintorelectronicformswithoutwrittenpermissionofIGIGlobalisprohibited.
The Politics of Establishing ICT
Governance for Large-Scale Healthcare Information Infrastructures
Gro-Hilde Ulriksen, University Hospital North Norway, Norwegian Center for E-health Research, Tromsø, Norway Rune Pedersen, University Hospital North Norway, Norwegian Center for E-health Research, Tromsø, Norway Gunnar Ellingsen, Arctic University of Norway, Faculty of Health Science, Tromsø, Norway
ABSTRACT
In Norway, the focus on interoperability and communication across healthcare practices has
increasedtheneedtoconnectICTportfoliosatdifferentlevelsofhealthcare,intolarge-scale
informationinfrastructures(II).Governinghealthcarepracticesisexceptionallycomplex,dueto
thediverginggoalsandpoliciesoftheheterogeneousactorsinvolved.Establishwell-functioning
ICTgovernanceorganizationstohandletheselargeinfrastructuresisthereforeimportant.Using
informationinfrastructuretheory,andgovernanceliteraturefromtheISfield,thispapercontributes
withempiricalinsighttothelongitudinalandpoliticalprocessofestablishingICTgovernancein
ahealthcarecontext,reportingfromoneofNorway’slargesthealthICTprojects,situatedinthe
NorthNorwayRegionalHealthAuthorityin2012–2016.Ourfocuswasonthefollowingresearch
questions:HowdoesorganizationalpoliticsshapetheprocessofestablishinganICTgovernance
organizationinaheterogeneoushealthcareenvironment,andwhatdoesittaketoestablishsuchICT
governanceorganization?
KEywORDS
Electronic Patient Records (EPR), Information Infrastructure (II), Information Systems (IS), Polycentric Governance, Regional ICT Governance
INTRODUCTION
Standardizationoftechnologyandworkprocesses,toreachseamlessintegrationsandsemantic
interoperabilityinNorwegianhealthcare,hasgainedincreasedfocusoverthelastyears.Thegrowing
needforinter-organizationalcollaboration(Croteau,Bergeron,2009;Dahlberg&Helin,2014)and
communicationhasraisedtheneedforregionalinformationandcommunicationtechnology(ICT)
portfolio.TheroleoftheEPRsystems,movingfromlocalinformationstoragesystems,tolarge- scaleuser-centeredworktools,hasbeenparticularlyimportant.Consequently,theICTportfolios
haveexpandedinsizeandcomplexity.Hence,well-functioningICTgovernanceorganizationsat
differentlevelsofhealthcarepracticeshasgainedincreasedfocus.ICTgovernanceincludehowto
designandimplementeffectiveorganizationsbycreatingflexibleICTandinformationsystem(IS)
structuresandprocesses(Patel,2002).Theoverallgoalisforgovernanceorganizationstoensure
successfuldeliveranceofhealthcareservices(Beratarbide&Kelsey,2009).Thereareincreasing
evidencerelatedtoestablishingaconnectionbetweenwell-organizedgovernanceofhealthcare
organizations,andimprovedorganizationalperformance(Tabish,2012).However,hospitalsand
healthsystemsstrugglewithmattersofgovernance,particularlyrelatedtocarestandardization,and
qualityimprovement(Tabish,2012).
When making an effort to regionalize and standardize ICT portfolios, ICT governance
organizationsareimportantformaintainingtheregionalfocusandhandlingchallengesalongthe
way.TraditionallyICTgovernanceorganizationswereruninatop-downmanner(Weill&Ross,
2004),thishashoweverrarelyprovenefficientorsuccessfulforheterogeneoushealthcarepractices
(Constantinides&Barrett,2014;McGinnis,1999).Therefore,apressingneedforshiftingtoamore
bottom-upgovernancestructure,focusingonthedynamicinteractionsbetweentechnicalandsocial
elementsinICTdesign(Constantinides&Barrett,2014)hasraised.Giventheincreasedambitions
ofinformationsharing,healthcareischaracterizedasinstitutionswithdifferentgoalsandpolicies,
differentICTportfoliosinplay,and,stakeholderswithdifferentinterests.Hence,itisnecessaryto
lookatthecomplexityofICTgovernance,andthechallengesofgoverningICTportfoliosatregional
levelsofhealthcare.Introducinginter-organizationalgovernanceisanattempttoovercomethelack
ofinteroperabilityandstandardsinhealthcare(Dahlberg&Helin,2014).
Thecontributionofthispaperistoprovideempiricalinsighttothelongitudinalandpolitical
processofestablishinganICTgovernanceorganizationwithinahealthcarecontext.Basedonthis,
weaskthefollowingresearchquestions:Howdoesorganizationalpoliticsshapetheprocessof
establishinganICTgovernanceorganizationinaheterogeneoushealthcareenvironment,andwhat
doesittaketoestablishsuchICTgovernanceorganization?
Wehavegatheredourempiricaldata,byfollowingthestepsofaregionalinitiativeintheNorth
NorwegianHealthAuthority.In2012,thishealthregioncompletedalargetender,anddecidedto
regionalizetheirnewICTportfolio.Tocarryoutthesechangestheyestablishedaregionalproject
(dubbedBigProject),torunfrom2012-2016.BigProjectwasoneofthelargestICTinvestmentsin
Norwegianhealthcare,andthemaingoaloftheprojectwastoestablisharegionalICTportfolioasa
foundationforregionallystandardizedpatientpathways,decisionsupport,andintegrationsbetween
clinicalICTsystems(Christensen&Ellingsen,2013).Aregionalization,includingstandardizing
EPRworkpractice,wasnecessaryrequirementsforreachingsuchgoals,andforenablingtheHealth
Authoritiestobetteradministrateandcomparethehospitalsintheregion.Inaddition,theBigProject
workedinclosecollaborationwiththelargestEPRvendorinNorway,ondevelopingamorestructured
andinteroperableEPRsystem,inordertocommunicateacrossheterogeneoushealthcarepractices
(Nasjonal-IKT,2012).
Thedatawascollectedbyusingaqualitativeinterpretivemethod(Klein&Myers,1999;
Walsham,1995),includingopen-endedinterviews,documentstudies,andparticipationinmeetings
andworkshops.Throughthisapproach,weaimedtoemphasizevariousviewpointsoftheprocessin
ordertoachieveadeeperunderstandingofthechallengesdetected.
Theoretically,weappliedinformationinfrastructuretheory;see(G.C.Bowker&Star,2000;
Hanseth&Lyytinen,2010;Hanseth&Monteiro,1998;Hanseth,Monteiro,&Hatling,1996;Star
&Ruhleder,1996)frequentlyusedtocharacterizeandanalyzelarge-scaleintegratedinformation
systemsportfolios(Garrod,1998;Meum,Monteiro,&Ellingsen,2011),andtheinterconnection
betweenusersandtechnologyinheterogeneoushealthcarepractices(Hanseth&Lyytinen,2010;
Hanseth&Monteiro,1998).WealsousedICTgovernanceliteraturefromtheinformationsystems
field;see(Beratarbide&Kelsey,2009;Brown,1997;DeHaes&VanGrembergen,2005;Simonsson
&Johnson,2005).
Therestofthepaperorganizedasfollows.First,thetheoreticalframeworkisintroduced.Next,
wepresentandelaborateonthemethod.Further,thecase,includingtheBigProjectandthenewEPR
isdescribe.Wethenpresentadiscussion,emphasizingondifferentgovernanceperspectives,and
methodsofstructuringanICTgovernanceorganization,aimedatmanaginglarge-scaleinformation
infrastructures.Last,weconcludethepaper.
THEORy
Thegoalsofintegratedcare,evidence-basedtreatmentandstandardizedpatientpathwayshaveled
healthcareorganizationstoinvestheavilyinintegratedICTsystems(Chantler,Clarke,&Granger,
2006;Chiasson,Reddy,Kaplan,&Davidson,2007;LeRouge,Mantzana,&VanceWilson,2007).
Accordingly,wearenotdealingwithjustonesystem,butinsteadwithaportfolioofinterconnected
systemsacrossinstitutional,departmental,andprofessionalboundaries.Asawayofconceptualizing
thisidea,thenotionofinformationinfrastructure(II)isparticularlyuseful(G.Bowker,Timmermans,
&Star,1996;Ellingsen,Monteiro,&Munkvold,2007;Star&Ruhleder,1996;Timmermans&Berg,
2003).Fromatechnicalviewpoint,assemblinganIIinvolvesdesigning,implementing,integrating,
andcontrollingincreasinglyheterogeneousICTcapabilities(Tabish,2012).Socially,creatingan
IIrequiresorganizing,andconnectingheterogeneousactorswithdiverginginterests,inwaysthat
allowIItogrowandevolve.Furthermore,IIsareheterogeneous,andopentoanunlimitednumberof
participants,suchasusers,vendors,andtechnicalcomponents(Hanseth&Lyytinen,2010;Hanseth
&Monteiro,1998),whichisimportantforuseinahealthcaresetting.Aparticularlyimportant
conceptistheinstalledbase(Hanseth&Monteiro,1998),whichimpliesthatanIIneverdevelops
fromscratch,butemergesandevolvesfromanexistinginstalledbase.WhendevelopingnewEPR
systems,consideringtheoldportfoliosandpracticesinHealthTrustsisimportant.Forthedifferent
partsofanIItocommunicate,standardsarecoreelements(Hanseth&Lyytinen,2010).Standards
ensurehigh-qualitycarethroughbestpracticesdevelopment(Timmermans&Berg,2003),increased
efficiency,aswellasensuringseamlesspatienttrajectoriesoverorganizationalborders(Pedersen,
Meum,&Ellingsen,2012).
ApressingquestionishowandtowhatdegreeanIIingeneralandstandardsinparticularcanbe
managedatdifferentlevelsofhealthcare.IntheIIliterature,severalauthors;see(Edwards,Bowker,
Jackson,&Williams,2009;Karasti,Baker,&Millerand,2010;Pipek&Wulf,2009),haveusedthe
notionofinfrastructuring,inordertoemphasizetheproactiveengagementwithlargeICTportfolios.
Theseinsightsarerelevantforunderstandingthemechanismsforchange;however,therehasbeenless
focusonthemoreformalgovernanceoforganizationalstructuresandconfigurationsofII’s.Thereis
anincreasedneedtoestablishICTgovernanceorganizationsthatmakedecisions,aswellasmonitor
results,andperformances(Beratarbide&Kelsey,2009),atdifferenthealthcarelevels.Ourfocusin
thispaperisoninterorganizationalICTgovernanceataregionallevel.
Mostinformationsystemshadin-houseICTgovernanceuntilthemid-1990s.Therefore,
ICTgovernancehasoftenbeenappliedfromaninternalperspective(Boynton,Jacobs,&Zmud,
1992;Brown,1997;Brown&Magill,1994;Sambamurthy&Zmud,1999).Itisthuschallenging
toestablishregionalinterorganizationalICTgovernance.ICTgovernancespecifiesthedecision
rightsandaccountabilityframeworktoencouragedesirablebehaviorinICTusage(Weill&Ross,
2005).WeadheretothefollowingdefinitionofICTgovernance:“Thepreparationfor,making,and
implementationofdecisionsregardinggoals,processes,people,andtechnology,onatacticaland
strategicleveloftheITorganization”(Simonsson&Johnson,2005).StarsandRuhleder(1996)
statedthattheconfigurationmechanismsofgovernancearetypicallyamixtureofvariousstructures,
processes,andrelationalaspects(Star&Ruhleder,1996).ImplementingICTgovernancecontributes
toensuresuccessfuldeliveryofhealthcareaccordingtoBeratarbide&Kelsey(2009).Theoverall
goalofanICTgovernanceorganizationis“toassurethestakeholdersthatthingswillgoasexpected,
andensurethesuccessfuldeliveryofhealthcareservices”(Beratarbide&Kelsey,2009).ManyICT- relatedmanagementframeworks,methodologies,andstandardsareusedtoday;see(Beratarbide
&Kelsey,2009;VanGrembergen,DeHaes,&Guldentops,2004).NoneformsacompleteICT
governanceframework,butallhavearoleinassistingorganizationstowardsmoreeffectivelymanaging
andgoverningtheirinformationandrelatedtechnologies(Beratarbide&Kelsey,2009),aswellas
identifyingICTgovernanceweaknesses.
Previously,atop-downapproachwithaclearICTgovernancestructuredefiningnecessary
decisions,andwhoshouldmakethem,wasfrequentlyused(Weill&Ross,2004).Managementstudies
promotedthisdesignbasedonpre-definedmodelsofworkpracticessee,forinstance,(Ashkenas,
Ulrich,Jick,&Steve,2002;Davenport,1993).However,suchstrongcontrollingICTgovernancefor
definingandmakingdecisions(Weill&Ross,2004),hasbeenineffective,andevenimpossibleto
applytoIIinhealthcare(Constantinides&Barrett,2014).Severalactorsontheclinicalandtechnical
sidesofhealthcareneedtobeincludedinsuchgovernance.Duetotheconstantgrowthincomplexity
anddeviationfromoriginalintentions,anIIisimpossibletogoverncompletelyinatop-downfashion
(Croteau&Bergeron,2009;Hanseth&Lyytinen,2010).
Ininterorganizationalcontexts(suchasinourcase),VanGrembergenetal.(2004)suggestthat
ICTgovernanceshouldincludecooperationmechanismstoimprovecoordinationofstakeholders
withdifferentICTbackgrounds(managementandgovernancehistories),andcompetence(ICTassets
andresources)(Dahlberg&Helin,2014).Thisbecauseinterorganizationalrelationshipsmature
dynamically,andcollaboratively,overvariousstates(Croteau&Bergeron,2009).Thepurposeof
suchgovernanceistoensurethatorganizationslikeHealthTrustshavestructures,processes,and
mechanismsforcollaboration,resolvingdisagreements,andorganizingworkontheinterorganizational
andorganizationallevels(Dahlberg&Helin,2014).Improvedqualityandmoreinteroperablehealth
informationisnecessary,butverychallengingtomatchwithICTgovernanceprinciplesandbenefits
inlargescaleinterorganizationalIIs.
However,despiteestablishingcooperationmechanisms,thesizeandscopeofanIImaybea
seriouschallengetoICTgovernance.Heterogeneousstakeholdershavedifferentgoalsandstrategies
forreachingthem,resultinginfrequenttension.Thisisparticularlyevidentinahealthcarecontext.
Asaresult,regionalizationprocessesmaybeextremelychallengingtoaccomplish.Anobvious
challengeisthetensionbetweenstandardizationandflexibility,recognizedbyHansethetal.(1996).
However,flexibilityisnecessaryatthelocallevelofahealthcareII,whichenableuserstowork
efficiently.Incontrast,theregionalperspectiveemphasizesaneedforstandardization,andtheability
tocomparedifferentunitsasapartofrunningamoreefficientandcost-effectivehealthcareservices.
Inthisregard,ConstantinidesandBarrett(2014)suggestapolycentricgovernanceapproachinwhich
differentstakeholdersareengagedindynamicandadaptivegovernanceprocesses(Constantinides
&Barrett,2014).
Polycentricgovernanceincludesorganizinganumberofgoverningunitsatdiverginglevels,
insteadofonemonocentricgovernanceunit(McGinnis,1999).Insuchgovernancemodel,thereisa
distributionofdecision-makingacrossorganizationallayers,andamongabroadrangeofstakeholders,
whereeachlayerdealswithassociatedsubjectsatagraduallylargerscaleandless-detailedlevel
(McGinnis,1999).Thisway,differentactorsinanII(suchasaHealthTrust)participateinICT
governancebycontrollingpartsofanICTportfolio.Consequently,thismayleadtoasmoother
regionalizationprocessinwhichtheactorsdonotneedtogiveupalllocalcontrol.Onekeyadvantage
ofpolycentricgovernanceisthepossibilityofcreatinggeneralformedrulesthatcanlaterbeadapted
tospecificlocalneeds(McGinnis,1999).
However,thismodeldoesnotrepresenta“fasttracktosalvation;”itrequiresthatactorsspend
extensivetimeandenergyonnegotiatingandcompromisingonacceptablecollaborativesolutions
(Latour,2005).Evenincaseswhereacommonforumisestablished,itmaybeimpossibletoagreeon
governancestructuresacceptabletoallparties,becauseoftheheterogeneityofinterestsandresources
involvedinhealthcareIIs(West,2007).Inordertograspthechallengesofgoverninginformation
infrastructures,itiscrucialtounderstandthevariousinterestsandassociatedmechanismsandhow
theyplayoutovertime(West,2007).
METHOD
Thisstudyispositionedwithinaqualitativeinterpretiveparadigm(Klein&Myers,1999).Itcontributes
toalongitudinalqualitativestudyconnectedtoalarge-scaleEPRprojectintheNorthernNorway
RegionalHealthAuthority.Analysisoflongitudinalresearchisacontinuousanditerativeprocess,with
anever-changingintensity,focusingondevelopingandincreasingtheunderstandingofaphenomenon,
byexploringdiverseviewpointswithinaspecificcontext(Klein&Myers,1999;Walsham,1995).
ThisNorthNorwegianHealthregionconsistsoffiveHealthTrustsincluding11hospitals.The
regionalEPRproject(BigProject)has25employeesand5sub-projects,ofwhichtwofocuseson
ERP.WeinterviewedparticipantsfromHealthTrusts,localandregionalmanagementorganizations,
RegionalHealthAuthorities,andBigProjecttoestablishdifferentviewpointsoftheregionalprocesses.
SinceregionalstandardshadnotyetbeenimplementedintheHealthTrusts,interviewingphysicians
andotherend-userswasnotrequiredatthispoint.Theirperspectiveswillbemoreimportantto
enlightenaftercompletingtheimplementationsofstandardsin2015–2016.
Thefieldworkbuildsonthefirstauthor’srole,workinginthestandardizationofpracticeproject
fortwoyears,inadditiontoparticipatinginworkshops,discussions,andmeetingsinthisproject,
andalsothedevelopmentofthenewEPR.Thedatacollectionincludes11open-endedinterviews
conductedin2014–2015.Exceptfromone,alltheactorsaskedagreedtobeinterviewed.The
interviewslasted60–120minuteseach.Theinterviewguidewassemi-structuredwithquestions
relatedtothestandardizationofpracticeprojects.Thisincludedprosandconsofstandardization,
whyregionalizationisimportant,andwhatregionalchallengesremainaftertheprojectsarefinished.
TherewerealsoquestionsconcerningchallengeswithestablishingandorganizingaregionalICT
governanceorganization.
RefertoTable1.Thefirstauthortranscribedtheinterviews,andanalyzed,andcategorizedthe
textintomainissuesincollaborationwiththeotherauthors.Weusedthehermeneuticcircle,moving
fromunderstandingpartsoftheprocesstounderstandingthewholeprocess(Klein&Myers,1999).
Thechallengesoforganizingaregionalgovernanceorganization,andhowtodealwithtension
betweendifferentactors,weresomemainissues.Thenwediscussedandreflectedonthesesubjects
inrelationtothecontext,thetheory,andtheresearchquestions.Inaddition,wesupplementedthe
dataanalysiswithprojectdocumentsandreportstoacquirethebestpossibleoutlineoftheprocesses.
CASE
The Regional Strategy
Afteraprolongedbidfortenderprocessin2011,theNorthNorwegianHealthAuthoritydecided
toinvestinnewclinicalICTsystemsforalltheir11hospitals,andatthesametimeregionalizethe
ICTportfolio.Asaresult,theHealthRegionestablishedBigProjectforthe2012–2016period.With
acostlikelytoexceed€100million(Christensen&Ellingsen,2013),thisprojectconstitutesoneof
Table 1. Overview of interviewed participants
Informant Time Background
Four informants from BigProject 60–90min Laboratory,nursing,healthsecretary,technical Three informants from regional ICT management 60–120min Technical,nursing.
Two local project leaders from Health Trusts 60min Nursing,occupationaltherapy Leader from the local governance organization,
UNN 60min Nursing
Leader from a Regional Health Authority 90min Economy
thelargestandmostambitiousICTprojectsinNorwegianhealthcare.Thegoalsoftheprojectwere
toestablish
• Standardizedclinicalpathways
• “Bestpractice”standardsforEPRworkpracticeandproceduresacrosstheHealthRegion
• Clinicaldecisionsupport
• Regionalintegrationsandinteroperabilitybetweenclinicalsystems
AcrucialpartoftheprojectwascontributingtodevelopinganewEPRsystem(NewArena),using
acompletelynewarchitecturewithauser-centeredconfiguration,andstructuredclinicalcontent.
AsthehospitalsintheHealthRegionalreadyhadanup-and-runningEPRsystem(ClassicEPR),a
crucialpartofthisprojectwastoestablishastrategyforasmoothtransitionbetweenClassicEPR
andNewArena.Inthenextsections,weelaborateinmoredetailontheseefforts.
Inthisprocess,BigProjecthadtheprimaryresponsibilityforhandlingthemajoractivities.
However,theexistingregionalICTmanagementorganizationwasalsoascribedacrucialrole.Their
250employeeswereresponsiblefordeliveringICTservices,aswellasrunningandmaintainingthe
technicalpartsoftheICTportfoliointheHealthRegion.TheregionalICTmanagementcollaborated
closelywithvarioussizedlocalICTorganizationsinthedifferentHealthTrusts.Inaddition,both
BigProjectandtheregionalICTmanagementcollaboratedwitharegionalclinicalICTadvisoryboard,
establishedforhandlingtheclinicalcontentoftheICTportfolioataregionallevel.Theadvisory
boardhadrepresentativesfromallthefiveHealthTrustsintheregion,andmetaboutonceamonth
toprovidestrategicrecommendationsfortheRegionalHealthAuthorities.Theadvisoryboardacted
asdecision-makersforregionalICTissues,andthusrepresentedatemporarydefactoregionalICT
governanceorganization.Evenso,itwasacommonunderstandingintheHealthRegiontoreplace
theadvisoryboardwithapermanentregionalgovernanceorganization,whichworkedonadaily
basis,whenthisorganizationwasestablished.
Developing New EPR
In2012,BigVendorstarteddevelopingNewEPRbasedonopenEHRarchitecture.OpenEHRbuilton
standardizedinformationmodels,opensourcecomponents,andhighlystructuredclinicalcontent,
includingarchetypesascorecomponents(Beale&Heard,2008).Archetypesarestructureddata
elementsofclinicalconcepts,envisionedtoensuretechnology-independentinteroperability,easy
reuseofinformation,andefficientdecisionsupport(Chen,Georgii-Hemming,&Åhlfeldt,2009).
Experiencedcliniciansareresponsiblefordefiningthearchetypes,thiswaytheclinicalpersonnel
controlwhatcontenttostructure,aswellashowandwhentodoit.Itispossibletobuildtheentire
internalstructureofschemes,processesanddecisionsupportintheEPR,byorganizingalldatain
archetypes,andcombiningthemtoformtemplates.Thereisacallforcloseregionalcollaboration,
tomaintainandbuildtheclinicalcontent,includingpatientpathwaysandarchetypesforNewArena.
ThegoalistohaveanewEPRsystemworkingacrossinstitutionalborderscapabletofollowthe
patients’entiretrajectories(Pedersenetal.,2012).
Tosupportthisorganizationally,theUniversityHospitalNorthNorway(UNN)establisheda
regionalarchetypegovernanceorganizationin2013with10employees.Thisunitwillsupportclinical
usersincreatingandmaintainingthearchetypesatvariouslevels(locally,regionallyornationally).
Theregionalarchetypegovernancewillbeorganizedatanoverallregionallevelinthenewgovernance
organization,independentofclinicalapplicationslikeEPR,radiologyandlaboratory.
TheHealthAuthorityneededtodecideonastrategytocombineClassicEPRwithNewArena,
sinceNewArenaisdevelopedandimplementedinmodulesoveratleastfiveyearswhileClassicEPRis
stilloperative.ThismadeitnecessarytobeabletomanagetwodifferentEPRsystemssimultaneously,
aswellasensurethatuserscouldswitchseamlesslybetweenthesystems.Therefore,theregional
ICTmanagementimplementedatechnicalsolution,toensurethattheoldandnewsystemscan
interactseamlessly.“Acontextsyncisinstalled,tomaketheswitchbetweenNewArenaandClassic
EPRseamlessforsystemusers.However,switchingbetweentwosystemsincreasestheriskofuser
errors,andtechnicalcomplications”(representativefromregionalICTmanagement).Thischange
istechnicallydemanding,aswellaschallenging,forusers,asattentiontowhatplatformtheyare
workingonisrequiredtoaccomplishtheirwork(Christensen&Ellingsen,2014).Afterimplementing
moremodulesofNewArena,somefunctionalitieswillbeinClassicEPRandothersinNewArena.In
addition,bothtechnologyanduseareverydifferentbetweenClassicEPRandNewArena.Anexample
describedbyChristensenandEllingsen(2014)fromthefirstpilotofNewArenaillustratesthis:The
newsystemhadstructureddatabasedonarchetypes,butClassicEPRdidnotsupportstructuredtext.
Physicianscreatedarchetype-baseddocumentsinNewArenatoplanoperations.Thentheysentthese
documentstoClassicEPR,andsecretariesincludedthedocumentsinthesurgery-planningmodule.
StructureddataregisteredinNewArenathenbecamefree-textdocuments,andthebenefitsofusing
archetypesdisappearedcompletely(Christensen&Ellingsen,2014).Thisindicatedtheriskofusers
notreceivinganyactualbenefitsofNewArena,untilthereareseveralmodulesimplemented.
NewArenaalsocallsforacloseengagementrelatedtouser’spractice,andmorerequestfor
ICTsupportandgovernanceclosertotheend-users.Thisrelatestothegoalofdesigningclinical
decisionsupportandpatientpathways,andtheneedtokeepthemconstantlyupdated.However,this
isanimpossibletaskfortheexistingICTmanagementorganizationtoprovide,duetoitsregional
role,andthusitsdistancefromusers.“Thedistancebetweentheclinicsandtheregionalgovernance
organizationistoofar.Itiscumbersometogetholdoftherightpersontosolveaproblem”(local
projectleader).Tomakethiswork,thereisaneedforaregionalgovernanceorganization.Inthefirst
pilotofNewArena,thetestingrelatedtothesurgeryoutpatientclinicconfirmedthatuserswould
requireclosefollow-uprelatedtomakethenewfunctionalitiesusefulforthem.
The Standardization of Practice Project
Toprepareorganizationallyforthenewsystem,andattaintheRegionalHealthAuthority’sgoalsof
higherquality,efficiencyandinteroperability,regionalstandardsandroutinesforEPRusagehadto
beestablished.StandardsareimportantforalargeIIsuchasaHealthRegiontoworkoptimally.Big
Project’sstandardizationofpracticeprojectwasthereforeinitiatedin2012.Thegoalwasto“increase
qualityandsafetyinpatienttreatment,throughstandardizingclinicalpracticerelatedtoEPRusage
acrosstheregion”(Nilsen,2013).Morethan500systemusersfromall11hospitalsintheregion
participatedinmappingEPRusageandestablishingregionalstandardsin2012–2013.Theproject
identifiedexistingworkpractices(theinstalledbase)atallhospitals,andusedabestpracticeprinciples
tostandardizeworkroutinesandprocedures.Inadditiontosystemusers,theEPRvendor,andboth
regionalandlocalICTmanagementorganizationsparticipatedinthisprocess.Theimplementation
oftheregionalstandardswillbecompletedin2015–2016,includingareassuchasorganizational
configurations,journalstructure,accesscontrol,laboratorywork,andworkflow(Nilsen,2014).A
consequenceoftheregionalstandardsareextensivechangestothedifferenthospitals’workpractices.
Forexample,afterimplementingthestandards,anewformofaccesscontrolwillberequiredtouse
theEPRsystem.Today,therearegreatvariationsrelatedtowhatusersatthedifferenthospitalscan
accessautomatically.Forsome,thisnewadmissioncontrolwillprovidethemwithautomaticaccess
tolessoftheEPRthantheyhavetoday.Anotherchangeisthatallhospitalsmustregisterequivalent
activitiesatthesameorganizationallevel,makinginformationeasiertocompareattheregionallevel.
Consequently,theorganizationalstructuringofthehospitalshastobealtered.
“Establishingtheregionalstandardsisasuccess,leadingtobettercollaborationwithinthe
HealthRegionthaneverbefore”(projectleader,BigProject).However,forsomestandardsithasbeen
difficulttoagree.Oneexamplerelatestoregistration.Theregionalstandardstates:“Registrationis
connectedtothepatient’sillness(Nilsen,2014).”Thismeansconnectingallpracticetoaspecialized
field,suchasear,nose,andthroat,orneurology.AprojectleaderinBigProjectstates:“Atasmall
hospital,activityregistrationcannolongerbeconnectedtothecliniciandoingthejob,butratherthe
illnessofthepatient.”Followingtheregionalstandard,allactivitiesareregisteredataregionallevel,
sinceallhospitalsinoneTrustsharethedepartmentsandsectionsconnectedtodifferentspecialized
fields.Thisway,theHealthAuthoritiesimprovedtheiroverviewofactivitiesrelatedtoeachfield.
However,thehospitalsthemselvesnolongerhavethesamelocaloverview.Localhospitalsdonotsee
thebenefitsofchangingtheirregistrationpracticeleavingthemwithlesslocalcontroloftheirdata.
Therehavebeenseveralattemptstryingtoreachanagreementonthismatter,withoutanylucksofar.
Similarchallengesarelikelytoappearafterimplementingthestandards,andtheusers’experience
howtheirworkdaysareaffected.ProjectleadersintheBigProjectunderlinetheneedforaregional
governanceorganization,toformastrategyforhandlingsuchissues,aswellasothersrelatedto
aberrations,modifyingexisting,orformingnewstandards.Withoutagovernanceorganization,they
fearthattheregionalstructureswillfallapartafterBigProjectiscompleted.“Regionaldecisions
havealreadybeeneffectuated,andthereisariskofthemdissolvingwithoutthenecessaryregional
governanceinplace”(projectleader,BigProject).
Consequently,thereisanincreasedneedforawell-structuredregionalinterorganizationalICT
governanceorganizationtofollowupontheresultsofthestandardizationofpracticeproject,and
prepareforNewArena.WorkingoutanoverallgoalforregionalICTmanagement,includingwhat
todoandhowtogetthere,isnecessary.“Itmaytakeseveralyearsandtheprocessmayneedtobe
doneinsteps,buttomoveforward,weneedtohaveastrategystatingwhattheregionwantsthis
organizationtoencompass”(projectleader,BigProject).
Establishing a New Regional Governance Organization
WhentheHealthRegionin2011decidedtoregionalizetheICTportfolioandestablishedBigProject,
theyalsostartedworkingonformingaregionalICTgovernanceorganization.However,itwasdifficult
tonegotiatethenature,form,andlocationofsuchorganization,preferablyhavingtheauthorityto
enforcestandardsonthevariousHealthTrusts,aswellasstrategicallymanagealargeICTportfolio.
TheexperiencesandlessonslearnedwiththeregionalICTmanagement,wasthatthisorganization
couldnotsufficientlysupportclinicalpractice,thusberesponsibleforregionalICTgovernance.There
isacleardifferencebetweenICTgovernanceandICTmanagement.ICTmanagementfocusesmainly
onsupplingICTservicesinadditiontoproducts,aswellasmanagingICToperations(DeHaes&
VanGrembergen,2005).ICTgovernanceismuchbroader,concentratingonperformingalongwith
transformingICTtomeetpresentbesidesfuturedemandsofthebusinessandthecustomers.
Today,allHealthTrusts,especiallythelargestone,havewell-functioninglocalICTmanagement
organizations,duetotheneedforusersupportandgovernanceclosetotheworkers.Thelocal
ICTmanagementattheUniversityHospitalalsoemergedasadefactoorganizationforclinical
ICTmanagement,preparingforthefutureclinicalgovernanceofNewArena,aswellasbeinga
keyplayerpreparingUNNfordevelopingaswellaspilotingthenewEPRsystem.“Myguessis
regionalfunctionalgovernanceisplacedinthebiggestHealthTrust,theyalreadyhaveanestablished
organizationforgoverningbothNewArenaandClassicEPR”(leader,BigProject).Givinguplocal
controlandICTmanagementforanewlyestablishedregionalICTgovernanceorganization,didnot
seemlikeatemptingoffer.However,eveniftheusersagreedontheneedforlocalclinicalgovernance
(i.e.,thelocalICTorganization),theactualcontentofthisorganizationwasfarfromclear.Atone
point,thisresultedinaterritorialdisputebetweenthelocalICTgovernanceatUNN,andregional
ICTmanagement.TheregionalICTorganizationlockedoutthelocalICTmanagementfromthe
administrationtoolinClassicEPR(usermanagement,access,roledefinitionsetc.),withtheargument
thatthiswasatechnicalissue.ThelocalICTmanagement,however,claimedthistoolwaspartof
theclinicalICTgovernance,anddemandedcontinuedaccess.Theyalsosupportedtheirclaimby
implicitlyreferringtotheregionalICTmanagement’smanagingrole:“ItistheHealthTrustthatown
thesystemanddecideswhogetsaccesstowhat”(leader,localICTgovernance).Thisindicateda
strongneedforaregionalICTgovernanceorganizationtohandlesimilarissuesinthefuture.
Afterdiscussingseveralsuggestionswithoutreachinganagreement,UNNwasin2013pointed
outtocompleteaproposalfororganizingregionalICTgovernance.Intheirproposalfrom2014,they
suggestedafragmentedgovernancemodelinwhicheachHealthTrustwereresponsibleforgoverning
separateareasoftheICTportfolioonbehalfoftheothers,meaningthatoneHealthTrustwould
governtheEPR;onethelaboratories,anotherradiologyandsoon.Thismodelwasestablished,based
ontheregionaldiscussions:“Manydiscussionsrelatestoestablishingonesmallgovernanceunitin
eachHealthTrust,oroneregionalgovernanceunit”(leader,localICTgovernanceorganization).The
solutionpresentedbyUNNdistributedgovernancecompetenceandlocalcontrolacrosstheHealth
Trusts.TheHealthAuthoritiespilotedthissolutionforradiologyin2014–2015.Afteranevaluation,
theywilldecidewhethertoapplythismodeltotherestoftheregionalICTportfolio.Thismodel
isinmanywayscomparabletoapolycentricgovernancemodel.Governanceisspreadoutinthe
organizationinsteadofassembledinoneunit(McGinnis,1999).
TheinformantswereskepticofapplyingsuchfragmentedmodeltoEPRgovernance,since
theEPRisverycomplex,andhasmanyintegrationsandinterconnectionswiththerestoftheICT
portfolio.ItisnecessarytoincludealargegroupoftechnicalandclinicalpersonneltohandleEPR
governance,andagroupworkingspecificallywitharchetypesandNewArena.Howtoorganizethisand
howtoseparateEPRrelatedclinicalcontent,iscomplicatedtoworkout.“Thesystemsaresoclosely
interconnected,especiallytheEPRandthelaboratory,thateveniftheHealthTrustagreestosplit
theirgovernancethisseemsimpossiblewithoutcompromisingtheinteroperability”(projectleader,
BigProject).Evenwithalltheskepticism,thismodelmadeitpossibletodefinewhowasresponsible
fordifferentclinicalgovernanceareas.“Itseemslikethebestsolutiontheregionisabletoagreeon
forthetimebeing”(representative,RegionalHealthAuthority).Afragmentedgovernancemodelwas
atleastastartingpointforregionalcollaborationongoverninganinterorganizationalICTportfolio.
Inaddition,establishingandupdatingregionalpatientpathwaysacrossHealthTrusts,primarycare
andotherinstitutionalboundarieshavetobeextensivepartsoftheregionalICTgovernance.
DISCUSSION
DeHaesandVanGrembergen(2005)statesthatICTgovernancecontainsamixtureofvarious
structures,processes,andrelationalmechanisms(DeHaes&VanGrembergen,2005).Weagree,
butweemphasizethatgoverninganevolvingIIshouldbelessconcernedwithcreatinguniform
organizationalstructuresforgeneratingorder,andfocusmoreonaprocessforhandlingdiverging
politicalinterests,managingtensions,aswellascomplexinterdependences.Thiscasehasillustrated
thatestablishingauniforminterorganizationalgovernanceregimeisaformidable,ifnotimpossible,
task.TakingintoaccountpreviousresearchoncomplexII(Bowkeretal.,1996;Hanseth&Lyytinen,
2010;Hanseth&Monteiro,1998;Star&Ruhleder,1996),thecurrentoutcomeisfarfromsurprising.
ModernIIshavebecomeincreasinglymoreinterconnectedandinterdependent.Atthesametime,
ICTsystems,andinparticularEPRshavebeenincreasinglyincludedinlocalpractice.Thus,the
infrastructuremustserveregionalaswellaslocalinterestssimultaneously.Inthiscasestudy,this
isexpressedbytailoringNewArenatotheclinicalpracticethroughthenewopenEHRarchitecture.
Atthesametime,theRegionalHealthAuthorityaimsatstandardizingpracticesacrosstheHealth
Trustsintheregion.
Thetwoperspectivesoftheregionalportfoliocallfordifferentsortsofgovernance:NewArena
requiresagovernanceregimegroundedinlocalpracticewithhighcompetenceonhowthenew
technologyaffectstheclinician’sdailywork.Thus,considerhowthefirstpilotofNewArenaatthe
surgeryoutpatientclinicidentifiedthatuserswouldneedclosefollow-upengagingwiththenew
functionalities.Incontrast,BigProject’sstandardizationofpracticecallsforamoreauthoritative
governanceregime.Theregionalstandardsandroutinesmustbeimplementedinclinicalpractice;
inaddition,someonehavetomakesurethattheusersadheretothestandardsforthestandardsto
continuetoevolvealongsideclinicalpractice.Atthispoint,theregionalICTadvisoryboardand
theregionalICTmanagementorganizationarenotequippedtohandlesuchagovernancetaskona
permanentbasis,sincetheyaremanagement,notgovernance,organizations.Thereisaneedfora
morepowerfulinterorganizationalgovernanceorganizationoperatingatanoveralllevelonadaily
basis,tosupportsuccessfuldeliveryofhealthcare.
Inaddition,governinganIIalsoimpliestakingintoaccountandbuildingontheexistingICT
portfolio,theinstalledbase(Hanseth&Monteiro,1998;Nasjonal-IKT,2012).TheBigProject
leadershaveconsideredtheexistingsystemwiththeircurrentstrategytoplanforyearsofinterplay
betweenClassicEPRandNewArena.ThisenablesseamlessintegrationofNewArena,byreplacing
ClassicEPRinastepwisemanneravoidinga“BigBang”implementation.OperatingthetwoEPR
solutionssimultaneouslyhowever,hascreatedchallenges,suchastheexamplefromChristensen
andEllingsen(2014)inwhichaprocessmovedfromNewArenabacktoClassicEPRresultinginan
outcomethatisthesameastoday;thus,noimprovementsinNewArenaaredetectedforusers.The
benefitsforusersmaynotbenoticeableuntilreplacingmost,orallpartsoftheoldsystem.
Fromagovernanceperspective,akeypointisthattheinterplaybetweentheoldandnewportfolios
requirethoroughtechnicalinsight.Simultaneously,suchatechnicalperspectiverelatescloselyto
clinicalpractice,sincetechnicalandclinicaldecisionsaffecteachother.Consequently,governingan
IIimpliesunderstandingandincludingdifferentinterrelatedareas,whereeachpartrequiresaunique
governanceregime.Thethreegovernanceperspectivesintroducedinthispaper,thelocal,theregional,
andthetechnical,areinterconnected.Changingoneareaoftheinfrastructuremayresultinunpredicted
changestootherareas(Vikkelsø,2005).Theseinteractionsmaycausetensionsinadditiontoconflicts
ofinterest.Forexample,pushingtooheavilyonaregionalperspectiveandstandardization,mayhave
unforeseeneffectsonlocalflexibility.Anexampleishowphysiciansatsmallhospitalslostlocal
overviewandauthorityoftheirpatientdata,whenthestandardizationofpracticeprojectimplemented
regionalstandards.Consequently,thingsthatareveryusefulfromaregionalperspective,becomes
aliabilityforlocalpractice.Accordingly,basedonthepreliminaryresults,thereareindicationsthat
regionalambitionhasbeenpushedasteptoofar,asthedifferentHealthTrustscouldnotagreeon
howtoorganizeagovernanceorganizationabletoserveallthevariousneeds.GivenNewArena’s
heavyinfluenceonfutureworkpractice(decisionsupport,patientpathways,structuredEPRcontent,
etc.),itisnotsurprisingthattheHealthTrustssoughthighlycompetentlocalICTgovernanceclose
toclinicalpractice,insteadofrelatingtoanewlyestablishedregionalICTgovernanceorganization.
Astrategyforsolvingthelocalandregionalchallengeshasbeentodividethegovernanceinto
smallerdomainssuchasEPR,radiology,laboratory,etc.,whereeachdomainisanchoredinoneof
theHealthTrustsinsteadofattheregionallevel.Thissolutionissimilartoapolycentricgovernance
model,withmultiplegoverningunits,severaloverlappingarenasofauthorityandresponsibility
(Constantinides&Barrett,2014).Tosomedegree,thismaysolvethelocal/regionaltensionwithin
thespecificareainquestion.Akeychallengewiththefragmentedgovernancestructuresuggested
isdefiningtheboundaries,thentheareasofresponsibilitybetweenthedifferentunits.Thus,several
independentorganizationalunitsendupcontrollingareasofthesamesystem,andtheICTmanagement
organizationthatdeliverstechnicalsolutionshavetocollaboratewithseveralHealthTrusts.In
addition,somepartsoftheICTportfolio,suchasEPRsandlaboratories,aresocloselyconnected
thatseparatingthemmayseemimpracticalifnotimpossible.Anotherchallengemayrelatetotwo
governanceorganizationsdisagreeingonatopic.Whodecidestheoutcome?Thesebordersarenot
clear-cut(aswehavepointedout),andrequirecumbersomenegotiationbetweenareasofresponsibility,
thusmakinggovernanceacomplextasktohandle.Suchfragmentedgovernancemodelshavebeen
impossibletoagreeoninthepast,accordingtoMcGinnis(1999).Evenincaseswhereacommon
forumwasestablished,ithasbeenimpossibletoagreeongovernancestructuresacceptabletoall
parties,sinceheterogeneousinterestsandresourcesareinvolvedinalargescaleII.
OneofthegoalsofNewArenaistooperateacrossinstitutionalborders,tofollowapatient’s
entiretrajectorygatheringallnecessarypatientinformationinoneplace.Thefragmentedgovernance
solutionsuggested,madeembracingNewArenaextracomplex.GovernanceofNewArenademands
aregionalfocusonclinicalcontentindependentofsystemvendors,leadingtoanincreasedneedfor
regionalICTgovernance.Thereisacallforcloseregionalcollaborationtomaintainandmodelthe
clinicalcontent,includingarchetypesandtemplates.Itisnecessarytotakeintoaccountthegoalsofthe
newsystem,whentheinterorganizationalICTgovernanceorganizationisestablished.Thisindicates
thattryingoutthesuggestedpolycentricgovernancemodelwillpotentiallycreateroomforendless
negotiationsplusaconstantneedforcompromises.Ifchoosingthismodel,akeysuccessfactoristo
defineclearly,whomakesthefinaldecisionswhenthedifferentgovernanceorganizationsdisagree.
Ifnot,itwillbedamagingforthewholeII,anditwillbechallengingtoassurethestakeholders
thatthingswillgoasexpected.Inaddition,itisnecessarytomakeanoverallstrategysecuringthe
appropriatehandlingofallnecessaryareasofinterorganizationalgovernance.
CONCLUSION
Giventheincreasedambitionsofinformationsharing,standardization,andinteroperability,toensure
successfuldeliveryofhealthcare,itiscruciallyimportanttoestablishawell-functioningII.Akeyfactor
forsuccessisestablishinganICTgovernanceorganization.Wehavediscussedseveralchallengesof
howandtowhatdegreeanIIingeneralandICTportfoliosinparticular,canbemanaged,byfocusing
onorganizationalstructuresaswellasprocessesonhowtoformallygovernII’s.Weemphasized
thelongitudinalandpoliticalprocessofestablishinganinterorganizationalICTgovernanceina
heterogeneoushealthcarecontext.
The goal is for the EPR systems to evolve from today’s information storage systems to
interoperableuser-centeredworktools.Standardizationoftechnologyandworkprocesses,aswell
asinterorganizationalgovernancecollaborationisnecessarytoreachsuchgoals.TheregionalICT
governanceorganizationmustoperateonadailybasis;makedecisions,aswellasmonitoringresults
andperformanceondifferenthealthcarelevels.Inaddition,standardsmustevolvealongsidetheEPR
tobeuseful.
ForsuchICTgovernanceorganizationtosucceedtheHealthAuthoritiesandtheHealthTrusts
havetodefineanoverallstrategyforwhattheywanttoincludeinthisorganization.Interorganizational
ICTgovernancehastoincludedifferentaspectsofgoverningtheregionalICTportfolio,including
local,regional,andtechnicalaspects,plustheongoingtensionsamongthem.RegionalizinganICT
portfolioischallenging,evenifrepresentativesfromHealthTrusts,ICTmanagementorganizations
andvendorsparticipateintheprocess,thestandardsestablishedmightnotalwaysfitlocalneeds.
Therefore,astrategyforhandlingregionaldisagreements,besidesevaluatingrequirementsforrevising
andaddingstandards,isalsoimportanttoworkout.Inaddition,itisnecessarytodefinethestructure
ofsuchICTgovernanceorganization.
ThefragmentedgovernancemodelsuggestedfortheNorthNorwegianHealthRegionissimilar
toapolycentricgovernancestructure,whichoffersopportunitiesfororganizingseveralgoverning
unitsatdivergingscalesinsteadofonemonocentricgovernanceunit.Thisisanattempttogetastep
closertoregionalcollaboration,andseemstobeasfarastheHealthTrustsarereadytogoatthis
point.Usingthismodel,theykeepsomelocalcontroloftheirICTportfolio.Afragmentedgovernance
solutiondemandsclosecollaboration,andclearlydefinedbordersbetweenthedifferentactors.This
impliesthatapolycentricICTgovernancestructuremaybeanacceptablebutchallengingsolution
foralooselyconnectedIIasaHealthRegion.
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