Investigating the role and impact of an information system in accrediting and delivering breast-screening services in Tasmania : a nexus between accreditation and practice

This dissertation presents a multi-method research approach for the systematic study of wicked problem domains (Rittel, 1984 [1972]), developed through an investigation of an information system (IS) within a health service organisation, BreastScreen Tasmania (BST). BST is an accredited organisation within a national screening and assessment Progam, BreastScreen Australia. The Program is a population health initiative that also provides multi-disciplinary diagnostic clinical services to individual clients/patients, measured against 176 National Accreditation Standards. The demographic change of ageing population is a crisis that threatens the sustainability of future health services and highlights a role for IS/ICT to deliver work efficiencies. Conflicting perspectives and competing models for assuring the quality and safety of health services assume a role for IS/ICT to provide data processing capabilities to support health service practices and to evaluate health service outcomes. An ‘e-health’ vision assumes that well-integrated information and standardised work practices will result in efficiency, effectiveness, safety and quality. But IS/ICT solutions often fail to accommodate the complexities of information use in health settings. This situation of competing perspectives, opposing forces and health IS/ICT failures indicates that health service delivery into the future is a wicked problem that cannot be easily defined and will not be solved by better IS design. The methodological contribution of this research is a structured process of inquiry that emphasises a human-centred perspective: patient-centred care, human centred computing and human centred research. The dissertation shows how a multi-method approach is systematically conducted, how appreciation of a problem situation for an organisation emerges and is studied over three-phases. Soft Systems Methodology was adopted as the conceptual framework for the research process. Grounded Theory Methodology provided a range of flexible strategies and lenses for qualitative data collection and analysis. A construct, ‘People, place and things’ (PPT), was developed and used as a heuristic device to sensitise the researcher to different units of analysis, techniques and lenses for structuring and modelling data, particularly drawing on Distributed Cognition, Communities of Practice and Activity Theory. Substantively, the research contributes a detailed single case of a health service delivery organisation with wicked problem properties. The investigation focused on the role and impact of a client record (electronic and paper) on two BST activities and their inter-relationships. Firstly, accrediting the delivery of its breast screening and assessment services and secondly supporting decision-making of both individual clinicians and clients/patients. More broadly, it also analysed how the IS impacted on the roles and interactions amongst the professionals working within BST. BST’s problem situation was identified as a nexus between accreditation and practice in which two forms of accreditation are in tension. These tensions are embedded in the information system supporting BST activities. BST uses a client information system to measure its performance at organisation level, which can conflict with social forms of accreditation such as professional memberships. This conflict is mirrored by the difference between population-level, evidence-oriented data and the meaning of data in the context of a specific client receiving a health service. Theoretically, the research contributes two conceptual models. Model one highlights that the nexus is embedded in the organisation’s information system and work practice design such that two forms of accreditation are in tension and must be managed. Artefacts used to measure performance construct organisation-level accreditation; individuals are accredited socially via membership. Model two highlights that the client record is fully integrated to provide data that is oriented to support three different purposes: evidence of organisation performance, supporting professional judgment and client decision-making. Boundary maintenance activities by a staff member in the role of institutional broker are required to manage the differences in meaning for each information orientation. This research has implications for the role of IS/ICT in health service delivery and accreditation, including assumptions on the benefits of information integration and work practice standardisation. IS design can readily embed principles and work processes that align with measuring standardised work by population-level data for health service quality assurance. However, the wicked problem characteristics affecting health services means that IS that prioritises population-level data-oriented accrediting models can fail to provide information to support social information interactions, including how work is measured for quality within professional memberships. In addition, providing an information system to monitor performance is important, but IS/ICT is also needed to effectively support health service practitioners and clients in making decisions and to provide feedback on individual performance. The outcomes of using this method demonstrate the value of a three phase, process inquiry approach utilising multiple methods. Socio-technical perspectives are useful for understanding wicked problem domains and the PPT-construct keeps the analysis open to a range of insights for understanding the information support provided in the context of health care delivery. Identifying social insights and social methods of measuring quality of performance of relevance to IS design is time consuming but critical to facilitate human-centred uses of information being supported by the design of technical artefacts for health service delivery contexts. IS design to support standardised work processes and that embeds non-social, quantitative forms of measuring that work is relatively straightforward. Understanding, modelling and developing IS that reflects social insights is much more complex but critical if the e-health IS are to have a positive impact on the current vision for patient-centred, safe and quality assured, effective and efficient health services into the future.