Project Description for Researcher Project: “Flexibility in Integration Processes in Public sector” (FIPP)

Summary: This project will investigate processes where ICT is employed in the public sector to establish and sustain networked collaborative work practices. Achieving change and learning in complex socio-technical assemblages involve handling of complexity, for which flexibility is a key strategy. Thus our focus is on flexibility in processes of integration of technical systems, work practices, procedures, and institutions. Analytically, the concept of flexibility is elaborated in three related and different research questions:

• How should integration be conducted so that the process is robust and practically achievable?
• How should integration be conducted so that it is sustainable?
• How should integration be conducted so that it is well balanced in terms of distribution of control and autonomy?

This study draws on a repertoire of theoretical and methodological resources from the intersection of CSCW, IS and STS. We will conduct three in-depth and longitudinal case studies employing participant observation, formal and informal interviews, and document analysis as the main data collection techniques. These cases illuminate different kinds of challenges to achieve flexible integration. Case one concerns reorganisation and process improvement in a large hospital. The second case studies the emergence of new collaborative patterns between primary and secondary health care services. Case three looks at the attempts at integrating and aligning the IT-systems of different entities in the welfare sector. These cases all exemplify phenomena that relate to achieving change in complex settings where the pre-existing and institutionalised collaborative arrangements pose significant challenges to changes. Building on the joint outcomes from these case studies, the project will aim to define guidelines for achieving more effective and efficient integration.

Relevance

This project is geared towards the core aim of the VERDIKT program: to produce generic knowledge on issues of fundamental importance related to how to achieve innovation and value creation through new collaborative work practices. Our focus is on the challenges of establishing and sustaining networked collaborative work practices. Specifically we address the need to achieve benefit realization from existing and recently implemented information and communication technologies (ICT) in the public sector, through focusing on flexibility in processes of integration of technical systems, of work practices, procedures, and institutions. With this focus our proposal involves issues that cut across all of the four main areas of the VERDIKT program. Below we will argue that an adequate understanding of challenges related to integration is crucial if the visions of the new network society shall be realised, and thus that we address issues of fundamental importance.

The current call for applications emphasises the themes of seamless networks and rich media/multimodal information. Our project is relevant to both themes:

• Change and improvement of public sector through ICTs necessitates possibilities of collaboration across seamless networks. For instance, before communication around patient cases between specialised health services and primary care institutions can take place on a routine basis, communication tools must be available and well integrated into the ordinary work practices. If using the tools requires additional time and resources, the usage level will likely be low.
• To achieve high-quality collaboration, appropriate and rich information needs to be communicated. Multiple types of data in different media need to be gathered, used, and communicated. For instance, when a patient is transferred from hospital to home care, the hospital physiotherapists’ usually communicate with home care personnel through textual reports. Knowledge transmission may be better facilitated through live video and audio communication where exercises can be demonstrated, rather than just described in text.

Both of these requirements are related to integration, the core theme of our proposal. Various technical systems will need to be interconnected, information from different data sources must be combined, and the rules, procedures and work practices of different institutions must relate to each other. However fundamental integration is in order for new collaborative work patterns to emerge, it is not trivial to achieve.

In the following section we will discuss relevant research on ICT-enabled organisational change through integration with a focus on the challenges. We will end by arguing for the need to study flexibility in integration processes, which is our core focus. The remainder of this document offers additional details on our proposed project.

Aspects relating to the research project

Background and status of knowledge

Reforms in the public sector are rooted in the belief that it is possible to change organizational structures, processes and ideologies through a top-down approach and by rational choice and design (Brunsson and Olsen, 1993). In current reforms a central organising principle is the ‘client focus’. Reorganisation according to this principle, such as for instance “patient-focused redesign”, aim at achieving a coherent presentation and delivery of services across different entities and administrative levels. Basic requirements for this are standards for common services, cooperation across institutions, sharing of information, shared registers, joint terminologies and shared technical platforms. Thus integration (both of technical systems and in terms of work practices and organisational processes) is fundamental for these visions to accrue.

This emphasis links with long-standing interests within the informatics community, where “integration has been the Holy Grail of MIS since the early days of computers in organizations” (Kumar and van Hillegersberg, 2000, p. 23), due to the fact that organisations over the years have acquired a portfolio of disparate information systems. Three core dimensions of integration are outlined by Hasselbring (2000): integration works through hiding distribution, standardising heterogeneity and negotiating autonomy. Practically, we can conceptualise different approaches to integration as distributed across a continuum between loose and tight integration. On one extreme, loose integration denote how different information systems are integrated only at a visual level (e.g. the presentation layer), for instance through a web-based portal retrieving data from the various sources, which still exists as separate, autonomous systems. On the other hand, with tight integration we may have streamlining of functionalities and data repositories of multiple systems. In between the two extremes, a variety of other forms of integration are possible, such as middleware, brokers and integration engines. Technically, integration refers to the degree of interoperability and interconnectivity among technical components, and relies on standardization at a certain level.

Generally speaking, integration is a strategy adopted when confronted with problems of heterogeneity and fragmentation. As such, integration is also a topic for other social sciences. Within organisational and management science it is usually cast in terms of organisational design, deciding on whether the work processes and organisational division should be vertically integrated into a hierarchy or horizontally integrated to support cross-cutting process flows (Mintzberg 1983). The aim of organisational design is finding the most appropriate balancing of the need for central control with the need for local flexibility. Despite the ubiquity and basic nature of the integration theme, there is relatively little research that tries to bridge the technical and non-technical aspects that are involved. The two dimensions are tightly interrelated: technical integration requires organizational, social and/or political integration and vice versa (see for instance Ellingsen and Monteiro, 2003). New ways of distributing work, of coordinating among different units, and of accounting for service deliveries are enabled and/or constrained by ICTs. Integration as a phenomenon cut across disciplinary boundaries, but has not been sufficiently studied from an interdisciplinary perspective. This deficiency has the effect that common practices of addressing the challenges are too narrowly focused on technical instrumentality. Approaches such as process modelling and redesign do not explicitly address complexity as a challenge, and we argue that this is the core problem that needs to be addressed.

We propose to address this deficiency in current knowledge, and draw on a rich body of studies of ICT from both Science and Technology Studies and Information Systems. These studies join theoretical, analytical and methodological resources from various disciplines in order to analyse what is called socio-technical assemblages. This implies a rejection of the view on technologies as isolated artefacts, and the adoption of a view that emphasises “relations and connections between artefacts, physical and mental skills, desires and interests, concepts and information” (Barry 2001, p.211). The complexity of this interrelation can not be reduced to a matter of simplistic alignment between ICT design and imposed rational objectives. On the contrary: design, implementation and use of ICTs in organizations is a non-predictable process (Ciborra et al, 2000). Unexpected effects are not simply due to poor modelling, simplistic design, bad management, but is part of the deeply paradoxical and political nature of this process (Hanseth et al. 2006, Vikkelsø 2005). For instance in the health care sector, when new ICTs are implemented and integrated with the existing infrastructure they become part of work practices adding to the complexity of the already intricate socio-technical system of practices. In this situation unpredictability of actions and unintended consequences are constant threats (Ash, Berg, Coiera 2004).

Contrary to many representations of technology-enabled revolutions that abound in popular and policy discourse, we prefer to view inventiveness and learning as not overlapping with the mere adoption of novel technologies. Rather we will look for “the novelty of the arrangements with other objects and activities within which artefacts and instruments are situated, and might be situated in the future” (Barry, 2001, p. 211-212). Consequently we argue that what needs to be better understood is how to achieve change and learning in complex socio-technical assemblages. This formulation comprises two interrelated dimensions, firstly, how to achieve learning and change, and secondly, how to handle complexity. In the literature on organizational change, ICTs are recognised to be a strong driving force in change processes, and to push organizations in situations where learning is paramount in order to achieve more than a superficial formal change (Argyris, 1992). Yet, such learning is not easy to achieve and organizations struggle frequently with their effort to use new technologies effectively (Robey et al., 2000). The significance of this is evident from the current strong focus on benefits realization and process improvement . Handling complexity is another major issue. Public sector entities, while complex in themselves, are elements in huge webs (networks), and are not easily changed. Moreover, when dealing with large-scale network technologies, or information infrastructures, unintended consequences and propagation of side effects constitute significant risks (Ciborra et al. 2000; Hanseth and Braa 1998 ; Rolland 2003). Thus integration, in the form of interconnectedness opens for new possibilities but also fragilities (Kallinikos 2006). Consequently, handling complexity requires flexibility as a key strategy, and our core focus on how to achieve flexibility in integration.

Objectives

The objectives are described in the grant application form.

Approach and case studies

Research approach

This study addresses the complexities of integration processes by drawing on a repertoire of theoretical and methodological resources from the intersection of research fields called Computer Supported Work, Information Systems Research and Science and Technologies Studies. We adopt an interdisciplinary approach with which all the researchers taking part in this project are familiar (Law 2004, Latour 2005, Mol and Mesman 1996, Star 2002). The research fields also share a field work tradition, mainly employing qualitative research methods and oriented towards involvement, participation and user-oriented studies, such as interventional ethnographies (Zuiderent 2000) or action research (Baskerville and Myers 2004).

Analytically, our core focus on flexibility in integration is separated into three related and different dimensions of integration:

1. How should integration be conducted so that the process is robust? I.e. which change strategies, approaches and methods for achieving change are practically achievable in complex settings, such as large, specialised hospitals?
2. How should integration be conducted so that it is sustainable? What is important when we aim at designing and implementing socio-technical arrangements that are possible to ‘live with’ and maintain over time?
3. How should integration be conducted so that it is well balanced? How can we decide what is appropriate in terms of tightness or looseness of integration, how should autonomy be distributed in the new socio-technical arrangements?

These different aspects of flexibility in integration are addressed through combining three in-depth and longitudinal case studies in different settings, employing participant observation, formal and informal interviews, and document analysis as the main data collection techniques. At one level of abstraction, these cases will offer the possibility for a comparative study of phenomena that relate to achieving change in an organisational or institutional complex setting, where the pre-existing, established, and institutionalised collaborative systems pose significant challenges to any change attempt. As such, the combination of cases will enable more general results to be formulated. At a concrete level, however, the cases complement each other by illuminating slightly different kinds of challenges to achieve flexible integration.

• Case one concerns reorganisation: Improving processes in established complex organisations (specialised health care) is a long-term and complex undertaking which require an incremental approach. The risk is that this will just reproduce the previous paper-based work organisation. How can radical change be achieved in a way that is practically possible, i.e. robust?
• Case two studies the emergence of new collaborative patterns: improved communication and exchange between the primary and secondary (specialist) health services will require coordinated change among many actors. Previous attempts, e.g. at telemedicine has had the problem of being unsustainable, having been pilots rather than projects. How to achieve sustainable integration?
• Case three looks at the attempts at integrating and aligning the IT-systems of several pre-existing and firmly established institutions. How do we decide how the inevitable heterogeneity are to be handled, and what the appropriate distribution of autonomy to the various entities could be?

The three planned cases are briefly described below.

Case 1: Integration of systems in a large hospital

One of the research sites in this project is Rikshospitalet-Radiumhospitalet Trust in Oslo. The Department of Informatics at the University of Oslo has had a long term research relation with the IT department at the hospital, dating back to 1996. Currently, Rikshospitalet is in a period of major ICTs based innovation processes with large investments. In the recent years, system integration has been identified as a critical objective for different reasons: costs saving, improved communication practices, medical error reduction, patient safety, improved patient management, time saving. The research at this site will start by focusing on the ongoing process redesign activities called “Omstilling 2006”. These activities aim at achieving tighter integration of work processes and IT systems as well as better utilisation of resources. These activities are expected to continue until 2011.

The research aim in case one is centred on the issue of representations of work practices. ICT enabled redistribution of work may conflict with existing work practices, distribution of responsibilities and power balance among users. A hospital is a complex organisation, where many work practices and patient trajectories are tightly interwoven. Any change needs to be coordinated and planned so that this complex mesh of processes are not disrupted. A too simplistic approach may overlook the importance of improvisation in hospital work and the role of informal communication practices, just to mention two crucial features that make hospitals work. Consequently, we want to study how appropriate existing process redesign methodologies are when this complexity is encountered. Are they robust, or not? And, if radical change is not feasible and possible, how can significant changes be achieved through incremental and inherently conservative strategies traditionally employed? The IT department at Rikshospitalet will be an active partner in this sub-project and has allocated a 20% position dedicated to research.

Case 2: Integration across different administrative levels

A second research site relates to attempts to establish new ICT-mediated collaborative patterns between actors who usually collaborate minimally or through other means than ICTs. Previous studies have shown significant reduction in mortality when the collaboration between the primary and secondary health care services are improved (NFR report 2002). Currently, the various information systems (for instance patient record systems) in the primary, secondary, and tertiary health care institutions are not integrated, and electronic message exchange exists only to a limited degree, despite a longstanding focus on these issues. The collaboration of specialists with the primary health care services at the municipal level is a central candidate for improvement. Municipal health services are differently organised compared to specialist health services, and are subject to different administrative and regulatory regimes. Established communication patterns are non-efficient, however, establishing new collaboration patterns is challenging. Several obstacles remain before this kind of services can be widely available. We propose to study such processes of establishment of new collaborative patterns and the change that these entail. The focus will be on discovering, analysing and starting to resolve the challenges that are encountered, both of a practical, technical, institutional, regulatory, legal and financial nature. What are appropriate models for this kind of cooperation? Flexible integration may mean possibility for communication on an “as-needed” basis, but what are the “business models” that can support this, and what changes do they entail? We plan to collaborate with and study the ongoing activities at Sunnaas Hospital at Nesodden outside Oslo, which that uses telemedicine technologies to improve the communication between the hospital and the municipal level around patient rehabilitation.

Case 3: Integration of welfare services in local municipals

The third case is focused on integration of ICTs and work processes in NAV-offices in local municipalities. The NAV (Ny Arbeids- og Velferdsforvaltning) reform is a particularly interesting case for studying the complexities of integration. Firstly, at the municipality level the reform implies an organizational merging of the former Public Employment Service, the Social Security Service, and the National Insurance Service into joint NAV-offices. Secondly, closely linked to this organizational change, tighter integration of existing incompatible ICT solutions as well as a common NAV ICT infrastructure are planned implemented . Recently the department of computer and information science, NTNU has conducted a study of the use of ICTs at Saupstad Service Centre in Trondheim (Rolland and Dingsøyr, 2006). Saupstad Service Centre has been a pilot site for reorganizing the Norwegian welfare services (Samordningsforsøket) , and has therefore already experienced some of the changes proposed in the reform. This research shows that the re-organizing towards common front-end services and multidisciplinary teams for solving cases that cut across departments have the potential for increasing both efficiency and quality of public services. On the other hand, however, the study also shows that integrating the existing legacy systems in one common solution is inherently problematic and risky due to the variety in work practices, gap in competencies, different juridical regulations, different organizational structures, and incompatibility of current solutions.

The project plan

The project will be implemented on two levels:

1. Three empirical case studies will be conducted according to the following activities:

a) identify actual challenges associated with ICT-enabled organizational change and integration b) study existing practices of addressing and managing the challenges that are encountered; and c) to suggest alternative strategies to achieve flexibility in integration.

1. Meeting, seminars and collaborations will contribute to:

a) Improve the competencies related to ICTs and integration in the public sector within and among the researcher’s home institutions (TIK, IFI, IDI); b) Build a Norwegian network of researchers and practitioners interested in advancing the understating of ICT enabled integration processes, and in exploiting their potentials c) Strengthen and support the existing informal international network among the research project partners, where some are part of the EU-thematic network ITEMS (Identifying Trends in European Medical Space). This allows increased formal visibility that may improve strategic positioning on both European and international levels. (Additional details on the project’s progress plan is in the grant application form.)

Budget

Budget information is found in the grant application form.

Project management, organisation and cooperation

The project will consist of four interrelated sub-projects:

• Case study 1 with one post doc (IFI, three years) and one researcher (TIK, 50 %, three years)
• Case study 2 with one PhD (TIK, three years) and one researcher position (IFI, 50 % over 1,5 years)
• Case study 3 with one PhD (IDI, three years) and one researcher position (IDI, 50 % over three years)
• One integrating project on top of these partial projects consisting of joint seminars, workshops, forums of learning, publication projects, etc. This integrating project will also take special responsibility for the theoretical and methodological reflection and development.

The project will be administratively located in, coordinated and managed from the Department of Informatics (IFI), University of Oslo. All the senior researchers on this project (Margunn Aanestad, Knut Rolland and Ingunn Moser) and the postdoc (Miria Grisot) have a background from or have been related to the “Information Systems” research group (IFI), mainly through the informal health informatics group. Moreover, the researchers have collaborated on empirical projects (for instance on parts of the development and implementation of EPR in the Rikshospitalet), in student supervision and examination, and on conference presentations and publications. They have their respective backgrounds from Informatics as well as Science and Technology Studies and social science/ organizational studies (see CVs), and so make a team that complement each other with their different disciplinary (theoretical and methodological) emphasizes. At the same time as they also share a position in the intersection of these research fields and are thus familiar with the body of literature that constitutes this cross-disciplinary field.

The project will have a management board (consisting of senior researchers from TIK, IFI and IDI) which will meet every 6th months. The project manager will track progress of activities, maintain collaboration within the team and be responsible for reports and deliverables to the Norwegian Research Council. We will establish a project website and a mailing list, as well as a shared workspace to serve as a common repository for field notes and preliminary results.

The research team aim at ensuring collaboration through a variety of measures:

• Weekly seminar for the project participants (PhD students, researchers and master students), aimed at reading and discussion of work in progress.
• Visits of Researcher and PHD from Trondheim to Oslo, and vice versa.
• Quarterly project meetings (mainly for the researchers, but also open to partners)
• Two two-days’ research workshops with international partners
• Exchange of PHD students with international partners
• Yearly seminars (Learning forums) with each of our project partners. The aim of these seminars is ongoing dialogue around preliminary findings and project progress.

International Partners

The involvement of international partners is not aimed at a comparative research approach; rather international partners have been selected for their knowledge and experience in conducting research in the proposed area of this application (organisational and social aspects of ICT). The selected partners are also part of an informal already working international network, that has developed over years and through various exchanges and collaborations, such as in the EU-thematic network ITEMS. This project therefore offers the opportunity to formalise and develop these running contacts and collaborations on a more committed and long term basis. The involvement of partners will provide valuable inputs and support, and participate as critical discussants and advisors in the different phases of the project through the joint workshops. They will also facilitate exchange of PhD students and participate in collaborative publishing efforts.

The international partners are:

• the Centre for Health Research, University of Lancaster, UK
• the Department of Sociology at the University of Lancaster, UK
• the Department for Health Policy and Management at the Erasmus University, Rotterdam, Netherlands.

Perspectives and compliance with strategic documents

Compliance with strategic documents

The proposed project is in line with the strategic plan of UiO (UiO, 2005) which emphasises the focus on long-term and basic research. Moreover the plan prioritises areas where UiO’s teaching and research offers a broad and significant knowledge fundament to enterprises and to society. These areas comprise basic understanding of human life, culture and generic technologies, research that may impact innovation and problem solving, and knowledge that is important to address basic and significant challenges in our societies. In a similar vein, the strategic plan of Department of Informatics (IFI 2006) emphasises the focus on development of informatics for the benefit of society, which is a core objective for our project. This application further contributes to IFI’s strategic goals as relates to achieving external funding for research projects, and addressing important business- and social challenges shall be addressed. In TIK, the planned project will be an opportunity to integrate the two focus areas, which are studies of innovation processes and studies of technology, science and culture.

Relevance to society

ICT-enabled reforms and change processes in the Norwegian public sector are highly related to effective use of ICT (see for instance the strategic plans “S@mspill2007” for the healthcare sector as well as the “eNorge 2009” plan for the public sector in general). The potentials for benefits and cost-savings, but also failure stories that address the challenges of managing large ICT projects are prominent themes in both public and policy discourse .

Environmental perspectives

Although the visions associated ICT in public sector (involving digitisation of the previously paper-based information flows, reduction of transportation and general improvement of work processes) often claim significant environmental effects, we do not address this specifically in this project.

Ethical aspects

Our research will involve access to potentially sensitive information about clients in health care or welfare settings. We will adhere to commonly used guidelines within social science research (e.g. www.etikkom.no/retningslinjer) and register our study with the Privacy Ombudsman at the University of Oslo. This implies that we will seek informed consent from all informants, and that we will voluntarily comply with the confidentiality regulations of the institutions. The dissemination activities where we offer feedback of findings and results to the partners will help us to ensure reliability and accountability in our research.

Gender equality and gender perspectives

Gender perspectives could be relevant to this problem domain, but are not explicitly incorporated into our research at the outset. It is an empirical matter whether they will be addressed.

Communication with users and exploitation of results

Communication with users

During our research we will have a focus on problems related to use of ICT in work practices. This is a focus which necessitates close collaboration with in-house staff during the field work period. In addition we plan the following activities:

• Two public seminars for Norwegian mixed audience: researchers, policy, public services, IT consultancies, etc. The first of these will be conducted during year one (to get problem definitions from the field), the second in year three to disseminate the results.
• Yearly seminars (Learning forums) with each of our project partners. The aim of these seminars is ongoing dialogue around preliminary findings and progress.
• The quarterly project meetings are mainly organised for the researchers but will also be open to partners.

As part of our dissemination plan we also plan to produce a guide or “handbook” on ICT and organizational change. The book will draw from the three case studies and provide more general “lessons learned”, practical guidelines and tools for practitioners. It will focus on how to achieve robustness, scalability and flexibility in the integration processes.

Dissemination plan

The Plans for scholarly and popular dissemination activities are in the grant application form.

References

• Argyris, C: On Organizational Learning, Blackwell, (1992).
• Ash, S M Berg, E Coiera: Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors, Journal of American Medial Informatics Association, 2004, 11,p.104-112.
• Barry A. Political Machines, 2001, The Athlone Press
• Baskerville R and M Myers: Special Issue on Action Research in Information Systems: *Making Is relevant to Practice – Foreword. MIS Quarterly, 2004, 28(3), 329-335.
• Brunsson, N and JP Olsen: The Reforming Organization. London, Routledge, 1993.
• Ciborra C et al.: From Control to Drift, 2000, Oxford University Press.
• Ellingsen, G and E Monteiro: A Patchwork Planet: Integration and Cooperation in Hospitals. In Computer Supported Cooperative Work (CSCW), 2003, 12(1), 71 – 95.
• Hanseth O and K Braa: Technolgoy as Traitor: emergent SAP infrastructure in a global organization. ICIS’98.
• Hanseth O, E Jaccuci, M Grisot, M Aanestad: Reflexive Standardization. MISQ, 2006, in press.
• Hasselbring W: Information Systems Integration, Communications of the ACM, 2000, 43(4), 32-8.
• IFI 2006: ”Strategisk plan 2006-2010 for Institutt for Informatikk, UiO”.
• Kallinikos J. Technology, Contingency and Risk. In Hanseth O and Ciborra C: The Duality of Risk, manuscript in preparation, 2006.
• Kumar K and J van Hillegersberg: ERP Experiences and Evolution. Communications of the ACM, 2000,43(4)23-6.
• Latour, B: Reassembling the social, 2005,Oxford
• Law, J: After method, 2004, Routledge.
• Mintzberg, H: Structure in fives: designing effective organizations, Prentice Hall, 1983.
• Mol, A. and Mesman, J. (1996)' Neonatal food and the politics of theory: some questions of method' in Social Studies of Science 26: 419-444.
• Robey, D M Boudreau, GM Rose: Information technology and organizational learning: a review and assessment of research, Accounting Management and Information Technologies, 2000,10, 125-155.
• Rolland K.: Re-inventing Information Infrastructure in Situated Practices of Use. PhD thesis 2003, University of Oslo.
• Rolland K and T Dingsøyr: The Issue of Competence in Transforming the Norwegian Welfare Sector: Some implications for future e-government initiatives, paper to be presented in ECIS 2006
• Star, SL.: Infrastructure and ethnographic practice. In Scandinavian Journal of Information Systems, 2002, 14 (2):
• UiO: ”Strategisk plan for Universitetet i Oslo 2005 – 2009” (Vedtatt av Universitetsstyret 14.06.05)
• Vikkelsø, S: Subtle Redistribution of Work, Attention and Risks: Electronic Patient Records and Organizational Consequences, Scandinavian Journal of Information Systems, 2005,17(1) 3-30.
• Zuiderent, T: Blurring the center. On the politics of ethnography. In Scandinavian Journal of Information Systems, 2002, 14 (2): 59-78