Understanding implementation: the case of a computerized physician order entry system in a large Dutch university medical center

Abstract

Most studies of the impact of information systems in organizations tend to see the implementation process as a "rollout" of technology, as a technical matter removed from organizational dynamics. There is substantial agreement that the success of implementing information systems is determined by organizational factors. However, it is less clear what these factors are. The authors propose to characterize the introduction of an information system as a process of mutual shaping. As a result, both the technology and the practice supported by the technology are transformed, and specific technical and social outcomes gradually emerge. The authors suggest that insights from social studies of science and technology can help to understand an implementation process. Focusing on three theoretical aspects, the authors argue first that the implementation process should be understood as a thoroughly social process in which both technology and practice are transformed. Second, following Orlikowski's concept of "emergent change," they suggest that implementing a system is, by its very nature, unpredictable. Third, they argue that success and failure are not dichotomous and static categories, but socially negotiated judgments. Using these insights, the authors have analyzed the implementation of a computerized physician order entry (CPOE) system in a large Dutch university medical center. During the course of this study, the full implementation of CPOE was halted, but the aborted implementation exposed issues on which the authors did not initially focus.

Figure 1.

Computerized physician order entry (CPOE) system implementation timeline. The timeline indicates key events during the implementation of the system.

Figure 2.

The structure of the computerized physician order entry (CPOE) system implementation team. The coordinators of each task force and the project leader formed the implementation team. The project leader was a physician who spent about half the time on the project and was for the other part still active in medicine. The project coordinator, a senior member of the information technology department, was responsible for all technical issues of the implementation and coordinated the members of the implementation team on a day-to-day basis. Each task force was responsible for a particular application domain. The task force “function departments” encompass departments such as radiology, nuclear medicine, pathology, and vascular ultrasound imaging. The task force for pharmacy applications was planned to become active in a later stage. The director of information technology was a member of the Steering Group.

Figure 3.

Dutch translation of the TDS7000 system screen. This menu screen allows doctors to see standing orders and patient data. Under the heading “Patientgegevens” (patient data), the last arrow is a reference to the DRG-like classification scheme (DBCs) that became mandatory in Dutch hospitals as of January 1, 2004. Note the coarseness of the system emulation compared with the finesse of the Windows environment (see Windows task bar).