Information Systems and Technology Projects in ...

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Chichester, UK: John Wiley & Sons. Wears, R. L., & Berg, M. (2005). Computer technology and clinical works: still waiting for Godot. Journal of the American ...
Information Systems and Technology Projects in Healthcare Organizations Jorge Gomes ISEG Lisbon University, Portugal Mário Romão ISEG Lisbon University, Portugal

INTRODUCTION The challenges facing healthcare organizations require more comprehensive and integrated solutions and efficient resource management as a means of eliminating inefficiencies and of achieving promised benefits. In academic literature, information systems and technology (IS/IT) have been recognized as being an organizational capability that can lead to competitive advantage and better performance (Bharadwaj 2000; Kohli & Devaraj 2003). Organizations recognize project management as being a fundamental tool for the development of initiatives which lead to the implementation of the organizational strategies (Crawford, 2005; Hodgson, 2002). One way that the effectiveness of IS/IT project management capability has been assessed is through the use of maturity models, with the underlying assumption that higher levels of project management maturity imply a higher effectiveness of project management capability (Kwak & Ibbs 2002; Sonnekus & Labuschagne, 2004). Our research focuses on the combination of the project management and maturity models approaches as a means of strengthening the final results of IS/IT projects in the healthcare sector. It is the authors' belief that this combination of approaches enhances not only the success of projects, but also the realization of the expected benefits. It is also important to emphasize that, by taking advantage of the specific features of each of these approaches, their structure will certainly increase the effectiveness of IS/IT projects in the health sector, by enhancing both the confidence of sponsors and investors, and also the achievement of the promise benefits. The maturity models approach provides a framework which helps organizations increase their capability to deliver projects on schedule, within budget, and according to the desired technical performance (Levin & Skulmoski, 2000). Projects are temporary achievements that are used to solve various types of tasks of variable size, and are applicable in a very broad range of business sectors (Maylor, 2001). Project management coordinates skills and organizational knowledge and follows the progress of a set of pre-

established activities in order to achieve objectives (Kronbichel, 2009). Many organizations fail to review whether the planned benefits of IS/IT projects have been achieved, or not, as they do not possess sufficient resources to undertake such a benefit review, and, moreover, they are constantly under pressure to deliver other projects (Bennington & Baccarini, 2004). Benefits management identifies goals and benefits by combining organizational changes and investments in IS/IT, and also by showing the way to achieve them (Gomes, Romão & Caldeira, 2013; Ward & Daniel, 2006).

BACKGROUND Literature review Whilst there is general agreement that IS/IT does indeed contribute to adding business value, there is uncertainty as to how these contributions were really obtained (Melville, Kraemer & Gurbaxani, 2004; Devaraj & Kholi, 2003). Although many studies have focused on the consequences of IS/IT investments, fewer studies have examined factors which impact the capability of IS/IT (Devaraj & Kholi, 2003). Project Management Institute (PMI) (2012) define project as a limited effort in time, which is undertaken to create a product, service or a result. The essence of project management is to support the implementation of these temporal initiatives under the framework of an organization’s competitive strategy, in order to successfully deliver a particular outcome (Milosevic, 2003; Senhar & Dvir, 2007). Project management is thus a set of management activities which is required to ensure that projects which are defined, planned and monitored, go on to achieve agreed objectives and benefits (Deveraj & Kohli, 2003). Kerzner (2009) highlights the importance of project management in the planning and control of organizations’ resources, helping to achieve, not only short-term goals, but also broader, temporal objectives. It appears that determining whether a project is a success, or not, is far more complex. Success is perceived differently by the different stakeholders involved in the projects (Freeman & Beale, 1992). The differences in success criteria definition should reflect the different interests and points of view, which leads us to conclude that project success is a multidimensional criterion (Freeman & Beale, 1992; Pinto & Mantel, 1990). Success criteria known as the ‘iron triangle’ have been criticized for their exclusive focus on the project management process, to the detriment of including the vision and goals of the different stakeholders (Baccarini, 1999; Bannerman, 2008). This classic approach remains the most widely used measure of project success and its main value is in offering a simple, direct measure of performance of the project, but it neglects whether the deliverables fulfilled the objectives of the project (Bannerman, 2008). The improvement in the success of projects results from increased maturity and organizational competence (Sergeant et al., 2010). Higher levels of maturity will, in most cases, lead to improved project

outcomes (Nieto-Rodrigues & Evrard, 2004). Projects which have multiple stakeholders, with different perspectives about the purpose of the project, usually have different expectations as to what the project should achieve (Lim & Mohamed, 1999). Since the success of a project depends on the perceptions of a large number of stakeholders, "absolute success" probably never exists in project management, but only "perceived success" (Baker, Murphy & Fisher, 1988). In the academic literature, we found examples of projects that have successfully completed the criteria of the "iron triangle", but resulted in disappointing business experiences (Shenhar et al., 2005). On the other hand, initiatives that did not meet the constraints of cost and time later proved to be successful (Pinto & Slevin, 1988). The understanding of the concept of project success has evolved over recent decades, and a gradual understanding is now emerging that project success requires a broader and more comprehensive definition. Aaltonen et al. (2008), state that the key issue in project management is managing the relationship between the project and its stakeholders. There is little evidence to suggest that process capability improvement result in improved project success, although a few studies are promising in this respect (Mullaly, 2006; Lee & Anderson, 2006). Maturity models have become an important evaluation tool for measuring the internal and external capabilities of organizations. Maturity models describe the development of an entity over time (Klimko, 2001) and they represent a structured collection of elements which highlight the characteristics of effective processes at different stages of development (Pullen, 2007). The maturity models approach provides a theoretical framework for improving the business outcome of an organization, for assessing their strengths and weaknesses, and also for allowing comparisons with industry best practices and also by benchmarking with similar organizations (Ibbs & Kwak, 2000). Several studies focus on the recognition of the benefits of investment in project management skills in organizations and others have discussed the issue of the correlation between level of maturity and the performance of projects (Ibbs & Kwak, 2000; Ibbs & Reginato, 2002; Mullaly, 2006). In an IS/IT discipline, maturity is considered to be a measure for evaluating an organization’s capabilities (Rosemann & Bruin, 2005). Measuring the maturity of organizations is a difficult and somewhat subjective task, as such an audit process focuses mainly on individuals’ tasks (Andersen & Jessen, 2003). Working with different types of projects within an organization requires standard models, in order to deliver successful future projects repeatedly and as a means of improving the quality of future projects and of gaining knowledge and learning from past successes and mistakes. The assessment of maturity typically involves variations along five developmental stages (Jugdev & Thomas, 2002). These assessment procedures help organizations to understand where they have been, where they are, and what processes they need to implement, in order to continue their implementation of management methodologies. The underlying assumption in the maturity models is that there is a relationship between

higher levels of maturity and improved organizational performance (Ibbs & Kwak, 2000; Lee & Anderson, 2006) and that this enhances project success.

The Healthcare sector Today, healthcare organizations are increasing focusing on the need for investment in IS/IT, with the goal of achieving the minimum level of benefits that these projects can attain. The study of the success or failure of these initiatives has become vitally important for the performance of these organizations (Rahimi & Vimarlund, 2007). Since the 1990´s, the health sector has sought to improve its effectiveness and efficiency by adopting IS/IT to increase quality levels (Raghupathi &Tan, 1999). The use of IS/IT in health sector is recognized as being a major factor which has improved clinical practices and supportive care (McDonald et al., 1998). The use of these systems provides an important support for specialized services and it increases the efficiency, quality and safety of patient care, and also reduces medical errors (Low & Chen, 2012). It is not always investments in IS/IT that result in efficiency and effectiveness gains, and thus it becomes essential to evaluate the factors that limit performance, and to identify opportunities for enhancing their use. IS/IT has the potential to dramatically change the way individuals or society see the healthcare sector, and also to provide tremendous opportunities for supporting professionals, and for improving effectiveness and efficiency in the health sector (Ammenwerth et al., 2006). There is a growing consensus that organizational factors are far more critical for the successful implementation of IS/IT, than technical considerations (Markus et al., 2000). Achieving successful change is much easier if all stakeholders are committed, and the earlier this commitment is achieved, the smoother is the path to a successful outcome (Bradley, 2006). We live in times where healthcare providers generate significant amounts of personal data about patients and the major obstacle to the management of this increasing volume of information is the difficulty, or inability, of sharing information across systems and between organizations (Grimson et al., 2000). Medical information needed for clinical decision making has increased dramatically, however the accessibility of health data is still poor, resulting in inappropriate decisions and sometimes in medical errors (Tierney, 2001). The use of informatics tools has been developed to increase the accessibility and management of medical information (Bleich, Beckley & Horowitz, 1985), with the aim of supporting medical decision, of increasing the coordination between different health care providers, and of promoting the use of guidelines, thereby improving the global quality of care (Pringle, 1988; Shiffmann et al., 1999). However, in addition to providing new capabilities, new technologies also impact the technical, social,

organizational, economic, cultural, and political dimensions of work in new and different ways (Anderson & Aydin, 1994). Observations of new technology implementations have shown that a change in technology alters roles, strategies, and paths to failure (Sarter, Woods & Billings, 1997). In recognizing this, the Institute of Medicine of the USA recommends examining new technologies for avoiding threats to safety and redesigning them to prevent undesirable accidents (Kohn, Corrigan & Donaldson, 2000). There is a widespread feeling that a significant proportion of initiatives in IS/IT healthcare have failed (Heeks & Davies, 1999). Studies have identified high failure rates in IS/IT projects in various sectors, including that of healthcare, particularly in hospitals (Kaplan & Harris-Salamone, 2009; Wears & Berg, 2005). The results of the implementation of IS/IT projects in healthcare have revealed a waste of financial resources in acquiring large sized systems, which are totally ineffective (Heeks, 2006). In various aspects, these implementations are different from other projects, in other industries. The key main differences were related to the environment, the diversity of systems and the devices that need to work, together with the challenge of integration and interoperability which is required to meet the expectations of different stakeholder groups regarding that which constitutes project success (Abouzhara, 2011). Healthcare projects are a complex undertaking, which depend largely on the quality of existing information (Bose, 2003). Proper training is a major determinant for success in the adoption of IS/IT by health professionals, and it has a great influence on the integration of technologies in clinical practice (Allen et al., 2000). The effectiveness of interventions aimed at the integration of IS/IT applications in the practices of health professionals tends to be influenced by several factors, which are related to individuals, professional groups, organizational and contextual characteristics, and the nature of the intervention per se (Grol et al., 2007; Aarts et al., 2004). One of the most critical factors recognized by the academic literature is resistance to change by healthcare professionals, particularly amongst doctors (Lapointe & Rivard, 2006; Phansalker et al., 2008). The complexity of systems, together with organizational diversity and the volume of investment required, as well as failure in adopting IS/IT, is all largely justified by the way that IS/IT is implemented, and by the need to identify best practices and to act on a number of critical factors, in order to reduce the chance of failure (Olson & Zhao, 2007). Cooke-Davis & Arzymanow (2003) identify organizational culture as exerting a positive influence on the development of superior project management practices.

FUTURE RESEARCH DIRECTIONS

Healthcare organizations require interdisciplinary cooperation and coordination. It needs to be highlighted that insufficient communication and missing information are among the major issues that have contributed to unintentional injury caused by medical mismanagement (Lenz & Reichert, 2007). IS/IT processes have the potential to significantly reduce the rate of these adverse events by providing relevant information in real time to all who need it (McDonald et al., 1984). An important challenge for the future is to seek for a real clinical integration of systems. Clinical integration between providers and hospitals has historically been a goal which is continually sought, but rarely achieved. It will become crucial that the design of future applications be integrated easier into existing systems, through open communication interface (Geissbuhler et al., 2001). The intersection of healthcare and social media represents another promising field of IS/IT research. Anderson and Agarwal (2010) demonstrate that individuals are more willing to share personal healthcare information if they think that it could help others. Social media platforms could provide aggregation through the mechanisms of information filtering and knowledge synthesis (Kane et al, 2009). Evidence-based medicine (EBM) is a form of medicine which aims to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research. EBM produces quantitative research, especially from randomized controlled trials (RCTs). A randomized controlled trial (Chalmers et al., 1981) is a type of scientific experiment whereby those studied are randomly allocated one or other of the different treatments under study. EBM has been gaining increased attention among researchers (Carey, 2006) as a tool for addressing concerns about healthcare costs and quality. Another emerging topic for knowledge discovery arises from the use of digital technology to enable new kinds of mathematical healthcare modelling and simulations (Lumpkin, 2007). Simulation models are distinguished from other types of conceptual models by the fact that they include simulated objects, such as people, which correspond to real objects, one-to-one. Development of such a model requires creating a population of simulated individuals who all have experienced important events which occur in real life with real people, and who respond to interventions in the same way as real people (Schlessinger & Eddy, 2002). Another research trend concerns the use of the combined knowledge about a person for predicting treatment response and this can thereby improve that person’s health (Redekop & Mladsi, 2013). This concept of personalized medicine allows for an earlier and more precise diagnosis, cheaper and more effective treatments, and the minimization of side effects of treatment (Glaser et al. 2008). Personalized medicine uses genomic medicine to take advantage of a molecular understanding of disease, in order to optimize preventive health care strategies and drug therapies whilst people are still well, or at the earliest stages of disease (Ginsburg & Willard, 2009). Another term which has emerged in recent years is

personalized healthcare, which extends the previous concept to address questions related to treatment monitoring and disease surveillance.

CONCLUSION Although project management emerges as being one of the main approaches used by organizations, there is no strong evidence in the literature of the success of the implementation of any of the available approaches in the health sector. This study attempts to show that organizational maturity contributes to the success of a project, through the systematic application of project management best practices. The combination of the project management and the organizational process maturity approaches provides a more efficient and useful framework for supporting decision-making. The approach proposed in this study tries to prove that it is easier to implement best practices in project management in organizations which have higher levels of organizational maturity, and that the correct combination between investments in IS/IT and management practices can also be a positive influence, leading to successful projects. We have a strong conviction that higher levels of organizational maturity have a positive influence on the success of projects implemented by organizations particularly in cases were good project management practices are in evidence.

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ADDITIONAL READING Aarts, J., Doorewaard, H., & Berg, M. (2004). Understanding implementation: The case of a computerized physician order entry system in a large Dutch University Medical Center. Journal of the American Medical Informatics Association, 11(3), 207-216. doi: 10.1197/jamia.M1372.

Flower, J. (2013). Healthcare Beyond Reform: Doing It Right for Half the Cost. Boca Raton: CRC Press, Taylor & Francis Group.

Hodge, J. G. (2003). Health Information Privacy and Public Health. Journal of Law, Medicine & Ethics, 31(4), 663-671. doi: 10.1111/j.1748-720X.2003.tb00133.x.

Hyrkäs, K. & Lehti, K. (2003). Continuous quality improvement through team supervision, supported by continuous self-monitoring of work and systematic patient feedback. Journal of Nursing Management, 11(2), 208-226. PMID: 12694365.

Low, C., & Chen, Y. H. (2012). Criteria for the evaluation of a cloud- based hospital information system outsourcing provider. Journal of Medical Systems, 36(6), 3543-3553. doi: 10.1007/s10916-012-9829-z.

KEY TERMS AND DEFINITIONS

Benefits Management: Benefits Management is an integral part of managing change and aims to increase the success of the measurable and significant benefits of investments in IS/IT for an organization

Critical Success Factors: Critical success factors are elements which are vital for a project to be successful.

Maturity models: A theoretical framework that helps organizations to increase their ability to deliver projects by assessing strengths and weaknesses, good sector practices and benchmarking with similar organizations.

Project Management: Project management is the application of processes, methods, knowledge, skills and experience to achieve the project objectives.

Project Management Success: project management success is measured mostly against cost, time and quality.

Project Success: project success is measured against the overall objectives of the project

Project Success Criteria: Project success criteria are the standards by which the project will be judged at completion.