Information Systems Research
Vol. 22, No. 3, September 2011, pp. 419–428
issn 1047-7047 eissn 1526-5536 11 2203 0419
http://dx.doi.org/10.1287/isre.1110.0382
© 2011 INFORMS
Editorial Overview
The Role of Information Systems in Healthcare:
Current Research and Future Trends
Guest Senior Editors
Robert G. Fichman
Carroll School of Management, Boston College, Chestnut Hill, Massachusetts 02467,
fichman@bc.edu
Rajiv Kohli
Mason School of Business, College of William & Mary, Williamsburg, Virginia 23187,
rajiv.kohli@mason.wm.edu
Ranjani Krishnan
Broad College of Business, Michigan State University, East Lansing, Michigan 48824,
krishnan@bus.msu.edu
I
nformation systems have great potential to reduce healthcare costs and improve outcomes. The purpose of
this special issue is to offer a forum for theory-driven research that explores the role of IS in the delivery of
healthcare in its diverse organizational and regulatory settings. We identify six theoretically distinctive elements
of the healthcare context and discuss how these elements increase the motivation for, and the salience of, the
research results reported in the nine papers comprising this special issue. We also provide recommendations
for future IS research focusing on the implications of technology-driven advances in three areas: social media,
evidence-based medicine, and personalized medicine.
Key words: healthcare information systems; special issue
Introduction
Research anchored in the healthcare context must
begin by reflecting on what is distinctive about healthcare and on how such distinctions could or should
inform our theorizing. Distinctiveness of the context
drives us toward new theory or theoretical extensions
that hold greater promise to explain IS phenomenon
(e.g., adoption and impacts). At the most general
level, a striking feature of the healthcare industry is
the level of diversity that characterizes patients (e.g.,
physical traits, and medical history), professional disciplines (e.g., doctors, nurses, administrators, and
insurers), treatment options, healthcare delivery processes, and interests of various stakeholder groups
(patients, providers, payers, and regulators).
Because of this diversity, research in healthcare is
eclectic and spans many disciplines, including economics, public health, business, epidemiology, sociology, and strategy. This is reflected in the diversity of
papers comprising this special issue, not only in terms
of the theoretical frameworks but also in the unit of
analysis employed. In the remainder of this section
we identify six theoretically distinctive elements of
the healthcare context that tie together the research
results reported in the nine papers comprising this
special issue.
The importance of healthcare to individuals and governments and its growing costs to the economy have
contributed to the emergence of healthcare as an
important area of research for scholars in business
and other disciplines. Information systems (IS) have
much to offer in managing healthcare costs and in
improving the quality of care (Kolodner et al. 2008).
In addition to the embedded role of information technology (IT) in clinical and diagnostics equipment, IS
are uniquely positioned to capture, store, process, and
communicate timely information to decision makers for better coordination of healthcare at both the
individual and population levels. For example, data
mining and decision support capabilities can identify potential adverse events for an individual patient
while also contributing to the population’s health by
providing insights into the causes of disease complications. Despite its importance, the healthcare domain
has been underrepresented in leading IS journals.
However, interest is increasing, as demonstrated by
the proliferation of healthcare tracks in IS conferences,
special interest groups, and announcements of special
issues among leading journals.
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The Stakes Are Life and Death
Healthcare influences the quality of our lives and
how we function within the society. Healthcare mistakes have serious consequences that can affect our
ability to carry out social and productive endeavors.
Recent reports highlight the gravity of adverse events
in hospitals and the dangers such events pose to individuals and the public (Piontek et al. 2010). More
generally, medical errors (a leading cause of adverse
events and other ills) are expensive, increase patient
hospital length of stay, and cost human lives (Classen
et al. 1997). At the population level, the failure to control infectious diseases can cause serious public health
issues. Therefore, healthcare quality is diligently pursued and vigilantly executed, and IS can facilitate
such pursuit by highlighting and monitoring errors at
various stages along the continuum of care.
In this issue, Aron et al. examine the association between IS and medical errors in three primary
healthcare processes—sensing, controlling, and monitoring. They focus on two types of errors—procedural
and interpretive. Using an agency framework, the
authors explore the relationship between hospital
management and clinicians and the complementarities between training and automation systems. After
all, humans are the primary response agents when
the technology detects a potential error. The tension
between innate and often subjective human experience and dispassionate automation poses challenges,
especially in the presence of conflicting situational
signals that demand an urgent response.
The findings emerging from Aron et al. are consistent with conventional beliefs that automation complements professional training and that in particular,
improved training enables professionals to exploit
automation. However, their findings in the domain of
error detection are counter to contemporary thinking
that the role of IS in enforcing quality is most effective
when promoting compliance with procedures and
other routine work. They find that training, combined
with automation, overcomes interpretive errors in decision making but not procedural errors. This points to
the importance of IT complementarities and provides
instances where technology may, in fact, increase the
incidence of errors (Fernandopulle and Patel 2010).
Finally, Aron et al. find that automation indeed influences agents’ behavior by serving as a record for their
actions, thus encouraging agents to act in the interests
of the principal. Previous IS literature has proposed a
panoptic role for IS in enforcing agency relationships
(Sia et al. 2002).
When potential healthcare risks extend to the larger
population, the demand for resources increases, as do
the consequences of improper resource deployment.
Many lives are at risk during outbreaks of infectious
diseases, such as severe acute respiratory syndrome
Fichman, Kohli, and Krishnan: Editorial Overview
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(SARS). In such cases, IS plays an essential role at both
patient and population levels. Mobilizing and coordinating hospital and public health resources becomes
a race against time, because controlling the spread of
the disease is just as important as treating it. Also
in this issue, Chen et al. examine the SARS outbreak
in Taiwan and develop seven guidelines for coordination of public health IS. Drawing on the loose
coupling framework, they find that increased involvement of public health agencies is not always helpful, especially when there is clinical uncertainty about
effective treatment mechanisms. They conclude that
coordination should be such that public health policy makers and healthcare providers can engage and
disengage as warranted during an outbreak. These
findings led Chen et al. to identify situations where
a decoupling between public health authorities and
the healthcare providers can enable parties to conduct
a more independent examination. Subsequently, coupling can be reactivated for public policy formulation
and communication.
These findings have significant implications for
the design and development of IS to support public
health policy. Combined with the findings of Kane
and Labianca (in this issue) regarding network centrality and influence, the loose coupling approach can
facilitate the development of new theory regarding
how influential actors in a loosely coupled network
can supplement or enhance a formally coupled network, for example, in a disease outbreak. This poses
another opportunity for theory development to find
the optimal balance of the actor and the technology
and their ability to decouple on an ”as needed” basis.
Healthcare Information Is Highly Personal
Another hallmark of healthcare information is that
it is highly personal. As a result, any transfer of
information between parties via technology involves
risks—both actual and perceived—that the information could fall into the wrong hands. Although electronic information can be made as secure as paper
records, electronic storage may be perceived as having
a higher likelihood of leakage, and such fears get further compounded by media attention. Thus, patients’
perceived probability of compromised privacy is often
higher than the actual probability.
Variations in individuals’ willingness to disclose
personal health information (PHI) is the focus of
Anderson and Agarwal (in this issue). Consistent
with prior research, the authors posit that individuals’ privacy concerns and trust in the electronic storage of PHI will affect willingness to disclose. Going a
step further, the authors explore how these effects are
moderated by three sets of contextual variables: the
type of information requested (general health, mental
health, or genetic), the purpose for which the information is requested (patient care, research, or marketing),
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and the type of stakeholder requesting the information (doctors/hospitals, the government, or pharmaceutical companies). In addition, the authors explore
the link between an individual’s emotions regarding
his/her current medical state and willingness to provide access to PHI. As a framework for their analyses, the authors use privacy boundary theory and the
risk-as-feelings perspective. Analyses using a nationally representative sample of 1,089 individuals indicate that the type of requesting stakeholder and the
purpose for which the information is being requested
are important moderators of the relationship between
concern and trust and willingness to provide access
to PHI.
An in-depth understanding of individuals’ willingness to disclose personal information is critical not
only because it has implications for effectiveness of
treatment protocols but also because of its impact on
public policy in dealing with epidemic outbreaks such
as SARS (Chen et al.). Anderson and Agarwal add
important insights to the literature on individuals’
disclosure decisions and offer guidance for healthcare
policy. For example, they find that the negative relationship between privacy concerns and willingness to
disclose is particularly acute when the information
request comes from government/public health agencies (versus hospitals or pharmaceutical companies).
Another interesting result is that individuals trust
nonprofit hospitals with electronic health systems to
a much higher extent than they trust government and
for-profit organizations, which might give advocates
of government-sponsored single-payer systems some
pause. Their results also suggest that individuals who
feel sad, angry, or anxious about their current health
status are more willing to provide access to their PHI
and that such individuals may more easily fall victim
to misuse of health information.
Digitization of health information has several benefits. However, the research of Anderson and Agarwal
underscores the need to understand the situational
factors that drive individuals’ comfort with sharing
healthcare information in an electronic format. One
implication of this research for policy makers is to
explore more stringent regulation of medical information, for example, to require that stakeholders clearly
identify who they are, for what purpose they will use
the data, and even to set limits on the amount of time
that the stakeholder will have access.
Healthcare Is Highly Influenced by Regulation and
Competition
While the paper by Anderson and Agarwal examines
the factors driving the propensity of patients to share
personal health information, Bandyopadhyay et al.
(in this issue) analyze the propensity of healthcare
providers to share patients’ records. Sharing of electronic health records (EHR) by providers can increase
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administrative efficiency, reduce healthcare costs by
eliminating unnecessary duplication of medical tests,
and most importantly, reduce medical errors. However, such sharing is much lower in the United States
relative to many other countries.
Recently, for-profit companies, notably, Google and
Microsoft, have made forays into the market for personal health records (PHR). The PHR draws health
information from multiple sources, including the
physician or hospital’s EHR, and provides the individual with the flexibility to manage his or her
own PHR. While such platforms are mainly intended
to serve patients, they may also hold the potential to improve the incentives for providers to share
EHR data. In this context, Bandyopadhyay et al.
use an analytical game-theoretic model to investigate three research questions: Do providers resist
EHR sharing, even when it increases social surplus? Which providers stand to gain most from EHR
sharing? What role can a Web-based PHR platform
play in solving incentive problems and encouraging providers to share EHRs? The authors analytically demonstrate that a downside of EHR sharing is
that customers will find it easier to switch providers,
resulting in loss of provider revenue. To ensure participation the PHR platform provider will have to selectively subsidize healthcare providers. The likelihood
of subsidization increases in the heterogeneity of the
value provided by healthcare providers to consumers.
The findings of Bandyopadhyay et al. contribute to
the literature on information sharing and switching
costs. Their results also provide insights into why the
United States lags behind Europe in sharing PHRs.
Most European countries have a single (public) payer
that has the ability to subsidize, as well as to exert
pressure, if required, for providers to share. Moreover,
the risk of sensitive health information leaking out
and being misused is reduced when there is less need
to transmit data across providers and platforms.
However, whether a public platform for EHR sharing (like the European countries) or a for-profit option
(like the focus of Bandyopadhyay et al.) is feasible in
the U.S. environment is complicated by issues related
to privacy and trust. Given the findings of Anderson and Agarwal (that patients are less likely to trust
either the government or for-profit organizations),
progress toward a public system in the United States
may face additional challenges.
Healthcare Is Professionally Driven and
Hierarchical
One of the barriers to healthcare technology adoption is that powerful actors in care delivery often
resist technology. Part of this arises from professional
norms: physicians are primarily concerned with treating the patient to the best of their ability and regard
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other activities as administrative irritants. Given the
hierarchical nature of healthcare, technology aversion
by an influential physician or nurse is likely to affect
other caregivers.
Two papers in this issue—Kane and Labianca and
Venkatesh et al.—use network theory to examine the
factors driving physician resistance to IS and the
effects of such resistance on outcomes. Venkatesh
et al. develop a model that encompasses physicians,
paraprofessionals (such as nurses), and administrative personnel to explore the drivers of system use
and the system’s effect on patient satisfaction. Kane
and Labianca explore the association between preference for IS avoidance and three outcomes: efficiency of care, patient satisfaction, and quality of care.
Although the fundamental questions are similar, the
two papers differ in the methods used and outcomes
studied, and have produced different (albeit complementary) contributions.
Social network theory suggests that an individual’s network position influences behavior and performance. Venkatesh et al. argue that variations in
healthcare technology use arise from network ties
within and across professional domains. Specifically,
they posit that more connected doctors are less likely
to use technology, owing to their greater acculturation and commitment to traditional medical practices.
They find that while the E-healthcare system in their
study has a positive effect on quality of care overall, in-group ties among doctors and out-group ties
to doctors has a negative effect on system use for
all groups, indicating that doctors likely hamper the
spread of technology. Physicians’ rejection of technology is a serious problem that can lead to poor quality
of care, medical errors, and low patient satisfaction.
When we add mistrusting patients (Anderson and
Agarwal) and nonsharing providers (Bandyopadhyay
et al., in this issue) to the problem of doctors who
not only make inadequate use of technology but also
adversely influence others’ usage of technology, the
situation is compounded and likely results in errors
(Aron et al.) and potentially serious public health consequences (Chen et al.).
Although Venkatesh et al. is a longitudinal study,
its focus is primarily on the initial implementation
of healthcare technology. Kane and Labianca build
on this topic by examining postadoption resistance.
They use the term IS avoidance to denote passive postadoption resistance where individuals avoid working with an information system despite the need and
opportunity to do so. Using archival data they examine the efficiency and quality effects of IS avoidance at
three levels: the individual user level (physician), the
shared group level (healthcare team, including paraprofessionals and administrators), and the configural
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group level (which accounts for the positions of individuals in the team). They supplement their findings
with qualitative data.
Quantitative analysis reported in the paper reveals
that IS avoidance is negatively associated with patient
outcomes only at the configural group level; at the
individual and shared group level there is no association with outcomes. The qualitative analyses provide
insights into this pattern of results. At the individual level, users who avoided the system were able
to compensate by using brokering relationships, i.e.,
assigning a representative to interact with the system on their behalf. At the shared group level, clusters of usage were observed, whereby individuals
who used or avoided the system tended to work
with other users with similar usage patterns. Thus,
these clusters could use a different mechanism (such
as Post-it notes or paper flags) and ensure that the
entire shared group had the same level of information. These results also provide insights into why IS
avoidance at the configural group level was associated with negative patient care outcomes. That is, the
network structures that evolved to compensate for IS
avoidance were less effective in compensating for the
adverse effects of avoidance when the avoiding individuals had a central position in the social network.
Health Care Is Multidisciplinary
The findings reported in the previous sections indicate that there are multiple barriers to the adoption
and use of IT in healthcare organizations, despite
robust findings that IT can improve patient outcomes.
Oborn et al. (in this issue) make a further contribution in this regard by studying whether, despite a
diversity of use of IT across different groups (which
could include avoidance), an overall unity in use can
emerge because of the multidisciplinary nature of
healthcare.
Most healthcare is provided in interdisciplinary
teams. For example, surgery requires a team consisting of the surgeon, the physician, anesthesiologists, diagnostic staff such as radiologists and pathologists, and nurses. These specialists may either be
housed within the same organization, or they may be
collaborating from different organizations. Regardless
of the organizational form, speedy access to reliable
health information is essential to ensure good patient
outcomes.
Oborn et al. conduct a field study of electronic
patient record use across multidisciplinary teams
using a practice theory lens (Orlikowski 2000) to
examine how healthcare IS applications become
objects that are embedded within embodied practices
and how individuals coordinate and align their uses
of technology with others across diverse practices. By
such a process of coordination and alignment, connections are established between specialist groups. Such
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connections are effective even if they are partial in
the sense that the elements of one specialist practice
do not get subsumed into that of another but are
translated by the other practice in a different manner. Oborn et al. refer to this process of coordination
and alignment of healthcare information technologies
in use as unity in diversity. They examine this process
using a year-long interpretive field study of a regional
breast care center in England that had recently introduced a Web-based clinical information system that
interfaced with the hospital’s administrative system
and used tablet computers to record information.
The breast cancer treatment was coordinated in a
team consisting of oncologist, radiologist, pathologist,
surgeon, and specialist nurses in surgery and oncology. Results reveal a dynamic interplay between unity
and diversity. Regarding diversity, different specialties differed in the type and the extent of use of the
new technology. For example, surgeons, who have
to perform physical exams, found it cumbersome
to carry around tablet computers and instead relied
on nurses to provide more extensive documentation.
This finding is similar to that of the study of Kane
and Labianca, which found evidence of brokering
relationships among different professionals. By contrast, radiologists were especially comfortable with
the use of technology in their assessments (because of
the high-tech nature of their profession) and actually
used the technology to obtain more influence in the
group. Oncologists found the technology bothersome
in emotionally charged patient encounters. However,
they used the technology in the patients’ absence to
support oncology research via easier access to information from other disciplines. Pathologists exhibited
idiosyncratic use, such as including narratives rather
than just tick boxes, perhaps owing to their academic
orientation. Despite this diversity in use, all parties
to care managed to coordinate their use of the technology to facilitate the multidisciplinary teamwork
essential for the success of the care.
Several implications for implementation and adoption of healthcare IS arise from Oborn et al. For
example, usage patterns are complex and entangled;
therefore, it is highly simplistic to classify usage
as use and nonuse (or rejection). Most individuals
involved in patient care have a variety of relationships
with others involved in the care of the same set of
patients, and these relationships vary across practices
and individuals. For example, nurses perceived technology as depersonalizing the patient-nurse relationship and, hence, continued to use their paper records,
which provided added flexibility to record important personal information. Nurses’ nonuse was not
driven either by their rejection of the technology or
by their lack of familiarity with it; nurses understood
the technology, supported surgeons in their patient
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encounters, and assisted with data entry during the
multidisciplinary meetings. Taken together, the studies of Oborn et al., Venkatesh et al., and Kane and
Labianca provide a nuanced understanding of the factors driving variations in the type and extent of use of
healthcare information technology by different types
of professionals involved in the treatment process.
Healthcare IS Implementation Is Complex with
Important Implications for Learning and
Adaptation
The healthcare delivery setting is characterized by a
tension between the need for orderly routines and the
need for sensitivity to variation in local conditions.
The need for routines arises from the importance of
high reliability in what are often life-and-death situations involving very personal matters. The need for
sensitivity to variation arises from the diversity of (a)
healthcare providers (with differing professional roles,
training, and experience), (b) patients (with differing
personal characteristics, conditions, and medications)
and (c) medical procedures and treatments—all of
which converge during healthcare delivery.
This tension between the routine and the variable
magnifies both the complexity and importance of
effective learning and adaptation surrounding healthcare IS implementation and use. Systems and implementation techniques that work well in one setting
may fail in another. In many ways, learning and adaptation are two sides of the same coin when it comes
to new IS. Learning is required to determine the best
way to adapt both technology and organization to
achieve a good fit between the capabilities the technology affords and the desired patterns of actual use.
Once the needed adaptations have been identified, a
different kind of learning is required to incorporate
these adaptations into organizational routines and to
ensure continuous improvement going forward.
Two papers from this special issue explicitly
address different facets of learning and adaptation
surrounding IS implementation and use. Goh et al.
focus on the implementation of a new clinical documentation system to develop a model of how
to achieve effective routinization of new IT, while
Mukhopadhyay et al. look beyond initial implementation to identify—for users of an IT-enabled physician referral system that has already been thoroughly
routinized—the factors affecting the rate of productivity improvement from learning-by-doing.
Goh et al. examine the mechanisms underlying
successful healthcare IS deployments from the perspective, of organizational routines—relatively stable
“action repertoires” executed by actors to accomplish
organizational work (Feldman and Pentland 2003).
The routines perspective, together with observations
from a longitudinal field study of a clinical documentation system (CDS) implementation, allows the
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authors to unpack the “black box” of adaptation and
learning surrounding new IT. The CDS provides critical support to daily operations by serving as a shared
information repository and facilitating communication among various care providers (nurses, physicians, fellows, medical residents, and others). The
quality and efficiency of healthcare delivery is heavily dependent on the efficacy of the daily routines for
creating, accessing, modifying, and using these documents, and so the shift from paper-based to systembased charts is a high-stakes endeavor.
Goh et al. use key concepts from narrative networks
(Pentland and Feldman 2007) and adaptive structuration (DeSanctis and Poole 1994; Markus 2010) to conceptualize healthcare IS as an intervention that alters
the flow of events in a narrative network. Specifically,
they propose a dynamic, process model of adaptive
routinization of healthcare IS that delineates the major
channels through which IS and routines interact, identifies the different stages in the dynamic coevolution
process, and isolates the pivotal role of two forms of
agency (leadership and personal innovativeness) in
enabling the virtuous cycle of coevolution. They find
that the key to successful implementation is to manage the coevolution process between routines and IS
and to actively orchestrate a virtuous cycle through
agent action.
Mukhopadhyay et al. look beyond implementation to address the ongoing processes of learningby-doing that occur after IS has become thoroughly
routinized. They use the distinctive contextual features of IT-enabled physician referral systems (IT-PRS)
as an occasion to extend learning curve models of
organizational improvement. A physician referral is
the transfer of care from one physician to another, an
act that has major financial implications and requires
extensive coordination to ensure quality and continuity of care. The success of this coordination process
depends on how effectively human agents use the
multitude of capabilities provided by the IT-PRS. The
IT-PRS provides the “glue” that ensures an accurate
and timely transfer of patients.
Learning curve scholars seek to model precisely
how the rate of learning in performing a routinized
task relates to cumulative experience with the task
and to individual and contextual factors. Prior work
has focused mainly on single types of workers performing single types of tasks. However, the diversity
of the healthcare context means that, as in the case of
IT-PRS, the same basic task can be performed by different kinds of actors with different initial skill sets,
which provides an interesting context to examine how
human agents learn. The authors develop learning
curve modeling extensions that account for multiple
agent skill types, multiple referral task types, and the
possibility of learning spillovers across task types.
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Findings reveal that skill and task type do influence
learning rates. Specifically, medical domain experts
are initially more productive but learn more slowly
on the medically intense referrals (i.e., emergencies)
compared with nondomain experts. In contrast, systems experts are initially more productive but learn
more slowly on the most procedurally intense referrals (out-of-network nonemergencies). Across all skill
types, the rates of learning increase with overall task
complexity, and significant learning spillovers occur.
The studies by Goh et al. and Mukhopadhyay
et al. both provide excellent examples of researchers
who have used the distinctive characteristics of the
healthcare delivery setting to anchor their theoretical framing and contribution. Although they utilized
frameworks developed outside of systems—narrative
networks in the former case and learning curve models in the latter case—they have utilized the contextual nuances to extend and enrich these frameworks
in ways that are bound to be recognized and appreciated by organizational researchers beyond IS.
Future Directions for Healthcare
IS Research
The nine the papers in this issue are representative of the primary streams of healthcare IS work
to date (Agarwal et al. 2010), and we believe much
can be done to move forward in these areas. However, we also see some notable gaps. In particular, we
see three areas where major technological advances
are opening new vistas of IT-driven healthcare practice that have not yet received much attention
from IS researchers: (1) social media in healthcare,
(2) evidence-based medicine, and (3) personalized
medicine.
Social Media in Healthcare
The intersection of healthcare and social media
represents a promising space for future IS research.
Social media communities have been particularly
active in the healthcare domain (Kane et al. 2009),
and this is no accident: the primary driver of value
in these communities—commons-based peer production (Benkler 2002)—appears especially well suited to
healthcare.
Peer production is a mode of production in which
individuals (usually unpaid) collaborate on a large
scale to produce work products without hierarchical control (firms) or market exchanges (prices, contracts) to guide them. Increasingly there is a trend
for individuals, often amateurs, to self-select and selforganize to edit medical articles on Wikipedia or to
share detailed information about their own medical
conditions and treatments in online communities like
Braintalk.com or Inspire.com. Although some specialists have found impressive generation and sharing of
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medical knowledge in these communities (e.g., Hoch
and Ferguson 2005), such a process challenges the status quo in the medical discipline, which is characterized by rigid hierarchies and strong norms about who
should be providing medical information.
Benkler (2002, 2006) notes several conditions that
increase value of peer production relative to markets
and hierarchies as applied to the production of knowledge products, and these conditions certainly hold in
the case of healthcare. First, in healthcare there seem
to be especially strong appropriation mechanisms (such
as a desire to make a social contribution or to increase
one’s social standing) to substitute for monetary compensation in motivating participation. As shown by
Anderson and Agarwal (in this issue), individuals are
more willing to share personal healthcare information when they think it could help others. Second, a
large pool of potential contributors is available that is
diverse in knowledge and motivation. Finally, there
exists a wide range of granularity of potential contributions (to ensure that people with varying levels
of knowledge and motivation will each have suitably
sized contribution opportunities) and mechanisms to
effectively aggregate these diverse contributions. This
is where emerging social media platforms come into
play, as these platforms provide for effective aggregation through the mechanisms of information filtering and knowledge synthesis (Kane et al. 2009)
We see a number of worthwhile questions for future
research at the intersection of healthcare practice and
social media:
• What conditions lead to the formation and vitality of health-oriented social-media communities?
• What are the most effective design rules for the
platforms supporting these communities? Greater or
fewer restrictions on who can participate? Anonymous or nonanonymous?
• What posture should large providers be taking
with regard to these platforms? Should they actively
encourage participation by their professional staff and
patients? How?
• Should data from social media communities be
used in medical research (as was recently done in a
study of off-label lithium use among ALS suffers on
PatientsLikeMe.com (Wicks et al. 2011))?
Evidence-Based Medicine
Evidence-based medicine (EBM)—“the conscientious,
explicit, and judicious use of current best evidence
in making decisions about the care of individual
patients” (Sackett et al. 1996)—is an idea that goes
back decades but has been gaining increased attention among researchers and in the popular press
(Carey 2006) as a tool to address concerns about
healthcare costs and quality. EBM stands in contrast
to anchoring decisions on personal habits, tangible
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and intangible incentives unrelated to care, or medical
traditions that have little or no empirical validation.
The marked variation across geographic locations in
how clinical interventions get prescribed for the same
conditions shows that factors other than evidence
influence medical decision making (Timmermans and
Mauck 2005).
The barriers to widespread adoption of EBM are
substantial; however, IS can play an important counteracting role. We highlight three barriers and potential IS contributions. The first is the dearth of
knowledge about the actual efficacy of many common treatments. The rise in digital storage of personal
medical information gives researchers opportunities
to discover knowledge about the link between treatments and outcomes on a scale that was not possible
previously. Another emerging avenue for knowledge
discovery arises from using digital technology to
enable new kinds of mathematical healthcare modeling and simulations (Lumpkin 2007). This implies that
implementation and use of healthcare analytics tools
and how they should be integrated with electronic
health records warrants future research attention.
A second barrier is the difficulty of getting newly
discovered knowledge into the hands of practitioner’s
in a way that actually influences practice. It often
takes a decade for medical research results to be
translated into clinical guidelines and an additional
decade for the guidelines to be widely diffused (Green
et al. 2009, L’Enfant 2003). A move to Internetenabled directed searches when confronted with specific cases (rather than generalized journal reading)
can enable practitioners to more efficiently utilize
their scarce reading time (Sackett et al. 1996). IS
researchers could investigate the antecedents and
consequences of directed searches, including which
Internet resources (e.g., search engines, medical information portals, and social media communities) are
most effective and which contextual factors (e.g., culture norms, incentives, routines) might enhance their
effectiveness.
A third barrier arises from practitioner resistance to
adoption of EBM, which is often connected to aversion to the standardized clinical guidelines that form
the basis of much EBM. Such resistance arises from
physicians’ desire for autonomy, incentive conflicts,
and fear of litigation. Potential solutions include treating guidelines as a rallying point for a comprehensive
program of change and involving end users (i.e., caregivers) in the design of guidelines (Timmermans and
Mauck 2005). It is interesting to note that these recommendations parallel longstanding IS implementation
wisdom. IS can also be used to promote education of
other stakeholders (e.g., patients, payers) on the efficacy of diagnostic and treatment options so that they
can hold caregivers more accountable.
426
Personalized Medicine
Personalized medicine means using knowledge about
an individual’s unique physiological makeup and
medical history to tailor medical care most appropriately to that individual. It promises to allow earlier
and more precise diagnoses, cheaper and more effective treatments, and minimization of treatment side
effects (Glaser et al. 2008).
Some of the best-known success stories come from
genetics-driven personalization, such as Herceptin,
a monoclonal antibody treatment that can be quite
effective—but just for women with a particularly
aggressive form of breast cancer. Another example is
warfarin, a coagulant that can now be more precisely
dosed based on certain gene variations that affect
individuals’ drug metabolization, thereby avoiding
thousands of cases per year of serious bleeding and
strokes (Aspinall and Hamermesh 2007).
When integrated with electronic medical records
(EMR) systems, IS tools can help practitioners use this
rich profile data to identify the best candidates for
particular interventions in much the same way that
marketers use consumer profile data to identify the
best prospects for a particular product. For example,
Duke University used EMR data to identify patients
who had risk factors predisposing them to complications from the H1N1 virus, thus allowing caregivers
to provide focused outreach efforts (McGee 2009).
The Cancer Biomedical Informatics Grid, launched in
2004, provides researchers with a shared repository of
medical data, together with analytics tools that can
help to identify the best candidates for clinical trials. Success in sequencing the human genome in a
cost-effective manner may usher in a future where a
person’s genome is a standard part of his or her electronic health record (Singer 2010).
We see four broad implications for future IS
research related to personalized medicine. The first
relates to infrastructure design. What architectures
will be needed to provide the processing cycles and
storage required to analyze detailed medical profile
data (including possibly entire genomes) on a large
scale? The second relates to analytics. What contextspecific factors will affect the adoption and use of
analytics to support personalized medicine in a clinical setting? The third relates to decision support.
Could the move to personalized medicine trigger
increased attention to rule-based systems and other
forms of advanced clinical decision support? Finally,
we see potentially dramatic implications for research
on privacy and security. Although genetic discrimination has been outlawed in the United States, for
many people fears persist that knowledge of their
genetic predispositions could fall into the wrong
hands and be used against them in decisions about
insurance and employment. Here again, IS solutions
Fichman, Kohli, and Krishnan: Editorial Overview
Information Systems Research 22(3), pp. 419–428, © 2011 INFORMS
can ensure anonymity of personal data, whether it
is about genetic predispositions or treatments. IS can
also enforce authorization controls and usage tracking
to ensure that all access is recorded.
Special Issue Process
In February 2008, an ISR announcement on ISWorld
and other outlets invited scholars from around the
world to submit papers for a special issue entitled
“The Role of Information Systems in Healthcare Organizations: Synergies from an Interdisciplinary Perspective.” In light of the diversity of healthcare delivery
systems across nations, the call encouraged submissions addressing all segments of healthcare, including providers (such as hospitals, physicians), payers
(such as government, insurers, and employers), and
consumers (patients). The special issue also encouraged submission of papers encompassing a variety of
theoretical and methodological perspectives.
Submissions were due in February 2009. A total
of 53 manuscripts was received. As a first pass, all
three senior editors evaluated each of the submissions to assess its fit with the special issue’s focus,
theoretical and methodological strengths and weaknesses, and novelty of contribution to understanding
of the role of IS in healthcare. After this assessment,
26 manuscripts were selected for further peer review,
each by two reviewers. At the conclusion of this peer
review, a total of 10 manuscripts were chosen for further revision.
Authors receiving a first-round revision decision
were invited to present their papers at the Special
Issue Workshop at Boston College in September 2009.
The goal was to provide feedback at the midpoint in
the revision cycle when there was still time to adjust
the revision strategy. Prior to the workshop, authors
were asked to submit a revision strategy and conduct
any revised analysis if requested by the reviewers.
All of the editorial review board (ERB) members,
reviewers, ISR SEs, and selected others were invited
to attend the workshop. Following the workshop,
authors documented the key points of guidance that
they received, and how they intended to incorporate this guidance. The handling SE worked with the
authors to resolve any conflicts between the original review package and the workshop feedback. The
authors’ report and the SE’s response were shared
with the reviewers, including those who were not in
attendance at the workshop, so that they could consider these issues when handling the revised paper.
The authors resubmitted their papers by January
2010, including a consolidated response document
covering both the original review package and advice
from the workshop. Eventually, nine papers were
accepted for publication in the special issue.
Fichman, Kohli, and Krishnan: Editorial Overview
427
Information Systems Research 22(3), pp. 419–428, © 2011 INFORMS
Acknowledgments
Many people have generously shared their time and effort
in keeping the process moving and bringing the special
issue into fruition. Jerry Kane served as the associate editor of the special issue and, in this role, was instrumental
in framing the special issue and in organizing and hosting
the Special Issue Workshop. In addition, Jerry stepped in,
on short notice, to provide much needed help as an ad hoc
reviewer. The guest editors express our sincere thanks to all
the members of the editorial review board and the reviewers for their time and effort and their willingness to work
under the tight deadlines, as well as to the attendees to
the Special Issue Workshop. The guest editors offer special
thanks to V. Sambamurthy, who as then EIC, supported our
vision of the salience of healthcare in IS research and to the
ISR editorial office in bringing this special issue to print.
Editorial Review Board Special Issue
Corey Angst, University of Notre Dame
Ramji Balakrishnan, University of Iowa
Indranil Bardhan, University of Texas, Dallas
*Michael Barrett, University of Cambridge, UK
Anandhi Bharadwaj, Emory University
Anol Bhattacherjee, University of South Florida
Carol Brown, Stevens Institute of Technology
*Brian Butler, University of Pittsburgh
*Mike Chiasson, University of Lancaster, UK
*Elizabeth Davidson, University of Hawaii
Sarv Devaraj, University of Notre Dame
Leslie Eldenburg, University of Arizona
John H. Evans, University of Pittsburgh
Samer Faraj, McGill University, Canada
Tina Blegind Jensen, Copenhagen Business School,
Denmark
Mark Keil, Georgia State University
Bill Kettinger, University of Memphis
Joe Labianca, University of Kentucky
Karen Locke, College of William & Mary
Lars Mathiassen, Georgia State University
Nirup Menon, George Mason University
*Carsten Osterlund, Syracuse University
Rema Padman, Carnegie Mellon University
Ajay Vinze, Arizona State University
Jim Warren, University of Auckland, New Zealand
*Molly Wasko, University of Alabama at Birmingham
*Attended Special Issue Workshop
Ad Hoc Reviewers
*Andrew Burton-Jones, University of British
Columbia, Canada
*Gordon Gao, University of Maryland
*Jerry Kane, Boston College
Liette Lapointe, McGill University, Canada
Eric Overby, Georgia Institute of Technology
Guy Pare, HEC Montréal, Canada
Brian Pentland, Michigan State University
Ray Reagans, Massachusetts Institute of Technology
Sandeep Sahay, University of Oslo, Norway
Matthew Shum, California Institute of Technology
Jeff Smith, Miami University of Ohio
Eli Snir, Washington University in St. Louis
Jonathan Wareham, ESADE, Spain
Sean Xu, Hong Kong University of Science and
Technology, Hong Kong
Kai Zheng, University of Michigan
Feng Zhu, University of Southern California
*Attended Special Issue Workshop
Other Special Issue Workshop Attendees
Rob Fichman, Boston College (workshop leader)
Rajiv Kohli, College of William & Mary (workshop
leader)
Ranjani Krishnan, Michigan State University
(workshop leader)
Jerry Kane, Boston College (workshop coordinator)
Ritu Agarwal, University of Maryland
Ravi Aron, The Johns Hopkins University
Shubho Bandyopadhyay, University of Florida
Yi-da Chen, University of Arizona
Ramkumar Janakiraman, Texas A&M University
Helen Kelley, University of Lethbridge, UK
Jie Mein Goh, IE Business School, Spain
Tridas Mukhopadhyay, Carnegie Mellon University
Eivor Oborn, Royal Holloway University of London,
UK
Zafer Ozdemir, Miami University of Ohio
Sam Ransbotham, Boston College
Param Vir Singh, Carnegie Mellon University
Tracy Ann Sykes, University of Arkansas
Viswanath (Venki) Venkatesh, University of Arkansas
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Journal of Information Systems Education, Vol. 25(4) Late Fall 2014
Patient Education as an Information System,
Healthcare Tool and Interaction
Antti Pirhonen
Department of Computer Science and Information Systems
University of Jyväskylä
Jyväskylä, Finland
Minna Silvennoinen
Agora Center
University of Jyväskylä
Jyväskylä, Finland
Elizabeth Sillence
School of Life Sciences
Northumbria University
Newcastle-upon-Tyne, UK
ABSTRACT
Patient education (PE) has a crucial role in the function of a healthcare organisation. For the care process of a patient, it is
essential to get the right information at the right moment and in the right form. This paper analyses PE as the primary mode of
interaction between a patient and a healthcare organisation. The approach is illustrated with a study among nurses based on
their conceptions about PE. Practical implications and the potential of ICT in PE in particular are discussed.
Keywords: Health care, Scenario-based design, Ethics
1. INTRODUCTION
Patient education (PE) is commonly conceptualised as a
discrete session in a hospital environment in which only the
patient, or sometimes the patient’s friend or relative, and the
healthcare practitioner, commonly a nurse are present.
During the PE session, the patient is provided with important
information about, for example, an approaching operation,
treatment plan, or nutrition instructions concerning a
particular disease or condition such as diabetes or severe
obesity.
Getting adequate information about the care plan is of
course not only the right of the patient, but also a cornerstone
of good life and wellbeing. There is, however, a clear need
for a broader view of PE than just the one way delivery of
information from the healthcare practitioner (nurse or a
doctor) to the patient. In PE, more attention should be paid to
the individual needs and resources of the patient. The focus
in the development of PE should be the information delivery
process as well as managing PE in an optimal way from the
patients’ perspective. One of the known success factors in
PE is that a sound basis for the communication and trust
327
between the patient and the healthcare organisation is to be
created. The patient –practitioner relationship is known to be
one of the key factors in the process of building trust
between the patient and the healthcare organisation
(FitzPatrick et al., 2005; Leske et al., 2012).
In the current paper we approach PE with the help of
group discussions with PE experienced nurses. Although we
were not able to collect data from patients themselves, the
discussions with the nurses provided important insights
about the need to develop PE from the point of view of
patients.
2. NURSES’ ROLE AND CONCEPTIONS ABOUT PE
New healthcare regulations demand that patients and
families assume greater responsibility for their own
healthcare and take a more active role in decision making. In
the UK this has been summarized as the “no decision about
me without me” approach. This shift in responsibility should
mean that PE plays a more important and central role in the
delivery of care; however, there is an evident lack of
appreciation of PE in health care which according to Redman
Journal of Information Systems Education, Vol. 25(4) Late Fall 2014
(2004), results from its non-prioritisation. The old
understanding of PE implies simply giving orders and
instructions to patients which Redman refers to as calls
“compliance to medical regimen”, the provider’s approach.
This should be replaced by the new approach which
highlights the patients themselves as an influential factor
affecting their treatment decisions. However this new
ideology requires that PE is established as a more central
role in the work of healthcare professionals.
Today the television, movies and the internet are an
important influence on patients’ conceptions of medical care
and this information overflow is constant (Lewis, 2003). The
role of the practitioners as educators becomes increasingly
important while the patients need help in finding the sources
of relevant information. The internet is a powerful resource
for patients seeking health information and advice. But the
quality and variability of online content means that,
unguided, patients are exposed to information that is
sometimes misleading, frightening or simply irrelevant.
Healthcare organisations are in a position to offer relevant
information to their patients in an easily accessible and
understandable form. Indeed time pressures on initial
appointments with general practitioners mean that GPs are
now starting to direct patients towards trusted reliable
sources of information online (NHS Choices, Patient UK) for
further reading. It is a known challenge that only a small
amount of the information provided in traditional PE
counselling sessions is understood by the patient and
solutions are needed for optimising this delivery. It is also
known that patients do not always follow the “doctor’s
orders” and that this is dependent on, inter alia, the
practitioners interpersonal skills or the patient’s level of
education (Smith et al., 2009). However it is also recognized
that if an appropriate level of trust and confidence are gained
during the patient education sessions, then the greater the
patients’ intention to follow the prescribed plan of care.
(Hayes, 2007). The content of the sessions then whilst of
course important is perhaps equaled by the manner in which
it is delivered.Indeed a central aspect of role of nurses in the
delivery of PE is actually to reduce patient anxiety
(Swindale, 1989).
Technological applications for PE have been developed
for a number of purposes including, as teaching material, as
decision aids, and as a method for acquiring informed
consent. . They are seen as an opportunity to lower costs as
well as facilitating easier retrieval and storage of information
(Stoop et al., 2004). However there are both failures and
success of these technological PE systems. The inclusion of
audio and video clips of patient stories, for example, to
enhance decision aids and thus improve decision making
itself remains controversial (Bekker et al., 2013). The
educational systems should offer patients a high level of
information and strive towards better comprehension,
enabling them to be more involved in decision making and
dialogue with the healthcare professionals. Prior to any
design process patients’ needs should be explicated in detail.
There is no requirement to try and design systems that
replace traditional face-to-face PE as these are likely to fail.
We know that face-to-face communication has been proven
to increase trust and therefore technology should only be
used as an additional element to supplement more traditional
means of PE (Stoop et al., 2004).
In the current study we explored the opportunities of
information and communication technology (ICT) in PE and
counselling. Since we were equally interested in the
perspective of the patient and the healthcare organisation (in
this case, a hospital), we chose to use nurses with experience
about PE as our informants. The purpose of this strategy was
to provide a direct view of the life of the nurses, as well as a
mediated view of the patient. The experience of the nurses
chosen to take part in the study actually meant we were able
to explore a wide range of mediated patient perspectives.
The study was conducted in the department of
gastroenterological surgery and the research context was preoperative PE session.
We gathered PE related ideas using a so called Rich Use
Scenario (RUS) method (Pirhonen et al., 2007). RUS was
originally created for the purpose of user-interface design. In
particular, the design of non-speech user-interface sounds
was in focus when the method took shape. In its original
usage, the idea was to encourage design panellists to identify
themselves with a character in a story. This story, typically
about some every day situation, allowed the character or
characters at some point to use the application whose userinterface was the subject of the design process.
In some cases the story has been implemented as a live
‘radio play’, (just reading the story aloud, see Pirhonen et al.
2006) and in some case studies as a recording (e.g., Pirhonen
et al. 2007). When the primary interest was the user-interface
sounds, the recorded version enabled the implementation of
those sounds.
The core idea of RUS is to identify oneself with a real
person and understand that person in a real life situation.
This is a starting point for the creation of something new
which would promote the construction of something
genuinely valuable for the imaginary – but credible –
character. The strategy focuses on just one or a couple of
fictional characters and this is very different from the typical
implementation of use- scenarios, which usually tries to
cover as many user types and contexts as possible. In RUS,
however, rather than striving for maximum coverage the
primary aim is to understand the human being. Empathizing
with the character of the story is supposed to result in a
different kind of design above and beyond a more
mechanical approach. The strategy is appropriate whenever
the intention is to design something for human beings,
whether a physical item, computer application, or a service.
The application of RUS started in the case of PE by
creating a vivid story about a patient and his experience in
hospital including PE. The story was suggested by a panel of
five experienced nurses. After some initial instruction and an
overview of the general framework for the method the rest of
the session focused on the creation of the story – starting
with the creation of the characters and the patient character
in particular. The creation of the actual story proceeded as a
form of collaborative story telling – one participant narrated
a section of the story and then handed over to another nurse
to continue. There was no strict order in terms of turn taking;
anyone who had an idea continued the story from where the
previous participant had finished. In the next stage, the
researchers finalised the story manuscript. Then another
328
Journal of Information Systems Education, Vol. 25(4) Late Fall 2014
panel session was organised. This consisted of a different set
of experienced nurses from the same department. There was
no overlap between the participants in the first and second
panels. The second session started with a brief introduction
before one of the researchers read out the story. This was
followed by a free flowing discussion in which the
researchers used a series of open-ended questions to promote
discussion. Initially the researchers were interested to know
whether the panellists had found the story credible and
realistic. Then the discussion proceeded to the details of the
story. The only explicit theme that the moderators explored
was whether the panellists had any ideas about how
contemporary ICT could be applied in PE. The overall
duration of both sessions was approx. 75 minutes. The
sessions were recorded and transcribed.
In the analysis of the transcription our aim was to find
themes that could form a thread throughout the discussions.
One theme was quite evident in the discussions: that of trust.
For instance, when the researcher asked the nurses what was
important for the characters of the story, one of the nurses
replied: “Probably that trust was created from the beginning.
They had a lot of sort of insecurity, and some kind of
prejudices, which then faded away”. Trust emerged as
something that should be pursued in the development of
healthcare i.e., the patients’ trust in healthcare is a selfevident objective. In order to enhance and develop trust there
appeared to be two complimentary strategies: to promote
practices that strengthen trust and to avoid practices that
weaken it.
1) Strengthening trust: Getting comprehensible
information; getting relevant answers to specific questions;
being able to share information and experiences; access to
peer support; timely information, for example, patients
having access to clear instructions about next steps
immediately after receiving news of their diagnosis; access
to emotional and psychological support in addition to
practical information; being able to receive information from
a trustworthy source; the importance of the primary nurse;
being able to have a dedicated point of contact at all stages
of the process as this generates a feeling of familiarity and
safety.
2) Weakening
trust:
Impenetrable
information;
overwhelming volume of information may cause anxiety and
diffidence; a shortage of resources - there are not necessarily
the resources to organise primary nurse or adequate amount
of PE.
3. TRUST AND E-HEALTH
Human contacts and direct interaction between healthcare
professionals and patients appear to be one key factor when
striving towards trust and avoiding anxiety. In our study,
trust emerged from the discussions amongst experienced
nurses, but indeed, trust has previously been found to be a
key factor in the actual recovery of a patient (Lee and Lin,
2008). Patient trust in their practitioner is known to lead to
empowering outcomes such as activating patients to create
their own goals and commit to their treatment plans (Leske
et al., 2012). Ongoing, trusting relationships are vital in the
health domain and when the patient is committed to
329
following the plan of care it is also likely that healthcare
costs will be reduced (Hayes, 2007).
In terms of information systems, this could suggest the
application of the primary nurse principle in providing care
and support as well as PE. With the help of appropriate
information systems, patient centred practices could be
promoted. In an example provided by Graf et al. (2003), a
productivity
and
benchmarking
system
provides
comprehensive workload, staffing, and productivity data
daily in real time for the effective management of nursing
resources which classifies patients according to their needs
for care, not according to the amount of nursing staff
working hours available. The authors argue that safe, quality
patient care, needs staffing and resource allocation decisions
made on the basis of patients’ needs for nursing care.
Likewise being able to signpost patients to appropriate PE
resources requires a sensitive understanding of his or her
specific information needs. In some cases these needs are
relatively straightforward and of a practical nature.
Practitioners can direct patients to ICT resources that allow
them to navigate to a ‘comfortable’ level of information, i.e.
the right amount of information given, for example, the stage
of their medical condition and their preferences in terms of
medical literacy. In other cases practitioners might identify
that the patient would value information and advice from
peers and welcome the opportunity to share experiences.
Reading or listening to other patients’ personal accounts may
help people to feel supported or may assist them in learning
to tell the story of their own illness or condition (Ziebland
and Wyke, 2012). In this case the practitioner must recognize
that patients often value experiences that provide a good
match in terms of condition severity, age, gender and outlook
(Sillence et al., 2013) and as such direct patients to relevant
websites. The development and deployment of ICT within
PE also needs to recognize the patient’s information needs in
addition to their level of competence with and acceptance of
ICT. Technological obstacles have proved to be
unanticipated barriers to using purpose built technology to
support healthcare needs (Maitland and Chalmers, 2009).
At a general level, we propose that gaining and
maintaining trust towards a healthcare organisation should be
taken as a primary criterion in the development of
healthcare, including applied information systems. The
starting point for PE-applications, for example, should not be
cost savings alone, but increased quality of information
delivery and interaction; if the development of such a system
weakens trust, it undermines its whole function. For instance,
Andreassen et al. (2006) found that technology mediated
communication between a patient and GP has an impact on
trust. Factors such as careful listening, responsive feedback,
and whether the patients feel that the doctor is able to
understand their distress or vulnerability were clearly
affected by the presence of communication technology. It
cannot be concluded, however, that the effect is always
negative; for instance there is some evidence suggesting the
appropriateness of e-mail communication between patients
and GPs (Roter et al., 2008).
Instead of seeing ICT only as a tool for mediating
doctor-patient communication, technology’s potential might
be in the efficient gathering and provision of information.
Following up on information imparted during discussions
Journal of Information Systems Education, Vol. 25(4) Late Fall 2014
with the doctor is one of the main drivers of internet use for
health purposes. Patients who have spent some time online
sifting and sorting information may also feel better prepared
for consultations with their healthcare professionals (Sillence
et al., 2007) These kinds of systems could save time that
could be better spent in, for example, face-to-face
communication (Andreassen et al., 2006).
Besides the importance of trust, another central
conclusion from our study was that PE can no longer be
conceptualised as a discrete function, only existing within
the realms of a traditional, dedicated face-to-face PE-session.
A patient wants to trust in the expertise of the healthcare
professionals around them and therefore takes all their
comments seriously regardless of the context. For instance,
medical doctors do not usually regard PE as being part of
their job. We argue, however, that for a patient, all
interaction with a doctor or with any other healthcare
professional has fundamentally the same significance as
dedicated PE-sessions. PE should not be thought of as being
easily packaged into separate elements rather as a process
that begins often before the first consultation and continues
throughout the health episode. During this time patients both
actively seek and passively receive PE from leaflets, medical
discussions and incidental comments, other patients, family
and friends and a range of media sources. Therefore the
elements enhancing trust should be acknowledged in all
patient-healthcare practitioner interaction situations as well
as in all situations when information is delivered from the
healthcare organisation to the patient. This will mean
recognizing situations which may not at first appear to be
about PE. Sessions, for example, that are arranged within the
healthcare organisation for groups of patients about to
encounter the same treatment are often viewed solely as
support opportunities for patients. These sessions, however
will provide patients with the opportunity to exchange
experiences, overhear information and ask questions of each
other and the medical staff. Patients may often be looking to
draw comparisons and to gain any additional information
about what the treatment procedure will be like for them as
an individual. Healthcare practitioners will need to be aware
of these opportunities and respond appropriately enhancing
the potential for the development of a trusting environment.
Such encounters within the healthcare organisation also
allow professionals to become aware of PE that patients are
exposed to outside of that setting and consider how best to
manage any issues arising from those other sources.
In terms of PE-applications, this can put pressure on the
development of ICT for healthcare. How can patients be
given the impression that they are important? How can they
be assured that we as human beings and healthcare
professionals care for them and will use all available means
to promote their health and well-being?
implemented, they inevitably have an impact on the
functions they deal with. i.e. it is a question of the classic
argument about the inseparability of the form and the content
(McLuhan, 1964)).
In PE, the intentions to apply ICT are typically based on
oversimplifications about the needs and nature of PE. When
handling PE as an information system, we should be aware
of the changes that the application of ICT causes. When ICT
is introduced as a new opportunity in PE, we should take
care that it remains an opportunity; if the introduction of a
new ICT based process implies the rundown of existing
practices then ICT is no more an opportunity but rather a
necessity. Too often, we do not allow different options a
chance to exist in parallel and let time show which one best
meets the real needs. Financial arguments are often presented
to justify the construction of one single form of service, but
if this results in the decline of the quality of PE, it has a cost
as well.
We have dealt with concepts at different conceptual
levels. First, we found that trust is a key issue. Second, we
concluded that interpersonal communication which indicates
caring and expertise is essential in the creation and
maintenance of trust. Thirdly, we argued that all these forms
of communication can be conceptualized within the
framework of patient education. Finally, at the most practical
level, we argue that whatever technology is used to enhance
communication it has to be applied in terms of trust and
ultimately the objectives of patient education. The
relationships between these concepts are illustrated in Figure
1. The illustration stresses that PE can be seen as the
overarching theme – it is the big picture within which, for
example, the applied technology (ICT) has mostly an
instrumental value.
4. DISCUSSION
The utilisation of contemporary information and
communication technology in patient education is frequently
handled as a straight forward solution to the existing needs.
The setting is familiar from numerous other contexts in
which the technology experts believe that they already
understand the needs. When ICT-based solutions are then
Figure 1. Conceptual framework
In the current paper, we propose a broad definition of
PE. In addition, we derive arguments about the utilisation of
ICT in PE from the actual objectives of PE. The chosen
strategy brings PE to the very core of the whole healthcare
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Journal of Information Systems Education, Vol. 25(4) Late Fall 2014
system. Rather than being patient (or even customer) centric,
we propose that the development of our healthcare systems
should be PE-centric. This is justified by the fact that
interaction between the patient and the representatives of
healthcare organisation is what healthcare is fundamentally
all about. We argue that if the communication between a
patient and a healthcare organisation works, it results in
benefits in:
•
•
•
the recovery of the patient or improved selfmanagement of the health condition
cost savings
well-being of the care-givers
As can be seen, the potential benefits are so central to the
whole healthcare system that the development of healthcare
could indeed be built around the concept of PE. The
proposed approach would help to see practical
implementations, like the utilisation of ICT, from an
appropriate perspective. In other words, once we have
formulated the objectives for PE, we could apply them as
criteria in individual ICT-projects.
5. ACKNOWLEDGEMENTS
This work is supported by European Social Fund (ESF)
in Finland.
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Journal of Information Systems Education, Vol. 25(4) Late Fall 2014
AUTHOR BIOGRAPHIES
Antti Pirhonen is a senior researcher and an adjunct
professor
in
interactive
technology. He is a doctor in
both educational sciences and
computer science. His primary
field of research is humancomputer interaction, as well as
information society studies.
Minna Silvennoinen is a post doc researcher in cognitive
science. She has a master's
degree in education. Her primary
field of research is medical skills
and expertise research in both
authentic work environments and
in
simulated
learning
environments.
Elizabeth Sillence is a senior lecturer in psychology. She
has a background in ergonomics
and a PhD in HCI. Her research
interests are focussed on trust
and
online
interactions
particularly within an e-health
context.
332
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