A Complexity Inspired Approach to

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A Complexity Inspired Approach to

Co-evolutionary Hospital Management Information
Systems Development
Vincent Shaw
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Overview of Presentation

• Research aim and questions
• Defining a HospMIS
• The challenge of HospMIS Design and
  Implementation
• Theoretical framework
• Complexity and Complex Adaptive Systems
• Organizational learning
• Research methods

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Overview of Presentation 2

• Contributions
• Context as extreme heterogeneity
• Managing heterogeneity with flexible standards
  and
• Flexible implementation processes
• Sustainability as co-evolution
• Concluding remarks

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1. Research Aim

• To develop complexity inspired conceptual models
  to
• understand the design,
• development and
• implementation of
• sustainable and scalable hospital management IS
• In resource constrained contexts

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What are my Research Questions?

• Given the complex nature of the hospital
  environment, what are the socio-technical
  considerations that contribute to the design of
  sustainable and scalable hospital management
  information systems in resource constrained
  settings?
• How can the implementation process be designed to
  accommodate unexpected contradictions that arise
  between the different realities of original
  intent and changing needs in the implementation
  process?

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2. Defining a HospMIS?
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The Components of the HospMIS
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3. The Challenge in HospMIS Development 1

• Fitting together
• Clinical work
• The organization that supports the clinical work
• ICTs used to manage information
• (Aarts, Peel et al, 1998)
• Organisational complexities of the hospital
  context (Hanseth and Lundberg 2001 Lundberg and
  Tellioglu 1999)

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The Challenge in HospMIS Development 2

• Heterogeneous and semantic interoperabilities
• Difficulty of achieving a balance between loose
  and tight integration of sub-systems (Monteiro
  2004).
• Frequent changes in reporting requirements
• Pressure to go big and adopt global solutions
  (Ellingsen and Monteiro 2003)

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The Challenge in Implementation

• Addressing design-reality gaps
• Negotiating standards
• Skills to support the implementation process
• Identification of skills required for support
• Development of appropriate skills

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4. Theoretical framework 1

• Drawn from Complexity Theory, and in particular
  complex adaptive systems
• Four key concepts
• CAS as agents with schemata adapting to the
  environment
• Non-linearity resulting in unpredicatble
  long-term outcomes
• Self-organizing groups and networks displaying
  emergent behaviour
• Co-evolution at the edge of chaos

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Defintions of Complexity

• A complex system is made up of a large number of
  parts that have many interactions (Simon 1969).
• Complexity in organisations has three dimensions
  
• vertical - the number of activities or subsystems
  (the number of hierarchies),
• horizontal - the number of job titles, or
  departments and
• third - the spatial dimension or the number of
  geographical locations in which the organization
  operates
• (Daft (quoted in Anderson 1999)) .
• Complex systems are typically organisations made
  of many heterogenous parts interacting locally in
  the absence of a centralised pacemaker and
  control (Fontana (1999) pg 14).

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Agents with schema adapting to the environment

• A CAS is a system of individual agents, who have
  the freedom to act in ways that are not always
  totally predictable, and whose actions are
  interconnected such that one agents action
  changes the context for other agents.
• Stock market, colony of ants, weather system,
  immune system

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Non-linearity resulting in unpredictable
long-term outcomes

• The sand pile example
• Self-organizing criticality small adjustments
  result in large-scale changes
• Non-linearity and indeterminate outcomes evolve
  as a result of both negative and positive
  feedback

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Self-organizing groups and networks displaying
emergent behaviour

• The ability to self organize is a characteristic
  of systems where independent agents behave
  according to a set of rules and not due to
  external control.
• Feedback loops modify the behaviours of agents

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Co-evolution at the edge of chaos
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Theoretical framework 2
Understanding technological change as
organizational learning
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Aborptive Capacity and Systems capabilities

• The policies, procedures, and manuals that are
  used to integrate explicit knowledge.
• Ensure behaviors are programmed in advance of
  their execution.
• Support knowledge absorption, but tend to be
  limited in scope and flexibility
• Negative overall effect on absorptive capability

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Aborptive Capacity and Co-ordination capabilities

• The ability to communicate between members of a
  group, and between groups.
• e.g. self-organizing groups which cut across
  layers of authority (hierarchy) and functional
  groupings.
• Less efficient in effecting knowledge absorption,
  but have an ability to be flexible and cover a
  broad scope of knowledge absorption
• Positive effect on absorptive capacity.

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Aborptive Capacity and Socializing capabilities

• Ability to create a corporate identity as well as
  a collective interpretation of reality.
• Socialization capabilities are path dependent and
  shaped by the history of the organization, and
  tend to foster isolationism.
• Organizations with strong socialization
  capabilities tend to reject outside knowledge
  that is different to their organizational code.
• Negative effect on absorptive capacity

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5. Research Methods 1

• Longitudinal case study approach
• Member of the HISP action research network
• As an empowering process, seeking local solutions
• Within an iterative cycle of action, reflection
  and learning

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Research Methods 2

• Primary data collection through
• Field notes and a personal diary, and reflections
  on various data sources
• Camera for documentation
• Recorded interviews and meetings some
  transcribed
• Filed visits and direct observation
• Secondary data sources through
• Official documents, reports policies, guidelines,
  etc

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Research Methods 3

• Data analysis through interpretive research
  methods using
• first and second-level analysis
• analysis as part of my doctoral studies
• Co-evolutionary growth process
• Theory used to inform data analysis and as a
  final product of my research

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6. Contributions 1 Understanding the context as
extreme heterogeneity

• Extreme heterogeneity manifested in hospitals
• Differences between departments
• Differences between hospitals
• Different professional groups, staffing levels,
  and skills base
• Extreme heterogeneity creating nested effects

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Complexity of the environment characterised by

• A broad range of challenges
• Limited control over information production
  activities
• Other complexities impinging on HospMISD
• As unanticipated non-linear effects

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• This Malawian Hospital had
• A touch screen EPMR for Paediatric patients
• The DHIS as the HospMIS
• This filing system for patient records

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Managing heterogeneity through flexibile
standards a) Adaptable paper tools
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The EDS as a Flexible Standard
Total deliveries Deliveries mothers under
18 Deliveries mothers over 18 Deliveries under
2500g Deliveries over 2500g
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Gateways as flexible standards
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The DHIS as a flexible standard
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Managing heterogeneity through flexibile
implementation processes

• Principle of integrated independence

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Process for accommodating non-linearity
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Flexible implementation processes contd

• Mindful innovation (Swanson and Ramiller 2004,
  Weick, Sutcliffe et al. 1999)
• Attractors as growth points (Braa et al 2007)
• Creation of networks and inter-dependencies
• Development of the Health Information
  Practitioner
• Introduction of redundancy

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The Challenge of Sustainability

• Sustainability is the challenge to make an
  information system work, in practice, over time,
  in a local setting. This involves shaping and
  adapting the systems to a given context,
  cultivating local learning processes, and
  institutionalizing routines of use that persist
  over time (as well as when the researchers leave
  and external funding is over). (Braa, Monteiro
  et al. 2004) (p. 338).

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Co-evolutionary model for sustainable HIS
Development
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7. Concluding remarks 1

• Limitations in this thesis can be identified
  related to
• Relative short periods of study of HospMIS
• Limited focus on cultural diversity and the
  impact of this on HospMIS
• Lack of depth regarding inter-organizational
  dimensions

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Concluding remarks 2

• Contributions can be defined in terms of
  development of ICTs
• Locally appropriate solutions in the south for
  the health sector
• Development of local capacity
• Development of sustainable organizations and
  processes
• Research in resource constrained contexts
• Research on FOSS
• Methodological issues such as
• Longitudinal action research projects
• Multi-level focus for data analysis

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Thank you