A health informatics in-depth evaluation study of the rural, across-distance implementation of a health information system: Implementing in the wild

BACKGROUND: This study involved the across-distance implementation of a Patient Administration System (PAS) in rural Australia, led by three health information managers (HIMs). The setting was a vast, rural health district with 10 widely dispersed health collectives ('agencies'), each encompassing a hospital and up to five additional facilities that delivered acute, rehabilitation, residential aged care, bush nursing and/or community health services to their rural and semi-rural populations. OBJECTIVE: The research aimed to examine, contemporaneously, the across-distance PAS implementation work of a team of HIMs. METHOD: This qualitative research adopted a bounded case study approach utilising the ethnographic methods of unobtrusive observation of the project committees (Steering Committee, Project Managers' Committee, Team Leaders' Committee) and in-depth interviews with the HIM team and other key actors. Temporally, the research primarily centred on the lead-up to Go-Live, via point-in-time snapshots and shadowing of the HIM team's work at different junctures. RESULTS: The HIM team enacted alignment with typical, health system implementation stages. Problems encountered were: Go-Live timings; consultation on design of referral functions; poor or absent report, referral, and billing functionalities; and universal health IT implementation issues of insufficient staffing resources and too-tight timeframes. Constantly problem-solving to (re-)balance tensions between the agencies' desire for an effective PAS and the realities of a government-imposed, standardised system, the HIMs imagined the new PAS and its impacts on the agencies' data collection processes, day-to-day operations, and patient care. From a distance, they intensively and collectively imagined and (re-)ordered technology, systems, policies, procedures, work and documentation practices, patient and information flows, and adjunct services, to establish a PAS with integrity and address the requirements of the purchaser agencies' directors, management, clinicians, HIMs, and finance and administrative staff. CONCLUSION: The HIM team applied knowledge of healthcare systems and processes, mitigated risk, and mediated the technology and the stakeholders' worlds. Their collaborative work to establish PAS-related order was congruent with our previous findings on the work of HIMs, Australia-wide.Implications for health information management practice:This case study research highlights the significance of HIMs' deep professional knowledge of (a) health informatics and information systems, and (b) healthcare agencies' data requirements, practices, and artefacts.