Information Systems Methodology for Building Theory in Health Informatics:
The Argument for a Structured Approach to Case Study Research
A. Alison Plummer
Department of Computing and Information Systems Faculty of Informatics and Communication
Central Queensland University Rockhampton, Australia [email protected]
Abstract
The health care environment is frequently described as hyperturbulent and information intensive. However, is the health care systems environment significantly different from the information systems environment in other industries? Are the methodologies and frameworks developed within the context of Information Systems research applicable to Health Informatics? This paper compares and contrasts the disciplines of Information Systems and Health Informatics including their conceptual foundations and research foci to investigate the appropriateness of Information Systems theory and methodologies for the discipline of Health Informatics.
The author endorses the structured-case methodological framework for health care information systems research that goes beyond description to build theory. The intent of the structured-case is to provide a mechanism to produce high quality case study research to gain deep knowledge and understanding about the organizational issues of information systems and their relationship to performance and outcomes.
1. Introduction and Background
Is the health care information systems environment significantly different from the information systems environment in other industries? Health care environments are frequently described as information intense, highly paradoxical, and hyperturbulent[1]. Health care has gone through more dramatic change at a faster rate than other industries causing this hyperturbulent environment [2].
Additionally, in terms of the information required to diagnosis, monitor and treat patients, as well as to administrate delivery, health care is indeed information intense. Strong professional cultures exist and can conflict within a health environment. Each of these cultures has different needs, priorities and perspectives concerning the
use of information technology for decision-making in a health care setting. From this, health care issues could then be described as more information intense, more organizationally complex, more turbulent, more paradoxical, more subjective, and more emotionally charged than other industries and businesses. It is this very complexity and subjectivity that supports the need for developing appropriate qualitative methodologies for research and theory building in the discipline of Health Informatics (HI).
Health Informatics has been concerned primarily with the use of technology for the optimal use of health-related information for decision-making and problem solving to improve health care outcomes [3]. Information systems consist of hardware, software, people, and processes. The discipline of Information Systems (IS) includes the study of both the social and technical aspects of the use of information technology for organizational decision- making and problem solving [4]. Both HI and IS face the same organizational issues when considering people and technology, including elements of power relationships, politics, and resistance. Not surprisingly, because of the cost, size, complexity, and organizational issues involved, a consistent high rate of failure for all types of information systems has been reported for all industries including health [5] [6]. This failure rate is estimated to be as high as 70% and costing companies between $80 and $145 billion annually1. The research indicates that organizational issues of structure, culture, power, politics, control, and resistance are likely to be of critical importance to the ultimate success or failure of a system as well as more technical and managerial issues [8] [9].
The discipline of HI has begun to recognize the value of applying IS theories and methodologies to HI practice to improve systems success [10]. In spite of this
1 In this context failure is defined as systems that are abandoned, over- budget, or not used as intended [7].
recognition, much of HI research tends to be focused on the cause and effect research approach of the natural sciences and tends to emphasize a technological imperative philosophy [11]. Much HI research up to this point has tended to take a factors-based approach to health information systems outcomes and has had more emphasis on the relationship of technology to performance and outcomes and less emphasis on the effects of organizational behavior on technology and performance [12] [13]. As previously stated, the importance of organizational behavior (including such concepts as structure, culture, change management, organizational learning, and knowledge to name but a few) on systems success has been recognized within the disciplines of IS and HI. In addition, the value of qualitative research methods, specifically case study, has been gaining credibility as a feasible way to study organizational processes within both disciplines. However, unlike IS, relatively little HI theory has been developed from case studies to understand how these organizational processes constrain or enable health information systems development and implementation. From a review of the HI literature, many case studies appear to be descriptive in nature rather than theory building. It is arguable that this is due to the complexity of the issues involved and the relative lack of exposure to IS theory and methods including case study research.
Case study research is the most widely used qualitative method in IS research precisely because of its usefulness in investigating the complex interactions between technology and organizations [14]. Within the realm of case study, there exists a dichotomy between positivist and interpretive approaches[15]. Each of these approaches has inherent strengths and weaknesses. Due to these limitations, several IS researchers have argued for the value of combining the two research approaches to optimise the relevance, rigor, and pragmatism of case study research [16] [14] [15] [17] [18]. The structured- case methodology presented in this paper is such a multi- method approach.
To summarize this section, it appears that it is the degree of intensity, not the nature of the organizational and information issues that differentiates the disciplines of IS and HI. The overall focus of both disciplines is on the goal of successfully integrating people and technology to improve outcomes and performance. The same high failure rate of information systems, due in part to organizational issues, has been reported. It is therefore reasonable to assume, given the similarities, that the same qualitative research methods, specifically the structured- case methodology, would be useful to achieve the goals of organizational research that builds theory and improves practice. The thesis presented in this paper is for the field of HI to make an ontological and epistemological leap from its natural science background to a discipline that integrates existing work from IS to progress relevant
quality research of organizational issues in both fields.
After presenting conceptual considerations and outlining the structured-case framework for case study research, the paper provides a health care systems example to demonstrate the concepts outlined in the paper.
2. Conceptual considerations
Information Systems is a multi-disciplinary field building on reference disciplines including organisational theory, decision science, information technology, and other management sciences. Due to the fact that IS is a relatively new field of study built on referent disciplines, there have been developmental issues such as the lack of a cumulative tradition, the lack of unifying theories, and the lack of consensus on appropriate research methodologies [19]. Many of these perspectives are currently being presented, refined, and argued about in the IS literature.
For example, [20] identified some very basic research tenets for IS including the need for more careful research methods, the importance of being exposed to research methods from other disciplines and importance of discovery research.
2.1 Organizational behavior
Although there continues to be much academic discourse within IS about research relevance including the use of referent disciplines, the development of sound theory, and appropriate research methodologies, progress has been made in terms of the growing acceptance of research diversity and “disciplined methodological pluralism” [21]. Conjointly, the importance of organizational considerations to systems success or failure has been clearly demonstrated as critical and has been a major focus of IS research. Overall, the primary focus of the discipline of IS remains the relationship between technology and organizational change [22]. [22] based their paper on the need for sound theoretical constructs for IS research concerning the impact of information technology on organisational behaviour.
[23]
called for a cumulative tradition, attention to organisational effects on IS performance and vice versa, and the recognition of IS success as a multi-dimensional construct. In the same article, the authors have organized the immense body of IS literature on “IS success” into a framework with five constructs, including organizational impact. The last dimension of the framework—organisational impact— is identified as the most important area for future research.However, they admit that attempts to measure organizational performance are few due to the “difficulty of isolating the contribution of the information systems function from other contributors to organizational performance”[23]. Nevertheless, this connection is of great interest and importance to organizations.
Health Informatics is also a blend of many referent disciplines including, but not limited to, psychology, sociology, anthropology, organizational behaviour, and management sciences [10]. However until recently, HI research has tended to focus on the technical development of clinical systems and has tended to favor the positivist approach of medically trained researchers [24]. Due to this perspective, the overall emphasis of this work has leaned toward a technological imperative philosophy. In spite of this, it is evident that the field is beginning to recognise the importance of organizational issues to systems success and discovering their own referent discipline of IS [10].
The following section discusses the connection of information systems success and organizational issues to information systems development (ISD) theory and research in both IS and HI.
2.2 Information systems development
As described in the introduction section of this paper, an extremely high rate of information systems failure has been reported in both the IS and HI literature. Partly in response to this high rate of failure, the formal study of information systems development (ISD) has become a major research area within IS [25] as well as in HI [26].
Within the discipline of IS, ISD is generally understood to be the formal, usually documented, process of developing a computer system. Information systems development methodologies (ISDM) have been defined as the various ways and means, tools, techniques, and models that are available to the information systems developer [27]. However, in this paper, the focus will be on the ISD “approach” taken, rather than describing the more formal ISD “methodology”. The ISD approach can be defined as “a set of goals, guiding principles, fundamental concepts, and principles for the ISD process that drive interpretations and actions in ISD” [28] p. 166.
One reason to focus on the ISD approach rather than the methodology is that many organizations do not recognize or consistently use a formal ISD methodology in their systems development. It has been reported that less than half of organizations actually use an ISD consistently [29]. The authors go on to suggest that this finding demonstrates a general misfit between methodologies and actual needs in practice.
There is a growing body of research indicating that the success of an ISD approach depends as much on political and social aspects as on technical aspects [30]. Again, these issues, which so heavily influence information systems outcomes, are difficult to define and measure and include intangible concepts such as power, politics and personalities. Frequently, organizations involved in information systems implementations tend to think of the people and processes involved as rational and technical in nature [30] [31] [32]. However, due to the consistent high
rate of information systems failures, it has become clear that ignoring the sometimes irrational and non-technical organizational and people issues greatly adds to the risk of failure of any project [33] [23] [34] [35] [8] [36] [6]
[37].
The ISD literature abounds with research on large systems development and implementation. From this research, many organizational aspects have been identified as being critical to a system’s success. Four of the most well documented critical success factors include:
• Organizational leadership and commitment;
• The establishment of an appropriate coordinating body or mechanism;
• Adoption of participatory approaches to ISD; and
• An iterative approach to development [38].
These same critical aspects of systems development have also been widely recognized within the field of Health Informatics [26]. However, to date there is still relatively little theory developed to understand how these processes constrain or enable information systems development and implementation in HI that addresses both the complex technical and organizational issues. [24] argue that that is due to the fact that there is still little research on organizational issues in the field of Health Informatics even though the need for techniques to implement information technology has been identified as an urgent need. These authors further identify three reasons why research into organizational issues has been scarce in HI:
1. The continuing quantitative, positivist research paradigm that predominates in the health sciences;
2. The intrinsic complexity of the organizational context (including culture and power); and
3. The organizational context of an IS project changes over time, that is, it is a process and not static [24].
In addition, much of the existing case study work on organizational issues in the health care area is descriptive in nature and does not build theory.
2.1 Case study research
Because of its usefulness in investigating the relationship between information systems and such intangible concepts such as organizational performance and success, the case study research method is the most widely used qualitative method in IS research [14].
Although there is growing awareness of the value of qualitative methods like case study research developed in IS (and other referent disciplines) to study organizational issues, from the above discussion it appears that the discipline of HI is just starting to come to grips with the problematic theoretical and methodological perspectives that must be addressed when attempting this kind of research. “From the review it becomes clear that theories and methodologies from social and business sciences are equally necessary tools to study the development,
implementation and the impact of information systems in healthcare. Such studies will evidently be case-based and focus on a systemic description of a complex and messy world” [11] p. 49 after [41].
However, it is important to consider that there are different types of case study methods normally differentiated as either positivist or interpretive in nature.
Each type has its own ontological and epistemological perspectives, adherents, and opponents. It is important to understand these perspectives in considering the appropriateness of these methods for IS or HI research including research design, implementation, evaluation, and of course acceptance by the relevant academic community.
In general, the ontological perspective of the positivist presupposes that there is a reality that exists independent of our knowledge of it. The belief in the nature of reality is that it is possible to absolutely discover and measure this reality through valid and reliable research constructs [15].
Epistemologically, the positivist approach in general conducts and evaluates research using experimental research criteria from the natural sciences ie. the use of controlled observations, controlled deductions, replication and generalizability [39]. The positivist is focused on the empirical testability of theories [14]. In general, the positivist approach tests theory by developing hypotheses and formal propositions. Hypotheses are developed with independent and dependent variables and attempts to measure these variables in a quantifiable way [40] [41].
The positivist approach to qualitative case study uses the case study methodology for exploratory research to develop hypotheses and multi-case methodology using positivist methods has been described as a way to introduce theory building and generalizability to case study research [42].
In contrast, the ontological perspective of interpretive case study research is that reality is social interpretation.
Society constructs a social reality that is perceived differently by different individuals and meaning comes through shared understanding. This reality can only be interpreted, not discovered [15]. Epistemologically, interpretive research attempts to understand phenomena through the meanings that people assign to them. The main intent is not to identify independent and dependent variables rather to make meaning out of the situation as the analysis of the data unfolds [40]. The primary purpose of interpretive research is to offer an interpretation of human conduct [15]. This approach is not concerned with replication, but with deeper understanding of the processes being investigated [14].
Both positivist and interpretive approaches to case study research have inherent strengths and weaknesses.
Most noticeably, the positivist view is criticized for its inability to account for the complexity and subjectivity of the social world and the interpretive view is criticized for its perceived lack of standardly recognized methodological rigor and generalizability. There is a
trade-off between these issues when favoring one approach over another [43].
Due to the limitations of each view, several researchers have argued for the value of combining the two research approaches to optimize the relevance, rigor, and pragmatism of case study research [16] [14] [15] [17,18].
[18] argues that the two views are not mutually exclusive and one can add value to the other. In terms of a multi- method approach “the most important conclusion is the desirability for a variety of approaches to studying information systems. No one approach to information systems research can provide the richness that IS, as a discipline, needs for further advancement” [17 p. 571].
Unfortunately, once a researcher has decided to mix positive and interpretive methods to some degree, there is no agreed upon way to do it [16]. It seems to be up to the philosophical leanings and research aims of the individual researcher to decide upon the right mix. This has led to the continuing problem of appropriately evaluating these types of methods. There are many practical difficulties in designing and implementing case studies that are both rigorous and effective. To be successful, “the rigor of the process used to arrive at the results and the validity of the findings and the conclusions reached need to be established [14]. In spite of the philosophical approach chosen to complete case study research, the best strategy would appear to be the thorough clarification and documentation of the overall research ontology and epistemology. In addition, the research questions need to be appropriate and answerable in a reasonable way, and of practical value [14].
As a final theoretical consideration, the question of rigor and relevance in case study research should be acknowledged. Although qualitative research, specifically case study methodology, has been widely accepted within IS and HI, there is still much debate concerning what constitutes quality case study research including how to design it and how to evaluate it. The perspectives of both the positivist and interpretive approach have value and there is a trade-off to be made between repeatable research design and usefulness in the real world of IS practitioners [44]. Both IS and HI are applied disciplines, therefore the research should be designed for the purpose of improving practice [45]. It has therefore been suggested that to improve relevance, research should be practice-driven, where the goal is effectiveness in actions, not natural science truth [18]. As demonstrated by the high rate of information system failure in both IS and HI, just because a particular technology is presented as being able to solve all information problems (the technological imperative view), there is still a high probability that it will fail once people and politics get involved. What would be useful is knowledge on how to implement large, complex systems in highly political, and culturally diverse environments (like health care) to improve such subjective measures as outcomes and performance.
Therefore, to accomplish this goal of relevance, and to address the problematic issues of researching organizational issues in information systems development and success as discussed above, this paper endorses a multi-method practice-driven case study approach such as the structured-case methodological framework described below. The structured-case approach combines the rigor of positivism and the deep knowledge of the interpretive approach, thereby providing a balanced approach needed for rigor and relevance for theory building in organizational research.
3. The structured-case study methodological framework
The structured-case study approach of [16] outlined in this section is a combined approach designed to improve rigor, and to build theory, which have both been identified as critical research needs. In addition to these goals, the approach is intended to guide research that will build a deep understanding of practice in the field. That is, it is intended for research that is practice-driven and not science-driven [46]. Although structured-case methodology leans toward an interpretive philosophy in its analysis and interpretation, it uses a more positivist approach to develop the “conceptual framework” of the model to document the process, guide the research, and build theory. The framework is intended to assist in the development of high quality case study research. It combines the themes (eg. “propositions”) and aims of the research (positivist perspective) with existing knowledge and the philosophical perspective of the research (interpretive perspective). The “structure” of the conceptual framework is built upon the conceptual framework process of [47].
The following description of the structured-case methodology is summarized here directly from [16] and should be referred to for a more complete explanation of the process. The structured-case methodological framework has three components:
• The conceptual framework to provide theoretical foundations;
• The research cycle, which is an iterative process that continuously refines the research; and
• The literature-based analysis to tie the research to theory.
The framework will change via the research cycle but the series of evolving models would be documented. The conceptual framework can be positioned at either extreme from a pre-set, positivist perspective or a grounded-type perspective with no pre-set assumptions. The important consideration is that the theory remains tightly linked to the data; the conceptual framework provides this mechanism. “The process of representing this conceptual structure, confronting it’s underlying assumptions, and
making it explicit is one of the keys to high quality research. The point of the structured-case approach is that the particular perspective of the researcher can be accommodated as long as it is formally designed and documented to maintain research thoroughness and soundness.
Figure 1 displays the structured-case methodological framework, which includes the components of the conceptual framework and the attached research cycle.
Although the entire process is displayed here as an integrative diagram, the process is meant to be fluid and iterative. The conceptual framework clearly sets out concepts and relationships of interest. The conceptual framework is a representation of the theoretical foundations, the research propositions, and existing knowledge developed from the literature and experience.
It also includes the main research themes and may start out as broad areas of interest and be refined through iterations of the research cycle.
The research cycle has been adapted from the action research problem-solving cycle. It is also iterative in nature and builds upon critical reflection. The research cycle includes four elements, illustrated in figure 1; plan, collect data, analyze, and reflect. The planning stage includes the development of the first and subsequent iterations of the conceptual framework, and the data collection protocol. The collect data stage is the process of obtaining the case study information that can include interviews and archival material from the target organizations. In the analyze stage of the cycle the data is coded for analysis and can include such methods as pattern matching and clustering of responses [41].
Analyse
Reflect Plan
Knowledge Research themes
Literature Insights Theoretical foundations
Collect data
Theory Series of
Conceptual frameworks Literature-based
scrutiny
Figure 1: The structured-case research cycle, after Carroll and Swatman, (2000).
The coding is again an iterative process and should be guided by the structural order of the conceptual framework. The reflection part of the research cycle critically evaluates the process, reviews the data, and revises the conceptual framework. Reflection includes asking such questions about meaning, alternative explanations, and contradictory evidence. Theory building also happens in the reflection stage when concepts are clarified and relationships are specified. There are three different levels of theory building including the development of:
1. Working relationships, based directly on data (substantive theory);
2. Theories involving some abstraction, still closely linked to data (formal theory);
3. Unifying theories that seek to explain behavior (formal theory).
This type of research is designed to build theories based on second level from discovering and analyzing relationships from the conceptual framework. The iterative research cycle moves the conceptual framework from substantive theory to more formal theory. The literature based scrutiny component of the conceptual framework (see figure 1) is also involved in building theory. The literature is reviewed to find conflict or agreement with the research findings. It is suggested that similar findings in different contexts contributes to more powerful second level theory.
Once again, the process of the structured-case methodology, graphically presented in figure 1, is continuous and uses the research cycle and iterations of the conceptual framework as a spiral towards understanding. This process can go on indefinitely. It is up to the researcher to decide when further iterations will add significant understanding to justify continuation, or if practical considerations such as time and funding circumscribe the process. In summary, the combined positivist/interpretive approach of the structured-case case study methodology outlined here can provide a useful way to investigate the complex and often ambiguous interactions between technology and organizational issues that so frequently curtail the successfulness of information systems. The following section is an example of the structured-case methodology from research in progress conducted in the area of health care information systems.
4. Structured-case -- a working example
The following structured-case study is research in progress investigating two large public sector health care organizations attempting to design and implement enterprise-wide data warehouses to improve organizational performance. Although the two organizations are similar in size and scope and started the development process at approximately the same point in time, they have experienced noticeably different rates and levels of
success [48]. From the concepts presented earlier in this paper including the similarity of IS and HI, and the critical importance of organizational issues to systems success, the major research theme considered the investigation of the organizational barriers to system integration within health care information systems using theories from the IS literature. The objectives of the research were then to investigate the process of health care system integration from an organizational perspective; and from that identify the associated optimal organizational success environment.
The first iteration of the conceptual framework was developed from a review of the literature, from the professional experience of the researcher, and from preliminary interviews with individuals from the organizations. The first conceptual framework is presented in figure 2. The framework lays out the four research dimensions of organizational structure, culture, learning, and ISD strategies that were chosen from the IS literature as likely variables with several associated theories for each variable that could be tested. In addition, the framework lays out the possible relationship of the four dimensions to the systems integration process, and the overall project outcomes in terms of improved organizational performance. This first framework provided a guide for the planning and execution of the first pilot case study by defining the scope and structure of the interview questions and the collection of the research data.
After the pilot case study, the data was coded and analyzed, the literature was re-revisited, and the second iteration of the framework was developed from a refinement of the original framework. This subsequent iteration is the “Optimal Success Conceptual Framework”
(figure 3) that was used to plan, execute, and analyze the case studies of the targeted organizations [26]. The Optimal Success Conceptual Framework added the arrows representing the interactions between the four dimensions and replaced the dimension of political resistance with organizational learning as a critical dimension. (From the previous research cycle, the understanding of politics was revised to be defined as behavior that resulted from the interactions between the dimensions of the framework, not as a specific dimension itself). In addition to adding the two-way arrows to illustrate the interactions between the four research dimensions, figure 3 also includes the specific theories taken from the IS literature listed under each of the four dimensions. The elements listed under each dimension were identified from theories in the literature as organizational characteristics that could be identified through case study research.
For example, the four elements of Culture listed in the Optimal Success Conceptual Framework of figure 3 include the four professional cultures existing in a health environment including medical, technical, scientific, and managerial as identified by [49]. The elements of ISD listed in figure 3 include leadership, participatory
Figure 2: Systems Integration Conceptual Framework, first iteration Information
Systems Development
Resistance
Culture Structure
Systems Integration Process
ImprovedOrganizational Performance
Information Systems Development
Leadership Participatory
Iterative Coordinating Body
Learning
Acquisition Sharing Utilization
Culture
Medical Technical Scientific Managerial Structure
Technocratic Anarchy Feudalism Monarchy Federalism
Improved Organizational
Performance
Systems Integration Process
P3
P1 P2 P4
P5
Figure 3: Optimal Success Conceptual Framework from Plummer, (2000), second iteration
Interim research cycles (see figure 1)
approaches, iterative development, and the establishment of coordinating bodies. These elements of information systems success were previously described in the conceptual considerations section of this paper. The elements of organizational learning and organizational structure were developed from theories of learning orientations [50] and information politics [51]
respectively. From this conceptual framework that includes the representation of the relationships of the organizational dimensions to be investigated and the underlying theories, the research propositions were developed (table 1). The propositions are also displayed in figure 3 as P1 – P5. The propositions are positioned in the diagram in relation to the specific research dimension under consideration and the systems integration process.
Thus, by using the structured-case methodological framework, the Optimal Success Conceptual Framework and the resultant propositions have been developed to provide the “structure” to continue an interpretive investigation of the research questions concerning systems integration in a health care information systems environment. In reality, many iterations of the conceptual framework have evolved between the first and second iterations presented here. For simplicity in describing the structured-case method, only the first and most recent iterations of the conceptual framework have been provided here. The research is currently in progress with the two case studies completed and the research cycle continuing through data analysis, reflection, and the modification of the conceptual framework informed by scrutiny of the literature to gain knowledge and build theory regarding health care information systems and improved organizational performance.
5. Conclusions
Information systems are multi-dimensional and multi- perspective. Thus they are difficult to design, implement and evaluate for real world applications. Information systems success in terms of organizational performance has been identified in both the IS and HI literature as very difficult to determine but of critical importance. It becomes clear that the use of more qualitative methods of investigation are deemed appropriate to these multi- disciplinary fields concerning human interaction and human decision making processes. This paper has developed the position that the disciplines of IS and HI differ only in terms of degree of intensity. Therefore, it is reasonable to suppose that the theories, methodologies, and frameworks developed within the context of IS are applicable to HI research into organizational issues. From this, the author has presented the argument for quality structured-case study research that can progress understanding, build theory, and thereby improve practice and outcomes.
It is hoped that the discipline of HI will continue to absorb the previous experience and learning of IS including theoretical and methodological developments concerning rigor and relevance to expand current dominant perspectives from positivist science-based methods to more include more interpretive methods (such as structured-case) that are more useful in practice.
Finally, in terms of using structured-case to investigate organizational issues, it is important to state one’s philosophical perspective and research intent as well as clearly documenting the process suggested by the structured-case methodological framework. In this way, both IS and HI researchers can engage in sound and relevant high quality case study research to gain deep knowledge and understanding about organizational issues and their relationship to performance and outcomes.
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Table 1: Propositions from the Conceptual Framework P1: Organizations displaying information structures of
technocratic utopianism, anarchy, or feudalism will resist systems integration through political behavior.
P2: Professional cultures with conflicting information values will resist systems integration through political behavior.
P3: The absence of one or more of the four ISD critical success factors will impede the systems integration process.
P4: The learning orientation stage of knowledge sharing is necessary to enable the systems integration process.
P5: the learning orientation stage of knowledge utilization is necessary to achieve the outcome of improved performance through information management.
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