Pacific Perspective
Pacific Perspective
Organizing for
e-MedicineModern health care organizations are confronted with the advent of new clinical e-health technologies as never before. Evidence suggests great difficulty in the implementation of these new technological advances.
Telemedicine is a good example of this problem. Originally conceived as a two-way video conference between a primary care provider and patient at one end, and a specialist at the other end, telemedicine has evolved into a clinical information technology sub-system in which multimedia e-mail and Web-based applications transfer precise and detailed clinical patient information between health-care providers, and sometime the patients themselves, accurately and rapidly across long distances. The result can be enhanced patient access to better health care, reduced total health care costs and, as a consequence of easy access to the most appropriate specialist expertise, higher overall quality of the health care delivered. Despite the great promise of clinical e-health solutions such as telemedicine, successful implementations with high use have been rare.
There are many reasons for poor implementation. Often legal barriers prevent tele-medicine from being used across political boundaries. The issue of reimbursement of health care providers services is often a barrier to use. Sometimes the technology does not perform as advertised and often these barriers are made even more impenetrable by inappropriate management and organization in health care.
Most modern health care organizations are conceived, designed and structured to promote effectiveness and efficiency of a bygone era; a time when quality was assured by formal authoritarian control, iron-clad rules, and a one-best-way mentality. However, today the most appropriate strategy for a health care organization embarking seriously into e-health solutions will be a strategy that requires a more organic and less mechanistic organization design.
For many health care organizations, a more organic organizational structure and culture will better match the cultural and knowledge/learning predispositions of the organization's members. Further, this harmony between the predisposition of the organization's membership and its strategic intent and organizational design will be instrumental in achieving higher use of e-health solutions.
In our new information technology rich environment, it is appropriate for us to raise questions about organizational design in health care organizations. In the late 1960s, C. Perrow, a highly respected sociologist, suggested in human service organizations where new technologies are manifest, the organizational structure needs to be less bureaucratic — less programming of tasks, fewer rules and regulations, fewer levels in the hierarchy, greater coordination by feedback, greater decentralization in decision making and a tendency to employ more highly trained professionals. Perrow's ideas of the late '60s and early '70s are, perhaps, even more relevant today in the United States.
Many of today's American health care organizations were designed primarily to insure quality of care at reasonable costs. Most of the major components of these designs — level of complexity, level of formalization, level of centralization and authoritarian organizational cultures — are a product of the pre-information technology age. Most major U.S. health care organizations have not experienced an organizational design renaissance since the 1950s. There are exceptions, but most organization's design modifications have been small and peripheral. The central tenet or organizational design in most health care organizations remains: Quality results from clear rules, high formalization, redundancy, high authority and intolerance for ambiguity.
Yet research on implementation of technology in organizations, in general, points to the need to match the characteristics of the technology with the characteristics of the users rather than attempt to change the attitudes, mental models, alliances or culture of the users. This is most likely true in health care organizations as well. In the United States, we argue, health care organizations, which have as a strategic intent the use of e-health technologies, need to re-address their organizational designs and move from a mechanistic to a more organic design.