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IMPROVING HEALTHCARE INFORMATION SYSTEMS - A KEY TO

EVIDENCE BASED MEDICINE

Thesis · June 2015

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LICENTIATE DISSERTATION

IMPROVING HEALTHCARE
INFORMATION SYSTEMS - A KEY
TO EVIDENCE BASED MEDICINE

HANIFE REXHEPI
Informatics
 IMPRO VING HEALTHCARE
INFORMATION SYST EMS - A KEY
TO EVID EN CE BASED MEDICIN E
 LICENTIATE DISSERTATION

IMPROVING HEALTHCARE
INFORMATION SYSTEMS - A KEY TO
EVIDENCE BASED MEDICINE
 

HANIFE REXHEPI
Informatics
 Hanife Rexhepi, 2015
Title: Improving healthcare information systems - A key to evidence based medi-
cine

University of Skövde 2015, Sweden

www.his.se

Printer: Runit AB, Skövde

ISBN 978-91-981474-7-6
Dissertation Series, No. 7 (2015)
ABSTRACT
Delivering good quality care is a complex endeavor that is highly dependent on patient in-
formation and medical knowledge. When decisions about the care of a patient are made,
they must, as far as possible, be based on research-derived evidence rather than on clinical
skills and experience alone. Evidence based medicine (EBM) is the conscientious and judi-
cious use of current best evidence in conjunction with clinical expertise as well as patient
values and preferences to guide healthcare decisions. Following the principles of EBM,
healthcare practitioners are required to formulate questions based on patients’ current
clinical status, medical history, values and preferences, search the literature for answers,
evaluate the evidence for its validity and usefulness, and finally apply the information to
the patient. Information systems play a crucial role in the practice of evidence based medi-
cine, by allowing healthcare practitioners to access clinical evidence and information about
the patients’ health as they formulate their patient-care strategies. However, current in-
formation systems solutions are far from this perspective for various reasons. One of these
reasons is that existing information systems do not support a seamless flow of patient in-
formation along the patient process. Due to interoperability issues, healthcare practitioners
cannot easily exchange patient information from one information system to another and
from one healthcare practitioner to another. Consequently, vital information that is stored
in separate information systems and which could present a clear and complete picture of
the patient cannot be easily accessed. All too often, units have to operate without
knowledge of the problems addressed by other healthcare practitioners from other units,
the services provided, medications prescribed, or preferences expressed in those previous
situations. The practice of EBM is further complicated by current information systems that
do not support practitioners in their search and evaluation of current evidence in everyday
clinical care.
Based on a qualitative approach, this work aims to find solutions for how future healthcare
information systems can support the practice of EBM. By combining existing research on
process orientation, knowledge management and evidence based medicine with empirical
data, a number of recommendations have been initiated. These recommendations aim to
support healthcare managers, IT–managers and system developers in the development of
future healthcare information systems, from a process-oriented and knowledge manage-
ment perspective. By following these recommendations, it is possible to develop infor-
mation systems that facilitate the practice of evidence based medicine, and improve patient
engagement.

I
SAMMANFATTNING
Alla patienter har rätt till en god och säker vård. Tillgången till patientinformation och me-
dicinsk kunskap är därför en nyckelfråga för att skapa förutsättningar för en sådan vård.
Beslut om behandling och vård skall så långt som möjligt baseras på bästa möjliga kun-
skap. Evidensbaserad medicin (EBM) innebär att beslut i den kliniska situationen baseras
på en kombination av senaste vetenskapliga evidens i kombination med vårdgivarens ex-
pertis och patientens preferenser.
Att basera beslut på vetenskap och beprövade erfarenheter har dock visat sig svårt för
vårdpersonalen. Det beror bland annat på att de har begränsad tillgång till informations-
system som stödjer en snabb och enkel tillgång till patientinformation över organisations-
gränserna. Tillgång till relevant information är en nödvändighet för att kunna garantera en
god och säker vård. Ytterligare en anledning är att befintliga informationssystem inte stöd-
jer vårdpersonalen till att enkelt hitta, sovra och använda vetenskaplig kunskap i vården.
Baserat på en kvalitativ forskningsansats, är syftet med licentiatavhandlingen att föreslå
lösningar för hur vårdens framtida informationssystem kan ge stöd till en evidensbaserad
medicin. Genom att kombinera existerande forskning inom processorientering, knowledge
management och EBM, har ett antal rekommendationer initierats. Dessa rekommendat-
ioner syftar till att vägleda ansvarig för hälso- och sjukvården, IT-chefer och systemutveck-
lare i utvecklingen av vårdens framtida informationssystem ur ett processorienterat och
kunskapshanteringperspektiv. Genom att följa dessa rekommendationer, är det möjligt att
utveckla informationssystem som underlättar utövandet av evidensbaserad sjukvårdare
och förbättrar patientens delaktighet i den egna vården.

III
ACKNOWLEDGEMENTS
Foremost, I would like to express my gratitude on this occasion to the participants of the
Future Healthcare Information Systems project and the Knowledge repository project.
They shared their time and thoughts with me, and without them, the projects would not
have been possible.
I would also like to express my deepest thanks to my two supervisors Rose-Mharie Åhlfeldt
and Professor Anne Persson. Their feedback, patience, encouragement, and immense
knowledge were key motivations throughout my PhD. Rose-Mharie, I would like to express
my deepest thanks for always encouraging my research, for providing insightful comments
and for allowing me to grow as a research scientist. I am also truly thankful for your dedica-
tion to both my personal and academic development. Anne, thank you for the excellent
feedback on this thesis and thank you for believing in me. Since the first day I met you,
which was in year 2008, you have motivated and encouraged me to believe in myself as a
researcher. You are a true inspiration to me for which I am grateful.
Next, I would like to thank my great colleagues at the University of Skövde. Some of them
deserve special thanks: Kristens Gudfinnsson, my colleague and friend, who has been a
great support in my academic and personal life. Thank you Kristens for always giving me
the extra push I need. Thanks also to my fellow PhD student Martin Brodin, who always
makes me laugh and who have never doubted to help me when I needed support. Further-
more, I would like to thank Professor Jeremy Rose for offering feedback on my research
method. In addition, a thank you to Joeri van Laere for the feedback on my thesis.
I express my heart-felt gratitude to Urban Carlén, whose faithful support and caring dur-
ing these years is so appreciated. Your support means the world to me. Thank you. I would
also like to thank my dear friend Eva Söderström. Eva, you are so humble and extremely
generous. A warm thank you for your guidance and support. I extend many thanks to my
friends Minna Aastrup and Tyra Bergström for their friendship and caring hearts.
Last, but certainly not least, I would like to thank my family for all their love and encour-
agement. For my parents, Isme and Izet Rexhepi who raised me to love learning and in-
spired me to seek higher education. Thank you Mom and Dad for showing me at an early
age that the function of education is to teach one to think intensively and to think critically.
For my brothers Besart and Mirsad for always encouraging and supporting me. No one has
contributed more to this PhD than Hasibe and Petrit. They have been with me through
thick and thin - "For you, I do it a thousand times over”.

V
PUBLICATIONS
Publications written as part of this thesis are listed below. Paper 1, 3 and 5 were published
prior to name change.

PUBLICATIONS WITH HIGH RELEVANCE

1. Krasniqi, H., Åhlfeldt, R-M. & Persson, A. (2011) Patients’ experiences of communi-
cating with healthcare – An information exchange perspective. Proceedings of the 15th
International Symposium for Health Information Management Research (ISHIMR),
2011, Sept 8-9 (pp. 241-251). Zurich, Schweiz.
2. Rexhepi, H., Åhlfeldt, R-M. & Persson, A. (2015) Challenges and opportunities with in-
formation system support for healthcare processes – A healthcare practitioner perspec-
tive. Proceedings of the 8th International Conference on Information Systems (IADIS),
2015, March 14 – 16 (pp. 61-69). Madeira, Portugal.
3. Krasniqi, H. & Persson, A. (2012) Web-based Knowledge Portals in Swedish-Healthcare
– Overview and Challenges. Scandinavian Conference on Health Informatics 2012, Oct
2-3 (pp. 9-12). Linköping, Sweden.
4. Rexhepi, H. & Persson, A. (2014) Worlds Apart – IT Strategies for Evidence Based Med-
icine Meets Reality. Submitted.
5. Åhlfeldt, R-M., Persson, A., Krasniqi, H. & Wåhlander, K. (2013) Supporting Active Pa-
tient and Healthcare Collaboration - A Prototype for Future Healthcare Information Sys-
tems. Proceedings the 16th International Symposium on Health Information Manage-
ment Research (ISHIMR) 2013, June 26 -28 (pp. 13-23). Halifax, Canada.
6. Rexhepi, H. (2015) Supporting Evidence Based Medicine – A Prototype for Future
Healthcare Information Systems. Proceedings of the 8th International Conference on
Information Systems (IADIS), 2015, March 14 – 16 (185-195). Madeira, Portugal.

VII
CONTENTS
1. INTRODUCTION .................................................................................................... 1 
1.1  Healthcare Information systems - challenges .................................................. 3 
1.1.1  Research problem ................................................................................. 4 
1.2  Research questions ......................................................................................... 7 
1.3  Delimitations .................................................................................................... 8 
1.4  Thesis structure ............................................................................................... 8 
2. THEORETICAL BACKGROUND .......................................................................... 11 
2.1  Evidence based medicine .............................................................................. 11 
2.2  Process orientation in healthcare .................................................................. 12 
2.3  Patient process .............................................................................................. 16 
2.4  Basic concepts of knowledge management ................................................. 17 
2.5  Definition of knowledge management............................................................ 18 
2.6  Is healthcare in need of knowledge management ......................................... 22 
2.7  Knowledge management and organizational processes ............................... 23 
2.8  The relationship between EBM, process orientation and KM ........................ 26 
2.9  Related Research .......................................................................................... 27 
3. RESEARCH METHOD ......................................................................................... 29 
3.1  Approaches to research................................................................................. 29 
3.2  Research process .......................................................................................... 30 
3.2.1  Literature review.................................................................................. 31 
3.2.2  Case study research ........................................................................... 32 
3.3  Case study one .............................................................................................. 33 
3.3.1  Interviews, observations and process modeling ................................. 33 
3.3.2  Prototype development ....................................................................... 36 
3.4  Case study two .............................................................................................. 37 
3.4.1  Interviews ............................................................................................ 38 
3.5  Qualitative analysis ........................................................................................ 41 
3.6  Good research practice ................................................................................. 42 
3.7  The trustworthiness of the research .............................................................. 43 
3.7.1  Credibility ............................................................................................ 43 
3.7.2  Dependability ...................................................................................... 44 
3.7.3  Transferability...................................................................................... 44 
3.7.4  Conformability ..................................................................................... 44 
4. RESULTS ............................................................................................................. 45 
IX
 4.1  Patients´ experiences of communicating with healthcare - An information
exchange perspective .................................................................................... 46 
4.2  Challenges and opportunities with information system support for healthcare
processes – A healthcare practitioner perspective ........................................ 46 
4.3  Web-based knowledge portals in Swedish healthcare – Overview and
challenges...................................................................................................... 48 
4.5  Worlds apart – IT strategies for evidence based medicine meets reality ...... 49 
4.6  Supporting active patient and healthcare collaboration - A prototype for future
healthcare information systems ..................................................................... 50 
4.7  Supporting evidence based medicine – A prototype for future healthcare
information systems ....................................................................................... 51 
5. SYNTHESIZED RESULTS ................................................................................... 53 
5.1  Future IS should support the principles of evidence based medicine............ 53 
5.1.1  A process-oriented approach, with supporting information systems ... 53 
5.1.2  Improve patient engagement through process-oriented information
systems ............................................................................................... 54 
5.1.3  Offer not only current information, but also relevant information
according to the patient process ......................................................... 55 
5.1.4  Future information system should enable a combination of access,
communication, creation and capture of medical knowledge.............. 55 
6. CONCLUDING REMARKS AND FUTURE WORK .............................................. 57 
6.1  Revisiting the research questions .................................................................. 57 
6.2  Contributions.................................................................................................. 59 
6.2.1  Summary of knowledge contributions ................................................. 59 
6.3  Future work .................................................................................................... 61 
7. APPENDIX ............................................................................................................ 63 
7.1  Appendix 1: Interview guide – Case study one.............................................. 63 
7.2  Appendix 2: Interview guide – Case study two (study one) ........................... 65 
7.3  Appendix 3: Interview guide – Case study two (study two) ........................... 66 
8. REFERENCES ..................................................................................................... 73 

X
C H A P TE R 1
INTRODUCTION
Delivering good quality care is a complex endeavor that is highly dependent on patient in-
formation and medical knowledge (Bose, 2003; Rezazadeh et al., 2014). When decisions
about the care of a patient are made, they must, as far as possible, be based on research-
derived evidence rather than on clinical skills and experience alone. Evidence based medi-
cine (EBM) is the conscientious and judicious use of current best medical evidence in con-
junction with clinical expertise as well as patient values and preferences to guide healthcare
decisions, see figure 1.1 (Sackett et al., 1996; Sackett et al., 2000). Clinical expertise refers
to the practitioner’s cumulated experience, education and clinical skills that the individual
acquires through clinical experience and clinical practice. The patient brings to the encoun-
ter his or her own personal preferences and unique concerns, expectations, and values that
must be considered. The best medical evidence, also called medical knowledge, is usually
found in medical guidelines, systematic reviews and other clinically relevant medical re-
search that has been conducted using sound methodology (Sackett et al., 2000). The pur-
pose of EBM is to provide a stronger scientific foundation for clinical work, in order to
achieve consistency, quality, and safety in care (Timmermans & Mauck, 2005). The evi-
dence based medical knowledge does not, by itself, make the decision, but it can help sup-
port the practitioner in the decision-making. Following the principles of EBM, practitioners
are required to formulate clinical questions based on the understanding of the patient’s
clinical condition. The patient’s condition can be understood by the past and present diag-
nosis, as well as laboratory and administrative data (El-Gayar & Timsina, 2014). After the
patient’s condition has been identified and synthesized into clinical questions, the practi-
tioner proceeds with the search of the literature for answers, evaluates the evidence for its
validity and usefulness, and finally applies the information to patients (Lenz & Reichert,
2007; Mayer, 2009). The degree to which the clinician can practice EBM is thus dependent
upon the availability of information about the patient (such as diagnosis, prognosis and
therapy) and medical knowledge (such as medical guidelines). Patient information is a pre-
condition for medical decisions and it is evidence based medical knowledge, clinical exper-
tise as well as patient values and preferences that guide these decisions. The full integration
of these components into clinical decisions enhances the opportunity for improved quality
and safety of care.

1
CH AP T ER 1 I NT RO D U CT IO N

Figure 1.1: The elements of EBM

Nevertheless, practicing EBM is challenging. One reason is the lack of information systems
(IS) that support a seamless flow of patient information (both medical and administrative
information) along the care process. This is highly disturbing, since the traditional single,
doctor-patient relationship is increasingly being replaced by one in which the patient is
managed by a team of healthcare practitioners, each specializing in one aspect of care
(Bose, 2003, p. 61). Such seamless and shared care critically depends on collaboration and
the ability to easily share information between healthcare providers (Iroju et al., 2013;
Bose, 2003). Collaboration between healthcare providers and the patient is also essential in
ensuring the proper delivery of the most appropriate care, since both parties share vital in-
formation. The healthcare practitioner offers evidence based treatment options, as well as
their risks and benefits, while the patient offers his/her experience of the medical condi-
tion, values and expectations (Oshima Lee & Emanuel, 2013). Considering and incorporat-
ing the values, preferences, needs and experiences of patients in, e.g., treatment plans are
important for the practice of EBM and crucial for the engagement of the patient in the deci-
sion-making.
EBM is also almost impossible to practice in the everyday clinical care, as healthcare practi-
tioners typically do not have the time to carry out literature research while the patient is in
the office. Therefore, literature searches will necessarily take place offline (Lenz & Reichert,
2007). Those practitioners who search for medical knowledge during the patient encounter
all too often find that existing knowledge may not necessarily correspond to the issue at
hand (Clancy & Cronin, 2005). Some healthcare practitioners may even decide not to ac-
tively look for the required medical knowledge because existing information systems are
not adequate enough to answer the clinical questions that arise. This raises the questions
whether patient information and medical knowledge can be provided in a more compact
and applicable form and whether information technology (IT) can improve the practice of
EBM. In order to find appropriate answers to these questions, it is important to initially
understand the characteristics of the healthcare organization.

2
 CH AP T ER 1 I NT RO D U CT IO N

1.1 HEALTHCARE INFORMATION SYSTEMS -

CHALLENGES
Traditionally, the healthcare organization has a functional organizational structure employ-
ing several thousand healthcare practitioners working in professional, functional and geo-
graphic groups. Each group has, according to Ben-Tovim et al. (2008), an internal, usually
hierarchical, structure, and orientates its work by the views held within its dominant pro-
fessional or organizational membership. Groups cherish their autonomy, which means
that, e.g., orthopedic surgeons or orthopedic units view the world from their orthopedic
perspective. Therefore, they only see and take responsibility for their specific part of the
care process. Patients, however, move horizontally across organizational units. This jour-
ney, also called the patient process, takes the patient from unit to unit, where he/she re-
ceives care from different healthcare practitioners. Since healthcare practitioners only see
and take responsibility for their particular component, no one (except the patient) has an
overview of the whole patient process. Therefore, poor coordination of the patient´s care is
common (Ben-Tovim et al., 2008).
The functional organizational structure has influenced how healthcare information systems
have been developed. A common scene within most hospitals and primary healthcare cen-
ters is the distribution of patient information along several departmental information sys-
tems (see figure 1.2). As a result, patient information is organized and managed by several
autonomous information systems, which contribute to the emergence of so-called islands
of information. These information systems have been developed at widely differing points
in time, by using different development paradigms as well as different software and hard-
ware platforms. Therefore, current healthcare information systems suffer from a number of
problems:
 They support single organizational units very well, but have trouble exchanging in-
formation between care units and between care providers and the community at
large, e.g., social insurance offices, resulting in poor inter-organizational communi-
cation and collaboration (Ministry of Health and Social Affairs, 2006; Perjons et al.,
2005).
 Electronic healthcare records (EHRs) have traditionally been developed mainly for
managing patient information (Berg, 2001a). They have also been developed sepa-
rately from general medical knowledge. Therefore, knowledge, such as medical
guidelines, is to a larger extent not integrated into EHRs. Instead, this knowledge is
stored in numerous autonomous IT-based knowledge repositories at different levels
(local, regional, national). Finding relevant medical knowledge is therefore difficult
(Rexhepi & Persson, 2013).
 They do not facilitate work activities. These activities, which may be helped by com-
puterization are performed manually, and consume 50 to 80 percent of the physi-
cian’s time (Perjons et al., 2005).
 They lack established common user interfaces, making them difficult to navigate
and use. Lack of “ease of use” prevents healthcare practitioners from achieving
specified goals with effectiveness, efficiency, and satisfaction (Berg, 2001a; Ministry
of Health and Social Affairs, 2006).
 They cannot easily compile and communicate information to accounting and man-
agement systems at executive and principal levels, or to national registers, such as
health data and quality registers (Ministry of Health and Social Affairs, 2006).

3
CH AP T ER 1 I NT RO D U CT IO N

 They do not facilitate patient engagement. Patients themselves cannot easily access
information about their care. Electronic communication with healthcare practition-
ers and the electronic booking of treatments and examinations is also limited (Min-
istry of Health and Social Affairs, 2006). Studies have shown that giving patients
more access to their health information can encourage them to participate in their
own care, self-manage their health condition, increase understanding of their medi-
cal issues, and improve patient–provider communication (Ricciardi et al., 2013;
Delbanco et al., 2012).

Figure 1.2: The structure of healthcare organizations

Since decisions about the care of individual patients must be made by interpreting patient
specific information according to relevant medical knowledge, sharing and accessing both
patient information and medical knowledge is crucial, in order to avoid medical errors, im-
prove diagnoses, avoid re-admissions and decrease duplicate testing. Despite this extensive
knowledge, the current fragmented system of healthcare that misses information and
knowledge, and lacks coordination is resulting in health-related injuries, low quality care and
wasted resources (Iroju et al, 2013; Perjons et al., 2005).

1.1.1 RESEARCH PROBLEM

Healthcare processes are characterized by a high degree of communication and cooperation
among physicians, nurses, and other groups of practitioners (Lenz, et al., 2002; Lenz
&Reichert, 2007) who participate in the care of the patient. For example, a frail elderly
person who sustains a hip fracture may require treatment from an orthopedic surgeon,
hospital nurses, hospital physical therapist, home care nurses, home care physical thera-
pists, a primary care physician and a primary care nurse. Each of these actors generates in-
formation that is needed by the others. In making decisions about patient care, healthcare
practitioners frequently raise questions in their practice. Although they are effective in
finding answers to questions they pursue, roughly half of the questions are never answered
(Del Fiol, Workman & Gorman, 2014), due to the lack of patient information and medical
knowledge. On this basis, it is almost impossible to practice EBM in everyday clinical care.

4
 CH AP T ER 1 I NT RO D U CT IO N

Information systems play a crucial role in the practice of evidence based medicine, by al-
lowing healthcare practitioners to access clinical evidence and information about the pa-
tients’ health, as they formulate their patient-care strategies (Wells, 2007; Del Fiol, Work-
man & Gorman, 2014). However, current healthcare information systems are not meeting
the expectations and rarely fulfill these requirements (Lenz, et al., 2002; Iroju, et al., 2013)
(see figure 1.3). Due to interoperability issues, healthcare practitioners cannot easily ex-
change patient information from one information system to another and from one
healthcare practitioner to another. Consequently, vital information that is stored in sepa-
rate information systems cannot be easily accessed, in order to present a clear and com-
plete picture of the patient. All too often, units have to operate without knowledge of the
problems addressed by other healthcare practitioners from another unit, including services
provided, medications prescribed, or preferences expressed in the previous healthcare set-
ting (Ben-Tovim et al., 2008). Medical procedures may become impossible to perform, if
information is missing, preparations have been omitted, or a preceding procedure has been
postponed, canceled or requires latency time. Depending procedures may then have to be
re-scheduled resulting in numerous phone-calls and time losses. If any results are missing
but urgently needed, tests or procedures may have to be performed repeatedly (Reichert,
2011, p. 5; Tan, 2005). In the absence of this information, a complex set of patient flows
emerges in which a patient’s medical records, necessary for care, have to be printed and
transmitted between and across units, which often leads to a high administrative load for
practitioners and, in the case of emergency care, lifesaving information may be unavailable
(Reichert, 2011; Lenz & Reichert, 2007). The printed copies of the medical record must
then be integrated into the recipient’s EHR, by adding a scanned version to the system or
typing a summary in the system. This can entail problems related to inefficiency and the
risk of making errors (Zwaanswijk, et al., 2011). The patient is also an important link in the
transfer of information between different healthcare providers. In the majority of care situ-
ations, the patient is the only common component between units and, by default, the pa-
tient is given the added responsibility of communicating his/her patient information, both
medical (e.g., medical notes, laboratory tests, diagnostic imaging reports, treatments, ther-
apies, medical list, allergies and x-rays) and administrative (e.g., appointments) between
healthcare providers. Consequently, patients often experience one or more omissions in the
information exchange. Common omissions that must be filled by the patient include: re-
counting medical history, because the healthcare provider has not received the records
from another provider, or having to bring the test results to an appointment (Patel, Barker
& Siminerio, 2014). When patients have to recount their medical history, it can negatively
affect the quality of care, especially if the patient does not want to disclose certain infor-
mation or communicates incorrect information. Despite the fact that patients take a great
responsibility in communicating information between different units, they are not actively
engaged in their own care. For example, they do not have quick and trouble-free access to
all-round information about their personal health status. Much of the patient's time is
therefore spent on locating and communicating information between healthcare practi-
tioners. Electronic booking of an appointment is also limited. The situation is further com-
plicated, as electronic communication between patients and care services is limited. Given
that collaboration between care providers and patients is essential in ensuring the proper
delivery of appropriate care for patients, the situation is not optimal.
As a consequence of the functional organizational structure with its associated autonomous
information systems, healthcare practitioners usually fail to communicate critical elements
of the care to the receiving unit. Bottlenecks may even occur when one unit sends a patient
to another unit that is not ready to take care of the patient (Vos, et al., 2011; Zwaanswijk et
al, 2011). In some cases, the patient may not even be adequately prepared for care in the
next unit, due to lack of coordination between units. The functional structure slows the de-

5
CH AP T ER 1 I NT RO D U CT IO N

cision-making, makes work coordination difficult, and inhibits communication, since each
unit “looks after their own interest, without realizing how their activities affect others or
the patient (Dunham-Taylor & Pinczuk, 2006).

Figure 1.3: Challenges with evidence based medicine

In making decisions about patient care, healthcare practitioners must also use current best
evidence (explicit/documented medical knowledge) in conjunction with clinical expertise
(tacit knowledge). Despite the broad availability of online evidence resources that can help
answer questions raised by healthcare practitioners, many of them remain unanswered
(Del Fiol, Workman & Gorman, 2014). Some healthcare practitioners do not even try to
search for the needed medical knowledge, because textbooks, journals, and existing infor-
mation systems are not adequate for answering the clinical questions that arise. Textbooks
may be out of date, information in journals is too difficult, if not impossible, to translate
into daily work practice and current information systems solutions, such as IT-based
knowledge repositories, are not widely used because they are: (1) not comprehensive, (2)
not integrated within EHRs, (3) information in the repository is not structured and there-
fore difficult to grasp, and (4) most of the IT-based knowledge repositories do not facilitate
the sharing of experience-based clinical knowledge. Given the situation, it is not surprising
that healthcare practitioners lack the time for such research while the patient is in the of-
fice. Since relevant medical knowledge is usually not available at the time decisions are
made, healthcare practitioners must rely on experience and consultation with seniors, ra-
ther than on best scientific medical evidence.
EBM thus requires the efficient exchange of and access to patient information and medical
knowledge. Questions that cannot be answered because valuable information and
knowledge is missing may lead to suboptimal patient-care decisions. In critical situations,
lack of patient information and medical knowledge may even lead to late or wrong deci-
sions (Reichert, 2011; McClellan et al., 2008; Del Fiol, Workman & Gorman, 2014). Lack of
information can also result in a high administrative load for practitioners, increased
healthcare costs, longer than required hospital stays and, most seriously, declining quality
of patient care (Iroju et al, 2013). Studies have shown that physicians and nurses are aware
of these problems and that an information system which provides quick and easy access to

6
 CH AP T ER 1 I NT RO D U CT IO N

up-to-date patient information and relevant medical knowledge in the context of patient
care decision-making is highly welcome. In an increasing way it is being understood that
correlation between medicine, organization and information is high, and that current func-
tional organizational structures and healthcare information systems offer sub-optimal sup-
port.

1.2 RESEARCH QUESTIONS

Improving quality and safety in healthcare requires that a variety of medical knowledge
and information about the patient is made available to healthcare practitioners when and
where it is needed. Therefore, this thesis aims to find solutions for how future healthcare
information systems can support the practice of EBM, by improving the availability of pa-
tient information (both medical and administrative information) and medical knowledge in
a way which can be seamlessly integrated with healthcare practitioners’ work practice.
Since safety and quality of care are strongly related to patient engagement, this thesis also
aims to find solutions to how patient engagement can be enhanced through improved pro-
vider-patient communication. Given this aim, the main research questions are (see figure
1.4):

1. What are the problems with the availability of up-to-date patient information, from
the perspective of patients?
Patients today have a growing desire to take greater control over their personal
health through access to their healthcare information. Patients' access to their health
information is a precondition for enabling patient engagement. Since patient en-
gagement is essential for improving quality and safety of care, this research question
aims to increase knowledge regarding how patients in Sweden experience the ex-
change of information with healthcare providers.

2. What are the problems with the availability of up-to-date patient information and
relevant medical knowledge when and where it is needed, from the perspective of
healthcare practitioners?
This question aims to identify the challenges that healthcare practitioners perceive
with regard to availability of patient information and medical knowledge, when mak-
ing decisions about the care of individual patients. It also aims to identify require-
ments for how information systems should support a seamless flow of information
and knowledge along the patient processes.

3. How can healthcare information systems support the availability of up-to-date pa-
tient information and relevant medical knowledge in a way which can be seamless-
ly integrated with healthcare practitioners’ work practice?
Based on the challenges and requirements identified in research questions 1 and 2,
this question aims to demonstrate, by using a prototype development, how
healthcare information systems can support the availability of up-to-date patient in-
formation and relevant medical knowledge in a way which can be seamlessly inte-
grated with healthcare practitioners’ work practice. The prototype is used to visualize
the solutions to the challenges/problems identified in research question 2.

4. How can healthcare information systems support patient engagement through im-
proved provider-patient communication?
Similar to research question 3, this question aims to demonstrate how healthcare in-
formation systems can improve patient engagement. The prototype that is used in re-
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CH AP T ER 1 I NT RO D U CT IO N

search question 3 will also be used for this question in order to demonstrate how in-
formation systems can support active involvement of patients in their own
healthcare.

5. What recommendations can be initiated for the development of future information

systems that (1) support healthcare practitioners’ access to up-to-date patient in-
formation and relevant medical knowledge in a way which can be seamlessly inte-
grated with their work practice and (2) improve patient engagement?
In addition to the prototype, a number of recommendations for the development of
healthcare information systems are given. These recommendations are based on the
findings from research questions 1, 2, 3 and 4.

Figure 1.4: The research design in respect to research questions, objectives and research papers

1.3 DELIMITATIONS
Developers of healthcare information systems around the world endeavor to increase the
quality of care by improving the availability of patient information and relevant medical
knowledge. However, healthcare organizations, both nationally and internationally, are still
characterized by an increasing number of medical disciplines and specialized units com-
prising diverse autonomous information systems. Although problems with autonomous
information systems are found in other countries, this work focuses on the Swedish
healthcare system. The delimitation derives primarily from the fact that acts and regula-
tions governing the storage and dissemination of information may vary between countries.

1.4 THESIS STRUCTURE

The thesis is composed of six chapters. Chapter 1 introduces the research area and research
problem, followed by a presentation of the research questions. It discusses the problems
facing the healthcare sector, with regard to information system support. The theoretical
background chapter (Chapter 2) provides an overview of the main theories used, and how
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 CH AP T ER 1 I NT RO D U CT IO N

they relate to each other. This chapter concludes with a presentation of related research.
The methodology chapter (Chapter 3) presents the main method and data collection tech-
niques used. It discusses the research approach applied to the research presented in this
thesis and is followed by a presentation of the research process. The chapter concludes with
reflections on the trustworthiness of the research.
Chapter 4 provides a brief summary of each research paper, focusing on aims and conclu-
sions drawn. A synthesis of the results is given in chapter 5. The synthesis is based on a
number of recommendations for the development of future healthcare information sys-
tems. The major findings of the research are concluded in chapter 6. Moreover, chapter 6
outlines the research contributions and presents suggestions for future work.

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C H A P TE R 2
THEORETICAL BACKGROUND
This chapter introduces and defines the main concepts and theories used in this thesis,
namely, EBM, Process Orientation and Knowledge Management (KM). When the defini-
tions of the concepts and theories have been given, the chapter continues with the descrip-
tion of how EBM, process orientation and KM are interrelated. The chapter concludes with
a presentation of related research.

2.1 EVIDENCE BASED MEDICINE

There are various definitions of evidence based medicine. A common denominator is the
use of current best evidence in making decisions about the care of individual patients. The
purpose of EBM is to improve quality, efficiency, and safety in care, through the provision
of a stronger scientific foundation for clinical work (Timmermans & Mauck, 2005). The
most common definition of EBM is that of Sackett et al., (1996);

EBM is "the conscientious and judicious use of current best evidence in conjunction with
clinical expertise and patient values to guide health [and social] care decisions”
(Sackett et al., 1996, p. 71).

The definition emphasizes that EBM requires integration of 1) individual clinical expertise,
2) patients´ values and preferences as well as 3) the best current evidence in the decision-
making for patient care. The integration requires healthcare practitioners to be careful and
thorough in what they do (named conscientious in the definition), and to use good judg-
ment and common sense (named judicious in the definition). Individual clinical expertise
refers to the practitioners’ proficiency and judgment acquired through their clinical experi-
ence and clinical practice. Best current evidence, means clinically relevant research. This
research is, according to Sackett, Rosenberg, Gray, Haynes and Richardson (1996), based
on the fundamental sciences of medicine and on patient-centered clinical research. In or-
der to work according to EBM, practitioners must use both individual expertise and the
best current evidence, together with the wishes, values and preferences of the patient, and
neither one alone is enough (Sackett et al., 1996: Aveyard & Sharp 2013). Sackett et al.,
(1996) emphasize that a lack of clinical expertise may lead to practice that becomes tyran-
nized by evidence and without best current evidence there is a risk that practice becomes
out of date.

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CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

Dawes et al., (2005) offer a similar, yet more holistic definition of EBM, by emphasizing the
importance of the practitioners’ explicit and tacit knowledge. EBM, according to the au-
thors, “requires that decisions about health and social care are based on the best availa-
ble, current, valid and relevant evidence. These decisions should be made by those receiv-
ing care, informed by the tacit and explicit knowledge of those providing care, within the
context of available resources”. A different definition of EBM is given by the Swedish Na-
tional Board of Health and Welfare (2014):

“EBM is based on the best clinical evidence from systematic research. Healthcare practi-
tioners must have good clinical knowledge and skill to be able to determine if the guide-
lines match the patient's health condition, clinical status and preferences”.

Unlike the other definitions presented in the aforementioned, the definition by the Swedish
National Board of Health and Welfare (2014) not only emphasizes a patient´s preferences,
but also the health condition and the clinical status of the patient, which indicates that
healthcare practitioners must have access to the patient’s medical history when making de-
cisions about the care of individual patients.
The foremost reason for using EBM is thus to improve the patient care delivery. Studies
have shown that when practitioners have access to patient information and scientific medi-
cal knowledge at the point of care, it changes their patient care management decisions.
However, as also discussed in previous sections, practicing EBM is difficult.

2.2 PROCESS ORIENTATION IN HEALTHCARE

Processes are the means by which organizations create value for their customers. “Process-
es are at the very heart of every enterprise”, claim Hammer and Stanton (1995, p. 4). Yet,
in healthcare, processes are fragmented across many organizational units. They are effec-
tively invisible and essentially unmanaged. In definitional terms, a process is a “structured,
measured set of activities across time and place, with a beginning, an end, designed to
produce a specified output for a particular customer or market” (Davenport, 1993, p. 5). A
similar process definition is that of Harrington (1991), which focuses on how input is con-
verted to results. Deming (1993) extends the definition by also including who does what.
This gives a broader perspective that can be useful when making improvement efforts.
Moreover, Hammer and Stanton (1995) discuss processes as a group of related tasks that
together create value for a customer. The interrelated work tasks are initiated in response
to an event that achieves a specific result for the customer of the process. The definition by
Hammer and Stanton (1995) emphasizes one of the important characteristics of a process,
namely, the customers who are the recipients of the defined outcomes of the process. A
similar definition is presented by the Swedish National Board of Health and Welfare
(2010), Hammer and Champy (1993), Reijers (2006) and Harrington (1991), who define
processes as a collection of activities that take one or more kinds of input and create an
output that is of value to an internal or external customer. This definition puts emphasis on
the input and output behavior of a business process that should result in some value to the
customer. The definition of the process as “a collection of activities” is however abstract,
since it neither implies the ordering of activities nor does it provide any other explanation
for how the activities in the process are executed (Weske, 2007). However, in the afore-
mentioned definition of business process by Davenport (1993), the relationship of process
activities is emphasized and considered, since the term “activities across time and place” is
used. Another slightly different definition of a process that is embraced in this work is giv-
en by Rentzhog (1998). He argues that a process is a “chain of interrelated activities that in

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 CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

a recurrent flow creates value for a customer”. Processes have, according to Rentzhog
(1998), five important characteristics (see figure 2.1):
 Interrelated activities: a group of related tasks that together create value for a cus-
tomer.
 Recurrent flow: activities in a process are recurrent.
 Customer perspective: the aim of an organizational process is to deliver value to
the customer. Therefore, organizations must adapt its processes to the customers
and their wishes.
 Focus on results: the results of the process must be of value for the customer. Re-
sults/outcomes from the process may be a physical product or a service, e.g.,
providing good quality care.
 Feedback: processes need to be continuously evaluated and improved. Therefore,
feedback on how well the organization has managed to meet customers’ wishes is
important.

Additionally, processes have three important objects; (1) input to a process, which could be
a patient referral, (2) a process uses resources, such as an information system, information,
knowledge, medical tools, etc., transforms inputs into valuable outputs, e.g., based on the
referral, carry out a patient encounter that leads to therapy. Furthermore, there are (3)
regulations, rules and recommendations for how things should be done in a process, such
as diverse medical guidelines, recommendations and clinical pathways that control how
activities should be performed within a process (see figure 2.1).

Figure 2.1: Five important characteristics of a process

Moreover, processes can be divided or categorized with respect to their function in an or-
ganization. An organization's primary processes, also called core processes, consist of the
broadly-defined set of processes that together meet the organization's overall business con-
cept. In the healthcare sector, this is the interaction between patients and practitioners.
Primary processes thus reflect the organization's core business, in other words, its main
source of living. Support processes are not directly involved in fulfilling the organization's

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CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

business idea, but provide the core processes with the necessary supporting resources, such
as employees, equipment, facilities, and materials. Support processes are, however, just as
important to the success of the organization as core processes (Rentzhog, 1998; Rummler &
Brache, 1996). Another important process is the management process which, according to
Rummler and Brache (1996), includes actions that managers should take to support the
organizational processes.
During the last decade, the healthcare sector has tried to move from functional to process-
oriented organizational forms. Yet, healthcare organizations are still characterized by an
increasing number of medical disciplines and specialized units (Lenz & Reichert, 2007).
Traditionally, hospitals have a functional organizational structure. The functional organiza-
tion is based on grouping individuals into organizational units, according to the function
they perform, such as orthopedics, surgery, physical therapy, etc. In a functional organiza-
tion, people who share common expertise and responsibility are grouped into independent
units. Each unit works to achieve its organizational goals, independently of other units. A
disadvantage of the functional organization is in its relationship with the patient. A patient
is usually treated by various healthcare practitioners from different levels of care. During
this process, the patient moves from unit to unit, receiving care from different practitioners
as they go (Ben-Tovim et al., 2008). Since communication and collaboration between the
various organizational units is deficient, due to the different goals, interests and back-
ground of the members of these organizational units, the patient may have difficulty receiv-
ing the care he/she needs (Shtub & Karni, 2010). To improve the quality of care, it is neces-
sary to overcome the traditional functional organizational structure. This can be achieved
by the implementation of a process-oriented organizational structure (Vos et al., 2011).
Process orientation in healthcare (as in other organizations) means designing healthcare as
a flow, or a process that reduces unnecessary repetition and preserves or increases the
quality in the remaining activities (Söderström, Åhlfeldt & Eriksson, 2009). The approach
is defined by Eriksson (2005) as a patient’s total care contact with caregivers in a process to
be carried out according to process guidelines and which are coordinated into a chain of
activities. Moving toward process orientation can according to Willaert et al. (2007) pro-
vide numerous benefits, including cost savings through a more efficient execution of work,
improved customer focus, etc. McCormack and Johnson (2001) have in their research
found that companies with strong signs of process orientation also performed better. The
study shows that the development of process orientation in an organization will lead to
positive outcomes, both from an internal perspective and a resultant perspective. Process
orientation has been shown to reduce inter-functional conflict and increase interdepart-
mental connectedness and integration, both of which impact long and short-term perfor-
mance (Willaert et al., 2007). Also Gonçalves, Hagenbeek and Vissers (2013) emphasizes
that moving toward process orientation will improve internal coordination, communica-
tion, speed, quality, financial performance, and increase customer satisfaction. By focusing
on activities that create value for customers and regarding the organization as linked chains
of activities, process orientation delivers a promising solution for a variety of perceived or-
ganizational problems in the healthcare and other functionally structured organizations
(Gonçalves, Hagenbeek & Vissers, 2013). In a process-oriented organization, practitioners
from different functions, such as orthopedics, surgery, physiotherapy, are thus all aligned
towards satisfying the patients’ needs of care. In contrast, in a function-based organiza-
tional setting, the functions are disconnected from each other and from the process of satis-
fying patients’ needs (Kumar et al., 2009; Kohlbacher, 2010; Reijers, 2006; Balasubrama-
nian & Gupta, 2005).
The starting point of a process-based organizational structure in healthcare requires the
identification of the core business process. The patient process is considered as one of the
most important processes by many healthcare organizations (SITHS, 1999; Åhlfeldt,

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 CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

2008). An important aspect of a process-oriented organizational structure is thus that it

focuses on the patients’ journey (process) through healthcare, instead of functional units.
According to Vos et al., (2011), in a process-oriented organization, all the different disci-
plines involved in the delivery of patient care have to work together as a group and strive to
achieve common goals. Implementing a process-oriented view within the healthcare sector
implies that the organization will pay attention to the patient process and focus on satisfy-
ing a patient's care needs, through the integration and coordination of healthcare services
across organizational boundaries based on integration agreements (Tello-Leal, Chiotti
&Villarreal, 2012). Working in teams empowers staff, decentralizes decision-making and
allows greater across organizational learning (Gonçalves, Hagenbeek & Vissers, 2013; Tel-
lo-Leal, Chiotti &Villarreal, 2012). From an organizational viewpoint, process orientation
enables the organizations to put the patients at the center of care. A process-oriented ap-
proach with supporting information systems is thus an important foundation for achieving
a system design that focuses on the patient process from the patient's perspective and
thereby sets the patients and their healthcare journey in the center of care (Åhlfeldt,
Persson, Krasniqi & Wåhlander, 2013; Perjons et al., 2005). In addition, adopting a pro-
cess-oriented view will lead to a more, patient-centered care process, cost reductions, and
quality improvements (Vos, et al., 2011).
In spite of the benefits offered by the process-based view, there are also some challenges in
applying the process perspective. Organizations pursuing the process approach appear to
have achieved only partial or marginal success, and in some cases, failure. The problems
have been traced to a number of sources. One is in the difficulty of identifying processes,
and a second is in their way of managing and redesigning processes (Kirka & Manning,
2005). Organizational processes represent a difficult challenge in identification and analy-
sis because they are often unknown quantities, have no names, are not represented in or-
ganizational charts, and examples are often disputed. Processes are also difficult to identify
because their boundaries are poorly defined. Processes are selected portions of larger
streams of activity. Process boundaries must according to Kirka and Manning (2005) be set
or established in this larger context, before they can adequately be identified. As bounda-
ries are arbitrary, managers are faced with the task of defining them, and often these defi-
nitions will be contested, resulting in discrepancies and internal conflicts.
The process perspective has also been criticized for its apparent de-manning of the organi-
zation. This has according to Kirka and Manning (2005) been traced to the need for new
styles of management that include the ability to coach, collaborate, communicate, motivate,
negotiate and work as a team player. Those maintaining traditional management styles of
command, control, resource allocation and assigning responsibilities may find themselves
rooted out of organizations as these styles have no place in a process organization. Adopt-
ing the process view is thus often a big change and demands full commitment from the
management. Without this commitment process orientation initiatives often fail to deliver
the expected results. The severity and the immense complexity of necessary transforma-
tional changes could be too big for some managers and organizations, leading them to the
failure track. Shifting to the process perspective is time consuming because it requires sig-
nificant changes in corporate culture, work design, management and philosophy. Tradi-
tional managers may balk when they have to give up power and authority. Employees have
to be trained to work effectively in a team environment (Sarlak, 2011). Despite these chal-
lenges, the process-based view is the proposed way of coping with the dynamism and com-
plexity of organizations (Mathisen & Krogstie, 2012).

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2.3 PATIENT PROCESS

The patient process in this thesis is defined in accordance with the definition of Winge et
al., (2007):

“To denote the sequence of treatments and other activities performed by health or social
care personnel for the patient and in which the patient and his relatives participate”

The definition implies that the patient process is the process that follows the patient
through an event of illness. During this process, different activities are performed by
healthcare practitioners in order to promote health. Patients whose conditions necessitate
complex care needs require care from a wide range of caregivers, such as primary and sec-
ondary care doctors and nurses. Each of these actors generates information that is needed
by the others. To ensure high quality and safe care, this information must be accessible to
healthcare practitioners in a uniform and transparent way, anywhere and anytime, as re-
quired by the patient process. For instance, healthcare providers need to exchange infor-
mation, such as clinical notes, observations, laboratory tests, treatments, therapies, drugs
administered, allergies, x-rays, etc. However, due to interoperability issues, patient infor-
mation is fragmented in the proprietary heterogeneous systems of healthcare organiza-
tions. Consequently, vital information stored in these systems cannot be easily accessed, in
order to present a clear and complete picture of the patient. One example of a patient pro-
cess and the care providers involved in the context of this process is presented in figure 2.2.

Figure 2.2: Example of a patient process and the care providers involved (Åhlfeldt, 2008).

Figure 2.2 thus represents an abstract view of a real patient process and illustrates the care
providers involved in the context of this process. In this example, 42 different contacts be-
tween the healthcare providers and the patient were made. The number of contacts be-
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 CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

tween the healthcare providers is not known. 20 of the 42 contacts, of which 14 were made
by the patient, were due to the poor management of information. Moreover, the whole pro-
cess was extended by two and a half months, due to the ineffective exchange of information
(Åhlfeldt, 2008). Organizational processes are frequently modeled internally in the organi-
zation. However, no one, to the best of our knowledge, has modeled the patient process,
although some projects, as “VITA Nova Hemma”, have indicated the need for this kind of
work (Perjons et al., 2005).

2.4 BASIC CONCEPTS OF KNOWLEDGE

MANAGEMENT
Researchers in the information system community address the question of defining
knowledge by distinguishing it from data and information. The assumption, according to
Fahey and Prusak (1998), seems to be that if knowledge is not distinguished from data and
information, then there is nothing new about knowledge management. A commonly held
view is that data are raw numbers and facts where the context or organization is not estab-
lished, while information is data presented in context, with some purpose and a discernible
organization that will have relevance to a situation, problem or some other condition (Wiig,
1994, p. 81; Wickramasinghe, Gupta & Sharma, 2005). Maglitta (1996) in Alavi and
Leidner (2001) defines data as raw numbers and facts, information is data that have been
processed and knowledge is information made “actionable”. Alavi and Leidner (2001) ar-
gue that raw data do not exist. They suggest that even the most elementary piece of data
has been influenced by the thought that led to its identification and collection (Alavi &
Leidner, 2001, p. 109). Davenport and Prusak (1998) describe information as a message,
usually in the form of a document or an audible communication. As with any message, in-
formation has a sender and a receiver and aims to change the way the receiver perceives
something. Knowledge is seen as broader, deeper and richer than data and information.
Davenport and Prusak (1998) suggest that knowledge originates and is applied in the
minds of people. In organizations, knowledge becomes embedded in documents, reposito-
ries, routines, norms and processes. Alter (2006), in accordance with Davenport and
Prusak (1998), views knowledge as an evolving mix of framed experience, values, contextu-
al information, and expert insight that provide a framework for evaluating and incorporat-
ing new experiences and information. Knowledge is thus necessary for using information
effectively, regardless of how brilliantly the information is gathered and combined. In fact,
people use knowledge about how to format, filter and summarize data as part of the pro-
cess of converting data into information (Alter, 2006). Nonaka & Takeuchi (1995) expand
this view by claiming that knowledge is context-specific. In order for knowledge to have a
meaning for the users, they must understand and have experience of the context, or sur-
rounding conditions and influences, in which the knowledge is generated and used. In ac-
cordance to Alavi and Leidner (2001), we posit that information is converted to knowledge
once it is processed in the mind of individuals and knowledge becomes information once it
is articulated and presented in the form of text and words. An important implication of this
definition of knowledge is that in order for individuals to arrive at the same understanding
of data and information, they must share a certain knowledge base. Another significant im-
plication of this view of knowledge is that since knowledge exists in the human mind, it
cannot be stored in an information system. However, through the use of information tech-
nology, we can process and store information that supports knowledge transformation
(Swan et al., 1999).
Knowledge is also defined as either (1) state of mind, (2) an objective, (3) a process, (4) a
condition or having access to information, or (5) a capability (Alavi & Leidner, 2001).
Knowledge viewed from the perspective of “state of mind” suggests that knowledge is the

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CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

fact of knowing and knowing is a condition of understanding gained through experiences.

From this perspective, it is not possible to computerize knowledge (Schubert, Lincke &
Schmid, 1998). According to knowledge as “state of mind”, the role of information technol-
ogy in KM is to enable users to search and retrieve information (Alavi & Leidner, 2001). By
making information available when it is needed, physicians can expand their knowledge
and apply this to clinical situations. Knowledge as an objective posits that knowledge can
be stored and manipulated independent of people. The process perspective focuses on
knowledge flow and the process of creating and sharing knowledge. The fourth view can be
seen as an extension of the view of knowledge as an object. It posits that organizational
knowledge must be developed and organized to facilitate access (Alavi & Leidner, 2001).
Finally, “knowledge can be viewed as capability with the potential for influencing future
action” (Alavi & Leidner, 2001, p. 110). These different views of knowledge lead to a differ-
ent strategy for knowledge management (KM) and different perceptions of how IT can
support KM. The perspective of knowledge relied on in this thesis is that of Davenport and
Prusak (1998), Alavi and Leidner (2001) and Alter (2006) and is related to knowledge as
“state of mind” and as a “process”.
Additionally, two dimensions of knowledge in organizations have been identified; tacit and
explicit. Nonaka (1994) argues that knowledge that can be expressed in words and num-
bers only represents the tip of an iceberg of the entire body of possible knowledge. Explicit
or documented knowledge refers to knowledge that is transmittable in formal, systematic
language. On the other hand, tacit knowledge has, according to Nonaka (1994), a personal
quality which makes it hard to formalize and communicate. Nonaka (1994) further argues
that tacit knowledge is deeply rooted in action, commitment, and involvement in a specific
context. The presence of both explicit and tacit knowledge is evident in the healthcare sec-
tor. Explicit knowledge is available, e.g., in EHRs, research reports, memos, e-mails, books
and manuals. Explicit knowledge can in turn arise from both internal and external sources.
Internal is all knowledge that is relevant to the practice of medicine, e.g., medical journals,
and also the skills and expertise of practitioners (e.g., nurses, physicians, managers). Ex-
ternal is indirect knowledge; legal, governmental and other documents that do not directly
affect patient treatment, but govern general medical practices (Wickramasinghe, Gupta &
Sharma, 2005). However, the knowledge embodied in, e.g., journals does not necessarily
and automatically convert into useful and usable knowledge, unless it is processed in the
minds of individuals and used. In other words, knowledge can only reside in the minds of
people (Acharyulu, 2011). Tacit knowledge, as mentioned earlier, is a type of knowledge
that exists in the minds of practitioners and is a result of people interacting with each other
and with the environment around them. This type of knowledge is also called know-how
knowledge and can be in the form of skills and competencies acquired through training and
interaction with the environment. Alavi and Leidner (2001) see a danger in the classifica-
tion of knowledge according to the dimensions of tacit and explicit, as there seems to be an
assumption that tacit knowledge is more valuable than explicit knowledge. Based on the
previously stated definitions of evidence based medicine, we argue that both tacit and ex-
plicit medical knowledge is crucial, when making decisions about the care of a patient.

2.5 DEFINITION OF KNOWLEDGE MANAGEMENT

Knowledge is considered to be the most valuable and critical asset of the organization.
With the entry into the “global knowledge society” where knowledge provides competitive
advantage, many consider KM a useful tool for business transformation and a key factor in
gaining and sustaining a competitive advantage (Wiig, 1994; Davenprot and Prusak, 1998;
Jennex, 2007). A general goal of KM, according to Heisig (2009), is to enhance the system-
atic handling of existing and potential knowledge within the organization.

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 CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

Although the term knowledge management is widely used, there is no established defini-
tion. Instead, there are varying opinions on what it is and how it should be used, if used at
all (Jennex, 2007; Jennex & Olfman, 2002). A contributing factor to this may be that KM is
drawn from a wide range of established disciplines, such as organizational learning, social
construction and social interaction (Senge, 1994; Nonaka & Takeuchi, 1995) resulting in a
multiplicity of terms that are often used interchangeably. Lack of consensus and precision
in terminology has resulted in conflicting definitions of KM (Beesley & Cooper, 2008;
Hicks, Dattero & Galup, 2006). Hicks, Dattero and Galup (2006) state:

“There is a consensus that data are discrete facts, but after that, consensus is lacking. The
lack of consistent definitions of data, information, and knowledge make rigorous discus-
sions of KM difficult” (Hicks, Dattero and Galup, 2006, p. 19).

Jennex (2005) describes KM as the practice of selectively applying knowledge from previ-
ous experiences of decision-making to current and future decision-making activities, for
the express purpose of improving the organization's effectiveness. Another key definition
includes Malhotra (1998), who considers that KM is the process established to capture and
use knowledge in an organization, for the purpose of improving organizational perfor-
mance. Alavi and Leidner (2001) have also a process view of KM. They argue that KM in-
volves distinct but interdependent processes of knowledge creation, knowledge storage and
retrieval, knowledge transfer, and knowledge application. Both Jennex (2005) and Mal-
hotra (1998) argue that KM concerns managing knowledge in such a way that benefits the
organization. Additionally, Heisig (2009) expands the definition by also including the
management of tacit and explicit knowledge. He argues that knowledge is managed
through specified processes for sharing, creating, using, storing and identifying both the
tacit and explicit knowledge of employees, for the purpose of enhancing organizational per-
formance and creating value (Heisig, 2009). Persson and Stirna (2007) have a similar defi-
nition. They argue that KM consists of a number of processes that cover the whole life cycle
of knowledge in an organization (see figure 2.3). The cycle is adopted from O’Dell et al.,
(1998) and is similar to the spiral of organizational knowledge creation presented by Nona-
ka and Takeuchi (1995). The model consists of four socially enacted “knowledge processes”:
capture and create, package and store, share and apply, transform and innovate. Carrying
out each of the four processes entails, according to Alavi and Leidner (2001), some degree
of social knowledge and interaction, even if the process is focused on explicit knowledge.
This is because individuals’ tacit knowledge is captured and represented in explicit form.
Furthermore, if information technology is utilized to store and share knowledge, the inter-
pretation of its output will be affected by social processes. A key strength of the KM process
model proposed by Persson and Stirna (2007) is the emphasis on knowledge innovation
(transform and innovate). This activity highlights the importance of transforming shared
information into knowledge which is in the human mind. People must thus learn from
shared information and learn to apply it in practice (Desouza, 2005).
Furthermore, Kezar (2005) argues that KM refers to the process during which organiza-
tions assess the data and information that exist within them, and the processes that make
the data and information meaningful and usable in the form of knowledge. Additionally,
Hari, Egbu and Kumar (2005), referring to Newman (1996), conclude that KM “directs and
enhances organizational decisions as to how, where, and when to create and account for
new knowledge”. Newman’s (1996) definition clearly states that KM is essential for manag-
ing knowledge in such a way that benefits employees’ knowledge creation and usage, and
the organization, by preventing knowledge loss. Capturing knowledge, thus prevents the
loss of critical knowledge and increases organizational knowledge (Hari, Egbu & Kumar,

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2005). A similar definition is given by Jones and Leonard (2009) who argue that KM is the
“process of acquiring knowledge from the organization or another source and turning it
into explicit information that the employees can use to transform into their own
knowledge allowing them to create and increase organizational knowledge” (Jones &
Leonard, 2009, p. 28). Similar to Newman (1996), Jones and Leonard (2009) emphasize
that KM can help organizations capture the tacit knowledge of their employees and change
it into organizational knowledge which can be used, even if the employee leaves the com-
pany. In this way, the organization prevents knowledge loss.
Finally, Swan, Scarbrough and Preston (1999) conclude that KM is the “process or practice
of creating, acquiring, sharing and using knowledge, wherever it resides, to enhance
learning and performance in organizations” (Swan, Scarbrough & Preston, 1999, p. 669).
KM, according to this definition, refers to the process in which organizations acquire in-
formation, store and share it, so that individuals in the organization can transform it into
knowledge, for the purpose of learning (Aggestam, 2008; Loermans, 2002). The inclusion
of “wherever it resides” refers not only to explicit knowledge, but also tacit knowledge that
resides in people´s minds (Loermans, 2002). When users utilize, e.g., stored information
that is relevant to the task at hand, and if the knowledge per se is new to the individual, in-
formation will be used and applied. When knowledge is used, a learning process takes place
at an individual level (Aggestam, 2008). In order to transform individual knowledge into
value which can benefit the organization, the individual knowledge must be transformed
back into information. The captured knowledge must be stored as information and will
again provide a foundation for the creation of new individual knowledge (Jensen, 2005).
Some researchers, such as Davenport and Prusak (1998), have claimed that tacit knowledge
cannot be managed. They even claim that if tacit knowledge is viewed as a part of KM, then
the term becomes a misnomer (Loermans, 2002). However, Nonaka and Takeuchi (1995)
argue that explicit knowledge is only the tip of the iceberg. Given that knowledge, both ex-
plicit and tacit, is critical for an organization, this thesis concludes that KM is to include all
knowledge. Subsequently, Loermans (2002) concludes that KM should include both explic-
it and tacit knowledge; otherwise, it would be difficult to distinguish it from information
management.
In conclusion, according to the definitions provided by the aforementioned researchers,
KM concerns the process that aims to capture and use knowledge in an organization. When
capturing accurate knowledge that is effectively used by employees, the organization can
improve its performance. The definition used in this thesis is influenced by the proposed
definition given by Persson and Stirna (2007), Abidi (2008), Alavi and Leidner (2001) and
Swan et al. (1999):

The goal of KM is to promote and provide relevant and timely knowledge (both explicit
and tacit) to healthcare practitioners where and when they need it to help them make
high quality and well-informed patient care decisions. It includes the process of captur-
ing, storing, sharing and using knowledge, wherever it resides, to improve the quality of
patient care. In practice, KM is pursuing this goal through the use knowledge-mediated
solutions and their integration in healthcare practitioners work practice.

The above definition concludes that the goal of KM, is to guide/support healthcare practi-
tioners in applying relevant knowledge, where and when they need it, in order to help them
practice evidence based medicine. In practice, KM is pursuing this goal through the ad-
vancement of innovative knowledge-mediated solutions and their integration in organiza-
tional workflows (Abidi, 2008, p. 3). Only when this knowledge is made available to others
and used by the members will it improve the quality and safety of care. Abidi (2008) em-
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 CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

phasizes that the adoption of KM in healthcare advocates a healthcare delivery system that
values medical knowledge as a vital resource to improve health outcomes. Abidi (2008)
further stresses that each healthcare practitioner has unique and specific knowledge needs,
depending on the clinical circumstance. Therefore, healthcare practitioners are not just
asking for mechanisms to easily access knowledge, but rather the incorporation of current
and relevant knowledge into daily work activities to support healthcare decisions (Abidi,
2008).

Figure 2.3: The knowledge cycle in organizations (Persson & Stirna, 2007).

To summarize KM, knowledge is a critical resource in any organization. Its members’ abil-
ity to retrieve and apply knowledge to organizational activities is crucial in the provision of
healthcare. KM deals with the process that makes knowledge actionable to members of the
organization. It involves the process of creating, capturing, packaging, storing, sharing and
using knowledge. Successful as well as effective knowledge sharing and application turns
into innovation - improvement of existing knowledge and creation of new knowledge. This
essentially closes the knowledge cycle (Persson & Stirna, 2007).
It is important to note that none of the above definitions of KM are purely technical in na-
ture. KM involves information technology as an enabler, but the actual KM is carried out by
the individuals in the organization (Persson, Stirna & Aggestam, 2008). KM consists thus
of a number of interrelated activities that may be supported using information technology.
For example, one way to provide appropriate knowledge to those that need it when it is
needed is to implement IT-based knowledge repositories that also prevent knowledge from
being lost when a specific employee leaves the organization (Aggestam, 2008). IT-based
knowledge repositories, which are sometimes called Electronic Knowledge Repositories
(EKR) or Digital Learning Repositories, are important solutions to the problems identified
in this thesis. IT-based knowledge repositories help organizations connect people with in-
formation and expertise for instance via online searchable libraries, discussion forums and
other elements. Thus, they provide a central location to collect, contribute and share both
explicit and tacit knowledge.
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CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

Moreover, for KM to be effective as a transformation tool, it must include an organizational

culture that promotes learning and knowledge sharing. A manager that is personally com-
mitted to learning and regards the sharing and use of best practice as critical for providing
good quality care, is also crucial. Information technology and KM have a symbolic relation-
ship, but it is important that technology does not become “the be all and end all” of KM.
Information technology can connect people, but it does not make KM happen. Developing
and implementing, for example, an IT-based knowledge repository does not, in itself, guar-
antee the usage and sharing of best practice and know-how. In fact, too much technology,
or the wrong type of technology, can hamper KM efforts (O´Dell, Grayson & Essaides,
1998; Aggestam, 2008). However, if information technology in KM practice is used correct-
ly, it will open up a new world to KM. For example, it can enhance knowledge creation, cap-
ture, storage, sharing and use of knowledge (Alavi & Leidner, 2001).

2.6 IS HEALTHCARE IN NEED OF KNOWLEDGE

MANAGEMENT
Healthcare organizations are facing many challenges, due to changes taking place in global
healthcare systems (Sharma, Wickramasinghe & Gupta, 2005). Sharma, Wickramasinghe
and Gupta (2005) argue that financial constraints, the growing complexities of research in
medicine, increased requirements from patients and advances in information technology
have strengthened the importance of incorporating the KM paradigm shift. Further, the
healthcare sector is information intensive, since it uses multiple knowledge areas, such as
those of medicine, and policies that assist healthcare practitioners in making decisions.
These multiple knowledge areas and the large number of interdependent disciplines make
the healthcare organization a knowledge intensive organization (Wahle & Groothuis,
2005). Additionally, since the healthcare organization is traditionally divided into different
levels, primary, specialist, and municipality care, it has resulted in the development of
small but very specialized areas of practice. As a result, the specialized practitioners have
unique tacit and explicit knowledge that has to be captured, disseminated and utilized by
other practitioners (Wahle & Groothuis, 2005). The specialization has also resulted in prac-
titioners that “know more and more about less and less” (Desouza, 2005, p. 14). Desouza
(2005) argues that physicians use about two million pieces of information to manage their
patients. It is estimated that medical knowledge increases fourfold during a practitioner’s
lifetime. Inevitably, this means that practitioners cannot practice EBM without updating
their knowledge. Furthermore, practitioners are also facing greater demands from patients
that are increasingly interested in participating in decision-making regarding treatment
choices and care possibilities (Desouza, 2005). El Morr and Subercaze (2010) further em-
phasize that any knowledge created by healthcare practitioners, irrespective of healthcare
level, is of utmost importance to all others, in order to provide good quality care. Efficient
interaction and exchange of knowledge among these actors is therefore a key issue for cre-
ating the best conditions for good quality care (Nicolini et al., 2008). Effective collabora-
tion in turn requires that relevant medical knowledge is made available, as needed, at any
time of the day and without technical difficulty (Wickramasinghe, Gupta & Sharma, 2005;
Abidi, 2007). Having access to the latest medical knowledge can, according to Grütter and
Eder (2002), mean the difference between life and death and between an accurate or erro-
neous diagnosis. Managing knowledge in healthcare organizations is hence crucial for the
optimal achievement of good quality care (Desouza, 2005)
Managing medical knowledge in healthcare organizations thus holds great promise for im-
proving healthcare delivery and, more critically, for dealing with information overload (Ali,
Tretiakov & Whiddett, 2009; Acharyulu, 2011). Wahle and Groothuis (2005, p. 30) have

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identified some arguments regarding why healthcare organizations need KM. The argu-
ments are:
 Healthcare organizations are knowledge intensive.
 There is a need and demand for optimizing the support of primary processes.
 Increased requirements from the patient for higher quality care and provision of
information related to treatment choices and care possibilities.
 The demand for efficiency and effectiveness.

2.7 KNOWLEDGE MANAGEMENT AND ORGANI-

ZATIONAL PROCESSES
KM is considered to be an important function for creating organizational value. However,
for organizations to gain maximum benefits from KM, they must link KM activities to or-
ganizational processes, such as the patient process (see figure 2.4) (Barnes, 2011). Edwards
& Kidd (2003, p. 133) assert that the best route for organizations to follow is to consider
KM in terms of organizational processes. This means looking at knowledge needs in terms
of their underlying business processes. El Sawy and Josefek Jr (2004) argue that the appli-
cation and generation of new domain knowledge take place in the context of the process.
Therefore, the key activities of the process are the central objects for analysis and design,
and KM has to demonstrate its benefits for the core processes (Heisig, 2009). Additionally,
Mertins, Heisig and Vorbeck (2003) and Deng and Yu (2006) argue that knowledge from a
process-oriented approach can be viewed as a crucial resource to fulfill process tasks. It can
also be understood as a product generated by this task or process (see figure 2.4). The au-
thors further emphasize that a process-oriented knowledge management approach requires
an integrative perspective of the elements of information and knowledge, as lack of one of
the elements can hamper the performance goals. Implementing the KM infrastructure
around the organizational process can thus create great value for process execution, pro-
cess recipients and the organization (El Sawy & Josefek Jr, 2004).

Figure 2.4: Knowledge is a crucial resource to fulfill the activities within the process.

Deng and Tian (2008) and Deng and Yu (2006) argue that KM activities which are not
combined with daily work tasks and integrated into organizational processes usually results
in situations where employees involved in the execution of the process feel that “they are
busy with the execution of more important tasks related to the process and that they do not
have time to spend on knowledge management activities such as searching for relevant
knowledge” (Deng & Tian, 2008; Deng & Yu, 2006). Therefore, integrating KM activities
into daily work tasks and responsibilities is a challenge to be solved. In recent years, indus-

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CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

tries have increased their attention to the potential benefits of linking KM to organizational
processes. However, to date, linking KM to processes has had less focus in healthcare or-
ganizations. This is somewhat surprising, as the patient process is characterized as
knowledge-intensive, consisting of many and critical decision activities that require per-
sonal judgment based on patient information and scientific evidence.
Consider the following hypothetical example in which the KM process and organizational
processes are interlinked. The setting is a healthcare organization where the core organiza-
tional process is the patient process. A specialist care physician receives a referral from a
primary care unit regarding a patient with hip pain. As the referral is processed and the
process for the patient encounter is planned and conducted, a considerable amount of in-
formation is collected, such as information from physical examinations, the patient’s medi-
cal record, and from current scientific medical knowledge. A great deal of information is
also exchanged between the patient and the physician and between the specialist care phy-
sician and the primary care unit. When the physician plans the patient encounter and con-
ducts the meeting, he/she must select the most appropriate examination and investigation
for the patient, based on the basis of evidence in conjunction with clinical expertise, the pa-
tient’s medical history, current clinical status, as well as preferences and values (Clancy &
Cronin, 2005; Lenz & Reichert, 2007). The patient encounter also requires the physician to
carry out some sort of decision-making, which involves an active interplay between various
medical knowledge modalities, spanning from explicit to tacit knowledge. More specifical-
ly, it may involve the consideration of medical knowledge from outside and inside the or-
ganization, such as (a) national and/or regional medical guidelines, (b) medical literature,
(c) physician’s tacit knowledge in terms of judgment and intuition, (d) discussions and con-
sultation with other practitioners. Enabling a healthcare practitioner to work according to
the latest scientific medical knowledge will require an analysis of the type of knowledge
needed in the different parts of the patient process. This knowledge, which may be in the
form of medical guidelines, can then be integrated with an information system. However,
beyond medical guidelines, a doctor may also need a different type of medical knowledge
and an information system must therefore support the doctor in identifying the required
knowledge in an easy way. To make decisions based on EBM, practitioners must be able to
access and integrate multiple knowledge types derived from various sources. Integration of
these knowledge types (both tacit and explicit knowledge) is especially essential, as
healthcare practitioners often have to deal with clinical situations which lack strong evi-
dence. For instance, the absence of explicit knowledge in a clinical case relating to the side
effects of a particular medicine reported by the patient may require practitioners to refer to
tacit knowledge, such as the clinical expertise of their peers (Abidi, 2005).
Additionally, every time the process is executed, new knowledge can be generated, e.g., if a
medical guideline recommends a new medication, patients' experiences of the medication
become important knowledge that must be captured and shared. Capturing, storing, shar-
ing and applying this knowledge can add value to the organization, but most importantly, it
can improve quality of care. Knowledge that has been identified and captured by a physi-
cian can thus be used to improve the patient process. However, for this to work, the KM
process must be smoothly integrated within the daily work activities of the patient process,
see figure 2.5 (Persson, Stirna & Aggestam, 2008). For example, if an organization wants to
develop an IT-based knowledge repository that is integrated within a process support sys-
tem, work must begin with 1) identifying what knowledge can be relevant for the execu-
tion of the different activities in the patient process, 2) identifying where the knowledge
could be found, also called “capture points”, which are situations or events where
knowledge is usually created, e.g., during a patient encounter, 3) identifying responsible
people for the capturing process. If, for example, a doctor has identified knowledge that
he/she perceives may be of interest to other colleagues, the doctor would then report to

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 CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

those responsible. In this process, one must also identify potential reviewers of the particu-
lar type of knowledge produced, 4) defining rules governing the kind of knowledge that
should be stored in the repository and in the process support system (Persson, Stirna & Ag-
gestam, 2008).
The integration of the KM process alone is, however, not sufficient for successful
knowledge management. The success of KM activities is also influenced by the enablers:
leadership, measurement, information technology and culture (see figure 2.5). For exam-
ple, the sharing and application of knowledge cannot be done mechanistically, by integrat-
ing medical guidelines into an information system, or by developing an IT-based repository
that supports sharing of knowledge, thus expecting the organization to suddenly start to
use and share knowledge. Particular attention should be paid to building a knowledge shar-
ing culture. A culture that encourages sharing and group learning helps KM initiatives.
Technology can only play a supporting role in knowledge sharing and application – its role
is to make knowledge sharing and application easier and more effective. To reinforce the
knowledge application and sharing, leadership is critical. Managers must participate in
sharing and show healthcare practitioners that they are personally committed to learning,
as sharing and usage of best practice are the most important aspects that individuals within
an organization can do (O´Dell, Grayson & Essaides, 1998; Persson, Stirna & Aggestam,
2008). They must motivate employees to share and especially show employees how to cap-
ture, share and use knowledge throughout the patient process, by giving people self-service
tools. The Chinese proverb fits well here; “Give a man a fish and you feed him for a day.
Teach a man to fish and you feed him for a lifetime”. Thus, in order to encourage sharing,
managers should not just hand out, e.g., web links where knowledge can be found - give the
fish. Instead, they must teach by giving employees the right tools with which to capture and
share knowledge – thus teaching them how to fish. Moreover, it is equally important to en-
courage practitioners to teach each other – learning how to fish from each other.

Figure 2.5: The integration of KM into organizational process and its enablers

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CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

2.8 THE RELATIONSHIP BETWEEN EBM, PRO-

CESS ORIENTATION AND KM
The definitions of the concepts and theories in the previous sections demonstrate a clear
relationship between evidence based medicine, business-process orientation, and
knowledge management (see figure 2.6). EBM aims to deliver high-quality care to an indi-
vidual patient, by eliminating decision-making based on more traditional methods in favor
of using scientific proof together with patient information, values and preferences, and
clinical skills. By integrating these elements into the decision-making, it will provide a
stronger foundation for clinical work to achieve consistency, efficiency, effectiveness, quali-
ty, and safety in medical care (Timmermans & Mauck, 2005). With an increased awareness
of the need for evidence based decision-making, knowledge management needs to be em-
ployed to ensure that knowledge is easily accessible, tailored, and shared among healthcare
practitioners. KM is also central to EBM, as it involves organizations and individuals that
create, capture and share both explicit and tacit knowledge (Quinn et al., 2014).
To ensure that relevant medical knowledge is made available to practitioners´, healthcare
organizations must adopt KM. Therefore, theory of KM has been described and discussed
in this chapter. However, successful knowledge management efforts require that KM activi-
ties are embedded into organizational processes. These can be any organizational process,
for example, the patient process. Once the process has been selected, information regard-
ing the kind of knowledge that will flow through the process and what knowledge is needed
during the different activities within the process must be identified and documented
(Barnes, 2011). As EBM comprises explicit and tacit knowledge, theory of KM can be used
to show how it can be linked in the execution of organizational processes, in order to en-
sure that only relevant medical knowledge is made available in the context of this process.
Thus, by grounding KM activities around the process, it can help the organization under-
stand the knowledge needs of health practitioners during the different parts of the process.
Hence, it will be possible to ensure that only relevant knowledge for the specific process is
made available to those who need it, when they need it (El Sawy & Josefek Jr, 2004).
Moreover, EBM comprises patient information, preferences and values. In order to im-
prove the quality and safety of care, this information needs to be available when decisions
about the care of individual patients must be made. Therefore, the concept of process ori-
entation has been adopted in this thesis. Process orientation places emphasis on organiza-
tional processes based on the patient perspective, instead of placing emphasis on functional
and hierarchical structures (Kohlbacher, 2010). A process-oriented approach with a sup-
porting information system is crucial, as it can streamline the flow of both patient infor-
mation and medical knowledge, and thereby ensure that practitioners always have access to
the right information when decisions must be made. Moreover, in order to contribute to
improvements in healthcare, one must view patient information and medical knowledge as
interconnected, continually impacting on each other. Therefore, when future healthcare
information systems are developed, they must consider the synergy between EBM, process
orientation and KM.

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 CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

Figure 2.6: The link between EBM, process orientation and KM

2.9 RELATED RESEARCH

In recent years, researchers have tried to resolve the gap between evidence and practice, by
introducing different solutions for how information systems can be used to support evi-
dence based medicine. For example, Winge et al., (2014) propose a solution in the form of a
Coordination Hub, an integrated software service that offers a number of information ser-
vices, which can facilitate the communication between different healthcare providers in
process conglomerations, thereby supporting patient-centered collaboration. Raghupathi
and Kesh (2007) have, in their research, explored the potential of service-oriented architec-
ture (SOA) in the development of interoperable EHRs, by developing a prototype SOA
model. Russ et al., (2010) have identified a set of characteristics for workflow systems that
support patient-care processes. The research from, e.g., Winge et al., (2014) and Russ et al.,
(2010) focuses on the communication needs of care providers and how the patient process
can be supported, by making individual patient information available at all points of care,
which of course is of interest for this work. However, none of these have taken a holistic
perspective that also includes the patient and their communication with healthcare provid-
ers.
Moreover, there is much research on different methods and tools for 1) translating clinical
guidelines into computer-based clinical guidelines and 2) improving the design of comput-
er-based clinical guidelines (see, e.g., Shalom et al., 2008; Shiffman et al., 2004). Other re-
searchers have focused on studying how clinical guidelines can be integrated into EHRs
and organizational workflows (see, e.g. Peleg, Keren & Denekamp, 2008; Shiffman et al.,
2004). For example, Peleg, Keren and Denekamp (2008), in their research, have studied
how encodings of guidelines in a computer-interpretable format and integration of them
with EHRs can enable the delivery of medical knowledge, in the form of patient-specific
recommendations, when and where needed. El-Gayar and Timsina (2014) have, in their
research, presented a research agenda for leveraging business intelligence and big data
analytics in evidence based medicine, and illustrate how analytics can be used to support
EBM. Furthermore, in their research, Lenz et al., (2007) have demonstrated how pathway
compliance can be improved, by developing a successful IT-application that brings pathway
recommendations to the point of care. The application is closely integrated into the elec-

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CH AP T ER 2 T HE O R E T IC AL B A C KG R O U ND

tronic patient record system and is based on workflow-enabled electronic forms in which
coded data from a central database are reused to place reminders and alerts. As the main
purpose of computer-based clinical guidelines is to decrease errors and increase quality
and safety, validation and verification techniques are other topics of interest to many re-
searches (Peleg, 2013). Although computer-based clinical guidelines include medical
knowledge, the management of knowledge from a KM perspective is seldom mentioned in
these research examples. Moreover, Fennessy and Burstein (2007), argue that computer-
based medical guidelines provide important summaries of good quality evidence, but they
are usually limited in scope and topic coverage. High costs and the amount of time involved
in developing them are seen as the main reasons. Therefore, and as a complement to com-
puter-based medical guidelines, IT-based knowledge repository solutions have been im-
plemented within healthcare organizations, but the results have often been unimpressive.
In Sweden, several national projects have been initiated, with the aim of developing IT-
based knowledge repositories. The solutions are built on web-based services that help prac-
titioners access and use explicit medical knowledge. Some well-known project initiatives
are “Kunskapsguiden” and “Vårdaktörsportalen”. These IT-based knowledge repositories
aim to give healthcare practitioners easy access to explicit medical knowledge, such as
medical guidelines, without supporting the second element of evidence based medicine,
namely sharing of individual clinical expertise. Moreover, the medical knowledge within
these knowledge repositories is made available in “document form”, containing a multitude
of pages. Even though these knowledge repositories contain crucial knowledge, none of
them are integrated with existing information systems, such as an EHR. They are thus
“stand-alone” systems that have been developed and are still being developed separately
from existing information systems. Finding relevant knowledge that is related to the clini-
cal situation, when it is needed, is therefore difficult.
An important project that forms the basis for this thesis is VITA Nova (acronym for Swe-
dish ”Vårdens IT-Arkitektur i Ny belysning”). The aim was to develop a methodology for,
and to investigate the potential of, process manager technology in healthcare. In the pro-
ject, a prototype system based on a process manager was built, integrating the work of the
various healthcare units along a limited patient process (the leg ulcer process). The focus
was on home healthcare providers using mobile devices that communicated with IT sys-
tems via a process manager (Perjons et al., 2005). The process manager has been used in
the prototype developed within case study one, “Future Healthcare Information Systems
project”, which is part of this thesis.
Based on the analysis of prior research and the scope of the problem that has been present-
ed in this thesis, we conclude that the various elements of evidence based medicine are
treated as distinct. Consequently, the information technology solutions that are presented
in current research deal with supporting one or some other elements of EBM. A holistic
perspective is thus missing. Information technology can contribute significantly to quality
and safety improvements in healthcare, only when 1) patient information and medical
knowledge are regarded as interconnected, such that they continually impact on each oth-
er, and 2) when the patient is seen as a distinct and active collaborator. Therefore, an effi-
cient synergy must be developed between future information systems and EBM. An addi-
tional limitation in existing research relates to the presented solutions for how medical
knowledge can be made available to healthcare practitioners. It seems that existing re-
search is either studying how guidelines can be integrated into EHRs or how IT-based
knowledge repository solutions can bridge the gap between evidence and practice. Consid-
ering that medical guidelines provide summaries of evidence, future research should also
examine how an IT- based knowledge repository can be used as a complement to comput-
er-based medical guidelines.

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C H A P TE R 3
RESEARCH METHOD
This chapter first describes the research approach applied to the research presented in this
thesis and then presents the research process. The chapter concludes with a discussion re-
garding ethical principles that have been considered while conducting the research.

3.1 APPROACHES TO RESEARCH

Research methods can be classified in various ways. Myers (1997) explains that one of the
most common distinctions between research methods is that between qualitative and quan-
titative research. Quantitative research methods originate from the natural sciences and aim
to study natural phenomena. Examples of quantitative methods include surveys, laboratory
experiments, as well as formal and numerical methods. Qualitative research methods, on the
other hand, aim to study social and cultural phenomena based on a complex, holistic picture,
formed with words, and reported in a natural setting (Myers, 1997; Jabar, 2009). Qualitative
research methods are designed to help researchers understand people, as well as the social
and cultural circumstances in which they live, by enabling them to verbalize thoughts about
the context under study. Qualitative researchers are interested in the beliefs, feelings and
interpretation of people (Williamson, et al., 2002). Hence, they tend to use qualitative re-
search methods, such as action research, case study research and ethnography. Qualitative
techniques for data collection include observations, interviews, questionnaires and text anal-
ysis (Myers, 1997). In qualitative research, the research participants are viewed as “helping
to construct the reality with the researchers” (Robson, 2011, p. 24). Bridget Byrne (2004) in
Silverman (2008) suggests that qualitative interviewing is “particularly useful as a research
method for accessing individual´s attitude and values – things that cannot necessarily be
observed or accommodated in a formal questionnaire”. The author further argues that
“open-ended and flexible questions are likely to get a more considered response than closed
questions and therefore provide better access to the interviewees´, interpretation of events,
understandings, experiences and options… [qualitative interviewing] when done well is
able to achieve a level of depth and complexity that is not available to other, particularity
survey-based, approaches” (Silverman, 2008, p. 114). Kaplan and Maxwell (1994) also argue
that the goal of understanding a phenomenon from the point of view of the participants and
its particular social and institutional context is largely lost when textual data are quantified.
Qualitative research methodology is viewed as significant in information system research,
due to the value of capturing and explaining what is going on in real organizations (Jabar,
2009). Additionally, as information systems research shifts from technological to managerial
and organizational issues, qualitative research methods become increasingly useful (Myers,
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CH AP T ER 3 R E S E AR CH M ET HO D

1997). Our field of study involves a complex social context in which the care of the patient
evolves from an isolated process towards a continuous one that incorporates multiple inde-
pendent units and different healthcare practitioners, each with their own requirements and
expectations of healthcare information systems. The social context makes it difficult to use
controlled experiments and/or survey methods. There may be some aspects of the area that
could be investigated by survey methods, but considering the research questions of the the-
sis, we have strong doubts about the relevance and effectiveness of such an approach. In
conclusion, we argue that answering the research questions requires a research approach
that focuses on understanding people and the social and cultural contexts in which they
communicate and act.
Taking the aim of this thesis and the discussion about the research methods into considera-
tion, we conclude that the case study approach in combination with data collection tech-
niques, such as interviews and observations, were the most appropriate methods to use, in
order to gain empirical data. A detailed description of the research process and the data col-
lection techniques that were used for each case study are described in the next section.

3.2 RESEARCH PROCESS

The research is based on two case studies (see figure 3.1). In 2009, a research project, Future
Healthcare Information Systems (FHIS), was initiated. This case study started before I for-
mally entered into my doctoral education. When I entered the project, interviews and obser-
vations with healthcare practitioners and patients had already been carried out as part of the
first research activity “A current state analysis” (see section 3.3.1). I entered the project in
the later phase of this research activity, where the plan was to carry out “As-Is” process mod-
els. Therefore, my work as a participant researcher in the FHIS project started with analyz-
ing the collected data from the interviews and observations and carrying out process model-
ing. I have also had a central role in the development and evaluation of the process support
system that is a central part of this work. The results of this case study have directly con-
tributed to research questions 1, 2, 3 and 4. Shortly after the FHIS project, I entered the
“Knowledge repository project” (KRP) which was a collaborative venture between Vård-
samverkan Skaraborg and the University of Skövde, Sweden (see figure 3.1). I had a leading
role in this case study for which I planned and executed the research. I also had the sole re-
sponsibility of analyzing the empirical data. Interviews were the main data collection tech-
nique used to collect the empirical data. The results of this case study contributed to re-
search questions 2 and 3. Moreover, within each case study, a literature review was carried
out in two distinct phases - an initial phase that aimed to gain knowledge about the studied
object and an adaptive phase where the literature was used to understand the empirical re-
sults in relation to existing research.

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 CH AP T ER 3 R E S E AR CH M ET HO D

Figure 3.1: Framework for the research design

3.2.1 LITERATURE REVIEW

According to Webster and Watson (2002), a literature review of prior research is an essential
feature of any academic project, since it creates a firm foundation for advancing knowledge.
Moreover, “it facilitates theory development, closes areas where a plethora of research ex-
ists, and uncovers areas where research is needed” (Webster & Watson, 2002, p, xiii). A lit-
erature review comprising two phases was carried out within each case study. In the initial
phase, the literature review involved identifying, locating, and analyzing documents contain-
ing information related to the research problem. This phase helped to gain knowledge about
the studied object, which included (Robson, 2011):
 Gaining knowledge about what is already known in the field of interest.
 Exposing gaps in knowledge and identifying principal areas of dispute and uncer-
tainty.
 Identifying variations of definitions used by researchers.
 Identifying general patterns to findings from multiple examples of research in the
field of EBM, business process orientation and KM.

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CH AP T ER 3 R E S E AR CH M ET HO D

In the adaptive phase, the aim of the literature review was to understand the empirical re-
sults in relation to existing research.
In order to identify relevant papers, the literature review started with the identification of
keywords. These were found by analyzing the concepts that are used in the research problem
and research questions. Some of the keywords used include: “information system and
healthcare processes”, “knowledge management and knowledge management processes”,
“evidence based medicine and knowledge management”, “patient engagement”, “evidence
based medicine and information systems”. When these keywords had been identified, the
literature review started with a general search of scientific papers through the use of various
databases, such as Worldcat Local, ScienceDirect, Google Scholar and MEDLINE (PubMed).
Papers were also found by searching in leading journals, such as Information Systems Re-
search, MIS Quarterly, Health Informatics Journal, and Journal of Knowledge Management.
As the search continued, alternative useful words that occurred during the searches were
added to a keyword list.
Papers were selected through reading the title and abstract. The reading of papers was itera-
tive, which means they were read several times, in order to ensure a correct understanding of
the content. Relevant phrases and concepts were underlined and summarized. While read-
ing the papers, I also paid attention to the reference list of each paper. The purpose was to
use Bates’ technique of “linking” (2002), which aims to find new references from the refer-
ence lists of others. The paper by Lenz & Reichert (2007) made an early impression, because
this paper has contributed to the identification of other relevant literature, such as Bemmel
and Musen (1997) who emphasize the importance of having access to patient information
and medical knowledge in medical decision-making.

3.2.2 CASE STUDY RESEARCH

Case study research is the most common qualitative method used in information systems
(Myers, 1997). Clearly, the case study research is particularly well suited to information sys-
tem research, since the object of the discipline is the study of information systems in organi-
zations, where the research interest has shifted to organizational rather than technical issues
(Benbasat, Goldstein, & Mead, 1987). A case study is, according to Yin (2002), an empirical
inquiry that investigates a contemporary phenomenon within its real-life context, especially
when the boundaries between phenomenon and context are not clearly evident (Yin, 2002).
In a case study, the case may be a group of people, organization, process, or an information
system. Since there is no standard definition of a case study, this thesis draws the definition
from Benbasat, Goldstein and Mead (1987, p. 370):

“A case study examines a phenomenon in its natural setting, employing multiple methods
of data collection to gather information from one or a few entities (people, groups, or or-
ganizations). The boundaries of the phenomenon are not clearly evident at the outset of the
research and no experimental control or manipulation is used”

Case study research is particularly appropriate for situations in which the examination and
understanding of the context is important, such as areas where there is little understanding
of how and why phenomena occur, and where the experience of individuals and the contexts
of action are critical (Williamson et al., 2002). Since patients’ experiences and requirements
of communicating with healthcare, as well as healthcare practitioners´experiences of the
availability of patient information and medical knowledge is not well understood, case study
research is appropriate for this thesis. Case study research uses multiple data collection

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 CH AP T ER 3 R E S E AR CH M ET HO D

techniques, such as interviews, observations, questionnaires, as well as document and text

analysis.
Two case studies have thus been included in this thesis. These cases are compatible because
they both deal with the availability of information, when and where it is needed by
healthcare practitioners and patients.

3.3 CASE STUDY ONE

The case study “Future Healthcare Information Systems” aimed to develop a prototype visu-
alization of a process support system (PSS) that demonstrates the requirements for future
process-oriented information system support in healthcare. The vision for the process sup-
port system is that healthcare practitioners, from all levels of healthcare, and patients should
have access to effective collaborative information systems that supports process-oriented
care in which the patient is a distinct and active collaborator.
The process support system was developed in close collaboration between researchers at the
University of Skövde, a local hospital in the Västra Götaland region of Sweden, and
healthcare organizations in the said region. The overall health care process is extremely
complex and endeavoring to tackle it all within one project would clearly not be feasible.
Therefore, one of the first tasks of the project was to select a suitable sub-process for the
work to focus on. Some criteria were used for the selection. The chosen sub-process should:
 Be one where the patient can play an active role,
 Be relevant for more than one level of care (primary care, hospital care and munici-
pality care) in order to demonstrate general applicability,
 Be relevant for more than one healthcare profession,
 Be complex enough, particularly in terms of information flow, to demonstrate a
substantial difference between the existing way of working and the proposed future
way of working, and
 Be frequent enough for the changed way of working to have a substantial impact on
both healthcare practitioners and patients.
The project selected the process of initiating, planning, carrying out and following up a pa-
tient’s visit to a healthcare provider. This process was termed “Patient Visit” and was limited
to involve only ambulatory care. It is frequently occurring and exists both in primary and
hospital care. Instances of the process in primary and hospital care also communicate with
each other. Hence, it involves the desired element of complexity. Several professional groups
are involved in the process and the patient needs to play an active role. Also, the chosen pro-
cess was suitable to demonstrate the intricacies of the communication between a patient and
healthcare providers. In order to be able to make the demonstrator concrete and illustrative,
two scenarios of the “Patient Visit” process were chosen for implementation (see paper by
Åhlfeldt et al., 2013).

3.3.1 INTERVIEWS, OBSERVATIONS AND PROCESS MODEL-

ING
The first step in the prototype development was to collect data regarding 1) how current in-
formation systems support healthcare practitioners in their daily work practice with regard
to availability of information, and to a certain extent availability of medical knowledge, 2)
how patients experience the exchange of information with healthcare providers, and 3) iden-
tify user requirements for future process-oriented information system support. For this pur-
pose, two main activities were carried out in the project:

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CH AP T ER 3 R E S E AR CH M ET HO D

1. A current state analysis:

This activity was carried out in close cooperation with healthcare practitioners as well as pa-
tients from an orthopedic clinic. Additional information was gathered from the cardiologist,
eye clinics, emergency units and primary care centers. The objective of this activity was to;
(1) explore and create a comprehensive picture of how current information systems support
healthcare practitioners’ and patients´ information needs and (2) identify requirements for
future information system support. For this purpose, interviews and direct observations
were seen as adequate techniques for data collection (Berg, 2001b). Eighteen semi-
structured interviews (see Appendix 1) and direct observations of healthcare practitioners
were conducted. The observations of the healthcare practitioners lasted from a half to a full
working day and involved visual inspection of their everyday work activities, observing what
and how tasks were being carried out.
Moreover, the consultations and conversations that took place between the patient and the
physician during the patient meeting were observed. In total, seven direct observations that
lasted between 10 - 20 minutes were conducted. Each observation was complemented with a
semi-structured interview, which made it possible to gain a deeper understanding of the data
collected through the observations. The aim of the interviews was to study how patients per-
ceive their patient process.
All interviews with healthcare practitioners and patients were taped, transcribed and ana-
lyzed (see section 3.5 for the qualitative data analysis), and lasted approximately two hours
each. During the interviews, the interviewer took notes of the responses, which allowed the
interviewer to highlight key points that needed further reviewing. All transcripts followed a
standard format and included the following information:
 Date, time and place (city and type of healthcare provider, e.g., primary care) of the
interview.
 The profession of the interviewee.
 To assure the interviewee anonymity, each interview was marked according to a
coding system, e.g., VN550, whose code key was kept at a different location to the
interviews, so that only the interviewer could identify the participants (Thomsson,
2010)
 List of acronyms (e.g., I = interviewee, and R = researcher, thus the interviewer).
An observation protocol was used to record information obtained during the observations of
the healthcare practitioners and the patient meetings. A descriptive notes section for the de-
scription of activities was also included in the protocol (Creswell, 2007). In addition, the re-
sults from the observations and the interviews were discussed with the healthcare practi-
tioners and the project team members.
The possibility of complementing direct observations with other techniques, such as inter-
views or questionnaires, is, according to Robson (2011), one of the main advantages of ob-
servation. Interviewing is a conversation for the purpose of gathering information about the
context under study (Berg, 2001b). Conducting semi-structured interviews enabled, in ad-
vance, the predetermination of the ground to be covered and the main questions related to
the patient meeting process to be asked. Although a list with predetermined questions was
prepared, the interviewer was allowed the freedom to change the order of the questions or
the way they were worded, in order to adapt to the flow of the interview and to explore issues
deemed important (Berg, 2001b). The interview questions were organized according to a
commonly used sequence, described by Robson (2011, p. 284) in figure 3.3.
Data obtained from the interviews and observations resulted in “As-Is” process models that
described the patient meeting. These models helped to gain an overall picture of the business
practice in the organization, and to describe how tasks are carried out during the patient
meeting and what kind of information is needed to perform various work activities. The
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 CH AP T ER 3 R E S E AR CH M ET HO D

models also helped to identify user requirements for the process support system. The pro-
cess models have played an important role in the communication between the domain prac-
titioners and the project’s researchers. Modeling business processes, or workflows, often
plays a central part in the development of information systems, as well as the re-engineering
of work practices (Krogstie, Sindre & Jørgensen, 2006).
The method used for modelling of the chosen process and for prototype development was
the Visuera method. The method was chosen for the following reasons:
 The Visuera method is a process modelling method that enables modelling of activi-
ties and related actors in an organizational process. One particular feature of the
method is that it integrates the flow of information with the activities in the process
and also allows for the definition of concepts used in the process. Since the general
focus of our research is to enhance the support that information can provide to
healthcare processes, this was considered an important feature.
 The models produced with the method are fairly easy for non-experts to under-
stand. Since an important part of the work was to have healthcare practitioners
evaluate the feasibility of the proposed future process before it was implemented in
the demonstrator, the aspect of usability for non-experts was considered to be es-
sential.
 The method comes with a supporting tool that can take a graphical model describ-
ing a process and the related information flows and “translate” it into simula-
tion/demonstrator of how a system will work and how it will look, without actually
implementing the system. Since the objective was to develop a demonstrator it was
a reasonable choice.
The method consists of five steps:
1. Analyzing the As-Is processes. In this step current activities are documented in a
graphical As-Is process model.
2. Specifying the requirements (To-Be). Here, components in the As-Is process mod-
els are identified, which have potential for being made more efficient. A To-Be pro-
cess model is developed. Efficiency can be achieved by:
i. Automating work currently being performed manually.
ii. Removing manual or automated tasks that are without any significance for
activities later on in the process.
iii. Improving the quality of activities in the process.
iv. Making sure that the end result of all activities has the highest quality.
v. Improving throughput time by adding, deleting or reassigning tasks in the
process.
vi. Improving information quality in the processes
3. Developing a supporting information system if technological change is necessary,
based on To-Be process models.
4. Deploying the new process and information system. In this step employees affected
by the information system are educated.
5. Production and monitoring of improved processes and their support systems.
The Visuera method follows strict rules and has its own tool; the Visuera Business Process
Modeler, which aims to ensure that process models have the same look and feel, regardless
of organizational domain. The process models contain only a few symbols that intend to be
intuitive. The process models can be abstracted or detailed into an unlimited number of lev-
els. The prototype, presented in this thesis, got all of its sample data and flow logic directly
from the process model. To increase the models' accuracy, they were discussed with
healthcare practitioners. It was important to make the models as generalizable as possible,
so that they could be valid for several different healthcare units.

35
CH AP T ER 3 R E S E AR CH M ET HO D

2. Modeling of the intended future state:

Based on the assessment of the current situation and the “As-Is” process models, work began
on specifying the requirements of the proposed future state (To-Be models). Identification of
the requirements began with an “idea seminar” with the project’s reference group. During
this seminar, a number of ”objectives” for the future state were identified. These objectives
and the current state description of the first project activity formed the basis for a number of
idea seminars/workshops with healthcare practitioners. During these seminars/workshops,
practitioners were asked to discuss objectives and ideas about how an ideal process for the
patient visit should work in the future and what type of information system support would
be needed to accomplish the goals. A total of four seminars were held with approximately 15
to 20 people per session. The purpose of these seminars/workshops was thus to identify user
requirements for the future state. Based on these requirements, the future patient meeting
process was elaborated, in order to identify the sub-processes and information flows. Process
models of the different sub-processes, comprising activities, roles, and information flows,
were then created. An important part of this work was to identify the detailed contents of the
information needed for the various activities in the process models. The information content
was sketched in forms with the Visuera Business Process Modelling 2007 tool. Subsequently,
the process models and the information content were validated by healthcare practitioners
during workshop sessions, brainstorming meetings, seminars and lectures. Moreover, a pa-
tient representative from a patient organization provided feedback on the models.

3.3.2 PROTOTYPE DEVELOPMENT

Based on the identified user requirements and after a number of iterations to ensure the
quality of the process models and the information content, key design principles for a future
process oriented information system were identified. To visualize the key principles a proto-
type of a process support system was developed with several user interface screens. The re-
sulting prototype was evaluated towards in relation to user requirements identified through
observations, workshops and interviews. In addition to this, identified user needs were also
evaluated against in relation to the Swedish national strategy for e-health and in seminars
involving healthcare professionals, patients and information system providers. Based on this
evaluation, the prototype was refined.
The findings of this case study have resulted in three published research papers:

Paper 1: Krasniqi, H., Åhlfeldt, R-M. & Persson, A. (2011) Patients’ experiences of communi-
cating with healthcare – An information exchange perspective. Proceedings of
the 15th International Symposium for Health Information Management Re-
search (ISHIMR) 2011, Sept 8-9 (pp. 241-251). Zurich, Schweiz.

I am the main author of this paper. I have had the

sole responsibility of analyzing and summarizing
the collected data. I have also had the sole re-
sponsibility of writing the paper. Feedback has
been given by the co-authors.

Paper 2: Rexhepi, H., Åhlfeldt, R-M. & Persson, A. (2015) Challenges and opportunities
with information system support for healthcare processes – A healthcare prac-
titioner perspective. Proceedings of the 8th International Conference on In-

36
 CH AP T ER 3 R E S E AR CH M ET HO D

formation Systems (IADIS) 2015, March 14 – 16 (pp. 61-69). Madeira, Portu-

gal.

I am the main author of this paper. For the pur-

pose of this paper, I have had the sole responsi-
bility to (1) analyze the data from the interviews
and observations, and (2) write the paper. The
process support system presented in this paper
has been developed together with the co-authors.

Paper 5: Åhlfeldt, R-M., Persson, A., Krasniqi, H. & Wåhlander, K. (2013) Supporting Ac-
tive Patient and Healthcare Collaboration - A Prototype for Future Healthcare
Information Systems. Proceedings the 16th International Symposium on
Health Information Management Research (ISHIMR) 2013, June 26 -28 (pp.
13-23). Halifax, Canada.

I am an important contributor to this paper. I

have had the sole responsibility for conducting
the literature review. Moreover, together with the
co-authors, I have been involved in developing
the process support system presented in this pa-
per. The paper has been co-written, meaning that
the authors have had a joint responsibility for the
writing.

3.4 CASE STUDY TWO

The “Knowledge repository project” was a collaborative endeavor between all the healthcare
providers in Skaraborg, a sub-region of Västra Götaland, and the University of Skövde, Swe-
den. The aim of the project was to;

“Explore the possibility of creating a structured, resource-efficient and sustainable model

for developing and managing a coherent IT-based knowledge repository for different are-
as of knowledge bases in healthcare. Coherent, means that there is one entrance to the
knowledge the portal includes. Healthcare practitioners can use the knowledge portal to
search and retrieve relevant knowledge”

Two studies were conducted within the frame of the project. The first study aimed at analyz-
ing the characteristics and challenges of Swedish IT-based knowledge repositories contain-
ing medical knowledge. This study not only identified challenges that current knowledge re-
positories in Sweden are facing, but also the need for a comprehensive IT-based knowledge
repository. Based on these results, the project continued with the implementation of the sec-
ond study which aimed at exploring:

 How healthcare practitioners experience the availability of medical knowledge

when and where they need it.
 What kind of medical knowledge is missing and/or difficult to obtain at the point of
care, as well as how they would like to access that information.
37
CH AP T ER 3 R E S E AR CH M ET HO D

 Conditions for developing a coherent IT-based knowledge repository for different

areas of knowledge bases in healthcare.

3.4.1 INTERVIEWS
Within the first study, 15 IT-based knowledge repositories were included in the analysis. To
collect empirical data, two data collection techniques were used: (1) inspection of the reposi-
tories according to predefined questions. This inspection aimed at collecting a variety of IT-
based knowledge repositories at national, local and regional levels, which would demon-
strate the multitude of approaches to creating knowledge repositories. The second method
was: (2) telephone interviews with managers of the IT-based knowledge repository (see Ap-
pendix 2). Since telephone interviews lack face-to-face non-verbal cues that researchers use
to pace their interviews and determine the direction in which to move, they are not regarded
as a major way of collecting qualitative data (Berg, 2001b). However, in accordance with
Berg (2001b), telephone interviews were an effective means of gathering data, owing to geo-
graphic locations (Berg, 2001b).
Within the second study, 62 semi-structured interviews were conducted with managers,
nurses and nursing assistants from primary, specialist, and municipality care (see Appendix
3). A letter requesting participation in the research project was sent to managers within each
municipality in Skaraborg, Sweden. A request was also sent to managers in primary care and
to different units at specialist care in Skaraborg, Sweden. The letter contained requests to
interview one manager, two nurses and two nursing assistants with varying experiences of
working in the healthcare sector. Since the results from the first study showed that, the ma-
jority of the IT-based knowledge repositories had physicians as the main target group, they
were excluded from this stage of the research study. The inclusion criteria also include fac-
tors such as different age range and gender. The managers then suggested one or two indi-
viduals who were willing to participate in the study. When the researcher started to gather
information from one person, or several people, the researcher was then put in touch with
others. However, there is always a risk with this type sampling. For example, there is a risk
that managers only suggest practitioners who are familiar with KM and who will talk well
about the organization. However, based on the analyzed data, managers have been success-
ful in recommending healthcare practitioners who were willing to share the KM difficulties
that the organization is experiencing. An equitable distribution of the professional roles that
participated in the study has been sought. Unfortunately, it was not possible to achieve an
even distribution between healthcare practitioners and managers at all three levels of
healthcare, which could weaken the results (see figure 3.2). However, in the qualitative in-
terviews, there is a condition known as theoretical saturation, which occurs when the re-
searcher, through a series of interviews, can see a clear pattern, and when no new data ap-
pear. For the purpose of this work, we therefore believe that theoretical saturation was
achieved at all three levels of healthcare. One can thus argue that the results are sufficiently
reliable to answer the research questions 2 and 3.

38
 CH AP T ER 3 R E S E AR CH M ET HO D

Figure 3.2: Overview of the conducted interviews

Within the second study, two interview guides were developed; one for managers and one for
practitioners, with associated questions based on the KM cycle/process, which means that
the following aspects were addressed (see Appendix 3):
 Processes for capturing and creating knowledge.
 Processes for packaging, storing, sharing, applying and measuring whether
knowledge has contributed to changes in the organization.
The practitioner interview guide also includes questions with regard to lack of medical
knowledge in a clinical situation, for example, “What kind of knowledge do you miss most
often? Why is this knowledge important for you?”
Interviews as the main data collection technique were thus used in both studies. There are
different forms of interviewing. A commonly used typology distinguishes between struc-
tured, semi-structured and unstructured interviews. This can, according to Robson (2011),
be linked, to some extent, to the depth of the response being sought. Using semi- structured
interviews as the main data collection technique was appropriate, as I wanted to focus the
interview around specific topics related to the availability of medical knowledge. The semi-
structured interview is, according to Williamson et al., (2002), closer to the unstructured, in-
depth interview, than to the structured, standardized form. This interview form is best suit-
ed when the researcher wants to capture and understand the respondent's perspective on a
situation or event under study (Williamson et al., 2002).
A set of questions were thus prepared beforehand in both cases, but as the interviews were
intended to be conversational, the interviewer changed the order of the questions or the way
they were worded, to adapt to the flow of the interview. The technique of “probing” recom-
mended by Robson (2011) was used. This helped the interviewer encourage the respondent
to provide more details to a response, i.e., to say more about a particular topic. Tactics, such
as “Can you give me an example?” “Tell me more about that”, “Why was that important to
you?”, were used. Additional unplanned questions were asked to follow up the answers
(Robson, 2011). Moreover, the interview questions were organized according to a commonly
used sequence, described by Robson (2011, p. 284) in the figure below.

39
CH AP T ER 3 R E S E AR CH M ET HO D

Figure 3.3: Sequence of interview questions

The interviews from the first and second study were taped, transcribed (with pauses and all
of the words spoken) and analyzed (see section 3.5 for qualitative analysis). The audio-taping
of a research interview is a considerable advantage, as it provides a permanent record. The
taping also allows the interviewer to concentrate on conducting the interview (Robson, 2011;
Kvale, 1997). During the interview, the interviewer took notes of the responses, which al-
lowed the interviewer to highlight key points that needed further reviewing. The transcrip-
tion processes started by first listening to each interview and thereafter starting the tran-
scription. In this way, it was possible to obtain a comprehensive understanding of the con-
tent of the interview. This approach also facilitated the transcription. When possible, the in-
terview was transcribed on the same day as it was conducted. All transcripts followed a
standard format and included the following information:
 Date, time and place (city and type of healthcare provider, e.g., specialist care, pri-
mary care) of the interview.
 The profession of the interviewee.
 To assure the interviewee anonymity, each interview was marked according to a
coding system, e.g., VN550, whose code key was kept at a different location to the
interviews, so that only the interviewer could identify the participants (Thomsson,
2010).
 List of acronyms (e.g. I = interviewee, and R = researcher, thus the interviewer).

The findings of this case study have resulted in three published research papers:

Paper 3: Krasniqi, H. & Persson, A. (2012) Web-based Knowledge Portals in Swedish-

Healthcare – Overview and Challenges. Scandinavian Conference on Health
Informatics 2012, Oct 2-3 (pp. 9-12). Linköping, Sweden.

I am the main author of this paper. For the pur-

pose of this paper, I have had the sole responsi-

40
 CH AP T ER 3 R E S E AR CH M ET HO D

bility for (1) analyzing the knowledge portals and

carrying out the interviews, (2) analyzing the em-
pirical data and (3) write the paper. Feedback has
been given by the co-author.

Paper 4: Rexhepi, H. & Persson, A. (2014) Worlds Apart – IT Strategies for Evidence Based
Medicine Meets Reality. Submitted.

I am the main author of this paper. I have had the

sole responsibility for (1) collecting and analyze
the data (2) write the paper. Feedback has been
given by the co-author.

Paper 6: Rexhepi, H. (2015) Supporting Evidence Based Medicine – A Prototype for Future
Healthcare Information Systems. Proceedings of the 8th International Con-
ference on Information Systems (IADIS) 2015, March 14 – 16 (185-195). Ma-
deira, Portugal.

I am the sole author of this paper. I have had the

responsibility to collect and analyze the data that
is presented in this paper.

3.5 QUALITATIVE ANALYSIS

The analysis of the empirical data has been conducted with inspiration from the Grounded
Theory research method. Grounded theory analyses are especially suitable when the re-
search attempts to understand the nature of the studied object (Sharan, 1988). Since this
work, seek to describe how practitioners experience the availability of patient information
and medical knowledge, as well as how patients experience the information exchange with
healthcare providers, grounded theory analysis was considered suitable, due to its ability to
produce a rich, deep description of people’s experiences. The aim of the analysis was to find
central core categories which, according to Robson (2011), are both at a high level of abstrac-
tion and grounded in the collected and analyzed data. This was achieved by carrying out two
kinds of coding: open coding and axial coding.
Open coding is the first step of the analysis that pertains to the initial discovery of categories
and their properties. This first step of open coding started by reading through the tran-
scribed interviews several times, in order to create a deeper understanding of the respond-
ents´ statements. The actual coding then started. The open coding of the transcribed data
has involved the line-by-line coding of words and phrases through the use of highlighting
(Strauss & Corbin, 1990). Each word or phrase was assigned a concept noted in the margin.
An example of a concept that was identified is “support in decision-making”. At this stage,
the coding was conducted directly in the word document program, by using the “insert
comment” function (see figure 3.4). When all the concepts had been identified, they were
grouped into border categories. An example of a category that relates to the above concept is
“information explosion”. Moreover, to obtain a better overview of the data, phrases and/or
words already marked with the associated concept were transferred to an excel sheet. In or-
der to identify the categories, the concepts and the phrases and/or words related to the spe-
cific concepts were closely examined and compared for similarities and differences, while
constantly questioning the data with the neutral inquiry; “what does this indicate and how
41
CH AP T ER 3 R E S E AR CH M ET HO D

does it relate to other concepts?” The open coding together with the questions asked are the
basic grounded approaches to the data and will, according to Glaser (1992), lead to emergent
discoveries.

Figure 3.4: An example of the coding process showing codes and concepts (text in Swedish) [interview 12]

Axial coding involved further exploration of the categories and concepts that were developed
in the process of open coding (Oktay, 2012; Strauss & Corbin, 1990). It was the process of
identifying the relationship between and within the categories. Furthermore, axial coding
provided depth to the description of the identified concepts, which evolved into a deep un-
derstanding of, e.g., how practitioners experience access to information in the patient pro-
cess and how patients experience information exchange with healthcare providers. It also
gave a deeper understanding of the difficulties practitioners experience with regard to avail-
ability of information and how they want future information systems to support their work
practice and thereby improve the quality of care delivery.
Consider the following example where categories are related to each other. When analyzing
the transcribed interviews that were conducted as part of the second case study, two major
categories which are critical to knowledge management work in an organization were identi-
fied, namely, “people’s interest in knowledge searching” and “a dedicated manager”. The
comprehensive analysis of these two categories clarified the relationship, i.e., if managers
are not personally committed to learning or do not regard sharing and using best practice as
critical parts of the quality of care, the attitudes of the managers effect people’s interest in
KM activities.
Throughout the analysis, “memo-writing” was used to record the researcher’s thoughts about
the meaning of codes, as well as how and why they occurred. Memos were also used to clari-
fy the relationship between categories, and to systematically question ideas in relation to
what had been said in the interviews (Sbaraini, et al., 2011; Glaser, 1992).
As this thesis is concerned with exploring and describing the phenomena under study, the
open and axial coding of grounded theory completed the interview analysis. The conclusion
is supported by Robson (2011) who argues that open coding and axial coding complete the
analysis, if the aim of the research is not to develop a theory. Otherwise, one must proceed
with the third step of the coding, namely, selective coding.

3.6 GOOD RESEARCH PRACTICE

This work is based on empirical data collected via semi-structured interviews and observa-
tions. According to (Robson, 2001), ethical issues lurk in any research involving people.
Therefore, the researcher should consider ethical principles when planning and conducting
research. Central to ethical principles is the idea of informed consent, “the right to be in-
formed”. Within this work, all respondents were informed about the research subject, the

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nature of the research, as well as that participation is voluntary and they can withdraw at any
time. Each respondent in the two case studies confirmed his or her willingness to participate
after having been informed of all aspects of the project, e.g., the aim of the project, how data
will be processed and how confidentiality will be maintained.
The respondents were also informed that the interviews would be recorded and transcribed,
to which they were required to give their consent. In addition, the respondents were in-
formed about the approximate length of the interview, how to contact the researcher later, if
they had any questions, who would be given access to the transcribed interviews, and how
the interviews would be analyzed. In this case, the respondents were informed that only re-
searchers from the project would have access to the interview material. Moreover, they were
informed that their comments may be used as quotes, but only with their consent and with-
out the possibility of linking the comments to the respondent. Just as in the interview stud-
ies, participants in the observation studies were given information about the aim of the re-
search, how the observations are related to the interviews and exactly what the researcher
intends to observe and analyze (Vetenskapsrådet, 2011).
“Giving anonymity and confidentiality to participants when reporting on research is the
norm” (Robson, 2011, p.207). The Swedish Research Council (Vetenskapsrådet, 2011) stress-
es the importance of researchers taking measures to protect respondent’s integrity. To pro-
tect integrity and the right to their private life, the interview recordings, the transcribed in-
terviews and the notes from the observations were kept safe and only made available to
those researchers involved in the studies. Additionally, to assure the respondents’ anonymi-
ty, each interview and observation was marked according to a coding system, e.g., VN550,
whose code key was kept at a different location to the interviews, so that only the interviewer
could identify the respondents (Thomsson, 2010).

3.7 THE TRUSTWORTHINESS OF THE

RESEARCH
Qualitative researchers strive for “understanding” the knowledge that comes from personally
visiting participants in their field, and from probing to obtain meanings (Creswell, 2007).
During and after a study, qualitative researchers ask; “did we get it right?” or “did we pub-
lish an inaccurate account?” (Creswell, 2007, p. 201). To answer these questions, the trust-
worthiness of the research is discussed on the basis of the concepts: credibility, dependabil-
ity, transferability and conformability.

3.7.1 CREDIBILITY
The credibility criterion concerns whether the results are credible or believable, from the
perspective of the participant in the research. This criterion corresponds to internal validity
in quantitative research (Lincoln & Guba, 1985). To increase credibility in the FHIS project,
different techniques for data collection, such as observations, interviews and process model-
ing, were used. The use of these various techniques made it possible to capture different di-
mensions of the same phenomenon. To test our interpretation, participants provided feed-
back on the collected data. For example, the business models were continuously discussed
and corrected, after feedback from participants.
Credibility can also be discussed within the frame of the Knowledge repository project, with-
in which two studies were conducted. The first study aimed at analyzing a number of Swe-
dish IT-based knowledge repositories. For this study, telephone interviews were conducted
with managers of the repositories. To increase credibility, respondents that participated in
the telephone interviews were given the opportunity to provide written feedback on the con-
clusions drawn from the interviews. Unfortunately, only a few took the opportunity to do so.
However, before the conclusion of each interview, the interviewer orally summarized the in-
43
CH AP T ER 3 R E S E AR CH M ET HO D

terview, in order to test interpretations and conclusions. In this manner, the respondent was
given the opportunity to correct any misunderstandings. During the second study,
healthcare practitioners and managers were interviewed. Unfortunately, the data collected
from this study were not validated with the respondents, which may be a limitation. The
conclusions from the study were, however, discussed with the project participants with in-
sight into the different levels of healthcare.

3.7.2 DEPENDABILITY
Dependability is a criterion which is considered equivalent to reliability in quantitative re-
search. It is concerned with the stability of the results over time (Lincoln & Guba, 1985). De-
pendability can, according to Lincoln and Guba (1985), be enhanced by using overlapping
methods and inquiry audits. In order to guarantee dependability, interviews were recorded
and transcribed in their original language. Overlapping methods have been used in the FHIS
project, which has strengthened dependability. By submitting the results from the FHIS pro-
ject and the Knowledge repository project to peer reviewed conferences, the research process
and the research results have been verified by an outside expert "auditor".

3.7.3 TRANSFERABILITY
Transferability can be enhanced by providing a thick description of the research domain and
the research results (Brown, 2005). We have sought a detailed description of the two empiri-
cal studies, so that the readers can decide for themselves whether the results are transferable
to their own contexts. However, we argue that parts of the results from the FHIS project can
be generalized to other healthcare organizations outside Sweden. For example, the challeng-
es identified in case study one are problems faced by healthcare organizations worldwide.
Furthermore, we believe that the challenges identified in the Knowledge repository project
are not unique to the healthcare sector and can therefore be generalized to other domains.

3.7.4 CONFORMABILITY
Conformability concerns whether the interpretations are based on the collection of data.
Strategies such as recorded interviews and field notes can enhance conformability, since rec-
orded data can be reviewed and examined (William, 2006). These two strategies have been
used in this work. Through record keeping, the researcher has been able to recheck the data
throughout the study. Furthermore, the transcribed interviews with associated memos facili-
tated the review of the identified categories. By using these strategies, conformability has
been enhanced.

44
C H A P TE R 4
RESULTS
This chapter provides a brief summary of each research paper, focusing on aims and con-
clusions drawn. In total, 6 research papers serve as the foundation for this thesis. The pa-
pers relate to different research questions and they all respond to the aim of this thesis.
Figure 4.1 presents an overview of how each of the research papers contributes to the re-
search questions.

Figure 4.1: Relations between the included research papers and the research questions

45
CH AP T ER 4 R E S UL T S

4.1 PATIENTS´ EXPERIENCES OF COMMUNI-

CATING WITH HEALTHCARE - AN INFOR-
MATION EXCHANGE PERSPECTIVE
Paper 1 aims to explore how patients experience information exchange with healthcare
providers and how this relates to the six areas that constitute good quality care. This paper
is based on case study one and the main results are:
 When seeking care for medical problems patients reported experiencing gaps in
information exchange among their providers and between themselves and their
providers.
 Patients often felt that physicians did not offer information that was matched to
their needs.
 Patients often felt that physicians did not listen to their perception of their own
illness.
 Patients commonly left their appointments feeling confused, unable to recall what
had been discussed, or simply missed information about their conditions and
treatments.
 Communication difficulties and missed information left gaps in patients’
knowledge about their current health condition and prognosis.
 Gaps in information exchange forced the patient to take a great responsibility in
communicating their health information to different providers. Therefore, much
of the patient's time was spent on locating and communicating information be-
tween healthcare practitioners, despite being ill or injured.
 Patients felt that they are not given the opportunity to influence their own patient
process.
 Deficiencies in information exchange between healthcare practitioners and pa-
tients prevent the fulfillment, to the extent that is possible, of the six areas that
constitute good quality care.
The conclusions in paper 1 state that Swedish hospitals demonstrate good medical out-
comes, but that unfortunately there are still far too many patients who do not receive care
in a timely manner and who are not given the opportunity to participate and influence their
healthcare. When the exchange of information does not function properly, patients’ health
status is also affected. The efficient exchange of information between healthcare providers
and patients is therefore a key issue for creating the best conditions for good quality care
and to give patients a sense of empowerment.

4.2 CHALLENGES AND OPPORTUNITIES WITH

INFORMATION SYSTEM SUPPORT FOR
HEALTHCARE PROCESSES – A
HEALTHCARE PRACTITIONER PERSPEC-
TIVE
Paper 2 is based on case study one and aims to (1) explore how healthcare practitioners in
Sweden experience information system support in their daily work practice, and (2) pre-
sent and illustrate how key design principles of a process support prototype can support
46
 CH AP T ER 4 R E S UL T S

healthcare practitioners in performing their work activities and increase patient engage-
ment.
To understand current information system support a current state analysis was first con-
ducted, involving both healthcare practitioners and patients. Observations and interviews
with healthcare practitioners, healthcare administrators, patients and patient organiza-
tions, process modelling and workshops involving professionals from a broad range of dis-
ciplines, were the main research activities.
The study findings confirm that healthcare practitioners lack access to patient information
when preparing and conducting patient visits, as well as when making decisions about the
care of the patient. Lack of patient information resulted in inefficiency problems, unneces-
sary waiting times for patients, and inefficient workflows. For example, during the observa-
tion studies, it was apparent that before a patient encounter a physician had to access sev-
eral information systems, in order to obtain an overview of the patient's medical history.
Although a number of different systems were used, the physician could never be sure that
he/she had a clear and complete picture of the patient. In the absence of this information, a
complex set of patient flows emerged during which practitioners had to spend valuable
time on locating and collecting relevant patient information.
In accordance with current research, the study findings also confirm that unstructured in-
formation in the EHR is a challenge for healthcare practitioners. As the information in the
EHR is recorded as free text, without limitations to the format or structure, reviewing them
manually was regarded as time-consuming. The unstructured format also made it difficult
for practitioners to extract important information. Another issue relates to terminology.
One doctor may have one background and training, whereas another doctor has another
background. Hence, they document differently and use different terminologies. Conse-
quently, there is a need to “rationalize” the data – render the terminology into standard
sets of terms. Lack of coordination of patient care was also identified as a major problem
affecting the care of patients. Interoperability issues were considered to be one of the rea-
sons. Another reason was the functional organizational structure of task specialization, re-
sulting in lack of care coordination. Lack of interoperable information systems and the ab-
sence of the electronic booking of treatments and examinations complicate the situation
even more. Moreover, a recurring problem experienced by the healthcare practitioners was
related to the care request/referral process. The problems are based on the following: (1) it
is not possible for healthcare practitioners or patients to electronically fill in and send a
care request, and (2) incoming care requests from primary care usually lack important in-
formation. Referrals that did not include the required information were always sent back.
This is, according to the healthcare practitioners, one of the reasons why patients do not
receive care within a reasonable period of time.
To address the above challenges, a prototype for a process support system was developed.
The vision for the process support system is that healthcare practitioners and patients
should have access to efficient collaborative information systems that supports a process-
oriented care where the patient is a distinct and active collaborator, meaning that:
 Appropriate parts of the process support system are available to both patients and
practitioners, and take into account usability for different user groups.
 The involved roles/users interact through the process support system. The under-
lying approach is process oriented.
 Various relevant individual information systems interact with patients and practi-
tioners through the process support system.
The demonstrated process support system is not a new information system that aims to re-
place an existing one. It is a process support system that can be viewed as a layer of ab-
straction or user interface above the various individual information systems, enabling the

47
CH AP T ER 4 R E S UL T S

enactment of the process and interaction between patients and practitioners through com-
puters and mobile devices, without accessing each individual information system. The pro-
cess support system drives the process forward, ensuring that it is carried out properly and,
hence, supports users in performing work activities. The process support system provides
thus a user interface to the various systems involved in performing a task. The principles of
the process support system are described in the paper by Åhlfeldt, et al. (2013) and in fig-
ure 4.2.

Figure 4.2: The principle of the PSS (Adapted from Perjons et al., 2005)

The architecture of the process support system makes it possible, at least in theory, to re-
place individual IT systems without significant effect on the user. The process support sys-
tem connects the following aspects:
 Access to relevant patient information, both medical and administrative.
 Process control providing integrated support for the user.
 Access to relevant medical knowledge through integration of medical guidelines
and an IT-based knowledge repository.
The conclusions in paper 2 confirm that a process support solution, such as the one de-
scribed in this paper, creates new opportunities to organize and coordinate healthcare. The
process support system focuses on the patient process and the information flows within
this process. For healthcare practitioners, the process support system solution improves
the availability of patient information in a uniform and transparent way, anywhere and an-
ytime, as required by the patient process. The process support system reduces double doc-
umentation and the manual handling of information, which in turn reduces the risk of
making errors. Since healthcare practitioners no longer need to spend time on locating pa-
tient information, more time can be spent on meeting patients. However, much work re-
mains before a process support system, such as the one presented in this paper, can be fully
implemented. For example, there is a need to render the terminology into standard sets of
terms and to determine the ownership and responsibility of a process support system that
crosses organizational boundaries and supports patient-centered care. Another challenge
regards who would be responsible for the ownership and the quality of the process data.

4.3 WEB-BASED KNOWLEDGE PORTALS IN

SWEDISH HEALTHCARE – OVERVIEW AND
CHALLENGES
Paper 3 is based on case study two that aimed to explore the possibility of creating a struc-
tured, resource-efficient and sustainable model for developing and managing a coherent

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 CH AP T ER 4 R E S UL T S

IT-based knowledge repository for different areas of knowledge bases in healthcare. The
goal of this paper was to report on an analysis of a representative number of Swedish IT-
based knowledge repositories. The analysis resulted in the identification of several chal-
lenges:
 IT-based knowledge repositories are usually designed to support specific func-
tions and particular target groups with particular needs of medical knowledge.
 Knowledge from IT-based knowledge repositories is usually infrequently available
in a form that can be acted upon at the time decisions must be made. The
knowledge is often structured in a hierarchical and linear manner comparable to
that of a book or report. When a large amount of information is presented to the
user at once, it can lead to confusion and complicate the filtering of unnecessary
information. In turn, it can lead to difficulties in managing situations that require
choices to be made. Also, this type of structure focuses on gathering information
rather than on learning. This problem emphasizes that future IT-based knowledge
repositories need to be developed using a governing method that structures
knowledge in a suitable way.
 Current IT-based knowledge repositories do not support the exchange of clinical
expertise.
 There is a lack of processes and resources in place for maintaining IT-based
knowledge repositories.

The conclusions in paper 3 confirm that IT-based knowledge repositories are becoming
more and more common in modern healthcare, not only in Sweden but throughout the
world. They have the potential to contribute to both prevention and treatment of health
problems, by supporting both healthcare practitioners and citizens with medical knowledge
when and where they need it. However, in order for IT-based knowledge repositories to live
up to expectations, a number of challenges need to be addressed, of which some have been
discussed in this paper. The issues addressed in this paper have an impact on the develop-
ment and the survival of IT-based knowledge repositories over time.

4.5 WORLDS APART – IT STRATEGIES FOR EV-

IDENCE BASED MEDICINE MEETS REALITY
Paper number 4 is also part of case study two and aims to (1) explore how primary, second-
ary, and municipality care in Sweden work with the process of managing knowledge, (2)
explore how healthcare practitioners experience the availability of medical knowledge
when and where they need it and (3) study conditions for developing a coherent IT-based
knowledge repository for different areas of knowledge bases in healthcare.
The following main issues were identified within this study:
 Healthcare practitioners lack access to evidence based medical knowledge when
preparing and conducting patient visits, as well as when making decisions about
the care of a patient. One of the main reasons is that the participating organiza-
tions have failed to embed the KM process in everyday processes. It is evident that
the processes and information flows are not understood and documented.
 The main barrier hindering the adoption of KM is related to people and organiza-
tional culture. For example, lack of effort, interest and skills needed to search for
medical knowledge among the massive volumes of research being produced was
common. The organization has also failed to establish a tacit knowledge-sharing
culture and to build a working environment that encourages the sharing of
knowledge.

49
CH AP T ER 4 R E S UL T S

 Practitioners lack access to adequate IT-support for accessing and sharing medical
knowledge.
 To simplify access and ensure the application of knowledge that guides practition-
ers in delivering good quality care, practitioners expressed an urgent need to inte-
grate medical guidelines and other relevant medical knowledge sources with
EHRs. There is also an urgent need of IT that supports the sharing of tacit
knowledge between practitioners within and outside the organization.
 As the main KM problems are related to people and organizational culture, a co-
herent IT-based knowledge repository should not be developed at this stage. In-
stead, it seems more relevant that the participating organizations focus on the sys-
tematization of their KM processes.

4.6 SUPPORTING ACTIVE PATIENT AND

HEALTHCARE COLLABORATION - A PROTO-
TYPE FOR FUTURE HEALTHCARE INFOR-
MATION SYSTEMS
The aim of paper 5 is to present and illustrate the main features of a proposed process- ori-
ented approach for patient information distribution in future healthcare information sys-
tems, by using a prototype of a process support system. The vision for the process support
system is that healthcare practitioners and patients should have access to effective collabo-
rative information systems that support process- oriented care in which the patient is a dis-
tinct and active collaborator. To achieve the vision, a healthcare process that is repeated
throughout the healthcare system and can demonstrate patient / healthcare communica-
tion, i.e., initiating, planning, carrying out and following up a patient’s visit to a healthcare
provider, was selected. This process was termed “Patient meeting”. To demonstrate how a
process-oriented information system can support an active patient and improve healthcare
collaboration, seven key design principles for the process support system were identified.
Some of the key design principles are the following:
 The patient processes is in focus: The process support system focus on the
patient process through healthcare and on the information that is needed during
this process, making sure that practitioners always have easy access to patient in-
formation; both medical information (e.g. medical records, lab-results, medical
list) and administrative information (e.g. appointments) in a timely manner. The
process support system also supports the patient's need for information and en-
gagement. For example, the patient can send in an electronic care request to pri-
mary and secondary care, and book appointments with doctors online.
 Shared goals for the patient visit: In order to ensure that healthcare practi-
tioners take into account the patient's expectations of the patient visit, the process
support system provides an opportunity for patients to state their expectations be-
forehand.
 The process support system is based on standardized information: To
improve the availability of information, it is essential that the information is
standardized and structured. To achieve this requirement in the process support
system, the information content of the national quality registers for selected diag-
noses has been used. The different types of information stored in quality registers
have been transformed into checklists for each diagnosis.
 Efficient information flows: By adopting a process-oriented approach the in-
formation flows can be more efficient. The process support system can ensure that
patients and practitioners always perform the correct activities during the differ-
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 CH AP T ER 4 R E S UL T S

ent parts of the patient process. A major advantage of a process-oriented approach

and tools to support the process is that the process support system drives the pro-
cess forward. When a task is completed, it will initiate and show nearby activities.
For example, when a healthcare practitioner in specialist care have written and
signed the final documentation for the patient record, the process support system
automatically picks up the form “response to care request” that will be sent back
to the physician in primary care.
 Digital booking and coordination of patient treatments and examina-
tions: The process support system enables electronic booking and coordination of
treatments and examinations. It is also possible to follow the status of these activi-
ties. If some activities, such as, e.g., laboratory tests, are not completed before the
scheduled patient visit, then this visit can be cancelled in advance. In this way one
prevents the patient to come to unnecessary meetings.
The main conclusions of paper 5 are the following;
 A visualized prototype is a suitable tool for illustrating both the opportunities and
constraints of future ideas and solutions in eHealth.
 A process support system, such as the one described in this paper, can provide
many advantages for healthcare practitioners and patients. However, technical
and organizational/management challenges need to be managed before a fully
functional process support system can be developed and implemented.
Examples of challenges that have been identified are:
 The interfaces between the process support system and the underlying IT-systems
need to be developed. This is especially important, as concepts are frequently de-
fined and written in different formats. However, it is not just a question of making
this technically possible; it is also a question of information quality.
 One of the main challenges relates to the ownership and management of the pro-
cess support system that crosses organizational boundaries and supports patient-
centered care, such as solving who owns all process data generated in the process
support system, who takes responsibility for the quality of the process data, who
will be the process owner of the entire patient process? If the technical challenges
can be solved, then this will be the biggest challenge for implementing the process
support system.

4.7 SUPPORTING EVIDENCE BASED MEDICINE

– A PROTOTYPE FOR FUTURE HEALTHCARE
INFORMATION SYSTEMS
The aim of this paper is to present and illustrate how a prototype visualization of a process
support system that was developed within case study one can support the availability of
relevant medical knowledge in a way which is seamlessly integrated with healthcare practi-
tioners’ work practice, and thereby enables healthcare practitioners to work in accordance
with EBM.
The study results confirm that a process support system can reshape the practice of EBM,
by making relevant medical knowledge available to those who need it and where they need
it. An important key solution to the problems identified in papers 2, 3 and 4 is to view pa-
tient information and medical knowledge as interconnected, such that they continually im-
pact on each other. This solution is based on the assumption that relevant medical
knowledge, such as medical guidelines, can be derived from previously entered patient da-
ta. In this manner, we can ensure that healthcare practitioners always have access to rele-
vant and the best explicit scientific medical knowledge, when and where they need it. Sub-
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CH AP T ER 4 R E S UL T S

sequently, since EBM also includes clinical expertise, an IT-based knowledge repository is
integrated into the process support system. An IT-based knowledge repository can thus fa-
cilitate the sharing, creation and capture of new knowledge.
Before we try to support EBM by means of a process-oriented information system, we must
be aware of the challenge related to organization specific consensus. Since the guidelines
for good medical practice exist at national, regional, and local levels, contradictions be-
tween the guidelines exist. Hence, a crucial challenge will be to agree on which medical
guidelines should be implemented within the process support system. Another challenge
relates to the responsibility for the ownership and the quality of the medical knowledge
within the process support system and within the IT-based knowledge repository.

52
C H A P TE R 5
SYNTHESIZED RESULTS
This chapter aims to present recommendations for the development of future healthcare
information systems, which are derived from the included research papers. Hence, these
recommendations constitute the final step towards answering research question 5. These
recommendations aim to support healthcare managers, IT–managers and system develop-
ers in the development of future healthcare information systems, from a process-oriented
and knowledge management perspective. By following these recommendations, it is possi-
ble to develop information systems that facilitate the practice of evidence based medicine,
and improve patient engagement.

5.1 FUTURE IS SHOULD SUPPORT THE PRINCI-

PLES OF EVIDENCE BASED MEDICINE
Future healthcare information systems must support the three elements of EBM in an inte-
grated manner and neither one alone is enough. This means that healthcare information
systems must contribute to improving healthcare quality and safety, by giving healthcare
practitioners access to both up-to-date patient information and relevant medical
knowledge in an integrated manner and at the point of care. Following the principles of
EBM, healthcare information systems must also enable patients to access, utilize, and share
their health information electronically. The following sections describe the conditions that
an information system requires in order to support the principles of EBM.

5.1.1 A PROCESS-ORIENTED APPROACH, WITH SUPPORT-

ING INFORMATION SYSTEMS
An evidence based practice requires the exchange of patient information between
healthcare practitioners from different disciplines and units. To support a cooperative work
process among healthcare practitioners and units, patient information must be accessed by
practitioners in a standardized and transparent way, anywhere and anytime. However, one
of the greatest challenges currently facing healthcare organizations is interoperability is-
sues. To achieve a seamless and secure transfer of information between practitioners, a
more process-oriented approach, with supporting information systems, must be consid-
ered. A process support system, as the one presented in paper 5, focusing on the patient
process, is one step towards that direction (Åhlfeldt, et al., 2013). A process-oriented ap-
proach is thus an important foundation for achieving a system design that focuses on the
care process from the patient's perspective and thereby sets the core process, i.e., the pa-

53
CH AP T ER 5 SY NT H E SI Z ED R E SU LT S

tient process, into focus (Åhlfeldt et al., 2013). This approach is also important as it focuses
on the results of the process, e.g., to provide good quality care (Rentzhog, 1998). The pro-
cess-oriented approach can streamline the flow of information and, with support from a
process support system, we can ensure that healthcare practitioners always have access to
the right patient information, when and where they need it. However, for information to be
a usable resource in the long term, it must have a standardized, nationally established
structure. Information must therefore be placed under a common regulatory framework
and form part of a uniform information structure (Ministry of health and social affairs,
2006). This will allow different information systems to manage and exchange information
more efficiently and securely.

5.1.2 IMPROVE PATIENT ENGAGEMENT THROUGH PRO-

CESS-ORIENTED INFORMATION SYSTEMS
Patient engagement is, according to Carman et al., (2013, p. 224), characterized by the
amount of information shared between patient and provider and how active a role the pa-
tient has in health decisions. Patient engagement is also recognized as a key component in
improving patient safety (Longtin et al., 2010). Without the efficient exchange of infor-
mation between healthcare providers and patients, patients are not able to participate and
be engaged in their own healthcare. However, patient engagement not only concerns giving
patients access to health information, it is also about engaging the patient in decision-
making, enabling the patient to contribute with health information (e.g., electronically fill
in a health declaration) and increasing their possibilities to communicate their expecta-
tions, values and preferences.
Since there is a growing body of evidence showing that patient engagement offers a promis-
ing pathway toward better quality healthcare, more efficient care, and improved population
health (see, e.g., Carman et al., 2013; Hibbard & Greene, 2013), future healthcare infor-
mation systems must also be developed from a patient perspective. Patient engagement can
be improved if a process-oriented approach with supporting IT-systems is adopted. As this
approach has a customer perspective, future healthcare information systems must be more
process oriented, from the perspective of the patient process, and more patient centered.
An example of how patient engagement can be improved is presented in paper 5. This ex-
ample is based on the idea that a process support system can change the traditional pa-
tient-model in which practitioners determine when, where and what type of care to offer
the patient, by allowing the patient to become a distinct and active collaborator. A patient
can become a distinct and active collaborator only when he / she is given easy access to in-
formation about their own care. As patient engagement is also about enabling patients to
take responsibility for their healthcare, they should be able to electronically submit health
information by, e.g., filling in a health declaration and by making their own appointments.
To help patients gain control over their care process, future information systems must also
be able to display what the next step in the process is supposed to be. Furthermore, in or-
der to ensure that patients’ expectations, values and preferences are captured before a doc-
tor visit, the patient should be able to submit this information electronically.
However, it must be stressed that an information system can only facilitate patient en-
gagement. It is healthcare practitioners’ beliefs, attitudes and behavior that have a major
effect on patient engagement (Longtin, et al., 2010). Therefore, it is essential for organiza-
tions to discuss issues, such as “how they perceive patient engagement, as well as ad-
vantages, obstacles, barriers to patient engagement, and how to encourage patients to par-
ticipate”. Only then can process-oriented information systems be used to their full poten-
tial.

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 CH AP T ER 5 SY NT H E SI Z ED R E SU LT S

5.1.3 OFFER NOT ONLY CURRENT INFORMATION, BUT ALSO

RELEVANT INFORMATION ACCORDING TO THE
PATIENT PROCESS
Having access to information about the patient at the right time is an important element of
EBM. To ensure an evidence based practice, clinical questions must be addressed at the
moment they arise. Therefore, future healthcare information systems should not only pre-
sent up-to-date patient information to healthcare practitioners, but also offer relevant in-
formation, according to the current context. Consequently, an important question to be
answered is how to determine what relevant information is. The question can be answered
by focusing on the type of information required within an episode of care and for a specific
illness or diagnosis.
In addition, the practice of EBM can be supported by bringing medical knowledge to the
point of care. Having access to relevant medical knowledge at the right time can mean the
difference between an accurate or erroneous diagnosis and treatment. Although medical
knowledge guides decisions about the care of an individual patient, this information is to-
day separated from patient information. This implies that the standard KM approach for
knowledge dissemination in healthcare organizations are the access approaches to stored
information, e.g., access to information that is stored on the intranet and/ or in IT-based
knowledge repositories, etc. Although such approaches are necessary, they are not always
sufficient. For example, if a physician is documenting in an EHR and has questions regard-
ing a specific diagnosis, the physician must use a different information system to find the
relevant medical knowledge. Therefore, a potential solution to this problem is to extend the
KM approach in healthcare so it goes beyond the traditional form of disseminating
knowledge through documents and unstructured information stored in distinct systems.
Ideally, medical knowledge, such as medical guidelines, should be embedded within a pro-
cess support system. In addition, recommendations derived from medical guidelines
should also be reflected in reminders. Consequently, practitioners would not have to explic-
itly look for guidelines, and therefore possibly avoiding the risk of missing important medi-
cal knowledge (Lenz & Reichert, 2007).
To ensure that only relevant knowledge is made available, the knowledge-sharing solution
should be carried out in two stages. In stage 1, medical knowledge, such as medical guide-
lines, should be matched with unique patient information within a process support system.
Medical guidelines can thus be derived from previously entered patient data. In this case,
the medical knowledge is more focused, thus case-specific and structured. Stage 2 should
provide a more holistic knowledge view that is related to the documented patient infor-
mation. This can be achieved by integrating an IT-based knowledge repository into a pro-
cess support system. This knowledge-sharing solution suggests that patient information
and medical knowledge should not be regarded as two separate aspects. Instead, they must
be viewed as interconnected, such that they continually impact on each other. This solution
is presented in detail in paper 6.

5.1.4 FUTURE INFORMATION SYSTEM SHOULD ENABLE A

COMBINATION OF ACCESS, COMMUNICATION, CREA-
TION AND CAPTURE OF MEDICAL KNOWLEDGE
The traditional view of KM in healthcare, regarding the dissemination of knowledge, is thus
the access approach. This view emphasizes knowledge access, but not the exchange of expe-
riences and the creation of new knowledge, which are important parts of EBM. Therefore,
to support healthcare practitioners in their practice of EBM, IT-based knowledge reposito-
ries should not only (1) be integrated within the process support system, in order to provide
a single integrated point of access, (2) provide access to more structured explicit medical
55
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knowledge, but also (3) include the communication perspective. This has been found to be
important, since explicit medical knowledge on its own is not sufficient for making deci-
sions. Even tacit knowledge is considered to have a strong influence on medical decision-
making. Therefore, the current traditional view of IT-based knowledge repositories must
evolve from simply being the one-way retrieval of information to becoming a two-way sys-
tem that provides collaborative and exchange features. Informal online discussion forums,
knowledge cafés, and communities of practice (CoPs) are examples of collaborative and ex-
change features. These features can be made available via an IT-based knowledge reposito-
ry that is integrated into a process support system. By including collaborative features,
healthcare practitioners can share their clinical expertise (this solution is presented in de-
tail in paper 6). For example, during a patient encounter, the patient informs the physician
about particular side effects of the drug Venlafaxin 20 mg that he/she has experienced. The
doctor prescribed the drug to the patient 8 months previously, after consulting the medical
guidelines. The physician, who has prescribed the same drug to patients for more than 20
years, has never heard of these particular side effects. Therefore, the doctor turns to the
discussion forum in the IT-based knowledge repository that is integrated into the process
support system. In the discussion forum, the physician seeks advice from colleagues about
the problem, by presenting a question. Practitioners from local, regional and national levels
with experiences of the topic respond by offering their knowledge of the problem. A debate
ensues between practitioners who share and discuss their clinical experiences, scientific
papers and theories (Abidi, 2007). Based on the discussion, important conclusions are
drawn that help the physician in the decision-making. Although the knowledge that is
shared in the discussion forum is not evidence based, it can, according to Abidi (2007), still
have a high trust value, as it originates from colleagues. The knowledge that is created in
the online discussion forum can be captured (if relevant) to explicit knowledge, which can
then be packaged, stored and shared through the knowledge repository, or be integrated as
a guideline in the process support system. However, to ensure the creation, identification
and use of new knowledge, the KM process must be integrated into organizational process-
es (see section 2.7). There must also be well-defined rules governing what knowledge
should be captured and stored, who should be responsible for capturing new knowledge,
who should be responsible for reviewing the quality of the captured knowledge, as well as
how it should be packed and stored (Persson, Stirna & Aggestam, 2008). Furthermore, the
enablers of the KM process must also be considered (see section 2.7).
Additionally, if an IT-based knowledge repository is to be integrated into an information
system, whether it is a process support system as the one described in this thesis or an
EHR, deciding which level (local, regional or national) the repository should be at and who
should be responsible for keeping it up to date is essential.

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C H A P TE R 6
CONCLUDING REMARKS AND FUTURE
WORK
This chapter summarizes the main findings of this work and its contributions. It also pre-
sents future work.

6.1 REVISITING THE RESEARCH QUESTIONS

To achieve the aim of this thesis, five research questions have been formulated.
The first research question is: What are the problems with the availability of up-to-date
patient information, from the perspective of patients? As shown in paper 1, the answer to
this research question is that patients experience gaps in information sharing among their
providers and between themselves and their providers. Gaps in the exchange of infor-
mation force patients to take a greater responsibility in communicating their health infor-
mation between different providers. Therefore, much of a patient's time is spent on locat-
ing and communicating information between healthcare practitioners, despite being ill or
injured. The study results also confirm that patients commonly left their appointments
feeling confused, unable to recall what had been discussed, or simply missed information
about their conditions and treatments. Many patients also feel that physicians usually do
not offer information that is matched to their needs, or suited to their individual ability to
absorb information. Communication difficulties and the lack of information leave gaps in
patients’ knowledge about their health status and about their future. Without adequate in-
formation, patients also feel that they are not able to successfully engage in their own care.
Inadequate information also results in feelings of uncertainty and insecurity. The results
also confirm that patients often feel that physicians do not listen to their perception of their
own illness. In addition, they feel that they cannot participate and influence matters affect-
ing their health, for example, they cannot influence appointments for doctor visits.
The second research question to address is: What are the problems with the availability of
up-to-date patient information and relevant medical knowledge when and where it is
needed, from the perspective of healthcare practitioners? This research question is based
on empirical data collected from two case studies. As shown in paper 2, information sys-
tems that support a seamless flow of information along the patient processes are not broad-
ly used in healthcare environments. Usually, healthcare organizations have their own au-
tonomous information systems that do not support cooperation between different organi-
zational units and medical disciplines. Consequently, vital information (both medical in-
formation about the patient and administrative information) stored in these systems can-
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CH AP T ER 6 CO NC LU DI NG R EM AR K S A ND F UT UR E W O RK

not be easily accessed, in order to present a clear and complete picture of the patient at the
point of care. Healthcare practitioners perceive the situation as worrying, as seamless and
shared care requires a high level of interoperability and information sharing among practi-
tioners involved in the care of a patient. Interoperability issues not only hamper access to
patients’ information, they also result in inefficiency problems, unnecessary delays for pa-
tients, and inefficient workflows. In addition to the issues with current information sys-
tems, it has also been found that the functional organizational structure complicates the
coordination of care. For example, when each practitioner only focuses on their own func-
tions, they usually fail to communicate critical elements of care to the receiving unit.
When analyzing the empirical data from case study 2, it was found that healthcare practi-
tioners had major difficulties in practicing EBM, as they lacked access to relevant explicit
medical knowledge when making decisions about the care of a patient. Insufficient time for
searching and capturing knowledge is one of the difficulties. This is due to the fact that
medical knowledge is not integrated with clinical workflow. Other difficulties include not
knowing where to search for relevant knowledge. This problem stems from the principal
shortcomings of EHRs and IT-based knowledge repositories. First, IT-based knowledge
repositories are located at different levels of the healthcare organization, they contain dif-
ferent types of medical knowledge and are often standalone applications poorly integrated
into the clinician’s workflow. Second, clinical decision support systems are not integrated
into EHRs. Lack of effort, interest and skills needed to search for knowledge among the
massive volumes of research being produced are other reasons. The research results also
confirm that medical knowledge which has been captured and shared has not always been
used, as it has suffered from shortcomings in its form. For example, the knowledge is usu-
ally presented in long documents, which makes it difficult for practitioners to absorb the
information. To simplify access and ensure the application of knowledge that guides prac-
titioners in practicing EBM, practitioners express an urgent need to integrate medical
guidelines and relevant knowledge sources with EHRs.
Tacit knowledge sharing amongst healthcare practitioners, such as the sharing of clinical
experiences, skills, or know-how, is known to have a significant impact on the quality of
decisions (Panahi, Watson & Partridge, 2012). The importance of tacit knowledge in
healthcare is well recognized and documented, yet the research results confirm that tacit
knowledge sharing is difficult to achieve. The organization has failed to establish a tacit
knowledge-sharing culture and to build a working environment that encourages the shar-
ing of knowledge. In addition, practitioners lacked access to adequate IT-support for shar-
ing their expertise and personal experiences. The healthcare practitioners emphasized the
need for IT that supports the sharing of tacit knowledge between practitioners within and
outside the organization.
The third research question to address is: How can future healthcare information systems
support the availability of up-to-date patient information and relevant medical
knowledge in a way which is seamlessly integrated with healthcare practitioners’ work
practice? To support the availability of up-to-date patient information and relevant medi-
cal knowledge future healthcare information systems must adopt a process-oriented ap-
proach, from the perspective of the patient process. They must also be more structured and
standardized. Moreover, to improve healthcare quality and safety, future healthcare infor-
mation systems should not only present current patient information, but also offer relevant
information according to the current context. For example, a physician at an orthopedic
unit should be given access to patient information that is relevant to that specific care epi-
sode.
Subsequently, since EBM heavily depends on both patient information and medical
knowledge, future information systems must view patient information and medical
knowledge as interconnected, such that they continually impact on each other. The inter-
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connection is crucial, as the availability of patient information is a precondition for medical

decisions and medical knowledge guides these decisions. Therefore, future information sys-
tems should support this view (see paper 6).
The fourth research question to address is: How can healthcare information systems sup-
port patient engagement through improved provider-patient communication? The short
answer to this research question is that a process-oriented information system that follows
the patient process can improve patient engagement. For example, a process support sys-
tem, as the one described in paper 5, enables patients to access information about their
own healthcare, which helps patients understand their health status and how it affects
them. Patient engagement can also be improved by enabling patients to electronically fill in
information regarding their own health, such as values, preferences and expectations, be-
fore a patient/doctor visit. Identifying patients’ values and preferences is important, as
these must guide all clinical decisions. By developing information systems in a way which is
inclusive, will enable patients to take control of their healthcare and therefore also empow-
er them.
The fifth research question to address is: What recommendations can be initiated for the
development of future information systems that (1) support healthcare practitioners’ ac-
cess to up-to-date patient information and relevant medical knowledge in a way which
can be seamlessly integrated with their work practice and (2) improve patient engage-
ment? Based on the knowledge that was acquired by answering research questions 1, 2, 3
and 4, it is possible to answer the fifth research question. The primary recommendation is
that healthcare information systems must support EBM. This means that healthcare infor-
mation systems must support the availability of up-to-date and relevant patient infor-
mation and medical knowledge (both access to and sharing of explicit and tacit knowledge)
along the patient process, facilitate for patients to electronically access information regard-
ing their healthcare and enable them to share their personal expectations, values and pref-
erences. This recommendation requires that healthcare information systems are more pro-
cess oriented from the patient process perspective, as well as structured, standardized and,
above all, more patient centered. A process support system with an integrated IT-based
knowledge repository, as proposed in papers 2, 5 and 6, is one step towards that direction.

6.2 CONTRIBUTIONS
The research presented in this thesis brings together knowledge from process orientation,
knowledge management and evidence based medicine. Through the use of qualitative re-
search methods, this work broadens our understanding of how information systems can be
used to improve the quality and safety of care, by supporting the availability of patient in-
formation and medical knowledge in a way which is seamlessly integrated with healthcare
practitioners work practice, and by supporting increased patient engagement. Hence, the
main knowledge contribution of this thesis is within the field of information systems.

6.2.1 SUMMARY OF KNOWLEDGE CONTRIBUTIONS

The findings have resulted in the following contributions:

 Increased knowledge about how patients in Sweden experience the exchange of

information with healthcare practitioners and how these experiences affect the
quality of care.

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CH AP T ER 6 CO NC LU DI NG R EM AR K S A ND F UT UR E W O RK

This knowledge is a contribution to practice, as it offers new insights and new ideas on how
to develop information systems that promote patient engagement. More specifically, this
knowledge contribution is presented in paper 1 and answers research question one.

 A “state of practice description” of how healthcare practitioners perceive availa-

bility of patient information, and identification of user requirements for future
healthcare information system support.

This knowledge is an important contribution to the field of practice, as it relates to how

healthcare practitioners perceive current information system support, with regard to the
availability of patient information, and how they want future information systems to sup-
port them in their daily clinical work practice. This knowledge contribution is presented in
paper 2 and answers research question two.

 A “state of practice description” of how practitioners perceive the availability of

medical knowledge and how healthcare organizations work with the knowledge
management process.

This knowledge contributes to the field of practice, by highlighting (1) how healthcare prac-
titioners perceive the availability of medical knowledge, when preparing and conducting
patient visits, as well as when making decisions about patient care, and (2) the challenges
healthcare organizations are facing when managing their medical knowledge. Therefore,
this knowledge contribution answers research question two and is presented in paper 4.

 A visualization demonstrating how patient engagement can be improved and

how healthcare practitioners can be given access to up-to-date and relevant pa-
tient information and medical knowledge in an integrated manner and at the
point of care, through the use of process-oriented information systems.

This knowledge contributes to the field of research and to the field of practice, by showing
that a visualized prototype developed in close collaboration with end-users is a suitable tool
for illustrating both the opportunities and constraints with regard to the ideas and solu-
tions of future healthcare information systems. The development of the prototype also con-
tributes to the field of research, as it demonstrates solutions for how a process support sys-
tem can facilitate the practice of evidence based medicine and improve patient engage-
ment. This knowledge contribution supports research questions three and four and is pre-
sented in papers 5, 2 and 6.

 A model that describes the relationship between EBM, knowledge management

and process orientation.

In addition to these primary contributions, the work has resulted in a conceptual model
that describes the relationship between EBM, KM and process orientation. Up until now,
no work has, to the best of our knowledge, linked EBM and its associated elements to pro-
cess orientation and knowledge management. This model was developed on the basis of the
literature review. Therefore, we believe that this integration is a contribution to research.

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 A set of recommendations for the development of future healthcare information

systems.

In order to address research question five, this thesis has provided a set of recommenda-
tions by which healthcare information systems can be refocused to improve patient en-
gagement, as well as the timeliness of patient information and relevant medical knowledge
along the patient process. The recommendations describe ideas for solutions that must be
considered before work can begin with the development of future information systems.
These recommendations can help avoid some of the more common pitfalls previously ob-
served in healthcare information system projects. This contribution relates to research
question five.

6.3 FUTURE WORK

Before a process-oriented information system, such as the one described in this thesis, can
be implemented in practice, a number of challenges must be managed. For example, fur-
ther research is needed regarding the ownership and responsibility of a process support
system that crosses organizational boundaries and that supports patient-centered
healthcare. Research regarding how the quality of the process data generated in a process
support system can be assured and who bears the main responsibility for ownership of the
process data are questions that future research must respond to. Subsequently, if a process
support, such as the one described in this thesis, handles medical knowledge, additional
challenges will arise. A crucial challenge, among others, will be to agree on the level that
the IT-based knowledge repository integrated into the process support system should be at,
the kind of knowledge that should be available in the repository, how this knowledge
should be presented, and who will be accountable for the quality of the medical knowledge.
A suggestion for future work is therefore to elaborate on what such an IT-based knowledge
repository that is integrated into the suggested process support system could look like and
how it could function. Subsequently, this work has provided a comprehensive picture of
how a process support system can improve patient engagement. Further research is needed
regarding how future process-oriented information systems can be developed so they are
more inclusive in the way they enable patients to take control of their healthcare and there-
by also empower them. Therefore, the next step is to examine other ways, than those
demonstrated in this thesis, to engage patients in their own healthcare. For example, future
research should examine what type of information patients want to access and why, as well
as how this information can be made available through a process support system. Further
research is also needed regarding how patients’ medical records can be made available
through a process support system and how patients can enter information into their medi-
cal records.

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APPENDIX
7.1 APPENDIX 1: INTERVIEW GUIDE – CASE
STUDY ONE

Frågor till vårdpersonalen Questions for healthcare practi-

tioners

Frågor relaterade till ”handläggning Questions regarding the “processing

av vårdbegäran” of the referral”

1. Vilka ingångar är möjliga för en 1. In what ways can a referral be re-

vårdbegäran? quested?
1. Hur går du tillväga när du regi- 2. How do you register the referral?
strerar vårdbegäran?
3. Vilka kriterier existerar vid priori- 3. What criteria exist for prioritizing
tering av vårdbegäran? Var kom- the referral? Where do these crite-
mer dessa kriterier ifrån? ria come from?
4. Vad innebär kompletterande re- 4. What does supplemental referral
miss? Vilken typ av komplette- mean? What types of supplements
ringar är det som behövs? are needed?
5. Hur prioriteras vårdbegäran? 5. How is the referral prioritized?
Frågor relaterade till ”planering av Questions regarding the “planning of
besök” patient visits”

1. Vad betyder ”gå igenom patientin- 1. What does it mean to go through

formation”? Vad är syftet? Vilka “patient information"? What is the
system används? Vem gör det? purpose? What systems are used?
Who does that?
2. Vad gör du när du planerar ett 2. What do you do when you plan a
mottagningsbesök? patient visit?

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CH AP T ER 7 AP P E N D I X

3. Hur vet du vilka prover som behö- 3. How do you know which samples
ver tas till mottagningsbesöket? that must be taken for the patient
Vilka svar krävs innan besöket bo- visit? What responses are required
kas och planeras? before the visit is booked and
planned?
4. Vad är “ELVIS” för typ av inform- 5. What type of information system
ationssystem? Är systemet inte- is “ELVIS”? Is the system inte-
grerat med andra informationssy- grated with other information sys-
stem som till exempel ”Melior” tems such as “Melior”?
5. Vilken typ av information innehål- 6. What type of information is in-
ler kallelsen som sänds till patien- cluded in the notification that is
ten inför ett besök? sent to the patient prior to a visit?
6. Hur går ombokningsprocessen 7. How does the cancellation process
till? work?
Frågor relaterade till ”genomförande Questions regarding “carrying out
av besök” the patient visit”

1. Vem ansvarar för ankomstförfa- 1. Who is responsible for the arrival

randet? Hur går man tillväga? process? How is this process car-
ried out?
2. Hur sker provtagningen vid an- 2. How is the sampling at the arrival
komstförfarandet? carried out?
3. Vad händer när vårdteamet möter 3. What happens when the care team
patienten? meets the patient?
4. Hur går patientmötet till? Vilken 4. How is the patient meeting carried
information behövs? Vilken till- out? What information is needed?
gång på information har du vid What kind of information do you
detta tillfälle? have access to during the patient
meeting?
5. Hur dokumenterar du patientbe- 5. How do you document the patient
söket? Hur skulle du vilja doku- meeting? How would you like to
mentera i framtiden? document the patient meeting in
the future?
6. Vilken information behöver du för 6. What information do you need in
att göra din bedömning? Har du order to make your decision? Do
tillgång till något beslutsstödssy- you have access to any decision
stem? Finns det behov för beslut- support system? Is there a need
stödssystem? Vilka är dessa be- for decision support systems?
hov? What are these needs?
7. Hur sker dialogen med patienten 7. How is the dialogue with the pa-
idag? tient carried out today?
8. Hur sker den fortsatta planering- 8. How is continuing care plan car-
en? Hur skulle du önska att plane- ried out? How would you wish to
ringen sker i framtiden? conduct the planning in the fu-
ture?
9. Hur används standardvårdplaner i 9. How are standard care plans used
det fortsatta planeringsarbetet? in the continued planning?

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 CH AP T ER 7 AP P E N D I X

10. Hur sker receptskrivningen? Vad 10. How is the prescribing of medica-
finns det för fördelar respektive tion carried out? What are the ad-
nackdelar med receptförskriv- vantages and disadvantages?
ning?
Frågor relaterade till ”planera fort- Questions regarding the “continued
sättning” planning”

1. Hur planerar du för fortsatt be- 1. How do you plan for the continued
handling/fortsatt utredning? Hur treatment / continued investiga-
skulle du vilja att det fungerade i tion and how would you prefer it
framtiden? to work in the future?
2. Vad innebär standardvårdplan? 2. What is a standard care plan?
Vad innefattar en standardvård- What type of information does a
plan? standard care plan include?
3. Hur sker uppföljning/återbesök? 3. How is the following up of a pa-
tient’s visit carried out?
4. Hur skrivs den slutliga doku- 4. How is the final documentation
mentationen? Vilken information written? What type of information
anges i dokumentationen? is included in the documentation?
5. Hur hanteras svar till inremitte- 5. How are the answers from the re-
rande instans? Finns det några in- ferring unit handled? Are there
tegrationsproblem? any integration problems?
6. Vilka kontaktytor finns med andra 6. What kind of collaborations do
vårdgivare? you have with other healthcare
providers? Which communication
channels do you use?
7. Hur involveras patienten i plane- 7. How is the patient involved in the
ringen av den fortsatta vården? planning of the continued care?
8. Hur skulle du vilja att patienten 8. How would you like to involve the
involveras i den fortsatta plane- patient in the continued planning
ringen av vården i framtiden? of care in the future?

7.2 APPENDIX 2: INTERVIEW GUIDE – CASE

STUDY TWO (STUDY ONE)

Frågor till ansvariga för kun- Questions for managers respon-

skapsportalen sible for the IT-based knowledge
repository

1. Vilka är kunskapsportalens mål- 1. Which are the user groups of the

grupper? Varför har denna mål- IT-based knowledge repository?
grupp prioriterats? Why has these user groups been
prioritized?

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CH AP T ER 7 AP P E N D I X

2. Vilken struktur och teknisk lös- 2. What type of structure and tech-
ning har valts för kunskapsporta- nical solution has been selected
len. Varför har dessa val genom- for the IT-based knowledge repos-
förts? itory? Why have these choices
been selected?
3. Vad har du för organisatorisk mo- 3. What type of organizational model
dell för kontinuerlig förvaltning, do you use for continuous man-
inkl. ansvarsförhållanden för kun- agement of the IT-based
skapsportalen? knowledge repository?
4. Hur utvärderas kunskapsporta- 4. How is the IT-based knowledge
len? Har kunskapsportalen fått repository evaluated? Has the IT-
genomslag i den aktuella mål- based knowledge repository had
gruppen/erna? an impact on the target group / s?
5. Vilka möjligheter och utmaningar 5. What opportunities and challeng-
ser du med kunskapsportalen? es do you see with the IT-based
knowledge repository?

7.3 APPENDIX 3: INTERVIEW GUIDE – CASE

STUDY TWO (STUDY TWO)

Frågor till chefer med ansvar för Questions for managers responsi-
kompetensförsörjning och kom- ble for competence maintenance
petensutveckling and skills development

Inledande frågor Opening questions

1. Vad ser du för utmaningar i att 1. What challenges do you see in keep-
hålla verksamheten “högkompe- ing the organization "highly
tent”? skilled"?
2. När anser du att verksamheten är 2. When do you think the organization
högkompetent? Vilka kriterier ar- is highly competent? What criteria
betar du mot? are you working towards?

Frågor relaterade till identifiering av Questions related to the identification

kunskapsbehov of knowledge needs

3. Hur tar du reda på om verksam- 3. How do you work with finding out
heten har den kunskap som be- whether the organization has the
hövs? necessary knowledge that is need-
ed?

Frågor relaterade till identifiering av Questions related to the identification

kunskapskällor of knowledge sources

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 CH AP T ER 7 AP P E N D I X

4. Hur arbetar du med att fånga in 4. How do you work with the capture
ny kunskap som behövs i verk- of new knowledge that may be
samheten. Varifrån hämtar du ny needed in the organization? Where
kunskap? do you capture new knowledge?
Frågor relaterad till processer för att Questions related to the processes for
sprida och implementer ny kunskap dissemination and implementation of
knowledge

5. Hur arbetar du med att sprida 5. How do you work with the dissemi-
och implementera ny kunskap i nation and implementation of new
verksamheten? knowledge in the organization?
6. Hur ser du på ett scenario där en 6. How do you view a scenario where
datorbaserade hjälpmedlen spelar computer-based aids play a role in
en roll för att sprida samt in- acquiring and disseminating
hämta kunskap. Vilka är möjlig- knowledge? What are the opportu-
heterna och utmaningar med ett nities and challenges with a com-
datorbaserat hjälpmedel? puter-based aid?

7. Om verksamheten erfar ”best 7. If new “best practice “occurs in your

practice” vilket ansvar tar du för organization, what responsibility do
att sprida denna kunskap till öv- you take in disseminating that
riga i verksamheten (både inom knowledge to other people (both
och utanför den egna verksam- within and outside the organiza-
heten)? tion)?
Typ av kunskap – Behov Type of knowledge – Needs

8. Vilken typ av kunskap behöver 8. What knowledge in the organization

oftast ”uppdateras” i verksamhet- does usually need "updating"?
en?

9. Vilken typ av kunskap är svårast 9. What kind of knowledge is most dif-

att fånga och implementera? ficult to capture and implement?

10. Vilka områden anser du att per- 10. What areas of knowledge do you
sonalen behöver mer kunskap feel that the employees need to
om? Varför är den kunskapen vik- know more about? Why is this
tig? knowledge important?

11. Hur skulle du vilja att den kun- 11. How would you like that knowledge
skapen görs tillgänglig och pre- to be made available and presented?
senteras? Varför just på ett sådant Why in such a way?
vis?

12. Vilken kunskap är viktigast att 12. What knowledge is most important
prioritera utifrån din arbetsroll to prioritize based on your profes-
och varför? sional role and why?

Frågor till vårdpersona- Questions for the

len healthcare practitioners

67
CH AP T ER 7 AP P E N D I X

Frågor relaterade till identifie- Questions related to the

ring av kunskap identification of knowledge
1. Vad gör du om ett behov av att 1. What do you do when you feel the
inhämta ny kunskap uppstår? need to acquire new knowledge?
2. Hur brukar du ta del av kunskap- 2. How do you take advantage of the
er och erfarenheert som redan knowledge and experiences that al-
finns inom organisationen? ready exists within the organiza-
tion?
3. Hur brukar du ta del av den sen- 3. How do you take advantage of the
aste forskningen och de senaste latest research and the latest find-
rönen inom ditt arbete? ings within your field?
Frågor relaterad till processer Questions related to the processes
för att sprida och implementer for dissemination and implemen-
av ny kunskap tation of knowledge
4. Hur arbetar man i verksamheten 4. How is new knowledge implement-
med att implementera ny kun- ed in the organization?
skap?
5. Hur ser du på ett scenario där da- 5. How do you view a scenario where
torbaserade hjälpmedlen spelar computer-based aids play a major
roll för att inhämta och sprida role in acquiring and disseminating
kunskap? Vilka möjligheter och knowledge? What opportunities and
utmaningar uppfattar du? challenges do you see?
6. I den bästa av världar, hur skulle 6. How would you like to have access
du vilja få tillgång till kunskap via to knowledge through your comput-
din dator? er?

Frågor relaterade till identifie- Questions related to the identifica-

ring av kunskapsbehov tion of knowledge needs
7. Vilken typ av kunskap saknar du 7. What kind of knowledge do you
oftast? Varför är den kunskapen miss most often? Why is this
viktig anser du? knowledge important for you?
8. Hur skulle du vilja att den kun- 8. How would you like that knowledge
skapen görs tillgänglig och pre- to be made available and presented?
senteras? Varför just så? Kan det Why so? Could there be other alter-
finnas andra alternativ? natives?

68
CH AP T ER 7 AP P E N D I X

69
R EF ER EN C E S

71
72
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 PUBLICATIONS IN THE
DISSERTATION SERIES

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PUBLICATIONS IN THE
DISSERTATION SERIES
1. Berg Marklund, Björn. (2013) Games in formal educational settings: obstacles for the
development and use of learning games, Informatics. Licentiate Dissertation, ISBN 978-
91-981474-0-7
2. Aslam, Tehseen. (2013) Analysis of manufacturing supply chains using system dynamics
and multi-objective optimization, Informatics. Doctoral Dissertation, ISBN 978-
91981474-1-4
3. Laxhammar, Rikard. (2014) Conformal Anomaly Detection - Detecting Abnormal Tra-
jectories in Surveillance Applications, Informatics. Doctoral Dissertation, ISBN 978-91-
981474-2-1
4. Alklind Taylor, Anna-Sofia. (2014) Facilitation matters: a framework for instructor-led
serious gaming, Informatics. Doctoral Dissertation, ISBN 978-91-981474-4-5
5. Holgersson, Jesper. (2014) User participation in public e-service development: guide-
lines for including external users, Informatics. Doctoral Dissertation, ISBN 978-91-
981474-5-2
6. Kaidalova, Julia. (2015) Towards a Definition of the role of Enterprise Modeling in the
Context of Business and IT Alignment, Informatics. Licentiate Dissertation, ISBN 978-
91-981474-6-9
7. Rexhepi, Hanife. (2015) Improving healthcare information systems – A key to evidence
based medicine, Informatics. Licentiate Dissertation, ISBN 978-91-981474-7-6
 HANIFE REXHEPI IMPROVING HEALTHCARE INFORMATION SYSTEMS - A KEY TO EVIDENCE BASED MEDICINE
V

HANIFE REXHEPI

Hanife Rexhepi has a background in information systems.

She holds a Bachelor of science degree in information sys-
tems, a Bachelor of science degree in nursing and a Master
of science degree in information systems from the Universi-
ty of Skövde, Sweden. Her current research is within the
field of process orientation and knowledge management in
healthcare.

2015

ISBN 978-91-981474-7-6
Dissertation Series, No. 7 (2015)
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