Citation: Thede, L., (June 15, 2009) "Informatics: Electronic Records and Organizational Culture"
OJIN: The Online Journal of Issues in Nursing Vol. 14 No. 3. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Informatics/Electronic -Records-Organizational-Culture.aspx
Healthcare is changing. We hear this from many sources. One change that you have probably already seen is the use of the computer for at least some documentation of care. However, at this writing, there are very few healthcare agencies that are already paperless, which is the ultimate goal of the move to electronic records. Thus most of us are involved in situations in which we, willingly or unwillingly, are doing some documentation on the computer while still maintaining paper records, printed reports, or both. In reality, the technology to make all of our healthcare agencies paperless exists today. This prompts the question: why have we not moved more rapidly in this direction?
The usual answers relate to the lack of resources, both time and money. However, a more important reason, although also a more hidden reason, has to do with organizational culture, which is defined informally, as "the way we do things around here" (Deal & Kennedy, 1982, p. 4). Anyone who has ever tried to implement a new system has found that the most difficult part of the implementation is not software, but "peopleware," i.e., "us"! We often resist the new way of doing things, attributing this resistance to a poorly designed system or our own temperamental shortcomings. We assume that the new system is value neutral (Hodas, 1993). Although occasionally this resistance is a result of poorly designed systems, even good systems are often slow to be accepted.
Mr. Hodas, in his 1993 article, described the difficulty in getting teachers to accept a new technology, and noted that "schools (read healthcare organizations) are themselves a technology." They are a way of behaving towards a specific goal, usually a tacit one, in which we abide by certain behaviors and values without fully understanding them. These behaviors preserve authority and maintain certain practices and values while minimizing or eliminating others. In healthcare we have optimized our agencies to the mission we believe society has assigned to us.
The 1999 Institute of Medicine (IQM) report To Err is Human has brought to our attention the high incidence and unfavorable outcomes of medical errors. Greater use of informatics, which for many users means entering into and retrieving data from computers, is often promoted as one of the methods to decrease these errors. It is assumed that our organizations, desiring to provide excellent patient care, will adopt this rational, deductive approach by using electronic records to reduce the number of medical errors.
This assumption misses the point that organizations do not always behave in a rational manner. We all seek our own perpetuity, whether of the organization or our place in it. Hence, we may experience the introduction of electronic charting as not just a challenge, but rather a disruption of our work. Given that these systems will, indeed must, create changes in work flow, this is not an irrational response. As a result our behaviors are often aimed at relieving the pressure created by these changes, rather than advancing a rational approach to solve a defined problem. The change from paper to electronic documentation appears to those outside of nursing, who too often may be administrators or information technology (IT) specialists, as an improvement. For clinicians, however, the introduction of the electronic record too often means disrupting our values and habits to accommodate this new technology.
Healthcare organizations have clearly defined lines of power, authority, and flow of information. They remain hierarchical organizations in regard to this power, authority and flow of information. …