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The aim of the this study has been to closely examine how the process of joint acquisition and implementation of a new clinical information system (CIS), undertaken in fall 2001 by two leading multi-hospital university health centres located in Montreal, has proceeded with an increasing structuration of inter-organizational collaboration at the organizational field level.
To do so, from a structurationist and discursive theoretical and methodological perspective, an in-depth longitudinal qualitative case study has been conducted from October 2001 to December 2005. Methods for generating empirical material have included face-to-face, one to one semi-structured interviews with CIS managers, clinicians and informatics staff; participant and non-participant observations of a considerable number of committee meetings; and archives of diverse documents such as minutes, CIS project management plan, CIS schemes of governance structure, vendor's milestones, communication and training plans, as well as media documents and government reports. Then, textual data has been analyzed through the adoption of temporal bracketing and critical discourse analytical strategies.
The key issues raised by this investigation are the following:
· It is well established that, despite the current imperative character of information technology in health care organizations, the implementation of new technology as a CIS always constitutes a very challenging process, due to the difficulties of attaining an adequate fit between technology and particular organizational contingencies.
· Taking this into account, the Montreal CIS Project appears additionally complex due to a number of reasons such as:
§ the presence of a group of researchers and clinician-researchers, who have triggered and partially funded the project so far;
§ the involvement in the project of not one, but two very complex organizations, competitors at the academic level, which are jointly implementing the same CIS, a feature that, although with positive results to date, slows processes and makes the negotiation with the vendor more burdensome;
§ the fact that these two organizations operate in a publicly-funded healthcare context, within which policy-decision makers play a determinant role;
§ the association of the project with the highly politicized and unresolved portfolio of new `mega-hospitals', a feature that, while justifiable for budgetary reasons, has largely increased the political complexity of the project.
· Indeed, and related to the aforementioned, the Montreal CIS Project has not yet achieved the two elements that, according to the literature, appear necessary in any technology implementation process of this nature, namely an adequate level of financial resources and a deep involvement of end-users (i.e. clinicians) from the very beginning of the project.
· Despite all these extremely difficult and intertwined contingencies, CIS stakeholders from these two hospitals have increasingly worked together at managerial, as well as clinical and technological levels around the CIS. From a structurationist perspective, it appears that the joint processes of CIS selection and initial CIS implementation, undertaken more than four years ago by both organizations, are compelling them to discuss, work through and rethink their respective organizational sets of rules and resources when looking for a shared technological solution meaningful to both. An overlapping of inter-organizational and organizational levels of conduct for CIS configuration is therefore triggering the restructuring of institutional principles of organizational autonomy, towards those suited to collaborative inter-organizational processes.
· What is more, such collaborative processes may have institutional implications beyond the space of collaboration that the two concurrent partners are creating around this (socio-) technological project.
· Nevertheless, as collaboration between both hospitals has never previously been undertaken, it may be stopped at any time. Difficulties in accessing financial resources required for CIS implementation will prevent the incorporation of clinicians from both hospitals into the project. This could adversely impact not only CIS implementation but also interactions between both hospitals, which may be undermined and brought to a halt, seriously threatening the possibility of institutionalization of the collaborative rules and resources.
In conclusion, the interest for a new CIS by a restricted and very committed number of individual actors from both hospitals has constituted the technological headlong that has precipitated a process of institutional change on the way to collaboration. After four years, this process is in a phase of pre-institutionalization. To be able to move from pre-institutionalization towards full institutionalization, these actors need to act as institutional entrepreneurs; that is they have to be able to leverage the sufficient resources that allow them to effectively realize their highly-valued ambition of jointly implementing their new CIS. The identification of a CIS Project Holder by hospital (i.e. a person with great reputation and well-known in the organization available to work full-time for the project), a formal commitment from hospitals top managers to financially support the project, or a better positioning of the project vis-à-vis policy decision-makers may constitute steps forward in this direction.