Advancing the integration of hospital IT. Pitfalls and perspectives when replacing specialized software for high-risk environments with enterprise system extensions.

BACKGROUND: Planning and controlling surgical operations hugely impacts upon productivity, patient safety, and surgeons' careers. Established, specialized software for this task is being increasingly replaced by "Operating Room (OR)-modules" appended to enterprise-wide resource planning (ERP) systems. As a result, usability problems are re-emerging and require developers' attention. OBJECTIVE: Systematic evaluation of the functionality and social repercussions of a global, market-leading IT business control system (SAP R3, Germany), adapted for real-time OR process steering. METHODS: Field study involving document analyses, interviews, and a 73-item survey addressed to 77 qualified (> 1-year system experience) senior planning executives (end users; "planners") working in surgical departments of university hospitals. RESULTS: Planners reported that 57% of electronic operation requests contained contradictory information. Key screens contained clinically irrelevant areas (36 +/- 29%). Compared to the legacy system, users reported either no improvements or worse performance, in regard to co-ordination of OR stakeholders, intra-day program changes, and safety. Planners concluded that the ERP-planning module was "non-intuitive" (66%), increased planning work (56%, p=0.002), and did not impact upon either organizational mishap spectrum or frequency. Interviews evidenced intra-institutional power shifts due to increased system complexity. Planners resented e.g. a trend towards increased personal culpability for mishap. CONCLUSIONS: Highly complex enterprise system extensions may not be directly suited to specific process steering tasks in a high risk/low error-environment like the OR. In view of surgeons' high primary task load, the repeated call for simpler IT is an imperative for ERP extensions. System design should consider a) that current OR IT suffers from an input limitation regarding planning-relevant real-time data, and b) that there are social processes that strongly affect planning and particularly ERP use beyond algorithms. Real improvement of clinical IT tools requires their independent evaluation according to standards developed for pharmaceutical subjects.

Operating lists are created by rational algorithms and use of power. What can a social scientific view offer surgeons?

PURPOSE: Algorithms for surgical operation planning are evidence-based. However, choices sometimes have to be made between medically equal solutions e.g. for staffing of sought-after operations. Such decisions are heavily influenced by micropolitics and power. The article examines the array of highly manipulated processes around operation theatre allocation of convenient time slots or staff, which play out in various ways in all of the world's main regional surgical cultures. METHOD: Essay supported by empiric data from an ethnographic power-analysis targeted to senior executive surgeons. Operations were categorized into "Interesting" (i.e. career-promoting) and "Uninteresting" (i.e. routine) operations. RESULTS: Fifty nine executives responded. Only one respondent contested the categorization of operations into Interesting and Uninteresting. The two categories were staffed according to significantly different criteria (p < 0.05). These were classified as Rational (e.g. "surgical expertise"), Social (e.g. "equity"), and Political (e.g. "status"). For Interesting operations, Rational criteria were deemed most relevant, while for the Uninteresting operations "equity" was ranked top. Moreover, we found significant differences between surgeons' and external observers' (experienced clerical and nursing staff) assessments of staffing decisions, the latter ranking Political motives higher. Decisions were almost exclusively negotiated among surgeons. 33% of respondents said they used subterfuges such as withholding information, incorrect duration-statements, and barter arrangements to defuse possible conflicts. CONCLUSIONS: Operating Lists are not merely the product of rational resource optimization. This article demonstrates the methodic feasibility of academic investigation into the typically tacit micro-political mechanisms in List-making. Developing such research further may potentially concern the practice and outcome of surgery.