Computer Supported Cooperative Work (CSCW)

, Volume 15, Issue 5–6, pp 537–572 | Cite as

Loose Coupling and Healthcare Organizations: Deployment Strategies for Groupware



Healthcare organizations are often organized in a modular, loosely coupled fashion where separate and semi-autonomous work units specialize in different areas of care delivery. This partitioning allows each unit to adapt to emerging practice standards in its area of expertise and to adjust to its local work environment. However, organizational loose coupling can limit the flow of information within organizations and can make it difficult to coordinate services when patients’ care is dependent on professionals from more than one unit. Groupware systems have the potential to improve coordination and information access in healthcare organizations. However, modularity and loose coupling make it difficult to introduce new systems when they span more than one unit, since authority is not always centralized and since perceptions and frames of reference on new deployments differ across units. In this paper, we define a groupware deployment framework for loosely coupled healthcare organizations that has two parts: a set of deployment challenges and a set of deployment strategies. The deployment challenges include: difficulties centralizing deployments, perceptions of inequity, role conflicts, and problems achieving critical mass. The deployment strategies outline a preliminary set of approaches for addressing the difficulties of deploying CSCW systems in loosely coupled healthcare organizations. We illustrate the framework by presenting a case study of a groupware deployment in a home care setting.


deployment planning groupware deployment healthcare human service organizations loose coupling 



This work was supported by a grant from the Canadian Institutes of Health Research (CIHR). We thank the clinicians and administrators in SDH who participated in and supported this research.


  1. Acuff, R.D., L.M. Fagan, T.C. Rindfleisch, B.J. Levitt and P.M. Ford (1997): Lightweight, Mobile e-Mail for Intra-clinic Communication. In Proceedings AMIA Symposium 1997, AMIA, pp. 729–733Google Scholar
  2. Aldrich H. (1979) Organizations and Environments. Englewood Cliffs, NJ: Prentice HallGoogle Scholar
  3. Ash J. (1997) Organizational Factors that Influence Information Technology Diffusion in Academic Health Sciences Centers. Journal of the American Medical Informatics Association, 4(2):102–109Google Scholar
  4. Ash J.S., D.W. Bates (2005) Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. Journal of the American Medical Informatics Association 12(1): 8–12CrossRefGoogle Scholar
  5. Bates D.W., M. Ebell, E. Gotlieb, J. Zapp, H.C. Mullins (2003) A Proposal for Electronic Medical Records in U.S. Primary Care. Journal of the American Medical Informatics Association 10(1):1–10CrossRefGoogle Scholar
  6. Berg M. (1999) Accumulating and Coordinating: Occasions for Information Technologies in Medical Work. Computer Supported Cooperative Work 8(4):373–401CrossRefGoogle Scholar
  7. Berg M. (2001) Implementing Information Systems in Health Care Organizations: Myths and Challenges. International Journal of Medical Informatics 64(2&3): 143–156CrossRefGoogle Scholar
  8. Bertrand A.L. (1972) Social Organization: A General Systems and Role Theory Perspective. Philadelphia: F.A. DavisGoogle Scholar
  9. Brusoni S., A. Prencipe (2001) Managing Knowledge in Loosely Coupled Networks: Exploring the Links Between Product and Knowledge Dynamics. Journal of Management Studies 38(7): 1019–1035CrossRefGoogle Scholar
  10. Burns L.R., S.L. Walston, J.A. Alexander, H.S. Zuckerman, R.M. Andersen, P.R. Torrens and D. Hilberman (2001): Just How Integrated are Integrated Delivery Systems? Results from a national survey vol. 26, no. 1, pp. 20–39Google Scholar
  11. Davies H.T.O., S.M. Nutley, R. Mannion (2000) Organisational Culture and Quality of Health Care. Quality in Health Care, 9(2):111–119CrossRefGoogle Scholar
  12. Dean M. (1993) News: London Perspective: Unhealthy Computer Systems. The Lancet 341: 1269–1270CrossRefGoogle Scholar
  13. Dick R.S., E.B. Steen (1991) The Computer-based Patient Record: An Essential Technology for Health Care. Washington, DC: National Academy PressGoogle Scholar
  14. DiTomaso N. (2001) The Loose Coupling of Jobs: The Subcontracting of Everyone? In Berg I., A.L. Kalleberg (eds) Sourcebook of Labor Markets: Evolving Structures and Processes. New York: Kluwer Academic/Plenum, pp. 247–270Google Scholar
  15. Fitzpatrick, G. (2000): Understanding the Paper Health Record in Practice: Implications for EHR’s. In Proc. Health Informatics Conference (HIC2000), Adelaide, AustraliaGoogle Scholar
  16. Glassman R.B. (1973) Persistence and Loose Coupling in Living Systems. Behavioral Science 18(2): 83–98CrossRefGoogle Scholar
  17. Goldberg, J.L. (1998): CaTCH: The Physician’s Workstation for Supporting Cooperative Medicine. In Proceedings of IRMA International Conference 1998, pp. 301–312Google Scholar
  18. Gomez E.J., F. del Pozo, E.J. Ortiz, N. Malpica, H. Rahms (1998) A Broadband Multimedia Collaborative System for Advanced Teleradiology and Medical Imaging Diagnosis. IEEE Transactions on Information Technology in Biomedicine 2(3): 146–155CrossRefGoogle Scholar
  19. Gomez E.J., F. del Pozo, J.A. Quiles, M.T. Arredondo, H. Rahms, M. Sans, P. Cano (1996) A Telemedicine System for Remote Cooperative Medical Imaging Diagnosis. Computer Methods and Programs in Biomedicine 49: 37–48CrossRefGoogle Scholar
  20. Greenbaum J., M. Kyng (1991) Design at work: cooperative design of computer systems. Hilldale, NJ: Lawrence ErlbaumGoogle Scholar
  21. Gremy F., J.M. Fessler, M. Bonnin (1999) Information system evaluation and subjectivity. International Journal of Medical Informatics, 56(1–3): 13–23CrossRefGoogle Scholar
  22. Grudin, J. (2003): Leaders Leading? A Shift in Technology Adoption. In Proceedings CHI 2003. New York: ACM Press, pp. 930–931Google Scholar
  23. Grudin J. (1994) Groupware and Social Dynamics: Eight Challenges for Developers. Communications of the ACM 37(1): 92–105CrossRefGoogle Scholar
  24. Handels H., Ch. Busch, J. Encarnacao, Ch. Hahn, V. Kuhn, J. Miehe, S.I. Poppl, E. Rinast, Ch. RoBmanith, F. Seibert, A. Will (1997) KAMEDIN: A Telemedicine System for Computer Supported Cooperative Work and Remote Image Analysis in Radiology. Computer Methods and Programs in Biomedicine 52: 175–183CrossRefGoogle Scholar
  25. Harrison S. (1992): Just Managing: Power and Culture in the National Health Service. London: MacmillanGoogle Scholar
  26. Hasenfeld Y. (1983) Human Service Organizations. Englewood Cliffs, NJ: Prentice HallGoogle Scholar
  27. Hodge M.H. (1990) History of the TDS Medical Information System. In: Blum B.I., K. Duncan (eds) A History of Medical Informatics. New York: ACM Press, pp. 328–356Google Scholar
  28. Horne S. (1992) Organization and Change Within Educational Systems: Some Implications of a Loose-Coupled Model. Educational Management and Administration 20(2): 88–98CrossRefGoogle Scholar
  29. Jones, H. and P. Hinds (2002): Extreme Work Teams: Using SWAT Teams as a Model for Coordinating Distributed Robots. In Proceedings CSCW 2002, ACM Press, pp. 372–381Google Scholar
  30. Joshi K. (1991) A Model of Users’ Perspective on Change: The Case of Information Technology Implementation. MIS Quarterly 15(2): 229–242CrossRefGoogle Scholar
  31. Kindberg, T. and N. Bryan-Kinns, R. Makwana (1999): Supporting the Shared Care of Diabetic Patients. In Proceedings of ACM SIGGROUP 1999, ACM Press, pp. 91–100Google Scholar
  32. Kitchener M., L. Gask (2003) NPM Merger Mania: Lessons from an Early Case. Public Management Review 5(1): 19–44CrossRefGoogle Scholar
  33. Kouzes J.M., P.R. Mico (1979) Domain Theory: An Introduction to Organizational Behaviour in Human Service Organisations. Journal of Applied Behavioural Sciences 15(4): 449–469CrossRefGoogle Scholar
  34. Kuhn K.A., D.A. Giuse (2001) From Hospital Information Systems to Health Information Systems: Problems, Challenges, Perspectives. Methods of Information in Medicine 40(4): 275–287Google Scholar
  35. Lauer T.W., K. Joshi, T. Browdy (2000) Use of the Equity Implementation Model to Review Clinical System Implementation Efforts: A Case Report. Journal of the American Medical Informatics Association 7(1): 91–102Google Scholar
  36. Lehoux P, C. Sicotte, J. Denis (1999) Assessment of a Computerized Medical Record System: Disclosing Scripts of Use. Evaluation and Program Planning 22: 439–453CrossRefGoogle Scholar
  37. Littlejohns P., J.C. Wyatt, L. Garvican (2003) Evaluating Computerised Health Information Systems: Hard Lessons Still to be Learnt. British Medical Journal 326: 860–863CrossRefGoogle Scholar
  38. Lorsch J.W. (1973) An Open-System Theory Model for Organizational Research. In Negandhi A.R. (ed.) Modern Organizational Theory: Contextual, Environmental, and Socio-cultural Variables. Kent, OH: Kent State University Press, pp. 132–144Google Scholar
  39. Makris L., I. Kamilatos, E.V. Kopsacheilis, M.G. Strintzis (1998) Teleworks: A CSCW Application for Remote Medical Diagnosis Support and Teleconsultation. IEEE Transactions on Information Technology in Biomedicine 2(2): 62–73CrossRefGoogle Scholar
  40. Mark, G. and S. Poltrock (2001): Diffusion of a Collaborative Technology Across Distance. In Proceedings GROUP 2001. New York: ACM Press, pp. 232–241Google Scholar
  41. Massaro T.A. (1993) Introducing Physician Order Entry at a Major Academic Medical Center: Impact on Organizational Culture and Behavior. Academic Medicine 68: 20–25CrossRefGoogle Scholar
  42. May C., R. Harrison, T. Finch, A. MacFarlane, F. Mair, P. Wallace (2003) Understanding the Normalization of Telemedicine Services through Qualitative Evaluation. Journal of the American Medical Informatics Association 10(6): 596–604CrossRefGoogle Scholar
  43. Meyer J., B. Rowan (1977) Institutionalized Organizations: Formal Structure as Myth and Ceremony. American Journal of Sociology 83(2): 340–363CrossRefGoogle Scholar
  44. Moore, M.B. (1996): Acceptance of Information Technology by Health Care Professionals. In Proceedings of the symposium on Computers and the quality of life 1996, pp. 56–60Google Scholar
  45. Muller M.J. (1991): PICTIVE – An Exploration in Participatory Design. In Proceedings CHI 1991, ACM Press, pp. 225–231Google Scholar
  46. Nielsen J. (1994) Usability Engineering. San Francisco: Morgan KaufmannGoogle Scholar
  47. O’Connell R.T., C. Cho, N. Shah, K. Brown, R.N. Shiffman (2004) Take Note(s): Differential EHR Satisfaction with Two Implementations under One Roof. Journal of the American Medical Informatics Association 11(1): 43–49CrossRefGoogle Scholar
  48. Orton J.D., K.E. Weick (1990) Loosely Coupled Systems: A Reconceptualization. Academy of Management Review 15(2): 203–223CrossRefGoogle Scholar
  49. Perrow C. (1999) Normal Accidents: Living with High-risk Technologies. Princeton, NJ: Princeton University PressGoogle Scholar
  50. Pinelle, D. (2004): Improving groupware design for loosely coupled groups. PhD Thesis, Department of Computer Science, University of Saskatchewan, Saskatoon, SK, CanadaGoogle Scholar
  51. Pinelle, D. and C. Gutwin (2005): A Groupware Design Framework for Loosely Coupled Workgroups. In Proceedings of ECSCW 2005 Google Scholar
  52. Pinelle, D. and C. Gutwin (2003): Designing for Loose Coupling in Mobile Groups. In Proceedings of GROUP 2003, ACM Press, pp. 75–84Google Scholar
  53. Sanchez R., J.T. Mahoney (1996) Modularity, Flexibility, and Knowledge Management in Product and Organization Design. Strategic Management Journal 17: 63–76Google Scholar
  54. Scheid-Cook T.L. (1990) Ritual Conformity and Organizational Control: Loose Coupling or Professionalization? The Journal of Applied Behavioral Science 26(2): 183–199CrossRefGoogle Scholar
  55. Schneider K., I. Wagner (1993) Constructing the ‘Dossier Représentatif’: Computer-based Information Sharing in French Hospitals. Computer Supported Cooperative Work 1: 229–253CrossRefGoogle Scholar
  56. Schoop, M. (1999): An empirical study of multidisciplinary communication in healthcare using a language-action perspective. In Proceedings of the Fourth International Workshop on the Language Action Perspective on Communication Modelling (LAP 99), pp. 59–72Google Scholar
  57. Schoop M., D.G. Wastell (1999) Effective Multidisciplinary Communication in Healthcare: Cooperative Documentation Systems. Methods of Information in Medicine 38(4&5): 265–273Google Scholar
  58. Scott W.R. (1987) Organizations: Rational, Natural, and Open Systems, 2nd ed. Englewood Cliffs, NJ: Prentice-HallGoogle Scholar
  59. Scott W.R. (1985) Systems within systems: the mental health sector. American Behavioral Scientist 28(5): 601–618CrossRefGoogle Scholar
  60. Southon F.C.G., C. Sauer, C.N.G. Dampney (1997) Information Technology in Complex Health Services: Organizational Impediments to Successful Technology Transfer and Diffusion. Journal of the American Medical Informatics Association 4(2): 112–124Google Scholar
  61. Spender J.C., P.H. Grinyer (1995) Organizational Renewal: Top Management’s Role in a Loosely Coupled System. Human Relations 48: 909–926CrossRefGoogle Scholar
  62. Staber U., J. Sydow (2002) Organizational Adaptive Capacity - A Structuration Perspective. Journal of Management Inquiry 11(4): 408–424CrossRefGoogle Scholar
  63. Tamblyn, R., A. Huang, R. Perreault, A. Jacques, D. Roy, J. Hanley, P. McLeod and R. Laprise (2003): The Medical Office of the 21st Century (MOXXI): Effectiveness of Computerized Decision-making Support in Reducing Inappropriate Prescribing in Primary Care. Canadian Medical Association Journal, vol. 169, no. 6Google Scholar
  64. van Mulligen, E.M., M. Diwersy, M. Schmidt, H. Burrman and B. Mons (2000): Facilitating Networks of Information. In Proceedings AMIA Symposium 2000, AMIA, pp. 868–872Google Scholar
  65. Wagner, M.M., S.A. Eisenstadt, W.R. Hogan and M.C. Pankaskie (1998): Preferences of Interns and Residents for e-Mail, Paging, or Traditional Methods for the Delivery of Different Types of Clinical Information. In Proceedings AMIA Symposium 1998, AMIA, pp. 140–144Google Scholar
  66. Weick K.E. (1976) Educational Organizations as Loosely-coupled Systems. Administrative Science Quarterly 21: 1–21CrossRefGoogle Scholar
  67. Weick, K.E. (1980): Loosely Coupled Systems: Relaxed Meanings and Thick Interpretations. In Paper Presented at the Annual Meeting of the American Educational Research Association, Boston, 1980Google Scholar
  68. Weick K.E. (1982) Management of Organizational Change Among Loosely Coupled Elements. In: Goodman P.S. (ed.) Change in Organizations: New Perspectives on Theory, Research, and Practice. San Francisco: Jossey-BassGoogle Scholar
  69. Westbrook, J.I., J. Braithwaite, R. Iedema and E.W. Coiera (2004): Evaluating the Impact of Information Communication Technologies on Complex Organizational Systems: A Multi-Disciplinary, Multi-Method Framework. In Proceedings of MEDINFO 2004, pp. 1323–1327Google Scholar
  70. Williams L.S. (1992) Microchips Versus Stethoscopes: Calgary Hospital MDs Face off Over Controversial Computer System. Canadian Medical Association Journal 147: 1534–1547Google Scholar
  71. Wilson T.D. (2001) Information Overload: Implications for Healthcare Services. Health Informatics Journal 7(2): 112–117CrossRefGoogle Scholar
  72. Wood J., D. Silver (1995) Joint Application Development, 2nd ed. New York: WileyGoogle Scholar
  73. Worth, E.R. and T.B. Patrick (1997): Do Electronic Mail Discussion Lists Act as Virtual Colleagues? In Proceedings AMIA Symposium 1997, AMIA, pp. 325–329Google Scholar

Copyright information

© Springer Science+Business Media B.V. 2006

Authors and Affiliations

  1. 1.Department of Computer ScienceUniversity of SaskatchewanSaskatoonCanada

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