1. health and fitness

June 9, 2013 (final version)
Research protocol: A systematic review of the impact of leadership on health
information technology adoption in health care providing organisations.
Tor Ingebrigtsen1,2,3, Andrew Georgiou1, Antonia Hordern1, Mirela Prgomet1, Yu Jia Julie
Li1, Farah Magrabi1, Robyn Clay-Williams1, Johanna Westbrook1, Jeffrey Braithwaite1
1
Australian Institute of Health Innovation, The University of New South Wales, Sydney,
Australia
2
Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø,
Norway
3
CEOs office, University Hospital of North Norway, Tromsø, Norway
Address for Correspondence:
Prof Tor Ingebrigtsen
Centre for Clinical Governance Research
Australian Institute of Health Innovation
The University of New South Wales
Sydney NSW 2052
Australia
Ph: 0403737775
Email: tor.ingebrigtsen@unn.no
1
1.
Background
Health services are increasingly constrained, and leaders are faced with the challenge of
building a patient-centred health care system delivering high-quality care in ways that are
beneficial both for patients and resource utilization. Successful adoption of health information
technology (IT) is considered a prerequisite for such high value health care (Cosgrove DM et
al 2013). Accordingly, leaders in health care must lead IT adoption, and training programs for
emerging leaders must provide the necessary competencies to do so.
Others have reviewed the concept of business management (leadership), as opposed to
specialised leadership of IT-support, in IT adoption in general (Bassellier G et al 2001). We
are not aware of reviews specifically addressing this topic in the context of healthcare
providing organisations, such as hospitals. We therefore suggest that an evidence gap exists
with regard to the role of leadership of IT adoption in healthcare. To address this, we aim to
conduct a systematic review to identify and synthesise evidence based empirical knowledge
on associations between leadership roles and attributes, and outcomes from IT adoption
processes in healthcare providing organisations. The research specifically aims to identify a
set of competencies, attitudes, subjective norms, perceptions of behavioural control and
intentions that leaders in different roles must possess, and behaviours that they must practice,
to achieve successful IT adoption.
2.
Method
2.1 Protocol and registration
The conduct of this systematic review is based on the recommendations in the Preferred
Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (Moher D
et al 2009).
Background information from textbooks on health IT, and IT-leadership in general (Coieira E
2003, Pearlson KE and Saunders CS 2010), confirmed the evidence gap. It also suggested that
research in the field of IT-leadership involves the use of varying qualitative, quantitative and
mixed methods, and showed that it is carried out and published across a wide range of
research traditions (social sciences, business, management and leadership). Accordingly, a
systematic review with meta-analysis of quantitative results is not considered feasible. We
therefore plan to apply a systematic narrative review method.
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The protocol is registered in the International Prospective Register of Systematic Reviews
(PROSPERO) (PROSPERO website 2013) with the registration number CRD42013004812.
2.2 Eligibility
Study eligibility criteria:
1. The study was conducted in an organisation that provide healthcare to patients (e.g.
hospitals, primary care organisations)
2. The study reports empirical data on the impact of leadership at an organisational line
level on outcomes from health IT adoption

Outcomes can be either organisational (e.g. speed or degree of adoption,
employee satisfaction, productivity, or other measures of organisational
performance) or clinical (e.g. patient outcomes, patient satisfaction).

Health IT is understood broadly as any IT system developed and/or
implemented to deliver or to support the delivery of healthcare to patients

Study methods can be qualitative, quantitative or mixed
Exclusion criteria
1. Descriptions of anecdotal personal experiences
2. Studies conducted in organisations related to healthcare, but not providing healthcare
to patients, such as

National healthcare political governance or legislative bodies

Social security providing organisations

Medical schools or other health education institutions

Infection- or other epidemiological surveillance systems

Cancer- or other disease registries

Health insurance providers

Pharmaceutical companies

Veterinary healthcare
3. Studies of generic infrastructure challenges linked to health IT-adoption in developing
countries
4. Studies not presenting empirical results on outcomes from IT-adoption, such as
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
Studies proposing theoretical frameworks

Studies describing simulations (and not empirical) data

Surveys and audits about general attitudes, opinions and perceptions of IT
adoption, or use of IT-systems, with no data on outcomes from adoption
processes
5. Studies focusing only on

Leadership of specialised IT support organisations

Leadership in adoption of isolated management systems or technical solutions
and standards

Informal leadership roles, such as “clinical champions”
without analysis of outcomes from interaction with clinical and/or line leaders
responsible for providing healthcare
6. Studies of leadership in adoption of specific medical devices (e.g. imaging equipment,
surgical equipment, radiation equipment, laboratory equipment, implantable devices
etc.)
Report eligibility criteria:
1. Articles published between 2000 and the end of May 21. 2013
2. Abstracts available in English
3. Full text available in English, German or Scandinavian languages
2.3 Information sources
The following databases will be searched:
1. Medline (via OvidSP)
2. Embase (via OvidSP)
3. Cinahl (via EBSCOhost)
4. Business source premier (via EBSCOhost)
The reference list of articles fulfilling eligibility criteria will be checked and additional
citations hand-searched with a snowball-approach.
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2.4 Search
To identify articles pertinent to our research objective, we developed a search strategy that
combined keywords and subject terms related to our four dimensions of interest:
1. The setting (healthcare providing organisation)
2. The technology in question (health IT)
3. The process of interest (adoption) and
4. The intervention to be studied (leadership).
We initially identified relevant keywords via the textbooks that had provided us with
background information and prompted us to conduct a systematic review, and from articles
identified from the reference lists of the textbooks. Subject terms were then identified through
preliminary exploration of the electronic databases. These preliminary searches did not
identify all articles providing background information, and we therefore refined our search by
exploring and adding new keywords and subject terms until the search identified all possibly
eligible articles that we were aware of. Table 1 shows the subject terms and keywords used in
the final search, and Figure 1 gives a diagrammatic representation of the search strategy and
the study selection process.
To maintain a uniform approach, the same search strategy will be applied to both databases
searched via OvidSP, and the equivalent terms will be substituted in the search strategy
applied via EBSCOhost.
2.5 Study selection
All citations obtained through the search will be subject to title and abstract screening by the
primary investigator (TI). The full text of titles that appear to possibly meet the eligibility
criteria will be comprehensively assessed by TI for eligibility. The selection of studies for
inclusion will be validated by another researcher (FM). Discrepancies will be resolved by indepth discussion and subsequent consensus before final decisions on inclusion and exclusion
are made.
2.6 Data collection process
Included articles will be reviewed in full text by the primary investigator (TI), and other
researchers (AH, FM, RC-W) will validate the data extraction. Included studies will be
critically appraised for validity and risk of bias, and key results will be recorded to a
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worksheet. When data in an article appears to be missing or unclear, attempts will be made to
contact the authors to acquire additional information or obtain clarification.
2.7 Data items
To aid the data collection process, a table has been developed into which data extracted from
each study will be documented. The table is intended to be iteratively revised during the data
collection process to ensure a convenient categorisation and level of detail in the extracted
data. Data items will include: the author, year and country of the study, the aim of the study,
the study design, setting and sample, the outcome measures, the key findings, and the authors
conclusion. Data on IT knowledge will be categorised as explicit or tacit, and data on leaders
attitudes, subjective norms, perceptions of behavioural control and actual proactive IT
behaviour and partnership with IT people will be registered.
2.8 Synthesis of results
A conceptual framework is considered necessary for analysis of the literature on health IT
leadership. In the social sciences, adoption of new technologies, including IT, is generally
understood as complex social interventions (Litwin AS 2011). Outcomes are considered
results from mutually reinforcing interactions between the (developing) technology, changes
in work processes, and organisational changes enabled by the technology. General research on
premises for successful IT adoption considers organisational factors, and especially
organisational capacity for change (change readiness), as more important than specific
characteristics of the technology itself. It is assumed that leaders at all levels in an
organisation face a series of strategic choices when new technology is about to be
implemented, and that the choices they make strongly influence outcomes from the
implementation effort in different organisational units (Avgar AC and Kuruvilla S 2011).
Bassellier et al (2001) explored the general concept of the IT competence of business
managers, defined as the knowledge that a manager possesses that enables him or her to
exhibit IT leadership in his or her area of operations. This knowledge is considered
complimentary to, but different from that possessed of specialised IT leaders. The combined
competencies of business- and specialised IT-leaders constitute the organisations IT
leadership competence. This research understands IT competence as a composite of explicit
(technology, applications, systems development, IT management and access to IT knowledge)
and tacit (experience from personal use, projects and management, and cognition of process
view and vision) IT knowledge. The emerging framework describes a set of specific
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competencies as prerequisites for effective IT leadership. In addition, it assumes that a set of
attitudes, subjective norms and perceptions of behavioural control combined with proactive
behavioural intensions and partnership with IT leaders also must be present for actual
conduction of effective IT business leadership (Figure 2).
Avgar et al (2012) proposed a framework that is specifically developed for analysis of
drivers and barriers in health IT adoption, based on the general understanding explained
above. The framework is two-dimensional, allowing analysis of organisational factors at three
line leadership levels (strategic, operational and frontline), over three different phases of
strategic choices (investment, implementation and use) (Figure 3). The authors suggest that
this aids analysis and understanding of how competencies, qualifications, capabilities and
behaviours of leaders at different organisational levels influence the degree of success during
different phases of IT adoption.
For our analysis, articles will be explored to identify evidence on how clinical leaders
IT competence, attitudes, norms, intensions and behaviours, as defined in the framework
developed by Bassellier et al, influence IT adoption in healthcare organisations. The findings
will then be organised according to the framework suggested by Avgar et al to understand
how different attributes of line leaders at different levels in healthcare organisations influence
IT adoption over time.
Ethics and dissemination
This review does not raise ethical concerns and we do not consider approval from a
committee for medical and health research ethics necessary.
We plan to publish the review in an international peer-reviewed scientific journal.
Funding statement
The primary investigator (TI) is supported with a 6 months research sabbatical granted by the
Executive board of directors for the University Hospital of North Norway, Tromsø, Norway.
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References
1. Cosgrove DM, Fisher M, Gabow P, et al. Ten strategies to lower costs, improve
quality, and engage patients: The view from leading health system CEOs. Health
Affairs 2013; 32: 321-7.
2. Bassellier G, Reich BH, Benbasat I. Information technology: Competence of business
managers: A definition and research model. Journal of Management Information
Systems 2001; 17: 159-82.
3. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews
and meta-analyses: the PRISMA statement. BMJ 2009; 339: 332-9.
4. Coiera E. Guide to health informatics. Hodder Arnold, London, UK, 2003.
5. Pearlson KE, Saunders CS. Managing and using information systems. A strategic
approach. John Wiley & Sons Inc, Hoboken NJ, 2010.
6. PROSPERO website. Accessed at http://www.crd.york.ac.uk/NIHR_PROSPERO/
27.05.2013.
7. Litwin AS. Technological change at work: The impact of employee involvement on
the effectiveness of health information technology. Industrial and labor relations
review 2011; 64: 863-88.
8. Avgar AC, Kuruvilla S. Dual alignment of industrial relations activity: From strategic
choice to mutual gains. Advances in Industrial and Labor Relations 2011; 18: 1-39.
9. Avgar AC, Litwin AS, Pronovost PJ. Drivers and barriers in health IT adoption.
Applied Clinical Informatics 2012; 3: 488-500.
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Table 1. Databases Search Strategy
OvidSP Search Strategy:
Medline and EMBASE
1 hospital information system/
2 information system/
3 information technology/
4 computer/
5 medical informatics/
6 electronic medical record/
7 computerized provider order entry/
8 medical order entry systems/
9 “picture archiving and communication
system”/
10 telehealth/
11 telemedicine/
12 decision support systems, clinical/
13 EMR.ti,ot,sh,ab,kw.
14 information technology.ti,ot,sh,ab,kw.
15 electronic health record$.ti,ot,sh,ab,kw.
16 electronic medical record$.ti,ot,sh,ab,kw.
17 electronic patient record$.ti,ot,sh,ab,kw.
18 radiology system$.ti,ot,sh,ab,kw.
19 PACS.ti,ot,sh,ab,kw.
20 laboratory system$.ti,ot,sh,ab,kw.
21 CPOE.ti,ot,sh,ab,kw.
22 computeri#ed physician order
entry.ti,ot,sh,ab,kw.
23 computeri#ed provider order
entry.ti,ot,sh,ab,kw.
24 computeri#ed communication
system.ti,ot,sh,ab,kw.
25 decision support.ti,ot,sh,ab,kw.
26 DSS.ti,ot,sh,ab,kw.
27 CDSS.ti,ot,sh,ab,kw.
28 information system$.ti,ot,sh,ab,kw.
29 1 OR 2 OR 3 OR 4 OR … 28
EBSCOhost Search Strategy:
CINAHL and Business Source Premier
S1 (MH “Hospital Information Systems”)
S2 (MH “Clinical Information Systems”)
S3 (MH “Information Technology”)
S4 (MH “Computers and Computerization”)
S5 (MH “Medical Informatics”)
S6 (MH “Computerized Patient Record”)
S7 (MH “Electronic Order Entry”)
S8 (MH “Picture Archiving and
Communication System”)
S9 (MH “Telehealth”)
S10 (MH “Telemedicine”)
S11 (MH “Decision Support Systems,
Clinical”)
S12 AB EMR
S13 AB information technology
S14 AB electronic health record$
S15 AB electronic medical record$
S16 AB electronic patient record$
S17 AB radiology system$
S18 AB PACS
S19 AB laboratory system$
S20 AB CPOE
S21 AB computeri#ed physician order entry
S22 AB computeri#ed provider order entry
S23 AB computeri#ed communication
system
S24 AB decision support
S25 AB DSS
S26 AB CDSS
S27 AB information system$
S28 S1 OR S2 OR S3 OR S4 OR … S27
Setting related
subject terms
and keywords
30
31
32
33
34
35
36
37
38
39
40
health care/
health facilities/
health care organization/
health service/
health center/
hospital organization/
hospital/
healthcare.ti,ot,sh,ab,kw.
medical.ti,ot,sh,ab,kw.
hospital.ti,ot,sh,ab,kw.
30 OR 31 OR 32 OR 33 OR … 39
S29
S30
S31
S32
S33
S34
S35
S36
(MH “Health Care Delivery”)
(MH “Health Facilities”)
(MH “Health Services”)
(MH “Hospitals”)
AB healthcare
AB medical
AB hospital
S29 OR S30 OR S31 OR … S35
Process
related
keywords
41
42
43
44
45
46
47
48
49
50
implement.ti,ot,sh,ab,kw.
implementation$.ti,ot,sh,ab,kw.
implementing.ti,ot,sh,ab,kw.
adopt.ti,ot,sh,ab,kw.
adoption.ti,ot,sh,ab,kw.
uptake.ti,ot,sh,ab,kw.
usage.ti,ot,sh,ab,kw.
utili#ation.ti,ot,sh,ab,kw.
investment.ti,ot,sh,ab,kw.
diffusion.ti,ot,sh,ab,kw.
S37
S38
S39
S40
S41
S42
S43
S44
S45
S46
AB
AB
AB
AB
AB
AB
AB
AB
AB
AB
Technology
related subject
terms and
keywords
9
implement
implementation$
implementing
adopt
adoption
uptake
usage
utili#ation
investment
diffusion
51
52
53
54
redesign.ti,ot,sh,ab,kw.
introduction.ti,ot,sh,ab,kw.
introduce.ti,ot,sh,ab,kw.
41 OR 42 OR 43 OR 44 OR … 53
S47
S48
S49
S50
AB redesign
AB introduction
AB introduce
S37 OR S38 OR S39 OR … S49
Intervention
related subject
terms and
keywords
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
hospital administration/
hospital administrators/
health care management/
leadership/
manager/
leader$.ti,ot,sh,ab,kw.
executive$.ti,ot,sh,ab,kw.
administrator$.ti,ot,sh,ab,kw.
developer$.ti,ot,sh,ab,kw.
implementer$.ti,ot,sh,ab,kw.
policy maker$.ti,ot,sh,ab,kw.
policymaker$.ti,ot,sh,ab,kw.
decision maker$.ti,ot,sh,ab,kw.
strategist$.ti,ot,sh,ab,kw.
manager$.ti,ot,sh,ab,kw.
governance.ti,ot,sh,ab,kw.
institute.ti,ot,sh,ab,kw.
55 OR 56 OR 57 OR 58 OR … 71
S51
S52
S53
S54
S55
S56
S57
S58
S59
S60
S61
S62
S63
S64
S65
S66
S67
(MH “Health Facility Administration”)
(MH “Health Facility Administrators”)
(MH “Leadership”)
(MH “Management”)
AB leader$
AB executive$
AB administrator$
AB developer$
AB implementer$
AB policy maker$
AB policymaker$
AB decision maker$
AB strategist$
AB manager$
AB governance
AB institute
S51 OR S52 OR S53 OR … S66
Search
limiters
73 29 AND 40 AND 54 AND 72
74 limit 73 to ((“English or German or
Norwegian”) and yr=“2000-Current”)
S68 S28 AND S36 AND S50 AND S67
S69 Limiters – Date Published from:
20000101-20131231; Language:
English, German, Norwegian
In OvidSP - ti,ot,sh,ab,kw = title, original title, subject heading, abstract, keyword heading
In EBSCOhost - AB = abstract
Search was conducted on May 21st 2013 in all databases.
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Figure 1. Diagrammatic representation of the search strategy
11
Figure 2. Framework for classification and analysis of IT-competencies (Bassellier G et al
2001)
12
Figure 3. Framework for analysis of IT adoption (Avgar AC et al 2012)
13