Prof Nilmini Wickramasinghe

The Application of Activity Theory
to Assess the Implementation of
a Chemotherapy Ordering System
Prof. Nilmini Wickramasinghe, PhD, MBA
Epworth HealthCare & Deakin University
2016
Epworth HealthCare
1
Agenda
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Introduction
Background
Activity Theory
Research Methodology
Mapping of Activity Theory
Discussion and Conclusion
2016
Introduction
•Motivation – large rate of failures and/or low user satisfaction of
ICT in healthcare contexts.
•Digitalisation processes can be optimised by saving time,
reducing error rates and most important supporting analysing,
evaluating, and creating knowledge from the collected data.
•Within healthcare - One area of clinical care that can benefit from
digitising is in cancer care, given the many and varied processes
involved.
•Focus on a specific not-for-profit tertiary hospital in Australia
which is introducing ARIA a computerised solution to manage
administration and treatment of chemotherapy from initial
diagnosis through to post treatment follow-up.
2016
Introduction (Continued)
•The administration of chemotherapy  complex given that
numerous staff are involved coupled with the intrinsic toxicity of the
medication as well as its generally low margin of safety [2].
•Risks with current handwritten based systems for chemotherapy
ordering include medical errors, poor quality of care, high costs.
2016
Background
• In Australia, approximately two thirds of patients are treated in a
private hospital [4].
• VMOS (unique in Australia) – independent consultants typically
have affiliations at many private hospitals and this makes adoption
of IT problematic  an appropriate implementation strategy needs
to be developed by especially taking social factors into consideration.
• Human Computer Interaction often used in order to include the
human factor into information systems  might be limited  The
use of computers in social, organisational, and political contexts
cannot be studied sufficiently because the relationship to the user´s
goals, plans and values cannot be easily analysed [6].
2016
Background (Continued)
• For these reasons Activity Theory is proffered as an appropriately rich and robust lens.
• Activity system of the process will be developed and contradictions are uncovered  a
much richer picture of the requirements for implementing a computerised physician order entry
system for the chemotherapy administration process in complex structures can be created.
2016
Research Question
How is Activity Theory useful to
study IT adoption in healthcare?
2016
Activity Theory:
• Object-orientedness:
– activities are directed towards their objects [9]
• Mediation:
– human activity is mediated by tools [12]
• Hierarchical structure of activity:
– activity consists of (three) layers  activity, actions, operations [9]
• Internalisation and externalisation:
– transformations between internal and external components of activity [9]
• Development:
– objective of study as well as a research strategy [13]
2016
Activity Theory:
Contradictions
• Contradictions in activity systems exist because activities are constantly
developing and even most-well planned actions involve failures, disruptions, and
unexpected innovations. [9]
2016
Research Methodology
• Qualitative data were collected using different
procedures.
– “Identifying Key Success Factors for the Adoption
and Implementation of computerised physician order
entry systems into the Australian Private Healthcare
Sector:”
• Observation, survey, interview, focus groups and
documents.
– Single case study. Data about the chemotherapy
process was collected by taking different literature
into consideration.
2016
Research Methodology
(Continued)
• Mapping of collected data to Activity Theory in order
to get insights into the activity system of the process;
– systematic approach by using the adaptive
mapping process described by Wickramasinghe
and Goldberg. [16]
– Result: contradictions of the chemotherapy
administration process were uncovered.
2016
Mapping of Activity Theory
Chemotherapy
administration processes
2016
Mapping of Activity Theory
The activity system of the
chemotherapy administration
process
2016
Mapping of Activity Theory
The activity system of the chemotherapy administration process
Division of
Labor:
Role
Responsibilities
Nurse
Administers drugs which also include tasks such as
educating patients and managing side effects.
Private Physician
Orders drugs which also include tasks such as making
treatment decisions and monitoring the effects of the
treatment .
Pharmacist
Dispense drugs which also includes tasks such as the
verifying the drug, clarifying identified discrepancies, and
accurate dispensing of chemotherapy.
2016
Mapping of Activity Theory
Contradictions
Sub-components
Subject- ToolObject and
Community – Tool - Object
Subject-Rules-Object and
Community – Rules Object
Subject-Object-Division of
Labour and CommunityDivision of Labour-Object
Uncovered Contradictions
• Human error e.g. wrong drugs, administering underdose or overdose
• Errors because of inherent properties of computerised system
• Errors involving misreading or misapplying source material
• Misinterpretation of hand-offs due to physician handwriting, miscommunication
involving verbal orders, or other assumptions
• Collaboration problems in working with the pharmacy and laboratory departments
• Use of abbreviations and acronyms which can easily be misinterpreted
• Electronic Medical Record: storage of data in unstructured data format as well as use
of differences in database schemes across healthcare institutions
• Resistance of Change
• No single authoritative source for chemotherapy regimens (leads to oncologists
creating customized order sets of commonly used regimens)
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Misaligned and/or divergent goals due to multifaceted employment arrangements
(nested principle agent relationships)
Resistance of Change
Discussion
• Activity Theory enables the modelling of implementation requirements of a computerised
physician order entry system of different user perspectives. Why is this helpful?
• Not only processes and technology are considered but there is also a high consideration of
people – in Activity Theory as subjects and community  Activity Theory can be classified
as an ontological framework in its own right or it can be combined with other theories to
develop an expanded and more comprehensive ontological framework.
• For practice Activity Theory and the identification of contradictions provides a much
richer picture of the chemotherapy administration process; thereby, enabling changes to be
made to clinical practice/use of technology to ensure optimal care outcomes.
2016
Discussion (Continued)
• The findings have shown to be beneficial and next steps include testing this model using
other contexts within healthcare.
• In addition, each relationship (or triangle) can be analysed separately in order to get
insights of problems and potential barriers. These uncovered contradictions build the basis to
develop measures for maintaining the relationship between the individual and social levels.
• Activity Theory is multidisciplinary and therefore activities are considered by different
disciplines depending on the context they are creating [8] e.g. healthcare, information
systems, change management.
• For completeness, we note that this is one of the first studies to use Activity Theory to
model a healthcare context, more confirmatory work is required to truly demonstrate its full
power and potential in this regard.
2016
Thank you
nilmini.work@gmail.com