Practitioners gain actionable insight from the study in several respects. Our results suggest that the coordinating benefit derived from Team DSU of CPOE, and Relational Coordination is a function of not only the strength of clinician relationships and team level appropriation of the advanced features of the clinical IS, but also the patient condition. By isolating each of the user roles, relationships, clinical tasks, and IS feature set across maximally different patient
conditions, our results suggest that as patient condition complexity and corresponding length of stay increases, so does the coordinating benefit provided by either IT-enabled or Relational Coordination mechanisms. This is especially apparent when focusing on the Vaginal Birth teams, which forms our baseline patient condition from a coordination perspective. It is important to note that Caesarean section births normally associated with more complicated deliveries had a
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separate CPOE order set and were purposely excluded from the study. Given that neither
mechanism imparted a significant path to PATSAT, and that Vaginal Birth patients are arguably in the prime of health, with fewer comorbidities, and consistent short duration in the hospital, it would appear that administrative and clinical staff focus on IT-Enabled, or Relational
Coordination improvement activities could be more effectively utilized elsewhere. We do not dispute that a positive impact related to the use of standardized best practices through order set creation and use could exist on Vaginal Birth teams. Our study was unable to detect the positive impact related to order entry due to universal adoption across medical units at Hospital A and B. We can only claim that reported use of the advanced features such as decision support, alerts or progress notes by Vaginal Birth teams does not covary with higher PATSAT.
Conversely, for patients with conditions characterized by higher acuity levels and associated with longer hospital stays, such as Organ Transplant, Pneumonia, and Cardiovascular Surgery, our results suggest that clinical teams derive an accentuated benefit through IT-Enabled and
Relational Coordination mechanisms. The standardized Relational Coordination path coefficients for each of these conditions is positive and highly significant, suggesting that teams which
communicate well, share goals, and demonstrate mutual respect achieve higher PATSAT. Ongoing research has shown that management interventions can be designed and implemented, that effectively improve team level attributes according to the seven dimensions measured by the Relational Coordination construct. For instance, organizations that invest resources focused on designing cross-functional spanner roles and cross functional performance measurement systems are shown to foster relationships that are robust to staffing changes over time (Gittell et al., 2010). Boundary spanners, or cross functional liaisons are individuals whose primary
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organizational objectives are to help integrate the work of others (Galbraith, 1973; Gittell, 2002). Examples of these individuals in a clinical setting are case workers, and primary nurses. In some hospitals, patients are assigned a primary nurse who is responsible for the patient for the duration of their stay (Gittell, 2002).
Our results suggest that clinical teams that appropriate CPOE functionality in a comprehensive manner, and maintain a complete patient record during a high acuity and lengthy hospital stay, derive a statistically significant benefit from the use of CPOE. While our supporting results were based on Pneumonia and the combined Organ Transplant and Pneumonia teams, we suspect that other patient conditions would derive similar results. It is important to note that our results weight equally the clinical structures supported by the features of the IS, namely the system alerts generated by drug-to-drug and drug-to-allergy interactions, clinical decision support functionality, system wide access to timely patient condition information such vital signs, and progress notes. Therefore we suggest that each of these clinical structures provides a
complementary component in the clinical care process, which ultimately provides a coordinating benefit and improved patient satisfaction.
Our results on the Pneumonia and combined Pneumonia/Organ Transplant teams are confounded by statistically significant negative standardized path coefficients between Team DSU of CPOE and PATSAT on the Cardiovascular Surgery and Hospital B Knee/Hip replacement teams. The Cardiovascular Surgery results may have been impacted by the inconsistent processes associated with the maintenance of patient vital signs during the patient stay on Cardiovascular critical care units. Due to the incomplete digital records associated with patients that passed through these units during their stay, perhaps teams that avoided the considerable time associated with digital
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entry spent more time at the patient bedside. Managers should be aware that potentially negative results are associated with system use that is not comprehensive, or use that is inconsistent across units.
Our alternative explanation for the negative path coefficient on the Cardiovascular and Knee/ Hip replacement surgery teams at Hospital B is related to the role of the mid-level on these teams. Given our operationalization to Team DSU of CPOE, involvement with the CPOE system by the responsible physician highly influenced the overall Team DSU score. For surgical teams with mid-level assignment typically associated with senior surgeons at the hospital, the mid-level typically handled the interface with CPOE. Therefore these teams would systematically reflect much lower Team DSU scores, not necessarily from a lack of engagement overall, but from very low scores attributed to the responsible physician. Therefore our results might suggest that clinical teams which incorporate mid-levels for system engagement may in fact derive the highest patient satisfaction results. Since the trend to incorporate mid-levels in acute care
facilities is nascent but growing quickly, our results with respect to the benefits of Health IT use by clinical teams with mid-level clinicians provide useful insights that will support further research into this role based phenomenon.
In summary, through the direct comparison of CPOE use according to lean measures (including Meaningful Use), along with Deep Structure Use, we found that the Faithful and Consensual Appropriation of the technology by clinical teams were salient predictors of favorable outcomes. Managers can then formulate nuanced combinations of user, task, and technology, and
harmonize best practices across clinician care teams. Secondly, the juxtaposition of the two coordinating mechanisms, CPOE and relational coordination, enables the evaluation of the
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relative importance of the realization of CPOE technology compared with the ongoing
development of team member relationships. Managers can then implement programs to enhance technology utilization or relationship building that is contextually relevant.