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From a theoretical perspective, our study makes four contributions of specific interest to the IS research community. The major contribution is the development and validation of a construct to assess IT-enabled coordination of clinical teams’ processes, which we denote as Team Deep Structure Use of CPOE. HIT researchers have also called for a clarification of the Health IT artifact (Agarwal et al., 2010), and a demonstration of clinical benefits from commercially available systems, as opposed to home grown solutions prevalent in the early CPOE literature (Agarwal et al., 2010). Our study is the first to clearly establish the availability of the core features of a mature Health IT environment, and subsequently link clinician reported team level use of the core features of the technology used to the support clinical care processes to the overall patient satisfaction with the clinical team. The HIT artifact is a commercially available system, rather than a unique CPOE system developed in house, which supports a replication of the research and the expectation that other hospitals can derive similar benefits.

While a deep understanding exists within the literature regarding lean measures of individual use, few studies (Pavlou et al., 2008; Pavlou & El Sawy, 2006) incorporate a rich or very rich conceptualization of use at the group or team level (Burton-Jones, Straub 2006). Our study captures use at the intersection of task, technology and users at both the individual physician and team level, while our level of analysis and conceptual model focus at the team level, as

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team use thereby extends how HIT research conceptualizes the role of IT-enabled coordination of clinical processes.

This study extends our prior understanding of the impact of Relational Coordination mechanisms in a clinical environment. Earlier studies by Gittell (2002) have evaluated the efficacy of

Relational Coordination mechanisms on patient outcomes, including patient satisfaction.

Relational coordination is conceptualized as a construct which captures the conditions necessary in the relationships between team members that foster spontaneous, informal coordination (Gittell, 2002). Yet no prior studies have concurrently measured Relational Coordination with an IT-enabled coordinating mechanism such as CPOE. Therefore this study provides a comparative evaluation of the efficacy of relational vs. IT-enabled coordination of clinical-teams’ processes with respect to patient care and satisfaction, thereby integrating and elaborating the two

conceptualizations of coordination in healthcare processes.

Prior studies which have evaluated the effectiveness of Relational Coordination (Gittell et al., 2010; Gittell, 2002) on patient satisfaction have required additional assumptions in their research design with respect to clinical teams, in comparison to our design. For instance, Gittell (2002) compares the Relational Coordination scores across orthopedic surgery units at nine different hospitals. These nine teams represent all the clinicians who would regularly care for patients on a given orthopedic surgery unit, and does not attempt to match the actual clinicians who provided care to each patient. Essentially all of the Knee/Hip replacement surgery patients cared for at Hospital A were matched to a composite Relational Coordination score of the entire group of clinicians who provided care at Hospital A. Our design incorporates considerably enhanced granularity with respect to clinician team membership. Based on archival data, we assembled

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teams according to the actual clinicians who provided care on a patient by patient basis.

Therefore our composite team score for relational coordination for each pneumonia team was not from the 121 individual respondent scores from the pre-identified pneumonia clinicians at

Hospital B, but from the actual “nine” clinicians who provided care to the specific patient. As a result, our research establishes a more direct causal link between Patient Satisfaction and the Relational Coordination scores, resulting in a significant contribution to this literature.

This study intended to illuminate how coordination mechanisms can be appropriated effectively by clinical teams. By linking the antecedents Faithfulness of Appropriation and Consensus on Appropriation to Deep Structure Use of the CPOE system, we illuminate the relationship between the structural components of the technology and the clinicians who apply it to their work. Given the level of resistance to Health Information Technologies reported in the extant literature (Bhattacherjee & Hikmet, 2007; Lapointe & Rivard, 2005, 2007), we expected that these two constructs would be especially salient in the domain. Utilization of the technology according to its spirit was expected to exhibit significant variance even in an environment where universal adoption is demonstrated. While Faithfulness of Appropriation and Consensus on Appropriation have been empirically tested with Satisfaction as the outcome variable (Chin et al., 1997; Salisbury et al., 2002), and with individual level use of collaborative banking software (Kang et al., 2012) to our knowledge this study is the first to test the antecedents’ impact on Team Deep Structure Use (Burton-Jones & Straub, 2006). Therefore this study extends the well- established perspectives in organization theory on the adaptive structuration of technology and work processes within the emergent context of HIT coordination.

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Our study results across all patient conditions suggest that higher reported levels of Faithfulness of Appropriation predict higher Team DSU of CPOE. Similarly, our study results also suggest that higher reported levels of COA are predictive of higher Team DSU of CPOE, with the exception of the Organ Transplant group. Adaptive Structuration Theory suggests that Teams that demonstrate higher FOA and COA will derive positive outcomes as a result of their appropriation of the Advanced IT (DeSanctis & Poole, 1994). Our results suggest that the

clinical task (variations in patient type), and the team structure (inclusion of mid-levels) impart a substantial impact on the relevance of the team appropriation of the IS and the related outcomes (PATSAT). These contextual influences add to our understanding of when Adaptive

Structuration Theory constructs are impactful on theoretical models, and in particular, in the Health IT domain.

Relating our theoretical contributions to our original research questions, we suggest that our results offer strong support for our second research question, namely “How does variation in

clinician team use of IT-based and relational coordination mechanisms affect patient satisfaction?”

Here we have established a measure of rich use in a HIT context through Team DSU, and we are the first to concurrently measure IT-enabled and Relation Coordination as predictors of PATSAT. We find that for patient types of high complexity, teams which report higher levels of Team DSU of CPOE and higher Relational Coordination capability, also report increased PATSAT.

With respect to our first research question, “Why do clinician teams exhibit heterogeneity in the use of IT-based mechanisms?”, our results are less conclusive, but still meaningful. To answer our first research question, we incorporated two theoretical perspectives, AST and Coordination Theory. From Coordination Theory, our expectation was that variation in the levels of task

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uncertainty and task interdependence, as reflected in the patient type rated by our expert panel, would establish a quantitative assessment of the moderating effect of patient type on the effectiveness of our two coordinating mechanisms. Our results were not significant, and

therefore did not support our hypotheses five through eight. Our second theoretical perspective, AST, was found to be a significant predictor of the variance in use of Team DSU of CPOE, as were other well established TAM constructs such as Usefulness and Ease of Use in some contexts. In particular, Faithfulness of Appropriation was found to be salient across all patient conditions, which is unique to the IS literature, and offers insights into the question of “Why teams exhibit heterogeneity of IT-enabled coordination mechanisms. In this context, FOA proved to be an even more consistent predictor of Team DSU than Team Perceived Usefulness, which is of particular interest to the IS literature.