Organizational challenges and struggles with user adoption of computerized clinical applications are common and, as yet, not easily overcome. This case study demonstrates the complexity of the issues and processes that need to be addressed in the implementation of new technologies to support the management of clinical information. These complexities arise in the management of the people, the processes and the technology associated with the change.

More specifically, experiences such as this illustrate that the perceived value and ease-of-use of applications and devices by clinicians are critical to their successful adoption. Healthcare has a pervasive history of information technology solutions being acquired and implemented without considering or rethinking the workflow of users. Although becoming increasingly recognized as a key success factor, the concept of users being engaged and supported as needed - pre- and post-system implementation - remains largely inadequate. Additionally, designating individuals with the responsibility to support the clinical-technical translation (e.g., clinical informaticians) is a strategy that has had a meaningful and successful benefit to implementations in many organizations.

The art of redesigning workflow processes to accommodate new tools to manage clinical information is also yet to be mastered by most organizations. Incorporating new applications of technology without rethinking existing practices is likely to result in inefficient and potentially unsafe workarounds. It is also important to consider that new risks and inefficiencies may arise by introducing new technologies into the work environment. Nonetheless, users' mental models and unaffected work processes should also be considered in the overall redesign of specific work activities.

As discovered in the UHN experience, redesigning workflow processes is likely to uncover organizational inconsistencies in practice and the inadequacies in existing policies with respect to new processes. Organizations need to be willing to acknowledge and address the discovery of practices that violate accepted standards and policies. In addition, new strategies may need to be developed to replace lost functions and mitigate new risks (e.g., electronic whiteboard to alert staff to new orders).

The design of applications and technologies to support clinical information management has markedly improved in recent years. However, the verdict is outstanding with respect to the most appropriate device to support the management of clinical information in healthcare settings by nurses and others. Trial and error and the responsiveness and affordability of devices seem to be prevailing criteria in organizations' choices of appropriate solutions. One might speculate that the ideal devices to support clinical computing have yet to be designed. In the meantime, it is unlikely that a single device will be identified to fit with the work patterns in all clinical settings. At best, efforts should be made to assure the device of choice works for the user and can be reasonably integrated with workflow processes without creating more work.

There is no question that the transition between manual and computerized information management poses many challenges in the delivery of safe clinical care. Similar to the dilemma of determining the most appropriate computing device, the most efficacious order of implementing specific applications remains open to debate. For those in the midst of implementing clinical information systems, early wins can be derived with solutions that are easy to use and bring value-adds to clinicians. This work necessitates thoughtful consideration of the scope and phasing of any implementation. Consider how much risk and disruption your organization is prepared to address in conjunction with the deployment of new technologies. These are disruptive technologies and success is largely dependent upon the diligence, attention and collaborative, collective energy of information technology and clinical experts. Support for users needs to be visible, sustained and grounded in the real world of the clinician community. The need to be accountable for quality, safe care in the face of learning new technologies is a concern for clinicians - a supportive, resource-supplemented infrastructure is essential to continue successful implementation of these new technologies. To chronicle and share experiences such as this is critical to our mutual learning about what works and secures success.

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