Three major conceptual frameworks: TTF, FITT, and ISTA.

    Order Description
    Discovery Question

    In a minimum of 400 words, compare and contrast the three major conceptual frameworks concerning technology and task: TTF, FITT, and ISTA.

    1.Fit between Individuals Task and Technology – FITT – Ammenwerth et al.

    2.Interactive Sociotechnical Analysis – ISTA – Harrison et al.

    3.Clinical Adoption Meta-Model – CAMM – Price & Lau

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    BMC Medical Informatics and
    Decision Making
    Research article Open Access
    IT-adoption and the interaction of task, technology and individuals:
    a fit framework and a case study
    Elske Ammenwerth*1, Carola Iller2 and Cornelia Mahler3
    Address: 1Institute for Health Information Systems, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol,
    Austria, 2Institute for Educational Science, University of Heidelberg, Germany and 3Dept. of Psychiatry, University Hospitals of Heidelberg,
    Germany
    Email: Elske Ammenwerth* – [email protected]; Carola Iller – [email protected];
    Cornelia Mahler – [email protected]
    * Corresponding author
    Abstract
    Background: Factors of IT adoption have largely been discussed in the literature. However,
    existing frameworks (such as TAM or TTF) are failing to include one important aspect, the
    interaction between user and task.
    Method: Based on a literature study and a case study, we developed the FITT framework to help
    analyse the socio-organisational-technical factors that influence IT adoption in a health care setting.
    Results: Our FITT framework (“Fit between Individuals, Task and Technology”) is based on the
    idea that IT adoption in a clinical environment depends on the fit between the attributes of the
    individual users (e.g. computer anxiety, motivation), attributes of the technology (e.g. usability,
    functionality, performance), and attributes of the clinical tasks and processes (e.g. organisation, task
    complexity). We used this framework in the retrospective analysis of a three-year case study,
    describing the adoption of a nursing documentation system in various departments in a German
    University Hospital. We will show how the FITT framework helped analyzing the process of IT
    adoption during an IT implementation: we were able to describe every found IT adoption problem
    with regard to the three fit dimensions, and any intervention on the fit can be described with regard
    to the three objects of the FITT framework (individual, task, technology). We also derive
    facilitators and barriers to IT adoption of clinical information systems.
    Conclusion: This work should support a better understanding of the reasons for IT adoption
    failures and therefore enable better prepared and more successful IT introduction projects. We
    will discuss, however, that from a more epistemological point of view, it may be difficult or even
    impossible to analyse the complex and interacting factors that predict success or failure of IT
    projects in a socio-technical environment.
    Background
    It is hard to imagine health care without Information and
    Communication Technology (ICT). Information technology
    in health care has existed for about four decades, and
    has gained widespread usage. Electronic patient records
    offer health care professionals access to vast amounts of
    patient-related information; decision support systems
    support clinical actions; and knowledge servers allow
    Published: 09 January 2006
    BMC Medical Informatics and Decision Making 2006, 6:3 doi:10.1186/1472-6947-6-3
    Received: 16 June 2005
    Accepted: 09 January 2006
    This article is available from: http://www.biomedcentral.com/1472-6947/6/3
    © 2006 Ammenwerth et al; licensee BioMed Central Ltd.
    This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
    which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
    BMC Medical Informatics and Decision Making 2006, 6:3 http://www.biomedcentral.com/1472-6947/6/3
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    direct access to state-of-the-art clinical knowledge to support
    evidence-based medical practice [1].
    Introduction of ICT can radically affect health care organisation
    and health care delivery and outcome. It is evident
    that the use of modern ICT offers tremendous opportunities
    to support health care professionals and to increase
    the efficiency, effectiveness and appropriateness of care
    [2,3].
    However, not all projects introducing IT in health care are
    successful. It is estimated that up to 60 – 70% of all software
    projects fail (e.g. [4]), leading to enormous loss of
    money within healthcare and also to loss of confidence on
    IT from the side of users and managers.
    It is interesting to recognize that the same IT system can be
    seen as success by one department or professional group,
    but as a failure or at least as problematic by another
    department or professional group. Various interconnected
    factors seem to exist that influence success or failure. In
    fact, the notion of success and failure has been largely discussed
    in the literature in the last years. We will not try to
    repeat the overall discussion here, but just refer to some
    good references ([5-11]).
    What we observe in any case is that the objective effects of
    the same IT system can largely differ in different settings.
    This is not surprising if we understand information systems
    as technical systems embedded in a social-organizational
    environment (see also [12]). The technology we are
    introducing in different clinical settings can be largely
    equal (e.g. the same PACS software in various radiological
    departments). But the socio-organizational setting may be
    quite different (e.g. different organization of workflow,
    different patient profiles, different motivation of staff, different
    management support, different IT history etc.),
    leading to different adoption processes of the same IT system,
    and thus to different effects (e.g. increased efficiency
    on one ward, user boycott on the other ward).
    What does this mean for a systematic IT management in
    hospitals? We argue that it would be helpful to know
    more about the factors influencing IT adoption, success
    and failure, and to be able to predict the effects in a certain
    setting.
    Therefore, at least two questions arise which should be
    answered by medical informatics research:
    1. What are the “socio-organizational” factors that influence
    adoption of an IT system in a given socio-organizational
    context?
    2. Based on the answers to question 1: Is there any way to
    predict the effects of an IT system in a certain context?
    The aim of this paper
    The aim of this paper is to present an approach to answer
    the first question. Based on a literature study, we will
    present a framework (the FITT framework) to better analyse
    the socio-organisational-technical factors that influence
    IT adoption. We will present the application of this
    framework in the analysis of a case study, describing the
    adoption of a nursing documentation system in several
    departments of a German University Hospital.
    With regard to the second question, we will argue that
    from some more philosophical point of view, the exact
    prediction of success and failure may not be possible at
    all.
    Previous work on IT adoption
    Analysis of the factors influencing adoption (and thus
    also success and failure) of IT systems in health care has
    been an issue in research for many years. We will define IT
    adoption as follows, based on the discussion in [13]: for
    voluntary used system, IT adoption is reflected in the
    usage of the IT system; for mandatory used systems, IT
    adoption is reflected in the overall user acceptance. In the
    next paragraph, we will analyse some research results on
    factors for IT adoption, focussing on general valid frameworks.
    Analysing the concept of information system (IS) success,
    DeLone [5] developed an information success model for
    management information systems. This model describes
    that the effects of IT on the user (the individual impact)
    and thus on the overall organization depends on the use
    and the user satisfaction. Those two aspects themselves
    depend on the quality of the IT system and the quality of
    the information in this system (Figure 1). This model was
    used to structure a broad literature review, but seems not
    to be further validated. The authors discuss that IS success
    is a multidimensional construct based on the interaction
    of factors, and that a corresponding measurement instrument
    should therefore include not only the described criteria,
    but also their interaction.
    IFnifgourmrea t1ion success model by DeLone [5]
    Information success model by DeLone [5].
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    The information success model is quite interesting as it
    describes the interaction of various factors. However, its
    shortcoming seems to be the isolated focus on IT quality
    and system quality, indicating that only the system’s quality
    itself determines the overall impact. This does not help
    to explain why the same IT system can be adopted in a different
    way, and have rather different effects, in various settings.
    The technology acceptance model (TAM) of Davis [14]
    tries to analyse why users adopt or reject a system. It
    defines the constructs “perceived ease of use” and “perceived
    usefulness” to predict attitude towards using and
    actual system use. Both factors themselves depend on features
    of the system (Figure 2).
    While trying to verify his model by questioning 112 users
    of one company, Davis [14] could partly confirm the
    expected links in his model. In his discussion, he stresses
    that this model is only usable for voluntary use of IT system,
    and that further factors should be included in his
    model, such as extrinsic motivation, user experiences with
    the system, and characteristics of the task to be supported
    by IT (e.g. complexity of a task).
    This TAM model was adopted and extended by other
    researchers such as [15,16] and [17]. For example, Dixon
    [16] extended it to the Information Technology Adoption
    Model (ITAM). He tried to refine the “system design
    features” of the TAM model by describing that an IT system
    has requirements (such as required IT knowledge of
    the users, or necessary technical infrastructure) that must
    be matched with the knowledge and skills of the users and
    with the available technical infrastructure. He called this
    “fit” and argued that perceived usefulness and perceived
    ease of use are not dependent on the system design features,
    but on this fit of user and system design features.
    The paper stays unclear whether the ITAM model was
    more formally validated. It is also unclear why those
    points already discussed as missing by Davis [14] (such as
    extrinsic motivation or task characteristics) were not
    included.
    All of the presented models seem to concentrate rather
    strongly on individual attribute of the users and of the
    technology, neglecting attributes of the clinical environment
    and of the supported clinical tasks that in our opinion
    are of high importance to understand IT adoption
    processes. ITAM is however interesting as it introduced the
    notion of fit, explaining that it is not individual attributes
    which are important, but the quality of fit between e.g. IT
    complexity and IT knowledge.
    The idea of fit is more comprehensively elaborated in the
    task-technology-fit model (TTF) of Goodhue [8,13,18].
    He takes into account not only technology and user, but
    he also considers the complexity of the clinical tasks
    which have to be supported by an IT system. He examines
    the influence of the three factors – individual abilities,
    technology characteristics, and task requirements – on
    performance and on user evaluation of IT systems, highlighting
    the significance of the interaction (fit) of those
    three factors (Figure 3). He argues that TTF (task-technology
    fit, or more correct task-individual-technology fit, as
    explained by [13]) is the extent to which technology functionality
    matches task requirements and individual abilities.
    Goodhue argues that user evaluation is a sufficient
    surrogate of TTF, and that it is appropriate for both mandatory
    and voluntary used IT system. The TTF model was
    used in the area of management information systems, and
    many of the proposed links within the model could be
    validated in studies in various studies with hundreds of
    users.
    TTF extends the other described models by concentrating
    on the fit. IT also includes the object of clinical task (e.g.
    task complexity, organization of tasks, interdependence
    with other tasks) to be supported by IT. However, TTF
    only focuses on the fit between user and technology, and
    between task and technology (see Figure 3). It does not
    consider the interaction of user and task – which is, however,
    in our opinion an important success factor for IT
    introduction projects. For example, introduction projects
    may fail because nurses are not sufficiently motivated for
    nursing process documentation at all, independent of the
    tool used, or physicians may not be motivated to do a
    complete order entry themselves, instead of ordering a
    nurse to complete the order, because of the additional
    time it will take them. In addition, TTF and derived models
    do not reflect on the dynamics of introduction
    projects. Attributes of users, task and technology frequently
    change over time in a clinical environment, and
    thus also their interaction and their fit change.
    However, the notion of fit has been found useful in many
    other studies, too. For example, Folz-Murphy [19]
    described problems of the fit between user requirements
    and available IT functionality. Zigurs [20] examined the
    fit between task and technology in the area of group supports
    systems. Dishaw et.al. [21] extended the TTF – com-
    FTeigcuhrneo l2ogy acceptance model (TAM) by Davis [14]
    Technology acceptance model (TAM) by Davis [14].
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    bined with the TAM model – with the construct of
    computer self-efficacy. With reference to the domain specific
    of users abilities the developed model of Dishaw
    et.al. also implied a relation between the attributes of user
    and task. The idea of fit seems thus to be helpful in various
    contexts.
    Overall, the presented approaches present a good basis for
    the analysis of the IT adoption; however, all of them show
    some limitations.
    Bases on this analysis of the literature, we will now present
    a framework of fit between individuals, task and technology
    (FITT framework), taking into account the processoriented
    character of an IT introduction. We will use our
    framework in a retrospective analysis of a corresponding
    case study.
    Methods: The FITT framework
    Based on the literature review, we found it useful to use
    the interaction (fit) of users, tasks and technology as the
    basis to better understand IT adoptions.
    Our FITT framework (“Fit between Individuals, Task and
    Technology”) is based on the idea that IT adoption in a
    clinical environment depends on the fit between the
    attributes of the users (e.g. computer anxiety, motivation),
    of the attributes of the technology (e.g. usability, functionality,
    performance), and of the attributes of the clinical
    tasks and processes (e.g. organisation, task
    complexity) (Figure 4).
    An “Individual” can represent an individual user or a user
    group. “Technology” can stand for the interaction of various
    tools needed to accomplish a given tasks (e.g. hardware,
    software, network). But the technology does not
    only comprise computer-based tools, but all tools used by
    the individuals to execute the tasks, therefore including
    also paper-based tools. “Task” comprises the wholeness of
    tasks and working processes that have to be completed
    (e.g. nursing documentation, order entry etc.) by the user
    and that are supported by the given technology.
    Many researchers focus on the aspect of “organisation”.
    Organisational aspects in our model are either part of the
    individual aspect (individuals work in various roles and
    various groups in an organization), or they are considered
    in the task aspect (the clinical tasks and processes are
    organized in a given way, with defined responsibilities).
    The objective of IT management can now be defined as
    reaching an optimal fit between technology, user and task.
    This means that e.g. user involvement in the selection
    process or a good user support can improve the fit
    between the three aspects. Individuals must therefore be
    sufficiently motivated and knowledgeable to execute a certain
    task. The technology must offer sufficient functionality
    and performance to support a given clinical task. And
    the user must be sufficiently trained to use a given technology
    adequately. An insufficient fit will probably lead to
    problems during implementation projects.
    The quality of fit depends on the attributes of the objects.
    The following list presents some examples on attributes
    that affect the various fit dimensions:
    • Attributes on individual level: IT knowledge, motivation
    and interest in the task to be completed, flexibility and
    openness to new ways of working, team culture, organizational
    context, cooperation within a team, and politics
    within an organisation.
    • Attributes on task level: Organisation of the tasks to be
    completed, activities and their interdependence, complexity
    of tasks.
    • Attributes on technology level: Stability and usability of
    a software or hardware tool, costs of a tool, functionality,
    available technical infrastructure, integration of tools,
    availability of tools in a certain clinical situation.
    In order to influence and improve the fit, management
    can directly influence those attributes of task, individual,
    and technology. For example, a reorganization of docu-
    FTiagsku-rTee 3chnology-Fit model (TTF) by Goodhue [8], [13], [18]
    Task-Technology-Fit model (TTF) by Goodhue [8], [13],
    [18].
    TbFehigtewu FreIeeTn T4 i nfrdaimvideuwaol,r tka s(1k) a: nITd- atedcohpntoiolong dyepends on the fit
    The FITT framework (1): IT-adoption depends on the fit
    between individual, task and technology.
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    mentation processes may improve the fit between task
    and technology; training sessions for users may improve
    the fit between technology and individuals; a software
    update may influence both the fit between technology
    and task (e.g. new functionality being implemented) and
    between individual and technology (e.g. usability being
    improved). Here are some examples for possible deliberate
    interventions on the three objects to influence and
    optimize the fit:
    • Intervention on the individual level: user involvement
    in system selection and introduction (change management),
    user training sessions, good user support, motivation
    by the management (leadership issues).
    • Intervention on the task level: Reorganisation of task
    and working processes (e.g. new ways for order entry),
    clarification of the responsibilities (e.g. for nursing documentation).
    • Intervention on the technology level: Hardware and
    software updates, redesign of paper-based forms, network
    upgrade.
    Besides the direct interventions on the three objects, there
    are also external factors that may influence the fit, but
    which cannot easily be controlled by the IT management.
    The following list presents examples for those external
    influencing factors:
    • Intervention on the individual level: Staff changes (e.g.
    reducing IT knowledge), workload of staff (e.g. reducing
    time for IT use), changes of hospital strategy (e.g. IT is now
    seen to contribute to competitiveness of the hospital).
    • Intervention on the task level: Rising complexity of the
    task (e.g. by new legal documentation requirements), general
    organisational changes in the organisation, changes
    in patient profiles.
    • Intervention on the technology level: New software
    standards, new technological achievements.
    Due to those external factors, there will never be a complete
    static situation with regard to the three fit dimension
    and therefore to IT adoption. The external factors can
    improve or deteriorate the fit, while the deliberate interventions
    of IT management will be aimed at steadily
    improving the fit. There may only be a partly stable situation
    where the positive and negative changes are mostly
    balanced. It is helpful to describe this fit management and
    fit dynamics as a loop-back system (Figure 5).
    The overall aim is to have an optimal fit to allow an easy
    IT adoption. As described, the fit model allows us to
    describe what we can do to influence and balance the fit.
    The larger the difference between the actual fit and the
    planned fit, the higher the problems during an IT introduction.
    For example, low fit between users and technology
    may lead to user frustration and finally to user boycott
    if no interventions (e.g. IT training sessions) are organized.
    We assume that this basic theoretical approach can help
    analyzing the process of IT adoption during an IT implementation
    project in a clinical environment in the following
    ways (Figure 6):
    1. Any disruptions during an introduction project can be
    described and analysed with regard to the disruption in
    one of the three fit dimensions (task-technology, technology-
    individual, or individual-task). This should help
    plan projects, as problems can be anticipated in advance,
    or can help to analyse problems in a project retrospectively
    in order to learn from them.
    2. Any intervention that is taken to improve a project, to
    make it successful, can be analysed and described with
    regard to one of the three objects (task, individual, or
    technology). Any of those interventions on the objects
    will thereby indirectly affect the fit dimensions.
    We will now present a case study where the FITT framework
    was applied in a retrospective analysis, to show how
    it can help describe and analyse an implementation
    project.
    Reanalysis of a case study: IT adoption and FITT
    framework in a German university hospital
    A computer-based nursing process documentation system
    was introduced on several wards of the University Hospitals
    of Heidelberg between 1998 and 2001. This introduction
    was accompanied by various evaluation activities
    which among others investigated the following aspects:
    • General computer knowledge and attitudes to computers
    in nursing before, during and after system introduction.
    • Nurses acceptance of the nursing care process (the task
    to be supported by the IT) before, during and after system
    introduction.
    • User satisfaction with the nursing documentation system
    before, during and after introduction.
    • Quality of nursing documentation before, during and
    after system introduction.
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    • Overall affects of the nursing documentation systems on
    nursing workflow.
    These evaluations were done e.g. based on standardized
    and validated psychometric questionnaires (given to all
    nurses, with return rates around 80%), standardized documentation
    quality audits (analysing the nursing records
    of 20 patients per ward at three points of time), and focus
    group interviews with 1 – 2 nurses per ward and with
    nursing and project management. Methods and results of
    the evaluation studies have been published e.g. in [22-
    25]. More details on all studies can be found in the corresponding
    German research reports [26-28] as well as in
    [29].
    In general, the evaluation results showed high user acceptance
    of the IT system, and positive effects e.g. on documentation
    quality. A detailed analysis, however, showed
    differences in the reactions of the wards with regard to the
    new IT system. On one (somatic) ward, user acceptance
    was much lower than on the other wards, and several
    problems during IT introduction occurred here. On this
    ward (ward C), user acceptance was very low shortly after
    the introduction, and remained rather low even months
    after it (Figure 7).
    The FITT framework was used to analyse the differences
    on the wards, the process of IT adoption, and the effects of
    interventions taken by the project and IT management to
    improve IT adoption. This analysis was based on the available
    results of the already mentioned various specific evaluation
    studies.
    In this paragraph, we will present the result of this analysis
    for two somatic and two psychiatric wards. As already discussed,
    three of them showed a quick IT adoption, one of
    them showed a more problematic introduction (Figure 7).
    A complete report of this analysis has been published in a
    German project report [27].
    All wards had used a paper-based documentation system
    prior to IT introduction which was now in part replaced
    by a computer-based system. This new IT system covered
    all steps of the nursing process (nursing anamnesis, care
    planning, documentation and evaluation of care – for a
    detailed explanation of the nursing process, see e.g. [30]).
    However, all functionalities were only used on the psychiatric
    wards where all steps of the nursing process were
    documented. The documentation on the somatic wards
    concentrated on the documentation of nursing anamnesis,
    care planning, nursing tasks, and omitting the evaluation
    of care. Nursing notes were written on all wards in the
    IT system.
    Dermatological ward
    The dermatological ward had 20 beds, around 12 nurses
    and a mean length of stay of about 10 days in 2000. The
    IT system was introduced in Sept. 2000. Questionnaires
    and documentation analysis were conducted three
    months before IT introduction and again in Dec. 2000
    and in June 2001. A focus group interview study was conducted
    in February 2002.
    The analysis on this ward found a rather uncomplicated
    and quick adoption of the new IT system. We will present
    the reanalysis of this case on the three fit dimensions:
    • Fit between individuals and task: This fit was mostly
    uncomplicated from the very beginning. Both ward managers
    and nurses stated in the interviews that they were
    tnFThaihegle riu neFrfbIleTuy e T6in fcdreiarsme wcetiwllyl o aarfffkfee c(c2tt )ian: tgDt rteihblieub tetehrsar etoeef itfnaitts ekdr,i vmteeencnthisnoionnlso sagnyd a nedx tfeitr,-
    The FITT framework (2): Deliberate interventions and external
    influences will affect attributes of task, technology and fit,
    thereby indirectly affecting the three fit dimensions.
    PFliagnunrineg 5, directing and assessment of the fit
    Planning, directing and assessment of the fit. While the fit can
    be managed by deliberate active interventions (e.g. by IT
    management), continuous external factors may influence it,
    too.
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    convinced of the necessity of a high-quality nursing documentation,
    for legal reasons and for the reputation of
    nursing. The nursing process was mostly well accepted, as
    the questionnaires showed. Documentation analysis and
    interviews confirmed that nursing documentation was
    more complete after IT introduction than before. However,
    as the intensive documentation audits showed, not
    all steps of the nursing process were well documented,
    and the documentation was in part not adequately
    adapted to the individual patient.
    • Fit between individuals and technology: This fit was
    uncomplicated from the very beginning. The young, motivated
    team with high IT skills had no problems in learning
    the new technology. Computer acceptance and computer
    security levels were found to be high from the very beginning
    both in the questionnaires and the interviews.
    • Fit between task and technology: This fit was a bit problematic
    at the beginning, as the documentation analysis
    showed. The pre-defined nursing care plans offered by the
    IT system were at first not sufficiently adapted to the need
    of this ward. In addition, the computer equipment was
    first insufficient (to small number of computers, too slow
    hardware) to support a timely documentation process.
    Because documentation has always been done in the ward
    headquarters, no mobile or bedside computers were
    found necessary.
    Summarizing, on the dermatologic ward, we found a
    good individual-technology fit after the IT introduction.
    The individual-task as well as the task-technology fit were
    not optimal at the very beginning (Figure 8).
    In order to improve the problematic fit dimensions,
    project management intervened as follows during the
    introduction period:
    • Intervention with regard to task: None.
    • Intervention with regard to user: Several onsite discussion
    to increase nurses’ knowledge of the nursing process
    and how to correctly use pre-defined standardized nursing
    care plans, to increase fit between individual and task.
    • Intervention with regard to technology: The predefined
    standardized nursing care plans were refined, to
    improve adaptation to the individual patient; hardware
    was updated and extended, thereby increasing fit between
    task and technology.
    Those interventions seem to have improved the fit. The
    nurses judge the support of documentation by the software
    and hardware equipment as rather good after two
    years both in the interviews as well in the standardized
    questionnaires. The documentation analysis also show an
    improvement in documentation quality.
    Paediatric wards
    The paediatric ward had 15 beds, around 13 nurses, and a
    mean length of stay about 5 days in 2000. The nursing
    documentation system was introduced in Oct. 2000.
    Questionnaires and documentation analysis were conducted
    three months before IT introduction and again in
    Jan. 2001 and in July 2001. A focus group interview study
    was conducted in February 2002.
    Compared to the other wards this ward showed rather low
    user satisfaction values with the nursing documentation
    system during the introduction phase. An analysis structured
    according to the FITT framework showed several
    problematic areas:
    • Fit between individuals and task: The detailed documentation
    audits showed that nursing documentation
    was incomplete both before and after IT introduction (for
    details, see [24]). The documentation audits showed that
    the amount of documentation rose heavily during IT
    introduction, but documentation quality did not increase
    in the same manner (e.g. inadequate adoption of standardized
    nursing care plans to the individual patient). User
    attitudes with regard to the nursing care process strongly
    declined after IT introduction (details e.g. in [23]). In
    questionnaires and interviews, users complained about
    high time efforts for documentation. These and other
    results indicated that the fit between individuals and task
    may have already been problematic before IT introduction,
    and now deteriorated after IT introduction, as the
    new IT tool forced a more complete documentation, without
    bringing obvious benefits to the nurses.
    • Fit between individuals and technology: Validated
    questionnaires as well as focus group interviews showed
    some initial problems handling the new hardware and
    software. As the questionnaires showed, the users were
    rather unfamiliar with computers in the beginning. Some
    of the users were not too enthusiastic to learn the new IT
    system. However, the general attitudes with regard to
    computers in nursing were comparable to the other wards
    and on a medium level at the beginning. All in all, there
    were only some smaller problems in this fit on this
    dimension.
    • Fit between task and technology: This fit was found to
    be very problematic. Focus group interviews with users
    and managers revealed that in the beginning the software
    was not optimally customized. For example, the predefined
    nursing care plans in the software were found to be
    insufficiently adapted to the patients of this ward (a problem
    comparable to the dermatological ward). Also, the
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    functionality and performance of the system was judged
    to be insufficient in some parts. For example, the repeated
    documentation of one item during a longer time period
    was not well supported. A big problem was also that no
    mobile computers or bedside terminals were available,
    which disturbed the common documentation workflow –
    while the nurses on this ward were used to documenting
    at least some aspects at the patients bedside, this had not
    been reflected by adequate hardware equipment in the
    introduction phase. From the users point of view, this all
    led to high and unnecessary time efforts for documentation.
    Summarizing, on this ward, all three fit dimensions were
    disturbed in the introduction period (Figure 9). Therefore
    it is not surprising that we found rather low user satisfaction
    (e.g., about half of the users wanted to stop using the
    software after three months) during this period.
    Due to these problems, project management decided on
    the following interventions which we have structured
    according to the FITT framework:
    • Intervention with regard to task: The workflow for documentation
    was reorganized, e.g. the number of items
    which needed to be documented were reduced, and some
    intermediate paper-based documentation was allowed to
    react on the missing mobile tools. This improved the individual-
    task as well as the task-technology fit.
    • Intervention with regard to user: Onsite training to
    refresh knowledge on nursing process and nursing documentation
    helped to increase the individual-task fit. Further
    individual training sessions with regard to computers
    in general and the software were organized. This helped
    increase the fit between individual and technology.
    • Intervention with regard to the technology: Missing
    functionality was implemented, erroneous functions were
    corrected, and hardware was updated to increase the performance,
    thus increasing the fit between task and technology.
    All those interventions affected the three fit dimensions
    differently. The repetition of the quantitative evaluation
    about 9 months after implementation indicated a clear
    improvement in user satisfaction, reflecting in our opinion
    an improvement in the fit, which was also supported
    by the interview study. In addition, in the documentation
    analysis, the amount of documentation was now found to
    be reduced.
    Psychiatric wards
    As both psychiatric wards were found to be rather similar
    in IT adoption, they will be discussed here together. The
    wards had 21 resp. 28 beds and around 19 resp. 17 nurses.
    Mean length of stay was around 21 resp. 14 days in 2000.
    The nursing documentation system was introduced in
    Nov. 1998 resp. Nov. 1999. Questionnaires and documentation
    analysis were conducted three months before
    IT introduction, in Febr. 99 resp. March 2000, and again
    in Aug 2000. A focus group interview study was conducted
    in February 2002 with nurses from both wards. Both
    wards had long-term experience with paper-based documentation
    of the nursing process.
    Both wards showed a mostly uncomplicated IT adoption:
    • Fit between individuals and task: This fit was uncomplicated
    from the very beginning. Nursing documentation
    and nursing process were highly accepted by ward management
    and nurses, as reflected in the questionnaires and
    interviews. Documentation analysis found high quality
    and completeness of documentation, even when some
    parts still appeared to be too standardized.
    • Fit between individuals and technology: Nurses were
    motivated to work with the new system. At the beginning,
    some nurses were not very IT experienced and had some
    initial problems, but computer acceptance scores were
    nevertheless high. User confidence and security in working
    with the IT system was found to be rather high.
    • Fit between task and technology: In the beginning, performance
    and functionality of the IT system were regarded
    a5FAwn6inigst sfhwuow retreh erares l 7)l t no4u wtrhsaienr dgq sud;e o1sc t=uio mnnoe “,nD 4tao =t iy oyoneu ss ;yw isnatdneimtc at”to eo dcno isfno ttuihnreu wem aweradonsr ko(infn ag=l l
    Answer to the question “Do you want to continue working
    with the nursing documentation system” on four wards (n =
    56 for all 4 wards; 1 = no, 4 = yes; indicated is the mean of all
    answers). The 2nd questionnaire was applied around 3
    month after IT introduction (except Ward B), the 3rd questionnaire
    at least 6 months after the 2nd.
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    as insufficient by the nurses. Also the quality of the predefined
    nursing care plans were found weak. Nurses felt that
    the system was not very useful to support nursing documentation
    in the first months.
    Summarizing, on these wards, the fit dimensions were
    rather good, with some problems only in the fit between
    task and technology (this comparable to the other wards)
    (Figure 10).
    Project management decided on the following interventions
    that we have structured according to the FITT framework:
    • Intervention with regard to task: None.
    • Intervention with regard to user: Some individual computer
    support was offered to increase fit between technology
    and individual.
    • Intervention with regard to the technology: Missing
    functionality was implemented, erroneous functions were
    corrected, and hardware was updated to increase the performance,
    therefore increasing the fit between task and
    technology.
    These interventions helped to optimize the fit. The evaluations
    after several months and even years after implementation
    showed high user satisfaction and an
    improvement in nursing documentation quality,
    although some functions of the system were still being
    criticised for not being adequately adapted to the specific
    needs of a psychiatric ward.
    Results: Facilitators and barriers to IT adoption
    Based on the result of the analysis of our different study
    wards, we will now collect the factors that seem to represent
    facilitators and barriers to adoption of a computerbased
    nursing documentation system. Based on the
    assumption that IT adoption depends on the fit between
    individual, task and technology, we found indicators in
    the reanalysis of our case study that affect IT adoption of
    nursing documentation systems (formulated in the way
    that the “higher/better” the attribute, the easier IT adoption):
    • Relevant attributes of individuals: Commitment to
    nursing process as basis for nursing, commitment to nursing
    care planning, commitment to written nursing documentation,
    commitment to own professional nursing role
    (IT as professional tool), acceptance of computers in general,
    acceptance of computers in nursing, computer skills,
    typing skills (may be correlated with computers skills),
    general computer knowledge in years, age of nurses (may
    be correlated with computer knowledge), professional
    experience (may be correlated with age), number and
    motivation of key-users, overall motivation of wards to
    introduce the system, climate of support and trust within
    the nursing team, quality management skills of nurses,
    low expectations with regard to computers and nursing
    documentation, low number of staff members and work
    load of ward, low staff fluctuation, low number of parttime
    staff, night watches and nursing trainees on the ward,
    commitment to standardisation of nursing tasks (IT as
    support, or IT reducing individuality of nursing).
    • Relevant attributes of the task of nursing documentation:
    Low complexity, amount and level of detail of documentation,
    clear organization, clearly structured place
    and time of documentation, quality of implemented predefined
    nursing care plans, low number of nursing tasks
    that have to be documented in each shift, low use of documentation
    (e.g. once per shift), long length of stay of
    patients, low complexity of patient profiles (children,
    adults), high use of documentation by other health care
    professionals, available time during routine work to learn
    the system, no parallel redundant use of different documentation
    media (IT, paper), clear agreements with
    regard to organisation of documentation, availability of
    nursing standards from other wards or earlier projects,
    high degree of standardisation of nursing.
    • Relevant attributes of the technology: Quality and
    amount of functionality of software, usability and user
    friendliness of software, stability and flexibility of software,
    quality and performance of hardware and network,
    availability of sufficient number of computers, availability
    of mobile computers, clear version and update management.
    Based on our analysis, the following interventions and
    external factors can be found which may have a positive
    influence on the fit between individuals, technology and
    tasks (mostly corresponding to the “active interventions”
    in Figure 5) and therefore on IT adoption:
    • Positively affecting individual-technology fit: IT training
    sessions, positive external norms (e.g. computers
    belong to nursing), high computer acceptance by nursing
    management, high motivation and training of key users,
    intensive user support, step-wise implementation of functionality
    (instead of all at one point of time), reduction of
    nursing workload during the introduction phase (e.g. by
    additional staff).
    • Positively affecting individual-task fit: Efficient training
    sessions on the nursing process, high acceptance of nursing
    process by nursing management, high external norms
    (e.g. nursing is an own profession), clarification of
    responsibilities within nursing documentation, reorganiBMC
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    zation and restructuring of nursing documentation processes,
    clarification of the sensible amount of nursing
    documentation (to avoid over-documentation), increased
    use of predefined nursing care plans, step-wise introduction
    of nursing process.
    • Positively affecting task-technology fit: Reorganisation
    and restructuring of nursing documentation, local adaptation
    of predefined nursing care plans, update of software
    functionality enabling the reflection of the tasks characteristics
    for a ward, increase in number and availability of
    computers, introduction of mobile tools in case the tasks
    make this necessary.
    Please note that the interventions do in fact directly influence
    attributes of individual, technology, or task, thereby
    only indirectly influencing one or two of the three fit
    dimensions. For example, by organizing additional training
    session, we can improve the IT skills (attributes) of the
    individuals, and thereby also indirectly influence the individual-
    technology fit.
    This analysis should highlight that – even for this rather
    restricted case study and the limited focus on nursing documentation
    – a variety of factors can be found that influence
    the fit between individuals, technology and task and
    therefore IT adoption. This supports the often discussed
    fact that success and failure is a rather complex and multidimensional
    construct.
    Discussion
    In this paper, we presented – based on an analysis of other
    IT adoption frameworks from the literature – a framework
    of the interaction between individual, technology and
    tasks (the FITT framework). This framework was used to
    support a structured retrospective analysis of the introduction
    of a nursing documentation system in a German University
    Hospital. The detailed analysis of the case study
    showed common features, but also differences of IT adoption
    of the wards which could be easily reflected and analysed
    based on the FITT framework.
    The FITT framework focuses on the significance of the
    optimal interaction (fit) of individual user, technology,
    and task. The fit between the attributes is more important
    than the individual attributes themselves. For example, IT
    skills of the users are not sufficient for the success of an
    introduction – rather, they must match the requirements
    by the IT software (e.g. software complexity).
    In our case study, the clear structure with three objects and
    three fit dimensions helped us reflect on the different reactions
    of the wards we had found in the evaluation studies,
    on the problems which occurred during introduction, and
    on the interventions of project management. We did not
    find any aspect that we could not easily structure within
    this FITT framework. This however can not be regarded as
    formal proof of completeness of our framework.
    The idea of fit has been introduced by other authors
    before, such as [16] or [18]. Nancy Levensen discussed in
    here keynote at the Information Technology in Health
    Care Conference (ITHC 2004) in Portland that system
    failure often depends on failures in the interaction
    between components, not on the quality of the components
    themselves that often do not present problems from
    an isolated point of view. Southon [31] discussed the fit
    between organization, technology and user skills. Lundberg
    [32] examined the interaction between actors (staff),
    artefacts (technology) and working processes during a
    PACS installation. And Palvia [33] analysed the significance
    of the factors task, technologies, user, and organisation
    during a system introduction.
    But none of those previous and the other analysed
    authors, to our knowledge, noticed the important interaction
    between user and task. There are many examples e.g.
    in the area of nursing documentation systems or computerized
    physician order entry where the users were not
    motivated to do a certain task – independent of the quality
    and functionality of the IT tool that was introduced!
    The reason why this interaction is often overlooked seems
    simple: In many cases, IT introduction is accompanied by
    organizational changes (e.g., when CPOE is introduced, a
    much higher documentation burden is suddenly put on
    the physicians), often leading to low user satisfaction or
    even user boycott (see example in [34]). These problems
    are then often attributed to the IT system (suspecting a
    low fit between IT and user or between IT and task). But
    in fact the problems are mostly coming from a more fundamental
    ill-acceptance of the new task to be done, thus
    reflecting a low fit between user and task! For an example
    of this ill-acceptance, see the detailed analysis of a CPOE
    introduction by Massaro [35].
    iFAnintgrauolydrseuis c 8toiof nth oef Ftiht eo cno am dpeurtmera-tboalosegdic dwoacrudm sehnotrattliyo na ftseyrs tem
    Analysis of the Fit on a dermatologic ward shortly after
    introduction of the computer-based documentation system.
    An arrow indicates problems with the fit, a sun indicates an
    uncomplicated fit.
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    Management of fit can be regarded as a loop back system,
    reflecting that the fit is never really stable, but that it is
    changing based on external factors or deliberate interventions,
    making fit management a constant and complex
    task for the whole life cycle of an IT system.
    In our case, all wards showed specific and time-dependent
    IT adoption processes while starting to work with computer-
    based nursing documentation system. Unfortunately,
    we could not analyse this process in detail, as the measurement
    points of the various studies were too different
    and irregular (the available data came from four partly
    independent evaluation studies). A more refined analysis
    would have needed an analysis in regular short intervals.
    Thus, all our presentations with regard to the dynamic of
    the IT adoption within the wards must be taken with care
    – e.g., in Figure 7, we do not know whether there have not
    been ups or down of user satisfaction in between the two
    measurement points.
    All wards are now working rather successfully with the
    computer-based nursing documentation system, however,
    still the fit is not in complete balance, as further
    changes are steadily occurring (e.g. new staff members
    need to be trained, new documentation standards have to
    be implemented, software errors lead to updates, refinement
    of organization of nursing documentation, new
    documentation guidelines leading to training session
    etc.). We expect that managing the fit balance is a continuous
    task which is never really completed, and can be
    described as a loop-back system (cp. Figure 5).
    Our case study shows the complexity of a broad introduction
    of an IT system in various settings: Individuals and
    tasks are rather different in the various settings, requiring
    high flexibility of the IT system and individual IT introduction
    and support activities to get the best fit for each
    ward. This helps to explain why we can find different IT
    adoption even when the same software and hardware is
    introduced.
    Interestingly, it seems that the involved users often are not
    able to distinguish between the various fit dimensions.
    For example, the nurses in our study partly expressed the
    opinion that the new software system was not usable.
    Detailed analysis revealed that at least some problems
    were based on the miss-fit between user and task – and
    not on a miss-fit between user and technology.
    In this context, we want to stress the significance of the
    user in IT introduction projects. Investing in user training
    and user support can have positive effects on both individual-
    task and individual-technology fit. In addition,
    user involvement in system design and selection helps to
    build more adequate systems, therefore also improving
    the task-technology fit. And, as Goodhue [8] shows, user
    evaluation is a good surrogate for the overall fit, explaining
    partly why user acceptance studies have found so
    widespread use (which should not be understood as to
    underestimate the significance of objective performance
    measures).
    In case we accept the FITT framework as a point of basic
    understanding of IT adoption – what are the following
    steps in ongoing development of this framework? Some
    may argue that the first logical step would now be to
    develop measurement instruments for the fit (as e.g.
    Goodhue [18] tries for his task-technology fit) which in
    fact seems necessary. The second step could then be to
    quantify the factors influencing the fit, to allow better and
    quantifiable prediction and planning of successful IT
    adoption – e.g. if we knew that IT skills explain around
    65% of the variability of fit between IT and users, then we
    may consider it useful to invest in training session. Comparable
    quantitative oriented research on factors was e.g.
    done by [23,36] or [37]. To achieve this goal, we would
    have to compile a complete list of attributes of tasks, technology
    and individual influencing the fit. However, this
    research approach would only make sense from a realistic
    (or positivistic) point of view where we expect that an
    absolute reality exists, where objects have attributes which
    we can unambiguously measured.
    From another perspective that is often called relativistic or
    constructivistic, this approach may be seen as misleading,
    as no absolute and measurable reality is thought to exist.
    In any case, we are dealing here with people whose reactions
    to given inputs cannot be precisely predicted – as
    von Förster [38] would put it, socio-technical systems are
    non-trivial systems. From this point of view, the significance
    of the various factors influencing the fit can only be
    analysed based on the background of a given setting, with
    all of the political, organizational and individual history
    influencing the fit. The isolated analysis of say four factors
    (out of an unknown but probably very large number of
    existing factors) can never lead to a significant and comdFAuingcautliyorsenis
    9ooff tthhee cFoitm opnu tae pr-abeadsieadtr idco wcuamrde snhtaotritolyn asfytsetre mintro-
    Analysis of the Fit on a paediatric ward shortly after introduction
    of the computer-based documentation system. One
    arrow indicates smaller problems with the fit, two arrows
    larger problems.
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    prehensive insight into what is going on in a given context.
    And a generalisation of interactions between these
    limited numbers of factors could never reflect all possible
    settings and would thus not be useful. Summarizing, from
    a more epistemological point of view, it may be difficult
    or even impossible to analyse the complex and interacting
    factors that influence the fit.
    Without adopting any specific research paradigm here, we
    would like to argue that research on factors influencing
    the fit (or IT adoption in general) must try to generalize
    from individual cases. We must come to a valid measurement
    instrument for the fit dimensions. And we are convinced
    that independent of the setting, there may be some
    priority of factors (e.g. in our case, we found IT skills to be
    less important than acceptance of the nursing process on
    all wards). Even such a rough priority list would help IT
    managers to optimize planning and directing of IT systems
    in clinical context – without trying to quantify the
    individual impacts and their interactions, which in fact
    does not seem helpful. Research in this direction has been
    done e.g. by [39] or [40].
    In any case, at the moment, the FITT framework presents
    a straight-forward analytic framework to describe and
    analyse IT adoption case studies. It is innovative in the
    sense that it clearly describes the objects and their interactions
    affecting the fit, understanding fit management as a
    loop-back system.
    The FITT framework was based on the retrospective analysis
    of the adoption of a nursing documentation system
    on four wards over 3 years. With regard to the broad literature
    we have discussed in the beginning, showing the
    usefulness of the notion of fit in various settings, we
    expect the FITT framework to be valid also for other IT
    types in other settings – but this still needs to be verified.
    The framework should now continue to be refined and
    also balanced to other adoption theories. And, as said, we
    need a valid quantitative measurement instrument for the
    three fit dimensions. The description of the dynamics of
    change can be improved by introducing a time axis into
    the framework. After further refinement and validation of
    this theoretical approach, we expect an even better support
    for the planning and evaluation of IT introduction
    projects.
    Conclusion
    In this paper, we presented – based on an analysis of other
    IT adoption frameworks from the literature – a framework
    of the interaction between individual, technology and
    tasks (the FITT framework). This framework was successfully
    used to support a structured retrospective analysis of
    the introduction of a nursing documentation system in a
    German University Hospital. Based on this case study, we
    derived facilitators and barriers to IT adoption of clinical
    information systems. This work should support a better
    understanding of the reasons for IT introduction failures
    and therefore enable a better prepared and more successful
    IT introduction projects.
    Competing interests
    The author(s) declare that they have no competing interests.
    Authors’ contributions
    The case study was planned and executed by EA. CI participated
    in the qualitative part of the case study, CM in the
    quantitative part of the study. The FITT framework was
    developed by EA and CI together. The paper was written
    by EA with the support of CI and CM.
    Acknowledgements
    We would like to thank all the staff from the various study wards as well as
    the large project team for their long-time dedication to this research
    project. A preliminary version of this paper was presented at the conference
    “Information Technology in Health Care (ITCH 2004)” in Portland in
    September 2004 [41].
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    Pre-publication history
    The pre-publication history for this paper can be accessed
    here:
    http://www.biomedcentral.com/1472-6947/6/3/prepub

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