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The purpose of this paper is to better understand how and why adoption and implementation of healthcare IT innovations occur. The authors examine two IT applications, computerised physician order entry (CPOE) and picture archiving and communication systems (PACS) at the meso and micro levels, within the context of the National Programme for IT in the English National Health Service (NHS).

To analyse these multi-level dynamics, the authors blend Rogers’ diffusion of innovations theory (DoIT) with Webster’s sociological critique of technological innovation in medicine and healthcare systems to illuminate a wider range of interacting factors. Qualitative data collected between 2004 and 2006 uses semi-structured, in-depth interviews with 72 stakeholders across four English NHS hospital trusts.

Overall, PACS was more successfully implemented (fully or partially in three out of four trusts) than CPOE (implemented in one trust only). Factors such as perceived benefit to users and attributes of the application – in particular speed, ease of use, reliability and flexibility and levels of readiness – were highly relevant but their influence was modulated through interaction with complex structural and relational issues.

Results reveal that combining contextual system level theories with DoIT increases understanding of real-life processes underpinning implementation of IT innovations within healthcare. They also highlight important drivers affecting success of implementation, including socio-political factors, the social body of practice and degree of “co-construction” between designers and end-users.

The originality of the study partly rests on its methodological innovativeness and its value on critical insights afforded into understanding complex IT implementation programmes.

The study aims to analyze the previous literature on government initiatives to implement health information systems (HISs).

Proknow-C (Knowledge Development Process-Constructivist) was used in the selection of the literature and in the bibliometric and systematic analysis.

The research identified a portfolio composed of 33 articles aligned with the research theme and with scientific recognition, as well as periodicals, authors, papers and keywords that stood out the most. Amongst the government initiatives in the 24 identified countries, England has been the most studied nation, and there is a certain prominence of research arising from developed countries. Electronic health records (EHRs) have been the most explored technology. Efficiency and safety of health care delivery, integration of information and among health organizations, cost reduction and economicity are the most expected benefits from government programs. The difficulties found are related to the broader context in which the system is inserted, to the management of the program, to technology itself and to individuals. The most emphasized difficulties identified in most countries were previous context marked by a lack of standardization/interoperability, acceptance of providers and users and project financing. The findings of the present article provide a theoretical framework for future studies, in addition to yielding a replicable process for future use.

This research may be considered original as it analyzes – through a constructivism-structured process (Proknow-C) – the phenomenon under investigation by gathering bibliometric and systematic review data concomitantly. The countries and technologies reported emerge from the process itself.

Health is at the center of society concerns, being characterized by the dilemma of contributing to the population well-being, while demanding high financial investments at the same time. In this sense, information technology (IT) becomes essential for the progress of the sector, directly impacting on how care practices are performed. This study aims to analyze the adoption of mobile devices in the mobile emergency care service (MECS) of the state of Rio Grande do Sul, Brazil.

The authors carried out a multi-method study with an initial qualitative exploration through a focal group, followed by a survey. Potential determinants and impacts of mobile device use on the work context of the MECS teams were identified. Following, we tested the proposed conceptual model applying a questionnaire to 350 professionals from a total of 160 bases throughout the State. Partial least squares structural equation modeling was used to test the hypotheses herein.

The authors found that Satisfaction with the Use of Mobile PHC (PHC – Primary Health Care) is determined by the application compatibility with MECS work, followed by the performance expectancy with the use of the technology and the technical support provided to the users – acting as important facilitators of this process; while the technological complexity inherent in the use of the technology appears as the main barrier to the success of this technology. Besides, the authors found that both intensity of Use and Satisfaction with the Use of the technology provide different benefits to those involved (teams, patients and the organization).

As limitations of the study, the authors point out to the fact that the data are from a single Brazilian State, and therefore, its results cannot be generalized. Another limitation is that the study considered only the use of a specific mobile technology, which requires caution when using this information in contexts where the health information technology is different, besides the fact that the findings may not be compatible in environments where IT adoption is voluntary.

The study can help managers of public and private organizations in the planning and implementation of different technologies, whether mobile or applied to the health context, as well as in the expansion of their use in their respective institutions.

The research contributes to other studies that realize that the adoption of IT can cause relevant changes to health being associated to productivity gains and improvement of the quality of service provided to society through different forms and solutions.

The adoption and use of IT – such as mobile devices – impacts on how care practices are performed in the MECS, providing different benefits to those involved (teams, patients and the organization).

Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy.

We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N = 154), analysis of policy documents (N = 111) and an action learning set, began in 2010–12, with additional data collection from key informants and administrative documents continuing in 2018–19 to supplement and update our findings.

Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load ‘ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed ‘floor' volume.

Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the ‘managerial workaround’ still further.

In the case of DRGs, the managerial workarounds were instances of ‘constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the ‘managerial workaround'.

Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection.

So far as we are aware, no other study presents and tests the concept of a ‘managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.