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The use of information technologies for knowledge sharing by secondary healthcare organisations in New Zealand
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 1 ( 2 0 1 2 ) 500–506
journal homepage: www.ijmijournal.com
The use of information technologies for knowledge sharing by secondary healthcare organisations in New Zealand Nor’ashikin Ali, Dick Whiddett ∗ , Alexei Tretiakov, Inga Hunter Department of Management, Massey University, Private Bag 11 222, Palmerston North, New Zealand
a r t i c l e
i n f o
a b s t r a c t
Article history:
Purpose: To explore the extent of use of information technologies (ITs) for knowledge sharing
Received 26 August 2011
by secondary healthcare organisations in New Zealand.
Received in revised form
Methods: We used a self-administered questionnaire to survey Chief Information Officers at
28 February 2012
all 21 of New Zealand’s District Health Boards regarding the extent to which their organ-
Accepted 29 February 2012
isations use knowledge sharing activities involving ITs. The list of activities to include in the questionnaire was compiled by reviewing the literature. We analysed the extent of use of the knowledge sharing activities using descriptive statistics, repeated measures ANOVA,
Keywords:
and correlation analysis.
Knowledge management
Results: The response rate was 76%. Although all the responding organisations reported
Medical informatics applications
using ITs to share knowledge, they used ITs to share documents significantly more than
Information seeking behaviours
to support discussions or to connect employees to experts. Discussions via teleconferenc-
Hospitals, public
ing, videoconferencing, and email lists were significantly more common than discussions
New Zealand
via social media technologies: electronic discussion forums, blogs, and on-line chatrooms. There were significant positive correlations between publishing and accessing documents, between using teleconferencing and using videoconferencing, and between publishing and finding contact details of experts. Conclusion: New Zealand’s District Health Boards are using a range of ITs to share knowledge. Knowledge sharing activities emphasising the sharing of explicit knowledge (via exchanging documents in electronic form) are significantly more common than knowledge sharing activities emphasising the sharing of tacit knowledge (via technology-mediated discussions and via using technology to connect employees to experts). In view of the evidence in the literature that information technology may be highly effective in supporting tacit knowledge exchanges, our results suggest that health organisations should consider greater adoption of ITs for sharing tacit knowledge. The finding that several organisations are currently making extensive use of teleconferencing and videoconferencing facilities and expertise databases suggests that these technologies are useful and could be of benefit to other healthcare providers and that barriers to their adoption can be overcome. In order to facilitate the wider adoption of technologies, early adopters of both relatively established technologies and of the emerging technologies such as social media should be encouraged to publish accounts of their experiences of success and lessons learnt from any failures so that the knowledge gained is disseminated to the wider medical informatics community. © 2012 Elsevier Ireland Ltd. All rights reserved.
∗
Corresponding author. Tel.: +64 6 3569099x2689; fax: +64 6 350 5661. E-mail address: [email protected] (D. Whiddett). 1386-5056/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2012.02.011
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 1 ( 2 0 1 2 ) 500–506
1.
Introduction
Over recent years, the health sectors in many industrialised countries have promoted the use of knowledge management to improve the safety, effectiveness, and overall quality of the services they provide. In the USA, the Institute of Medicine issued the “Crossing the Quality Chasm” report [1] that singled out knowledge management as a high priority for healthcare. In England and Wales, the National Health Service embarked on a programme of reform that included expanding the use of knowledge management techniques [2,3]. In New Zealand, the Ministry of Health issued the WAVE (Working to Add Value through E-information) advisory group report [4] calling for better use of knowledge management in healthcare. Recent studies of knowledge management and information-seeking behaviours of practitioners highlighted the role of informal networks or “communities of practice” in the decision-making processes of doctors [5,6]. Nicolini et al. [6] also noted the importance that practitioners place on access to local knowledge that is tailored to a specific context, as opposed to more generic knowledge such as research publications. These findings emphasise the importance of knowledge sharing occurring locally. One approach to improving the use of knowledge in the health sector has been the development of sophisticated information systems that integrate electronic knowledge bases with electronic health records and clinical decision support tools [7]. However, a recent study of healthcare organisations in the USA [8] found that even large and well-funded organisations struggle to develop and maintain such complex systems. In contrast, the use by health organisations of ad hoc knowledge management systems relying on commonly available information technologies (ITs) to share local knowledge has received little attention from researchers. Our study contributes to bridging this gap by examining the extent to which healthcare organisations in New Zealand use commonly available ITs to support knowledge sharing activities. We derived the activities to include in the survey from a review of the literature. We divided the activities into three broad categories: sharing documents, supporting discussions, and locating expertise. For sharing documents, the activities were (a) publishing documents on computer networks [9], (b) accessing documents on computer networks [10], and (c) exchanging documents as email attachments [11]. For supporting discussions, the activities were (a) discussions via email lists [11], (b) discussions via electronic discussion forums [12], (c) discussions via blogs [13], (d) discussions via chatrooms [14], (e) teleconferencing [15], and (f) videoconferencing [16]. For locating expertise, the activities were (a) publishing contact details of experts on computer networks (via shared drives, web sites, groupware, social networking sites, etc.) [17] and (b) searching for contact details of experts on computer networks [18]. To explore the extent of use of these knowledge sharing activities, we conducted a descriptive survey using a questionnaire asking the respondents to specify the extent to which each of the activities is used in the respondent’s organisation. The survey targeted all District Health Boards (DHBs) in
501
New Zealand, represented by their Chief Information Officers (CIOs). The rest of this article is organised as follows. Section 2 presents the participant characteristics, the details of the questionnaire design, and the survey administration procedures. Section 3 presents the analysis of the data; we compare the extent of use for different activities and explore correlations between the activities. Finally, Section 4 outlines the implications for knowledge sharing practice.
2.
Method
2.1.
Participant characteristics
The New Zealand government funds free secondary healthcare in public hospitals, which are managed by DHBs [19]. The DHBs have integrated information technology services provided under the direction of CIOs. We used a DHB as a unit of study. Each DHB was represented by its CIO, who completed our survey questionnaire on behalf of the DHB. We assumed that CIOs can provide accurate responses about the use of ITs for knowledge sharing in their organisations. To ensure the well-being of the research participants and to comply with the Massey University regulations we followed the approval and notification procedures prescribed by the university. We informed the participants of their rights, including the right not to participate in the research, in the form prescribed by the university regulations. The participants gave informed consent by choosing to fill in the questionnaire.
2.2.
Questionnaire design
The questionnaire consisted of 13 questions. The first 11 questions asked about the extent to which the respondent organisations use knowledge sharing activities involving ITs. We selected the activities to include in the questionnaire based on the literature on the use of information technology for knowledge sharing in organisations. For a list of activities covered by the survey, literature sources supporting their inclusion, and the corresponding survey items, refer to Table 1. In the survey questionnaire, we asked the respondents to indicate the extent of use for each activity, specifying whether it is used not at all, seldom, often, or very often in their organisation. In statistical analysis, we mapped these anchors to 0, 1, 2, and 3, respectively. Following the first 11 questions we included an open-ended question requesting the respondents to list any other activities involving the use of ITs for knowledge sharing at their organisations, in addition to the activities explicitly mentioned in the questionnaire. The last question was on the size of the organisation.
2.3 .
Survey administration
We piloted the questionnaire with two university lecturers and eight PhD students, as well as three employees in the New Zealand healthcare sector. Based on the feedback from the pilot participants, we refined the questionnaire to improve its comprehensibility.
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Table 1 – Knowledge sharing activities involving information technology. Activity Sharing documents DOC.ACCESS DOC.EMATT DOC.PUBLISH Supporting discussions DISC.BLOG DISC.CHAT DISC.ELIST DISC.FORUM DISC.TELCONF DISC.VIDCONF Locating expertise EXPERT.FIND EXPERT.PUBLISH
Survey item We access documents published by our colleagues on computer networks (via shared drives, web sites, groupware, social networking sites, etc.) We exchange documents as email attachments with colleagues We publish documents on computer networks (via shared drives, web sites, groupware, social networking sites, etc.) to share them with our colleagues
[10]
We use blogs to share opinions/information We discuss issues via chatrooms We discuss issues via email lists We discuss issues via electronic forums We use teleconferencing to discuss issues We use videoconferencing to discuss issues
[13] [14] [11] [12] [15] [16]
We use computer networks (shared drives, web sites, yellow pages, groupware, social networking sites, etc.) to find contact details of people with knowledge and/or expertise We use computer networks (shared drives, web sites, yellow pages, groupware, social networking sites, etc.) to publish contact details of people with knowledge and/or expertise
[18]
We distributed the revised questionnaire to the CIOs of the 21 DHBs. Hard copies of the questionnaire were mailed to named individuals with an accompanying letter and a prepaid envelope. After the first mail-out and the subsequent return of completed questionnaires, we sent to the non-respondents the first reminder, which included a URL to an online version of the survey. The reminder elicited further responses. We mailed the second reminder as a letter with an extra hard copy of the questionnaire. This further increased the response rate.
2.4.
Analysis
We used repeated measures ANOVA tests to compare the levels of use of knowledge sharing activities involving the use of ITs and used Pearson’s correlation tests to assess the significance of correlations between activities. The significance level of .05 was used throughout. Data manipulation and analysis was performed using R version 2.13.0.
3.
Results
3.1.
Response rate
Sources
The response rate was 76%. Fifteen responses arrived as hard copies, and only one arrived via the online questionnaire, giving a total of 16 responses. Out of these responses, 10 responses arrived within two weeks of the initial mail out, four responses arrived after the first reminder, and two responses arrived after the second reminder. Since the respondents were CIOs, the response rate of 76% we achieved was high considering the time constraints on people in such positions. The response rate was much better than in most studies targeting CIOs as respondents; the response rates in such surveys are typically of the order of 20% [20,21]. All respondents answered all questions; there were no missing values, and all responses were usable.
3.2.
[11] [9]
[17]
Extent of use of knowledge sharing activities
Fig. 1 summarises the responses by presenting the breakdown of extent of the use ratings for each activity, with activities arranged by descending mean extent of use. CIOs in nine of the 16 respondent organisations characterised the majority (six or more) of the activities included in the survey as used often or very often. CIOs in all the respondent organisations characterised at least three of the activities as used often or very often. Using email to exchange documents as attachments was the most prevalent activity (rated very often by 83% of the respondents). “Discussing issues via chatrooms” activity did not occur at all. Table 2 presents the summary statistics of the findings by providing mean values and 95% confidence intervals for each of the activities. A repeated measures ANOVA test confirmed that different activities were used to different extents (p < .001).
Fig. 1 – Breakdown of extent of the use ratings for knowledge sharing activities involving the use of ITs. Activities are arranged by descending mean extent of use. For definitions of activities, see Table 1.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 1 ( 2 0 1 2 ) 500–506
the difference between the two activities related to locating expertise was not statistically significant (p = .09).
Table 2 – Average extent of use of knowledge sharing activities involving information technologies. Activity
Extent of use M
SD
DOC.EMATT DOC.PUBLISH DOC.ACCESS DISC.TELCONF DISC.ELIST DISC.VIDCONF EXPERT.FIND EXPERT.PUBLISH DISC.FORUM DISC.BLOG DISC.CHAT
2.75 2.69 2.62 2.12 1.88 1.69 1.56 1.31 0.69 0.38 0
0.58 0.60 0.62 0.81 0.89 0.79 0.96 1.01 0.60 0.62 0
3.2.4. Other uses of information technology for knowledge sharing
95% CI LL 2.44 2.37 2.30 1.70 1.40 1.26 1.05 0.77 0.37 0.05
UL 3.06 3.01 2.95 2.55 2.35 2.11 2.08 1.85 1.01 0.70
Note: M, mean; SD, standard deviation; CI, confidence interval; LL, lower limit, UL, upper limit. Activities appear in the order of decreasing use. For definitions of activities, see Table 1.
3.2.1.
Sharing documents
The most commonly used knowledge sharing activities were associated with sharing documents electronically, with over 90% of respondents characterising all the three activities in the sharing documents category as used often or very often. Sharing documents was most frequently performed by exchanging documents as email attachments (DOC.EMATT), followed by publishing documents electronically (DOC.PUBLISH), and accessing documents electronically (DOC.ACCESS) (see Table 2 for details). As one would expect from small differences in means and broad confidence intervals, these differences were not statistically significant (p = .74).
3.2.2.
Supporting discussions
Discussion activities most commonly occurred via teleconferencing (DISC.TELCONF), followed by email lists (DISC.ELIST), and videoconferencing (DISC.VIDCONF). Electronic discussion forums (DISC.FORUM) and blogs (DISC.BLOG) were used less frequently. Chatrooms were not used at all. The results of a repeated measures ANOVA test suggested that the differences between more frequently and less frequently used discussion activities were significant (p < .001). However, a similar test for just the three activities involving more established technologies (teleconferencing, email lists, and videoconferencing) found no significant differences (p = .27). A similar test for the remaining three discussion activities involving newer, less established technologies (discussion forums, blogs, and chatrooms) also found no significant differences (p = .08). Thus, the discussion activities naturally separated into two groups: the activities relying on more established technologies (which are used more often), and the activities relying on comparatively new technologies (which are used less often).
3.2.3.
503
In their answers to the open question regarding knowledge sharing activities that were not in the questionnaire, respondents mentioned using peer-to-peer text messaging, publishing information on YouTube (sharing videos on the Web), and accessing external Web services such as knowledge bases and decision support sites.
3.3.
Correlations between knowledge sharing activities
We used correlation analysis to determine the statistically significant relationships between the knowledge sharing activities. Only three correlations were statistically significant at the .05 level: • Publishing documents on computer networks (DOC.PUBLISH) significantly and positively correlated with accessing documents on computer networks (DOC.ACCESS) (r = .92; p < .001). • Publishing contact details on computer networks (EXPERT.PUBLISH) significantly and positively correlated with finding contact details (EXPERT.FIND) (r = .76; p < .001). • Using teleconferencing (DISC.TELCONF) significantly and positively correlated with using videoconferencing (DISC.VIDCONF) (r = .79; p < .001).
3.4.
Organisation size
Besides information about the extent of use of knowledge sharing activities, the survey also captured organisation size. The respondents’ organisations had large workforces ranging from 800 to 9000 employees, with the median size of 2550. We examined correlations between organisation size and the extent of use of knowledge sharing activities involving ITs. We found that only one activity, discussions via blogs (DISC.BLOG), correlated significantly with organisation size (r = .62; p = .01), suggesting that the number of potential users should be large for discussions around blogs to become established.
4.
Discussion
We identified the extent of use of knowledge sharing activities involving commonly available ITs by DHBs in New Zealand. The results indicate that the CIOs of the DHBs perceive their organisations as extensively using ITs for knowledge sharing; more than 50% of the respondents checked often or very often for most of the knowledge sharing activities in the survey. This finding is consistent with the claim by Orr [22] that the New Zealand health sector is evolving to rely more and more on ITs for knowledge management.
Locating expertise
In terms of the extent of use, using computer networks to find and to publish contact details of experts followed teleconferencing, videoconferencing, and email lists. The difference was small but statistically significant (p = .02). At the same time,
4.1.
Sharing explicit knowledge
The extent of use for knowledge sharing activities involving document sharing was higher and statistically significantly
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different from the extent of use for discussion activities or for publishing and finding expertise. Thus, the dominant knowledge sharing activities involving the use of ITs in the surveyed organisations were supporting the sharing of explicit knowledge, rather than the sharing of tacit knowledge. Explicit knowledge is formal knowledge that can be codified and captured as documents, while tacit knowledge is informal and know-how knowledge that can only be transmitted in direct interaction, such as joint action or discussion, with the individuals who possess it [18,23]. Sharing documents as email attachments occurred extensively. This finding is consistent with the finding by Didham et al. [24] that New Zealand healthcare organisations extensively rely on email as a communication medium. Publishing and accessing documents on computer networks require more technical knowledge than using email; thus, one might expect that email attachments would be used more extensively than publishing on computer networks. However, in our study the difference was not significant. Publishing documents and accessing documents on computer networks were statistically significantly and positively correlated. The positive correlation suggests that publishing documents on computer networks does not result in excessive information overload, so that when more information is made available, more, and not less, information is accessed – employees are not relying on withdrawing strategy to deal with information overload. Refer to [25] for a detailed discussion of withdrawing strategy.
4.2.
Sharing tacit knowledge
Teleconferencing is easier and less expensive to use than videoconferencing. However, although the estimated mean extent of use for teleconferencing was higher than for videoconferencing, the difference was not significant. Significant positive correlation between using teleconferencing and using videoconferencing suggests that the two activities meet similar needs, such as the need to provide media-rich connectivity to support virtual teams. Activities involving the use of ITs for publishing and for finding contact details of experts were used less often than discussion activities involving established ITs. The two activities were significantly positively correlated, similarly to sharing and accessing documents, offering additional support to the conclusion that withdrawing strategy to deal with information overload is not used. Discussion activities relying on social media technologies – discussion forums, blogs, and chatrooms – were used significantly less often than discussion activities relying on more established technologies. The social-media technologies were rarely used to support discussions in respondents’ organisations, although there are reports in the literature suggesting that these technologies are effective in promoting the exchange of knowledge in industrial organisations (e.g. [26–28]). Furthermore, Doc2Doc, which is run by the British Medical Journal, is an example of a successful social media site used primarily by healthcare professionals [29]. These reports suggest that social media technologies might be effective in promoting tacit knowledge sharing in healthcare organisations and further research on critical success factors for
adopting such systems in healthcare context is desirable. We note that prior studies indicate that organisational culture and management support may influence employees to participate in electronic discussion forums [30–32].
4.3.
Limitations of the study
This study is based on frequency of use as reported by CIOs according to their perceptions. Measuring the actual usage would result in more accurate numbers but was not feasible, as it would interfere with the functioning of the participating organisations. The generalisability of the results and conclusions may be limited because of the nature of the respondents’ organisations. The DHBs in New Zealand are large organisations with high levels of information technology infrastructure and expertise [22]. The results, therefore, may not apply to smaller organisations, such as the organisations found in primary care, or to healthcare organisations in countries that give less priority to information technology infrastructure in healthcare.
4.4.
Conclusion
New Zealand’s District Health Boards are using a range of ITs to share knowledge. Knowledge sharing activities emphasising the sharing of explicit knowledge (via exchanging documents in electronic form) are significantly more common than knowledge sharing activities emphasising the sharing of tacit knowledge (via technology-mediated discussions and via using technology to connect employees to experts). Thus, although the sharing of tacit knowledge in healthcare organisations is highly important and healthcare professionals tend to value tacit knowledge exchanges with their colleagues more than access to formalised knowledge [33], health professionals are not taking advantage of the full potential of ITs to facilitate such sharing. The finding that several organisations are currently making extensive use of teleconferencing and videoconferencing facilities and expertise databases suggests that these technologies are useful and could be of benefit to other healthcare providers and that barriers to their adoption can be overcome. In order to facilitate the wider adoption of technologies, early adopters of both relatively established technologies and of the emerging technologies such as social media should be encouraged to publish accounts of their experiences of success and lessons learnt from any failures so that the knowledge gained is disseminated to the wider medical informatics community.
Author contributions All authors contributed to the conceptualisation and design of the study. NA conducted the survey and managed the acquisition of data. NA,AT performed the data analysis. All authors contributed to the interpretation of the results. NA drafted the article and all co-authors were involved in the revision of the article and approval of the final version of the manuscript.
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Summary points What was already known on the topic: • Health authorities promote the use of knowledge management. • Health workers prefer tacit knowledge they gain in interactions with colleagues to explicit knowledge available as documents. • Cases of successful use of social media technologies for knowledge sharing in organisational contexts are documented in the literature. What this study added to our knowledge: • Secondary care organisations in New Zealand extensively use information technologies to share explicit knowledge. • Secondary care organisations in New Zealand use information technologies to share explicit knowledge to a significantly greater extent than for sharing tacit knowledge. • Secondary care organisations in New Zealand rely on established technologies to transfer tacit knowledge to a significantly greater extent than on social media technologies.
Competing interests The authors declare that they have no conflicts of interest in relation to this article.
Acknowledgements We thank Chris Dever, Chairman of New Zealand’s DHBs CIO group, for providing the list of contacts of the CIOs, as well as the CIOs who took the time to respond to our questionnaire. We also thank Dr. Jan-Lockett Kay, Massey University, for her feedback on the information technology environment in healthcare and Dr. Barry McDonald, Massey University, for advice on statistical analysis.
references
[1] Committee on Quality of Healthcare in America Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, The National Academy Press, Washington, DC, 2001. [2] Department of Health, The NHS Plan: A Plan for Investment A Plan for Reform, The Stationery Office, London, 2000. [3] S.P. Bate, G. Robert, Knowledge management and communities of practice in the private sector: lesson for modernising the National Health Service in England and Wales, Public Administration 80 (2002) 643–663. [4] WAVE Advisory Board, From Strategy to Reality – The WAVE Project, New Zealand Ministry of Health, Wellington, 2001.
505
[5] M. Dawes, U. Sampson, Knowledge management in clinical practice: a systematic review of information seeking behaviour in physicians, International Journal of Medical Informatics 71 (2003) 9–15. [6] D. Nicolini, J. Powell, P. Conville, L. Martinez-Solano, Managing knowledge in the healthcare sector, International Journal of Management Reviews 10 (2008) 245–263. [7] S. Abidi, Knowledge management in healthcare: towards ‘knowledge-driven’ decision-support services, International Journal of Medical Informatics 63 (2001) 5–18. [8] D.F. Sittig, A. Wright, L. Simonaitis, J.D. Carpenter, G.O. Allen, B.N. Deobbeling, A.M. Sirajuddin, J.S. Ash, B. Middleton, The state of the art in clinical knowledge management: an inventory of tools and techniques, International Journal of Medical Informatics 79 (2010) 44–57. [9] K. Desouza, Facilitating tacit knowledge exchange, Communications of the ACM 46 (2003) 85–88. [10] B.J. Bowman, Building knowledge management systems, Information Systems Management 19 (2002) 32–40. [11] J.L. Zhao, K. Akhil, A.S. Edward, Workflow-centric information distribution through e-mail, Journal of Management Information Systems 17 (2000) 45–72. [12] P. Gray, S. Tehrani, Technologies for disseminating knowledge, in: C.W. Holsapple (Ed.), Handbook on Knowledge Management, vol. 2, Springer, Lexington, 2003. [13] C.L. Hsu, J.C. Lin, Acceptance of blog usage: the roles of technology acceptance, social influence and knowledge sharing motivation, Information and Management 45 (2008) 65–74. [14] J.A Powell, M. Darvell, J.A.M. Gray, The doctor, the patient and the world-wide web: how the internet is changing healthcare, Journal of the Royal Society of Medicine 96 (2003) 74–76. [15] H. Tolhurst, S. Dean, Using teleconferencing to enable general practitioner participation in focus groups, Primary Health Care Research & Development 5 (2004) 1–4. [16] S.M. Lee, S. Hong, An enterprise-wide knowledge management systems infrastructure, Industrial Management & Data Systems 102 (2002) 17–25. [17] G.P. Huber, Organizational learning: the contributing processes and the literatures, Organization Science 2 (1991) 88–115. [18] E.V. Hippel, Sticky information and the locus of problem solving: implications for innovation, Management Science 40 (1994) 429–439. [19] New Zealand Ministry of Health (Internet), District health boards (updated 2011 July 1; cited 2011 August 1), Available from: http://www.moh.govt.nz/districthealthboards. [20] C. Armstrong, V. Sambamurthy, Information technology assimilation in firms: the influence of senior leadership and IT Infrastructures, Information Systems Research 10 (1999) 304–327. [21] H.F. Lin, G. Lee, Perceptions of senior managers toward knowledge-sharing behaviour, Management Decision 42 (2004) 108–125. [22] M. Orr, Evolution of New Zealand’s health knowledge management system, The British Journal of Healthcare Computing and Information Management 21 (2004) 28–30. [23] M. Alavi, D.E. Leidner, Knowledge management and knowledge management systems: conceptual foundations and research issues, MIS Quarterly 25 (2001) 107–136. [24] R. Didham, I. Martin, R. Wood, K. Harrison, Information technology systems in general practice medicine in New Zealand, The New Zealand Medical Journal 117 (2004) 1–6. [25] R. Savolainen, Filtering and withdrawing: strategies for coping with information overload in everyday contexts, Journal of Information Science 33 (2007) 611–621.
506
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[26] M.H. Zack, Managing codified knowledge, Sloan Management Review 40 (1999) 45–58. [27] T.H. Davenport, D.W. De Long, M.C. Beers, Successful knowledge management projects, Sloan Management Review 39 (1998) 43–57. [28] S. Paroutis, A.A. Saleh, Determinants of knowledge sharing using Web 2.0 technologies, Journal of Knowledge Management 13 (2009) 52–63. [29] BMJ Publishing Group (Internet), About Doc2Doc (cited 2011 Aug 1), Available from: http://doc2doc.bmj.com/about.html. [30] U. Kulkarni, S. Ravindran, R. Freeze, A knowledge management success model: theoretical development and
empirical validation, Journal of Management Information Systems 23 (2007) 309–347. [31] R. McDermott, C. O’Dell, Overcoming cultural barriers to sharing knowledge, Journal of Knowledge Management 5 (2001) 76–85. [32] C. O’Dell, C.J. Grayson, If only we knew what we know: identification and transfer of internal best practices, California Management Review 40 (1998) 154–174. [33] J. Gabbay, A. Le May, Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care, British Medical Journal 329 (2004) 1013–1016.
journal homepage: www.ijmijournal.com
The use of information technologies for knowledge sharing by secondary healthcare organisations in New Zealand Nor’ashikin Ali, Dick Whiddett ∗ , Alexei Tretiakov, Inga Hunter Department of Management, Massey University, Private Bag 11 222, Palmerston North, New Zealand
a r t i c l e
i n f o
a b s t r a c t
Article history:
Purpose: To explore the extent of use of information technologies (ITs) for knowledge sharing
Received 26 August 2011
by secondary healthcare organisations in New Zealand.
Received in revised form
Methods: We used a self-administered questionnaire to survey Chief Information Officers at
28 February 2012
all 21 of New Zealand’s District Health Boards regarding the extent to which their organ-
Accepted 29 February 2012
isations use knowledge sharing activities involving ITs. The list of activities to include in the questionnaire was compiled by reviewing the literature. We analysed the extent of use of the knowledge sharing activities using descriptive statistics, repeated measures ANOVA,
Keywords:
and correlation analysis.
Knowledge management
Results: The response rate was 76%. Although all the responding organisations reported
Medical informatics applications
using ITs to share knowledge, they used ITs to share documents significantly more than
Information seeking behaviours
to support discussions or to connect employees to experts. Discussions via teleconferenc-
Hospitals, public
ing, videoconferencing, and email lists were significantly more common than discussions
New Zealand
via social media technologies: electronic discussion forums, blogs, and on-line chatrooms. There were significant positive correlations between publishing and accessing documents, between using teleconferencing and using videoconferencing, and between publishing and finding contact details of experts. Conclusion: New Zealand’s District Health Boards are using a range of ITs to share knowledge. Knowledge sharing activities emphasising the sharing of explicit knowledge (via exchanging documents in electronic form) are significantly more common than knowledge sharing activities emphasising the sharing of tacit knowledge (via technology-mediated discussions and via using technology to connect employees to experts). In view of the evidence in the literature that information technology may be highly effective in supporting tacit knowledge exchanges, our results suggest that health organisations should consider greater adoption of ITs for sharing tacit knowledge. The finding that several organisations are currently making extensive use of teleconferencing and videoconferencing facilities and expertise databases suggests that these technologies are useful and could be of benefit to other healthcare providers and that barriers to their adoption can be overcome. In order to facilitate the wider adoption of technologies, early adopters of both relatively established technologies and of the emerging technologies such as social media should be encouraged to publish accounts of their experiences of success and lessons learnt from any failures so that the knowledge gained is disseminated to the wider medical informatics community. © 2012 Elsevier Ireland Ltd. All rights reserved.
∗
Corresponding author. Tel.: +64 6 3569099x2689; fax: +64 6 350 5661. E-mail address: [email protected] (D. Whiddett). 1386-5056/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2012.02.011
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 1 ( 2 0 1 2 ) 500–506
1.
Introduction
Over recent years, the health sectors in many industrialised countries have promoted the use of knowledge management to improve the safety, effectiveness, and overall quality of the services they provide. In the USA, the Institute of Medicine issued the “Crossing the Quality Chasm” report [1] that singled out knowledge management as a high priority for healthcare. In England and Wales, the National Health Service embarked on a programme of reform that included expanding the use of knowledge management techniques [2,3]. In New Zealand, the Ministry of Health issued the WAVE (Working to Add Value through E-information) advisory group report [4] calling for better use of knowledge management in healthcare. Recent studies of knowledge management and information-seeking behaviours of practitioners highlighted the role of informal networks or “communities of practice” in the decision-making processes of doctors [5,6]. Nicolini et al. [6] also noted the importance that practitioners place on access to local knowledge that is tailored to a specific context, as opposed to more generic knowledge such as research publications. These findings emphasise the importance of knowledge sharing occurring locally. One approach to improving the use of knowledge in the health sector has been the development of sophisticated information systems that integrate electronic knowledge bases with electronic health records and clinical decision support tools [7]. However, a recent study of healthcare organisations in the USA [8] found that even large and well-funded organisations struggle to develop and maintain such complex systems. In contrast, the use by health organisations of ad hoc knowledge management systems relying on commonly available information technologies (ITs) to share local knowledge has received little attention from researchers. Our study contributes to bridging this gap by examining the extent to which healthcare organisations in New Zealand use commonly available ITs to support knowledge sharing activities. We derived the activities to include in the survey from a review of the literature. We divided the activities into three broad categories: sharing documents, supporting discussions, and locating expertise. For sharing documents, the activities were (a) publishing documents on computer networks [9], (b) accessing documents on computer networks [10], and (c) exchanging documents as email attachments [11]. For supporting discussions, the activities were (a) discussions via email lists [11], (b) discussions via electronic discussion forums [12], (c) discussions via blogs [13], (d) discussions via chatrooms [14], (e) teleconferencing [15], and (f) videoconferencing [16]. For locating expertise, the activities were (a) publishing contact details of experts on computer networks (via shared drives, web sites, groupware, social networking sites, etc.) [17] and (b) searching for contact details of experts on computer networks [18]. To explore the extent of use of these knowledge sharing activities, we conducted a descriptive survey using a questionnaire asking the respondents to specify the extent to which each of the activities is used in the respondent’s organisation. The survey targeted all District Health Boards (DHBs) in
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New Zealand, represented by their Chief Information Officers (CIOs). The rest of this article is organised as follows. Section 2 presents the participant characteristics, the details of the questionnaire design, and the survey administration procedures. Section 3 presents the analysis of the data; we compare the extent of use for different activities and explore correlations between the activities. Finally, Section 4 outlines the implications for knowledge sharing practice.
2.
Method
2.1.
Participant characteristics
The New Zealand government funds free secondary healthcare in public hospitals, which are managed by DHBs [19]. The DHBs have integrated information technology services provided under the direction of CIOs. We used a DHB as a unit of study. Each DHB was represented by its CIO, who completed our survey questionnaire on behalf of the DHB. We assumed that CIOs can provide accurate responses about the use of ITs for knowledge sharing in their organisations. To ensure the well-being of the research participants and to comply with the Massey University regulations we followed the approval and notification procedures prescribed by the university. We informed the participants of their rights, including the right not to participate in the research, in the form prescribed by the university regulations. The participants gave informed consent by choosing to fill in the questionnaire.
2.2.
Questionnaire design
The questionnaire consisted of 13 questions. The first 11 questions asked about the extent to which the respondent organisations use knowledge sharing activities involving ITs. We selected the activities to include in the questionnaire based on the literature on the use of information technology for knowledge sharing in organisations. For a list of activities covered by the survey, literature sources supporting their inclusion, and the corresponding survey items, refer to Table 1. In the survey questionnaire, we asked the respondents to indicate the extent of use for each activity, specifying whether it is used not at all, seldom, often, or very often in their organisation. In statistical analysis, we mapped these anchors to 0, 1, 2, and 3, respectively. Following the first 11 questions we included an open-ended question requesting the respondents to list any other activities involving the use of ITs for knowledge sharing at their organisations, in addition to the activities explicitly mentioned in the questionnaire. The last question was on the size of the organisation.
2.3 .
Survey administration
We piloted the questionnaire with two university lecturers and eight PhD students, as well as three employees in the New Zealand healthcare sector. Based on the feedback from the pilot participants, we refined the questionnaire to improve its comprehensibility.
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Table 1 – Knowledge sharing activities involving information technology. Activity Sharing documents DOC.ACCESS DOC.EMATT DOC.PUBLISH Supporting discussions DISC.BLOG DISC.CHAT DISC.ELIST DISC.FORUM DISC.TELCONF DISC.VIDCONF Locating expertise EXPERT.FIND EXPERT.PUBLISH
Survey item We access documents published by our colleagues on computer networks (via shared drives, web sites, groupware, social networking sites, etc.) We exchange documents as email attachments with colleagues We publish documents on computer networks (via shared drives, web sites, groupware, social networking sites, etc.) to share them with our colleagues
[10]
We use blogs to share opinions/information We discuss issues via chatrooms We discuss issues via email lists We discuss issues via electronic forums We use teleconferencing to discuss issues We use videoconferencing to discuss issues
[13] [14] [11] [12] [15] [16]
We use computer networks (shared drives, web sites, yellow pages, groupware, social networking sites, etc.) to find contact details of people with knowledge and/or expertise We use computer networks (shared drives, web sites, yellow pages, groupware, social networking sites, etc.) to publish contact details of people with knowledge and/or expertise
[18]
We distributed the revised questionnaire to the CIOs of the 21 DHBs. Hard copies of the questionnaire were mailed to named individuals with an accompanying letter and a prepaid envelope. After the first mail-out and the subsequent return of completed questionnaires, we sent to the non-respondents the first reminder, which included a URL to an online version of the survey. The reminder elicited further responses. We mailed the second reminder as a letter with an extra hard copy of the questionnaire. This further increased the response rate.
2.4.
Analysis
We used repeated measures ANOVA tests to compare the levels of use of knowledge sharing activities involving the use of ITs and used Pearson’s correlation tests to assess the significance of correlations between activities. The significance level of .05 was used throughout. Data manipulation and analysis was performed using R version 2.13.0.
3.
Results
3.1.
Response rate
Sources
The response rate was 76%. Fifteen responses arrived as hard copies, and only one arrived via the online questionnaire, giving a total of 16 responses. Out of these responses, 10 responses arrived within two weeks of the initial mail out, four responses arrived after the first reminder, and two responses arrived after the second reminder. Since the respondents were CIOs, the response rate of 76% we achieved was high considering the time constraints on people in such positions. The response rate was much better than in most studies targeting CIOs as respondents; the response rates in such surveys are typically of the order of 20% [20,21]. All respondents answered all questions; there were no missing values, and all responses were usable.
3.2.
[11] [9]
[17]
Extent of use of knowledge sharing activities
Fig. 1 summarises the responses by presenting the breakdown of extent of the use ratings for each activity, with activities arranged by descending mean extent of use. CIOs in nine of the 16 respondent organisations characterised the majority (six or more) of the activities included in the survey as used often or very often. CIOs in all the respondent organisations characterised at least three of the activities as used often or very often. Using email to exchange documents as attachments was the most prevalent activity (rated very often by 83% of the respondents). “Discussing issues via chatrooms” activity did not occur at all. Table 2 presents the summary statistics of the findings by providing mean values and 95% confidence intervals for each of the activities. A repeated measures ANOVA test confirmed that different activities were used to different extents (p < .001).
Fig. 1 – Breakdown of extent of the use ratings for knowledge sharing activities involving the use of ITs. Activities are arranged by descending mean extent of use. For definitions of activities, see Table 1.
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the difference between the two activities related to locating expertise was not statistically significant (p = .09).
Table 2 – Average extent of use of knowledge sharing activities involving information technologies. Activity
Extent of use M
SD
DOC.EMATT DOC.PUBLISH DOC.ACCESS DISC.TELCONF DISC.ELIST DISC.VIDCONF EXPERT.FIND EXPERT.PUBLISH DISC.FORUM DISC.BLOG DISC.CHAT
2.75 2.69 2.62 2.12 1.88 1.69 1.56 1.31 0.69 0.38 0
0.58 0.60 0.62 0.81 0.89 0.79 0.96 1.01 0.60 0.62 0
3.2.4. Other uses of information technology for knowledge sharing
95% CI LL 2.44 2.37 2.30 1.70 1.40 1.26 1.05 0.77 0.37 0.05
UL 3.06 3.01 2.95 2.55 2.35 2.11 2.08 1.85 1.01 0.70
Note: M, mean; SD, standard deviation; CI, confidence interval; LL, lower limit, UL, upper limit. Activities appear in the order of decreasing use. For definitions of activities, see Table 1.
3.2.1.
Sharing documents
The most commonly used knowledge sharing activities were associated with sharing documents electronically, with over 90% of respondents characterising all the three activities in the sharing documents category as used often or very often. Sharing documents was most frequently performed by exchanging documents as email attachments (DOC.EMATT), followed by publishing documents electronically (DOC.PUBLISH), and accessing documents electronically (DOC.ACCESS) (see Table 2 for details). As one would expect from small differences in means and broad confidence intervals, these differences were not statistically significant (p = .74).
3.2.2.
Supporting discussions
Discussion activities most commonly occurred via teleconferencing (DISC.TELCONF), followed by email lists (DISC.ELIST), and videoconferencing (DISC.VIDCONF). Electronic discussion forums (DISC.FORUM) and blogs (DISC.BLOG) were used less frequently. Chatrooms were not used at all. The results of a repeated measures ANOVA test suggested that the differences between more frequently and less frequently used discussion activities were significant (p < .001). However, a similar test for just the three activities involving more established technologies (teleconferencing, email lists, and videoconferencing) found no significant differences (p = .27). A similar test for the remaining three discussion activities involving newer, less established technologies (discussion forums, blogs, and chatrooms) also found no significant differences (p = .08). Thus, the discussion activities naturally separated into two groups: the activities relying on more established technologies (which are used more often), and the activities relying on comparatively new technologies (which are used less often).
3.2.3.
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In their answers to the open question regarding knowledge sharing activities that were not in the questionnaire, respondents mentioned using peer-to-peer text messaging, publishing information on YouTube (sharing videos on the Web), and accessing external Web services such as knowledge bases and decision support sites.
3.3.
Correlations between knowledge sharing activities
We used correlation analysis to determine the statistically significant relationships between the knowledge sharing activities. Only three correlations were statistically significant at the .05 level: • Publishing documents on computer networks (DOC.PUBLISH) significantly and positively correlated with accessing documents on computer networks (DOC.ACCESS) (r = .92; p < .001). • Publishing contact details on computer networks (EXPERT.PUBLISH) significantly and positively correlated with finding contact details (EXPERT.FIND) (r = .76; p < .001). • Using teleconferencing (DISC.TELCONF) significantly and positively correlated with using videoconferencing (DISC.VIDCONF) (r = .79; p < .001).
3.4.
Organisation size
Besides information about the extent of use of knowledge sharing activities, the survey also captured organisation size. The respondents’ organisations had large workforces ranging from 800 to 9000 employees, with the median size of 2550. We examined correlations between organisation size and the extent of use of knowledge sharing activities involving ITs. We found that only one activity, discussions via blogs (DISC.BLOG), correlated significantly with organisation size (r = .62; p = .01), suggesting that the number of potential users should be large for discussions around blogs to become established.
4.
Discussion
We identified the extent of use of knowledge sharing activities involving commonly available ITs by DHBs in New Zealand. The results indicate that the CIOs of the DHBs perceive their organisations as extensively using ITs for knowledge sharing; more than 50% of the respondents checked often or very often for most of the knowledge sharing activities in the survey. This finding is consistent with the claim by Orr [22] that the New Zealand health sector is evolving to rely more and more on ITs for knowledge management.
Locating expertise
In terms of the extent of use, using computer networks to find and to publish contact details of experts followed teleconferencing, videoconferencing, and email lists. The difference was small but statistically significant (p = .02). At the same time,
4.1.
Sharing explicit knowledge
The extent of use for knowledge sharing activities involving document sharing was higher and statistically significantly
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different from the extent of use for discussion activities or for publishing and finding expertise. Thus, the dominant knowledge sharing activities involving the use of ITs in the surveyed organisations were supporting the sharing of explicit knowledge, rather than the sharing of tacit knowledge. Explicit knowledge is formal knowledge that can be codified and captured as documents, while tacit knowledge is informal and know-how knowledge that can only be transmitted in direct interaction, such as joint action or discussion, with the individuals who possess it [18,23]. Sharing documents as email attachments occurred extensively. This finding is consistent with the finding by Didham et al. [24] that New Zealand healthcare organisations extensively rely on email as a communication medium. Publishing and accessing documents on computer networks require more technical knowledge than using email; thus, one might expect that email attachments would be used more extensively than publishing on computer networks. However, in our study the difference was not significant. Publishing documents and accessing documents on computer networks were statistically significantly and positively correlated. The positive correlation suggests that publishing documents on computer networks does not result in excessive information overload, so that when more information is made available, more, and not less, information is accessed – employees are not relying on withdrawing strategy to deal with information overload. Refer to [25] for a detailed discussion of withdrawing strategy.
4.2.
Sharing tacit knowledge
Teleconferencing is easier and less expensive to use than videoconferencing. However, although the estimated mean extent of use for teleconferencing was higher than for videoconferencing, the difference was not significant. Significant positive correlation between using teleconferencing and using videoconferencing suggests that the two activities meet similar needs, such as the need to provide media-rich connectivity to support virtual teams. Activities involving the use of ITs for publishing and for finding contact details of experts were used less often than discussion activities involving established ITs. The two activities were significantly positively correlated, similarly to sharing and accessing documents, offering additional support to the conclusion that withdrawing strategy to deal with information overload is not used. Discussion activities relying on social media technologies – discussion forums, blogs, and chatrooms – were used significantly less often than discussion activities relying on more established technologies. The social-media technologies were rarely used to support discussions in respondents’ organisations, although there are reports in the literature suggesting that these technologies are effective in promoting the exchange of knowledge in industrial organisations (e.g. [26–28]). Furthermore, Doc2Doc, which is run by the British Medical Journal, is an example of a successful social media site used primarily by healthcare professionals [29]. These reports suggest that social media technologies might be effective in promoting tacit knowledge sharing in healthcare organisations and further research on critical success factors for
adopting such systems in healthcare context is desirable. We note that prior studies indicate that organisational culture and management support may influence employees to participate in electronic discussion forums [30–32].
4.3.
Limitations of the study
This study is based on frequency of use as reported by CIOs according to their perceptions. Measuring the actual usage would result in more accurate numbers but was not feasible, as it would interfere with the functioning of the participating organisations. The generalisability of the results and conclusions may be limited because of the nature of the respondents’ organisations. The DHBs in New Zealand are large organisations with high levels of information technology infrastructure and expertise [22]. The results, therefore, may not apply to smaller organisations, such as the organisations found in primary care, or to healthcare organisations in countries that give less priority to information technology infrastructure in healthcare.
4.4.
Conclusion
New Zealand’s District Health Boards are using a range of ITs to share knowledge. Knowledge sharing activities emphasising the sharing of explicit knowledge (via exchanging documents in electronic form) are significantly more common than knowledge sharing activities emphasising the sharing of tacit knowledge (via technology-mediated discussions and via using technology to connect employees to experts). Thus, although the sharing of tacit knowledge in healthcare organisations is highly important and healthcare professionals tend to value tacit knowledge exchanges with their colleagues more than access to formalised knowledge [33], health professionals are not taking advantage of the full potential of ITs to facilitate such sharing. The finding that several organisations are currently making extensive use of teleconferencing and videoconferencing facilities and expertise databases suggests that these technologies are useful and could be of benefit to other healthcare providers and that barriers to their adoption can be overcome. In order to facilitate the wider adoption of technologies, early adopters of both relatively established technologies and of the emerging technologies such as social media should be encouraged to publish accounts of their experiences of success and lessons learnt from any failures so that the knowledge gained is disseminated to the wider medical informatics community.
Author contributions All authors contributed to the conceptualisation and design of the study. NA conducted the survey and managed the acquisition of data. NA,AT performed the data analysis. All authors contributed to the interpretation of the results. NA drafted the article and all co-authors were involved in the revision of the article and approval of the final version of the manuscript.
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Summary points What was already known on the topic: • Health authorities promote the use of knowledge management. • Health workers prefer tacit knowledge they gain in interactions with colleagues to explicit knowledge available as documents. • Cases of successful use of social media technologies for knowledge sharing in organisational contexts are documented in the literature. What this study added to our knowledge: • Secondary care organisations in New Zealand extensively use information technologies to share explicit knowledge. • Secondary care organisations in New Zealand use information technologies to share explicit knowledge to a significantly greater extent than for sharing tacit knowledge. • Secondary care organisations in New Zealand rely on established technologies to transfer tacit knowledge to a significantly greater extent than on social media technologies.
Competing interests The authors declare that they have no conflicts of interest in relation to this article.
Acknowledgements We thank Chris Dever, Chairman of New Zealand’s DHBs CIO group, for providing the list of contacts of the CIOs, as well as the CIOs who took the time to respond to our questionnaire. We also thank Dr. Jan-Lockett Kay, Massey University, for her feedback on the information technology environment in healthcare and Dr. Barry McDonald, Massey University, for advice on statistical analysis.
references
[1] Committee on Quality of Healthcare in America Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, The National Academy Press, Washington, DC, 2001. [2] Department of Health, The NHS Plan: A Plan for Investment A Plan for Reform, The Stationery Office, London, 2000. [3] S.P. Bate, G. Robert, Knowledge management and communities of practice in the private sector: lesson for modernising the National Health Service in England and Wales, Public Administration 80 (2002) 643–663. [4] WAVE Advisory Board, From Strategy to Reality – The WAVE Project, New Zealand Ministry of Health, Wellington, 2001.
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[5] M. Dawes, U. Sampson, Knowledge management in clinical practice: a systematic review of information seeking behaviour in physicians, International Journal of Medical Informatics 71 (2003) 9–15. [6] D. Nicolini, J. Powell, P. Conville, L. Martinez-Solano, Managing knowledge in the healthcare sector, International Journal of Management Reviews 10 (2008) 245–263. [7] S. Abidi, Knowledge management in healthcare: towards ‘knowledge-driven’ decision-support services, International Journal of Medical Informatics 63 (2001) 5–18. [8] D.F. Sittig, A. Wright, L. Simonaitis, J.D. Carpenter, G.O. Allen, B.N. Deobbeling, A.M. Sirajuddin, J.S. Ash, B. Middleton, The state of the art in clinical knowledge management: an inventory of tools and techniques, International Journal of Medical Informatics 79 (2010) 44–57. [9] K. Desouza, Facilitating tacit knowledge exchange, Communications of the ACM 46 (2003) 85–88. [10] B.J. Bowman, Building knowledge management systems, Information Systems Management 19 (2002) 32–40. [11] J.L. Zhao, K. Akhil, A.S. Edward, Workflow-centric information distribution through e-mail, Journal of Management Information Systems 17 (2000) 45–72. [12] P. Gray, S. Tehrani, Technologies for disseminating knowledge, in: C.W. Holsapple (Ed.), Handbook on Knowledge Management, vol. 2, Springer, Lexington, 2003. [13] C.L. Hsu, J.C. Lin, Acceptance of blog usage: the roles of technology acceptance, social influence and knowledge sharing motivation, Information and Management 45 (2008) 65–74. [14] J.A Powell, M. Darvell, J.A.M. Gray, The doctor, the patient and the world-wide web: how the internet is changing healthcare, Journal of the Royal Society of Medicine 96 (2003) 74–76. [15] H. Tolhurst, S. Dean, Using teleconferencing to enable general practitioner participation in focus groups, Primary Health Care Research & Development 5 (2004) 1–4. [16] S.M. Lee, S. Hong, An enterprise-wide knowledge management systems infrastructure, Industrial Management & Data Systems 102 (2002) 17–25. [17] G.P. Huber, Organizational learning: the contributing processes and the literatures, Organization Science 2 (1991) 88–115. [18] E.V. Hippel, Sticky information and the locus of problem solving: implications for innovation, Management Science 40 (1994) 429–439. [19] New Zealand Ministry of Health (Internet), District health boards (updated 2011 July 1; cited 2011 August 1), Available from: http://www.moh.govt.nz/districthealthboards. [20] C. Armstrong, V. Sambamurthy, Information technology assimilation in firms: the influence of senior leadership and IT Infrastructures, Information Systems Research 10 (1999) 304–327. [21] H.F. Lin, G. Lee, Perceptions of senior managers toward knowledge-sharing behaviour, Management Decision 42 (2004) 108–125. [22] M. Orr, Evolution of New Zealand’s health knowledge management system, The British Journal of Healthcare Computing and Information Management 21 (2004) 28–30. [23] M. Alavi, D.E. Leidner, Knowledge management and knowledge management systems: conceptual foundations and research issues, MIS Quarterly 25 (2001) 107–136. [24] R. Didham, I. Martin, R. Wood, K. Harrison, Information technology systems in general practice medicine in New Zealand, The New Zealand Medical Journal 117 (2004) 1–6. [25] R. Savolainen, Filtering and withdrawing: strategies for coping with information overload in everyday contexts, Journal of Information Science 33 (2007) 611–621.
506
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 1 ( 2 0 1 2 ) 500–506
[26] M.H. Zack, Managing codified knowledge, Sloan Management Review 40 (1999) 45–58. [27] T.H. Davenport, D.W. De Long, M.C. Beers, Successful knowledge management projects, Sloan Management Review 39 (1998) 43–57. [28] S. Paroutis, A.A. Saleh, Determinants of knowledge sharing using Web 2.0 technologies, Journal of Knowledge Management 13 (2009) 52–63. [29] BMJ Publishing Group (Internet), About Doc2Doc (cited 2011 Aug 1), Available from: http://doc2doc.bmj.com/about.html. [30] U. Kulkarni, S. Ravindran, R. Freeze, A knowledge management success model: theoretical development and
empirical validation, Journal of Management Information Systems 23 (2007) 309–347. [31] R. McDermott, C. O’Dell, Overcoming cultural barriers to sharing knowledge, Journal of Knowledge Management 5 (2001) 76–85. [32] C. O’Dell, C.J. Grayson, If only we knew what we know: identification and transfer of internal best practices, California Management Review 40 (1998) 154–174. [33] J. Gabbay, A. Le May, Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care, British Medical Journal 329 (2004) 1013–1016.