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With the goal to achieve a better understanding of the challenges to communication technology adoption in the clinical setting, we conducted intensive observations of activities of clinical and administrative staff in a large teaching hospital's surgical unit prior to and 8-months postimplementation of an electronic whiteboard communication tool (eWhiteboard). The hospital IT department developed the e-Whiteboard for the support of inter-team coordination of patient status within the surgical flow. After the system had been integrated into the work process for 8 months, we conducted another round of intensive observations. The RATE data collection platform was utilized in both studies. Data were coded and analyzed quantitatively. Qualitative observational notes complemented the statistical results. We compared the pre-and post-implementation observational data with regard to communication load, types of coordination breakdowns, triggers, and consequences. Additionally, a questionnaire on perceived usefulness of the eWhiteboard was administered. We found that the introduction of the electronic whiteboard reduced the communication load associated with patient care. Participants reported the application useful and the overall satisfaction was rated very high. However, the observational data indicated an increase in coordination breakdowns related to patient status and the rise of an unanticipated communication load enabler and interruptions source -the lack of trust in other humans. We conclude that the types of metrics used to evaluate technology adoption may very well influence the outcomes reported. In the environment we studied, we identified a socio-technical issue, lack of trust in other humans, as the principle challenge to what would have otherwise been termed successful adoption. One implication is the development of a predictive model of user experience, including trust, based on strong candidate predictors derived from meta-analysis of existing related studies.

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Coordination in healthcare settings is a complex distributed process, mediated by a number of artifacts. We describe the coordination mechanisms in a surgical unit and identify the critical themes and structures of coordination that reveal the coordination needs of clinicians. Interestingly, we find that intra-team coordination works well despite the fact that it is mostly implicit. It is inter-team explicit coordination that presents significant overhead, the main effort being in maintaining awareness system-wide. We discuss the implications for eHealth systems design.

Coordination breakdowns in clinical work are a common concern for patient safety. To design technology that facilitates coordination and prevents breakdowns, we need to be able to reliably detect them and analyze their impact in daily work. A breakdown detection method is proposed as a useful approach to the management of breakdowns in inter-team coordination within the context of the daily operations of surgical units. By mapping information flow expectations for various information needs in clinical work -such as patient status information flow, schedule status information flow, staffing coordination information flow, etc. -an analyst can derive a set of predictions that serves as input to the algorithm for detecting the breakdowns. The method was verified over data from three sets of observational studies in two different hospitals. Performance analysis demonstrates excellent detection rate. The method can be utilized to assess the amount of breakdowns for different types of breakdowns, before and after technology implementation.