Seite - 174 - in Applied Interdisciplinary Theory in Health Informatics - Knowledge Base for Practitioners

1.3 Establishing relationships and divisions of labour to support the intervention (Cognitive participation). Cognitive participation refers to ‘the relational work that people do to build and sustain a community of practice around a new technology or complex intervention’[2]. While making sense of an intervention is a necessary step, successful implementation also requires that participants use this knowledge to establish responsibilities and divisions of labour that will support it. The components of cognitive participation point to the more specific sub-types of work that take place within this domain Who are the key people and what are they doing? (Initiation) Implementation of new technologies or practices in healthcare services is often delegated to a small group of managers and professionals [3]. These people frequently take the lead in setting up systems, procedures, and protocols, as well as engaging with others involved in implementation to ensure that necessary actions are undertaken. This construct draws our attention to questions of process: how have key people been identified? How has their role been established? In the case of the EHR implementation within a GP surgery, we expect that (at least) four kinds of key people will exist: clinicians (who retrieve information for the purpose of providing treatment and care); administrators (who provide support to clinicians through information work); specialist health informatics and IT staff (who support implementation with specialist knowledge and skills); and patients (who are directly and indirectly interacting with this system as those move along pathways of care and treatment). Our focus here is on how key people are identified as such, and what events take place to initiate their involvement in this regard. The relative visibility of key people within different role groups may depend on their relationship to those driving implementation. For example, if implementation of the EHR is driven primarily by clinicians and IT staff, the significance of administrators may not be immediately obvious to these project leads if their regular working practices do not expose them fully to the relevant functions of this group. Successful identification of key people and their initiation as such therefore requires detailed investigation of both formal and informal contributions within complex healthcare processes. Informal conversations with staff at all stages and levels of involvement can be just as valuable as more formal types of data (e.g. role descriptions) in informing both planning and evaluation of implementation with respect to initiation. How do participants become involved in the intervention? (Enrolment) Identifying participants and involving them in the work of implementation extends beyond key people; we also need to explore the practical processes by which others will be involved in implementing the intervention. Returning to the previous example (i.e. a new EHR within a GP clinic) we need to think about how different people will be bought in (or enrolled) as active participants. This is not the same as gaining consent to implement or change something but refers to the processes by which people become actively involved. Enrolment thus depends to a large degree on understanding the context in which participants operate, and again the focus is on how this occurs. For example, some initiatives may invite staff to take on specific tasks to drive implementation, and make them explicit points of contact for other staff affected by the intervention. M.BracherandC.R.May / ImplementingandEmbeddingHealth InformaticsSystems174