Seite - 178 - in Applied Interdisciplinary Theory in Health Informatics - Knowledge Base for Practitioners

How do participants evaluate the impact of the intervention individually? (Individual appraisal) Communal appraisal processes are also related to the work that individuals do to evaluate the impact of interventions of their own work, as well as the contexts in which they are set. Thinking back to our earlier example of the EHR within the GP surgery, individual clinicians may evaluate not only the worth of the programme, but its impact on their other tasks. If the system complicates and increases their workload, this may lower the value of the intervention to the clinician regardless of the overall impact on other areas of work within the surgery. From the point of view of understanding implementation, the focus here is on the processes by which individuals appraise the intervention, and the context in which different participants operate may influence this (i.e. the context and priorities of clinicians and administrators may differ relative to the other activities in which they are involved). Can participants modify aspects of the intervention, and if so how? (Reconfiguration) Appraisal work, both individual and collective, may lead to attempts by participants to modify practices associated with the intervention, or even aspects of the objects associated with it (e.g. diagnostic tools, patient information systems). For example, those leading implementation of the (hypothetical) EHR within a GP surgery may evaluate whether the benefits of the new system outweigh additional costs in terms of extra time or resource investment in using it. If they feel that aspects of the system negatively impinge on other important kinds of work, they may seek to modify aspects of the system. Depending on intervention design and the setup of implementation, this might involve asking developers to redesign some part of the front end, or to add features that allow it to integrate with other information systems within this space. However, more informal attempts may also be made to reconfigure how they work with the system (“work- arounds”), particularly if a route to requesting formal changes is not visible or practical. This may result in aspects of the new system being used alongside other systems or practices, in ways that were not anticipated by developers, and were not part of the original intervention design. 1.6 Relationships between the constructs The ordering of constructs follows a general pattern from initial sense making, through organisational work to prepare for implementation, then the operational work of implementation, evaluation of its success, and potential reconfiguration. However, other kinds of connection between constructs are also possible, particularly following initial implementation when embedding the new procedure over a longer period may require revisiting or revising earlier steps. For example – work to set up the intervention, which would fall under the domain of cognitive participation, may reveal unforeseen implications for service, that require revisiting some earlier sense-making processes to address them and move forward. Similarly, evaluation work following initial implementation of an intervention that would map the reflexive monitoring construct, may reveal issues relating to how different people made sense of the intervention, that were not apparent until it went into service, and requiring changes to coherence-related activities. Coherence-related activities may also affect reflexive monitoring processes – M.BracherandC.R.May / ImplementingandEmbeddingHealth InformaticsSystems178