If the hospital management does not change its approach to the existing workflow and organisation structure when introducing an IT system, the transition from paper based patient records (PPR) to electronic patient records (EPR) will have no influence on the cost/quality relation. Therefore, the EPR system has to be integrated into the core health care processes that generate the costs. These costs emerge whenever clinical decisions are taken by physicians and caretakers. Not the system but the people are responsible for an economic health care management and need to be trained. As a result, the hospital has to be turned into an organisation which enables the concept of "double-loop" learning. This implies that fundamental values are questioned, amounting to changes in workflow and the way in which the work is organised.
To develop this kind of organisational insight, hospital staff members have to adopt two essential disciplines, as researcher Nikula points out. Clinicians are in need of system thinking and shared visions to acquire a holistic view of their organisation. In turn, a technological insight requires the ability to grasp both the possibilities and constraints of the IT system. Ideally, these two types of insight ought to be present in the same individual or group. The Nikula model distinguishes four combinations:
- low level of organisational insight combined with low level of technological insight. This leads to an ad hoc selection of new technology, depending on the latest hype.
- low level of organisational insight combined with high level of technological insight. Here, the IT potential is not experienced as an asset to the organisation's visions and objectives.
- high level of organisational insight combined with low level of technological insight. This is characterised by a negative and passive attitude towards the new system.
- high level of organisational insight combined with high level of technological insight. Here, the choice of technology is motivated by the organisation's needs.
During the summer of 1999, Rolf Nikula has utilised this model in interviews with clinicians in both hospitals of Ystad and Helsingborg, which are located in the southern part of Sweden. The data acquired via the qualitative method of interviewing provides valuable information on how a new EPR system may be received by the clinical staff. It enables the project management to decide which order is best to involve the different hospital departments in the EPR implementation, depending on their level of organisational and technological insight. Units which feature category 4 are ready for immediate EPR use but groups belonging to class 2 first need to develop shared visions. In turn, the people adhering to category 3 need to receive a clear picture of the system's potential to enhance their technological open-mindedness. The category 1 units will require a mixed treatment of both organisational and technological awareness to prepare them for successful EPR implementation.