IUPUI

Unintended Consequences of

Information Technology in Healthcare

A Review of the Literature

Christopher Kiess

5/4/2009

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Table of Contents Abstract ................................................................................................................. 3

Introduction ........................................................................................................... 4

Methods ................................................................................................................ 5 Table 1: Literature Search Methods ............................................................................................... 6 Table 2: Literature Search Criteria .................................................................................................. 7

Background ........................................................................................................... 7 1.1 History of Unintended Consequences .................................................................................... 7 1.2 Unintended Consequences in Healthcare Introduction..................................................... 8 1.3 Developing a Taxonomy of Unintended Consequences .................................................. 9 Table 3: Types of Unintended Consequences .......................................................................... 12 Table 4: Extent and Importance of Unintended Consequences .......................................... 13 1.4 Increased Mortality as an Unintended Consequence ...................................................... 14 1.5 Medication Errors as an Unintended Consequence ........................................................ 15

Conclusion .......................................................................................................... 16

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Abstract

Introduction: The unintended consequences of technology implementation

have been discussed recently in the literature with a small number of studies

representing the body of work to date. There has been no effort to compile these

results into a single body of work as of the writing of this paper. This paper will

examine unintended consequences of technology in the healthcare environment

with a review of the literature and provide recommendations for moving forward

in addressing the issues presented. Methods: An extensive literature search was

performed using both keywords and exploiting the controlled vocabulary of 5

databases to develop a body of literature representing the primary areas of

interest. Results: The search resulted in 14 articles being accepted for analysis

representing 7 studies and 4 reviews. Conclusion: The unintended

consequences of healthcare technology is a new field of exploration representing

only a small number of studies. These studies, however, are providing us with a

taxonomy of both practical examples and categories of the different types of

unintended consequences. This provides a foundation with which we can begin

to move forward in solving the problems we see in relation to technology and

humans interacting. Research must continue in this field and we must move

forward in developing systems to define and outline how we will approach the

implementation of technology from sociological, technical and sociotechnical

perspectives.

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Introduction

The effective implementation of IT systems is a high-priority area for the nation,

as it is increasingly important in improving quality, enhancing patient safety, and

decreasing costs. The Institute of Medicine (IOM) and National Academy of

Engineering have advocated widespread adoption of information technology (IT)

to improve quality, evidence-based practice, and to reduce medical errors

(Agrawal & W. Y. Wu, 2009; Building a Better Delivery System, 2005; Institute of

Medicine (U.S.), 2001; To Err Is Human, 2000). More effective use of IT is

recommended in integrating point-of-care access to health literature and

evidence-based guidelines; computerized decision support systems;

computerized clinical data; automation of decisions to reduce errors; and

electronic communication among providers and patients into practice (Agrawal &

Mayo-Smith, 2004; Doebbeling, Chou, & Tierney, 2006; Institute of Medicine

(U.S.), 2001; Mayo-Smith & Agrawal, 2007; Morrissey, 2003; Coiera, 2003; Cors,

n.d.). IT has three major benefits for improving quality: enhanced surveillance

and monitoring, increased guideline-based adherence, and decreased

medication errors (Chaudhry et al., 2006).

The benefits of information technology have been extensively documented

in the medical literature and have been shown to decrease errors, improve

processes and workflow, increase adherence to evidence-based guidelines and

decrease cost (Agrawal & W. Y. Wu, 2009; Chaudhry et al., 2006; Einbinder & D.

W. Bates, 2007; P. G. Shekelle, S. C. Morton, & Keeler, 2006). The

implementation of information technology affects numerous hospital processes

from finance to patient care and education (Doebbeling et al., 2006; Institute of

Medicine (U.S.), 2001). The type of information technology implemented in

medical institutions varies and can include clinical decision support (CDS) tools,

computerized physician order entry (CPOE), medication reconciliation and

medication dispensing systems (Bails, Clayton, Roy, & Cantor, 2008; Hatcher &

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Heetebry, 2004; Motulsky, Winslade, Tamblyn, & Sicotte, 2008). Much has been

written concerning specific obstacles related to the implementation of health

information technology (HIT). These include staff resistance to implementation

(Ward, Stevens, Brentnall, & Briddon, 2008), communication problems between

the physician and patient as a result of technology (Makoul, Curry, & Tang, 2001;

Teutsch, 2003) and workarounds as a result of design (Halbesleben, D. S.

Wakefield, & B. J. Wakefield, 2008). These obstacles have been referred to a

number of times in the medical literature as “unintended consequences” (Joan S

Ash, Berg, & Coiera, 2004; Joan S Ash, Sittig, Emily Campbell, Guappone, &

Dykstra, 2006; Joan S Ash, Sittig, Emily M Campbell, Guappone, & Dykstra,

2007; Joan S Ash, Sittig, Dykstra, Emily Campbell, & Guappone, 2007, 2009;

Joan S Ash, Sittig, Dykstra, et al., 2007; Joan S Ash, Sittig, Poon, et al., 2007;

Emily M Campbell, Sittig, Joan S Ash, Guappone, & Dykstra, 2006; Harrison,

Koppel, & Bar-Lev, 2007).

A recent study published in the New England Journal of Medicine cited

physician resistance as one of the top barriers to the implementation of

electronic-records systems in hospitals (Jha et al., 2009). Physician and staff

resistance are primary barriers to the implementation of technology (Ward et al.,

2008) and facilitators to unintended consequences in the form of workarounds

(Halbesleben et al., 2008). Unintended consequences and failure in the

implementation of technology in hospitals can, in part, be attributed to the lacking

of a sociotechnical approach (Coiera, 2003, 2007; Ward et al., 2008).

This paper will examine unintended consequences of technology in the

healthcare environment with a review of the literature and provide

recommendations for moving forward in addressing the issues presented.

Methods

An extensive literature search was performed using both keywords and exploiting

the controlled vocabulary of each database to develop a body of literature

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representing the primary areas of interest. Five primary databases were chosen

and a set of keywords was developed to employ in searching (see Table 1).

Compound keywords were used as phrases and limits on fields were set to title

and abstract in all searches moving to broader search sets if satisfactory results

were not found. Compound searches were performed in which terms were

searched to develop a search set that was then coupled with a subsequent

search using Boolean logic and processing. This exploited the keyword search

for maximum results. Articles were selected and their bibliographies mined for

further resources, which were then added to the initial set. Keyword adjustment

was an iterative process through the search. The controlled vocabularies in each

database were exploited for all possible and relevant terms as well with the

subsequent mining of the bibliographies taking place with those resources.

Table 1: Literature Search Methods

Databases Searched Keywords PubMed, HAPI, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews

Unintended consequences, medical errors, technology, workarounds, CPOE, Computerized Provider Order Entry, Computerized Physician Order Entry, CDS, Clinical Decision Support

The criteria for selection of articles were divided by topic and different criteria

applied for each topic (see Table 2). As the literature is relatively obscure in this

area, the criteria set were minimal to obtain maximum results and inclusion in the

review. Moreover, no criteria were set per technology. That is, there were no

stipulations made in relation to whether the literature related to any of the topics

referred to CDS, CPOE, EHR, EMR, HIS, LIS or IT in general. The interest of this

review was set to unintended consequences and the general criteria were that

the subject matter merely had to relate to healthcare settings in terms of

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technology. The literature search for unintended consequences resulted in 14

articles being accepted for analysis representing 7 studies and 4 reviews.

Table 2: Literature Search Criteria

Topic Criteria for Selection Unintended Consequences Age – 5 years or less

Level of Study – Review or data backed Length – no less than two pages Other – Unintended Consequences must be primary topic

Background

1.1 History of Unintended Consequences Unintended Consequences has largely been a term used in economics or

sociology and refers to outcomes – positive or negative – that are not foreseen or

part of the original intent with the initial action. It may well have first been widely

discussed in concept as part of Adam Smith’s Invisible Hand Theory developed

during the Enlightenment Period (Smith, 1977). The Invisible Hand was a

concept Smith used to describe how an individual agent in an economy strives

for their own wealth having little regard for those they interact with. Their intention

is to make themselves wealthy by producing goods and services. But, their

goods and services are valued by others creating a system that is ultimately

beneficial for the entire society.

It was not until the twentieth century that the term, Unintended

Consequence, became widespread at the hands of the sociologist, Robert K.

Merton (Merton, 1936, 1996). Merton evaluated unintended consequences as a

result of what he termed “purposive action” where the action is not behavior-

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based but rather an action taken when one or more alternatives existed. Under

Merton’s Theory there can be positive or negative unintended consequences as

a result of our actions. Merton outlined five primary causes of unintended

consequences:

• Not understanding the complexity of the problem well enough to make an

educated choice

• Being ignorant of the range or complexity of the situation

• Subjugating the long term for short term gains or interests

• Basic values (cultural values, policies or laws) may conflict with the given

change

• Self Fulfilling Prophecies often have an opposing affect to the prophecy

An example of Merton’s theory can be seen in modern society. Building projects

are often seen as a benefit to a given community. However, a new shopping mall

or superstore often can have negative consequences to include subjugation of

local (smaller) businesses, local suppliers are subjugated, congested roadways

near the site, decrease in communication in the community and

commercialization of the community.

1.2 Unintended Consequences in Healthcare Introduction

Unintended consequences can occur in a number of differing industries and

professions and they are almost always sociologic at root. The relationship

between humans and technology has been written on extensively over the past

several decades (Krug, 2005; Moggridge, 2007; Don Norman & Dunaeff, 1994;

Donald A. Norman, 2002, 2005, 2007). Most recently, there have been attempts

to understand these relationships in healthcare and an emerging inquiry into the

unintended consequences resulting from the implementation of technology and

the interaction of healthcare professionals with new technology.

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Prior to the work of Coiera and Ash, there was relatively little discussion of

unintended consequences in the healthcare literature (Joan S Ash et al., 2009; D

W Bates et al., 1999; Patterson, Cook, & Render, 2002). The earliest article

found was a 1998 analysis of the benefits and detriments to electronic medical

records (Silverman, 1998). The article cites two primary problems with electronic

medical records – lack of privacy and costs associated with implementation and

upkeep. This latter category is reported on in later works by Ash and her

colleagues (Emily M Campbell et al., 2006; Joan S Ash et al., 2009; Joan S Ash,

Sittig, Poon, et al., 2007; Joan S Ash, Sittig, Dykstra, et al., 2007). With the

exception of the first sentence, Silverman did not specifically use the term

“unintended consequences” in his analysis or maintain a primary focus on it.

Negative consequences resulting from new technology implementation are often

reported in the literature without using the specific terminology, “unintended

consequences” or focusing on the distinct sociologies related to the

consequences. Wachter used the term “unforeseen consequences” in his

general assessment of computerization in healthcare but maintains a focus on

quality and safety in healthcare from an administrative viewpoint. McDonald

described near misses in an article outlining the potential hazards of bar-code

administration in patient misidentification. There are a number of articles

correlating adverse drug events with computerization of processes (Han et al.,

2005; McAlearney, Chisolm, Schweikhart, Medow, & Kelleher, 2007; Nebeker,

Hoffman, Weir, Bennett, & Hurdle, 2005). But, these works have not discussed

unintended consequences as a concept in and of itself.

1.3 Developing a Taxonomy of Unintended Consequences

It was Ash et al. who spearheaded the research on unintended consequences

with her studies beginning in 2003 (Joan S Ash et al., 2004) and began defining

unintended consequences as a concept. There are only a small number of

studies with which to proceed with and knowledge at this point of the problems

associated with the implementation of information technology is minimal – our

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results largely in a set of descriptive categories. These categories are essential

for understanding the effects of technology both good and bad. But, there is even

less in the literature in terms of suggestions to avoid these consequences (Joan

S Ash, Fournier, Stavri, & Dykstra, 2003; Joan S Ash et al., 2007; Coiera, 2007).

It is imperative to continue both researching and categorizing unintended

consequences as they occur in healthcare environments and further our

explorations of suggested solutions.

Ash et al. explored unintended consequences first as part of

research including three different countries across the United States, Europe and

Australia. The results were the first attempt at categorizing the errors resulting

from the unintended consequences of implementation of technology. The original

intent of the study concerned gathering qualitative data in institutions using

Patient Care Information Systems. In gathering and analyzing the data, the

observers began to discover patterns indicating there existed possibilities of

errors occurring within these systems or attitudes reflecting this knowledge (Joan

S Ash et al., 2004). This initiated a series of related studies to both analyze the

existing data from new perspectives and obtain more data (Joan S Ash et al.,

2004; Joan S Ash et al., 2006; Joan S Ash et al., 2007; Joan S Ash et al., 2009;

Joan S Ash, Sittig, Dykstra, et al., 2007; Joan S Ash, Sittig, Poon, et al., 2007;

Emily M Campbell et al., 2006). The body of work Ash and her colleagues have

produced has provided insight into:

• The types or categories of unintended consequences

• Types of unintended consequences specific to clinical decision support

systems (CDS)

• Sociological consequences to implementation

• Quantification of the importance of the types of unintended consequences

• The extent or prevalence of unintended consequences

• Solutions and implementation recommendations

The initial publishing of the resulting analysis of qualitative data yielded two

primary categories of unintended consequences – errors involving the entry or

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retrieval of information held in the system and errors in communication and

coordinating patient care (Joan S Ash et al., 2004). Both types of errors were

further broken down into subcategories where there were problems described

with the human-computer interface (wrong person orders, juxtaposition) that had

not been designed with a complex “interruptive” environment in mind. Hospitals

are environments where interruptions are common and thus systems must be

designed with this in mind. Cognitive overload and shifts in cognitive patterns

due to restructuring the charting process was another finding. Structuring the

information often results in forcing the physician to enter comments a certain way

and in a certain field. Physicians were found to be frustrated with pre-populated

fields allowing for no modification. Other works have shown physicians cannot

troubleshoot and diagnose in the same fashion as before since the information is

presented differently and, thus, interpreted differently (Harrison et al., 2007). Ash

et al. described the phenomenon as a “loss of overview” where the physician can

no longer get the big picture. Misunderstanding the complexity of the work was a

third subcategory and is described as seeing the work completed in linear

fashion rather than an interactive hub of activities. This can lead to problems in

the processes already in place and are exacerbated by an inflexible system. The

fourth and final subcategory refers to the change in communication patterns

among workers. Entering an order in a system is not effectively communicating

that order to anyone other than whoever receives the order on the other end.

This means a nurse working with a doctor may not know a medication was

ordered or another physician could conceivably enter a duplicate order. But, the

communication (or feedback) from the system can also prove frustrating for the

end-user. Alerts, for example, can often overwhelm the user and be ineffective in

prompting the user to new or improved behavior. These categories were

eventually fleshed out further with added analysis and data gathering to form a

taxonomy in which 9 types of unintended consequences were represented (See

Table 3).

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Table 3: Types of Unintended Consequences

Type of Unintended Consequence Example

More/New Work Issues

Multiple Passwords Responding to alerts Entering required information or more detailed information Extra time

Workflow Issues

System “re-orders” the workflow HCI problems Inconsistencies between system and policy/procedures

Never Ending Demands

More space required for computers Persistent upgrades Screen space not large enough Perpetual training Maintenance

Paper Persistence

Paper process does not end

Communication Issues

Communication patterns change as a result of system Physicians and nurses spend more time entering information than at bedside

Emotions

Frustration and anger on the part of professionals in attempting to use systems and alter workflow

New Kinds of Errors

Juxtaposition errors Automated entry

Changes in Power Structure

IS/IT become authorities Those who know how to use system leverage that knowledge Administrators can track compliance more easily

Overdependence on Technology

System failures leave hospitals merciless

With the 9 types of consequences, Ash and colleagues later developed an 8-

question survey deigned to determine both the extent – or prevalence – of the

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types and the overall level of importance of each type to hospitals with

implemented CPOE. 176 full interviews were conducted via telephone – the

results of which can be seen in table 4. Rated the highest in terms of importance

were system demands, communication and workflow issues. The lowest rating

went to shifts in power and new types of errors. Most interesting to note is there

did not appear to be any correlation between the length of time each hospital had

owned the CPOE system and unintended consequences. Ash et al. also noted

there were both positive and negative unintended consequences involved in

implementation of CPOE and that hospitals can either work to avoid the negative

unintended consequences or simply accept them as part of developing a new

system.

Table 4: Extent and Importance of Unintended Consequences

Category

No

Yes (Less important)

Yes (moderately

to very important)

N

More work or new work

8 40 125 173

Workflow 6 15 149 170 System Demands 10 21 143 174 Communications 8 20 146 174 Emotions 8 28 140 176 New Kinds of Errors

15 77 82 174

Power Shifts 61 50 61 172 Dependence on the Technology

14 15 138 167

As part of the same series of studies, Ash and her colleagues were also able to

compile data on Clinical Decision Support Systems and unintended

consequences therein (Joan S Ash et al., 2007). There were two primary

categories derived from this data – those consequences related to the content of

the system and those related to the presentation of the system. Those

consequences related to the content of the system were a shift in roles and

responsibilities, the currency of the content and wrong or misleading content. The

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consequences related to the presentation of the system included rigidity of the

system (or the inability to tailor certain procedures or notifications), alert fatigue

(developed from too many alerts) and sources of potential errors such as auto-

complete fields and paper routing issues. Three primary recommendations

followed analysis in this study. To address the currency of the system and the

content it was suggested a knowledge management structure be developed with

interdisciplinary participation. In this way, a knowledge base can be developed

and can address many of the issues outlined in the problems related to content.

In relation to presentation problems, the recommendations were two: implement

a taxonomy designed to mediate the number of automated alerts determine what

fields need structure data versus those that do not. The need to capture

structured data often results in rigidity for the input of information. When this

structure is not needed, it can be removed (or not added) to the system to allow

more flexibility to the end user.

1.4 Increased Mortality as an Unintended Consequence

A study performed by Han et al. originating in the Children’s Hospital of

Pittsburgh reported an increase of 3.77% in mortality after the implementation of

a CPOE (Han et al., 2005). This study caused somewhat of a stir and generated

concern in the field of medicine. This was later commented on by Dean Sittig and

Ash in a commentary published in the same journal (Sittig, Joan S Ash, Zhang,

Osheroff, & Shabot, 2006). A study published that same year, however, showed

a significant decrease in mortality after implementation of a CPOE (Del Beccaro,

Jeffries, Eisenberg, & Harry, 2006). An expert panel was then constructed to

evaluate the two studies and develop an understanding of the differences in

results (Ammenwerth et al., 2006). The primary findings showed the two studies

were difficult to compare due to differing study designs and sampling. Also, the

Han study had implemented their CPOE in a six-day time period rather than

using a slow implementation process. The primary recommendation of this paper

was to ensure a socio-technical approach was taken in implementation that

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would recognize the differences within organizations and to ensure future

informaticians are educated in these approaches.

1.5 Medication Errors as an Unintended Consequence

Koppel et al. also conducted a study at the Philadelphia Veteran’s Administration

using both quantitative and qualitative methods to examine the effects of CPOE

on medication errors. Their study resulted in finding of 22 different classes of

errors, which they then divided into two large categories –interface issues and

information errors due to faulty systems implementation and integration. The

information related errors largely revolved around medication and medication

reconciliation. Some of these errors clearly lacked foresight into who would use

the system and how it would (or should) be used. For example, dosing of

medications was set from a pharmacy purchasing perspective so that the

medications were listed in the system as they were ordered from suppliers. This

meant a single dose could be more or less than what was standard for the

physician or clinic. This resulted in both under and overdosing. There were

scheduling problems with the cancellation of medication orders and renewal of

medications. Within the system cancelling a medication was a different process

than medication renewal meaning the system was prone to errors if the physician

forgot to complete the entire process. An alert process for allergy medicines

failed to notify the physician until after the order was sent meaning in a highly

interruptive environment, the alert could possible never be seen. Errors with the

interface included unclear log-on and off procedures where physicians could

potentially enter orders under another physician’s id. Other errors included

contemporaneous charting as a time barrier, improper alerts, errors in which the

procedures in the institution are subjugated or ignored. The study findings

confirm what Ash et al. find and what Ammenwerth et al. recommend –

sociotechnical approaches are necessary to address these errors prior to

implementation.

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Conclusion

The implementation of technology in a stable environment is a challenge. But,

implementing a system in an environment as complex as healthcare exacerbates

an already difficult situation. In hospitals you have:

• Systems that do not communicate with one another

• A patient who often will move from unit to unit and, thus, system to system

• An ever-changing series of guidelines, information and new treatments

• Inconsistent human nature (i.e. doctors and nurses)

• Administrators who sometimes use systems to force policy rather than

medical standards and guidelines

• Designers who often have little understanding of medicine or the workflow

challenges in a hospital

The above represents a series of moving parts that must synchronize and work

towards a common goal. In designing systems the complexity of a hospital is

often not realized and it is evident we must adjust our approach in order to build

a better system and give our physicians and nurses tools that help rather than

hinder their work. If we were to suppose a hospital is much like an ecology, we

might understand how we can best approach the problems outlined in this

writing.

Island ecology is a subject that has fascinated scientists for years and has

been the subject of science writer David Quammen on a number of occasions

(Quammen, 1998, 1997). Island ecology is often equated with the term “insular

biogeography” and islands pose certain challenges in that species (both plant

and animal) are much more vulnerable to extinction based on their insulation

from other ecologies. The dodo bird is, perhaps, the most famous example of an

island species that became extinct as a result of its island habitat. The same

concept has been explored in relation to the division of state parks in the United

States. The 20th century saw many state parks being split to allow logging

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companies passage through or the make room for travel. A result has been the

species in those parks have gone extinct. To cite an example, the Bridge

Mountains and The Crazy Mountains both lost their species of Grizzlies once

they had been insulated through development projects (Quammen, 1999). We

have also seen this same concept occur in the Amazonian Forest in what has

been termed “ecosystem decay” as a result of fragmenting the forest (W. F.

Laurance et al., 2002). The more complex and connected an ecosystem is, the

better its chance of survival. If we were to see hospitals as complex ecosystems

where connections between humans and systems must remain (as well as

connections between humans and humans), we would begin to understand just

how complex the system is and how our interventions can harm rather than help.

Chaos Theory is a related theory and has also proved useful in evaluating the

environment of organizations (Thiétart & Forgues, 1995). It is of value in

understanding the nature of chaotic environments where change occurs rapidly.

Both the interconnectivity of hospitals and their chaotic nature must be

understood and addressed prior to interventions.

A sociotechnical approach has been discussed in the literature in relation

to unintended consequences (Harrison, Henriksen, & Hughes, 2007; Harrison et

al., 2007) and is worthy of pursuit. History has shown that a frequent response to

problems with technology have been to develop new technologies to address

existing issues (Don Norman & Dunaeff, 1994; Donald A. Norman, 2002, 2007).

However, this sort of patchwork approach ignores the social interaction between

humans and technology. In order to best develop these interactions, we must

approach the problems that are social in nature and understand how they affect

the technology we have developed through ethnographies, interviews, data

analysis and observations. We must then gain an understanding of how to build

systems in coalition with those who will use them through participatory design,

collaboration in system development and maintaining iterative processes in

design.

Unintended consequences in healthcare technology is a new field of

exploration representing only a small number of studies. These studies, however,

18

are providing us with a taxonomy of both practical examples and categories of

the different types of unintended consequences. This provides a foundation with

which we can begin to move forward in solving the problems we see in relation to

technology and humans interacting. Research must continue in this field and we

must move forward in developing systems to define and outline how we will

approach the implementation of technology from sociological, technical and

sociotechnical perspectives.

19

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