The Future of IT in Academic Medicine: People Forward

Information technology "problems" are not always what they first appear. Rather, they might reflect issues related to organizational culture that lead to dissonance or a sense of misalignment of organizational elements. This dissonance could be pervasive and system-wide, reflecting larger issues within the organization that can impede its ability to innovate and change successfully. Addressing the nontechnical side of IT challenges requires meaningful engagement that humanizes interactions.

Background

In 2015, the Faculty of Medicine (FoM) at the University of British Columbia (UBC) launched a review of its information technology (IT) support function, called The Future of IT. This review examined a number of issues, including financial constraints, perceived dissatisfaction with the value of IT services, and a prevailing feeling that the form of IT support then in place did not align with the FoM's needs and functions.

UBC oversees the only medical school in British Columbia (BC), which is an area larger than the states of California, Oregon, and Washington combined, with a population of more than 4.6 million. The FoM is divided into four separate medical school regions that involve the participation of three other universities and partnerships with six different health authorities, with teaching occurring at more than 100 clinical sites. Academic and clinical domains are not integrated in Canada; responsibility for academic and clinical activities is held separately by the university and the health authorities, respectively.

Support for IT in the FoM is provided by many diverse groups and individuals. These include a central university IT group, an IT group specific to academic medicine, numerous IT groups based in health authorities and hospitals, and IT groups specific to departments, schools, research institutes, and research centers. Individual researchers and their staff provide specialized or general IT support to their research group, and IT groups from affiliated academic institutions provide local support.

The geographic distribution, lack of clinical-academic integration, size, and complexity of the FoM and diversity of IT service providers from different jurisdictions have substantial implications for the delivery of IT. In addition, IT must be delivered to users with a diverse spectrum of needs, including clinical practitioners, educators, researchers, learners, staff, and administrators.

Future of IT Review Approach and Methodology

The Future of IT review was undertaken at the request of the dean of the FoM at UBC and ran from November 2014 to November 2015. A steering committee composed of representatives from FoM departments, schools, and centers; UBC's central IT; and one of BC's health authorities oversaw the initiative. This group was responsible for writing a report summarizing findings and recommendations. The membership of the steering committee was intended to represent a cross-section of IT users across the system.

The steering committee decided not to rely exclusively on an external firm to conduct the review, believing that an external consultant would not have sufficient context knowledge and understanding of the FoM. Instead, they implemented a hybrid model using an externally contracted project manager (who had senior IT executive experience) and an internal supporting project team. The committee felt that adopting this hybrid model would allow a deeper examination of the root causes of the challenges facing IT.

The steering committee emphasized that stakeholder (user) engagement should be a key aspect of the review, and the project team did substantial planning to ensure that user engagement remained a key focus. Throughout the spring of 2015, the Future of IT project team reached out to organizational units across the FoM to understand their technology needs and challenges. The project team conducted interviews, focus groups, regional site visits, and standing-committee visits. In all, they conducted more than 69 formal and dozens of informal consultations throughout 2015.

The scope of the Future of IT initiative included the following elements:

• IT strategy and governance: Examining existing governance processes and structures and recommending new ones
• Service scope, delivery, and funding: Clarifying the scope of services required by FoM organizational units and individual members (faculty, staff, students/learners, and administrators) and the costs associated with their delivery, and determining the technical and organizational structure needed to deliver the required services
• Client requirements and engagement: Determining client IT requirements and processes required to ensure ongoing engagement of clients
• Continuous improvement of IT: Establishing mechanisms for feedback and continuous improvement of IT services
• Industry benchmarking: Comparing the performance of IT in the FoM with industry IT benchmarks, including those of the American Association of Medical Colleges (AAMC) Group on Information Resources (GIR) and Gartner (a technology market research firm)

Finding the Expected

As might be predicted with such a review, a number of the findings¹ were not surprising and were actually expected as outcomes. These findings can be grouped into the following key themes:

• Gaps in fundamental IT service: IT services considered essential to enable users to carry out their day-to-day activities were often missing or variable from site to site. For example, wireless access to the Internet was not readily available at every clinical teaching site.
• Lack of integration with health authorities: IT challenges were especially apparent at hospital sites (most of FoM's education and research activities take place at hospital sites and rely on systems, infrastructure, and health information provided and controlled by the health authorities). Uncertainty regarding who was responsible for service in a given area often led to inadequate service delivery and sizable service gaps for users.
• Lack of clarity in governance: A lack of understanding of how IT decisions are made in the FoM was evident. For users, it was unclear who held responsibility for making decisions about IT and establishing IT priorities. Some FoM organizational units enjoyed relatively good IT service support, while others had problems meeting their basic requirements.
• Challenges with funding and financial reporting: Significant challenges with the IT funding model and financial reporting were identified. Financial reporting issues made it difficult to accurately determine how much was being spent on IT in the FoM.
• Deficiencies in capital and resources: Deficiencies in capital and resources to support the development and sustainment of programs or initiatives within units were apparent.

Issues with Organizational Culture

In addition to the factors just described, a majority of respondents (57 percent) in the Future of IT study identified organizational culture issues within the FoM as having an impact on IT service delivery.

Organizational culture can be defined as a "shared pattern of assumptions"² that a group uses in solving problems of external adaptations (for example, goals, strategies, and generally "how things are done") and internal integration (for example, how people relate to one another, the hierarchy that exists). These "shared assumptions have worked well enough to be considered valid"³ and are viewed as the correct way to perceive, think, and feel in relation to these problems. The assumptions in turn influence attitudes and patterns of behavior within the organization.

Issues related to organizational culture can lead to a situation that can be summarized by the concept of organizational dissonance,⁴ which refers to "a state of tension that arises from the misalignment of key organizational elements." When present, organizational dissonance "influences trust, goal clarity, organizational citizenship"⁵ and can ultimately influence an organization's ability to innovate and change successfully.

Although not IT issues per se, the organizational culture issues observed throughout the stakeholder engagement were acute. The FoM, having been transformed over a 10-year period from a small, mostly urban medical school to one that has expanded and distributed across a large geographical area,⁶ appears to demonstrate the hallmarks of an organization that requires stabilization and new ways to conduct business in a highly distributed environment. Key issues identified during the review that are related to culture in the FoM and that are responsible for organizational dissonance can be summarized into several broad themes. Each is accompanied by a quotation that highlights user perspectives around these issues.

Shared Values and Community

• Belief that department, school, institute, center, and individual-specific requirements are not well understood by central administration
• A feeling that needs of regional (distributed) sites are not always considered by central administration
• Little history of collaboration between organizational units
• A sense that drivers and priorities differ significantly among groups

"The 'out of sight' of a regional site is pervasive … there is a need for site representation … that's how trust is built." —March 25, 2015

Interaction and Communication

• No formal processes to make regional stakeholders feel a part of the FoM
• Inconsistent communication among groups, leading to communication silos
• Lack of meaningful involvement of users in IT planning and delivery

"It is an organizational problem but with an IT opportunity — an opportunity to change culture and break silos." —February 24, 2015

Governance

• Hierarchical reporting structure and slow decision making

"…should consider flattening the current structure instead of being too hierarchical, so that good ideas percolate up and decisions can be executed quicker." —March 3, 2015

Collectively, the issues in organizational culture within the FoM at UBC have led to a high level of disconnectedness of regions from the "mother ship," with trust lacking between many parts of the organization and widespread skepticism about the ability of the faculty and university's IT service providers to meet the requirements of users.

Virtual Distance: A Potential Explanation for Organizational Dissonance

While examining the causes of organizational dissonance, we came across an organizational psychology framework called Virtual Distance. The Virtual Distance concept, pioneered by Karen Sobel Lojeski, Richard Reilly, and Peter Dominick, may account at least in part for the organizational dissonance found in the UBC FoM during the Future of IT project.⁵ As originally conceived, virtual distance refers to a sense of disconnectedness of individuals, groups, or units where the primary mode of interaction among them is through the use of technology rather than in person.⁷ Geographic, technological, and sociocultural factors contribute to virtual distance, which contains three core elements⁸: physical distance, operational distance, and affinity distance.

• Physical distance refers to distance-related factors, including geographic separation and differences in time zones.
• Operational distance refers to a reliance on collaboration technologies as a predominant means of enabling communication across the organization. Prevalent use of these technologies may interfere with effective collaboration or communication on a regular basis. Operational distance is manifested by the extent to which meaning can be garnered from an interaction based on a sufficient level of organizational context, the extent to which our priorities might vary, the extent to which collaboration technologies might malfunction (e.g. webconferencing, WiFi, Internet, etc.), and the extent to which the distribution of individuals is asymmetrical, which can lead to a form of segregation or isolation in the mothership location.
• Affinity distance refers to interpersonal or inter-organizational affiliations and emotional or social connectedness. Affinity distance is influenced by a variety of factors, including the degree to which people's values and beliefs do not align, the amount to which people feel relationship tensions caused by differences in both formal or informal social status, the extent to which people haven't worked with each other before, and the extent to which people do not feel as though their futures are interconnected.

A higher level of virtual distance results whenever one or more of the core elements increases (see figure 1). From an organizational perspective, high virtual distance is associated with reduced overall effectiveness of the organization due to less trust, cooperation, innovation, clarity of roles and goals, satisfaction and commitment, and, ultimately, success. Affinity distance has the most significant impact of the three core elements. Therefore, any attempts to reduce virtual distance must first be designed to reduce affinity distance, in addition to addressing factors responsible for higher levels of physical and operational distance.

As virtual distance increases, organizational trust, cooperation, and innovation decrease. Meaningful engagement can be used in an attempt to address the issues resulting from operational and affinity distance.⁹

Bringing People to the Fore to Reduce Organizational Dissonance

In light of the elements contained in the virtual distance conceptual framework, it is not surprising that a geographically dispersed entity such as the UBC FoM would experience challenges and difficulties in the areas of shared values, sense of community, communication, interpersonal and inter-institutional interactions, and overall governance, all of which were highlighted in the Future of IT review. While clearly not specifically related to IT, the organizational dissonance that occurs as a result of elements emphasized in the virtual distance concept significantly interferes with and amplifies issues related to IT service delivery. Improving the overall IT service function must therefore include measures designed to address the operational and affinity distance factors. (We concede that little can likely be done in relation to physical distance factors.)

Importance of Engagement

To address the organizational dissonance issues identified within the FoM, we chose to implement processes intended to increase user engagement in all facets of IT in the FoM, and thereby effectively "humanize" the IT service delivery function to a greater degree than ever before. Engagement in this context "implies a dynamic relationship between the individual and the institution; the individual participates in and is more involved with the institution."¹⁰ Notably, successful implementation of user engagement processes is expected to have beneficial effects on core elements of virtual distance and, in particular, on key aspects underlying affinity distance (see figure 1).

A multiplicity of approaches taken will, we hope, reduce organizational dissonance as it relates to IT in the FoM at UBC (see table 1). Each approach has expected beneficial outcomes and impacts one or more of the core elements of virtual distance.

Table 1. Approaches used to reduce organizational dissonance

Approach	Expected Outcome	Virtual Distance Core Element Addressed
Federated governance: A decision-making structure where unit-based decisions are integrated into and complement enterprise governance	Clarifies roles, responsibilities, and scope of decision making Enables more nimble unit-based decisions, while recognizing the need for universal platforms and services	Operational/Affinity
Grass roots governance: Participation of users at all levels of the organization in planning and federated decision making	Enables users to have meaningful involvement	Affinity
Direct end-user IT support: Conditions that allow for development of relationships and understanding between IT support staff and clients	"Humanized" interactions between IT support and clients Improved communication and trust	Operational/Affinity
Vision, mission, and goals for IT: A clear articulation of what is expected from the IT function	Shared values Sense of community	Affinity
Client service managers: Staff whose sole focus is client engagement	Client advocacy Understanding of needs Monitoring of satisfaction and continuous improvement	Operational/Affinity

Initial Progress on Initiatives to Address Organizational Dissonance

We have seen early progress on the approaches taken to reduce organizational dissonance in the FoM.

Federated and Grass-Roots Governance

The process of developing a new approach to governance of IT in the FoM is well underway. An IT Committee has been formed whose current role is to oversee the development and execution of the IT strategy for the FoM, including processes to address cultural issues in the IT domain, and to provide recommendations to the dean regarding IT service delivery. Notably, this committee includes not only representatives from FoM IT and administration but also faculty members, with the latter serving as a way to ensure IT users' issues and needs are heard and addressed. This group has taken Initial steps to establish a framework that will enable and support a federated governance model in the FoM. Presentations and updates are made regularly to the highest level of FoM administration, ensuring that the administration is informed of issues and changes being made and is supportive of them.

Processes to ensure broad-based "grass roots" FoM participation in decision making for IT have also begun. Linkages with select academic and operational governance bodies are being created as a means to achieve this and also to ensure that recommendations from the IT Committee to the dean align with their needs. Based on lessons learned from the outcomes of these initial interactions, linkages with other bodies, either existing or newly created, will be established to ensure the IT Committee receives advice and input from relevant individuals or functional groups.

Client Services Managers

Client services managers have been identified and an engagement plan developed. Activities are now underway based on this plan. Discussions with all academic units have explored needs and refined existing or developed new arrangements for the IT support they require. As a consequence of these interactions, more than 90 percent of the Service Level Commitments for the current fiscal period have been renewed. Assessment of various FoM groups' needs has resulted in the migration of support for their IT and desktop needs to the FoM, rather than the local health authority.

Direct End-User Support

The creation of the client services manager function and the initial direct interactions with academic units about IT needs and/or issues is the first step in "humanizing" the interactions, improving communication, and building trust with IT.

Concluding Observations

Messages. IT "problems" are not necessarily a reflection of IT issues; rather they might reflect issues or challenges arising from organizational culture (dissonance), which may be pervasive and system-wide, reflecting larger issues within the organization. Meaningful engagement that humanizes interactions is a fundamental part of what an organization must do to address the nontechnical side of IT challenges.

Implications. Effective implementation of the approaches proposed will require a paradigm change in how IT is delivered and supports the academic mission, including but not limited to enhanced personal interactions and novel decision-making processes.

Limitations. System-wide organizational issues might interfere with solutions in the IT domain and other areas, including progress, innovation, and successful change.

Future. A commitment to meaningful engagement of users that humanizes interactions at multiple levels of the organization (including operational and governance levels) is required. Engagement approaches must be carefully planned and continually improved. Dedicated client service roles are required. The problem must first be defined using terms that are meaningful to the academic mission, then focus can be put on the IT aspects. A clear recognition of IT as an enabler by the organization's executive team is necessary to achieve the paradigm change required.

We hope the changes being introduced within the UBC FoM will have the desired effects. Academic medicine's transformative promise of using IT to achieve its mission cannot be realized without faculty, staff, student/learner, and administrator engagement and participation, which the Future of IT review's findings and recommendations facilitate.

Acknowledgments, Funding, Disclaimers, Ethical Approval

Acknowledgments: The authors wish to thank the members of the University of British Columbia Faculty of Medicine Steering Committee on the Future of IT; special acknowledgment to Sarah Mair and Ted Stedman.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

Notes

1. Future of IT Project Steering Committee, Faculty of Medicine, University of British Columbia, "Future of IT in the Faculty of Medicine — Findings and Recommendations," December 3, 2015.
2. Robert T. Golembiewski, ed. Handbook of Organizational Behavior, 2nd ed. (New York: Marcel Dekker, 2001).
3. Edgar H. Schein, Organizational Culture and Leadership: A Dynamic View, 2nd ed. (San Francisco, John Wiley and Sons, 1992).
4. Steve Werner and Zahir I. Latheef, "Organizational Dissonance: Development of a New Construct," Abstract, Academic Management Proceedings (January 2013); doi:10.5465/AMBPP.2013.10448abstract.
5. Karen Sobel-Lojeski, Richard Reilly, and Peter Dominick, "The Role of Virtual Distance in Innovation and Success," Proceedings of the 39th Annual Hawaii International Conference on System Sciences (2006): 25c; doi: 10.1109/HICSS.2006.484.
6. David Snadden, "Expanding undergraduate medical education in British Columbia: A distributed campus model," Canadian Medical Association Journal, Vol. 173 (2005): 589; doi: 10.1503/cmaj.050439
7. Karen Sobel-Lojeski, "The Subtle Ways Our Screens Are Pushing Us Apart," Harvard Business Review Digital Articles [serial online], April 8, 2015.
8. Karen Sobel-Lojeski, "Comments on Virtual Distance from 11/4 and 11/9," Ways of Knowing. A Virtual Seminar (blog).
9. Karen Sobel-Lojeski and Richard Reilly, Uniting the Virtual Workforce: Transforming Leadership and Innovation in the Globally Integrated Enterprise"(San Francisco: John Wiley and Sons, 2008).
10. Diana Oblinger, "Designed to Engage,"EDUCAUSE Review, Vol. 49, No. 5 (September/October 2014): 13.

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Michael Allard, MD, is professor and head of the Department of Pathology and Laboratory Medicine at the University of British Columbia; he is also a cardiovascular pathologist and research scientist in the Centre for Heart Lung Innovation at St. Paul's Hospital in Vancouver, British Columbia.

David Lampron, MBA, is the director of Information Technology at the Faculty of Medicine at the University of British Columbia in Vancouver, British Columbia.