Workarounds in the Shadow System: An Ethnographic Study of Requirements for Documentation and Cooperation in a Clinical Advisory Center

Abstract

Objective

Hospital information systems (HIS) are meant to manage complex work processes across healthcare organizations. We describe limitations of HIS to address local information requirements and how they are circumvented at different organizational levels. Results can be used to better support collaboration in socio-technical systems.

Background

Workarounds describe a mismatch between a technology’s purpose and its actual use, whereas shadow systems are unofficial IT systems circumventing limitations of official systems to support workflows. Boundary infrastructures are conceptualized as the entirety of all (in)formal digital and analog systems connecting different communities of practice in a socio-technical system.

Methods

An ethnographic study with observations and semi-structured interviews was conducted and analyzed through categorization and iterative coding.

Results

Several digital-analog workarounds are employed for documentation and a shared server functions as a shadow system to support workflows in ways the HIS cannot. For collaborative documentation, all (official and informal) information sources were used simultaneously as part of an interconnected boundary infrastructure.

Conclusion

Formal and informal IT systems are interconnected across different organizational levels and provide insights into unmet information requirements, effective and problematic work practices, and how to address them to improve system functioning. An integrated perspective on boundary infrastructures, workarounds, and shadow systems may advance system analysis, providing a more comprehensive picture of IT requirements than any concept alone.

Application

Workarounds and shadow systems highlight that HIS should support systemic and local needs. Customized interfaces in HIS to support search, access, and exchange of relevant data might help to mitigate current shortcomings.

Keywords

workarounds hospital information systems boundary infrastructures ethnographic methods computer supported cooperative work

Introduction

Effective cooperation across multi-disciplinary teams and locations is a prerequisite for performance quality in highly specialized fields such as healthcare. In healthcare organizations, the cooperative work processes are supported by large-scale hospital information systems (HIS), which are meant to manage all flows and interchanges of information across the entire organization. But when the HIS is unable to meet the multi-faceted and locally diverse requirements for interprofessional collaboration, unofficial work practices may emerge (Salahuddin et al., 2020). Instead of classifying them as merely problematic practices (Vanderhook & Abraham, 2017), we illustrate in this article that unofficial work practices can provide meaningful insights into everyday collaborative work and how to best support it. To do so, we differentiate three related concepts of unofficial work practices: Workarounds, Shadow Systems, and Boundary Infrastructures. In combination, these concepts capture unofficial work practices at complementary organizational levels (i.e., the individual, workflow, and system level) and therefore provide an integrated perspective on the socio-technical challenges for human-systems integration in cooperative settings such as healthcare organizations. Based on data from ethnographic fieldwork, we illustrate (1) how HIS fail to meet their intended function as the universal information management system and (2) which unofficial local practices of documentation and collaboration have emerged instead. This article contributes to Human Factors and Ergonomics research by showing how to map out unofficial work practices, using the related but distinct concepts of workarounds, shadow systems, and boundary infrastructures to gain insights into individual, workflow, and system-level requirements for effective cooperation in complex socio-technical organizations.

Related Work

HIS Between Standardization and Flexibilization

Hospital information systems are large-scale hospital-wide information infrastructures that are mainly intended to support patient care (Besiso et al., 2018; Islam et al., 2018). But HIS are also meant to support other competing functions related to, for instance, legal and billing requirements, which may interfere with clinical support (e.g., Feufel et al., 2011). In other words, HIS face the challenge of having to support a multitude of work processes across a diverse array of medical and non-medical work domains. Consequently, HIS must possess a broad set of functionalities to be able to support the different local requirements across an organization (Granlien & Hertzum, 2009; Martin et al., 2006; Morrison et al., 2011). At the same time, they are bound to achieve system-wide standardization of work processes and thus must guarantee and support universal performance requirements, such as data integrity, privacy, and accessibility (Chiang et al., 2011). Such competing requirements result in shortcomings (mainly with respect to flexibilization) that become salient when HIS are integrated into local collaborative practice. Examples from the literature show that HIS may distract from the doctor-patient interaction (Koopman et al., 2015; Pelland et al., 2017), incomplete records in HIS hamper the interaction between healthcare professionals (e.g., Savoy et al., 2021), information retrieval in large HIS often requires extensive clicking and time (Bossen, 2006), and structured forms increase documentation efforts to satisfy clinical and secondary functions such as billing (Berg, 1999).

Due to “the difficulty in translating among specialties, stakeholders, clinicians, and implementers” (Kaplan & Harris-Salamone, 2009, p. 295) and the constant tension between standardization and flexibilization (Fitzpatrick & Ellingsen, 2013), users of HIS have been shown to require additional media, artefacts and (unofficial) procedures, e.g., workarounds, to make the HIS work for flexible collaboration. As one result, paper records tend to persist alongside HIS as a backup medium for documentation and coordination (Cabitza et al., 2019; Chen, 2010; Fitzpatrick, 2004), which facilitates backup but creates discontinuities between digital and analog modes of documentation (Hardstone et al., 2004). Similarly, studies on institution-wide information infrastructures have acknowledged the complexities arising from the need to integrate HIS with other systems used locally to establish a seamless flow of information (Ellingsen & Monteiro, 2003; Johannessen & Ellingsen, 2009).

Workarounds and Shadow Systems

The concept of workarounds refers to a mismatch between how technology is intended to be used and how it is actually used by individual workers (Ejnefjäll & Ågerfalk, 2019). When both system capabilities and/or processes are unable to serve the needs/requirements of the people in the organization, they start to develop strategies how to reach the target in spite of the obstacles they encounter (Alter, 2014). Workarounds are often omitted in formal system or process documentation (Dupret, 2017; Gerson & Star, 1986; Pallesen & Jacobsen, 2018) and only become visible in actual work practices (e.g, Mörike, 2022). In healthcare, studies framed workarounds as temporary work practices (Zhou et al., 2011), as “clever methods for getting done what the system does not let you do easily” (Ash et al., 2003, p. 195), as means to meet remaining weaknesses of a new system prior to implementation (Bjørn & Boulus-Rødje, 2015), or as a potential threat to patient safety (Halbesleben et al., 2008; Patterson et al., 2006).

Closely related to workarounds is the concept of shadow systems, which refers to digital technologies and infrastructures that emerge to support work where official information systems do not (Behrens, 2009; Fürstenau et al., 2021; Györy et al., 2012; Haag & Eckhardt, 2017; Mallmann et al., 2018). They exist in parallel to the official information systems and are part of underground or “bootlegging” activities, a kind of work that is performed around formal practices (Abetti, 1997; Augsdorfer, 2008; Daskalopoulou et al., 2019; Pearson, 1997). Vest et al. (2014) considered shadow systems to be an extreme form of a workaround. We argue, however, that they are distinct to workarounds, as they emerge on the workflow-level rather than the individual level with a material manifestation in the form of often complex digital artifacts, sometimes even duplicating entire formal IT systems (Behrens & Bandara, 2004). Specifically, shadow systems are deeply embedded into the information infrastructure (Fürstenau & Rothe, 2014) to support the coordination of entire workflows that may connect multiple departments and teams. Workarounds, in contrast, are implemented at the individual level and focus on the facilitation of work for individual employees. Shadow systems thus foster collaboration on a workflow-level and, by doing so, might support individual-level workarounds as part of a larger workflow. Shadow systems yield highly innovative potential (Köffer et al., 2015) which makes them a powerful instance to help researchers understand everyday lived working practice in socio-technical systems.

Boundary Infrastructures

The concept of boundary infrastructures extends the idea that collaboration across multi-professional fields requires standardized but flexible, situation-specific solutions to satisfy information needs: These infrastructures are conceptualized as the entirety of all formal and informal information systems and artifacts that are used to organize information and cooperative work across communities of practice at the system-level (Bowker & Star, 1999). A compelling definition of communities of practice is “people doing things together” (Becker, 1986). Bowker and Star (1999) suggested that that collaboration between different communities of practices is often enabled by boundary objects. They can be understood as digital, non-digital, or hybrid artifacts (Bardram & Houben, 2018; Spiehl et al., 2020) that are both specific and ambiguous enough to support information exchange within and between potentially diverse communities. That is, boundary objects function as “anchors or bridges” that enable information exchange and cooperative work among heterogeneous groups (Star & Griesemer, 1989, p. 414). Boundary infrastructures, as the entirety of all boundary objects in a socio-technical system, consequently, are a dynamic network of digital, analog, and hybrid information artifacts that foster the cooperation in everyday practice. Boundary infrastructures are not congruent with a single system such as a HIS but consist of all official and unofficial technologies and artifacts used in parallel. In other words, they comprise official IT systems but also all workarounds and shadow systems.

Objective

HIS are deployed to manage the complex flows and interchanges of information across entire healthcare organizations but face challenges supporting local/disciplinary requirements for information and multi-professional collaboration. And although there is research to show that paper-based records are often used to compensate for this gap (Piras et al., 2019; Saleem et al., 2011), the ongoing use of additional digital artifacts such as spreadsheets (Daskalopoulou et al., 2019) or legacy systems (Behrens & Bandara, 2004), is thus far largely ignored. To get a fuller picture of unofficial (digital) work practices in healthcare systems, we leverage the concept of workarounds, which has mainly been used to describe unofficial work practices at the individual level and complement it with the workflow-level concept of shadow systems. We argue that workarounds and shadow systems represent crucial elements of boundary infrastructures, a system-level concept. In particular, we use these concepts to illustrate how cooperative work practices permeate different levels of the organization and how a combination of the identified concepts can be used to gain valuable insights into individual, workflow-related and system-level requirements for and potential threats to effective cooperation of complex socio-technical organizations.

Method

Setting

We carried out ethnographic field research in an interdisciplinary clinical advisory center to understand the unofficial work practices on different organizational levels and across paper-based records, the official HIS, and other digital artifacts. The clinical advisory center provides multi-professional advice and care for patients who might be affected by a genetic disorder that may increase their risk of cancer over the lifespan. The center operates and collaborates across multiple departments (e.g. gynecology, radiology, human genetics, coordination, documentation) within the hospital and beyond (e.g., with an external laboratory). The hospital uses a central HIS enabling all departments to access patient-related and other relevant information as basis for care and consultation processes.

Data Collection

The first two authors of this paper (FM, LHS), who are both members of the Division of Ergonomics and trained in ethnographic research methods (Madden, 2017), collected data in the advisory center as non-medical researchers. The data collection took place between June and October 2019, and both the number of observation hours and the duration of the interviews are comparable to data collected in previous studies of comparable scope and complexity (Kiossis et al., 2020; Patterson et al., 2006; Patterson, 2018; Ventres et al., 2006). All employees at the center were informed at a staff meeting prior to the beginning of the fieldwork about the study and recruited on a voluntary basis. They were furthermore informed about the potential of becoming a peripheral participant and that they had the opportunity to request that any data collected about them be deleted. During fieldwork, the researchers took handwritten notes of the observed technology interactions, work routines, and jottings of the conversations, which were written out at the end of each day into detailed, consolidated field notes. The interviews were audio-recorded and transcribed.

We observed and interviewed six employees of the clinical advisory center, including both medical professionals and administrative staff and personnel with both coordinating and managerial roles (Table 1). The participants were accompanied through (parts of) their workday and we aligned the fieldwork flexibly to work routines at the center and participants’ preferences. For instance, we accommodated two medical nurses who wished to give their interview together. While we formally accompanied six participants, the ethnographic observations encompassed about a dozen other employees of the center who interacted with the colleagues we accompanied. Furthermore, the observations included two team meetings with 10–15 participants.

TABLE 1.

Study Participants

Participants	Pseudonym	Observations (hours)	Interview (min)
Administrative staff	A1	8 hrs	30 min
Administrative staff	A2	12 hrs	45 min
Administrative staff w/coordinating function	A3	22 hrs	60 min
Medical nurse	M1	9 hrs	45 min
Medical nurse	M2	9 hrs	45 min
Clinician w/managerial function	M3	4 hrs	60 min
Center team meetings		5 hrs
Total		60 hrs	240 min

Data Analysis and Ethical Considerations

The aggregated and anonymized data were analyzed in a two-step process: (1) categorization of – both physical and digital – interprofessional communication spaces, pathways, and tools in the data (Rashotte et al., 2016), (2) iterative coding of the ethnographic data in relation to the three concepts outlined above. All authors were intensely involved into the iterative data analysis and coding process with regular joint coding reviews: the data obtained was triangulated via both observations and interviews with the participants and across professional fields. Ultimately, the coding allowed us to map the observed work practices to workarounds, shadow systems, and boundary infrastructures to a point of data saturation across different organizational levels.

All research activities complied with the tenets of the Declaration of Helsinki and were approved by the Institutional Review Board of the Department of Psychology and Ergonomics (IPA) at Technische Universität Berlin (#SL_01)). Informed consent was obtained from each participant and for full transparency the results were presented to the people working in the advisory center and subject to feedback discussions during an online team meeting in the summer of 2020. To avoid any risks that individuals might be identified based on the data we relay in this paper, we do not provide specific examples but rather present representative but abstracted cases that convey an accurate description of the work practices but cannot be traced back to any individual performing it.

Results

The HIS at the Advisory Center

The hospital has a central HIS all departments can access. It contains an electronic health record of the hospital’s patients with their treatment/therapy history in the house if applicable. The functions most relevant for the center are (1) the team calendar to manage the counseling sessions, (2) the documentation of consultations and services including information for the accounting/billing department, (3) the template function facilitating the composition of medical reports, and (4) access to and maintenance of the patient record with the possibility to attach (scanned) medical reports and documents. These functionalities of the HIS seem vital for everyday work at the center but, as the following quote suggests, they ultimately do not seem to rely on the HIS technology alone:

“Hm, I think I can’t get around the HIS. [In case of an outage] I simply wouldn’t be able to use it. I would then take care of other things and write everything up on my ToDo list until the HIS is up and running again…” (Interview M3)

Thus, everyday information work at the advisory center seems to circle around the HIS at a first glance. But the interviews and a close observation of the different work practices revealed that the collaborative work at the multi-professional clinical advisory center is enabled not by the HIS alone, but by an additional set of analog and digital artifacts as well as unofficial work practices at different levels of the organization.

Workarounds at the Individual Level

When the staff in the documentation department prepares the patient’s information for the counseling session, they must understand the possible kinship relations (i.e., if the patient’s mother, daughter, aunt or niece might already be a patient). One documentation team member explained that the information about a patient’s maternal aunt or stepsister could potentially be extracted from the HIS, but that the procedure to get this information is cumbersome and thus requires a significant time investment. Therefore, the team has established a workaround to match relevant paper records without having to revert to the HIS. This workaround centers around a spreadsheet file, which is both maintained and accessed regularly, to allow quick and easy access to kinship relations of patients who already have visited or are about to visit the center.

“It’s either when a new patient arrives or when we get a medical report: We have to investigate who is related to whom to file all of it correctly when we have to do the matching work. For this I use this spreadsheet file to find out quickly which records are the right ones.” (Interview, admin team member)

In a similar workaround, another spreadsheet file was created to facilitate targeted information retrieval that could not as easily (or not at all) be accommodated using the HIS. This second file was used for reporting and controlling purposes at the center level, such as billing and case-reporting with health insurance providers. To do so, the file documented the completed counseling sessions at the center on an aggregated level together with an indication of how many patients have been admitted to the early detection program and therefore are eligible for more frequent ultra-sound and magnetic resonance imaging scans than standard health insurance would cover otherwise.

The workarounds identified in the documentation department are associated with the need to access information on patients in relation to their kin (i.e., to other patients) or patients in relation to the advisory center (i.e., an organizational unit of the hospital). Because the HIS cannot easily provide information at different levels of aggregation, the staff invented these workarounds to circumvent effortful retrieval, reporting, and controlling processes. The workarounds we identified (and their corresponding digital artifacts) suggest that the HIS is as a standardized, general-purpose tool for the administration of individual patients, but does not accommodate the specific local needs of a center advising and treating a specific group of patients (e.g., those with genetic predisposition for cancer and potentially their extended families).

The Shadow System at the Workflow-Level

The workarounds presented above are enabled via a shared server structure functioning as a shadow system, which complements the official HIS by hosting the spreadsheets for the workarounds. Moreover, our data suggests that this shadow system supports additional functions needed to support everyday cooperative work practices between the different departments at the advisory center and, ultimately, between physicians and patients. These functions seem to be mainly related to the increased need for information to prepare patient encounters in a personalized healthcare setting as compared to a setting providing conventional healthcare:

The administration staff member opens a document file on the shared server with information about new patients and explains that new patients are only fully set up with a patient record file in HIS at the first counselling session. Therefore, these document files on the server are used to pass on information about the patient to the medical staff so that they can individually prepare for the counselling session. Then the administration team member opens the shared server’s folder structure to illustrate how each counselling day has its own folder containing the completed preparation files of the patients who have an appointment for this day and any further relevant documentation the patients have provided electronically upfront. (Field notes D3)

In difference to conventional care, relatively detailed information on patients is required at a point in time when the patient record is not yet fully setup in the HIS. The shared server supports for this personalized healthcare setting by enabling the exchange of patient-related information between the administration team and the consulting physicians, who can access the information at their desk to prepare for the counseling sessions. The shadow system therefore not only hosts documents enabling the workarounds described above. It also fosters the collaborative information transfer at a moment when the patient is not yet fully registered in the HIS.

“To prepare I refer to the document file provided by the documentation team. With the limited time available I primarily take this information as the input guiding the counselling session.” (Interview, medical staff member)

This example illustrates the role of a shadow system (here a shared server structure) and how it complements the official IT infrastructure (i.e., the HIS) at the level of workflows. Specifically, the shadow system provides the same functions as the HIS but a different point in time on the patient trajectory. By supporting workflows at different time scales, it enables cooperative work practices between physicians and documentation department at a genetic advisory center and, more importantly, personalized care delivery in a hospital organization that thus far mainly supports conventional care.

Boundary Infrastructures for a System-Level Perspective

The results so far have illustrated that the standardized functionalities provided by the HIS are complemented by workarounds to meet local requirements (e.g., spreadsheet files to analyze patient data at different levels of aggregation). These digitally supported workarounds are in turn rendered possible through a shadow system that facilitates unmet local requirements for documentation, preparation, and the coordination of workflows in a personalized healthcare setting. Together with the HIS, workarounds and the shadow system function as a boundary infrastructure comprising all (in)formal, digital, and analog artifacts that facilitate information exchange and collaborative work within and between the departments at the advisory center. In light of recent trends toward evidence generating medicine—an approach where data generated by routine care are used to advance knowledge and improve care activities (e.g., Embi & Payne, 2013)—staff used the entirety of all (un)official information systems simultaneously to work on, exchange, and document data files: To file case-based patient information into a national research database, patients’ paper records, the screen with patient-related information in the HIS, and at least one of the spreadsheets with more aggregated patient data was consulted in parallel. The documentation team member switched back and forth between the sources to be able to fill out all required fields in the database. And the other team member we accompanied explains:

“Here we document the anonymized cases, and I have to use these files and spreadsheets in addition to the HIS to fill out all the fields. I want to be very detailed here since the database is used for research nationwide and it’s important that our cases are represented here.” (Interview, Administration staff member)

While the previous examples illustrated individual-level practices through workarounds and workflow-level processes via the shared server, these findings highlight the need to look at unofficial work practices also from a system-level perspective to appreciate the essential interconnectedness of both formal and informal information systems for everyday work practices such as those related to big data analyses (e.g., an advisory center practicing evidence generating medicine).

Discussion

In summary our results illustrate how individual-level workarounds and workflow-level shadow systems complement the standard data management functions of the official HIS to support coordinated work in an individual department of the hospital organization (i.e., the clinical advisory center). Figure 1 summarizes the unofficial work practices that we were able to identify by using all three concepts—workarounds, shadow systems, and boundary infrastructures—and focusing at different levels of the organization—the individual, workflow, and system level.

Figure 1.

Mapping of unofficial work practices at different organizational levels.

The unofficial work practices we observed across organizational levels of the advisory center highlight that the current standard setup of the HIS does not support local requirements for cooperation within and between individual departments of the healthcare organization. As a result, workers at the sharp end of the organization come up with more or less efficient and safe work practices to satisfy their information needs. Insights into these unofficial work practices help to (1) outline requirements for system re-design and (2) threats to system safety, which we will elaborate in turn.

In the case of the advisory center, several implications for a HIS re-design can be identified. First, the various workarounds at the individual level illustrate the need for functions supporting data aggregation at different levels of granularity (e.g., the individual patient, their extended family, or patient populations based on medical characteristics). Second, at the workflow-level, the multidirectional use of digital artifacts on the shared server (the shadow system) suggests that a more flexible timing of data entry and access procedures is needed. Finally, perspectives on the boundary infrastructure reveal a need for functions supporting the integration of data sources and formats to open HIS for data scientific approaches such as evidence generating medicine. Although we can only provide a first example in this paper, we hope that is shows how the three concepts––workarounds, shadow systems, and boundary infrastructures––can be used as a set to understand cooperative work practices across all levels of an organization and reveal related information needs for system design.

Of course, workarounds and shadow systems do not only provide important insights into information needs. They also point to legitimate sources of concern for system administrators and managers: shadow systems emerge locally without input or knowledge from official IT-support teams and they often fall short in terms of quality assurance parameters such as data security, data privacy, and access control. (Rentrop & Zimmermann, 2012; Walterbusch et al., 2017). As a result, when an organization is hit by a major incidence or the colleague primarily responsible for the system is suddenly unavailable, the work processes might get interrupted, resulting in consequences ranging from short-term glitches to potential legal consequences (Daskalopoulou et al., 2019). Thus, taking unofficial work practices seriously and addressing the underlying needs—this must not, in any case, be misunderstood as simply undoing them or prohibiting their use—may also provide important directions to help improve overall system safety and reliability.

Limitations

This is an explorative study, which is based on a limited sample of participants providing insights into their lived work practice in a highly specialized clinical setting, which is part of a major university hospital in Germany. Thus, we do not claim that our results generalize to other healthcare settings or can serve as the sole basis for re-designs of HIS. Rather, the results we presented should be interpreted as an example used to highlight the interconnectedness of the three concepts––workarounds, shadow systems, and boundary infrastructures––and how they can be used to leverage system analyses. More research in other domains is necessary to corroborate these initial insights.

Practical Implications

Our findings suggest that system analysists and designers should not only focus on usability and user experience of IT systems (i.e., the classic user-centered approach). They should also study end users’ daily work routines and practices across all levels of an organization, revealing what they actually (need to) do and know in situ (a use-centered approach; Flach & Dominguez, 1995). To do so, observations and interviews may be used as in this paper to reveal gaps between existing IT infrastructures and employees’ actual information needs (e.g., Mörike, 2022) and generate input for the design and safety management of complex socio-technical work systems (e.g., Patterson et al., 2006). In other words, if we think of healthcare professionals not only as users of a technology but also as experts who can teach us about the digital infrastructures needed for the sharp end of clinical care, we will be better able to more closely align enterprise-wide information systems with the requirements for day-to-day clinical work.

Conclusion

Our findings suggest that combining the concepts of boundary infrastructures (a system-level concept), workarounds (an individual-level concept), and shadow systems (a concept focusing on collaborative workflow processes) helps to widen the perspective of system analysists toward a more user and use-centered approach and provides a fuller picture of information systems requirements in high-performance cooperative work environments than any conceptual lens by itself.

Key Points

Hospital information systems (HIS) fall short to address local information requirements––workarounds and shadow systems emerge to circumvent these limitations

Perspectives on boundary infrastructures (i.e., the combination of official IT systems, workarounds and shadow systems) may advance system analyses, providing a more comprehensive picture of IT requirements than any concept by itself.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Frauke Mörike

Frauke Mörike is a postdoctoral researcher at the Division of Ergonomics of the Department of Psychology and Ergonomics (IPA) at Technische Universität Berlin. She holds a bachelor’s degree in business information systems engineering from the Baden-Württemberg Cooperative State University in Mannheim/Germany (2002) and a master’s degree (2012) and PhD (2017) in social anthropology from Heidelberg University/Germany. From 2002–2013 she worked as IT-professional in the pharmaceutical industry.

Hannah L. Spiehl received her master’s degree in Human Factors from Technische Universität Berlin/Germany in 2020.

Markus A. Feufel heads the Division of Ergonomics of the Department of Psychology and Ergonomics (IPA) at Technische Universitat Berlin. He holds an engineering degree in audiovisual media (2003) from Hochschule der Medien Stuttgart/Germany and a master’s degree (2006) and PhD (2009) in Human Factors and I/O Psychology from Wright State University, Dayton, OH.

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