Litwin - 2011-Technological Change at Work The Impact of Employee PDF

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Technological Change at Work: The Impact of Employee

Involvement on the Effectiveness of Health Information
Technology
Adam Seth Litwin
Cornell University, aslitwin@cornell.edu
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Technological Change at Work: The Impact of Employee Involvement on the
Effectiveness of Health Information Technology
Abstract
The link between employee involvement (El) and organizational performance is not clear-cut, and the
diffusion of information technology (IT) in the workplace complicates this relationship. The author argues
that new technologies offer an important avenue by which El can improve hrm performance. He also
contends that those studies that do consider El in the context of technological change may be focusing
exclusively on workplace-level features of the employment relationship, ignoring variation in functional-
and strategic-level aspects of employment relations. To test this hypothesis, he uses Kaiser Permanente
Northwest Region’s patient scheduling module as an exemplar to investigate the extent to which this
particular technology interacts with El to affect clinic-level improvements in patient satisfaction. He
studies the impact of the technology over the period October 2004 to August 2007 across 16 clinics to
identify variation across sites. Measuring outcomes from a dataset that includes employee and patient
surveys, interviews, archival data, and clinic observations, he finds that the use of IT is associated with
performance increases and that these effects are greater in those clinics achieving higher mean levels of
El. This study presents the first empirical evidence of the potential of El to enhance the effectiveness of
health IT.
Keywords
employee involvement, organizational performance, information technology, technological change
Disciplines
Labor Relations | Performance Management | Technology and Innovation
Comments
Required Publisher Statement
© Cornell University. Reprinted with permission. All rights reserved.
Suggested Citation
Litwin, A. S. (2011). Technological change at work: The impact of employee involvement on the
effectiveness of health information technology [Electronic version] Industrial & Labor Relations Review,
64(5), 863-888.
This article is available at DigitalCommons@ILR: https://digitalcommons.ilr.cornell.edu/articles/1036

TECHNOLOGICAL CHANGE AT WORK: THE IMPACT
OF EMPLOYEE INVOLVEMENT ON THE EFFECTIVENESS
OF HEALTH INFORMATION TECHNOLOGY
ADAM SETH LITWIN*
The linkbetweenemployeeinvolvement (EI) and organizational perfor-

manceis notclear-cut, and thediffusionofinformation technology (IT) in
theworkplace this
complicates relationship. The author argues thatnew tech-
nologies offer an importantavenue by which EI can improve firmperfor-
mance.He alsocontendsthatthosestudiesthatdo considerEI in thecontext
oftechnological changemaybe focusing exclusivelyon workplace-level fea-
turesof theemployment ignoring
relationship, variation in functional-and
aspectsofemployment
strategic-level relations.To testthishypothesis,he uses
KaiserPermanente Northwest Region'spatientscheduling moduleas an ex-
emplarto investigatetheextenttowhichthisparticular technology interacts
withEI to affectclinic-level
improvements in patientsatisfaction.He studies
theimpactofthetechnology overtheperiodOctober2004 to August2007
across16 clinicstoidentify acrosssites.Measuring
variation outcomesfroma
datasetthatincludesemployeeand patientsurveys, interviews, archivaldata,
and clinicobservations,he findsthattheuse ofIT is associatedwithperfor-
manceincreasesand thattheseeffects are greaterin thoseclinicsachieving
highermeanlevelsofEI. Thisstudypresents thefirst empiricalevidenceof
thepotential ofEI toenhancetheeffectiveness ofhealthIT.
new to the studyof workand em- ested in the connection between EI and
ploymentmight be surprisedto learn
Those performance, their agreement about the
thatthe linkbetweenemployeeinvolvement strengthof the link is far from universal.
(EI) and organizational performance is Nevertheless,thewidespreaddiffusionof in-
more elusivethanit appears. In fact,though formationtechnology(IT) since the 1980s
scholarsfroma numberofmanagementsub- has heightened our need to understand
domains including organizationalbehavior how human and technologicalcapital inter-
(OB), human resources (HR), and even In- act in production.Since it has been shown,
formationSystems(IS) have long been inter- forexample, thatmanyof the benefitsonce
* AdamSethLitwin isAssistantProfessorofManage- summit, aswellasfromthoseatthe2010annualmeet-

mentattheCarey Business
School, JohnsHopkinsUni- ingsoftheLaborandEmployment Associa-
Relations
anda research
versity, affiliate
attheEmployment Policy tion,theSloanIndustryStudies andthe
Association,
ResearchNetwork. Academy ofManagement. He alsoacknowledgesthe
He thanksThomasA. Kochan,ErikBrynjolfsson,many employeesatKaiserPermanentewhofacilitated
Emilio andLarry
J.Castilla, W.Hunter forcomments thisresearch.
on thisandearlier forfeed-
He is alsograteful
drafts. Additional
analysesandcopiesofthecomputercode
backfromseminar participantsat theMassachusettsusedtogenerate theresults inthispaperare
presented
Institute
ofTechnology,theLondonSchoolofEco- available fromtheauthor byemailinghimataslitwin@
nomics,JohnsHopkinsUniversity,NewYork University,jhu.edu.
and CornellUniversity's 2010 healthcare reform Thisarticle wasaccepted bytheprioreditors.
Industrial Relations
andLabor Review, 2011).©byCornell
Vol.64,No.5 (October University.
Print 2162-271X/00/6405
0019-7939/Online $05.00
863
This content downloaded from 132.236.173.158 on Mon, 07 Dec 2015 20:26:23 UTC
All use subject to JSTOR Terms and Conditions
864 INDUSTRIAL AND LABOR RELATIONS REVIEW
assumed to arise from IT actually arise industriesthat,thoughnot explicitly focused

throughthe interplayof IT and featuresof on the interplayof EI and IT, implythat
the employmentrelationship (Bresnahan, technologyinvestmentsreturnmore to the
Brynjolfsson,and Hitt 2002; Brynjolfsson, investingfirm when complemented with
Hitt,and Yang 2002), could the conversebe EI structuresand processes (Batt 1999;
true- thatsome of theproductivity gainsan- MacDuffieand Krafcik1992). If one accepts
ticipated of EI are actually channeled these implications,then there is reason to
through the effectiveimplementationof questionwhethera "technology-alone" strat-
new technologies? egy will realize policymakers'expectations.
The extentto whichEI, in the implemen- These findings,however,mustbe reconciled
tationof IT, tightensthe link betweeneach witha more ambiguous set of studiesfrom
of theseinputsand measuresof productivity the IS literature,which,I argue, is focused
has immediateimplicationsforboth policy too narrowlyon workplace-levelmanifesta-
and research.Froma policyperspective,no- tions of EI, failingto hold constantimpor-
where is the need to answer this question tant employmentrelations featuresat the
more acute thanin the healthcaresector.In functionaland strategiclevels.Indeed, ifthe
the United States,wherethe industryhas re- theorized complementarity obtains,the re-
centlybeen the targetof contentiousand sultscould help piece togetherwhathas been
controversial legislativereform,thereis near a theoreticaland empiricalpuzzle byreveal-
(and rare) universalagreementthatthe dif- ing a common situationin whichEI can be a
fusionof health IT is criticalto improving positivedriverof performance.This would
efficiencyand service quality- a belief explain whymanagers maintain this belief
backed up by billions of dollars in govern- and continueto relyon EI despitethedearth
mentincentivesto thoseadoptingelectronic of empiricalevidence in its favor(Freeman
health records (EHRs). For example, the and Kleiner2000). That is,beneficialeffects
Health InformationTechnology for Eco- of EI may come in part throughthe imple-
nomicand ClinicalHealth (HITECH) Act- mentationof new technologies.This makes
part of the economic stimulus package sense ifEI structures and processesallowfor
passed and subsequentlyreferredto as the two-way communication between the front-
AmericanReinvestment and RecoveryAct- lines and strategic-leveldecision-makers
allocated $46 billion of economic stimulus higherup in the organizationalstructureas
fundstowardsadvancingEHR technologies. well as forfrontlineinvolvementin training
Reformers justifythe allocation of these re- and optimizationaround the new technol-
sources by blaming the slow diffusionof ogy. Therefore, the extent to which em-
health IT for the poor performanceof the ployee involvementin the implementation
healthcareindustry, markedbyskyrocketing of a new IT systemmoderatesthe effective-
costs and poor qualityoutcomes relativeto ness of the technologyis a question whose
other countries (Kaiser FamilyFoundation answerhas immediateconsequences in both
2007). The Obama administration, citinga the researchand policyrealms.
RAND Corporation study (Hillestad et al. In thispaper,I begin to addressthisissue
2005), points to a projected annual savings by testingfor the performanceeffectsof a
of $81 billionfromthe effective deployment specifictypeof health IT at varyinglevelsof
of healthIT systems. workplace-level EI whileholdingfunctional-
To date,however,policymakers have little and strategic-level variables in place. I do
or no empiricalevidenceto supporttheirop- so by examining the implementationof
timisticexpectations,nor do theyhave data one piece of an EHR system - a scheduling
on the organizationalor employmentcondi- -
module across a single region of Kaiser
tionsneeded to translatethesenew technol- Permanente, the nation's largest, not-for-
ogies intoimprovedperformanceoutcomes. profithealthplan. I drawfirston qualitative,
What theydo have are a numberof careful observationaldata to developan understand-
studiesof employmentpracticesfromother ing of the processesbywhichthescheduling
EMPLOYEE INVOLVEMENT AND THE EFFECTIVENESS OF HEALTH IT 865
module facilitatesthe workof frontlineem- EmployeeInvolvementand

ployees.This stage of data-gathering also al- TechnologicalChange
lows me to identifya performancemeasure
Employee Involvement in Human
directlytied to the effectiveuse of thispar- Resources and Organizational
ticulartechnology, an outcome of interestto
theorganizationitselfand measuredreliably Behavior
acrossclinicsovertime.Myinvestigation also The fields of HR and OB offera far-
illustratesthe specificwaysin whichworkers reachingliteratureon EI, theorizingthe ef-
and union representativesare involved in fects of "participation"largely through a
the development,deployment,and use of psychologicalor motivationallens. In the
theIT, particularly thoseformsofEI thatthe UnitedStates,empiricalanalysesdate at least
organization believes willimprovethe effec- as farback as theHawthorne(Roethlisberger
tivenessoftheschedulingmodule. The study and Dickson 1939) and Harwood (Coch and
also sheds light on the business strategy French 1948) studies. These foundational
servedby the technologyand the nature of pieces from the "human relations"school
the employmentcontractlinkingthe tech- firstcame to symbolizethe benefitsatten-
nology'susers to the investingorganization. dant to participation,but were later (and fa-
This qualitativeevidence is then used to de- mously) maligned for theirmethodological
velopcontext-specific measuresofworkplace- shortcomings,in particular,their lack of
level EI practices and IT in use and to controls.Subsequent and more carefulanal-
conduct a longitudinalanalysisof the indi- ysesofEI haveyieldeda much more cautious
vidual and joint effectsof IT and EI on per- view of its instrumentality over organiza-
formanceacrossmultiplehealthcareclinics. tionalperformance.Motivatedbyanecdotal
The studyoffersa numberof advantages and ideological accounts of the importance
over existingones. First,it allowsus to hold of EI, Locke and Schweiger's(1979) exten-
constantmanyof the unobservablecontex- sive reviewof what theylabel "participatory
tual factorsthatremainunaccounted forin decision-making"concluded that though
national, cross-industry studies of IT's per- participationmay drivejob satisfaction,it
formanceeffects(e.g., see Brynjolfsson, Hitt, does not reliablyinfluenceproductivity.
and Yang 2002; Caroli and van Reenan 2001) In the absence of evidence of a universal
as well as in large-n studiesseekingto make relationship,HR and OB theoristshave at
sense of El's moderatingrole in IT deploy- least soughtto answertwooverarchingques-
ment (e.g., see Choe 1996; Kim and Lee tions. Contingency theories (e.g., Vroom
1986). Second, the study leverages the andYetton 1973) attemptedto explain when
strengthof a case studyapproach byinvesti- or under what organizationalconditionsEI
gating a veryspecific,well-definedtechno- should be used to boost performance.
logical change- somethingthat cannot be Though contingencymodels examiningem-
done in national studiesin which IT is fre- ployee-leveltraitsand theappropriatenessof
quentlydefined rathervaguely(Brown and different typesof decisionshave found little
Campbell 2002) and thathas yetto be done support in the data (Miller and Monge
even in more-groundedstudiesof EI and IT 1986), more organizationallygrounded ap-
(Mirvis,Sales, and Hackett 1991). Third, proaches have indeed indicated a link be-
ratherthan relyingon measuresof revenue tweenEI and performance.Ranter's(1983)
or profit,itrelieson a contextually appropri- empirical work, for example, suggested
ate, homogeneous performance measure that EI is appropriate for frontlinestaffif
such as thatsuggestedby Ichniowski,Shaw, theyhave knowledgeor expertise- tacitor
and Prennushi (1997) and MacDuffie explicit- notavailableat higherrankswithin
(1995). Finally,thestudysupplementsmore- the organization, results that have since
grounded examinations of employment been replicated and generalized (Latham,
practicesand IT developed largelyin manu- Winters, and Locke 1994; McCaffrey,
facturingratherthanin the servicesector. Faerman,and Hart 1995; Scully,Kirkpatrick,
and Locke 1995) . AsidefromaskingwhenEI One notable exception in the HR literature

mightboost performance,HR and OB re- is Mirvis,Sales, and Hackett's (1991) com-
searchhas examinedhowEI shouldbe imple- parison of twoverydifferent technologies-
mentedto promoteitsperformancebenefits. computerized machinery in a metal
That is, ascribing Locke and Schweiger's fabrication factory and word processing
(1979) "non-results"to a unitaryconceptual- technologyin a publishingcompany.They
ization of participation,researcherssought concluded thata top-downdeploymentstrat-
to determinewhat institutionalformsof EI egylike thatused in the factoryproved less
mightstrengthenthe link between EI and effectivethan the more participatory, train-
performance.Their findingssuggestedthat ing-focused strategy
employed in thepublish-
self-directedteamsin whichEI centerson ev- ing house. Their findingsare undermined,
erydayworkare much more likelyto drive however,byan "apples to oranges"research
performancethan are weakerformsof par- design,and more widelycited contributions
ticipation,such as offlineproblem-solving to the HR literatureare much more likelyto
groupsor qualitycircles(Cotton et al. 1988; treattechnologysolely as a source of mea-
Cotton 1993). However,even thisseemingly surementerror (Huselid and Becker 1996;
safe conclusion has been called into ques- Locke and Schweiger1979) ratherthan as
tion on methodological grounds (Leana, an appropriateobject of study.As a result,
Locke, and Schweiger1990). despitea wealthof theoreticaland empirical
The HR and OB literaturedivergewith worklinkingEI to performance,HR and OB
respectto theirtreatment oftechnology.The researchhas yetto fullyexamine EI and IT
work of Edmondson, Böhmer, and Pisano in tandem.That is, it has yetto considerex-
(2001) exemplifies OB's most-nuanced plicitlyand carefullythe possibilitythatEl's
examinationof the role of technologyin or- empiricallyelusiveperformanceeffectsmay,
ganizations.ChannelingRanter'sconceptu- at leastin part,come throughitsmoderation
alization of frontlineworker knowledge, of the technology-performance link.
theyexplain the effectiveness of new tech-
nologies as a consequence of the form of
User Participationand Technological
worker knowledge- tacit or codified-
Change in InformationSystems
requiredto leveragemore fullynew technol-
ogies. In a related qualitative study,the Researchersin the field of Management
authors examined the collective learning Information Systemsor moresimply, IS, have,
processof those responsibleforimplement- of course,long been concerned withthe as-
ing the same technology,arguing that the sociationbetweenaspectsofworkplacetech-
deep entrenchmentof routinesdeveloped nologicalchange and businessperformance.
around old technologiescan limitthe suc- Furthermore,there is a well-developedem-
cess of new ones (Edmondson et al. 2003). piricalstreamwithinthe IS domain thatex-
This need to realignworkflows around new amines the moderating effectsof what it
technologiesis a ubiquitous one and indi- labels "user participation"or "user involve-
cates the largerdisruptionto organizational ment"on the link betweeninformationsys-
routinesoccasioned bytechnologicalchange temsdesign (ISD) and myriadorganizational
(Barley1986). It followslogicallythatthisis outcomes (e.g., He and King2008). Ives and
a timein whichclearertwo-way communica- Olson (1984: 387), for example, theorized
tion regardingmanagers' rationale for the that user involvementis simply"a special
changeand frontline workers'resultingtrain- case of [participatorydecision making] in
ing needs would benefitall partiesinvolved. whichusers and systemdesignerssubstitute
Despite the fact that OB, in particular, forsuperiorsand subordinates."Therefore,
considersthe role of technologyin organi- these and other researchershave adopted
zations generally,neither HR nor OB re- Locke and Schweiger's(1979) conventionof
serves a place for technology in theory, partitioning expected benefits into two
linkingHR practicesto organizationalper- broad categories:job satisfactionand im-
formance(Becker and Huselid 1998, 2010). proved performance. Their studies have
yieldedthe same set of tentativeconclusions broadly (e.g., Choe 1996; Hunton 1996a;
as those in OB, namelythatuser participa- Hunton and Beeler 1997; Hunton and Price
tion drivesattitudinaland behavioral mea- 1997) abstractaway from the set of larger
sureslikejob satisfaction but has littleor no institutionalfeatures guiding the various
effecton performance. manifestationsof employee involvement.
The IS literature,however,goes one step These include forcesthatemploymentrela-
further. A numberof studieshave proffered tionsscholarsknowto be essentialto under-
contingencymodels to account fordifferent standing work-relatedphenomena, such
organizationalfactorspotentially moderating as business strategyand the nature of the
the relationshipbetweenuser participation contract- implicit or explicit- governing
in ISD and measures of performance.For the relationshipbetweenworkersand firms
example, Hunton and colleagues (Hunton (Dunlop and Weil 1996; Levine 1995).
1996b; Hunton and Price 1997) employed
experimental techniques, collecting data EmployeeInvolvementand
from individual workersor students after
TechnologicalChange in
seeking to manipulate the degree of per- EmploymentRelations
ceivedinstrumentality ofworkervoice. Some
subjectswere affordedno voice at all, and In this paper, I am leveraging employ-
otherswereplaced along a continuumof in- ment relationstheoryto fillgaps leftby the
creasinglevelsof instrumentality. In the lan- HR and OB literatureson the one hand,
guage of employment relations, rightward and the IS literatureon the other.That is, I
movementsalong thiscontinuumwould be am more closely considering the role of
labeled "informationrights,""consultation technologyin approaches to EI and bring-
rights," and finally,
at thefarright-hand side, ing a broader conceptualizationof the em-
"co-determinationrights" (Freeman and ploymentrelationship than that found in
Lazear 1995). In addition, net increases in received EI research in the IS field.This is
the level of voice instrumentality result in possible because scholarsof employmentre-
improvedattitudinaland performancemea- lations have an abiding interest in what
sures.Withrespectto the findingsregarding Dunlop (1958 [1993]) labeled the "techno-
attitudinalmeasures,theseresultsfallin line logical context."In fact,the field'snuanced
withfindingsfromIS researchpredicatedon conceptualization of technologyis part of
broad, national surveys(e.g., Choe 1996; whatset pluralistindustrialrelations,thatis,
Kimand Lee 1986), multi-organization stud- employmentrelations, apart from earlier
ies (e.g., McKeen, Guimaraes,and Wetherbe approaches to the studyof work and em-
1994; McKeen and Guimaraes 1997), and ployment.Marxists,for example, portrayed
even some mixed-method,multi-site, single- new technologies and the technological
organization studies (e.g., Hunton 1996a; change process as a deliberate strategyon
Hunton and Beeler 1997). However,theper- the partof managersto tightencontrolover
formanceeffectsdetectedunder experimen- workersand the labor process throughde-
tal or quasi-experimental conditionsare not skilling(Braverman1974;Marx1849 [1978]).
consistentlyreplicated in multi-method, Employmentrelationscriticizesthisview as
multi-sitestudies (Brodbeck 2001; Hunton deterministic,adopting more of an institu-
1996a; Hunton and Beeler 1997). tional perspective,payingveryclose atten-
The source of this ambiguityand of the tion to the interplayof technologyand EI in
broaderfindingofweakperformanceeffects production.1
of EI in ISD (He and King 2008) is the IS
literature'stendencyto examine the success
of IT projectsoutsidethe contextof the em- 1Scienceandtechnologystudies
(STS) combatstech-
determinism
nological ina different
manner,byshin-
ploymentrelationship.That is, even those
inga spotlight
onhumanagency.
Though morefocused
analysesthatcontrolforor hold constantfea- on "technologies
ofconsumption"thantherealmof
turesof the technologyitself(e.g., Brodbeck production (cf.Noble1984;Oudshoorn and Pinch
2001) or even of the organization more 2007:556),STScountersdeterministic
approachesby
Over thepastthreedecades, in particular, greaterforthoseworkersreportinghighlev-

employmentrelations research has deliv- els of involvementin problem-solvingand
ered a growingbody of evidence on the ef- participation.
fectsof technologyand workplacepractices, Interestingly, employmentrelations re-
motivatedin part by the highlyvisibleand search thatfocusedon EI and performance
widelyreported early experiences of Gen- to the exclusionof technologyhas been un-
eral Motors(GM) and othersin the auto in- able to establisha conclusivelink between
dustrywithinvestments in automation.Case EI and economic performance (Cappelli
study research has documented thatin the and Neumark 2001; Freeman and Kleiner
1980s,GM investedbillionsof dollarsin au- 2000; Kleiner,Leonard, and Pilarski2001).
tomationtechnology - $650 million in one Appelbaum and Batt (1994) suggestedthat
GM factoryalone (Kochan 1988)- but did measurement error may be the problem,
not achieve the expected performanceim- since neither researchersnor practitioners
provementsor achieve the levels of perfor- have a single,shared understandingof the
mance observedinJapanese plantsin North meaning of EI or how it actuallyoccurs in
Americaor inJapan (Krafcik1988). Instead, workplaces.Instead, the dominant finding
follow-upcase studyand quantitativeanaly- in the literatureon high-performance work
ses demonstratedthat the combination of systems(HPWS) is that"bundles" or clusters
new technologies and innovativeemploy- of employment practices, not individual
ment practices that positioned shop floor practices,are the true driversof economic
workersto "give wisdom to the machine" performance (e.g., Becker and Huselid
(MacDuffie and Krafcik 1992; MacDuffie 1998; Ichniowski,Shaw,and Prennushi1997;
1995) is whatdeliversthese levelsof perfor- MacDuffie1995). Of course,the instrumen-
mance. This evidence suggeststhata "bun- talityof El-inclusivebundles of employment
dle" of innovativeemploymentpractices, practices also stands on firm theoretical
inclusiveofopportunitiesforworkerinvolve- ground. At the same time, consistentwith
ment in problem solving, moderates the aforementionedfindingsfromHR and OB
returnon investments in new technologies.2 (Cotton et al. 1988; Cotton 1993), it appears
These results have subsequently been thatnot all formsof EI "pack the same per-
replicatedin other manufacturingsettings, formancepunch." That is, purelyconsulta-
including a few service industries.Kelley tiveofflineformsof EI, such as the "quality
(1996), forexample, showed thatincreased circles"popularized in the 1980s and 1990s,
computerizationin the machined products generallyyieldweak performanceimprove-
sector drives larger productivitygains in ments,ifany (Levine and Tyson1990).
firmsthat involveworkersthroughpartici- I advance theoryalong two lines. First,I
patory structures.Likewise, Batt (1999) profferan alternativeexplanation for the
found thattelecommunicationssales repre- empiricalelusivenessof the El-performance
sentativeswith access to new technology link. I theorize that the implementation
outperformthose not using it, and that of new technologies,IT in particular,offers
the size of the performanceincrementis one avenue bywhichEI positively influences
firmperformance,therebyfillinga gap in
the managementliteratureleftby scholars
examining thewaysthatactualusersoftechnology as of employment relations, HR, and OB.
wellas thesocialenvironment morebroadly shape an employmentrelationsapproach-
ofnewtechnologies,
characteristics implying thatemer- Taking
characterizedby organizationaland phen-
ofIT andtheimpact
gentmanifestations ofnewhard- - I that
wareandsoftware,forexample,dependonearly stage omenological groundedness suggest
between
"negotiations" actors.
therelevant the deployment of an IT system,withitsun-
2Interestingly,
inhisgroundbreaking empiricalstudy, avoidable disruptionto organizationalrou-
MacDuffie (1995)measured technologyverycarefully tines(Barley1986;Edmondson,Böhmer,and
in an effort
toisolatetheperformance effects
ofem-
ployment bundles.
practice However,hedidnotfocus Pisano 2001), occasions an opportunityto
on thewaysthatcertain employment practicesman- leverageEI to the organization'sadvantage.
aged to"unlock"newtechnologies. That is, those workplacesthat successfully
includeworkersin the deploymentwillshow talitylevel of workers'voice opportunities

largergains fromthe use of the new system (ranging from no voice at all to near co-
than workplacestakinga more traditional, determination) (Hunton 1996a; Hunton
top-downapproach- a processsuggestedby 1996b; Hunton and Beeler 1997; Hunton
Mirvis,Sales, and Hackett(1991). Because it and Price 1997; Lawrence, Goodwin, and
draws on what we already know about the Fildes 2002).
ways employment practices complement Where the IS literaturefalls short,how-
new technologies,the theorybegins to clar- ever,is with respect to the two tiersof the
ify the ambiguityof the El-performance employmentrelationsframeworkthat exist
link.Furthermore,the argumentallows for above the workplacelevel. The middle level
a critique of the HR and OB literature's of the employmentrelationship,immedi-
treatmentoftechnology,suggestingan addi- atelyabove the workplacelevel, is what has
tional contingency heretofore largely ig- come to be labeled the "functional"level of
nored bythese fields. the employment relationship. It encom-
The second theoretical advance is passes the processand outcomes of negotia-
founded on the received research fromIS tions,eitherexplicitlyin the unionized case
that,despite directexaminationof the phe- or more implicitly in thenon-unionizedone.
nomenon,has been unable to pin down El's By omittingthislevel of the employmentre-
moderationoftheIT-performance link.This lationshipfromits analysis,the IS literature
is a resultof thatfield'snarrowconceptual- ignoresa numberofimportantdeterminants
ization of the employment relationship. of El's instrumentality over the effectiveness
The three-tieredapproach to the studyof of new IT. The question arises,forexample,
employment relations, first proposed by have frontlineusers been assured thattheir
Kochan,Katz,and McKersie(1986) as a gen- earnest attemptsto use the technologywill
eralizationand extension of Dunlop (1958 not result in job loss or wage reductions?
[1993]) and since extended (Budd 2004), Located at the uppermostlevel of the em-
offersa useful lens for understandingthis ploymentrelationshipin thethree-tier frame-
issue. The bottom tier of this model, the work is what Kochan, Katz, and McKersie
workplace level, refers to those activities (1986) referredto as the "strategic"level,
throughwhichworkersand theirsupervisors whichincludes the strategiesand structures
relateto one anotheron a dailybasis (Katz, thatexertlong-runinfluenceson the nature
Kochan, and Colvin 2008: 6). This includes of the relationshipbetween a firmand its
variousformsof workerrepresentationthat workers.These include issuesrelatedto busi-
the IS literatureputs under the umbrellaof ness strategiesas well as decisionsregarding
user participation.The IS literaturehas, in the employmentor HR strategiesnecessi-
fact, been meticulous in its consideration tated (or allowed for) by these strategic
and measurement of differentstructures choices (Kochan, McKersie, and Cappelli
for guiding these interactions (e.g., see 1984). In the absence of details about mat-
Boland 1978), sometimeseven employinga ters at the strategiclevel, readers of IS re-
grounded, inductive approach that allows search know nothing, for example, about
the data to speak to the differentformsof the largergoals servedbythe effective use of
EI thatmightemerge in a given sample of new IT, nor can theyunderstandhow deci-
IT projects (see McKeen, Guimaraes, and sions made at the strategiclevel drivebehav-
Wetherbe 1994; McKeen and Guimaraes iors at theworkplacelevel.
1997). The common ways they measure Consider this illustrationpredicated on
workplace-level EI include the incidence of the business strategytypologypromulgated
workerrepresentativesin the implementa- byPorter(1980). The IT whose deployment
tion process (see Boland 1978; Brodbeck workersare being asked to facilitatemaybe
2001; Yeh and Tsai 2001), the extent of part of a businessstrategyfocused solelyon
workerinput sought at differentstages of cost minimization,with the resultingHR
the developmentprocess (see Kim and Lee strategy being to minimizelabor costsand to
1986), and, as noted earlier,the instrumen- maximize output. This "cost leadership"
business strategyoften goes hand-in-hand EI, but it also pays special attention to
withan autocraticapproach to HR in which functional-and strategic-level aspects of the
supervisorsseek to "drive" rather than to employment relationship, holding them
"motivate"workers(Arthur1992). Hence, in place to identifythe moderatingrole of
participatorystructuresat the workplace EI in IT deploymentthroughvariationin
level may prove ineffective,since workers workplace-levelmeasures of EL In thisway,
should see littlereward,and in fact,some one can see how EI complementsIT in the
real penaltiesassociated withthe success of production and deliveryof healthcare ser-
the new technology.Alternatively, EI activi- vices. Establishingthis relationshipreliably
tiesin theworkplacemayemergefrommore requires a deep understandingof the tech-
of a "differentiation" business strategyin nologyand of workplace-level aspectsof the
whichthe firmseeks to leverageits assets- employmentrelationship,includingrelevant
including its human ones- as a source of workflows and measuresof EL The IS litera-
competitiveadvantage.Under thisscenario, turehas actuallypaid close attentionto what
workersare not a "necessaryevil" or a cost employmentrelationsscholarswould label
to be minimized,but ratheran object of in- workplace-level variationin EI, thoughexist-
vestmentthatmustbe developed,rewarded, ing studiesof the effectsof EI and IT on per-
and empowered.As a resultof the commit- formance in employment relations have
ment thattheyreceivefromthe firm,work- actually been criticized for failing to do
ers can comfortably believe that theirwork (Brown and Campbell 2002; Ichniowski
to make the new technologymaximallyef- et al. 1996). Even the IS studies,however,ig-
fectivewillbe rewarded.In thislattercase- nore functional-and strategic-level features
differentiation- even workplace-level EI of the employment relationship. Conse-
structures thatappear identicalto thoseem- quently,I focusfirston issuesat thetwohigh-
ployed under a cost leadership strategy est tiers of the employmentrelationship,
should be farmore instrumental in boosting describingthe workplace-levelEI variations
performance. in these structures.That is, I describe the
Lab-basedexperimentalstudiesin IS nec- functionaland strategicaspectsof EI and of
essarilyneglect forcesabove the workplace the Kaiser Permanente labor management
levelbydesign.That is,the experimentalap- partnership(LMP), particularly withrespect
proach was called on specificallyto forestall to the organization'sstrategyfor its EHR
the influenceof institutionsthatin real or- system.This detail provides the context
ganizational settingswould be situated on needed to reliablyinterpretthe quantitative
the functionalor strategiclevels. However, resultsthatfollow.
in the case of the fieldexperimentsand the
multi-organizational or broad national stud- Functional-and Strategic-Level
ies, these features of the employmentrela-
are unmeasured contextualvariables Aspectsof EmployeeInvolvement
tionship at Kaiser Permanente
that impinge on the relationshipbetween
workplace-levelEI and economic perfor- KaiserPermanente,the integratedhealth
mance. My employmentrelationsapproach insurerand healthcareprovider,was chosen
bridges the gap between HR and OB's ap- forthisstudyin partbecause of itspioneer-
proach to EI (whichunder-theorizes therole ing businessstrategy.It has been a forerun-
of technology)with the IS literature'sap- ner in healthcare's conversion from
proach to EI (whichgivesshortshriftto the paper-based to electronic recordkeeping
nuances of the employmentrelationship). and, at the same time,has a historyof pro-
motingEI as part of an overall labor man-
agement partnership(Kochan et al. 2009).
Technologicaland Once fullydeployed, Kaiser's EHR system,
OrganizationalContext KP HealthConnect,will include a fullcom-
This studynot onlyintegratestechnology plementof interoperableadministrative and
and technologicalchange into researchon clinicalhealthIT applications.One of these,
Table1. Highlightsof the KP HealthConnectEffectsBargainingAgreementbetween

KaiserPermanenteand the Coalition of KaiserPermanenteUnions
• commit tothe"successful • extend existing

language on
implementation ofKP andjob andwage
flexibility
HealthConnect andthefull M securitytochangesengendered
realizationofitsbenefits." ^j¡ bynewtechnology.
• engage indevelopment, T . commitment
•. . «an
. .tocreate • followa process
r forincorporat-
r
. . . and , Joint
. .
implementation,
r. . environment ^where ^ cc. . . cfreely
allstair ° intothebargaining
ing о о unitnew
continuous improvement . ^transformation
.inthe c . effort.
rr ^ „ jobscreated 7thetechnology.
by
efforts
ateach ,r engage • fundKPHealthConnect ,labor
,
stage,
regionallyandnationally. coordinatorsineachregion and
forrelease, andtraining
backfill,
demands from
arising the
initiative.
Source
: KPHealthConnect
Effects effective
Bargain, 5 April
2005.
whichI referto as the "schedulingmodule," and now administersa national KP Health-

is used for scheduling officevisits,proce- Connect "EffectsBargain" agreement gov-
dures,and lab testsin each region's outpa- erningjob and wage protectionsforworkers
tient or "ambulatory"clinics- essentially, as they relate to the EHR initiative(see
large-scaledoctors'offices.3 Table 1). Together,theseprovisionsand per-
The LMP is a cooperative arrangement sonnel assignmentsestablishtheimportance
betweenKaiserPermanenteand thirty union of labor to the KP HealthConnect initiative
locals representingworkersin seven of its and seek to assure that this systemwill ad-
eight regions (Kochan et al. 2009). As of vance the interestsof the workforceas well
2008, the Coalition of Kaiser Permanente as Kaiser'sgoals. Further,the agreementun-
Unions (CKPU) and thus,the LMP, covers derlinestheneed forflexibility at all levelsin
about 86,000 Kaiser employees.The config- processes and workflowsand for the active
uration of the CKPU replicates that of its involvementof labor representativesand
management-sidecounterparts,creatingla- frontlineworkersin developing and imple-
bor-management "partners"at everylevel in mentingthe initiative.In exchange,the doc-
everyregion in which the CKPU represents ument creates and funds regional KP
workers.At the apex of the LMP in its HealthConnect union representativesto
Oakland-based office sits a representative representlabor alongside IT and operations
fromKaiser- a seniorvice presidentreport- leads at the top of each region'sKP Health-
ing directlyto Kaiser'sCOO - alongside the Connect projectteam.Among otherprotec-
CKPU's director. tions,the agreementmakes guaranteeswith
The LMP fundsa full-time KP HealthCon- respectto trainingand preparationas wellas
nect union coordinatorat the national level commitsto mitigatingthe effectsof staffing
to representthe interestsof the CKPU with challengesthatwould inevitably occur in the
respectto thissystem'sdevelopment,deploy- run-up to implementation,somethingthat
ment, and ongoing use. It also negotiated prior research makes clear is essential for
the effectiveness of EI (Levine 1995).
The EffectsBargain establishedthe cre-
3Theterm isoften
"outpatient" usedtodescribethose ation of at least one full-timeKP HealthCon-
patientsexpectedtocheck-in andoutofthehospital nect labor coordinator to serve on each
on thesameday.However, sincethisstudydoesnot
addressanything or hospital regionalleadershipteam.Since thelabor co-
relatedto "inpatients"
care,I usetheadjectives and"outpatient" ordinatorwas charged withmonitoringKP
"ambulatory"
interchangeably. HealthConnect-relatedservice process and
workflow change experimentsand pilots,he the new technologywitha clear up-frontin-

or she also assumedresponsibility foridenti- vestmentmuch like thatwhichtheywereex-
fyingand respondingto demands forfront- pectingfromthe workforce.Though much
lineworkerinvolvement arisingin thecourse of what the super-usersdid was informal,
of the initiative.In the aggregate, Kaiser their participation - and by extension,the
expected labor's activeparticipationin con- participation of all those frontlineworkers
figuring,implementing,and eventuallyen- whom theytouched- made the scheduling
couragingoptimaluse ofKP HealthConnect. module more effectivethroughfour main
In exchange,workersweregivena sayin how channels.
the systemwould be deployedand used and First,duringtheirtravelsthroughoutthe
were assured thatthe effortput forthto use region, the super-userssought suggestions
the technologywould not resultin job loss on how to improvethe systemor itsrollout.
or wage reductions. Through weeklymeetings,theyrelayedthis
One ofKaiser'sregionaloperations,Kaiser informationto the labor coordinators,who
Permanenteof the Northwest,signaled its ensured it was integratedinto the planning
commitmentto both the Partnershipand being done bythe regionalleadershipteam.
KP HealthConnectby fundingtwo employ- It was through this process that frontline
ees to serveas KP HealthConnectlabor co- staffpointed out thatthe transitionbetween
ordinators,each pulled directlyfrom the scheduling systemscould not be done in
bargainingunit. With clinical functionality waves- by clinic, by department,or by any
largelyin place, the regionturnedto one of wayotherthanwhatwould eventuallybe la-
KP HealthConnect's non-clinical applica- beled a "big bang." This is because Kaiser
tions,the schedulingmodule. The labor co- patients,even thoughassigned to a specific
ordinatorsassumed their positions on the providerin a specificclinic,drawon services
local configurationteam alongside IT and frommanydepartmentsand oftenmultiple
operationsleaders,programmers, and appli- facilities.Aside fromcommunicatingthisup
cation specialists.They also began assem- to managementthroughtheirlabor coordi-
blinga cadre ofbargainingunitmembersto nators,the super-usersalso made a related
serveas "super-users," who would ultimately case withrespectto training,also voiced at
serveas the primarylinkbetweenthe work- the strategiclevelbythe regionallabor coor-
place level and employmentrelationsfea- dinators:as a consequence ofthe decisionto
turesat the functionaland strategiclevels. go with a "big bang" rollout,all end-users
would have to be trainedbefore"go-live."
Trainingwas, in fact,the second area in
Workplace-Level Aspectsof Employee
Involvementat Kaiser Permanente
whichsuper-users playeda keyrole in thede-
ploymentof the scheduling module. They
Super-userswere support staffend-users workedwithregionaltrainersto develop and
drawn from throughoutthe Northwestre- lead sessionsfor theirfrontlineco-workers.
gion. At any one time,therewere approxi- This introductory trainingoccurred mainly
mately15-20 active super-users.They were but it called
at the regional trainingfacility,
the firstto learn how to use the scheduling upon the super-usersto scope out opportu-
module and servedas liaisonsbetweenfront- nitieswithinthe clinicsto ensure staffwere
line supportstaffand the regional configu- up and runningon the technology.Later on
ration team. As the region grew closer to in theprocess,theyplayeda similardual role
the
implementing system in the springand in follow-upor "optimization"training.
summerof 2005, super-users were temporar- Super-userswere also charged withcom-
ily transferred from their regular roles on municatinginformationdownwardfromre-
the frontlines to full-timeliaisons.Not only gional leadershipto thoseon the frontlines,
did thisallow them to travelthe region an- a responsibility thatoftenincluded as much
sweringquestions and facilitatingthe train- justification communication.For exam-
as
ing of otherbargainingunitmembers,but it ple, management's recognition that staff
also demonstratedthefirm'scommitmentto fromall clinicswould have to be trainedbe-
fore the rollout reinforcedthe need for studies (e.g., Bresnahan, Brynjolfsson,
and
some extraflexibility fromthe rank-and-file. Hitt 2002; Kim and Lee 1986; Mirvis,Sales,
In particular,the short time frame meant and Hackett 1991). That is, I demonstrate
that some trainingwould have to occur in thatEI around new IT increasesthe technol-
the eveningsand on weekends, a decision ogy's effectiveness,relyingon variationin
thatwas not welcomedbytheworkforce. workplace-level EI measures, holding con-
Finally, super-users provided ongoing, stant employmentrelationsfeaturesat the
"just-in-time" support for co-workersnot functionaland strategiclevels.
onlyaround the timeof thedeployment,but
thereafter as well.These expertswould even-
return to theirjobs able to serve as Technologyand Workflow
at
tually Kaiser Permanente
theirworkplace'sdefactoleaders and "go-to"
people for all matters technological and Through interviewswith managers and
work-relatedpertainingto the KP Health- labor leaders in Kaiser's national headquar-
Connect schedulingmodule. Indeed, super- ters as well as those in multiple regions,
usersplayedjust as vitala role in theinitiative the Northwestregion's scheduling module
whentheyreturnedfull-time to theirregular emerged as one withclear and measurable
positions. Managers and frontlinestaffre- performance improvement expectations.
portedtheirbeing in demand as KP Health- Furthermore,itwas implementedin organi-
Connectresourcepeople in clinics,providing zational unitsdoing the same workand that
co-workers withquick answersto the sortsof were similarenough on otherdimensionsto
"just-in-time" questions that arose as those provideforsuitablecomparisons.Headquar-
who were alreadyformallytrained became tered in the suburbs of Portland,Oregon,
everydayusers. the regionemploys880 physiciansand 8,900
Despite the sturdystructuresupporting employeesto servejust over 480,000 "mem-
the mandate forworkforceparticipationin bers"(patients). The regionspansthegreater
termsof the organization'slong-termgoals metropolitan Portland and Vancouver,
for the technologyand in the agreement Washingtonareas. It offersambulatorycare
governingemploymentrelationsissuesrelat- through27 outpatientmedical officebuild-
ing to KP HealthConnect, interviewswith ings, 15 of which serve as hubs for primary
frontlinestaffin manyclinicsacrossmultiple care- familypractice,pediatrics,and inter-
Kaiserregionsrevealeda greatdeal ofwork- nal medicine. The studyfocuses on these
place-level variation in just how involved primarycare clinicsin partbecause so many
workersfelt theywere in the project. This of the performanceoutcomes of interestto
deviationbetween stated policies and their Kaiser are shaped by the member's experi-
impacton the ground is actuallyquite com- ence withhis or her primarycare physician
mon in studies linking employmentprac- (PCP). Bounding the sample in this way,
tices to performance (e.g., Bartel 2004; moreover,allows the researcher to spend
Jones,Kalmi, and Kauhanen 2009). Within time in all of the clinics,accountingfor or
well-definedregional boundaries, however, assuring the non-variationin contextual
therewas littleor no variationin functional- characteristics.For example, including ap-
and strategic-levelstructuresbolsteringEI in pointment-making procedures beyond pri-
support of the new technology.Further- marycare would introducevariationacross
more,withintheseconfines,attributes of the specialtiesand ancillaryservices.
IT module itself- includingwhen it "went The schedulingmodule addressed a very
live"- as well as a host of contextualvari- concrete set of organizationalchallenges-
ables, can be reasonably assumed not to inefficienciesand patientdissatisfactionwith
vary. I exploit these advantageous quasi- the appointment-settingprocess. Among
experimentalconditionsin order to under- otherchallenges,thosesupportstaffcharged
take a more carefulanalysisof El's role in withsettingpatientappointmentsusing the
IT implementationthan that permittedby legacy scheduling applications frequently
the research designs employed in earlier found themselves asking even long-term
Kaiser members for data that should be tinginput fromworkersand ensuringthey

permanently linkedto a member'shealthre- wereproperlytrainedcould potentiallymiti-
cord number (HRN), namelycontactinfor- gate thesechallenges.
mation. The legacy systemalso made it
difficult to schedule regularlyrecurringap-
Complementarity betweenEmployee
pointmentsand oftenlacked up-to-datein- Involvementand Information
formationon providers'availabilityvis-à-vis
vacation scheduling,"panel support" time, Technology
or the use of planned or unplanned leave. At Kaiser, the new IT- the scheduling
To understandhow thiswould have a neg- module- served as a tool forworkers,pro-
ative impact on economic performance, viding them real-time,up-to-dateinforma-
consider the process by which members tion that facilitatedtheir abilityto better
makea primarycare appointmentbyphone. meet a strategicgoal. Therefore,one might
They dial their clinic's appointmentsline. expect thatjust turningthe technologyon-
The call is receivedbya memberintakespe- which occurred at the same time across all
cialist (MIS). The MIS opens the schedule clinics examined- would boost perfor-
correspondingto the member's PCP and mance. Whereas there was no inter-clinic
searchesforthe firstavailable appointment variationin when the IT "went-live," there
timeor thefirstavailabletimeslotamenable was variationin the levels of EI achieved in
to the member.This onlydisposes of about each clinic.Atsome clinics,workersreported
40% ofcases. More frequently, largesections the frequentpresence of and relianceupon
ofa provider'sschedule would be blocked as so-calledsuper-users.However,at otherclin-
"unavailable"for one of the reasons listed ics, workersclaimed not to have had their
above. The MIS would then transferthe ideas or concernssolicitedor consideredor
memberto the medical assistant(MA) sup- reportedbeing trainednot bya fellowfront-
portingthe appropriateprovider.If the MÍA line workerin the formof a super-user, but
picksup thephone, he or she could override ratherby a manager or regional IT staffer.
or correctthe schedule. If insteadthe MA is This inter-clinicvariationin EI is what en-
servinganother patientor is otherwiseun- ables the identificationof the theorized
available, the patient calling could leave a complementarity betweenEI and IT. While
message. If the patient ever called again, the IT mightboost performanceacross-the-
possiblyreturninga call fromthe MA, he or board, these improvementsshould be mea-
she would have to begin the processagain at surably larger under higher levels of EI.
the clinic's call center,in which the MIS Finally,as alluded to above, these quasi-
would attempt to make an appointment experimentalconditions allow for an un-
and would likely run into the same precedented,"apples to apples" comparison
complication. of before-and-aftereffectsin verysimilaror-
The end resultwas that75-80% of mem- ganizational sub-unitsdoing identicalwork
bers initiallydenied an appointmentwould and using the same new technology (cf.
ultimately be givenone withinan acceptable Mirvis,Sales, and Hackett1991).
time frame. However,this chain of events
came at the greatexpense ofpatientsatisfac-
Methods
tion withthe appointment-making process.
Furthermore,appointment-setting required For it to be truethatEI facilitatedthe de-
4-5 "touches"frommore highlypaid MAsin ploymentof the schedulingmodule, it must
addition to MISs, rather than the single be shownthatvariationin EI drivesvariation
touch of one MIS. Effectiveuse of the new in performance.This analysisdoes so bymea-
schedulingmodule could address thisissue suringthe performanceimpactof the same
and the patient dissatisfactionthat arose technology - the schedulingmodule- in 16
fromit. However,the new technologywould clinicsin thesame regionaloperationsof the
certainlycause a disruptionto existingrou- same organizationover a 35-monthperiod
tinesforsettingpatientappointments.Get- beginning in October 2004 and ending
Table2. DefinitionsofVariables
Variable Description Source
Employee Involvement
index sumofresponses to8 survey
items (listedbelow) employees
suggestionshavebeenvalued answeredona 7-point scaleinwhich
Likert-type employees
1 = "strongly and7 = "strongly
disagree" agree",
andthenstandardized
issues
havebeenignored answeredona 7-point scaleinwhich
1 = "strongly and7 = "strongly
disagree" agree",
andthenstandardized,withcoding subsequently
reversed
unionized super-user answeredona 7-point scaleinwhich
improves myuse 1 = "strongly and7 = "strongly
disagree" agree",
andthenstandardized
affectedstaff
wereaskedfor answered ona 7-point scaleinwhich
guidance 1 = "strongly and7 = "strongly
disagree" agree",
andthenstandardized
introduced totechnology binary variable
createdfroma question allowing employees
bya unionmember respondentstochoosebetween a fellowunion
member, a member oftheIT staff,
ora manager
receivedfollow-up
training binary variable
createdfroma question allowing employees
from a unionmember respondentstochoosebetween a fellowunion
member, a member oftheIT staff,
ora manager
ona "super-user"
relies binarycreatedfroma yes-or-no
question employees
intheir clinic
madespecific recommenda- binary createdfroma yes-or-no
question employees
tionsforeffective
use
satisfaction
with of
length answeredona 9-point scaleinwhich
Likert-type patients
tomake 1 = "extremely
phonecallrequired and9 = "extremely
dissatisfied"
appointment andthenstandardized
satisfied",
TimeTrend linear timetrendbeginningwiththefirst

month ofdata, archival
interviews,
i.e.,October2004= 1,November 2004= 2,. . ., andclinic
records,
August 2007= 35 observation
Transition
Period dummy tocapture
variable performancefluctuations archival
interviews,
around thetimeof"Go-Live";
setto0 forallmonths andclinic
records,
except June, andAugust
July, 2005 observation
Module-in-Use dummy variable
to the
capture effectsof"Go-Live"; archival
interviews,
setto0 untilSeptember 2005,andthensetto1for andclinic
records,
allmonths until
theendoftheobservation period observation
TimeSince"Go-Live" linear timetrendbeginningwiththefirst
month in archival
interviews,
which September 2005= 1,October2005= 2,. . ., andclinic
records,
August 2007= 24 observation
August 2007. Measures of IT "go-live"are study.Table 2 detailsall of thevariablesused

constructedfrominterviews,archival data, in the quantitativeanalyses.
and clinicobservations.Performanceis mea- The analysisleverages the multi-method
sured usingKaiser'sPatientSatisfactionSur- nature of the researchin numerousways.It
vey,and EI is assessed using a new surveyof uses the rich qualitativeinformationto un-
employees designed specificallyfor this derstand the processes that generated the
data and, more directly, to constructtempo- tablishment.In thiscase, onlythoseemploy-

ral variables,such as when the technology ees expected to use the schedulingmodule
was "switchedon." This allowsfora number in the course of theireverydayworkare in-
of methodological benefits.For example, cluded in the analysis. This technique
qualitative research revealed why the sched- also avoids "frame-of-reference" problems
uling module was such an attractivechoice (Hunter and Pil 1995) by asking frontline
forin-depthstudy - its directconnection to workersthe veryEl-related questions that
a well-measuredoutcome of greatinterestto theyshould knowthe answersto- not ques-
Kaiser managers.Whether the new system tions about a broad EI construct.Third,
was effective could be measuredbypatients' Gerhartet al. (2000) suggestedthatdrawing
perceptions theappointment-making
of pro- on multiple respondentsfrom each estab-
cess. Indeed, Kaiser had for many years lishmentdisposes of inter-rater is-
reliability
collected patient-leveldata on the appoint- sues, though theyalso noted that research
ment-settingprocess as part of a mailed designsbounded to a smallnumberof orga-
paper-and-pencil Patient SatisfactionSurvey nizational sub-units and a homogenous
sent shortlyafteran appointment.Though groupofworkersrarelysuffer fromthisprob-
the use of these typesof "localized" perfor- lem anyway. Finally,perhapsthe mostsignifi-
mance measuresposes a challenge forgen- cant methodological challenge to studies
eralizability,a number of researchers have linkingemploymentpractice"inputs"to per-
argued for their use on reliabilitygrounds formance "outputs"occurs when the same
(e.g., Hunter and Pil 1995), claiming that instrument is used to collectboth.In thisway,
theyprovidea more directcausal link than so-called "common method bias" generates
do financialperformancemeasures. Some inflatedcorrelationsbetween EI,
artificially
researchershave chosen to use such mea- IT use, and performance(Podsakoffet al.
sures even when more generalizable dollar 2003). However,theresearchdesignhere cir-
figures could have been easily imputed cumventsthecauses ofcommonmethodbias
(see Bartel, Ichniowski,and Shaw 2007; withits collection of the independent and
Ichniowski, Shaw, and Prennushi 1997; dependent variablesfromcompletelysepa-
MacDuffie1995). rateand unrelatedsources- one long in ex-
Due largelyto thenewnessof the technol- istence for organizationaluse and another
ogy,Kaiser'shuman resourcerecordsdo not conceived of and administeredyears later
containreliablemeasuresof the flavorof EI purelyforthe purposesof thisresearch.
examined here. Though Kaiserconductsan Having describedand justifiedkeymeth-
annual poll of itsemployees,the instrument odological choices,I willnextbrieflyexplain
has only recentlybeen augmented with a the variables constructedfrom qualitative
single and verybroad question about the research- those pickingup when the tech-
healthIT system.Therefore,the best option nologywas turnedon and thoseintendedto
was to develop a new employee surveyspe- control for random performance move-
cificallyfor thisstudy,ensuringthat the EI mentsaround the time the technologywas
measures were not about some broad EI turned on. Likewise,there are variablesto
construct,but about EI in the contextof the capture the trendingof the performance
deploymentofthisspecificIT module.There variables, allowing for the separation of
are a numberofadvantagesto surveying em- trendfromthe changes engendered by the
ployeesdirectly, and then aggregatingthese use of the schedulingmodule. Then, I de-
data to the clinic (i.e., establishment)level. scribe in detail the PatientSatisfactionSur-
First,EI measurescannot be biased byindi- vey and the employee surveyand explain
vidual clinic-levelmanagerswantingto offer how relevant variables were constructed
an idealized account of EI (Jones,Kalmi, fromquestionnaireitems.Finally,I explain
and Kauhanen 2009). Second, Huber and the estimationstrategythat relies on these
Power (1985) suggest that single-response data, focusingon how it identifiesthe mod-
bias be tackledbyaskingsurveyquestionsof eratingeffectsof EI on the effectiveness of
the "most-informed respondent"in the es- the new technology.
PerformanceTrends,Transitionto the PatientSatisfactionand Ease

New Technology,and Module-in-Use of Scheduling
The observationrepresentedin the archi- I constructeda dependent variablefrom
val data occurs overa 35-monthperiod. It is an item on the Patient SatisfactionSurvey
importantthat the influenceof trend over asking respondentsto rate on a nine-point
this period be controlled for in order to Likert-type scale theirsatisfaction"withthe
meaningfully identifythe effectsof the new lengthof timespenton the phone to sched-
technology. The first linear time trend ule the appointment."At the same time,the
("Time Trend") begins with October 2004 surveyalso included thequestion,"Wereyou
and ends withAugust 2007. The next step able to get the appointmentscheduled by
towardidentifying the theorizedeffectsis to talkingtojust one person?"This allowed for
detect the discontinuity in performanceas- confirmationthat this specificformof pa-
sociated with turningthe new technology tientsatisfactionwas, in fact,drivenby the
on. The schedulingmodule wentlive across efficiencywithwhichone's appointmentre-
all clinicsobservedat the end ofJuly2005. quest was disposed of. The continuousvari-
Therefore,if a single dummyvariablewere able and the dependent variable were
used to capture the discontinuity, then all stronglyrelated. Those who answered"yes"
monthsfromAugust2005 onwardwould be for the binaryperformanceitem were, on
set to equal one. However,in order to con- average, more satisfiedwith the length of
trolforperformancegyrationsaround "go- time required to make their the appoint-
live,"the analysispresentedhere allows for ment(t= 74.4,jfr<.001), providingsome face
June,July,and August 2005 to be labeled validityforrelianceon thesingle,continuous
"transitionmonths."That decision gets op- dependent variable (Furr and Bacharach
erationalizedwiththe binaryvariable"Tran- 2008; Schwab2005).
sition Period," which equals zero for all With approximately43,000 patient re-
monthsexcept the threejust noted. There- sponses,the responserateforthe surveywas
fore,"Module-in-Use"does not begin to take 35%, whichstacksup favorablyto compara-
on the value of one until September 2005, ble customersurveysadministeredby mail
just afterthe period of transition.This was a (Kaplowitz, Hadlock, and Levine 2004).
conservative choice, since it potentially Though managementcould not providethe
"dummiesout" the benefitsthat would ac- necessarydata dismissingthe possibilityof
crue fromthe IT being in use in Julyand response bias, thisbias should be consistent
August.Changesin thenumberof transition over the timeperiod studied.Furthermore,
monthsallowed foralmost no differenceat the marketingliteraturesuggeststhat dis-
all in any of the subsequent estimates.A gruntled or dissatisfiedpatients may be
second linear time trend- "Time Since more likelythan othersto respond to such
'Go-Live'"- captures the month-to-month surveys(Richins 1983). To the extent that
changes (as opposed to thestructural break) thisis true and thatthe use of the technol-
associated with "go-live."Therefore,it car- ogy dissatisfiespatients, it only serves to
riesa value of zero untilSeptember2005, at make the statisticalestimatesmore conserva-
whichpointthesecond lineartimetrendbe- tive, that is, biased away from theorized
ginsat one and increasesbyone up to 24 for results.
August2007. Thus, as operationalizedin the
paper, there are 8 pre-"go-live"months,3
transitionmonths, and 24 post "go-live" EmployeeInvolvementin
months.4 IT Deployment
Measures of EI were developed froman
author-administeredemployee survey of
4Sincethepanelisunbalanced, num- MAs and MISs. Responses to eight survey
thetotal
however,
berofobservations
isnotsimply to
equal 16 x35
clinics items were summed to construct the EI
months. index. The firstfouritemsare:
1) Mysuggestionsrelatingto thedesignand have been directly canvassed for their

improvementof [the scheduling mod- thoughtson effectivesystemuse. Alterna-
ule] have been valued; tively,they may have relied frequentlyon
2) My issues or complaints about it have guidance from a super-user.Summing an-
been ignored; swers into a composite measure therefore
3) There is at least one bargaining unit captures the overall level of EI in thiscon-
memberin myofficewho helps me be a text,even thoughthereis no a priorireason
betteruser of [the schedulingmodule]; to expect a high correlationbetweenitems
and (Bidwell2009). 5
4) Beforeitwasrolledout,thepeople whose The surveywas piloted on both frontline
workwould be affectedwere asked for workersand union and managementlead-
guidance. ers, and then administered electronically
throughthe organization'sintranetin Fall
Each was answered using a seven-point 2007- shortlyafter the end of the con-
Likert-typescale in whichseven represented structeddata series.Althoughorganizational
strongagreement.The second itemwas re- constraintspreventedthe surveyfrombeing
verse-coded.The remainingfouritemswere run earlieror multipletimes,conductingit
binary in nature. Respondents answered wellaftertheimplementation oftheschedul-
questions on whethera fellowmember of ing module provided assurance thatthechief
the bargainingunit introducedthemto the concern- recall bias- would actuallymake
scheduling module, provided them with the findingsmore conservative.The survey
their follow-uptraining on the module, achieveda responserateof 58%, amounting
or otherwiseserved as an on-siteexpert or to 268 MAs and 128 MISs thatuse the tech-
"super-user"forthe schedulingmodule. Re- nologyin the course of theireveryday work.
spondents also answered yes or no as to Analyses confirmed that those MISs who re-
whethertheyprovided any specificrecom- sponded had about the same average age
mendationson additionalwaysthatthe sys- and job tenure as those who did not. The
temcould be used to meet itsstrategicgoals. MA respondentshad the same average ten-
As a furtherreliabilitycheck, the surveyin- ures as theirnon-respondingcolleagues,but
cluded an open-endedquestionaskingwork- were marginallyolder, on average, than
ers to document a specificsuggestionthat those thatdid not respond- 41.8 yearsver-
they had made. This step provided addi- sus 39.3 years(¿=2.44, p< .Ol).6 Not surpris-
tional confidence that respondentsunder- ingly,the number of responses fromeach
stood exactlythe kindsofEI theywerebeing clinic- ranging from eight to 43- was
asked about (Hunter and Pil 1995). mainlydrivenbyclinicsize.7
The employeesurveyincluded questions
derivedfromthe author'sobservationsand EstimationStrategy
interviewsto measureEI relevantto employ-
ees in thisparticularorganizationalsetting, In thissectionI demonstratethatthe use
similarto the methodologicalapproach ad- of the IT is associated with performance
opted byBidwell(2009) . AccordingtoJarvis,
Mackenzie,and Podsakoff(2003), the con-
structionof formativeindicators such as 5Thisscaleproves reliable
onlymarginally byconven-
these ratherthan more traditional"reflec- tionalstandards a lowalpha
(a =.58). Nonetheless,
tive"measuresmakes sense when indicators doesnotindicatelowreliability
inthecaseofformative
measures likethatemployed forEI (Bidwell 2009;
"define"differentaspects or dimensionsof BollenandLennox1991; Mackenzie,
Jarvis, andPodsa-
the constructand when indicatorsneed not koff 2003).
be interchangeable.In Kaiser's case, there 6 I couldnottestforrandomness withrespecttosex.
were multiplewaysin whichworkersmight However, alloftheMAsandMISssampled
nearly were
women.
have participatedin the IT initiative,and 7Thework ofGerhartandcolleagues(2000)suggests
any one of themcould effectively substitute thatevena verysmallnumber ofrespondents should
for any other. For example, a workermay beenough toensure instudies
reliability likethisone.
increasesat the clinicleveland thattheseef- variableis the two-way, interac-

multiplicative
fectsare greaterin those clinicswithhigher tion of "Module-in-Use"with EI. Whereas
mean levelsof EI. The moststraightforward the point estimateon "Module-in-Use"will
wayto illustratethe moderatingrole of EI is establish the influence of the scheduling
to collapse the data into a dataset of clinic- module on performance,the estimatefor
months, and then to regress the perfor- the two-way interactionestablishesthe mod-
mance measure on a vectorof independent eratingimpactof EI.
variables.These variableswould include con- Given the dependence structureof the
trols,namelyfortrend,but also main effects data, the usual assumptionsrequiredof OLS
forIT "go-live"and forEI. The focal explan- do not hold. In particular,one would expect
atoryvariablewould be the two-way, multipli- thatthe errortermswould be systematically
cativeinteractiontermcrossingIT "go-live" correlatedat the clinic level. Accommodat-
("Module-in-Use")withEI, and a statistically ing thisdata structurerequires a longitudi-
significant,positivecoefficientestimateon nal model, multilevel in the sense that
thistermwould supportthe theory.Indeed, individualobservationsare of clinic-months
withsome modificationsto account for the "clustered"in clinics.Therefore,the models
dependency structureof the data and per- estimatedhere insteadpartitionthevariance
formance gyrationsright around the "go- terminto a random effectat the clinic level
live"month,thisis essentiallyhow the paper in addition to the usual zero-expectation
teststhe impactof EI and IT on the continu- errorterm.That is, the observationscan be
ous performancemeasuredescribedabove- assumed independent conditional on the
patientsatisfactionwiththe length of time random effect,and the estimatescan be in-
requiredto make an appointment. terpretedwiththe same ease as typicalOLS
On a practicallevel,thisrequiresmelding coefficients(Skrondal and Rabe-Hesketh
patients' responses to the Patient Satisfac- 2004). 8
tion Survey - the dependent variable- with
employee responses to the employee sur- Results
vey- the independent variable. Calculating
the mean EI index foreach clinicis straight- Table 3 presentssummarystatisticsfrom
forward.Given thatworkerswere only sur- the surveyof the Northwest'ssupportstaff.
veyed once, this measure is time-constant. Recall thatmeans are calculated using only
Aggregatingthe patient satisfactiondata is responses from those MAs and MISs ex-
onlyslightly morecomplicated.About43,000 pected to use the schedulingmodule in the
patient observations were linked to the spe- course of theirwork.The firstsetofvariables
cificPCP withwhomthe patient-respondent representsthe four continuous items con-
made the appointment,and then these data tributingto the EI scale. Notice how in all
were crossed witharchivalmanagerial data fourcases, means hovernear the neutralre-
placing physiciansinto specificclinics over sponse (4 = "neitheragree nor disagree"),
time.Followingjones,Kalmi,and Kauhanen albeit with significantvariation about the
(2009) and Bartel (2004), I do thisbytaking mean. Overall, only 11% of respondents
the averageof patientsatisfactionresponses claimed that theywere firstintroduced to
byclinicbymonth,standardized- a method the technologyby a fellowmember of the
that furtherstrengthensthe reliabilityof bargainingunit (as opposed to a manageror
these specific performance measures an IT staffer),though18% assertedthatthey
(Harter, Schmidt, and Hayes 2002). The had, in fact,receivedfollow-uptrainingfrom
models include on the right-handside the a co-worker.About 40% noted the impor-
variables to capture trend ("Time Trend" tance of "super-users"- fellowmembers of
and "Time Since Go-Live") and transition
("TransitionPeriod") as well as the main ef-
fect of the new technology being in-use 8Thetime-constant
nature
oftheEI measureunfortu-
("Module-in-Use")and of EI ("EmployeeIn- theestimation
natelyprecludes of clinic-level
fixed
volvement").Finally,the focal independent effects
withthesedata.
Variables
Table3. DescriptiveStatisticsforWorker-Level
Included in the EmployeeInvolvementIndex
Variable Mean Std.Dev.
havebeenvalued
suggestions 3.99 1.53
issues
havebeenignored 3.57 1.65
unionizedsuper-user
improvesmyuse 4.01 1.77
affected wereaskedforguidance
staff 3.77 1.52
introduced bya unionmember
totechnology 0.11 0.31
received
follow-up from
training a unionmember 0.18 0.39
relies intheir
ona "super-user" clinic 0.39 0.49
madespecificrecommendations use
foreffective 0.15 0.36
Notes:
Valuesbasedon responsesfromthosemedical (MAs)and
assistants
member intakespecialists
(MISs)reporting
expected use of thesystem
(n = 396).Thefirst
fourcomponents oftheEI indexwereanswered on a
seven-point, scalein which1 = "strongly
Likert-type disagree"and 7 =
agree",
"strongly thoughthevaluesfortheseconditemhavebeenreversed
Theremaining
foreaseofcomparison. fouritems arebinary.
the bargainingunit pulled fromtheirregu- Table4. DescriptiveStatisticsforDependent

lar,frontlinepositionsto assistin the devel- Variables,byClinic
opment and deploymentof the system - to
theirsuccessfuluse of the schedulingmod- with
Satisfactionlength call
ofphone
tomake
required appointment
about 15% of respondents
ule. Interestingly,
specificallyrecommendedwaysin whichthe Clinic
Name Mean Std.Dev. n
systemcould be used more effectively, the
Bruford -0.07 1.01 4,051
details of whichwere validatedwiththe re- 0.01 1.00
Collins 2,078
sponses to a free-form textfieldincluded in 0.004 0.99 2,864
Copeland
the survey.For example, some workerssug- Dolenz 0.04 0.96 4,056
gested the need for"write"privilegesin ad- Escovedo 0.09 0.97 3,016
dition to "read-only"privilegesat certain Fleetwood 0.20 0.93 3,046
screens.Otherspointedout theneed to make Henley 0.09 0.97 3,371
sure that a patient'scontact details remain Mullen -0.10 1.05 1,028
on-screen throughout the appointment- Peart -0.02 0.97 3,084
Peterson -0.04 1.04 976
settingprocessor theneed to allowthehome Schock -0.05 1.02 2,898
phone number field to be left emptyfor Slichter -0.08 1.02 2,921
thosepatientshavingonlya cell phone. Oth- -0.07 1.04 3,018
Starkey
ers had suggestedthe creation of shortcuts Torres -0.03 1.01 2,992
for frequentlyused "bundles" of mouse Ulrich 0.08 0.90 255
clicks,like those required to make certain, Watts -0.07 1.04 3,194
regularlyoccurringtypesof officevisitap- Notes:
ValuesbasedonresponsestoPatientSatisfaction
pointments.A simpleANOVAwas estimated inwhich
Survey, theitem- "satisfaction
withlengthof
on theEI index to ensurethatthereare truly to makeappointment"- is stan-
differences-in-means across clinics as op- phonecallrequired
atmeanzeroanda standard
dardized ofone.
deviation
to
posed noisy data withineach creatingthe Survey overa 35-month
werecollected
responses period
false appearance of differentmeans (F = fromOctober2004toAugust2007.
1.78,/><.05).
Table 4 breaks out the dependent vari-
able- a patient'ssatisfaction
withthe length that the overall sample mean was equal to
of the phone call required to make the ap- zero and the standard deviation equal to
pointment - for each (de-identifiedand re- one. Therefore,each clinic's mean for the
labeled) clinic, derived from patient-level variableas reportedin Table 4 is relativeto
data. The variable was standardized such the overallsample average. Over the obser-
Table5. IT and EmployeeInvolvementas Determinantsof PatientSatisfactionwithLength

of Phone Call Required to Make an Appointmentforan OfficeVisit
Variables 1 2 3 4 5
TimeTrend 0.01*** -0.01** -0.05*** -0.05*** -0.05***
(6.98) (-2.73) (-5.21) (-4.87) (-5.03)
TimeSince"Go-Live" 0.03*** 0.06*** 0.06*** 0.06***
(4.97) (5.65) (5.30) (5.46)
Transition
Period 0.15* 0.15* 0.15*
(2.26) (2.25) (2.36)
Module-in-Use 0.44*** 0.43*** 0.42***
(6.31) (5.87) (6.02)
Involvement
Employee 0.03 -0.14
(0.43) (-1.89)
X Employee
Module-in-Use Involvement 0.27***
(4.06)
n 496 496 496 468 468
clusters 16 16 16 15 15
R2 .11 .16 .26 .25 .28
Notes:
Multilevel
random effects
regressionwith tests
significance performed usingrobust
standard
errors.Depen-
dentvariableismeanpatient
satisfaction
withthelength oftimeittooktomakeanappointment bytelephone for
ina given
eachclinic month.Sincenrepresentsclinic-monthsand"clusters"
isthenumberofdistinct
clinicsincluded
ineachestimate,their
quotient
representsthemeannumber ofmonths ofdatasuppliedbyeachclinic.
Inthefirst
model,forexample,eachclinic onaverage,
contributes, 31months ofdata.
*Statistically atthe.05level;**atthe.01level;***atthe.001level.
significant
vation period of October 2004 to August in the second model revealsa positiveasso-
2007, the Fleetwoodclinic averaged .2 stan- ciation between the use of the scheduling
dard deviationsabove the sample mean, the module and theperformancemeasureitwas
highestof all the clinics.The clinic labeled intended to influence.Despite the negative,
Mullen achieved the lowest performance month-to-month effectof the overall time
and the widestvariationon thismetricover trend("Time Trend"), the post-implementa-
the sample period. tion time trend is actuallypositiveand re-
Table 5 displaysthe multilevelmodels es- mains so for all subsequent estimates.
timatedon the datasetof clinic-months, be- Consistent with anecdotal accounts, cus-
ginning with a simple model considering tomer service sufferedprior to the imple-
onlythe effectsof a linear time trend.The mentationoftheschedulingmodule,a trend
firstmodel showsa smallbut statistically sig- thatreverseditselfwiththe transitionto the
nificantmonth-to-month increase in the de- new system.Moreover,withoutthe new tech-
pendent variable between October 2004 nology,it appears thatmonth-to-month per-
and August 2007. Once a separate, post- formancewould have continued to decline.
implementationtrendis added on the right- The next model adds two dummyvariables
hand side (in the second model), the capturingtransitionto ("TransitionPeriod")
estimatedpartialslope on the originaltime and deploymentof the scheduling module
trendturnsnegativeand remainsso forthe ("Module-in-Use").Both estimatesare posi-
remainingmodels to be estimated.By con- tive and statistically
significantin this and
trast,the post-implementationtime trend the remainingmodels. Also note the point
("Time Since 'Go-Live'") that firstappears estimate on the post-implementation time
trenddoubles. That means thatonce one ac- theorybuilding (see Dunlop 1958 [1993];
countsfora structuralbreak in the timese- Slichter1941; Slichter,Healy,and Livernash
ries, one can see evidence of a large (.44 1960), thatfocushas been largelylimitedto
standarddeviations),one-timejump in per- trade union responses to new technologies
formance as well as a steady,sizable (.06 thatwereintendedto serveas substitutes for
standard deviations) month-to-month per- labor.As IT and othernew technologiesbe-
formanceincreaseassociatedwiththesched- come even more ubiquitous, employment
ulingmodule, despitewhatwould otherwise relations scholars would do well to look
be a declining performancefunction(-.05 withinboth the IT and EI processesat work
standarddeviationseach month) over time. to betterunderstandhow and whytheyin-
These effectsare not sensitiveto changes in teract to affectperformanceoutcomes. In
the waythe transitionperiod is operational- thiscase, reliance on the mixed-methodap-
ized, such as one month or twomonthson proach indicativeof employmentrelations
eitherside of the transitionfromlegacysys- as well as employmentrelationstheoryen-
temsto the new IT. abled an explanation of El's moderationof
The last two models in Table 5 incorpo- the IT-performancelink,one that the OB,
rate the effectsof EI on the efficacyof the HR, and IS literatureshave been unable to
technology.Model 4 incorporates only a establishconclusively.In particular,bymore
main effectforEI. Interestingly, thispredic- richlyconsideringthe role of EI around new
torhas an estimatedperformanceeffectthat workplacetechnologies,thesefindingsbuild
is insignificantlydifferentfrom zero. This on the OB and HR literature'seffortto es-
provides face validity,since the EI variable tablisha link betweenEI and performance.
should onlybe measuringEI related to the This analysisalso benefitsfromthe workof
IT deployment, meaning that its effect IS researchers,who have developed a rich
should onlyshow up when crossedwiththe literatureon the moderatingeffectsof user
technologymeasure. It is also worthnoting participation,but withsimilarlyambiguous
that the inclusion of the EI variable in the resultsto those delivered by OB and HR.
fourthmodel does virtuallynothingto the The distinctionbetweenthe approach of IS
point estimatesof all thosevariablescarried as a field and thisstudyis that ratherthan
overfromthe threeversionsof the equation focusingsolely on workplace-levelfeatures
previouslyestimated. The fifthand final of the employmentrelationshipsuch as the
model in Table 4 adds the two-way interac- incidence of trainingand whetheror not
tion to directlycapture the incremental, employees were asked for feedback, this
moderatingeffectof EI on the IT-perfor- studyis also informedby importantaspects
mance link. Controllingforall of the other of theemploymentrelationshipthatexiston
effects,an increase of one standard devia- the functionaland strategiclevels.Since EI
tion in the EI index increases the effective- is nota purelyworkplace-level phenomenon,
ness of the technology by .27 standard these aspects must be fullyconsidered-
deviations.Interestingly, the estimateforthe eithercontrolledforor held constantbyvir-
main EI measure remainsinsignificant, fur- tue of the researchdesign,in order to make
ther demonstratingthat El's performance valid inferencesfromworkplace-level data.
impactappears to come throughitsmodera- The design of the studyallowsfora clean
tion of the scheduling module's effecton separation of the technologyinputs from
performance, just as one would expectgiven the EI inputsthatmanagementtheorysug-
thespecificflavorofEI thatitmeasures.The gests complementone another in produc-
resultsare also robustto manydifferent ways tion.The greatbenefitof IT is thatit makes
of operationalizingthe EI measure. more information available to frontline
workers (Bresnahan, Brynjolfsson, and
Hitt 2002; Brynjolfssonand Mendelson
Discussion and Conclusions
1993). However,pushinginformationdown-
Though employmentrelationshas long ward and outward- in this case, up-to-date
acknowledgedthe role of technologyin its informationon patients and on physician
- will do much less to influence

availability contingencyalong the lines of those already
performanceifthoseworkerswho willneed considered such as characteristicsof the
to use the technologycannot shape how it is workersthemselves(see Miller and Monge
used, are not "broughton board" withclear 1986) or aspectsof the typeofknowledgere-
communicationfrommanagers and union quired to do the work (Latham, Winters,
representatives, and are not offeredproper and Locke 1994; McCaffrey, Faerman, and
training.For example, with respect to the Hart 1995; Scully,Kirkpatrick,and Locke
schedulingmodule at ELaiser, aspects of the 1995), I am suggestingthatthe new technol-
technology and of the organizationnecessi- ogy is itselfa channel throughwhich EI in-
tated that some traininghad to occur out- fluences performance. Therefore, the
side of regularworkinghours,and the labor findingsI presenthere fold into an emerg-
coordinatorsand the super-usersplayed a ing streamof the OB literatureconsidering
keyrole injustifying thisunpopular decision thewaysthatsocial structure,organizational
to the region'sworkforce. attributes,or attributesof the work itself
More specifically,Kaiser Permanente's moderate the link between new technolo-
deploymentof its schedulingmodule- one gies and organizational performance
- (Edmondson, Böhmer, and Pisano 2001;
componentofitsmuch largerEHR system
was associatedwithclinic-levelperformance Edmondson et al. 2003). In this case, how-
improvements. However, these improve- ever,the grounded nature of the research
mentswere more than 50% greaterin those suggests that it is variation in EI around
clinicsin whichworkersscored one standard implementation that moderated the IT-
deviationgreaterthan average on a contex- performancelink.
tual measure of EI. It appears thatalthough Despite a deep interestin EI, HR as a field
the scheduling module provided workers practicallyignorestechnologyas an object of
acrossall the clinicsadditional,real-timein- study(see Batt 1999). In thisstudy,I demon-
formationon provideravailabilityand pa- stratethattechnologymustbe examined in
tient information,employees made better depth as an avenue throughwhich EI can
use of that informationwhen theyunder- drive organizationalperformance.Further-
stood management'sstrategicrationale for more, the rich,qualitativedescriptionof EI
the system,when theywere able to commu- structuresand processes at the functional
nicatetheirown ideas and concernsback up and strategiclevels facilitatesa deeper un-
to the strategiclevel, and, most critically, derstandingof workplace-levelEI data than
when theywere availed of fellowfrontline thataffordedbythe IS literature.It would be
workerswho could ease them throughthe wrong,though,to viewthisgap in the IS lit-
deploymentprocess and provide introduc- erature as a purelymethodologicalone. In
toryand follow-uptraining. fact, it appears to be theory-driven in the
This studyoffersconvincingevidencethat sense thatIS concernsitselfwitheither"user
EI in implementationmoderatesthe perfor- participation"or "userinvolvement," but not
mance effectsof IT. Whereas earlierempiri- with"employeeinvolvement"perse. That is,
cal worksuggestedthe importanceof EI in the fieldhas been verycarefulin definingits
thisway (Mirvis,Sales, and Hackett 1991), constructs.Barki and Hartwick's(1989: 53)
the relationshiphad yetto be demonstrated distinction,castinguser participationas "a
by looking at the effectiveness of identical set of behaviors or activitiesperformedby
technology,with people doing the same users in the systemdevelopment process"
work,in nearly identical workplaces,over and user involvementas "a subjectivepsy-
time,under varyinglevels of employee in- chological state reflectingthe importance
volvement.Scholars of OB should welcome and personal relevance of a systemto the
thesefindings,fortheyoffera much-needed user," has been widelyadopted, extended,
explanationfor the persistenceof EI struc- and called upon to operationalizethesevari-
turesand processesdespitea lack of empiri- ables in empirical studies. The field has
cal evidence in their favor (Locke and nevercalled on an actual EI construct,how-
Schweiger1979). Rather than proposing a ever,mostlikelybecause the fieldcenterson
the technologyratherthan on the nuances sign in which strategic-,functional-,and

oftheemploymentrelationshipin whichitis workplace-levelattributesof the employ-
being designed and deployed. Put another ment relationshipcan all varywould allow
way,IS has not considered the nature and for a rich, quantitativeassessmentof El's
details of the employmentrelationshipbe- moderationof the IT-performancelink.An
yond thatwhich is immediatelyconcerned equally promisingnext step would be addi-
withthe design and use of the technology tionalqualitativetheory-building thatfleshes
itself- thosefeaturesof the employmentre- out in greaterdetail how variationin func-
lationshipthat exist above the level of the tional- and strategic-levelstructuresand
workplace. processes- in addition to EI at the work-
Withrespectto Kaiser,we know thatob- place level- coalesce to driveorganizational
servedEI scoresat each clinicwereachieved performance.
withina verytightlydefined set of employ- One mightchallenge these resultson a
ment relationshipfeatures.All of the work- numberof grounds.The issues of reliability
ers under studyhad a credible promise of and constructvalidityare the most critical,
employmentand wage security, one example in partbecause boththeEI and performance
of a functional-levelemploymentrelation- measureswere developed or chosen specifi-
ship featurethat goes unmeasured even in cally for this studyratherthan taken from
those IS studies that are carefulto control previouslyvalidatedinstruments. The result-
fororganizationalcharacteristics such as size ing EI measures were those thatemergedas
and structure (see Choe 1996). Further- importantto the effectiveuse of this tech-
more, the technologyunder studywas in- nologyin thissetting.Likewise,the perfor-
tended to address a veryspecificbusiness mance measure was chosen for its tight
and inefficien-
issue, patient dissatisfaction couplingwiththe effective use of the sched-
cies associatedwiththeappointment-making uling module. Withrespectto endogeneity,
process.This goal itselfwasjust one element one mightargue thatthose clinicsthatwere
of a much largerbusinessstrategycentered "ready" for the technologybased on ob-
on the use of IT to betterservepatients.EI servedmeasuresof EI or some other unob-
featuresabove the workplacelevel, such as servedfactorswere,not surprisingly, able to
the establishmentof labor coordinatorsand use the technologymore effectively. Withre-
theirabilityto communicateinformationup spect to these issues,reliance on qualitative
and downfromthe frontlinesactuallypaved investigationin addition to the statisticales-
the wayforthe effectiveness and usefulness timatesofferssome assurance of the find-
of workplace-levelEI structures,like the ings' overallvalidity.For example,itwas the
presenceof super-users. deliberative,pre-statistical investigativepro-
Note that this study incorporates the cess thatdeterminedthatthe "go-live"date
functionaland strategiclevelsof theemploy- was set at the regionalleveland was not cho-
ment relationship but does not measure sen clinic by clinic based on each clinic's
their performanceeffects.Rather,it takes readiness.Finally,giventhe unique features
advantageof quasi-experimentalconditions of the Kaiser labor management partner-
to hold thesevariablesconstant,eliminating ship,furtherworkis needed to determineif
themas a source of unobservedheterogene- similareffectsare observed in more tradi-
ityin workplace-levelmeasures.This suggests tional, unionized settingsor in non-union
tworelated next stepsforresearchersinter- settingsthat provide other employee voice
ested in these under-studiedemployment arrangements.However,it is reasonable to
relationshiplevels in the EI literature.On believe thateven non-unionworkplacescan
the empiricalside, one could takeveryclean identifyand select frontlineworkersto sup-
measures of characteristicsrelated to the port an implementationeffortlike the one
contractlinkingworkersto theiremployers describedhere. In fact,suchworkplaceshave
as well as to the longer-term goals thatem- clearlybecome the driversof employment
ployershave for theirorganizationand for practice innovations,including the growth
the technologyunder study.A multilevelde- ofvariousformsofEI (see Brysonet al. 2007;
Osterman 1994; Osterman2000). Broaden- The immediateimplicationforboth poli-

ing or redirectingtheseprogramsto encom- cymakersand healthcare administratorsis
pass IT implementationscould ostensiblybe that health IT can improve organizational
executed at relativelylow cost, a result outcomes.Therefore,itmakessense thatthe
withobviousimplicationsformanagers.This governmentshould promote the diffusion
is certainlya fruitfulavenue for future of EHRs and related technologies,and for
research. practicesand physiciansto respond accord-
This studysheds some much needed light inglyto those incentives.Significantly,poli-
on IT and EI in the servicesector,and out- cies thatseek onlyto encourage theadoption
side ofmanufacturing, theone thathas been of health IT as opposed to the adoption of
the focus of most of the empiricalwork to both the technologyand the employment
date on the employmentpracticecorrelates practicesthat more fully"unlock" it are, at
of organizationalperformance.Therefore, best, incomplete. Such costly mandates-
the resultsnot only offera lens into the like those that appear in the 2009 stimulus
service sector and "service processes" (as package- should also include language to
opposed to manufacturing's"production encourage the adoption of employmentin-
processes") more broadly,but theyalso in- volvementstructuresand processes along
formthe fastestgrowingsector of the U.S. the lines of those taken up in the case pre-
economy- healthcare. sented here.
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OF EMPLOYEE INVOLVEMENT ON THE EFFECTIVENESS

OF HEALTH INFORMATION TECHNOLOGY

ADAM SETH LITWIN*

The linkbetweenemployeeinvolvement (EI) and organizational perfor-

* AdamSethLitwin isAssistantProfessorofManage- summit, aswellasfromthoseatthe2010annualmeet-

assumed to arise from IT actually arise industriesthat,thoughnot explicitly focused

module facilitatesthe workof frontlineem- EmployeeInvolvementand

and Locke 1995) . AsidefromaskingwhenEI One notable exception in the HR literature

Over thepastthreedecades, in particular, greaterforthoseworkersreportinghighlev-

includeworkersin the deploymentwillshow talitylevel of workers'voice opportunities

Table1. Highlightsof the KP HealthConnectEffectsBargainingAgreementbetween

• commit tothe"successful • extend existing

whichI referto as the "schedulingmodule," and now administersa national KP Health-

workflow change experimentsand pilots,he the new technologywitha clear up-frontin-

Kaiser members for data that should be tinginput fromworkersand ensuringthey

TimeTrend linear timetrendbeginningwiththefirst

August 2007. Measures of IT "go-live"are study.Table 2 detailsall of thevariablesused

data and, more directly, to constructtempo- tablishment.In thiscase, onlythoseemploy-

PerformanceTrends,Transitionto the PatientSatisfactionand Ease

1) Mysuggestionsrelatingto thedesignand have been directly canvassed for their

increasesat the clinicleveland thattheseef- variableis the two-way, interac-

the bargainingunit pulled fromtheirregu- Table4. DescriptiveStatisticsforDependent

Table5. IT and EmployeeInvolvementas Determinantsof PatientSatisfactionwithLength

- will do much less to influence

the technologyratherthan on the nuances sign in which strategic-,functional-,and

Osterman 1994; Osterman2000). Broaden- The immediateimplicationforboth poli-

Brynjolfsson,Erik,LorinM. Hitt,andShinkyu Yang. tion, andCooperation inIndustrial

Ives,Blake,andMargrethe H. Olson.1984."UserIn- on Participative Decision Making: A Critique ofCot-

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