Measuring Business Excellence

Performance improvement in hospitals: leveraging on knowledge asset dynamics through the introduction of an
electronic medical record
Luca Gastaldi Emanuele Lettieri Mariano Corso Cristina Masella
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Luca Gastaldi Emanuele Lettieri Mariano Corso Cristina Masella, (2012),"Performance improvement in hospitals: leveraging on knowledge
asset dynamics through the introduction of an electronic medical record", Measuring Business Excellence, Vol. 16 Iss 4 pp. 14 - 30
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Rocco Reina, Concetta Cristofaro, Assunta Lacroce, Marzia Ventura, (2012),"Managing the knowledge interdependence with electronic
medical record", Measuring Business Excellence, Vol. 16 Iss 4 pp. 31-41 http://dx.doi.org/10.1108/13683041211276429
Rhonda J. Richards, Victor R. Prybutok, Sherry D. Ryan, (2012),"Electronic medical records: tools for competitive advantage", International
Journal of Quality and Service Sciences, Vol. 4 Iss 2 pp. 120-136 http://dx.doi.org/10.1108/17566691211232873
Van Mô Dang, Patrice François, Pierre Batailler, Arnaud Seigneurin, Jean-Philippe Vittoz, Elodie Sellier, José Labarère, (2014),"Medical
record-keeping and patient perception of hospital care quality", International Journal of Health Care Quality Assurance, Vol. 27 Iss 6 pp.
531-543 http://dx.doi.org/10.1108/IJHCQA-06-2013-0072

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 Performance improvement in hospitals:
leveraging on knowledge asset dynamics
through the introduction of an electronic
medical record
Luca Gastaldi, Emanuele Lettieri, Mariano Corso and Cristina Masella
Downloaded by UNIVERSITAET OSNABRUCK At 09:11 30 January 2016 (PT)
Luca Gastaldi,
Emanuele Lettieri,
Mariano Corso and
Cristina Masella are all
based in the Department of
Management, Economics
and Industrial Engineering,
Politecnico di Milano, Milan,
Italy.
PAGE 14 j MEASURING BUSINESS EXCELLENCE
Summary
Purpose – This study seeks to further the current debate about how to systematically improve hospital
performance by enhancing and balancing knowledge exploration and knowledge exploitation
capabilities through the development of an electronic medical record (EMR).
Design/methodology/approach – The study has an interpretative, inductive perspective, based on
multiple and embedded case studies. Three large size Italian hospitals that have introduced an EMR
were considered. Evidence was gathered by triangulating multiple sources of evidence.
Findings – Three emergent strategies of EMR development are identified. Pros and cons of each
strategy are stated and a set of propositions to be tested in further research are formulated. These
results provide hospital managers and professionals with clearer guidelines about how to improve
performance by implementing a tailored strategy to balance knowledge exploration and knowledge
exploitation through the development of an EMR.
Originality/value – Most of the literature on EMRs is focused on the benefits, the barriers and the
enablers of their adoption. Little is understood about how hospital managers and professionals might
leverage on the EMR to ambidextrously combine knowledge exploration and knowledge exploitation,
and thus increase hospital performance. The study addresses this gap and offers original insights to
advance both theory and practice.
Keywords Knowledge exploration, Knowledge exploitation, Health care,
Information and communication technologies, Electronic medical record, Hospitals, Health services,
Service improvements, Italy
Paper type Research paper
1. Introduction
Despite increasing investments, many change efforts within the healthcare industry are
neither sustainable nor successful (Agarwal et al., 2010). Most healthcare systems are
criticised as being poorly prepared to meet the changing needs of their population
(Finchman et al., 2011). Current limitations result in unexplained practice variation, gaps
between evidence and practice, inequitable patterns of utilisation, poor safety and
unaffordable cost increases.
These challenges are increasingly forcing hospitals to do more with less (Garavaglia et al.,
2011), and improve their performance. Out of the many proposed interventions, the
management of knowledge assets is critical to improving hospital performance since
hospitals are highly knowledge-intensive organizations (Van Beveren, 2003). The delivery of
efficient, high-quality care depends on the ability of professionals to exploit their current
knowledge, and develop it through its continuous recombination and contextualisation (Li
et al., 2002; Habersam and Piper, 2003; Radaelli et al., 2011). In fact, the complexity and
j VOL. 16 NO. 4 2012, pp. 14-30, Q Emerald Group Publishing Limited, ISSN 1368-3047 DOI 10.1108/13683041211276410
 specificity of care delivery require hospital professionals to combine knowledge from
different disciplines and professions (Finchman et al., 2011).
From this viewpoint, past research in knowledge management (e.g. Oshri et al., 2004; Corso
et al., 2008; Durcikova et al., 2011; Schiuma, 2011) confirms that the capability of any
organization to create sustainable organizational value resides not only in the ownership of
knowledge assets guaranteeing the present competitive advantage (knowledge
exploitation), but also in the ability to understand and govern the continuous development
of knowledge assets necessary to renew its organizational capabilities (knowledge
exploration). A major challenge lies in the contradictory nature of these activities, which are
tremendously difficult to attain simultaneously (Andriopoulos and Lewis, 2009)
Starting from these considerations, Schiuma et al. (2008) underline that an analysis of
knowledge asset dynamics cannot disregard the tangible resources, since the nature and
the properties of these resources influence the development of intangible ones. From this
viewpoint, scholars (e.g. Kane and Alavi, 2007; Lettieri et al., 2008; Corso et al., 2009; Joshi
et al., 2010) are increasingly recognizing the role that information and communication
technologies (ICTs) can play. ICTs are critical not only for supporting knowledge
management initiatives and nurturing innovation (Tantiverdi, 2005; Marchet et al., 2012),
but also for enhancing a firm’s knowledge assets (Sambamurthy and Subramani, 2005;
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Davenport et al., 2008) and they offer opportunities to conciliate the capability to exploit the
current knowledge with the capability to explore new and better ways of creating knowledge
(Joshi et al., 2010). The expected result is an overall improvement in both cost rationalisation
and quality enhancement (Lettieri and Masella, 2009; Mithas et al., 2011).
The Electronic Medical Record (EMR) has emerged as one of the most promising ICT-based
solutions able to unfold this potential within the healthcare domain (Jha et al., 2009). An EMR
is a digital repository of patient data that is shareable within a hospital. Typical EMR systems
incorporate features such as a clinical data repository, computerised patient records,
decision support applications, integration with other systems, and transaction processing
capabilities (Angst et al., 2010). Although these tangible resources have an enormous
potential to impact knowledge asset dynamics and hospital performance (Bates et al.,
2003), the results of EMR introductions are often well under expectations (Simon et al.,
2007). As a matter of fact, most hospitals:
B Continue to barely give the EMR (as well as to other ICT-based solutions) a second
thought as a source of innovation (Simon et al., 2007).
B Do not adequately analyse the organizational changes required to make all the benefits
associated with the EMR become a reality (Bates et al., 2003).
Thus, instead of being considered strategic resources, EMRs are often simply confused with
other healthcare technologies, and generalized as one of the drivers in rising healthcare
costs (Hartley and Jones, 2005). Since the results of EMR introduction are tremendously
variable, hospital managers are debating which EMR introduction strategies should be
preferred to balance knowledge exploration and knowledge exploitation (Angst et al., 2010).
Past research on this topic failed to provide managers with clear guidance, since it focused
on benefits (Bates et al., 2003), barriers (Simon et al., 2007), and determinants of adoption
(Miller and Tucker, 2009). Little is known about how the EMR is introduced and how this
introduction might contribute to increasing both knowledge exploration and knowledge
exploitation capabilities, and, thus, to improving hospital performance.
Based on this background, this study offers new insights to our understanding of how to
solve the quest for systematically improving hospital performance by enhancing and
balancing knowledge exploration and knowledge exploitation capabilities through the
introduction of an EMR. In particular, we are interested in both: analysing the feasibility of the
EMR as a trigger and an enabler of improved knowledge asset dynamics, and
understanding which strategies are emerging, within hospitals, for improving their
performance by unfolding EMR capability to advance both knowledge exploration and
knowledge exploitation.

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VOL. 16 NO. 4 2012 MEASURING BUSINESS EXCELLENCE PAGE 15
 2. Methods
The nature of our inquiries suggested a multiple case study design (Eisenhardt, 1989a)
according to an interpretative, inductive perspective (Eisenhardt, 1989b). This type of
perspective is coherent with our aim of capturing ‘‘the holistic and meaningful
characteristics of real-life events’’ (Yin, 2003). The choice of multiple case studies has
yielded more generalizable and robust results than single cases (Eisenhardt and Graebner,
2007). Three large size hospitals in Lombardy (Northern Italy) have been studied during the
introduction of their EMRs. The three hospitals are similar in terms of beds, employees, and
ICT budget (Table I).
Case-based research requires a clear identification of the unit of analysis (Yin, 2003). In this
regard, we adopted an embedded design. The EMR introduction process has been
selected as the first unit of analysis. By ‘‘EMR introduction process’’ we mean the set of
activities and users involved in the adoption, the usage and the improvement of an EMR.
This unit of analysis provides a privileged viewpoint to better understand the support
delivered to the exploratory and exploitatory activities of the hospital. In order to improve the
likelihood of rich, accurate theory (Martin and Eisenhardt, 2010) we considered the hospital
as a second unit of analysis, and the Lombardy healthcare system as the context in which to
perform the cases (Yin, 2003).
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Data collection relied on several data sources: face-to-face interviews, phone

conversations, follow-up emails, and archival data such as internal documents, press
releases, websites, and news articles. The primary data source was composed of 27
semi-structured interviews conducted over a three-year period with the Chief Information
Officers (CIOs) and at least one other C-level officers, e.g. Chief Executive Officers (CEOs),
Chief Financial Officers (CFOs) and Chief Medical Officers (CMOs), as well as – using a
snowball technique (Patton, 2002) – with other knowledgeable informants involved in the
EMR introduction process. Within each firm, the authors continued recruiting informants until
additional interviews failed to dispute existing, or reveal new, categories or relationships.
Table II summarises the informants involved in the research.
A key advantage of the study is its three waves of data collection (Ozcan and Eisenhardt,
2009). In the first wave a focus has been put on the different ICT-based solutions present
inside the hospitals. The main information achieved is synthesised in Table III and Table IV. In
the second and in the third waves of interviews a focus has been put on the knowledge asset
strategies followed in each hospital, and – as data collection and analysis unfolded – the

Table I Details of the hospitals included in the research

Hospital Hospital A Hospital B Hospital C

Teaching status Non-teaching Teaching Teaching

Beds 989 952 1,114
Employees 3,608 3,814 3,826
Ownership Public Public Private
2011 overall ICT budget 4,800,000 e 5,000,000 e 6,200,000 e

Table II Informants involved in the research

Hospital Hospital A Hospital B Hospital C Total

Number of interviewsa 8 10 9 27
Interviews to the Chief Information Officer (CIO) 3 4 3 12
Interviews to the Chief Executive Officer (CEO) 2 2 3 7
Interviews to the Chief Financial Officer (CFO) 1 2 3
Interviews to the Chief Medical Officer (CMO) 1 1 2
Interviews to physicians and/or nurses 2 2 1 5
a
Notes: Each interview lasted approximately one-and-half hours

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PAGE 16 MEASURING BUSINESS EXCELLENCE VOL. 16 NO. 4 2012
 Table III ICT-based solutions in the three hospitals studied
Macro-areaa Solutionb Hospital Ac Hospital Bc Hospital Cc

Digitalisation (DI) DI1

DI2 C C C
DI3 D
DI4 C C C
DI5 C C C
Internal Integration (II) II1 F C C
II2 C
II3 D D D
External Integration (EE) EI1 F F
EI2
EI3 F F D
Analytics (AN) AN1
AN2 F
AN3 F
a
Notes: The four overarching macro-areas of ICT-driven innovation have been defined by the authors
of the paper through a deep analysis of the literature and a focus group with a multidisciplinary group
of more than 60 healthcare practitioners among which: C-levels (CEOs, CFOs, CMOs and CIOs) of
the principal Italian hospitals, national and international health technology suppliers, professionals
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from national and international healthcare associations, and healthcare experts; bRefer to Table VI for
the definitions of all the ICT-based solutions listed in this table; cC means ‘‘present at January 2009’’; D
means ‘‘under development in the period from January 2009 to December 2011’’; F means
‘‘development starting before the end of 2012’’

interviews became increasingly focused (Andriopoulos and Lewis, 2009) on the activities
and the users involved in the adoption, the usage and the improvement of their EMR.
Following recommendations for multiple case theory building (Eisenhardt, 1989b;
Eisenhardt and Graebner, 2007), within- and cross-case analyses have been performed
with no a priori hypotheses. The corresponding author built a first draft of individual write-ups
that triangulated all of the data to emphasize themes that were supported by different data
collection methods and confirmed by several informants (Jick, 1979). The other authors
integrated the first draft with their comments, and highlighted missing details that have been
successively filled with calls and emails (Ozcan and Eisenhardt, 2009). Once the write-ups
were consolidated, each author read them to form an independent view (Yin, 2003) and
develop preliminary concepts and rough theoretical explanations (Bingham and Eisenhardt,
2011). Finally, a cross-case analysis has been performed – using replication logic across
the cases – to probe for alternative theoretical relationships and constructs that might fit the
data better than the initial emergent theory (Gilbert, 2005). From the emerging constructs
and themes, tentative relationships between constructs were formed. Then these initial
relationships were refined via replication logic-frequently revising each case to compare and
verify occurrence of specific construct, relationships, and logics (Ozcan and Eisenhardt,
2009).
Once the cross-case analysis was underway, the researchers cycled among the emergent
theory, case data, and literature to further refine the emerging construct definitions,
abstraction levels, construct measures, and theoretical relationships (Gilbert, 2005). The
cycles continued until a strong match between the cases and the emergent theory was
achieved (Ozcan and Eisenhardt, 2009). To converge on a parsimonious set of constructs,
the authors focused only on the most robust findings (Andriopoulos and Lewis, 2009), asking
the informants of the three hospitals to review them in order to solve discrepancies.

3. Findings
The findings are organised in two sections. The first analyses the feasibility of EMR as a
trigger and an enabler of improved knowledge asset dynamics within hospitals. The second
outlines three strategies for making EMR able to impact knowledge asset dynamics.

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VOL. 16 NO. 4 2012 MEASURING BUSINESS EXCELLENCE PAGE 17
 Table IV ICT-based solutions adopted by a generic hospital
Macro-areaa Id Solutionb Definitionc

Digitalisation (DI) DI1 Tools supporting service management and ICT-based solutions used in the admissions process, in
delivery directing user flows within the HCO (e.g. the electronic
management of queues), and in communications oriented
towards users who are waiting for service delivery
DI2 ICT security ICT-based solutions that guarantee the production of
informational data, preventing access by unauthorised
individuals and guaranteeing access even after
catastrophic events
DI3 Virtualisation ICT-based solutions that create a virtual version of HW,
operating systems, storage devices or network resources
DI4 Systems for the dematerialisation of clinical ICT-based solutions that lead to the elimination of
documents paper-based or film-based documents used in a
department, transforming them into electronic documents
DI5 Systems for the dematerialisation of ICT-based solutions that eliminate paper-based
administrative documents documents used in the administrative offices of a HCO,
transforming them into electronic documents
Internal Integration II1 Administrative management systems ICT-based solutions for the management of accounting,
(II) financial flows, logistics, etc
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II2 Human resources management systems ICT-based solutions for the management of all aspects
related to the hospital’s personnel (legal, economic, social,
as well as attendance and absences, etc)
II3 EMR ICT-based solutions that provide support for the
computerised, uniform, updated and integrated
management of personal, clinical patient data throughout
the entire cycle of medical assistance provided by the
HCO
External Integration EI1 Digital services for patients ICT-based solution to deliver services to patients through
(EI) digital channels; included in this category are
communications services, including those for patient
access to clinical information, those supporting the use of
health care resources, CRM services, and services to
support interaction among patients
EI2 Regional medicine and home health ICT-based solutions that respond to the aims of creating
assistance integration between the HCO, district services and family
doctors, with the involvement of local communities of
interest
EI3 Integration with the EHR ICT-based solutions used to create integration with the
platforms for Electronic Health Records (EHRs), defined as
the record format for health care data generated by various
people in charge of treatment in the same territorial area
Analytics (AN) AN1 Computerised drug management systems ICT-based solutions to support drug prescription,
preparation and administration
AN2 Clinical governance tools ICT-based solutions that support clinical decisions with the
objective of improving the quality of services offered, and
reaching/maintaining elevated health care standards
(e.g. the systems to define diagnostic paths or report
incidents)
AN3 Governance dashboards ICT-based solutions that support governance and
administrative decisions with the objective of improving the
quality of administrative processes (e.g. the business
intelligence tools adopted to balance the peaks of service
demand)

Notes: aThe four overarching macro-areas of ICT-driven innovation have been defined by the authors of the paper following a
comprehensive analysis of the literature and a meeting with a multi-disciplinary group of 66 practitioners among which were: C-levels
(CEOs, CFOs, CMOs and CIOs) of the principal Italian HCOs, national and international health technology suppliers, professionals from
national and international health care associations, and health care experts; bThe ICT-based solutions listed in this table have been
defined through a thorough analysis of the literature and the focus group mentioned in notea; cThe definitions are based on the literature
analysis and on suggestions provided through a social agreement by the health care practitioners participating in the meeting mentioned
in notea

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PAGE 18 MEASURING BUSINESS EXCELLENCE VOL. 16 NO. 4 2012
 3.1 EMR as trigger and enabler of improved knowledge asset dynamics
Knowledge asset dynamics are conducive to performance improvement (Schiuma et al.,
2008; Schiuma, 2011). This outcome requires an organisation to overcome the contrast
between knowledge exploration and knowledge exploitation by ambidextrously
combining on the one hand, search, variation, risk-taking, experimentation, play,
flexibility, discovery and innovation, with on the other, refinement, choice, production,
efficiency, selection, implementation and execution on the other. Durcikova et al. (2011)
argued that this ambidextrous capability leads to better organisational performance. The
reason is that the organisation maintains a paradoxical focus on both current (knowledge
exploitatory efforts) as well as future (knowledge exploratory efforts) processes of value
generation – experiencing positive reinforcing cycles (Lewis, 2000) that progressively
solve the multiple and interrelated tensions underlying the divergence present not only
between knowledge exploration and knowledge exploitation (Andriopoulos and Lewis,
2009), but also between the related outcomes of cost reduction and quality improvement
(Smith and Lewis, 2011).

A first element emerging from all the three cases is that – focusing on producing, finding,
analysing and sharing information through digital media (Freeman, 2007) – EMR
manifests its ambidextrous potential in triggering and enabling augmented capabilities in
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knowledge exploration and knowledge exploitation by increasing the coordination among

hospital processes. For instance, the CEO of hospital A stated: ‘‘I’ve always thought of
ICT as a lever to cut costs. As a matter of fact, there are tremendous benefits in terms of
quality improvement as well: once you connect the different departments, you discover
new and better ways to provide healthcare services and have an impact on patients’
outcome’’. The literature about paradoxical thinking provides three reasons supporting
this claim.
First, the more the clinical processes within a hospital are coordinated through an EMR,
the easier the discovery of the specific underlying tensions explaining the contrast
between knowledge exploration and knowledge exploitation. In fact, there are many
interrelated tensions causing knowledge exploration and knowledge exploitation to
diverge (Andriopoulos and Lewis, 2009), and one of the key issues that a hospital faces
is the identification and the representation of these tensions (Lewis, 2000). The fact that
the tensions are entangled with organisational processes (Smith and Lewis, 2011) makes
the latter a central component for rendering each tension as salient. As a consequence,
the more the hospital processes are coordinated, the more opportunities become
available for the identification and the representation of the intricate set of tensions
explaining the contrast between knowledge exploration and knowledge exploitation, and,
ultimately, to the effective utilisation of knowledge assets. The cases show that, by
leveraging on process coordination, EMR increases the possibilities to effectively balance
knowledge exploration and knowledge exploitation (see also Tables V-VII from this
viewpoint).
The second reason is linked to the first one. The more EMR connects hospital processes,
the more a hospital has opportunities to develop and experience the capabilities to
address the paradoxical nature of knowledge exploration and knowledge exploitation
(Andriopoulos and Lewis, 2009). For example, in hospitals A and C the coordination of
the clinical processes realised through the EMR has allowed to connect Radiology and
the Laboratory departments, with the end results of quicker as well as better diagnoses
that, before the introduction of the EMR, were considered impossible. Moreover, the more
the processes are coordinated, the quicker the latent tensions derived by the inertial
forces expressed by a hospital’s employees are rendered salient. In other terms, process
coordination accelerates the speed of the reinforcing cycles through which the tensions
among knowledge exploration and knowledge exploitation are progressively solved within
the hospital. For instance, at the end of the introduction of the EMR, the CMO of hospital
C registered ‘‘a reduction in the time to achieve a complete effective diagnosis of roughly
30 per cent’’.

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VOL. 16 NO. 4 2012 MEASURING BUSINESS EXCELLENCE PAGE 19
 Table V Main findings of the interviews performed on the hospital A
Representative informants
Adoption Usage Improvement quotes

Stimulus:a Impact on knowledge Challenges/issues: ‘‘My ideas are pretty clear. I

Reducing the inefficiencies in
clinical data management
External pressures (EHR
integration)
Improving the effectiveness of
the treatments
Problems:
Minor: initial technological
resistance of the physicians
(used to work according to own
workflows)
Minor: tender writing (previsions
of the modular extensions;
willingness to avoid pure
cost-oriented vendors)
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exploration and knowledge
exploitation:
Step 1: macro-coordination
among inter-departmental
processes (knowledge
exploitatory radical innovation)
Step 2: management of a set of
projects in each unit to use the
shared data (knowledge
exploratory incremental
innovation)
Ambidextrous approach:
Departmental level: ICT-driven
process coordination
Organisational level: temporal
differentiation and administered
Balancing standardisation
requirements with practitioners’
customisation needs
Managing user resistance
Next steps:
Major: continuing the
development of the EMR
Minor: better integrating with the
regional EHR (not only the
mandatory data)
Minor: developing an
administrative management
system
know exactly what I want from
an EMR and where we’ll end.
However, I have to take into
account the annual resources in
my hands. This solution is the
best compromise I’ve found’’
(CIO)
‘‘. . . and this ‘technician’ comes
to tell you that you have to
change a decennial, effective
way of working!’’ (Physician)
‘‘This year [2009] we integrate;
the next one [2010] we’ll start a
verticalisation in each
department to see how we can
use the shared data. Then we’ll

integration restart the process of integration

Performance impact: . . . and so on and so forth’’ (CIO)
Initial: cost rationalisation ‘‘Our main focus was cost
Final: initial þ quality rationalisation, but we ended
improvement also with a better service’’
(CMO)
‘‘EMR is on the agenda also for
the year 2012’’ (CEO)

Notes: aThe alternatives are listed in the order of importance specified by the informants

Finally, process coordination favours both the differentiation (e.g. Lavie et al., 2011) as
well as integration (e.g. Eisenhardt et al., 2010) approaches used to overcome the
contrast between knowledge exploration and knowledge exploitation. In fact, the former
and the latter highly benefit from the coordination among organisational processes. On
the one hand, developing separate contexts for knowledge exploration and knowledge
exploitation, differentiation approaches necessitate a recombination and a synthesis of
the contrasting efforts, which are sped up by the ICT-driven process coordination realised
through the EMR. For example, hospital B has started the introduction of its EMR by
digitalising all the processes of its paediatric intensive care department. While new
diagnoses were explored within this department, the other hospital units continued to
exploit their traditional diagnosis techniques. Once process digitalisation was
accomplished within the paediatric intensive care, the extension of the relative benefits
to the rest of the hospital has been simplified by the presence of a digital backbone
connecting the hospital units. On the other hand, the effectiveness of integration
approaches is linked to their pervasiveness, which in turn can be enhanced through a
stronger coordination among hospital processes, and, thus, through the introduction of an
EMR. For example, the cross-unit collaboration on clinical pathways that has been
spontaneously developed by the units of hospital A was fostered by the digital integration
of inter-departmental processes realised through the EMR.
As depicted in Tables V-VII, in all hospitals the EMR has enabled better knowledge asset
dynamics, which have allowed to:
B improve the overall organisational capabilities to explore and exploit;
B better balance knowledge exploration and knowledge exploitation at different levels
(mainly the departments and the whole hospital); and
B achieve better performance in terms of both cost rationalisation and quality improvement.

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 Table VI Main findings of the interviews performed on the hospital B
Representative informants
Adoption Usage Improvement quotes

Stimulus:a Impact on knowledge Challenges/issues: ‘‘One by one we make all of

Improving the effectiveness of
the treatment
External pressures (EHR
integration)
Reducing the inefficiencies in
clinical data management
Problems: Minor: decision from
which department to start
(efficiency vs potential
pervasiveness)
Minor: clearly understand the
necessities of the physicians
Minor: technical problems
linked to the customisation of the
EMR to the workflows of the pilot
department and to
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exploration and knowledge
exploitation:
Step 1: coordination of the
intra-departmental processes –
one department at a time
(knowledge exploratory radical
innovation)
Step 2: extension of the
achieved benefits to the other
departments with the
coordination of
inter-departmental processes
(knowledge exploitatory
incremental innovation)
Ambidextrous approach:
Department level: ICT-driven
Balancing practitioners’
customisation needs with
standardisation requirements
Homogenising the different
sections of the EMR
Next steps:
Major: better integrating the
patients to the healthcare
processes – offering digital
services through the site of the
hospital
Major: developing a clinical
governance support system
(extracting value from the digital
data)
Minor: continuing the
them happy! Seriously: a focus
on each department –
combined with a good overall
design – allows us to
understand and better meet the
demands from the lines of
business’’ (CIO)
‘‘We are simply doing what we
have done within each
department. But on a bigger
scale. Information has to be
available everywhere if you want
to truly achieve the relative
benefits’’ (CEO)
‘‘Standardisation? It was a
bloodbath, but it was worth it’’

interoperability issues process coordination development of the EMR (CIO)

Organisational level: temporal ‘‘The end results? Better
differentiation and emergent treatment, quicker diagnoses,
integration and brand new research fields
Performance impact: ready on the shelf waiting for us’’
Initial: quality improvement (Physician)
Final: initial þ cost ‘‘The risk is to create a set of
rationalisation fantastic islands with kilometres
of sea separating them’’ (CMO)
‘‘The unique rejection issues are
encountered once you try to
extend the ‘tailored’ feature to
other departments. In these
cases, some revisions are
necessary’’ (CIO)
‘‘The next piece in this jigsaw is
the patient’’ (CEO)

Notes: aThe alternatives are listed in the order of importance specified by the informants

This evidence leads to the following proposition:

P1A. The ICT-driven coordination of the processes of the hospital units realised through
the introduction of an EMR positively affects the capability of a hospital to overcome
the contrast between knowledge exploration and knowledge exploitation, and
increase its performance – both in terms of quality improvement and cost
rationalisation.

The cross-case analysis showed that the level of digitalisation previously accomplished by
the hospital affects the capability to successfully introduce an EMR. In fact, all hospitals in
the sample had high percentages (higher than 40 per cent) of clinical documentation
already digitalised when they began the introduction of their EMR. The CIO of hospital C
stated that EMR is ‘‘a natural prerequisite that the current evolution of information systems
alone makes impossible to avoid’’. All informants agreed on the fact that EMR is the natural
‘‘next step’’ to accomplish after having digitalised most of hospital units. In the words of the
CEO of hospital A: ‘‘We’re simply doing what we have done within each department; but on a
bigger scale. Information has to be available ubiquitously to actually achieve all the benefits
associated with ICT’’. Overall, it is thus possible to complement the previous proposition with
the following one:

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VOL. 16 NO. 4 2012 MEASURING BUSINESS EXCELLENCE PAGE 21
 Table VII Main findings of the interviews performed on the hospital C
Representative informants
Adoption Usage Improvement quotes

Stimulus: a Impact on knowledge Challenges/issues: ‘‘I was tired of hearing from

Improving the effectiveness of
the treatments
Reducing the inefficiencies in
clinical data management
External pressures (EHR
integration)
Problems:
Major: diffused pressures to
realise the EMR as soon as
possible (necessities of
data-sharing among physicians)
Major: engagement by the
whole organisation (both the
creation as well as the
maintenance during the
adoption)
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exploration and knowledge
exploitation:
Step 1: alternate knowledge
exploratory and knowledge
exploitatory investments
focusing on the most critical
department and functionalities
Step 2: progressive
enlargement of the operational
base to more functionalities and
departments (combinations of
incremental and radical
innovations)
Ambidextrous approach:
Departmental level: ICT-driven
process coordination and
Financial exposure (resolution:
cost compression with hardware
virtualisation)
Maintaining engagement during
the change management
process (resolution: mixture of
eLearning and Face-to-Face
training)
Next steps:
Major: better integrating the
patients to the healthcare
processes – offering digital
services through the site of the
hospital
Major: developing a set of
governance dashboards
every physician I meet how ‘it
would be great to have an EMR’.
I knew it! [. . .] But now we have
these conditions. I thought: let’s
shut them up once and for all!’’
(CIO)
‘‘Engagement is everything in
such projects; and everything
has to start from the board’’
(CEO)
‘‘With these kinds of solutions
you simply cannot adopt a
‘big-bang’ go-live’’ (CIO)
‘‘Being an IRCCS doesn’t
simplify things . . . ’’ (CIO)
‘‘If you want to train more than

Major: managing the change
management process
(especially its initial
communication)
temporal differentiation
Organisational level: domain
differentiation and heuristic
integration
Performance impact:
Initial: –
Final: cost rationalisation and
quality improvement
(extracting value from the digital
data) for the management of the
hospital
2,000 employees, eLearning is a
mandatory road . . . but we’ve
combined with eLearning a
smart, face-to-face
‘train-the-trainer’ approach’’
(CEO)
‘‘When I looked at the budget
and the investment plan I threw
my hands up in despair [laugh]’’
(CFO)
‘‘We had to run like a sprinter,
but now we have a full EMR’’
(CEO)
‘‘The entire hospital was
breathing down my neck, urging
me to end the project as soon as
possible‘‘ (CIO)

Notes: aThe alternatives are listed in the order of importance specified by the informants

P1B. The level of digitalisation accomplished within the main hospital units moderates
the capability of EMR to overcome the contrast between knowledge exploration
and knowledge exploration.

3.2 Strategies for making the EMR able to impact knowledge asset dynamics
One of the greatest limits of the literature on EMR resides in the lack of actionable knowledge
explaining how this ICT-based solution can be introduced (Jha et al., 2009). Recently, Angst
et al. (2010) have analysed the diffusion of EMR. However, their ‘‘social contagion’’ lens does
not provide professionals with clear guidelines for introducing this ICT-based solution.
Our study addresses this limitation by investigating the strategies that hospitals are following
in order to introduce an EMR. Tables V-VII, summarise the main findings from the cases. For
each of them, the tables report:
B the stimuli that have led to the decision of investing in an EMR solution;
B the problems faced during its adoption;
B the impacts produced on knowledge exploration, knowledge exploitation and on the
performance of the hospital;

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PAGE 22 MEASURING BUSINESS EXCELLENCE VOL. 16 NO. 4 2012
 B the approaches used to balance the knowledge exploratory and the knowledge
exploitatory activities related to (or enabled by) the EMR;
B the challenges and the issues faced during its usage and/or improvement;
B the next steps to be accomplished according to the informants interviewed; and
B some of their quotes that are representative of the elements depicted in the table.
To complement the analysis, it is useful to refer to Table III and Table IV for an overview of the
other ICT-based solutions already present in the hospitals when they began introducing the
EMR.
The cross-analysis of the cases confirmed that different strategies do exist for improving
hospital performance by combining knowledge exploitation and knowledge exploration
through the introduction of an EMR. None of them has emerged as dominating, but each
strategy:
B is better suited for improving efficiency or effectiveness;
B needs tailored organizational arrangements to overcome potential resistance;
B has specific pros and cons.
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If the first noticeable effects on hospital performance are produced after consistent time lags
(usually two and half years), initially the focus is put on what the CIO of hospital B has called
‘‘protected niches’’: departments and/or EMR functionalities mostly detached by the core
services offered by the hospital, in which there is progressive experimentation of the
ICT-based process coordination potential of the EMR. These protected niches allow to not
only ‘‘achieve in short time lags the tangible results to be shown to both the strategic board
as well as to the users, but also avoid the over-complications associated with the
development of a pervasive solution such as the EMR – at least in the initial stages of its
introduction’’ (CIO of hospital A). Moreover, the rest of the hospital can continue along its
paths to overcome the contrast between knowledge exploration and knowledge exploitation
– making the ambidextrous balance easily achievable. The aforementioned decision of
hospital B to begin introducing its EMR in the paediatric intensive care department is
oriented toward reducing the initial interdependencies among those processes to be
integrated and those that are adopted in other departments to effectively leverage on
knowledge assets. Similarly, hospital A focused on a specific EMR functionality, namely
therapy management, in order to initially concentrate its efforts on a set of inter-departmental
processes for which ICT-based coordination is not particularly critical in the delivery of
healthcare services. Overall, the following proposition is suggested:
P2A. The first investments in the introduction of an EMR solution should be devoted to
the intra- or inter-departmental coordination among the processes of protected
functional niches.

According to the informants, the coordination of clinical processes (e.g. the management of
the admissions, demission and transfer activities in hospital B) brought opportunities to
leverage more on knowledge assets than on the coordination of administrative processes
(e.g. the management of the informal consent in hospital B). This explains why, during the
initial phases of EMR introduction, CIOs tend to focus on clinical processes rather than
administrative processes. If all the informants underlined the higher value associated to the
coordination of the former in comparison to the latter, they have also emphasised the higher
difficulties in accomplishing the coordination of clinical processes due to both their
pervasiveness as well as their centrality in the creation of value for the hospital. In fact, all
hospitals in the sample have accomplished administrative coordination to collect what
informants have called ‘‘quick wins’’ between large waves of clinical coordination. In the
words of the CFO of hospital C: ‘‘The benefits of an EMR are undoubtedly present. However
they’re diluted throughout the entire hospital. Sometimes it’s better to focus on administrative
processes. They won’t save lives, but their automation provides quick wins’’. Overall, the
following proposition is proposed:

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VOL. 16 NO. 4 2012 MEASURING BUSINESS EXCELLENCE PAGE 23
 P2B. The coordination of clinical processes is more likely to allow EMR to balance
knowledge exploration and knowledge exploitation than the coordination of
administrative processes.

The cross-analysis of the cases highlighted the presence of three different strategies to
introduce an EMR (Figure 1): a horizontal strategy, a vertical strategy, and a transversal
strategy.
Horizontal strategy (followed by hospital A): this strategy seems particularly useful when the
EMR is introduced mainly to achieve efficiency in clinical data management. First, a focus is
put (knowledge exploitatory radical innovations) on the macro-coordination among the
different hospital units of a specific transversal EMR functionality (e.g. therapy
management). After the accomplishment of this common horizontal base, a set of
incremental projects in each hospital unit is accomplished to explore new and better ways of
using the shared data. Then, the hospital focuses on a new functionality (e.g. the one relative
to the management of outpatients), and the cycle starts over from the macro-coordination of
the relative processes. This typology of EMR introduction tends to privilege system
integration over the meeting of physician customisation requirements.
Vertical strategy (followed by hospital B): this strategy seems particularly useful when the
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EMR is introduced mainly to achieve effectiveness in clinical data management. Hospital

units are analysed sequentially one by one (e.g. paediatric intensive care, cardiology,
neurology, oncology, emergency department, etc) in order to explore radical, new and better
ways to deliver their services by the ICT-based coordination of unit processes. Once a unit
has achieved its goals, the benefits (e.g. new diagnoses and/or treatments) are diffused with

Figure 1 Three alternative strategies of EMR introduction

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PAGE 24 MEASURING BUSINESS EXCELLENCE VOL. 16 NO. 4 2012
 the other hospital units through a set of knowledge exploitation incremental projects. Then,
the attentions move to another unit, and the cycle starts over from the coordination of its
processes. This typology of EMR introduction tends to privilege the meeting of physician
customisation requirements over system integration.
Transversal strategy (followed by hospital C): this strategy seems particularly useful when
the EMR is introduced to simultaneously achieve effectiveness and efficiency in clinical data
management. To combine these objectives, knowledge exploratory and knowledge
exploitatory investments are alternated, and each time a focus is put on the most critical
hospital units (e.g. the emergency department) and/or EMR functionalities (e.g. in the
diagnostic area). Through a combination of incremental and radical innovations, the
‘‘coordinated base’’ is progressively enlarged to more hospital units (the laboratory, the
radiology department, etc) and EMR functionalities (e.g. therapy management, outpatient
management, etc). This typology of EMR introduction tends to balance physician
customisation requirements with system integration, by also to request high levels of
organisational engagement (especially in the strategic board), economical resources, and
project management capabilities.

4. Conclusions
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EMR is a solution that, if well managed within a hospital, allows not only to balance the
exploitation of current knowledge with the exploration of new knowledge, but also to
achieve improvements in hospital performance. However, the results of EMR introduction
are tremendously variable, and hospital managers experience pitfalls and shortcomings
in their implementation. This study offers new elements to further the on-going debate
about the capability of EMR to enable knowledge asset dynamics and thus leads to more
efficient and high-quality healthcare services. In particular, Table VIII outlines the main
contributions of the achieved finding, which are relevant from a theoretical as well as an
empirical viewpoint.

Table VIII Theoretical and empirical contributions of the findings

Id Proposition Theoretical contribution Empirical contribution

1a The ICT-driven coordination of the EMR allows to balance knowledge The balance between knowledge
processes of the hospital units realised exploration and knowledge exploitation exploration and knowledge exploitation
through the introduction of an EMR (ICT can be used as a lever to achieve realised through an EMR allows to
positively affects the capability of a ambidexterity) increase the performance of a hospital
hospital to overcome the contrast between
knowledge exploration and knowledge
exploitation, and increase its performance
– both in terms of quality improvement and
cost rationalisation
1b The level of digitalisation accomplished Boundary conditions moderate EMR EMR introduction should start only after a
within the main hospital units moderates successfulness in balancing knowledge specific maturity in the digitalisation of
the capability of EMR to overcome the exploration and knowledge exploitation hospital assets
contrast between knowledge exploration
and knowledge exploration
2a The first investments in the introduction of Necessity to focus on the processes Outline of three alternative strategies to
an EMR should be devoted to the intra- or through which the ambidextrous balances develop an EMR and some empirical
inter-departmental coordination among between knowledge exploration and insights to lead its development (starting
the processes of protected functional knowledge exploitation are progressively from a functional niche by initially focusing
niches achieved rather than on how they are on clinical process coordination rather
maintained (traditional focus of the than on administrative process
literature) coordination)
2b The coordination of clinical processes is
more likely to allow EMR to balance
knowledge exploration and knowledge
exploitation than the coordination of
administrative processes

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VOL. 16 NO. 4 2012 MEASURING BUSINESS EXCELLENCE PAGE 25
 From a theoretical perspective it is necessary to divide the contributions this paper provides
to the EMR literature from the contributions provided to the literature on knowledge
exploration and knowledge exploitation. In the first case, the paper starts filling the gap
regarding how an EMR can be introduced, and how this introduction can contribute in
improving healthcare performance. In the second case there are two major contributions
provided by this paper. First, it focuses on the role that a mostly unconsidered lever (ICT) can
play in the contrast between knowledge exploration and knowledge exploitation, showing
that an EMR can – under specific conditions – foster a performance-enhancing balance
between them. Second, it contributes in shifting the traditional research attention from the
notion of balance itself to the process of balancing knowledge exploration and knowledge
exploitation.
From an empirical perspective, the paper provides healthcare practitioners with clear
guidelines and three potential strategies to synergistically balance the activities on their
knowledge assets, and, thus, increase hospital performance. The empirical insights coming
from the cross-case analysis are interesting and useful for the following actors in a hospital:
B The CIOs who need models to increase the knowledge exploratory and knowledge
exploitatory impact of the EMR introduced in their hospitals.
B The CEOs who aim to learn more about how to encourage the successful introduction of
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EMR within their hospitals.

B The CFOs who wish not only to use EMR as a driver of cost reduction, but also as a tool to
control the financial situation of their hospitals.
B The CMOs who are committed to exploiting EMR in order to increase the quality of
services in their hospitals – safeguarding clinician needs.
The results at this stage are still preliminary, and need to be further refined. However, the
work represents a good starting point to frame the potential research that could be
interesting to perform in the future. From this viewpoint, the main problem of this work’s
findings concerns their generalizability. The focus on a specific lever (EMR), on a specific
industry (healthcare) and on a specific context (Lombardy), combined with the extensive
use of an interpretative logic risk producing ‘‘very idiosyncratic phenomena’’ (Eisenhardt,
1989b) – not easily generalizable to other contexts.
There are two further developments already planned in order to fill this gap. First, it would be
useful to combine the interpretative-oriented methodology used in this work with a more
inductive and quantitative-oriented set of vertical researches that could formally test the
effectiveness of the proposed contributions in all their details. The second one is a
progressive extension of the research context to other healthcare systems – both Italian as
well as European – in order to test the effectiveness of the strategies and the propositions
emerged during the empirical analysis, and see how the considerations achieved change
according to the different contingent contexts of analysis tackled.

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About the authors

Luca Gastaldi is a Research Fellow in the Department of Management, Economics and
Industrial Engineering at Politecnico di Milano. He holds a Master of Science and a PhD in
Management, Economics, and Industrial Engineering from Politecnico di Milano. His
research is focused on the strategic management of ICT-driven innovation, with an emphasis
on the healthcare industry. He works as an applied researcher and consultant in the ICT in
Healthcare Observatory of the School of Management of Politecnico di Milano. Luca
Gastaldi is the corresponding author and can be contacted at: luca.gastaldi@polimi.it
Emanuele Lettieri is an Assistant Professor at the School of Management of Politecnico di
Milano, Italy. He holds a Master of Science and a PhD in Management, Economics, and
Industrial Engineering from Politecnico di Milano. His research interests concern innovation
management for performance improvement in healthcare, with a particular emphasis on two
main topics: the assessment and institutionalization of emerging technologies in healthcare
organizations, and the design and implementation of strategies for promoting
knowledge-sharing behaviours among healthcare professionals. Recently, he has
enlarged the scope of his research to investigate the role that technology can play in
triggering and enabling sustainable, effective healthcare delivery. His research has been
published in journals such as Health Policy, International Journal of Technology Assessment
in Healthcare, Journal of Medical Internet Research, Health Care Management Science,
Business Ethics, European Management Journal, Journal of Knowledge Management, and
Knowledge Management Research and Practice.
Mariano Corso is Full Professor at the Department of Management, Economics and
Industrial Engineering of Politecnico di Milano, where he teaches Organization and Human
Resource Management. He is responsible for the PhD program in Management at
Politecnico di Milano. He is a co-founder and member of the scientific board of the
Observatories on ICT and Management of the School of Management of Politecnico di
Milano, and responsible for different Observatories including the ICT in Healthcare
Observatory. His major research interests and consulting expertise relate to organization,
change management and ICT governance. He has promoted and coordinated national and
international research programmes on knowledge management and communities of

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VOL. 16 NO. 4 2012 MEASURING BUSINESS EXCELLENCE PAGE 29
 practice. His research has been published in journals such as Technovation, Measuring
Business Excellence, International Journal of Technology Management, Creativity and
Innovation Management, Journal of Knowledge Management, Production Planning and
Control.
Cristina Masella is a Full Professor at the Department of Management, Economics and
Industrial Engineering of Politecnico di Milano, where she teaches Healthcare Management
and Economics and Business Administration. She is the Director of the Department. Her
research interests concern innovation management in healthcare. She is particularly
interested in the role of information and communications technology (ICT) as both trigger
and enabler of sustainable high quality healthcare delivery. With respect to this she has led
national and international research projects aimed at institutionalizing large-size
telemedicine-based services. She also collaborated with the Health Directorate of the
Lombardy Region (Italy) to evaluate the undergoing telemedicine-enabled solutions for
improving the cost-effectiveness of chronic care delivery. Her research has been published
in journals such as Health Policy, International Journal of Technology Assessment in
Healthcare, Telemedicine and e-Health, BMC Health Services Research.
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PAGE 30 MEASURING BUSINESS EXCELLENCE VOL. 16 NO. 4 2012
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