Toward an Effective Strategy for the Diffusion and Use of Clinical Information Systems

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This is a review of Davidson and Heineke's 2007 article, Toward an Effective Strategy for the Diffusion and Use of Clinical Information Systems. [1]

Research questions

  1. Why has the full benefit of IT (especially electronic medical records) in health care not yet been realized despite 40 years of efforts in this endeavor?
  2. What driving and restraining factors affect the spread, use, and effects of information technology in the health care sector in the U.S?


The authors believe that the full impact of IT care has not been realized because the path from availability of applications to their anticipated benefit passes through a series of stages and progress can be stopped at any stage. This paper presents a comprehensive framework of those steps that researchers, practitioners, and policymakers should use to focus their efforts on unanswered questions.

Data Source/Setting

This viewpoint paper was presented at the Third International Conference on Technology in January, 2007.


The authors outline the following steps between the availability of health information system applications and the production of benefits:

  1. Make Health Information System Applications Available
  2. Adopt Health Information System Application
  3. Use HIS Application
  4. Change Work Processes
  5. Improve Quality, Enhance Efficiency, Reduce Costs

This process is not strictly linear

The paper involves a discussion of each step, and the research questions which remain unanswered at each step. For instance, in step 1, it is noted that much of the commercial development of systems has been on practice management applications instead of clinical management applications (because their ability to enhance revenues, increase return-on-investment is less, and involve physicians). In step 2, it is noted that there is no ”business case” for improving the effectiveness or quality of care with or without IT. In steps 3 and 4, it is noted that there is an expanding literature in this area, but that many questions remain (i.e. what functionalities are being used by physicians, how are these changing work processes?). The authors feel that Step 5 studies are premature and this is giving a distorted picture, due to the questions in preceding steps not yet being fully answered.


This paper is a thorough review of a conceptual framework developed by the authors to research why the full impact of IT in healthcare has not been realized; and that focus on the effects of IT on the quality, efficiency and cost of health care are premature and distorted (“productivity paradox”). This is because too many key questions remain unanswered by the HIT in the organizations and the physicians using them.


This is a monumentally important paper. Current implementation literature has uncovered only a “tip of the iceberg” to understand why HIT diffusion over the past 40 years has been so slow and unsuccessful, and why the magnitude of gains in quality, efficiency and cost of care has been modest at best. The research agenda it sets forward is important for policy makers, institutions, and physicians alike.


  1. Davidson, SM, Heineke, J. Toward an Effective Strategy for the Diffusion and Use of Clinical Information Systems. JAMIA 2007, Jun 14(3):361-7.