| | Creating the context for technology: New realities for structure, media, space, and timeContext—circumstances in which an event occurs; a setting.1 Technology—the use of scientific knowledge to solve practical problems; (Gr. tekhnologia—systematic treatment of an art or craft)1 The newest and most exciting space—is where machines are actually in charge but have enough awareness to seek out people to help them when they get stuck. —Joe Flowers The introduction of new technologies into the marketplace is occurring at warp speed. For healthcare professionals in education, practice, regulation, and research, there is increasing tension between the need for reliable operations and the need to introduce and manage new technologies. For example, new wireless communication devices, reference personal digital assistants, hi-fidelity manikins for every specialty, and software for concept mapping are but a few of the products being introduced regularly. With limited time, personnel, and funds, how does one continue to get the “work” done and have time to consider and test new products? To be sure, one individual cannot do it alone. Significant support is needed from the organization in which the work is being done—the organizational context is the window to solving this dilemma. The plethora of new products requires a new context for the work of technology to thrive. This article provides a brief overview of traditional organizational conditions for operations, the changes occurring as a result of the digital world, and new considerations and configurations for a more supportive organizational context. Moving to a more supportive environment for technology will necessarily support professionals as they work to integrate technology into their work. Organizational context traditionally includes both internal and external attributes. Political, social, cultural, and economic conditions form the major forces for the external environment, whereas structure, authority, roles, reporting relationships, physical space, technology, and financial resources form the internal environment of an organization. Traditional organizations have established reporting relationships defined by job roles and responsibilities supported by a culture of hierarchal or shared leadership decision making, physical office spaces allocated based on the individual's level of power and authority, and expectations for work days of at least eight hours and work weeks of at least forty hours. To be sure, most organizational contexts are designed to focus on operations as the primary goal. The introduction of new ideas and technology receives much less attention and resources in the traditional structure. The advent of the Internet and the resulting changes in structure, media, space, and time have rendered this model no longer viable.1 The very nature of health care and the ways in which healthcare services are organized, packaged, delivered, and evaluated have been forever changed by the technology advances in clinical care, teaching, documentation, and data storage. Specifically, changes have occurred in four areas: the availability and sharing of information; the media used for knowledge transfer; the range and types of relationships between and among providers, educators, students, and patients; and the time required to transfer and share information. These changes are driving the creation of new structures to support this evolving work. Redefining structure  The widespread availability of the Internet, digital device real-time communication, and self-organizing social networks has blurred traditional organizational power and authority boundaries. The once clearly-defined levels of authority, communication pathways, and spans of control, lines of accountability, and role relationships are being redefined by a reality that requires open lines of communication and access to information. The availability of text messaging, instant messaging, and social networks has contributed greatly to the new model for work. Interestingly, these technologies are used informally in healthcare organizations for personal communication. Thus, the technology skills may, in fact, be present—it is the organizational healthcare context that now needs to adopt these technologies in patient care communications. Communication with anyone at any time is now possible and occurs regularly. Communications between executives, managers, and staff are now horizontal, vertical, diagonal, up, and down. Traditional lines of authority and chains of command communication are no longer effective or efficient. The structure for education and patient care also changes dramatically with the introduction of virtual technology for education and patient care. Staffing and scheduling processes necessarily become more complex as staff locations vary more widely. Virtual systems require new models for staffing in a global world that links educators and students and caregivers and patients. Redefining media The second dimension that has changed significantly is the media by which information is transmitted and shared. Communication media has evolved from physical to electronic, from isolated to interactive. The assumptions related to the media or vehicle for transfer of information including written, oral, and video modalities as the primary vehicles are challenged in nearly every venue. No matter how well text is written, it is not an interactive medium. Paper and pen were once the most reliable form of communication; now, digital files are becoming the norm. Audio-video media has also dramatically decreased the need for travel and physical presence. Physical presence has long been managed with the multi-user conference line. As global communication occurs quickly and efficiently with access to the Internet and a video camera, connections with multiple individuals in many locations are commonplace. Heavy desktop computers have been replaced with flat screen monitors and handheld devices. Data storage capacity is significant because sophisticated users have unlimited access to information on the Internet. Leadership roles are evolving to roles of accessing, filtering, and interpreting information for others. Redefining space As structures and media evolve, the role of physical space and location is also changing. In large, complex facilities, the physical space between individuals, offices, and geographic locations that once resulted in a delay in communication between individuals, as well as a delay in the transmittal of paper documents, is now minimized and in some cases eliminated. The need for individual office space is questioned regularly. Communication modalities are more electronic and data is available virtually; new assumptions about physical space are emerging. The utility and purpose of individual private office space and the affordability of spaces used less than 10% of the time provide an opportunity for new configurations. Redefining time Traditionally, work is accomplished at the workplace during specified hours. With the widespread availability of the Internet, shared files, and social networks, time has become almost irrelevant. Work now occurs at any time in any location across the globe. Waiting time for global dialogue is nearly nonexistent. The challenge to schedule time with multiple individuals has decreased dramatically with new media resources. No longer is the individual waiting for the mail to arrive; the email is waiting for the individual! The new work is about creating balance between work and personal time. Future considerations Healthcare professionals consider and select new technology for communication, documentation, diagnostics, decision making, robotics, and training on a regular basis. The goals for consideration of new technology include quality improvement, increased efficacy and efficiency, environmental consciousness, and affordability. As the context is evolving, the following guidelines are offered to optimize the selection and integration of technology into current systems: 1.Mission-driven—the core values and work of health care must continue to be the fundamental reason for all context decisions. 2.Tri-modal structure—three modes of work must now be supported: the first model focuses on routine operations for reliable service; the second model focuses on innovation work; and the third model focuses on the work of transition or bridging the gap between the work of operations and the work of innovation. 3.Professional role requirements—knowledge, skills, and abilities in:•visioning and strategic planning in a tri-modal world, •operations for patient care; •computer literacy; •openness to new ideas, the ability and courage to challenge assumptions/status quo, and tolerance for creativity; •intellectual capability for complex problem solving and synthesis of new models; •innovation leadership, i.e., creating the context and conditions for innovation to occur;2 •enthusiasm; •conflict utilization; and •course correction and creative destruction of the outmoded work of the past. 4.Partnerships and networks—bridging the gap between the generations, specifically digital natives and digital immigrants;3 the coupling of disciplines (nursing, medicine, rehabilitation, informatics, engineering, design, etc.) in a way that emphasizes interdiscipline; and the unique contributions of each discipline to create rich partnerships for better outcomes. In addition, support for electronic networks based on standards and standard language in applications with interoperability is needed desperately. 5.Business rationale and funding—financial allocations based on proposals that include:•description of the new product or service, •the intended purpose or goal of the innovation, •projection of costs specific to accomplish the innovation, •costs excluded from proposal and rationale for exclusion, •projected benefits and rationale for valuing of benefits, •a timeline for the project from initiation to benefits realization, •anticipated profit or loss, •nonfinancial benefits expected, •anticipated risks and plans to mediate risks, and •an overall summary of both short-term and long-term value to the organization and community are needed to function effectively.4 6.Physical space—new designs for both virtual and in-person work that support operations, transition, and innovation work, as well as allocation for devices, servers, equipment, and software/hardware are needed. Space for teamwork rather than individual workspace is preferred. What is not clear is the appropriate mix of on-site face time and off-site time in which communication occurs using audio and visual technologies. Even with the best of technologies, physical gatherings remain an essential part of the work processes. To be sure, there is nothing better than a welcome hug from a long-time colleague or the welcoming hand extended to a new member of the team. As the organization moves forward, the efforts will continue to determine how best to optimize human gatherings and the available technology. New assumptions about physical space will focus on value, flexibility, and multipurpose use for both individuals and teams. The digital world requires leaders to continually challenge assumptions related to organizational structures, information transfer media, physical workspace, and time for transactions. Although the evolution of traditional structures and processes has increased the chaos in health care, new and more effective systems are emerging. New documentation and data management technology has increased the organization's capacity to compete, solve problems, innovate, meet challenges, and achieve goals—and this is directly related to the healthy flow of information. References  Corresponding author: Dr. Kathy Malloch, 7116 West Behrend Drive, Glendale, AZ 85308
Kathy Malloch, PhD, MBA, RN, FAAN is a Clinical Professor at Arizona State University College of Nursing and Healthcare Innovation, and President, KMLS, LLC, Glendale, AZ. PII: S0029-6554(09)00016-5 doi:10.1016/j.outlook.2009.01.010 | 
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