| How is it that health data, information and knowledge (evidence) is taken up or not in health care governance? Fieldwork was undertaken in a Canadian regional health board as members routinely went about the work of governing an exemplary integrated health delivery system (excluding only community physicians) for 300,000 people with a budget of approximately {dollar}500,000,000. Institutional ethnography (Smith, 1987) provided an analytic method, theoretical orientation and a philosophical paradigm compatible with a health informatics framework. Meeting transcripts, related documentation, key interviews and observational data obtained from 1999 to 2002 were data sources. This thesis provides support for two knowledge claims: (1) longstanding governance practices developed to ensure accountability for resource management are in dynamic tension with those emerging to ensure the health of the population; and (2) institutional ethnography provides a method compatible with, and supplementary to, current health informatics approaches. Specifically, the regional health authority Board investigated used traditional and standardized governance practices, including face-to-face monthly meetings, with prescribed leadership roles and process rules of order including voting procedures. The Board primarily ratifies recommendations worked up by Board committees and is apprised on internal and external developments as they affect organizational objectives by the chief executive officer and senior employees. Two medical advisors representing public health and the medical chief of staff have a privileged reporting relationship. Information is transmitted on paper supplemented with oral presentation. I traced the everyday work practices of this Board to their institutional ruling relations---widespread and interconnected practices of government, law, medicine and administration that organize how their work is accomplished. Governments create regional health boards by provincial legislation with the sole legal mandate to govern the health delivery system within their region and in concert with a regulatory framework that prescribes their responsibilities as employers and property owners. They are bound by legislation to create policies and procedures to specify how their work will be done. Governance models and rules of order are adapted that are in widespread use. Boards are legally bound to govern in the interest of the people of the region and to report on health system performance regarding health and resource use. Information about resource allocation and use such as budget and auditing statements and financial indicators are standardized, well understood and supported. In this Board, indicators for monitoring the population health status and estimating the effect of organizational performance on the health of the population are in the early stages of implementation. The opportunities for decision support include web based provision of electronic documents with enhanced functionality for board members and throughout their organization to facilitate knowledge translation, communication and telecommunication support for meetings between board members and stakeholder advisor liaisons, information infrastructure development support in collaboration with provincial and national organizations, and the development of tailor made decision support tools such as digital dashboards. Finally, new types of decision support are suggested---those that provide governing structures with information on the subjective experiences of health and health care that are typically omitted, as complex human experience is translated into simplified knowledge objects. |
