Technological Forecasting & Social Change 174 (2022) 121222

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Technological Forecasting & Social Change

journal homepage: www.elsevier.com/locate/techfore

Big data analytics for clinical decision-making: Understanding health sector

perceptions of policy and practice
Kasuni Weerasinghe a, *, Shane L. Scahill b, David J. Pauleen a, Nazim Taskin c
a
Massey University, Auckland, New Zealand
b
University of Auckland, Auckland, New Zealand
c
Bogazici University, Bebek, Istanbul, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: The introduction and use of ‘big data and analytics’ is an on-going issue of discussion in health sectors globally.
Analytics Healthcare systems of developed countries are trying to create more value and better healthcare through data
Clinical decision-making and use of big data technologies. With an increasing number of articles identifying the value creation of big data
Big data
and analytics for clinical decision-making, this paper examines how big data is applied, or not applied, in clinical
Healthcare
Social representation theory
practice. Using social representation theory as a theoretical foundation the paper explores people’s perceptions of
big data across all levels (policy making, planning, funding, and clinical care) of the New Zealand healthcare
sector. The findings show that although adoption of big data technologies is planned for population health and
health management, the potential of big data for clinical care has yet to be explored in the New Zealand context.
The findings also highlight concern over data quality. The paper provides recommendations for policy and
practice particularly around the need for engagement and participation of all levels to discuss data quality as well
as big-data-based changes such as precision medicine and technology-assisted clinical decision-making tools.
Future avenues of research are suggested.

1. Introduction with traditional hardware or software (Raghupathi and Raghupathi,

Story of Jane: Jane was formerly a dietician who now works as a clinical
consultant on health-IT projects. Back in the days when she was practising
clinically, Jane had a family of four patients (parents and two teenagers)
whose combined weight was over a ton. Jane said, “I used to sit there as a
young dietician going through my food diary that we’d been trained to use
with questions like, ‘what do you eat for breakfast? Have you managed to
decrease your butter intake?’ And I often thought to myself ‘if I could go and
live with them, I would be able to help them!’”. Being an optimist Jane un­
derstands that although it is not possible to live with this family, today’s
technology can enable us to understand their food cues − why they ate the
way they did, the context for making the choices they were making − allowing
her to be more influential over her delivery of care. She believes that modern
technology with real-time updates and patient-generated data has the po­
tential to help patients like this family.
This paper discusses the potential of big data and analytics related
technologies and their application in clinical care and decision-making
with the potential to aid clinicians like Jane. Big data in healthcare re­
fers to large and complex electronic data sets that cannot be managed
2014). The increasing use of modern technologies within healthcare
systems is generating masses of data that have the characteristics of big
data. Health data has always been large, but modern technological de­
velopments have added more to the variety, velocity and volume of
health data (Weerasinghe, 2019, 2018). Even more fascinating are the
technological developments around big data that have allowed the
healthcare sector to improve the accuracy of its data and so create
greater value. With the help of big data analytics, healthcare systems can
discover patterns and trends within data to improve patient care, save
lives, and lower costs (Bates et al., 2014; Raghupathi and Raghupathi,
2014). Those managing healthcare systems are currently looking at
improving outcomes (both health and financial), population health
analysis, and streamlining clinical decision-making with the help of big
data and analytics (Roski et al., 2014; Weerasinghe et al., 2019). There is
an evolving body of literature discussing the application of big data for
clinical decision-making (e.g., Bates et al., 2014; Dang and Mendon,
2015; Ginsburg and Phillips, 2018). However, the perceptions of big
data in clinical care by stakeholders across healthcare are not suffi­
ciently addressed in the literature.

* Corresponding author.
E-mail address: w.m.k.g.weerasinghe@massey.ac.nz (K. Weerasinghe).

https://doi.org/10.1016/j.techfore.2021.121222
Received 8 March 2020; Received in revised form 10 September 2021; Accepted 11 September 2021
Available online 23 September 2021
0040-1625/© 2021 Elsevier Inc. All rights reserved.
K. Weerasinghe et al.
Researchers of the big data phenomenon tend to be more interested
in technical dynamics such as capabilities of tools, potential of analytics,
infrastructure requirements, and security measures (Shin, 2015). Less
research has looked into social dynamics such as people’s perceptions,
willingness to use, and perceived challenges (Weerasinghe et al., 2018).
Because social dynamics concern the subjective understanding of a
technological phenomenon, they often reflect and affect the use of
technology (Dulipovici and Robey, 2013). Therefore, the social dy­
namics around big data are crucial for the success of big data imple­
mentations in the context of clinical decision-making. As there is
minimal literature examining the social dynamics of big data (e.g.,
Eynon, 2013; Shin and Choi, 2015; Weerasinghe et al., 2019), more
research is called for (Shin, 2015). In this paper, we explore how people
across the healthcare system understand the potential importance and
use of big data analytics for clinical decision-making. The research
question being addressed is: “how do stakeholders within healthcare
perceive the use of big data and analytics for clinical decision-making?”
Addressing this question will lead to recommendations to maximise the
potential of big data in the clinical care context.
While technological phenomena can be investigated around social
dynamics or technological dynamics, this paper presents an examination
of the social dynamics of big data using Social Representation Theory
(SRT) (Moscovici et al., 1984) as a theoretical foundation. SRT is a
theory originating from social psychology, which provides a holistic
ground for meaning-making within social groups when new situations
emerge (Andersén and Andersén, 2014). Representation of a phenom­
enon (concept, object, or situation) is the central idea of SRT, and as
such, representations are influenced by social pressure, opinions, social
negotiation, and collective sense-making of a group (Dulipovici and
Robey, 2013).
Being a forward-thinking system and showing drastic developments
despite challenges, the authors have chosen the New Zealand (NZ)
healthcare system as the context for this research (Ministry of Health,
2014). The NZ Health Strategy released in 2016 (NZ Health Strategy:
Future Direction) identifies high-level direction for the NZ healthcare
system from 2016 to 2026 (Minister of Health, 2016). One of the key
themes this strategy identifies is healthcare as a “smart system”. The
theme ‘smart system’ concerns taking advantage of modern and
emerging technologies to discover and develop effective innovations
across the healthcare system. Research1 that aims to understand social
dynamics of big data in NZ is relevant and necessary.
The paper is organised as follows. Section 2 provides a background of
the relevant literature. Section 3 explains the theoretical foundation of
this study. Section 4 discusses methodology used, followed by Section 5
which presents the empirical findings and analysis. Section 6 discusses
the findings. Section 7 concludes the paper, addresses implications and
limitations of the study and provides recommendations.
2. Background literature
This section introduces the pivotal literature around the use of in­
formation systems (IS) in healthcare and big data, the potential of big
data and analytics for healthcare, and specifically clinical decision-
making.
2.1. Healthcare information systems
With the growth in population, diseases and medications, the
complexity of healthcare delivery has also increased (Wyber et al.,
2015). Service delivery in healthcare has always depended on the in­
telligence and hard work of clinical practitioners. Only recently have
1
This paper focuses on clinical decision-making which is a part of a larger
study that looked at perceptions of big data analytics across NZ healthcare. Data
collection for this research took place from 2016-2018.
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Technological Forecasting & Social Change 174 (2022) 121222
practitioners been supported by information technologies (Celi et al.,
2013). Contemporary literature reports a growing interest in using data
to aid practitioners in healthcare (Mace, 2014; Patil et al., 2014). In­
formation technology (IT) and the deployment of information systems
(IS) have been identified as central to the change (Bush et al., 2009). The
focus of IS in healthcare is on improving patient care, service quality,
operational efficiency and patient satisfaction (Peng et al., 2014). This is
achieved by reducing medical errors, streamlining clinical processes,
increasing productivity and controlling healthcare costs. IS use in
healthcare is classified into two categories: (i) Clinical IS (e.g., Elec­
tronic Medical Records (EMR), Picture Archiving and Communication
Systems (PACS), Laboratory Information Management Systems (LIMS),
and telemedicine systems), and (ii) Administrative IS (e.g., Human
Resource Management (HRM) systems, Supply Chain Management
(SCM) systems, Enterprise Resource Planning (ERP) systems, and payroll
systems) (Menon et al., 2009).
2.2. Big data
‘Big data’ is an increasingly common topic both in industry and
academia (Davenport, 2013; Watson, 2014). Halevi and Moed’s (2012)
review of the literature on big data found that research involving the
term ‘big data’ dates back to the 1970s and refers to large amounts of
complex data used in computer modelling and development of hardware
and software in the fields of linguistics, geography and engineering.
However, the use of the term ‘big data’ became common from 2008
onwards (Halevi and Moed, 2012) when Internet-based social media
companies grew and started generating rapidly aggregating chunks of
unstructured data (Davenport and Dyché, 2013). In simple terms, big
data refers to enormous amounts of structured, semi-structured and
unstructured complex data produced by a wide range of computer ap­
plications and electronic devices (Emani et al., 2015). The 5Vs − volume
(large amounts of data, e.g., a single organ scan using modern tech­
nology generates 10 gigabytes of data), variety (many different types of
data, e.g., data from Electronic Medical Records (EMR), laboratory data,
research-related data, insurance claims data, and patient behaviour
data, wearable devices, social media), velocity (data generated and used
in near-real time, e.g., use of sensor technology and an increasing
number of wireless medical devices are capable of monitoring patients
continuously and communicating real-time clinical records to health­
care providers), veracity (accuracy of data, e.g., connected devices to get
data directly such as blood pressure monitors) and value (meaningful
data, e.g., bringing together data from sources outside of healthcare to
create value within healthcare) − are used to distinguish big data from
small data (Burns, 2014; Emani et al., 2015; Saporito, 2013; Weer­
asinghe et al., 2019).
It is evident that big data is an important field of study given the
increasing discussions about it in IS (Abbasi et al., 2016; Baesens et al.,
2016). IS scholars investigating big data have taken various approaches.
Abbasi et al. (2016) proposed a research agenda to investigate big data
through the information value chain. Blazquez and Domenech (2018)
elaborated on the socio-economic changes brought to organisations and
sectors by implementations of big data technologies. Maass et al. (2018)
identified two perspectives for big data research in IS − (i) theory-driven
research, and (ii) data-driven research − and talked about the impor­
tance of theory-driven big data research. While highlighting the op­
portunities of big data for organisations, such as making faster and
better decisions, gaining better knowledge about customers, providing
customised and personalised outreach and gaining economic benefit,
(Phillips-Wren et al., 2015) developed a framework to use big data in the
context of business intelligence. Schermann et al. (2014) highlighted the
importance of: (i) education and training for responsible use of big data,
(ii) development of modelling tools for consideration of big data, and
(iii) development of resilient models for responsible use of big data
through research. Baesens et al. (2016) discussed technical and mana­
gerial issues in business transformation associated with big data.
K. Weerasinghe et al.
Nonetheless, there is a common argument across IS research that more
research is desirable to understand the phenomenon of big data across
different disciplines (Maass et al., 2018; Schermann et al., 2014).
2.3. Big data analytics in healthcare
Recent developments in technology and training around big data
analytics have opened up promising avenues for the healthcare sector to
improve healthcare delivery (Nash, 2014; Weerasinghe, 2019). For
example, using Hadoop clusters to economically store massive amounts
of data, or introduction of data scientists who now can make sense of
large (volume) and complex (variety) data generated in near-real time
(velocity). With these recent advances, the healthcare sector is now
capable of deriving accurate data (veracity) to create value through big
data analytics for improved healthcare delivery (Wyber et al., 2015).
The complex nature of the healthcare system, resistance to change by
healthcare practitioners, uncertainty of returns and privacy concerns
within the healthcare system have resulted in a delay in healthcare
systems utilising big data technologies (Groves et al., 2013; Lv and Qiao,
2020; Weerasinghe, 2019). It is clear, though, that the healthcare sector
needs more efficient practices, more research, and better tools to analyse
and take advantage of the enormous amounts of under-utilised, complex
data it generates (Chawla and Davis, 2013).
Clinical IS and Administrative IS generate enormous volumes and
varieties of data at high velocity. For example, a single organ scan can be
completed in one second and a full body scan in 60 s. One scan can
generate 10 gigabytes of data, and illustrates the volume of healthcare
data that is being created (Burns, 2014). Healthcare data is also varied as
it comes from a range of sources such as clinical IS, research-related
data, insurance claims data, and patient behaviour data (Patil et al.,
2014). These data – structured, semi-structured, and unstructured –
appear in various forms such as: reports of patient, family, medical, and
surgical histories, laboratory results and digital images from PACS and
so forth (Frost and Sullivan, 2012). Healthcare data is also accumulating
at an exponential rate (Wyber et al., 2015). For example, the use of
sensor technology and the increasing number of wireless medical de­
vices are capable of monitoring patients continuously and communi­
cating real-time clinical records to healthcare providers (Frost and
Sullivan, 2012). Although data with high volume, high variety and high
velocity have been generated by the healthcare sector for some time,
data-driven approaches to create value in healthcare were often
considered too complex, if not impossible, because the available tech­
nology to analyse this data was not mature enough (Ginsburg and
Phillips, 2018; Wyber et al., 2015).
Recently, high income countries have recognised the importance of
big data analytics for healthcare (Ginsburg and Phillips, 2018; Lv and
Qiao, 2020; Prewitt, 2014). Literature highlights that use of big data can
bring huge cost savings to healthcare sectors across the world (Bakker
et al., 2020; Groves et al., 2013; Wang et al., 2018). Harnessing big data
could have significant implications for healthcare delivery. Predicting
disease outbreaks, detecting gaps in care delivery, discovering the most
effective treatments, identifying patterns related to medication
side-effects and hospital readmissions, improving pharmaceutical
research, and precision medicine are some of the identified benefits of
big data analytics for healthcare (Bates et al., 2014; Blasimme et al.,
2018; Collins, 2016). McKinsey & Company has identified the potential
benefits of big data analytics across three main health areas: (i) clinical
care and decision-making, (ii) population health, and (iii) research and
development (R&D) (Groves et al., 2013).
2.4. Clinical decision-making
Although clinicians strive to provide the best possible care, some
studies have shown gaps in the most suitable approach to care (Bates
et al., 2003). Clinical decision-making involves a diagnosis and a sub­
sequent decision made by a clinician based on estimating the extent of
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Technological Forecasting & Social Change 174 (2022) 121222
illness of a patient and through making assumptions and determining
whether to go ahead with a treatment plan, to do further testing, or the
like (Pauker and Kassirer, 1980). Use of evidence-based medicine (EBM)
has increased the structure of decision-making processes, thereby
replacing purely ad-hoc decisions made by clinicians (Dang and Men­
don, 2015). Clinical decision-making tools provide evidence-based de­
cisions, patient-specific assessments, and/or recommendations
(Kawamoto et al., 2005). Clinical decisions supported by data from
health information systems can assist decision makers to achieve gains
in performance, reduce gaps between knowledge and practice, and
improve patient safety (Bates et al., 2014; Sahay, 2016). Basic compu­
terised clinical decision support tools include: care reminders,
patient-specific recommendations, and prescribing support, which can
reduce medical and prescribing errors and ensure standards are met
(Kawamoto et al., 2005). Use of big data analytic techniques on big
healthcare data sets provides better clinical decision support (Bakker
et al., 2020; Dang and Mendon, 2015).
The focus of this paper is on using big data analytics for improved
clinical care through the use of clinical decision support tools. Big data
and analytics provide opportunities for clinical care to go beyond the
data recorded in the EMR and to find new data sources such as patient-
generated data, data from wearable devices and genomics to improve
clinical decision-making (Wang et al., 2018). One exciting way forward,
based on big data and analytics, is the potential of precision medicine
that uses genomics to create individual patient treatment strategies
(Agusti et al., 2016; Jameson and Longo, 2015; Roski et al., 2014).
Technological developments around big data analytics have made ad­
vancements in precision medicine (Ginsburg and Phillips, 2018). Other
potentially important improvements to clinical decision-making
through big data analytics include but are not limited to: identifying
clinically appropriate and effective treatments, and predictive analysis
and risk calculations and modelling (Raghupathi and Raghupathi, 2014)
for better and improved healthcare delivery.
In this paper, we explore how people across the NZ healthcare system
understand the potential importance and use of big data analytics for
clinical decision-making. The approach taken is discussed in the
following sections.
3. Theoretical foundation: social representation theory
Social Representation Theory (SRT), a theory from social psychol­
ogy, is used as the theoretical underpinning of this study. For this paper
SRT is used to guide the research design of the empirical study (Wal­
sham, 2006). SRT, developed by Serge Moscovici in 1961, provides a
holistic stance to understand meaning-making within groups. Repre­
sentation of a phenomenon (concept, object or situation) is the central
idea of SRT, and is created within a social group for the purpose of
understanding and communicating (Moscovici, 1963). Representations
are shaped within a social group by the actors’ thoughts, feelings and
behaviours (Wagner et al., 1999). Therefore, a representation has three
elements: (i) the object that is represented, (ii) the individual who builds
the understanding, and (iii) the group to which the individual belongs
(Dulipovici and Robey, 2013). SRT is deemed ideal to investigate social
dynamics around big data as it provides a foundation to understand
meaning-making within groups exposed to new situations (Weerasinghe
et al., 2018).
Although boundaries of social groups were loosely defined in the
early definitions of SRT (e.g., Moscovici, 1963), most recent use of SRT
identifies smaller groups (Dulipovici and Robey, 2013). Moscovici
(1988) identifies three types of representations that guide the formation
of groups to study, which are: (i) hegemonic, (ii) emancipated, and (iii)
polemic. A hegemonic representation is straightforward, naturally
known and not produced by the group (e.g., the sun, where almost
everyone clearly knows what it is). An emancipated representation is
formed within a group but also may have sub-groups within the main
group that have created the representation differently (e.g., manager,
K. Weerasinghe et al.
within the larger group people are aware of the role of their manager,
however there may be subgroups with differing representations of the
manager due to their experiences with her). A polemic representation
has conflicting meanings and may require studying groups with con­
trasting perceptions (e.g., climate change: two opposing views of climate
change are seen with those who accept climate change and those who do
not) (Moscovici, 1988). As identified by (Weerasinghe et al., 2018) big
data and analytics is an emancipated representation, with the possibility
of creating different representations across the healthcare sector, hence
it is anticipated that big data and analytics could be socially constructed
within a group, which may have sub-groups that contribute to the rep­
resentation or offer different representations.
According to (Moscovici et al., 1984) a social representation is
formed through two component processes: (i) anchoring, and (ii)
objectification. Anchoring refers to classification of a new phenomenon
typically through past experience, common background, and aspirations
of the group. This develops a common understanding within the group,
by classifying the unknown into a known arrangement (Wagner et al.,
1999). Objectification is the individual mapping of the phenomenon. It
supports anchoring by mapping with examples, models, and images. For
this paper SRT guided the development of the theoretical framework
discussed in Fig. 2 by identifying the three elements for SRT: (i) the
object as big data in the clinical decision-making context, (ii) the indi­
vidual(s) as policy makers, planners, funders, and clinicians, and (iii) the
group healthcare sector levels the individuals belong to (these are
further discussed in the next section).
Scholars have demonstrated an interest in bringing SRT into IS
research (Dulipovici and Robey, 2013; Gal and Berente, 2008).
Reviewing studies in past IS research, (Gal and Berente, 2008) illus­
trated how such studies could make a more significant contribution if
studied through SRT. Studying social representations brings not only
methodological direction but also conceptual richness, which could be
useful for IS/IT research (Dulipovici and Robey, 2013; Gal and Berente,
2008). Dulipovici and Robey (2013) applied SRT to explore how a
Knowledge Management System (KMS) was perceived and embraced by
different groups of people within an organisation and how this influ­
enced business-IT alignment. Using SRT to investigate social dynamics
of technology phenomena has been adopted in this paper. While (Duli­
povici and Robey, 2013) investigated group representations of KMS
within a selected organisational context, this paper explains represen­
tations and anchoring and objectification processes within broader
groups of the healthcare sector.
4. Methodology
The context for this research is the NZ healthcare system. NZ has
been an early adopter of technology for healthcare delivery, introducing
EMRs in the early 1990s (Protti et al., 2008). The healthcare system in
NZ is under pressure to deliver within fiscal constraints, with challenges
including an ageing population, burgeoning chronic disease and
increasingly complex and expensive pharmaceuticals and other medical
technologies. Being a forward-thinking system and showing significant
developments despite the challenges (Minister of Health, 2016), NZ is
ideal for the purposes of this research. Due to the association of many
different organisations, actors, and structural divisions within the NZ
healthcare system it is identified as a complex system that can be
investigated through the notion of macro‑meso-micro (MMM) levels
(Weerasinghe et al., 2018). The NZ healthcare system is governed by the
Ministry of Health (MOH). The MOH is made up of directorates/business
units which have their own area of responsibility (e.g., the directorate
for system strategy and policy, directorate for data and digital, and
directorate for population health and prevention (Ministry of Health,
2019). The NZ healthcare system also has key organisations that support
healthcare planning and delivery (e.g., District Health Boards (DHBs),
Primary Health Organisations (PHOs), and other non-government or­
ganisations (NGOs)).
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Technological Forecasting & Social Change 174 (2022) 121222
Based on the work of (Cumming, 2011; Scahill, 2012; Weerasinghe
et al., 2018) identified MMM within the NZ healthcare as: (i) macro as
the government organisations (such as MOH or its directorates/business
units) that govern technology implementations around big data, (ii)
meso as the planning, funding as well as implementing organisations
(such as DHBs, PHOs, or technology vendors), and (iii) micro as the
frontline doctors such as General Practitioners (GPs) and secondary care
doctors, and nurses.
Because of the nascent character of research on this topic, an
exploratory case study design was used for data collection and analysis
(Benbasat et al., 1987). Other characteristics that suited this exploratory
research design are: (i) having a ‘how’ research question (how can big
data and analytics aid clinical decision-making?), (ii) the researcher has
no locus of control over behavioural elements, and (iii) the event under
study (implementing big data analytics in healthcare) is contemporary
(Yin, 2014). Further, the qualitative approach allows an in-depth un­
derstanding of the complexity of the phenomenon (e.g., the use of big
data in the healthcare context) or process (e.g., clinical decision-making
process) and allows the generation of propositions and/or recommen­
dations (Bentahar and Cameron, 2015).
The use of SRT promotes collecting data from individuals and
interpreting at a group level. Sector levels (MMM) were identified as the
smallest unit of analysis. Data were collected from individuals and
analysed and interpreted at each sector level to understand the concept
of big data in the context of clinical decision-making. Consequently, the
study takes a single embedded case approach (Yin, 2014) with
MMM-level as an embedded unit of analysis within the single case of the
NZ healthcare sector (see Fig. 1).
A single case is preferred when the aim of the research is to gain a
deeper understanding about dynamics associated with a phenomenon
and to make valid inferences (Eisenhardt, 1989; Kratochwill and Levin,
2015). Within the healthcare sector, the identified MMM levels based on
SRT have different tasks and responsibilities associated with big data
analytics, and therefore are likely to construct different representations
of big data. Thus, having MMM as an embedded unit within the single
case of healthcare will minimise the abstract level of analysis, allowing
for examination of operational details within the identified case (Yin,
2014). This also aligns with SRT, which promotes looking at different
group representations (Dulipovici and Robey, 2013). Although three
groups (MMM) are to be analysed, this is not a multiple case study
because all these subsector levels belong to the same case of the NZ
healthcare sector. However, similar to cross-case analysis in a multiple
Fig. 1. Single embedded case study design.
K. Weerasinghe et al.
case study, analysis can be undertaken across the MMM levels (Yin,
2014). This approach is expected to deepen and widen the under­
standing gained from the analysis and strengthen the findings of the
single case.
Based on this case study design and SRT as the theoretical founda­
tion, a theoretical framework was developed (see Fig. 2) to guide the
empirical study. The framework developed through the direction and
understandings of SRT provides clear guidance to understand: (i) what
to study (big data strategy, implementation, and generation at their
respective levels), (ii) where to study (across MMM levels), and (iii)
whom to study (policy makers, planners, funders, and clinicians).
Using this framework in the context of clinical decision-making,
representation of big data and analytics is studied within three groups:
macro, meso, and micro. As seen in the theoretical framework at the
macro level, the focus of the investigation is big data around health
strategy. Similarly, at the meso level, the focus is on big data imple­
mentations. At the micro level the focus is around the generation and use
of big data for clinical decision-making. Therefore, the interview ques­
tions and the data collection focused the discussion around strategy and
implementation, and generation of big data at each MMM level. The
theoretical framework anticipates that social representations at each of
the three levels may influence the other levels (as shown by arrows
labelled influence).
To answer the research question, three interview schemas
(Appendix A) were developed to address the three different MMM levels
(Liamputtong and Ezzy, 2005). The interview schemas (all three) were
piloted in two stages: (i) with a non-industry participant, and (ii) with a
healthcare sector expert. The piloting strategy helped refine the inter­
view schemas for better data collection (Yin, 2014). Semi-structured
interviews were conducted to gather rich data from participants (Mer­
riam, 2009). Purposive sampling techniques were used as the research
required gathering data from informants who were involved in con­
structing policies, planning, and implementing, or who have the po­
tential to use clinical decision-making tools with big data analytics
(Miles et al., 2014; Patton, 2015). A snowball sampling strategy was also
used to ask informants to direct the researchers to other possible par­
ticipants (Miles et al., 2014). Thirty-two (six macro, seventeen meso and
thirteen micro2) in-depth interviews were conducted ranging in dura­
tion from 45 to 60 min. The number of interviews at each level was
subject to data saturation (Fusch and Ness, 2015). More interviews were
conducted at the meso level as there were different subgroups within the
meso level (DHBs, PHOs, academics and vendors), and more data were
needed to understand this level and to reach theoretical saturation
(Mason, 2010). Demographic profiles of the participants are given in
Appendix B to highlight the diverse nature of participants representing
the MMM levels. The inclusion of this demographic information on the
participants is to provide an insight into the types of participants
interviewed, variations in their backgrounds and their experience in the
NZ healthcare system.
SRT guided the data collection process and allowed data to be
collected at the individual level (unit of observation) yet analysed at a
group level (Dulipovici and Robey, 2013). Individual interview data was
analysed and interpreted at each of the three sector levels (unit of
analysis) to understand perceptions of big data in the NZ healthcare
context. General inductive thematic analysis (Thomas, 2006) was used
to analyse the data. An inductive approach was adopted as the research
design was exploratory in nature and there was a need to see what ideas
emerged from the data rather than the literature. Following accepted
qualitative data processes (Miles et al., 2014) data was transcribed,
2
Nine general practitioners and doctors along with four meso-level partici­
pants who had clinical responsibilities who also answered the micro
questionnaire.
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Technological Forecasting & Social Change 174 (2022) 121222
cleaned and coded.3 Each MMM level was separately coded as informed
by the research design (Braun and Clarke, 2006). All themes at each
MMM level were analysed separately to identify categories (Thomas,
2006). Developed categories were re-analysed to remove any unnec­
essary categories and to merge similar ones (Thomas, 2006). A sample of
themes and categories is given along with an interesting and relevant
quote for each theme in Appendix C. Once each MMM level analysis was
completed, a cross-case analysis (Yin, 2014) was done to identify the
agreements and disagreements across the levels. The chosen observa­
tions (explained in the Discussion section) were selected based on their
relevance and importance to the research question, rather than based on
the quantity of data in that category (Braun and Clarke, 2006). In order
to ensure rigour of the findings a report containing the results was sent
to the participants for feedback.
5. Findings and analysis
The findings are discussed in three sections explaining each of the
MMM levels as identified in the theoretical framework. The explanations
of findings focus on how big data in the clinical decision-making context
is represented (as per SRT) in each of the three groups.
5.1. Macro level
The findings demonstrate the social representations of big data at the
macro level in clinical decision-making were that it was seen as an issue
yet to be explored but also with a low priority. It was observed that at the
macro level big data is represented as a part of modern evolving tech­
nology, and the participants identified its application in the clinical care
context as something to be explored in the future. Still, participants saw
the application of big data as more advanced in implementation in some
areas of clinical care, such as precision medicine. Representations also
showed that participants view health strategy as playing a key role in
dealing with difficulties in using big data, such as data quality. These
representations are further discussed below with example quotes from
participants.
From a policy maker’s point of view, the potential of big data for
clinical decision-making in NZ is yet to be explored. This view is epi­
tomised by a macro-level senior policy maker who said that;
“It’s a little bit too early to understand how data can help clinical
decision-making. What you might find at the macro organisation X is
that, while I have been doing a lot of work under the XYZ board,
there’s not a lot of people who understand the potential of big data in
a clinical environment. They [people working at the macro-level
organisation] are probably more interested in big data and the
whole health system.” (MAC1)
Compared to the system-wide problems mentioned in the quote
above and the application of big data analytics to such problems, the use
of big data for clinical decision-making has a very low priority at the
policy level. Although low priority, people in policy roles do see that big
data and analytics have potential in the setting of clinical care. As stated
by another macro-level senior manager,
“… the biggest potential for me is in the clinical care side. In the
public health side, I think we’ve actually been doing a lot of what we
do [population health analysis] anyway.” (MAC2)
Therefore, the macro-level organisations are investigating the use of
evolving technologies to improve care delivery. They highlight that they
are continuously looking for new technologies that will change the
model of care in a positive way. Precision medicine is one such
3
Data has been collected and stored in accordance with Ethics committee
requirements (in a University password-protected drive, for a period of 5 years).
K. Weerasinghe et al.
Fig. 2. Theoretical framework to investigate Big data across the NZ healthcare sector (based on (Weerasinghe et al., 2018)).
technology and is of growing interest to the government. As previously
described, precision medicine provides individualised care as opposed
to generic care. Precision medicine is also predictive in nature; by un­
derstanding the genomic makeup of a person and their medical history it
has the potential to predict the future health status of a patient. How­
ever, major improvements to the IT infrastructure are needed to
implement genomic use for patient care. Currently in NZ, projects under
the ‘precision medicine’ umbrella are run as research projects with
technology vendors. There is an acknowledgement that precision med­
icine will in the future create very useful tools for the healthcare system:
“The concept is articulated, there are various suppliers that are
interested in developing precision medicine capability, ‘ABC’ will be
one. And there is an acknowledgement that precision medicine at
some point in time will create some very useful tools for the
healthcare system to use.” (MAC5)
Data quality and accuracy is seen as a huge problem and as a barrier
for implementing big data and analytics in healthcare. However, it was
pointed out by participants that the NZ Health Strategy now ensures: (i)
connected information, (ii) a well-defined National Health Index (NHI)
,4 and (iii) understanding of data collection settings. Therefore, the NZ
health strategy is expected to lead to improved accuracy and quality of
big healthcare data that will later be used for big data analytics to make
clinical decisions, undertake population health analytics, or achieve and
measure health outcomes.
Another important finding of this big data study was the potential for
the Internet of Things (IoT), with its ability to capture data from devices
both at clinics and hospitals, as well as remotely through patient-
wearable devices. Policy makers seem open to the concept of IoT and
its use to capture big data to improve clinical decision-making. How­
ever, the authors are not aware of informed research or policy in this
area in NZ.
5.2. Meso level
Due to the nature of the NZ healthcare system and the definition of
meso‑level planners, funders and implementers, there were four types of
participants at this level from: (i) District Health Boards (DHBs), Primary
Health Organisations (PHOs), (iii) university academics, and (iv) tech­
nology vendors. While we considered these four groups to be separate
within the meso level, generally, similar representations of big data were
observed. Where there was divergence between the representations,
such differences were highlighted through the discussion. The discus­
sions at this level as explained in Fig. 2 were focused on big data
implementation.
The representations of big data specifically by DHBs and PHOs
4
The NHI number is a unique identifier assigned to every person who uses
health and disability support services in New Zealand.
6
Technological Forecasting & Social Change 174 (2022) 121222
showed that they are primarily interested in realising outcomes, both
medical and financial. Precision medicine is a key field that DHBs are
interested in, but less so in PHOs. Managers and clinical leaders at the
meso level agreed that the current situation is far from realising the full
potential of big data. According to a knowledge manager of a PHO, if big
data is a continuum with the initial state being reporting, the middle
state being knowledge, and the latter state being wisdom:
“… so we [NZ healthcare] are still very much at that reporting level
rather than data for the analytics and the predictive risk modelling
and all of those kinds of things. At the simplest end we talk a lot in the
system about counting general practice consultations.” (MES9)
The representations at the meso level were influenced by the previ­
ously implemented systems for clinical care and their operations. It was
established that most General Practice information systems do not
provide a holistic view of their clinic as a health provider and business.
The current most sophisticated systems available to GPs are mainly just
prompting systems, reminding GPs to take necessary action to identify
cohorts of people with specific health issues. However, the meso‑level
PHO participants argue that the starting point for big data is primary
care and the government needs to put more effort into primary care to
succeed in health-sector-wide big data approaches. Answering a ques­
tion regarding the current state of clinical decision-making, a PHO
clinical director claimed that:
“Decision support in healthcare in general is still at a relatively
rudimentary stage. Most of it tends to be warnings. … but for a lot of
decision support you need to be careful because people can just get
warning fatigue, they can get decision support they don’t want.”
(MES2)
However, participants also claimed that there are improvements to
tools as well as new tools being implemented for clinical decision-
making although they are not big data tools. As explained by a clinical
director, there is a national project in NZ on population health which
uses genomics information and they are likely to be using big data
technologies. These tools are available to doctors and can be used for
clinical decision-making. However, only those who have an interest in IT
volunteer to be a part of these types of initiatives.
The role of clinicians has been highlighted by both clinical leaders
and health-IT managers as being important in achieving success with
clinical decision-making tools using big data. However, it was pointed
out that in their understanding and experience a lot of clinicians are
unaware of the potential of big data analytics. An academic involved in
several big-data-related projects confirms this:
“At the moment there’s a disconnect between all the data people are
collecting about themselves and what clinical people are able to do
with it. And so clinical people have no interest in it, at the moment.”
(MES13)
K. Weerasinghe et al.
Although participants highlighted that most clinicians are not aware
of the potential of big data analytics it was clear to the meso‑level
participants that clinicians want better systems and better data to
improve point-of-care service to patients and they are advocating the
need for this. Therefore, if the clinicians were shown positive results
they would be the first people to support big data analytics tools for
clinical decision-making.
Similar to what was experienced by some of the macro-level partic­
ipants, several managers at the meso level have also come across tech-
savvy clinicians who already use big data analytics type approaches
for clinical decision-making. As explained by an academic:
“I met a doctor a couple of years ago who was using the genetic data
to match treatments he was giving patients with deep vein throm­
bosis (DVT). There are several treatments a patient with DVT can
use. Now what this doctor has done is, he’s got a little kit, he does a
genetic test on his patients and he can directly match from the ge­
netic test to the drug and he’ll give the right drug to the patient.”
(MES13)
Participants state the importance of planned systems and accurate
data as critical to making better clinical decisions. Getting access to
information seems to be a problem across the healthcare system. Par­
ticipants in IT roles emphasised the need to provide better access to data
to enhance clinical decision-making tools. It is understood by meso‑level
participants that big data analytics will bring great opportunity for
better clinical decision-making tools. In addition, having better decision-
making tools could help managers make better use of the workforce as
even those with lower levels of experience or qualifications will be able
to make the right clinical decisions.
Another key area of interest at the meso level is patient-generated
data that can be captured by devices used by patients. According to
the knowledge manager of a PHO:
“I often talk about my mother who when she was identified with
blood pressure issues at 70 bought herself a blood pressure monitor.
And I sit there from an analytics perspective and go gosh, well if we
were getting the record of her blood pressure every day, we would
actually know when there’s a change and then we’ve actually got the
ability to get some true predictive data and know what her true
normal is.” (MES9)
Similar to the above comment a participant from an IT vendor
organisation explained the importance of patient-generated data, high­
lighting that:
“There are huge numbers of data points that we’re not even
capturing at the moment, and we’re not even asking them [patients]
to give us or feed into our systems.” (MES17)
Thus, patient-generated data was identified as the ‘source of truth’ by
participants and is seen as revolutionary for the current practice of
healthcare delivery. However, utilising patient-generated data is at the
bottom of the priority list within the healthcare system, as there are
many other priorities to achieve with big data at the population level.
Common dialogue at the meso level was that the government needs to
work more in this area of connecting big data and analytics for clinical
care. According to a Clinical Leader at a DHB:
“…the other would be around the interoperability of the systems so
that we can aggregate data or good use of such systems for clinical
care. So again, that sort of standards and interoperability should
happen at the national policy level.” (MES1)
5.3. Micro level
At the micro level GPs and secondary care doctors were interviewed.
Based on the theoretical framework (see Fig. 2) the dialogue at this level
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Technological Forecasting & Social Change 174 (2022) 121222
focused on exploring representations around big data generation and
use. At the micro level, representations showed that most clinicians do
not see the same level of value from ‘system-generated advice’ as other
levels. They have trust issues resulting from experience with systems
containing bad data (e.g., unreliable, low quality, inaccurate data) fol­
lowed by medico-legal issues. At the moment decisions are based on raw
data at point of care for general practices as well as in hospitals. How­
ever, doctors do understand that anecdotes are not the best form of
medicine, and hence see the importance of data for clinical decision-
making. However, it was emphasised that they need to be sure that
data is of good quality. At present, there are manual decision support
tools available which require clinicians to manually record and calculate
to act on urgent issues. The doctors see this as problematic as it is
dangerous to rely on a busy clinician to check things manually and act
on them.
Both hospital doctors and GPs understand the importance of good
quality data in systems. Doctors will be reluctant to use data in which
they have no confidence. In their view, tools that will aid clinical
decision-making will need to have a similar testing process as pharma­
ceuticals going to market, because although such innovations may be
theoretically correct, they must first be tested in practice. Clinicians
explain that people outside of clinical areas, although working in the
health sector, do not understand why clinicians are mindful and hesitant
about using data and tools for clinical decision-making. Clinicians sug­
gest their work environment and professional responsibilities are
different as they must deal with the consequences (medico-legal con­
straints) if something goes wrong, as this anaesthetist explains:
“People from outside the clinical areas don’t necessarily appreciate
that as much as the clinicians do because they don’t have to wear the
consequences of all those decisions they have to make.” (MIC1)
This anaesthetist added that one key reality in clinical healthcare is
that “patients do not have undo buttons” (MIC1) and if a system makes
an error and the clinician acts on it, it could be fatal. Thus, the doctors
always question the quality of data. It was seen that all this questioning
and reluctance to use systems for clinical decision-making comes down
to patient safety and making sure nothing goes wrong. A simple example
provided by a clinician was a prescribing system giving a fatal dose at a
paediatric ward without accounting for the fact that the patient was a
child. Clearly, they have reasons to question the accuracy of decision-
making tools in practice.
Clinicians in hospitals see the benefits of information analysis for
hospital management, especially for measuring outcomes, although not
so much for clinical decision-making. However, they point out that their
medical training does not include training around information analysis,
although it could be beneficial for their roles. Use of clinical decision-
making tools was seen by GPs as impractical due to the nature of con­
sultations. An older doctor claimed that consultations are given in a very
short time span, and it is difficult to use any tool in this timeframe.
However, senior doctors say that due to their experience it is possible to
“cut corners” (MIC2) and they claim that much younger doctors may
benefit from clinical decision support tools.
GPs also talked about patient-generated data and thought it was a
good way to get to know the patients better, as the patients themselves
can record data about their health with greater frequency (e.g., seven
consecutive readings of blood pressure done at home versus one reading
at the clinic) and share it at the consultation. However, micro-level
participants claimed that most of the apps that patients use are apps
that are made for a different market and may be problematic when used
in NZ due to the standard funded 15 min medical consultation. A GP
claimed that most patients do not use apps even when requested:
“We’ve shared this [mobile app to capture blood pressure] with
probably over 300 people. Only one or two sent back data” (MIC2).
Another GP highlighted an issue, saying doctors do not work 24/7 in
K. Weerasinghe et al.
the GP practice and if a patient record was shared with him on his
mobile he does not want to look at it when he is not working and this
could be potentially life-threatening to a patient.
6. Discussion
This study aimed to understand how big data and analytics are so­
cially represented at three MMM levels of the NZ healthcare sector in the
context of clinical decision-making. At macro and meso levels, in order to
understand social representations of big data in the clinical care context,
dialogue was based on strategy and implementation of big data
respectively, while at the micro level the talk was about data generation
and use. This discussion section addresses the findings in light of the
literature. It also considers the implications for policy, practice, and
future research.
6.1. Practical implications
Four observations are presented and implications and recommen­
dations posited: (i) the micro level reports a lack of engagement with
tools, so precision medicine may be problematic, (ii) the macro level
does not understand the need to prioritise the developments around
clinical decision-making tools, (iii) problems of data quality and accu­
racy, and (iv) problems in potential to use patient-generated data.
6.1.1. Observation 1: possible issues with developing precision medicine
solutions
The Government has funded precision medicine research projects in
conjunction with DHBs and IT vendors. Our findings align with the
literature (e.g., Agusti et al., 2016; Ginsburg and Phillips, 2018) where
precision medicine will be used to improve clinical decisions for both
primary and secondary care. According to (Jameson and Longo, 2015)
growing interest in precision medicine has been shown from policy
makers to clinicians. While our findings confirm that policy makers,
planners, and funders are interested in precision medicine, clinicians
have conflicting opinions. A few secondary care clinicians have shown
interest in using advanced tools for clinical decision-making, whilst GPs
do not due to time constraints. GPs are struggling to do more with the
little time they have in consultations and do not feel comfortable using
IT tools more often during consults. Therefore, promoting the produc­
tivity of precision medicine tools and emphasising how such tools will
make day-to-day tasks more efficient as opposed to more
time-consuming is important. We recommend having workshops and
open forums highlighting the benefits of precision medicine for primary
and secondary care to improve engagement.
6.1.2. Observation 2: low priority for clinical decision-making tools at
strategic level
Clinical decision-making tools using big data do not rate as a priority
at the macro level. Many other pressing issues that affect health out­
comes are commanding more immediate attention. This is a key issue,
and a reason why big data analytics for clinical decision-making is a low
priority amongst the other levels. Both macro and meso levels show an
increasing interest in using advanced analytics to measure performance
over clinical decision-making. Although there are other issues that need
immediate attention, according to (Groves et al., 2013) clinical care and
decision-making is also an important aspect of modern healthcare.
Healthcare systems need to be looking at utilising big data for better and
improved clinical decisions (Raghupathi and Raghupathi, 2014). We
recommend that IT-assisted clinical decision-making remains on the
agenda. We recommend that open communication with meso and micro
levels about their needs (through workshops) for clinical
decision-making tools would be a good starting point.
6.1.3. Observation 3: issues around data quality and accuracy
As an early step towards better use of big data and analytics, all three
8
Technological Forecasting & Social Change 174 (2022) 121222
levels commented on the importance of data quality and accuracy (ve­
racity in the 5Vs). From a macro and meso perspective the government
and the planning and funding bodies are taking necessary measures to
ensure the capture of accurate data. According to (Emani et al., 2015)
ensuring accurate data is the key to achieving big data success. Our
findings align with the literature and confirm that credibility of data
sources is critical (Saporito, 2013; Sathi, 2012). Although the govern­
ment has taken measures to improve data veracity by utilising GPs to
validate accuracy of data, such uncompensated tasks are not seen as
acceptable by GPs and data cleansing by this means is of questionable
use. Therefore, we recommend allocating remuneration for GPs to
ensure accurate data collection. In addition, minimising manual data
entry and maximising the IoT will ensure the accuracy of data capture.
For example, blood pressure readings could be auto-recorded rather
than the nurse transcribing them. Modern instruments have ports that
can be connected to computer systems with the potential to be auto­
matically recorded (King et al., 2016).
6.1.4. Observation 4: issues around the use of patient-generated data
Patient-generated data is seen as a ‘game changer’ by meso‑level
participants. With more frequent and accurate data about patients, se­
nior executives see patient-generated data adding significant value for
clinical decision-making. Patient-generated data is currently in the
spotlight due to the increase of smartphone users and development of
applications and remote devices (Howie et al., 2014; Shapiro et al.,
2012). The benefits of big data for clinical care identified by (Groves
et al., 2013) can be extended to include benefits that can be realised by
patient-generated data. Patient-generated data includes but is not
limited to: vital signs, stress levels, mood, physical activity, weight, diet,
medications, and sleep patterns (Wood et al., 2015). Although both the
literature and meso‑level participants discuss the possible benefits of
patient-generated data, findings from the micro level show disagree­
ment through their practical experience. As pointed out by a GP who
shared an app with over 300 patients with high blood pressure, only two
patients actively used the app to share data with the doctor. Another GP
explained that only a few patients bring in recorded data, even when
requested to do so. Therefore, agreement is seen across meso and micro
levels relating to the immature state of patient-generated data. We
recommend more open discussion to inform patients of the benefits of
patient-generated data. However, the scope of this study did not include
investigating the views of patients. This is a rich avenue of future
research.
6.2. Implications for theory
Our study has implications for theory. By using SRT we can now
better understand emerging technology by not only identifying in­
terdependencies but also acknowledging the fact that the perception
(representation) is critical in establishing the conditions for successful
planning, design and implementation of the ‘technology’ under
consideration. Framing through SRT allows this. The multilevel study
facilitated by SRT acknowledges the presence of different representa­
tions by different groups (MMM). At the macro level the use of SRT
enabled us to understand the perceptions of policy makers and how they
see the potential of big data in the context of clinical decision-making,
discussing policy, the tools, and the users (clinicians). At the meso
level we explored funders and planners’ views on initiating and building
projects that are used for big-data-based clinical decision-making. At the
micro level, we investigated the doctors’ (GPs and hospital doctors)
representations of using big data for clinical decision-making. As noted
in the findings, their representations are often at odds. Having an un­
derstanding of both similarities and differences can help researchers and
practitioners frame and approach problems associated with the imple­
mentation of emerging technologies.
Additional theoretical concepts provided by SRT are anchoring and
objectification which allow us to explain certain findings in research and
K. Weerasinghe et al.
to develop strategies to overcome misalignment of representations. For
example, by studying anchoring − the formation of the representation
by the group through activities such as discussions, communications,
and documentation within the MMM levels – we found that there is a
lack of anchoring activities around the concept of big data. There was no
common discussion of the concept of big data or its application at any
level. One implication of this for initiatives might be to facilitate single
and cross-level discussions about big data, its areas of potential, issues
and opportunities as part of the planning process. Objectification – the
mapping of an individual’s values to the representation − was seen
throughout most of the discussions with the participants as they mapped
their own past experience, education background, roles and even age to
their understanding of the concept of big data. Objectifications such as
GPs claiming computer-assisted clinical decision-making tools may not
be very helpful, as they do not have the necessary skills to use tools or
valuing interactions with patients more than dealing with a computer
system can be dealt with: (i) by providing more training around tools,
and (ii) providing support (such as through forums or workshops) to
understand the benefits that such tools can bring.
While this is an early application of SRT in information systems
research, we see significant potential in the use of SRT, especially in the
context of novel phenomena such as big data. The initiatives around
such phenomena are still emerging and therefore representations are
evolving and are not yet embedded in actual policy or projects. Addi­
tionally, investigating sociotechnical representations will allow early
detection of strengths, issues and opportunities around the novel tech­
nology that will eventually come into play.
7. Conclusions, implications, limitations and future work
As a contemporary topic, big data and analytics has gained mo­
mentum in the healthcare context. Use of big data in healthcare is
beneficial in three main areas: (i) clinical care and decision-making, (ii)
population health analysis, and (iii) research and development (Groves
et al., 2013). As an interesting and less researched area, this paper fo­
cuses on the use of big data and analytics for clinical decision-making (e.
g., Bates et al., 2014; Dang and Mendon, 2015; Ginsburg and Phillips,
2018). The application of big data in the context of clinical
decision-making is in the spotlight due to the technological de­
velopments around big data and analytics (Ginsburg and Phillips, 2018).
The potential of big data in the field of clinical care and decision-making
includes but is not limited to: precision medicine, use of
patient-generated data, better risk analysis, and preventative care.
Although such benefits have been identified, the uptake of big data and
analytics is slow in the field of clinical care. Addressing this, this paper
presents a study investigating MMM levels within the NZ healthcare
system to explore the potential of big data for clinical decision-making.
The contributions of this paper are threefold: methodological, theoret­
ical, and practical.
Methodologically, the paper extends past literature (e.g., Dulipovici
and Robey, 2013; Gal and Berente, 2008), by developing a framework
using SRT as a methodology and using the framework to investigate a
research problem. This study is an early application of SRT in IS
research. Although developing a framework through SRT has been
conceptualised by (Weerasinghe et al., 2018), that work does not verify
the use of the developed framework in practice. This research contrib­
utes to the gap in the literature by validating the use of SRT as a
methodological lens to develop a theoretical framework and using it to
empirically investigate this research phenomenon. The use of MMM
levels (as an embedded case) in framing the research is a methodological
contribution as it reduces the complexity of the system and looking for
differences across important subsectors in the healthcare context.
Theoretically, the paper contributes to literature on SRT as an early
application of theory in IS research, big data, and analytics in the context
of clinical decision-making. Additionally, while big data as a techno­
logical phenomenon has had a substantive research focus around its
9
Technological Forecasting & Social Change 174 (2022) 121222
technical dynamics and challenges, less focus has been given to inves­
tigating its social dynamics such as users’ understanding, commitment,
value and so forth (Shin, 2015). Therefore, as a study of social dynamics
this paper contributes by explaining how people across the health sector
perceive big data and analytics in the context of clinical decision-making
(Weerasinghe et al., 2019). It also contributes to the big data literature,
with its findings around veracity and data quality (Emani et al., 2015).
The paper confirms the importance of veracity and elaborates that the
issue of data quality is a very real one in the context of health in New
Zealand. Although the systems and the authorities advocate for practices
to improve veracity and data quality, in practice there are many prob­
lems perceived by the micro-level users.
Practically, the study contributes to the on-going discussion on the
use of big data and analytics for clinical decision-making, thereby
making contributions to the fields of policy and practice. The overriding
conclusion from this study is the need for a national discussion around
the benefits of using big data analytics for clinical decision-making. This
high-level macro discussion should include meso and micro-level
stakeholders. While the data shows that clinical decision-making is a
low priority across the sector, we argue that it is important that clinical
decision-making is thought about while also focusing on outcomes and
population health. The importance of precision medicine is highlighted
at the macro and meso levels resulting in relevant work around policy
and implementation; however, the readiness of the clinicians for preci­
sion medicine is under question. Transparent discussions with clinicians
about the benefits of precision medicine need to occur.
The efforts of the government to address issues of data quality are
seen to be insufficient by GPs as they are not incentivised for validating
data. As data quality and veracity are key issues, the government needs
to allocate more remuneration to GPs undertaking efficient data vali­
dation. Tech-savvy clinicians around NZ are working on their own
projects to fix problems they come across. This is seen as a positive in­
fluence by both the macro-level government and the meso‑level plan­
ners and funders. Such work can be promoted so that other clinicians can
use those systems and also will be motivated to find ways to fix
problems.
Patient-generated data, a key interest at the meso level, will require
more work in terms of policy and strategy development. In the early
stages, use of patient-generated data simply means sharing a mobile app
with patients and getting constant updates on an identified health issue
(e.g., high blood pressure). Although a few doctors have tried this, in
practice it is unlikely to work due to the lack of motivation from pa­
tients. Therefore, open forums with patients to discuss the benefits of
patient-generated data are needed.
Due to the nature of clinical professions, clinicians are hesitant to use
IT tools unless they are proven to provide accurate results supporting
optimal decision-making. Therefore, the development of clinical
decision-making tools needs to involve clinicians and have a transparent
process of testing. The transparency of the testing process is important to
enable the clinicians to accept a tool and promote its use in their clinical
environment.
One limitation of this study might result from the difficulty in
recruiting micro-level participants. The success rate for GPs and hospital
doctors was less than 20%. The sample of younger doctors was minimal.
This may have been due to their busy schedules. Thus, the study might
not have achieved a representative sample. However, a follow-up
quantitative study can provide further verifications and a more gener­
alised understanding.
From observations that were explained in the discussion, explicit
propositions can be formulated to be explored in depth (qualitative
study) or tested (quantitative study) in future research. We have further
identified several other avenues for future research including: (i) un­
derstanding patients and their perception of patient-generated data, (ii)
the potential of precision medicine for primary care, (iii) understanding
medical profession views on the use of information systems, (iv) un­
derstanding user dynamics for data quality and future issues, and (v)
K. Weerasinghe et al. Technological Forecasting & Social Change 174 (2022) 121222

understanding healthcare sector and organisational complexity, and
potential conflicts amongst stakeholders and their effects on modern
technological developments. In addition to these, we also suggest that
research investigates the application of big data and analytics in the field
of population health and health outcomes in a similar way to obtain a
comprehensive understanding of this aspect of use within the healthcare
system as a whole. Another possible future research area is to investigate
group decision-making/large-scale decision-making (Liu et al., 2019) in
the healthcare context with the use of big data.
CRediT authorship contribution statement
Kasuni Weerasinghe: Conceptualization, Writing – original draft,
Methodology, Investigation, Data curation. Shane L. Scahill: Method­
ology, Supervision, Writing – review & editing. David J. Pauleen:
Conceptualization, Supervision, Writing – review & editing. Nazim
Taskin: Supervision, Writing – review & editing.

Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.techfore.2021.121222.

Appendix

Appendix A: Interview schemas

Appendix A.1 Macro interview schema

Section A: Demographics interview questions

1 How many years have you been working in the healthcare sector?
2 How many years have you been working in a policy making or advisory role?
3 What is your current position(s)?

Select which role to go forward with.

1 How long have you been in this position?

2 Apart from working in the healthcare sector do you have a background in
a Business
b IT
c Other: …………………………………….

Section B: Interview questions

General information

1 Looking from a health-IT perspective, what are the responsibilities of your organisation towards the NZ healthcare system?
2 Can you describe your role and responsibilities within your organisation? To whom do you report? And who reports to you? (Where do you fit in
the company structure?)

Social representation of big data

1 There have been on-going discussions around the use of big data analytics in healthcare. In the literature there are different ideas relating to big
data. I’m really interested in getting to know what your perception of big data is. What do you understand by the term big data?
2 I am interested in your view on the contribution that big data could make in the health care sector. Do you think using big data and big data
analytics could be used for better planning and delivery of healthcare? Prompts: areas clinical care, R&D, population health
a If so how?
b If not why not?
c Not sure?

Note for interviewer: big data analytics refers to making use of tools and technologies to analyse large amounts of data that comes from a variety of sources.
The sources could be a variety of healthcare information systems – clinical care, and administrative decision-making as well as consumer generated data.

1 Could you talk a bit about what might have influenced or informed your understanding of what big data is?

Prompt: Do you think your understanding of big data was influenced by discussions you had with other board members or any other factors?

1 Do you think that this (your) perceptions/ understandings are common across the board/organisation/department? Or have you seen any different
views in others?

Business-IT alignment (through a social dimension lens)

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K. Weerasinghe et al. Technological Forecasting & Social Change 174 (2022) 121222

1 I’ve looked at the health-IT program 2015–2020 on the NHITB’s website/MOH health strategy. So where do you see big data analytics within this
program?
2 Can you explain to me the reasons why big data is presented in that way (or not presented) in the health-IT program/strategy? (What were the
reasons for including big data in the health-IT program/health strategy?)

Note: history of IT success? Big data analytics in healthcare success stories from other countries? Industry pressure? Need?

1 In your opinion is there anything missing or included which shouldn’t be included (related to big data)?
2 Can you give me some examples of use of big data, big data analytics tools that you might know of?
3 I am interested in better understanding degrees of alignment in health care. Do you think the big data analytics initiatives (outlined within the
health-IT plan/health strategy or the example you’ve given) align to the government’s healthcare objectives? If so can you elaborate, if not why
not?

To what extent do you think the big data analytics will actually facilitate the government objectives?

1 So far we have talked about big data as a concept and the involvement in it from a top level view. Have you experienced a need for big data
initiatives coming from regional or local level at healthcare provision as opposed to a strategic level?
2 We are looking at macro, meso and micro level alignment. What is your perspective of DHBs’ (meso) and healthcare providers’ (micro) role in
successfully implementing such big data initiatives?
3 Who do you think might be the potential beneficiaries of big data initiatives, and why? (Sub groups? Researchers? Medical centres/clinicians?
Consumers?)
4 Big data initiatives are identified in the health-IT program. Who do you think are going to be running them? Also, who are the potential users?
5 Who else do you recommend I talk to at a policy making level about big data? Are you able to introduce me to other high level people who are
involved in health-IT policy making?

Appendix A.2 Meso interview schema

Project title: Exploring the influence of big data analytics on business-IT alignment in the NZ healthcare sector: A socio-cognitive approach
As at: 1st Feb 2017
Researcher: Kasuni Weerasinghe
Supervisors: A/P David Pauleen, Dr Nazim Taskin, Dr Shane Scahill
General information

1 Can you tell me a bit about your educational background?

2 From a health-IT perspective what are the responsibilities of your organisation towards NZ healthcare?
3 How many years have you been working in the healthcare sector?
4 What is your current position(s)?

(If many, select which role to go forward with.)

1 How long have you been in this position?

2 What is your role and responsibilities?
3 To whom do you report? Who reports to you?
4 Have you done any work with the MOH or its business units? If so can you talk a bit about that?
5 Do you interact with (other) PHOs/ DHBs/ other organisations? How?

Big data

1 What does big data mean to you?

2 What contribution does it make to healthcare? Do you think big data and big data analytics could be used for better planning and delivery of
healthcare?
3 What might have influenced or informed your understanding?
4 Do you think this view of big data and its use is common across your organisation and the people you work with? Or have you seen any different
views?
5 Why is big data different from the normal data that we have?
a Is it types of analytics?
b Does it require new skills?
c Does big data influence the organisation’s structure and roles?
d Is it the change in IT infrastructure?
e Do you see IT architecture changing with big data? (methods, models and technologies used)

Current situation

1 Are you aware of any current or planned big data analytics projects by your organisation? Can you describe them a bit? Are you involved? (Clinical
care, outcomes, precision medicine etc.)
a Are you aware of the business objectives of these project/s?
b What healthcare objectives (overall heath objectives) are these projects catering to? What benefits does it bring to the patients?

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K. Weerasinghe et al. Technological Forecasting & Social Change 174 (2022) 121222

c Who benefits from these projects?

d Who are the (potential) end users? How involved are they in these kinds of projects?
e In your view how does this/these project/s facilitate user objectives?

Or,
What is the current position of your organisation’s use of big data?
What is your understanding of the current situation of big data in NZ health sector?

1 Do you think big data can be used to improve services of your organisation? If so how?
2 Do you have any concerns about big data use in health?
3 What do you think the policy-makers’ role is with regard to the success of big data initiatives?
4 Do you think any improvement is needed with regard to health IT policy for the successful use of big data?
5 Do you see a need for any improvements by your organisation to cater to the big data hype?
6 Who else do you suggest I talk to?

Appendix A.3. Micro interview schema

As at: 02nd Jan 2018

1 Can you tell me a bit about your educational background?

2 How long have you been a doctor?
3 Do you have experience working in any other industry? Do you have any IT experience?
4 What is your current role? How long have you been in this role?
5 What are your responsibilities both clinical and administrative/managerial?
6 GPs: Do you own the practice or are you a salaried employee here?

Hospital doctors: To whom do you report? Who reports to you?

1 Are you able to talk about the responsibilities of your organisation towards NZ healthcare from a health IT perspective?
2 What sort of IT systems do you use at your practice/work? Can you talk a bit about what they are and how they help your work?
3 How would you describe the use of data in these systems? How does the data help you do your daily tasks?
4 Do you see any issues around using data in these systems?
a How can these issues be mitigated? What can you (doctors) do better?
b What can PHOs do to mitigate such issues?
c What can the government do to mitigate such issues?

(Data quality, privacy and security)

1 Are you using any IT systems for clinical decision-making? Can you explain?
2 Would you prefer to have more information available to improve the consultation (or do you think the information you have is sufficient)? Can you
explain?
3 Have you ever heard of the term big data? What does big data mean to you?

If no, define – big data is data that’s large in volume, complex in the sense of lots of different varieties, so in health obviously things like text with
scans, x-rays, other reports and even most modern things like data from patients’ Fitbits maybe. And also there’s an element of real time in big data so
something like collected now and used in near real time. The use according to international research says that this type of health data has a huge
potential for things like measuring the performance of the healthcare system and population health and even to be used in the clinical frontline to
improve clinical care.
What do you think about this in the NZ context?

1 What are your thoughts about using such data for clinical decision-making?
a What are the issues that you see in using such big data in clinical decision-making?
b Is there anything that bodies like the PHO, DHB or the government can do to mitigate such issues? (OR improve the use?)
2 What are your thoughts on patient-generated data? i.e. collecting data from a blood pressure monitor or from a patient’s phone?

(Prompt: What about patient-generated data in huge volumes that constitutes big data not just own practice clinical data)

1 Do you see any issues around using patient-generated data?

a How can these issues be mitigated?
b What can PHO do to mitigate such issues?
c What can the government do to mitigate such issues?
2 Are there any other technologies or information systems that you see or know of or have heard of which could improve your quality of work?
3 What do you think might have influenced you to think about data (both about data in systems and patient-generated data) in this manner?
4 Have you seen any different perspectives about data from others around you?
5 Can you explain your best and worst experience of using system generated data? (you might even talk about an experience of a colleague?)
6 From a health-IT perspective how would you describe the role of your PHO? What do they do to help you (or not) do your work?
7 From a health-IT perspective how would you describe the role of the Ministry of Health? How do they help you (or not) do your job better?

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K. Weerasinghe et al. Technological Forecasting & Social Change 174 (2022) 121222

8 Have you been involved in doing any work with the MOH or the NHITB from a health-IT perspective? If so can you talk a bit about that?
9 If GP only: How would you describe your interaction with the PHO, from a health IT perspective?
10 If GP only: How would you describe your interaction with the DHB, from a health-IT perspective?

IF hospital doctor: Can you talk about how the DHB administration communicate with you about health IT?

Appendix B: Demographics of the participants

Participants Organisation type Organisation Role Main focus of the role Number of years of experience ICT experience
(IT or health) in healthcare (research)

MAC1 Policy Making Body Macro Senior Executive IT 15 years Yes

organisation X
MAC2 Policy Making Body Macro General Manager Health > 20 years No
organisation X
MAC3 Policy Making Body Macro General Manager Health > 16 years No
organisation X
MAC4 Policy Making Body Macro Manager Health > 35 years No
organisation X
MAC5 Policy Making Body XYZ Board Senior Executive IT 10 years Yes
MAC6 Policy Making Body Macro Manager Health > 10 years No
organisation Y
MES1 Funding and Planning DHB X Clinical Lead Health 23 years Yes
(Secondary Care)
MES2 Funding and Planning Body DHB X Clinical Director Health > 30 years Yes
(Secondary Care)
MES3 Funding and Planning Body DHB Y Manager IT < 6 months Yes
(Secondary Care)
MES4 Funding and Planning Body PHO A Senior Manager Health 26 years Yes
(Primary Care)
MES5 Funding and Planning Body DHB Z Clinical Director Health 45 years Yes
(Secondary Care)
MES6 Funding and Planning Body PHO B Manager IT > 10 years Yes
(Primary Care)
MES7 Funding and Planning Body PHO C C-level Manager IT < 1 year Yes
(Primary Care)
MES8 Funding and Planning Body PHO D Technical staff IT > 4 years Yes
(Primary Care)
MES9 Funding and Planning Body PHO E Knowledge IT 25 years Yes
(Primary Care) Manager
MES10 Funding and Planning Body PHO F C-level Manager IT < 2 years Yes
(Primary Care)
MES11 Funding and Planning Body PHO F Technical staff IT < 2 years Yes
(Primary Care)
MES12 Funding and Planning Body PHO C C-level Manager IT > 10 years Yes
(Primary Care)
MES13 University University X Academic Health-IT 40 years Yes
MES14 University University X Academic Health-IT > 15 years Yes
MES15 Funding and Planning Body DHB X Epidemiologist Health-IT 20 years Yes
(Secondary Care)
MES16 Vendor organisation Vendor X Manager IT > 10 years Yes
MES17 Vendor organisation Vendor X General Manager Health > 20 years No
MIC1 Hospital Hospital X Specialist Doctor Health 10 years No
MIC2 General Practice GP W GP Health > 35 years Yes
MIC3 General Practice GP X GP Health 29 years Yes
MIC4 Hospital Hospital Y Specialist Doctor Health 25 years No
MIC5 Retired – GP Health 50 years Yes
MIC6 Hospital Hospital Z Doctor Health 29 years Yes
MIC7 General Practice GP Y GP Health 29 years No
MIC8 General Practice GP Y GP Health 10 No
MIC9 General Practice GP Z GP Health 29 years No

Appendix C: Sample of findings illustrating themes and categories

Categories Themes Description of the theme Representative quotes

Macro: Use of big data for Social Representation: Big data has significant potential in “I think the biggest potential for me is in the clinical care side. In the public
Clinical Decision- Significant Potential clinical decision-making health side, I think we’ve actually being doing a lot of what we do anyway”
Making (MAC2)
Anchoring: Low Priority Problems more serious than clinical “There’s not a lot of people who understand the potential of big data in a
decision-making require immediate clinical environment. They are probably more interested in big data and the
attention whole health system” (MAC1)
Macro: Guidance of Social Representation: Health strategy provides more “So the strategy is all about a person centred view of every person in NZ
Health Strategy Opportunity opportunity to use big data which is the electronic health record, it’s a summery view only. Keeping with
(continued on next page)

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K. Weerasinghe et al. Technological Forecasting & Social Change 174 (2022) 121222

(continued )
Categories Themes Description of the theme Representative quotes

Meso: Importance of
Patient generated data
Micro: Current Point of
care
Micro: Clinical Profession
Anchoring: Policy
Social Representations:
Fragmented systems
Objectification: Medical
training
Policy makers are not thinking about
the use of patient generated data
Systems in use does not talk to each
other and it is difficult getting
information needed
Medical training does not include
information analysis
that key information which is available universally across the system, that
the details of that drill down through links into electronic medical records
and clinical data repositories which are scattered across the entire health
system.” (MAC5)
“…nobody is looking at it [patient generated data] and saying we need to
think about what we can do with that data to transform the health system so
we can handle the silver tsunami.” (MES14)
“…everyone’s got different systems and different platforms and different
data management platforms which makes it very difficult if we want to
compare say our data in Christchurch with say a group in Auckland. We’re
not using the same structures.”
“When you do medical training, you obviously you develop analytical
thinking skills but in a different way. Not so much in terms of information
analysis or operations management which are important for managing the
hospital but not part of our training. So that’s all new to all of us. ” (MIC1)

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Kasuni Weerasinghe (PhD) is a Lecturer in the School of Management at Massey Uni­
versity, Auckland, New Zealand. She has a background in Information Systems and her
research focuses on big data analytics, socio-technical perspectives, strategic IS/IT align­
ment and health information systems. Her work has appeared in the Australasian Journal
of Information Systems (2018) and has been presented in conferences like Australasian
Conference on Information Systems and Pacific Asia Conference on Information Systems.
Shane L. Scahill (PhD) is an Associate Professor and Head of School in the School of
Pharmacy at Auckland University, Auckland, New Zealand. His-research area includes
health services research, health policy, organisational culture, Big Data and health, clinical
decision-making processes, and personal knowledge management of pharmacists. Shane’s
work has appeared in journals such as Health Policy, New Zealand Medical Journal, Health
Policy and Technology and International Journal for Quality in Healthcare. He serves as an
associate editor for Labour and Industry and the Journal of Pharmaceutical Policy and
Practice.
David J. Pauleen (PhD) is Professor of Technology Management at Massey University,
New Zealand. His-current research revolves around wisdom in management, personal
knowledge management, knowledge management, cross-cultural management, emerging
work practices, and virtual team leadership dynamics, communication and technology.
His-work has appeared in numerous top journals including: Information Systems Journal
(2018), Decision Sciences Journal (2018), Journal of Business Ethics (2019, 2013),
Journal of Management Information Systems (2003–04), and Journal of Information
Technology (2001). He is editor of the book, Cross-Cultural Perspectives on Knowledge
Management (2007), and co-editor of Personal Knowledge Management: Individual,
Organizational and Social Perspectives (2010) and the Handbook of Practical Wisdom:
Leadership, Organization and Integral Business Practice (2013). He has co-authored the
books, Wisdom, Analytics and Wicked Problems: integral decision-making in the infor­
mation age (2019) and Management Decision-Making, Big Data and Analytics and is the
co-editor of the Routledge Practical Wisdom in Leadership and Organization Series.
Nazim Taskin (PhD) is an Assistant Professor in the Management information Systems
Department at Bogazici University, Istanbul, Turkey. His-research area includes strategic
IS/IT alignment, Enterprise Systems, Big Data and Analytics, decision making, and
knowledge management. His-work has appeared in journals such as the International
Journal of Information Management; International Journal of Knowledge Management;
Journal of Knowledge Management; Australasian Journal of Information Systems, and the
International Journal of e-Collaboration. He serves as an associate editor for Journal of
modelling in Management. He has co-authored book Management Decision-Making, Big
Data and Analytics.