Knowledge Management Research & Practice (2009) 7, 249259

& 2009 Operational Research Society. All rights reserved 14778238/09

www.palgrave-journals.com/kmrp/

Knowledge sharing using codification and collaboration technologies to improve health care: lessons from the public sector
Brian E. Dixon1 Julie J. McGowan1,2 and Gary D. Cravens1
Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
2 1

Correspondence: Brian E. Dixon, Regenstrief Institute, Inc., 410 W. 10th St., Suite 2000, Indianapolis, IN 46202, USA. Tel.: 1 317 423 5582; Fax: 1 317 423 5695; E-mail: bdixon@regenstrief.org

Abstract Knowledge management (KM) enables the public sector to support knowledge transfer across organizations and communities. This case study tells the story of how one U.S. Government agency has been able to support change within the health-care industry to adopt and use information and communication technologies. The study focuses on the role and use of codification and collaboration technologies in KM practice. The study also describes the agencys emphasis on evaluation of these techniques in support of continuous quality improvement of KM practice. Building on previous work in KM, the study extends the traditional dialectic on codification and collaboration, blurring the lines between formal and informal forms and suggesting that both approaches may be necessary to achieve desired impacts on government and societal challenges. Knowledge Management Research & Practice (2009) 7, 249259. doi:10.1057/kmrp.2009.15
Keywords: case study/studies; knowledge sharing; good practice; collaborative systems; ontology

Introduction
Modern government utilizes a broad range of information and communication technologies (ICT) to capture, store, manage, and disseminate data, information, and knowledge used for policy-making and public administration. An emphasis on public sector ICT over the past few decades has resulted in a myriad of databases, networks, and systems across and within federal, state, and local government entities. Increasingly federal and state policies are placing greater emphasis on Web-based delivery of information and services (Wood et al., 2008). Modern government therefore requires appropriate distribution and management of disparate systems and the information and knowledge captured, stored, and communicated by those systems (Metaxiotis & Psarras, 2005). Without such governance, sophisticated technologies simply create, maintain, and make available useless, disconnected fragments of information. The approach suggested by Henry (1974) to ensure that information systems enhance both government and society is knowledge management (KM). Henry is not alone in this suggestion. Several scholars from a variety of disciplines have suggested that KM has the potential to transform public administration through the distribution and use of knowledge supported by ICT (Liebowitz, 2004; Gorry, 2008). In this paper we present a case study of the National Resource Center for Health Information Technology (NRC) website, a public sector website

Received: 30 August 2008 Revised: 13 March 2009 Accepted: 3 June 2009

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designed to support information and knowledge sharing among health-care organizations (e.g., hospitals, physician offices, nursing homes). The site is novel because it is the only website in the U.S. that provides knowledge resources, including best practices, lessons learned, and scholarly knowledge, about the adoption and use of health information technologies without the need for registration or membership. Furthermore, the NRC website is one of only a handful of public sector ICT applications designed specifically for knowledge sharing. The case study describes a real-world attempt to integrate collaboration and codification in a meaningful way to share knowledge among front-line clinicians, clinical managers, ICT professionals, and health system administrators. Building on previous scholarship in KM, the case study suggests the use of a combination of collaboration and codification techniques to maximize knowledge sharing across a large and diverse set of audiences. Several formal (e.g., knowledge classification) and informal (e.g., social bookmarking) techniques are described, providing KM and ICT professionals with ideas they can use in their organizations. The case study was developed based on several years of evaluation data. We routinely employ quantitative and qualitative evaluation methods to capture feedback on the user experience. This data helps us continuously improve the site and the techniques we use to effectively share knowledge with our target audiences. In the case study, we describe the evaluation methods and lessons learned from implementation of the various techniques. We further describe the challenges associated with the techniques and evaluation of KM practice. Researchers and practitioners alike will be interested in our findings and the framework we suggest as a way to approach comprehensive knowledge sharing. In the following section, we outline the theoretical framework underlying the case study. We review the nature of knowledge and important foundational work in KM. We then present the methodology of the study, followed by the NRC case. The evolution of the NRC is described, starting with its initiation in 2005. We further describe major revisions in 2006 and 2007, as well as current projects in development. We then discuss the findings of the case and their interpretation in the light of recent KM scholarship.

or application to some domain. To extend our examples of data and information, the [diabetic] patients hemoglobin A1c was 7.9, slightly above the threshold that distinguishes those patients with controlled versus uncontrolled diabetes.

Theoretical framework The theoretical framework for this case study is rooted in the objectivist construct, which holds that knowledge is characterized by objective truths and facts (Wilson, 2005). Recently the traditional objectivistconstructionist dialectic has been critiqued (Williams, 2008) and a new dialogue with four discourses has been suggested (Deetz, 1996). One of these is the normative discourse, which is used in place of a strict objectivist framework for this study. Research within the normative discourse recognizes that technology can play a vital role in knowledge discovery and sharing (Schulte & Stabell, 2004). ICT in the normative discourse is employed to aid in the storage and transfer of knowledge, making knowledge available for retrieval by others across time and space (Schultze & Leidner, 2002). Review of recent KM scholarship The concept of KM is difficult to define (Earl, 2001). KM has been applied in many industries, and its working definition has been redefined several times based on the context of its use (Kakabadse et al., 2003). Although various definitions exist, KM is, at its core, a process involving four key actions: knowledge capture, knowledge sharing, application of knowledge, and knowledge creation. Figure 1 illustrates the KM process, adopted from Liebowitz (2004). As depicted in Figure 1, the KM process is cyclical in nature. The process involves not only knowledge capture and sharing but also the application of existing knowledge and the creation of new knowledge, which is then fed back into the process. Drawing upon recent reviews of the KM literature (Takeuchi, 2001; Kakabadse et al., 2003;

Knowledge Capture

Theories of knowledge and KM

Knowledge Definitions of knowledge abound in the information science and KM literature. We illustrate our use of the terms information and knowledge using Liebowitz (1999). Whereas data are discrete symbols, images, and facts (e.g., 7.9), information is data that has meaning and structure (e.g., the patients hemoglobin A1c was 7.9). Knowledge is the result of a structured process. This process can involve one or more of the following: reasoning, abstraction, association with other information,
Knowledge Creation Knowledge Sharing

Application of Knowledge

Figure 1 The knowledge management process. (Adapted from Liebowitz, 2004).

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Lloria, 2008), we further describe the actions involved in the KM process: 1. Knowledge capture: Capturing knowledge involves several steps. First, knowledge must be identified. This step usually involves experts humans or expert systems to identify the desired knowledge for a given use case (e.g., medical librarians might be tasked to identify the latest evidence on the treatment of heart disease). Knowledge is captured, sometimes extracted, and then stored. Processes for knowledge capture date back to ancient times, although the modern American literature often emphasizes electronic means such as storage in databases (Lloria, 2008). Often knowledge is codified in some manner during this step, using an ontology or taxonomy, to make locating specific knowledge lessons or documents easier when retrieved at a later date (Kim, 2005). 2. Knowledge sharing: Sharing knowledge connects individuals who seek knowledge to the knowledge that is most relevant. This stage of the KM process often involves the use of a system typically electronic to locate and retrieve knowledge (Galup et al., 2003). An expert directory, for example, connects a knowledge seeker to the person or people who possess the knowledge sought (Hai Chen Tan et al., 2006). Extranets provide users with a private Web portal through which they can search and access knowledge (Ciabuschi, 2005). Tools and processes are developed by knowledge managers to enable quick and efficient retrieval of relevant knowledge, which is challenging and requires an understanding of knowledge seekers behavior and needs (Sacco, 2006). 3. Application of knowledge: Knowledge is valuable only if it can help you achieve your goal. For example, knowledge about the causes of heart disease probably is not very helpful to a researcher who is interested in understanding why people ignore their physicians advice about unhealthy eating habits. In addition to relevancy and applicability, knowledge must also be understood by the recipient. Literacy is a crucial area of investigation, for example, in health-care research aimed at information systems that provide medical information to patients (Eichner & Dullabh, 2007). 4. Knowledge creation: This stage of the KM process focuses on the creation of new knowledge. Rooted in a tradition that promotes innovation and improvement, KM seeks to transform an organization or society (Kakabadse et al., 2003). New knowledge is gleaned from the application of different realities coalesced around a desired goal (Nonaka & Toyama, 2003). Transformation requires more than just insight into best practice. Transforming an organization or society requires acting on knowledge gained. The application of knowledge leads to new ways of thinking and doing, which produces new knowledge. The following case study is designed to explore the KM approach employed by a public sector website.

Specifically, the study focuses on the codification (e.g., knowledge dictionaries, expert directories) and collaboration (e.g., groupware, online communities of practice (CoPs)) methods used to promote knowledge sharing. Previous research in KM has described codification and collaboration in terms that connote a formalinformal dualism (Lloria, 2008), similar to that of the objectivist subjectivist dialectic. In other words, codification tends to be described as primarily formal in nature, with an emphasis on meticulous processes for harvesting, classifying, and storing objective knowledge for later access via ICT (Cowan & Foray, 1997). Collaboration, on the other hand, is described as an informal approach whereby knowledge is socially identified, shared, and consumed (Hall, 2006). The KM literature possesses several examples of real-world practices that utilize both methods to appropriately manage knowledge within or between organizations (Ciabuschi, 2005; Tan et al., 2006; Spallek et al., 2008). While the NRC case study presents another example of formal codification and informal collaboration techniques, the study also describes informal codification and formal collaboration techniques that advance how codification and collaboration can be used to enrich the practice of KM and enhance its impact on organizations, government, and society.

Methods
In this paper, we explore the case of a public sector website utilized by the U.S. Government as a means of knowledge sharing. The agency sponsoring the website, the Agency for Healthcare Research and Quality (AHRQ), is a small entity within the U.S. Department of Health and Human Services (DHHS). Although small when compared to other DHHS agencies, such as the Food and Drug Administration (FDA), AHRQ has an important role. Namely, AHRQ is responsible for conducting and supporting research to improve the quality, safety, efficiency, and effectiveness of health care. The agency accomplishes its mission both through external grants and contracts as well as internal projects, such as the National Healthcare Quality and Disparities Report (AHRQ, 2008a). The reports and studies funded by AHRQ identify challenges in health-care delivery as well as innovations that some health-care organizations have developed to meet those challenges. Because of the importance of the research funded by the agency, AHRQ is deeply concerned with dissemination of the ideas, theories, and innovations generated by its grantees and contractors. This has led the agency to focus on the development of a range of methods by which study findings are shared. Traditional communications practices remain a vital part of AHRQs dissemination strategy. For example, the agency works with researchers to publish findings in peer-reviewed journals. Investigators are also encouraged to develop local dissemination plans that include press releases, outreach to trade journals, and target pitches to national media outlets such as the New York Times and Wall Street Journal.

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In recent years, the agency has begun to focus on Web-based approaches for delivering information and knowledge to its stakeholders clinicians, policymakers, health-care analysts, and the public. AHRQ currently uses a variety of Web-based information services, including email listservs, an electronic newsletter, and reallysimple syndication (RSS). The agency also uses a variety of websites to collect, organize, manage, and deliver information and knowledge to certain audiences. The public sector website sponsored by AHRQ under investigation in this paper is the AHRQ National Resource Center for Health IT site http://healthit.ahrq.gov. The site was created as a means of knowledge sharing across public and private health-care organizations in the U.S. The site was developed and is maintained by the National Resource Center for Health IT a publicprivate collaborative involving several non-profit and academic organizations. Although a vehicle for dissemination about AHRQ and its investment in health IT research, the main purpose of the NRC website is to disseminate best practices for the adoption and use of health IT, gathered from AHRQ projects, to a diverse set of audiences. The site is among a very small group of public sector websites solely focused on knowledge sharing. This is an explorative case study of theory building purpose. We investigated the role of codification and collaborative ICT for knowledge transfer between individuals from different organizations. The investigation draws on a variety of data collected for NRC website improvement over the past 3 years. As recommended by Wood et al. (2003), the NRC employs a variety of evaluation methods to capture metrics and feedback related to its public website. One method is quantitative data gathered using standardized questionnaires, such as the American Customer Satisfaction Index (ACSI) online customer survey (Wood et al., 2008). Another method is the use of focus groups with a broad range of health-care representatives. A third method is the routine collection website metrics and key performance indicators, such as the unique visitor count and popular documents downloaded from the site. The authors have been involved to varying degrees, based on their length of service, with the evaluation of the website. Two of the authors (BED and JJM) played lead roles in designing the materials (e.g., focus group discussion guides) used to collect feedback on the website. The exception is the ACSI online survey, which was developed by an independent contractor. Two of the authors (BED and GDC) were responsible for recruiting, managing, and conducting the feedback activities. Finally, as part of his regular job duties, one of the authors (BED) is responsible for reviewing the website metrics and key performance indicators and reporting them to AHRQ on a monthly basis. In this study we reflect on the wealth of feedback, comments, metrics, and survey data collected over the past 3 years. The main use of this data is to continuously improve the NRC website. We seek to use the information

to (1) make the site more available to users when searching for knowledge and (2) ensure that the knowledge on the site is in the appropriate form(s) for consumption by users in a way that makes knowledge sharing effective and efficient. We strongly believe that to adequately meet the needs of knowledge seekers you must understand their needs (Kankanhalli et al., 2005; Hall, 2006) and evaluate your progress towards meeting those needs (Wood et al., 2003). Our instruments and methods for data collection primarily involve questions that ask about both the information and knowledge needs of website users and user reactions to prototypes designed for future deployment on the AHRQ health IT website. Users are also asked, in general, to comment on what information (e.g., what are electronic health records?) and knowledge (e.g., 10 best practices for integrating electronic health records into a family medicine clinic) they think the AHRQ-sponsored website should include. In the following section, the case of the NRC website is presented. The drivers of the sites development and its characteristics are described. We also present early lessons from the site and its evolution since 2005. Finally, we discuss the results of our most recent attempt to understand users information and knowledge needs as well as improve the usability of the website.

The NRC website

The need for a site The health-care industry is in a state of rapid evolution. Health care in the U.S. is under extreme pressure to deliver higher quality, safer care more efficiently. Adopting and using health IT electronic medical records, telemedicine, interoperable health-care networks is viewed by many as one of the key methods by which health care should transform itself (Kohn et al., 2000; Chaudhry et al., 2006). The transformation of health care via information technologies has been slow. Currently less than 15% of physicians in the U.S. have a basic electronic health record system in their practice (DesRoches et al., 2008). Furthermore, the U.S. lags behind most other developed nations in its adoption and usage rates (Anderson et al., 2006). Funding is often cited as the major barrier to faster adoption of health IT (Bates, 2005). The introduction of IT, however, causes fundamental transformation in the delivery of health-care services, and organizational issues often present as large if not larger barriers to adoption (Overhage et al., 2005; Zafar & Dixon, 2007). Small organizations, including critical access hospitals and physician practices operated by just one to three doctors, find it particularly hard to adopt and use health IT due to costs and a lack of knowledge in how to select, implement, and integrate IT into the delivery of health care. The Bureau of Labor Statistics (2007) estimates that 18 of the 20 fastest growing occupations between 2004 and 2014 will be in the health care and computer science

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fields, further evidence that, despite some current resistance, change is coming for health care in the form of ICT. This change will likely be accelerated by the American Recovery and Reinvestment Act of 2009, which appropriated nearly $19 billion for the acquisition and use of ICT in health care. Hospitals, physician practices, and other health-care providers therefore need education, guidance, and support to effectively change how they deliver patient care with ICT (Dixon, 2007). Access to organizational and human resources to manage change is scarce, prompting the AHRQ to create a National Resource Center for Health Information Technology (NRC). As part of its strategy to address the knowledge gap among U.S. healthcare organizations, AHRQ and the NRC decided to create a public website to stimulate knowledge sharing.

The site and its components The AHRQ health IT website was created in 2005. The initial website was designed to inform the public about AHRQs investment in health IT research and to support AHRQs grantees through knowledge sharing. There was little information on the public site beyond a basic description of AHRQs investment (e.g., total dollars awarded, purpose of the health IT initiative). Behind the scenes, the NRC was developing, in parallel, a private Web portal or extranet for AHRQs grantees and contractors. This portal was designed to provide basic functionality for CoPs, a model used to facilitate knowledge sharing (Hislop, 2004). Various communities were established between groups of similar AHRQ projects. Discussion boards provided a space for dialogue concerning research design, implementation challenges, and success stories. For example, several projects used the boards to converse about content standards for exchanging laboratory results between provider organizations. The group discussed the various standards available, providing examples extracted from their own lab result repositories. The exchange of ideas and samples prompted some of the provider organizations to change the format of their output, enhancing the semantic interoperability of health IT systems in these communities. Document sharing tools enabled groups to upload items they thought others would find valuable. For example, several grantees uploaded their draft request for information (RFI) documents they planned to release to vendors for a bid process. By examining other draft documents, each organization was able to enhance its own document to include important, previously unaddressed, questions that would ultimately yield knowledge to inform a decision-making process. The NRC was further able to analyze the various documents and develop a synthesized prototype RFI document for distribution to additional AHRQ-funded project teams that did not participate in the original online group. In late 2005, AHRQ directed the NRC to merge the private and public websites into a single, publicly

accessible website. Search tools and knowledge about AHRQ grants and contracts were added. In particular, the agency asked the NRC to collect and share lessons learned from the grants and contracts. So the NRC formed a KM team to proactively seek out stories (e.g., narratives from the project teams point-of-view) and lessons (e.g., how did the project improve adoption rates post-implementation?) from the 100 grants and contracts. The team organized a series of phone calls in which grantees and contractors were interviewed about their successes and challenges. The team also extracted information about the grants and contracts from quarterly progress reports required by the agency. The interviews often enabled the KM team to ask follow-up questions based on these reports. Then the KM team abstracted the stories and lessons into Web-based knowledge artifacts. The knowledge was uploaded to the website, and some of the knowledge was further summarized into documents, printed, and distributed at health-care conferences (AHRQ, 2008b). In addition to the knowledge provided by AHRQs contracts and grants, the NRC also created a Knowledge Library to house Web-based resources (e.g., information documents, knowledge artifacts). A selection policy was established to ensure that selected resources met U.S. Government regulations, and a team of subject matter experts was established to review and approve collected resources. Although several sources are peer-reviewed (e.g., journals, conference proceedings), the vast majority of selected items come from non-peer-reviewed sources. For example, the NRC has had success in gathering sample legal and governance documents that enable health information exchange (HIE) the exchange of discrete data elements from patient medical records between hospitals, laboratories, and physician practices. The legal and governance issues surrounding health information exchange are numerous (Dimitropoulos, 2007), yet there are more than 100 communities in the U.S. currently attempting to overcome the hurdles associated with HIE (Rosenfeld et al., 2006). The documents in the NRC Knowledge Library were selected as examples to help these communities avoid lengthy and costly barriers. At minimum, they provide a starting point from which other communities can engage stakeholders in meaningful dialogue regarding the trust, business agreements, and security involved when exchanging protected health information.

Early lessons The management of a public sector website is challenging (Gorry, 2008). Common website elements, such as persistent cookies, customer feedback, and links to other websites, are often prohibited or require oversight in the public sector. For example, U.S. Government websites generally do not allow for a section in which the user can login. This makes connecting a public site and a private portal via an easy click here to login link impossible. Because the login page cannot be linked from any page

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on the public website, the NRC was restricted from expanding its CoPs beyond a finite set of individuals namely the grantees and contractors to whom AHRQ awarded money for health IT research. A limited number of participants kept discussions and document repositories from expanding to cover the full range of experiences and ideas related to health IT adoption. Furthermore, as work directly related to the grants and contracts increased, project teams complained about the time required to log in and contribute to the communities a common barrier for CoPs (Liebowitz, 2004). Lacking a critical mass, the health IT communities quickly devolved. Conversations became stagnant and few documents were ever added to the community repositories. Attempts by NRC staff members to keep the communities alive were not enough as users abandoned the communities after a short time probably after one or two visits in which they discovered there was not much activity or archived knowledge. Our experience with online CoPs is contrasted with our experience supporting CoPs through more traditional methods, including face-to-face meetings and the telephone. Throughout the existence of the NRC, at each opportunity in which the NRC asked for feedback, users have communicated a strong desire for the ability to interact with one another on an ongoing basis. Recently, when asked about their needs, physicians, nurses, clinical managers, practice managers, policymakers, researchers, students, and health-care analysts all reaffirmed their request that the NRC do more to develop and sustain CoPs. Specifically, stakeholders have asked for monthly, or more frequently, opportunities in which interested parties can participate in a conference call, or login to a Webinar, and interact with others like me. One stakeholder referred to such calls as group therapy for [IT system] implementers. The NRC supports such opportunities through its public Webinar and Open Forum series. AHRQ also hosts an annual conference where grantees and contractors can gather and share lessons in a face-to-face format. The Webinars and conferences have been successful according to feedback from participants. The Webinars routinely attract more than 250 diverse individuals from all walks of the healthcare industry. The annual conference involves over 400 representatives from the AHRQ project portfolio. Several participants informed us through feedback mechanisms that they learned they werent alone in dealing with implementation frustrations and challenges while attending an open forum conference call or Webinar sponsored by the NRC. This may suggest the NRC should adhere to the more traditional approach, favoring telephone and face-to-face discussions. Recent research (Spallek et al., 2008), however, suggests that a better approach may be to combine methods. Spallek and colleagues found that members of an online dental informatics community utilized ICT tools to augment regular phone and in-person CoP activities. The combination of methods led to sustained

success and positive user feedback. Such experiences challenge the NRC to consider a similar approach for the future. To organize knowledge in a way that makes Web-based retrieval efficient and easy, the NRC developed a dynamic taxonomy (Sacco, 2006). Initially the NRC sought to adopt an existing taxonomy, but the NRC soon discovered that no existing taxonomy was broad enough to encompass the breadth of terminology used in the health IT field (Dixon et al., 2007). The NRC proceeded to create a taxonomy and refine it through a number of activities to classify collections of health IT knowledge. For example, a first use of the taxonomy was the codification of items in the Knowledge Library. Thousands of documents were extracted from websites and bibliographies, and subject matter experts applied metadata to the documents using terminology in the taxonomy. The taxonomy was also used by the KM team to classify each of the more than 100 grants and contracts that make up the AHRQ portfolio. Each use of the taxonomy provided an opportunity for the NRC to improve it. When nearly complete, the NRC featured the taxonomy on a Web page so users could use the taxonomy to browse the collection of items within the Knowledge Library. The taxonomy was then evaluated as part of a broad website usability test. Feedback from the usability testing revealed that users did not perceive the taxonomy as useful. Many users were confused by its structure, and other users did not appreciate its comprehensiveness by indicating it was too long. This feedback led the NRC to create a simplified, hierarchical user-friendly version of the taxonomy. The structure of the taxonomy is still intact, but it was abbreviated and re-organized to emphasize a vocabulary better understood by users. Sacco (2006) has demonstrated that improved visualization of a taxonomy can guide users more quickly to topic areas and categories of interest. The popularity of Google is producing a user population that prefers to search for knowledge using query tools rather than browse for it using a well-designed information architecture (Luther, 2003; Battelle, 2005). Expert systems are used on the backend of the NRC website to maintain the sites catalogued knowledge and serve up knowledge when queried using a search engine. Despite efforts to tweak much of the out-of-the-box expert system functionality, usability testing revealed some limitations of the taxonomy. First, terms such as best practices are well understood by those developing and using the taxonomy to codify site knowledge. However, many of the knowledge artifacts often use this phrase in the body of the document. This caused confusion when searching for best practice artifacts and the resulting search yielded several false positives. Second, usability testing revealed that users often do not search using the same terminology constructed during the creation of a formal taxonomy. This makes advanced weighting and associations driven from a taxonomy

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useless. An immediate workaround for this challenge is the use of more robust synonymy within the taxonomy to reasonably guess at the many variations a user might employ during a search. Natural language processing (Strzalkowski, 1995; Friedman & Hripcsak, 1999) is another alternative. A final option might be to engage users in the development of the taxonomy.

Current projects The NRC is currently engaged in a number of additional projects involving codification and collaboration ICT. Among them is the integration of social bookmarking tools, such as AddThis. Social bookmarking tools enable users to share news stories, blog entries, and other Web content items through social networking applications like Facebook and Google Groups. By selecting a content item and posting it to ones profile on a social networking site, an individual indicates an interest in that content item. This interest may reflect a desire to discuss the item with others. For example, bloggers often post links to news articles, online documents, and videos they comment on in their blog entries. The interest may also reflect a vote of confidence in the item. For example, an individual may host a favorite articles on the environment list and post articles there they think others should read about environmental issues. Social bookmarking opens the door for users to more easily share items they find at the NRC website, supporting our primary goal of increasing knowledge sharing within the health IT community. Social bookmarking further enables the NRC to capture real-time metrics on (1) popular content and (2) terminology users feel applies most to a particular artifact. User-tagged knowledge will help the NRC to better understand which artifacts users vote with their feet as being most current or relevant to health IT industry trends. User-defined metadata are also a form of feedback, helping the NRC to better understand the language used by health care and health IT practitioners. User-driven data such as bookmarks and tags will enable the NRC to ultimately improve the findability of important knowledge contained within the site, which also supports our primary goal. Social bookmarking and other Web 2.0 trends suggest bigger implications, however, for the NRC site and our practice of KM. User tags effectively extend the NRCs formal codification processes to include user-driven meta-data, terminology, and associations beyond those contributed by NRC-employed subject-matter experts. A resulting future dynamic taxonomy for the site will most likely be a hybrid between the current expert taxonomy and a folksonomy, or an organic taxonomy developed entirely by a community of users. This implies a more informal approach to codification. The NRC is also rethinking how target sub-audiences access the breadth of knowledge available on the site. Originally the NRC envisioned all users entering the site through a general landing (or home) page. Based on user feedback, we now recognize that some users seek

knowledge from a narrow perspective (e.g., only show me knowledge for doctors). This new approach will be challenging as it will require significant changes to the way in which users interact and perceive their context within the site. It will further necessitate upgrades to our taxonomy to ensure we encompass the breadth of medical perspectives in addition to the existing terminology relevant to health information technologies. Knowledge seekers who desire such functionality will be included during development to ensure the end product will meet their needs. Other users will also be consulted to ensure the functionality does not disrupt their use of the site.

Discussion: towards a new model for KM practice

The case of the NRC website has much to offer the field of KM. First, the story of the NRC demonstrates a successful application of KM practice in the government and health-care sectors. This case study further illustrates that KM involves a mixture of codification and collaboration techniques that are used together to achieve success. Finally, the case study demonstrates that KM is an evolutionary process that requires periodic evaluation and reflection in order to continuously improve quality and the user experience. The NRC case study illustrates the KM process depicted in Figure 2, derived from Nonaka & Takeuchi (1995). Although similar to the KM process as conceived by Liebowitz (2004), Figure 2 more clearly depicts the codification and collaboration techniques described in this case study. Codification of knowledge occurs at three steps in the NRCs practice of KM. First, knowledge is codified when it is captured. The KM team collects knowledge using a variety of methods, including but not limited to grantee information abstraction and relating grantee information to scholarly evidence and industry trends. Then the team applies the NRCs dynamic taxonomy in describing the core content of the knowledge. For example, an article on best practices for designing bar codes and wristbands for inpatients is tagged with labels such as Bar-Coded Medication Administration, Bar-coding, Hospital, and Nursing. Once the knowledge has been formally codified using the taxonomy, the knowledge is stored on the Web in the Knowledge Library. This step involves different methods designed to further codify the knowledge, including a process to identify the group(s) of knowledge seekers who would be especially interested in the knowledge. For example, the bar-coding document may be further distinguished as a best practices document obtained from the peer-reviewed literature and authored by an AHRQ grantee from the state of Michigan. A link may also be associated with the document that points to the grants profile page. Once stored, the knowledge is managed using policies and procedures that align with U.S. Government guidelines for the persistence of data on a federal website. Finally, the knowledge artifact is published to enable users to

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Identify Knowledge

Capture Knowledge

Create Knowledge

Codification Store and Manage Knowledge

Apply Knowledge Collaboration

Share Knowledge

Figure 2

The NRC knowledge management process.

access it. This step involves processes to ensure the artifact is flagged as new and marketed to the most appropriate subset of the NRCs target audiences. Collaboration similarly occurs in multiple ways. First, the NRC employs a variety of ICT to support collaboration between AHRQ-funded project teams. Discussion boards allow for the exchange of dialogue around appropriate implementation strategies and health IT adoption trends. Other ICT tools, such as file sharing, online project management resources, and wikis enable project teams to efficiently exchange a variety of knowledge and artifacts. Making these tools available to users, however, is not enough to sustain knowledge transfer. The NRC also engages users in CoPs using phone conferences, Webinars, and face-to-face meetings. The CoPs have full access to the ICT tools, although there is no requirement that a given CoP use the ICT nor do you have to join a CoP to utilize the ICT tools. The NRC dedicates significant resources to actively managing the phone conferences, Webinars, and face-to-face meetings. Active management appears to be a key component to sustaining CoPs and ICT tool utilization (Spallek et al., 2008). At minimum the two approaches are strongly correlated, based on feedback provided by users of the NRC website and CoP activity attendees. Active management as described here can be considered a formal approach to collaboration as it requires organizational resources to schedule meetings, provide logistics for face-to-face encounters as well as large Webinars, prioritize meeting topics, and facilitate meetings and related CoP activities. The formalness provides structure to an otherwise highly organic, often loosely organized, set of activities. The final steps in the NRCs practice of KM, application of knowledge and knowledge creation, are important as

they provide evidence for the value and benefits of KM. Knowledge seekers who visit the NRC website may apply knowledge gained from the site locally within their health-care organizations. For example, a survey downloaded from the Health IT Survey Compendium could be used within a hospital to gauge clinician readiness for IT system implementation, or perhaps a knowledge artifact on bar-coding might help a Chief Nursing Officer select a system to print bar-coded wristbands for inpatients. Knowledge gained from the NRC website or CoP activity may further be discussed among colleagues or presented to local peers for review and evaluation. Discussion and collaboration locally translates into application of the knowledge. Unfortunately we do not currently capture robust data on the application of knowledge. Through focus groups we have been able to capture some anecdotal evidence that this is occurring, but we need a more structured approach to gather and report out on the success of the site to our stakeholders. Demonstrating such value is important for sustainability, especially in the public sector (Gorry, 2008). Evaluation of this step, however, is complex and remains a challenge. The creation of new knowledge and its evaluation is equally as challenging. We assume that new knowledge is created through the application of accessed knowledge, as well as local organization processes of interpreting, discussing and applying the knowledge. However, we do not have robust methods for measuring these activities. Such activities are a future direction for us. Codification and collaboration methods naturally overlap in the knowledge sharing step. Codes and metadata ensure that knowledge is ready for download and easily accessible through Web searches. Codification technologies can also help users navigate or browse a

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Table 1

Codification and collaboration ICT techniques and recommended evaluation strategies

Codification ICT Collaboration ICT Active management of CoP meetings and Webinars Focus groups Discussion boards, File sharing, Wikis Utilization

Formal techniques

Expert taxonomy, Knowledge classification, Review of artifacts Usability testing Folksonomies, Social bookmarking Web analytics

Informal techniques

website to find the knowledge they seek. Collaboration ICT enables knowledge sharing by convening people to share ideas and discuss knowledge artifacts. The NRC case study illustrates more than just the use of both codification and collaboration ICT. Successful knowledge sharing, based on our experiences, is achieved through the use of both formal and informal techniques within each form of ICT (Table 1). There are many such techniques as described in the KM literature, and we do not prescribe any one set of them. The context of the knowledge sharing may necessitate a different set of techniques than the ones we describe in this case study. The critical point is that knowledge managers should draw upon both formal and informal techniques to enhance ICT-supported KM practices. In the case of the NRC, formal codification (e.g., expert taxonomy, knowledge classification) is the foundation for the backroom processes that make knowledge sharing possible and a dynamic website that enables users to access the knowledge gained through projects supported by AHRQ. Informal codification techniques (e.g., social bookmarking, folksonomies) connect users to knowledge in new and evolving ways. Newer ICT is allowing users to contribute to the NRCs management of AHRQ-funded project knowledge while providing feedback that will enhance the traditional, backroom processes. Both techniques are supporting our mission to provide the highest quality user experience possible for those seeking health IT knowledge. Informal collaboration techniques (e.g., discussion boards, file sharing, wikis) provide users with the opportunity to connect and share knowledge with a wide range of other AHRQ-funded project teams. These ICT tools can support knowledge transfer, but experience has shown that just because one builds it doesnt mean it will be utilized. To support CoPs through ICT requires a critical mass of users, organizational support, and leadership (Gorry, 2008). This may be best provided through formal collaboration techniques (e.g., active management) in which CoPs are provided some structure to support community members and sustain CoP activities. Combining formal and informal collaboration techniques may better situate CoPs to succeed in the long run. Underlying the NRCs KM process is an emphasis on evaluation. We agree with Wood et al. (2003) that evaluation is necessary for ICT, and we advocate iterative evaluation of KM processes. The NRC constantly seeks

feedback and examines ways that it can improve the website and other aspects of knowledge sharing it promotes through its activities. Attention to user needs is important, and it is something that may be overlooked by those in the information science and KM fields (Kankanhalli et al., 2005). We believe that more can be done to understand how users seek knowledge, how they de-codify it, and how they apply it locally (Hall, 2006). In each quadrant within Table 1, we indicate which evaluation methods align with the various formal and informal techniques to support continuous improvement of the NRCs KM process. Formal codification techniques are evaluated with usability testing that places formal knowledge representations in front of experts and realworld users for feedback. Informal codification techniques can be tracked with Web analytics tools that capture information on the volume of social bookmarks added as well as the metadata assigned to the bookmarks. Formal collaboration techniques are evaluated using focus groups and other qualitative research methods to appropriately capture open-ended feedback from users to improve audience engagement. Informal collaboration ICT tool utilization is tracked to understand which tools are being utilized, allowing the KM team to monitor the volume of activities in various CoPs.

Conclusion
Henry (1974) said that KM was a new concern for public administration. Today, KM plays a central role in modern government (Liebowitz, 2004). That role is often to make diverse and disparate knowledge sources interoperate, coordinate, and cooperate in the pursuit of good governance and societal change. For the AHRQ National Resource Center for Health IT, KM is supporting the improvement of patient care and safety by providing health-care organizations and professionals access to scarce knowledge resources about health information technology. To maximize its impact in changing health-care delivery in the U.S., the NRC chose to employ a combination of codification and collaboration ICT as well as a variety of formal and informal techniques as a part of its knowledge sharing strategy. Traditional and 2.0 approaches were deployed to reach a broad and diverse audience. Each approach was evaluated and refined over time to ensure quality and usability. This set of ICT and techniques described in the case study is not

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necessarily the best set for other organizations to use, but it has worked well for the context of use within the NRC. Other KM practitioners should consider how the approaches, lessons, and challenges described might apply in the context of their organizations. Although the framework presented here is working well for the NRC, our experience provides limited data on the usefulness of the framework to others. Therefore KM practitioners should evaluate the methods and techniques described in the case study when applied in their organizations. Additional data and evaluation are necessary for further refinement and demonstration of the various techniques effectiveness in enhancing knowledge sharing. Data on the replication of the

complete framework in another context would also be valuable. In the future, the NRC will seek to better understand how users are applying the knowledge gained from the site, and we further desire to identify new knowledge created as a result of using the site. By exploring the use of the sites health IT resources, we hope to continue our efforts to improve how we deliver resources and quantify the impact of these resources in advancing health care in the U.S. Future investigations will also help us better understand how KM can more effectively ensure that knowledge is not simply disseminated but applied towards solving public problems and societal challenges.

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About the authors

Brian E. Dixon is a Health Information Project Manager with the Regenstrief Institute. He has primary responsibilities in the area of health information exchange, including research and development projects involving the Nationwide Health Information Network (NHIN) and the exchange of data between public health agencies and electronic health records. He also manages the online website of the AHRQ National Resource Center for Health IT. Julie J. McGowan is Associate Dean for Knowledge Informatics and Translation and a Professor of Knowledge Informatics and Pediatrics at the Indiana University School of Medicine. Her research interests include knowledge capture and dissemination, evaluation of applied medical informatics, social networking, and bibliometric analysis. Gary D. Cravens is a Graduate Assistant with the Regenstrief Institute. His current research involves providing medication histories to outpatient clinics. He previously worked on the online website of the AHRQ National Resource Center for Health IT. He is also a Ph.D. student in the Indiana University School of Informatics with a focus on seizure prediction.

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