Case Studies in Health IT Implementation & Sociotechnical Aspect of Health Informatics

Case Studies in Health IT ImplementationPart 1 (September 19, 2014)

Nawanan Theera-Ampornpunt, M.D., Ph.D.

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Leviss (Editor) (2010)

H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations

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• Form a group of 3-4 individuals (8 groups total)

• Each group is assigned 2 case studies• Today (September 19, 2014)

– Mini-Lecture on Sociotechnical Issues– Group reading on assigned case studies

(but skip the Author’s Analysis & Editor’s Commentary sections)

– Group discussion– Read Author’s Analysis & Editor’s

Commentary– Identify lessons learned

Instructions (Part 1)

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• After this session– Each group prepares a 10-minute

presentation• Next Thursday (September 25, 2014)

– Each group is allotted 10 minutes combined to present analysis of the two cases

– For each case (5 minutes)• Summary of the Case Study• Synthesis of Lessons Learned (based on

group’s opinions, Author’s Analysis & Editor’s Commentary)

Instructions (Part 2)

Sociotechnical Aspect of

Health Informatics

Nawanan Theera-Ampornpunt, MD, PhDSeptember 19, 2014

Except where citing other works

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Sociotechnical Systems• Coined in 1960s by Eric Trist, Ken Bamforth &

Fred Emery

• “An approach to complex organizational work design that recognizes the interaction between people and technology in workplaces.” (Wikipedia)

• “Interaction between society's complex infrastructures and human behaviour.” (Wikipedia)

http://en.wikipedia.org/wiki/Sociotechnical_system

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People-Process-Technology

Technology

ProcessPeople

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“People & Organizational Issues” (POI)• POI focuses on interactions between people

and technology, including designing, implementing, and deploying safe and usable health information systems and technology.

• AMIA POIWG addresses issues such as– How systems change us and our social and clinical

environments– How we should change them– What we need to do to take the fullest advantage of

them to improve [...] health and health care. – Our members strive to understand,

evaluate, and improve human-computer and socio-technical interactions.

http://www.amia.org/programs/working-groups/people-and-organizational-issues

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“People & Organizational Issues” (POI)• We bring varied perspectives, methods, and tools

from– Humanities, Social science, Cognitive science– Computer science and informatics– Business disciplines– Patient safety– Workflow– Collaborative work and decision-making– Human-computer interaction & Usability– Human factors– Project and change management– Adoption and diffusion of innovations– Unintended consequences– Policy.

http://www.amia.org/programs/working-groups/people-and-organizational-issues

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Health IT Successes & Failures

Kaplan & Harris-Salamone (2009)

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Health IT Successes & FailuresWhat success is• Different ideas and definitions of success• Need more understanding of different stakeholder

views & more longitudinal and qualitative studies of failure

What makes it so hard• Communication, Workflow, & Quality• Difficulties of communicating across different

groups makes it harder to identify requirements and understand workflow


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Health IT Successes & FailuresWhat We Know—Lessons from Experience• Provide incentives, remove disincentives• Identify and mitigate risks• Allow resources and time for training, exposure,

and learning to input data• Learn from the past and from others


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Health IT Change Management

Lorenzi & Riley (2000)

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Considerations for a successful implementation of CPOE

Ash et al. (2003)

ConsiderationsMotivation for implementationCPOE vision, leadership, and personnelCostsIntegration: Workflow, health care processesValue to users/Decision support systemsProject management and staging of implementationTechnologyTraining and Support 24 x 7Learning/Evaluation/Improvement

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Minimizing MD’s Change Resistance

• Involve physician champions• Create a sense of ownership through

communications & involvement• Understand their values• Be attentive to climate in the organization• Provide adequate training & support

Riley & Lorenzi (1995)

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Reasons for User Involvement• Better understanding of needs & requirements• Leveraging user expertise about their tasks &

how organization functions• Assess importance of specific features for

prioritization

• Users better understand project, develop realistic expectations

• Venues for negotiation, conflict resolution

• Sense of ownership• Pare & Sicotte (2006): Physician ownership

important for clinical information systems

Ives & Olson (1984)

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Critical Success Factors in Health IT Projects

Theera-Ampornpunt (2011)

Communications of plans & progressesPhysician & non-physician user involvementAttention to workflow changesWell-executed project managementAdequate user trainingOrganizational learningOrganizational innovativeness

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The “Special People”

Ash et al. (2003)

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Ash et al. (2003)

• Administrative Leadership Level– CEO

• Provides top level support and vision

• Holds steadfast• Connects with

the staff• Listens• Champions

– CIO• Selects champions• Gains support• Possesses vision• Maintains a thick skin

– CMIO• Interprets• Possesses vision• Maintains a thick skin• Influences peers• Supports the clinical

support staff• Champions

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Ash et al. (2003)

• Clinical Leadership Level– Champions

• Necessary• Hold steadfast• Influence peers• Understand other

physicians

– Opinion leaders• Provide a balanced

view• Influence peers

– Curmudgeons• “Skeptic who is

usually quite vocal in his or her disdain of the system”

• Provide feedback• Furnish leadership

– Clinical advisory committees

• Solve problems• Connect units

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Ash et al. (2003)

• Bridger/Support level– Trainers &

support team• Necessary• Provide help at the

elbow• Make changes• Provide training• Test the systems

– Skills• Possess clinical

backgrounds• Gain skills on the

job• Show patience,

tenacity, and assertiveness

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Unintended Consequences of Health IT

• “Unanticipated and unwanted effect of health IT implementation” (ucguide.org)

• Must-read resources– www.ucguide.org– Ash et al. (2004)– Campbell et al. (2006)– Koppel et al. (2005)

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Ash et al. (2004)

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• Errors in the process of entering and retrieving information– A human-computer interface that is not suitable

for a highly interruptive use context– Causing cognitive overload by

overemphasizing structured and “complete” information entry or retrieval

• Structure• Fragmentation• Overcompleteness

Ash et al. (2004)

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• Errors in the communication and coordination process– Misrepresenting collective, interactive work as

a linear, clearcut, and predictable workflow• Inflexibility• Urgency• Workarounds• Transfers of patients

– Misrepresenting communication as information transfer

• Loss of communication• Loss of feedback• Decision support overload• Catching errors

Ash et al. (2004)

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• Errors in the communication and coordination process– Misrepresenting collective, interactive work as

a linear, clearcut, and predictable workflow• Inflexibility• Urgency• Workarounds• Transfers of patients

– Misrepresenting communication as information transfer

• Loss of communication• Loss of feedback• Decision support overload• Catching errors

Ash et al. (2004)

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Campbell et al. (2006)

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Campbell et al. (2006)

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Koppel et al. (2005)

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Koppel et al. (2005)

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Some Risks of Clinical Decision Support Systems• Alert Fatigue


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Workarounds


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Human-Computer Interaction

• “A discipline concerned with the design, evaluation and implementation of interactive computing systems for human use”

• Interdisciplinary– Computer Science; Psychology; Sociology;

Anthropology; Visual and Industrial Design; …

design

implementationevaluation

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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Foundations of UI Design (1)

• Human psychology– Short-term & long-term memory– Problem-solving– Attention

• Design principles– Conceptual models; knowledge in the world;

visibility; feedback; mappings; constraints; affordances


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Foundations of UI Design (2)

• Understanding users and tasks– Tasks, task analysis, scenarios– Contextual inquiry– Personas

• User-centered design– Low, medium, and high-fidelity prototypes– visual design principles

• Evaluating designs– Without users: cognitive walkthroughs; heuristic

evaluation; action analysis– With users: qualitative and quantitative methods


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Human Factors

• “The study of designing equipment and devices that fit the human body and its cognitive abilities” (Wikipedia)

• Also known as “Ergonomics”• Specialties

– Physical ergonomics– Cognitive ergonomics (including HCI)– Organizational ergonomics (including

workplace design)– Environmental ergonomics

http://en.wikipedia.org/wiki/Human_factors_and_ergonomics

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Usability

• “Refers to how well users can learn and use a product to achieve their goals and how satisfied they are with that process” (Usability.gov)

• “The ease of use and learnability of a human-made object” (Wikipedia)

• “The extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use (ISO)

• Key methodology: user-centered designhttp://en.wikipedia.org/wiki/Usability

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Usability & Usable Systems

• Usefulness = Usability + Utility (Jakob Nielsen)

• Dimensions of usability– Learnability: How easy it is for users to accomplish

basic tasks the first time?– Efficiency: Once learned, how quickly can users

perform tasks?– Memorability: When returned after a period of non-

use, how easily can users re-establish proficiency?– Errors: Frequency, severity, recoverability– Satisfaction: How pleasant it is to use?

http://en.wikipedia.org/wiki/Usability http://www.useit.com/alertbox/20030825.html

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User Experience

• “The way a person feels about using a product, system or service” (Wikipedia)

• Focuses on the feelings and perceptions of users

• Subjective

http://en.wikipedia.org/wiki/User_experience

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HCI & Usability Resources

• Usability.gov• Useit.com• Edwardtufte.com• National Institute of Standards and

Technology (NIST)– http://www.nist.gov/healthcare/usability/index

.cfm– Technical Evaluation, Testing, and Validation

of the Usability of Electronic Health Records – NIST Guide to the Processes Approach for

Improving the Usability of Electronic Health Records

http://en.wikipedia.org/wiki/User_experience

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References• Ash JS, Berg M, Coiera E. Some unintended consequences of information

technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004 Mar-Apr;11(2):104-12.

• Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician order entry: the importance of special people. Int J Med Inform. 2003 Mar; 69(2-3):235-50.

• Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc. 2003 May-Jun;10(3):229-34.

• Campbell, EM, Sittig DF, Ash JS, et al. Types of Unintended Consequences Related to Computerized Provider Order Entry. J Am Med Inform Assoc. 2006 Sep-Oct; 13(5): 547-556.

• Ives B, Olson MH. User involvement and MIS success: a review of research. Manage Sci. 1984 May;30(5):586-603.

• Kaplan B, Harris-Salamone KD. Health IT success and failure: recommendations from the literature and an AMIA workshop. J Am Med Inform Assoc. 2009 May-Jun;16(3):291-9.

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References• Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL.

Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005 Mar 9;293(10):1197-203.

• Lorenzi NM, Riley RT. Managing change: an overview. J Am Med Inform Assoc. 2000 Mar-Apr;7(2):116-24.

• Paré G, Sicotte C, Jacques H. The effects of creating psychological ownership on physicians’ acceptance of clinical information systems. J Am Med Inform Assoc. 2006 Mar-Apr;13(2):197-205.

• Riley RT, Lorenzi NM. Gaining physician acceptance of information technology systems. Med Interface. 1995 Nov;8(11):78-80, 82-3.

• Theera-Ampornpunt N. Thai hospitals' adoption of information technology: a theory development and nationwide survey [dissertation]. Minneapolis (MN): University of Minnesota; 2011 Dec. 376 p.

Case Studies in Health IT Implementation & Sociotechnical Aspect of Health Informatics

Healthcare

med inform

information

patients misrepresenting

authors analysis

communication

interactive

successes

ui design