case studies in health it implementation & sociotechnical aspect of health informatics (august...
TRANSCRIPT
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Case Studies in
Health IT Implementation
August 25, 2016
Nawanan Theera-Ampornpunt, M.D., Ph.D.
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1st Edition
Leviss (Editor)
(2010)
H.I.T. or Miss: Lessons Learned from Health
Information Technology Implementations
2nd Edition
Leviss (Editor)
(2013)
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• Form a group of 4-5 individuals
• Each group is assigned 3-4 case studies
• Today’s class
– Group reading on assigned case studies
(but skip the Author’s Analysis & Editor’s
Commentary sections)
– Group discussion on each case study
– Read Author’s Analysis & Editor’s
Commentary
– Identify lessons learned
Instructions
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• On September 15, 2016, each group
shares & discusses on each case
study for about 5-10 minutes/group
– Summary of the Case Study
– Synthesis of Lessons Learned (based
on group’s opinions, Author’s Analysis &
Editor’s Commentary)
Instructions
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Sociotechnical
Aspect of
Health Informatics
Nawanan Theera-Ampornpunt, MD, PhDSeptember 15, 2016
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 & Failures
What 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
Kaplan & Harris-Salamone (2009)
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Health IT Successes & Failures
What 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
Kaplan & Harris-Salamone (2009)
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Health IT Change Management
Lorenzi & Riley (2000)
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Health IT Change Management
Lorenzi & Riley (2000)
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Health IT Change Management
Lorenzi & Riley (2000)
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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)
Considerations
Motivation for implementation
CPOE vision, leadership, and personnel
Costs
Integration: Workflow, health care processes
Value to users/Decision support systems
Project management and staging of implementation
Technology
Training and Support 24 x 7
Learning/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 & progresses
Physician & non-physician user involvement
Attention to workflow changes
Well-executed project management
Adequate user training
Organizational learning
Organizational innovativeness
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The “Special People”
Ash et al. (2003)
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The “Special People”
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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The “Special People”
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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The “Special People”
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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Unintended Consequences of Health IT
Ash et al. (2004)
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Unintended Consequences of Health IT
• 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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Unintended Consequences of Health IT
• 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 errorsAsh et al. (2004)
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Unintended Consequences of Health IT
• 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 errorsAsh et al. (2004)
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Unintended Consequences of Health IT
Campbell et al. (2006)
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Unintended Consequences of Health IT
Campbell et al. (2006)
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Unintended Consequences of Health IT
Koppel et al. (2005)
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Unintended Consequences of Health IT
Koppel et al. (2005)
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Some Risks of Clinical Decision Support Systems
• Alert Fatigue
Unintended Consequences of Health IT
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Workarounds
Unintended Consequences of Health IT
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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
From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen
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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
From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen
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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.