For Ramathibodi Hospital Administration School's 5th Healthcare CIO Certificate Program

1. Case Studies in
Health IT Implementation
Part 1 (September 19, 2014)
Nawanan Theera-Ampornpunt, M.D., Ph.D.

2. 2
H.I.T. or Miss: Lessons Learned from Health
Information Technology Implementations
Leviss (Editor)
(2010)

3. 3
Instructions (Part 1)
• 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

4. 4
Instructions (Part 2)
• 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)

5. Sociotechnical
Aspect of
Health Informatics
Nawanan Theera-Ampornpunt, MD, PhD
September 19, 2014 Except where
citing other works

6. 6
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

7. 7
People-Process-Technology
Technology
People Process

8. 8
“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

9. 9
“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

10. 10
Health IT Successes & Failures
Kaplan & Harris-Salamone (2009)

11. 11
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)

12. 12
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)

13. 13
Health IT Change Management
Lorenzi & Riley (2000)

14. 14
Health IT Change Management
Lorenzi & Riley (2000)

15. 15
Health IT Change Management
Lorenzi & Riley (2000)

16. 16
Health IT Change Management
Lorenzi & Riley (2000)

17. 17
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

18. 18
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)

19. 19
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)

20. 20
Critical Success Factors in Health IT Projects
Communications of plans & progresses
Physician & non-physician user involvement
Attention to workflow changes
Well-executed project management
Adequate user training
Organizational learning
Organizational innovativeness
Theera-Ampornpunt (2011)

21. 21
The “Special People”
Ash et al. (2003)

22. 22
The “Special People”
• Administrative
Leadership Level
– CEO
Ash et al. (2003)
• 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

23. 23
The “Special People”
• Clinical Leadership
Level
– Champions
• Necessary
• Hold steadfast
• Influence peers
• Understand other
physicians
– Opinion leaders
Ash et al. (2003)
• 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

24. 24
The “Special People”
• Bridger/Support level
– Trainers &
support team
• Necessary
• Provide help at the
elbow
• Make changes
• Provide training
• Test the systems
Ash et al. (2003)
– Skills
• Possess clinical
backgrounds
• Gain skills on the
job
• Show patience,
tenacity, and
assertiveness

25. 25
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)

26. 26
Unintended Consequences of Health IT
Ash et al. (2004)

27. 27
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)

28. 28
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 errors
Ash et al. (2004)

29. 29
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 errors
Ash et al. (2004)

30. 30
Unintended Consequences of Health IT
Campbell et al. (2006)

31. 31
Unintended Consequences of Health IT
Campbell et al. (2006)

32. 32
Unintended Consequences of Health IT
Koppel et al. (2005)

33. 33
Unintended Consequences of Health IT
Koppel et al. (2005)

34. 34
Unintended Consequences of Health IT
Some Risks of Clinical Decision Support Systems
• Alert Fatigue

35. 35
Unintended Consequences of Health IT
Workarounds

36. 36
Human-Computer Interaction
• “A discipline concerned with the design,
evaluation and implementation of
interactive computing systems for human
use”
evaluation implementation
• Interdisciplinary
design
– Computer Science; Psychology; Sociology;
Anthropology; Visual and Industrial Design; …
From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

37. 37 37
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

38. 38 38
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

39. 39
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

40. 40
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 design
http://en.wikipedia.org/wiki/Usability

41. 41
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

42. 42
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

43. 43
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

44. 44
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.

45. 45
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.