Change

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TMHG 526CHANGENawanan Theera-Ampornpunt, M.D., Ph.D.Faculty of Medicine Ramathibodi HospitalMahidol UniversityOctober 10, 2014

http://www.slideshare.net/Nawanan

2003 M.D. (1st-Class Honors) Ramathibodi2009 M.S. (Health Informatics) University of Minnesota2011 Ph.D. (Health Informatics) University of Minnesota

CurrentlyFaculty of Medicine Ramathibodi Hospital• Instructor, Department of Community Medicine• Deputy Executive Director for Informatics (CIO/CMIO)Chakri Naruebodindra Medical Institute

Contactsnawanan.the@mahidol.ac.thSlideShare.net/Nawananwww.tc.umn.edu/~theer002groups.google.com/group/ThaiHealthIT

Introduction

Outline• Change & IT• Theories on Change• Change Management• Change Management & Sociotechnical Issues in Informatics

• Bad Changes: Unintended Consequences of Health IT

• Usability & Human Factors• Case Studies

Change Management References

Lorenzi & Riley (2004)

Change Management References

http://www.ncbi.nlm.nih.gov/pubmed/10730594

“The only constant is change”

Heraclitus

Change & IT

Class Exercise #1Discuss with your neighbor:

• What changes does an IT implementation bring about?

• What are the risks of those changes?• What are the implications of those

changes for implementers?

Reasons for Change•Fix existing problems•Add more desirable features•Process improvement•Address a specific policy/strategy•Business needs•Keep up with new technologies•Regulatory compliance•Could be internal or external

“To improve is to change...”

Winston Churchill

IT Implementation Failures

Theories on Change

Theories on Change•First-order change

• “A variation in the way processes and procedures have been done in a given system, leaving the system itself relatively unchanged.”

• E.g. creating new reports, new ways to collect same data, refining existing processes

Watzlawick, Weakland, & Fisch (1974), cited in Lorenzi & Riley (2000)

Theories on Change• Second-order change

• The system itself is changed• Usually a result of a strategic change or a major crisis such as a threat against system survival

• Involves redefinition or reconceptualization of the organization’s business and how it’s conducted

• E.g. changing from paper to electronic medical records, automated teller machines

Watzlawick, Weakland, & Fisch (1974), cited in Lorenzi & Riley (2000)

Theories on Change•Middle-order change

• “Represents a compromise; the magnitude of change is greater than first-order change, yet it neither affects the critical success factors nor is strategic in nature.”

Golembiewski, Billingsley, & Yeager (1976), cited in Lorenzi & Riley (2000)

Theories on Change• Lewin’s Field Theory: 3 fundamental types of conflict situations in a person (“force fields”)• Standing midway between 2 positive goals of approximately equal strength• When there are 2 good systems to purchase

• Standing between 2 approximately equal negative goals• Make a choice of a system that will not completely meet the needs

• Opposing positive and negative forces• System users vs. IT people

Change Resistance

Change Resistance in the News

Washington Post (March 21, 2005)

“One of the most important lessons learned to date is that the complexity of human change management may be easily underestimated”

Langberg ML (2003) in “Challenges to implementing CPOE: a case study of a work in progress at Cedars-Sinai”

Cost of Change in IT• Time & effort to learn• Sense of control / sense of belonging of workers

• Sense of control of middle managers (information systems increase ability of executives to know what’s going on and have more direct control)

• Loss of position, power, networks“Power shift”

“The changes we dread most may contain our

salvation”Barbara Kingsolver, in Small Wonder

Change Management

Change Management• “The process by which an organization gets to its future state, its vision.”

•Starts with creating a vision for change and empowering people as change agents to achieve the vision.

• “Change management encompasses the effective strategies and programs to enable those change agents to achieve the new vision.”

Change Management Process•Assessment•Feedback and Options•Strategy Development• Implementation•Reassessment

Types of Change• Operational changes

• Changes that affect the way the ongoing business operations are conducted

• Strategic changes• Changes in strategic business direction

• Cultural changes• Affect basic organizational philosophies by which the business is conducted (e.g. implementing CQI)

• Political changes• Staffing changes, primarily for political reasons

Types of Change• Microchanges

• Differences in degree• E.g., modifications, enhancements, improvements, & upgrades of information systems

• Megachanges• Differences in kind• E.g., a new system or a very major revision

Ash et al. (2003)

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

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

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

The Special People

Change Management and Sociotechnical Issues in

Informatics

• 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

Sociotechnical Systems

Technology

ProcessPeople

People-Process-Technology

• 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

“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

“People & Organizational Issues” (POI)

Health IT Successes & Failures

Kaplan & Harris-Salamone (2009)

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

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

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

Considerations for a successful CPOEimplementation

• 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)

Minimizing MD’s Change Resistance

User Involvement in Health IT:A True Story

• 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)

Reasons for User Involvement

Theera-Ampornpunt (2011)

Technological Sophistication

Functional Sophistication

Integration Sophistication

Managerial SophisticationProposed Addition

The Missing Piece in IT Adoption

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

Critical Success Factors in Health IT Projects

Theory of Hospital Adoption of Information Systems (THAIS)

Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cyclehttp://www.gartner.com/technology/research/methodologies/hype-cycle.jsp

Gartner Hype Cycle

Rogers (2003)

Rogers’ Diffusion of Innovations: Adoption Curve

Leading a Change

http://www.ted.com/talks/lang/th/derek_sivers_how_to_start_a_movement.html

Bad Changes: Unintended Consequences of Health IT

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)

Unintended Consequences of Health IT

Ash et al. (2004)

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)

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)

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)

Campbell et al. (2006)

Koppel et al. (2005)

Some Risks of Clinical Decision Support Systems• Alert Fatigue

Workarounds

Usability & Human Factors

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

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

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

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

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

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

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

HCI & Usability Resources• Usability.gov• Useit.com• Edwardtufte.com• National Institute of Standards and Technology

(NIST)• http://www.nist.gov/healthcare/usability/index.cf

m• 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

• All IT implementations are change• Changes differ in nature, scale, and magnitude• Change resistance is common and natural• Overcoming change resistance requires a good change management strategy

• Pay attention to the “POI” or sociotechnical aspect• Balance between People, Process, & Technology

Summary (1)

• Shared vision & commitment, user engagement, communication, workflow considerations, & training are key

• Understand the Adoption Curve• Health IT can have unintended consequences: bad changes, requiring change management & project evaluation

• Attention to usability & human factors will help manage changes

Summary (2)

Case Studies

Leviss (Editor) (2010)

Leviss (Editor) (2013)

Case Studies on Change Management

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.

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.

Change

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