Sociotechnical Aspects: Clinicians and Technology Lecture 3_slides

Editor's Notes

• #2: No audio. Recording preparation.
• #4: The Objectives for Sociotechnical Aspects: Clinicians and Technology are to: Describe the concepts of medical error and patient safety Discuss error as an individual problem and as a system problem Compare and contrast the interaction and interdependence of social and technical “resistance to change” Discuss the challenges inherent with adapting work processes to new technology Discuss the downside of adapting technology to work practices and why this is not desirable Discuss the impact of changing sociotechnical processes on quality, efficiency, and safety
• #5: This lecture discusses sociotechnical aspects of health care. A sociotechnical system is a system in which people and technology interact. These interactions can be straightforward, or they can be quite complex. Organizational characteristics of the sociotechnical system are modified by this interaction, for better or for worse. Optimization of one element in this system, either the social element or the technical element, without close attention to the other element, may be detrimental to the organization.
• #6: Medicine and technology are closely interrelated, and one could argue that medicine has traditionally been dependent on technology for its progress. One example that illustrates this point is the story of the microscope. This story begins in Italy, in the fourteenth century, when advances in optics led to a better understanding of lens making. In 1590, the Dutch lens makers Hans and Zacharias [zak-uh-rahy-uhs] Jansen, developed the microscope. Eighty-five years later, in 1675, Anton van Leeuwenhoek [ahn-tone fawn lay-vehn-hook] examined blood, insects, cells, and bacteria under the microscope. In another advance, in 1938, Ernst Ruska [ehrnst ruhs-kuh] developed the technique of electron microscopy, which allowed researchers to gain a detailed understanding of the structure of organs at the subcellular level. Each development in technology led to an advancement in medicine.
• #7: Clinicians have historically integrated technology into their practice of medicine. For example, in 1816, Rene Laennec [ruh-ney la-neyk] invented the stethoscope. The stethoscope has been considerably refined since that early prototype. It’s now lighter, it has improved acoustic properties, a diaphragm was added, and now an electronic version of the stethoscope is available. Clinicians have uniformly adopted the iterative modifications of this technology into their practice in order to improve patient care.
• #8: Technology is now the primary driving force of medicine. A vast array of technological resources are available in clinical practice, surgery, radiology, pharmacy, assistive technology, and medical education. The availability of an electronic health record (EHR) and other clinical and administrative information systems has changed the paradigm of clinical information collection, storage, and recovery. The advancement of mobile technology used by both clinicians and patients continues to change the paradigm.
• #9: Technology has assisted researchers in the design and evaluation of their research projects and has even promoted the evolution of the scientific method. For example, complex statistical calculations were once performed by hand, but now software packages such as SPSS [S-P-S-S] are used extensively for the same tasks. Technology helps to advance reproducible scientific breakthroughs. For example, after the discovery of penicillin, technology was key in refining its production and defining how it could be used. At the time when penicillin was first synthesized, stockpiles were scarce, and the penicillin was recycled in order to use it on multiple patients. Technology is also essential to practice some forms of medicine. For example, Robert G. Edwards received the Nobel Prize in Medicine in 2010 for developing the technique of in vitro [ihn-vee-troh] fertilization. His innovation would have been impossible without the assistance of technology.
• #10: There has been an explosion in the amount of medical literature published in the second half of the twentieth century, and now a vast amount of information is available to clinicians. Much of this information is rapidly superseded by newer, more pertinent data, and because some of this new information improves patient care, clinicians need to constantly update their knowledge base. In the past, clinicians relied on textbooks and on consultations with other clinicians for meeting their information needs. Now there’s an increasing reliance on the online database of medical literature that is easily accessible via the Internet. Advances in technology require clinicians to learn new skills. For example, cardiac pacemaker technology continues to change. Invasive cardiologists need to update their skills, in an iterative fashion, as advances in technology transform the products and procedures that they are trained to use.
• #11: The primary focus of clinical medicine remains the clinician-patient relationship. The patient and clinician establish this relationship during a clinical visit and foster it during subsequent encounters. Technology is changing this relationship as well, however. In addition to the clinician and the patient, computers play a major role in the exam room. Clinicians must learn to integrate the use of computers with their activities and clinical decision-making efforts while also engaging with the patient. In addition, clinicians are using email, patient portals, and cell phones to engage and communicate with the patient—which at times can eliminate the need for a face-to-face meeting. Clinicians must be comfortable using new technology while maintaining good practice standards and engaging with the patient and their families.
• #12: The following slides examine the phenomenon of change in the context of health care. Change is an alteration in organizational structure or organizational function. Organizations are in a constant state of change, yet the extensive use of technology in health care hastens these cycles of change. Certain types of technology may be entirely transparent to the end user, and their implementation may be welcomed by individuals and groups. For example, most physicians embraced pagers and cell phone technology because these devices allowed them to be reached and to respond remotely. Mobile devices such as smart phones and tablets allow physicians to be more flexible with accessing clinical systems and responding to patient needs regardless of their location. The freedom to address patient care issues from locations other than the bedside has been welcomed. However, some technologies are intrusive and significantly change the workflow; one example is implementation of the EHR system in the clinical setting. Clinicians are more reluctant to use technologies that they perceive to be counterproductive or contrary to their clinical focus and impede how they practice medicine. To quickly adapt new technologies and information systems, clinicians must see the value and benefit to clinical practice, clinical outcomes, patient safety, or workflow.
• #13: As change occurs in a health care organization, it occurs in parallel with the delivery of health care because clinicians can’t stop taking care of patients while they master new systems. In the past, physicians could see patients, write orders, and plan for care without intersecting significantly with technology. Now, with the advent of the EHR and other clinical systems, the social and technical aspects of patient care are interdependent. Changes in technology require clinicians to make substantial changes to the way they deliver patient care. The converse is also true; changes in patient care may require changes in technology. Successful implementations must address people and processes as well as technology. Implementations should proactively address the integration of information systems with operational processes, procedures, workflow, job duties, and staff capabilities.
• #14: Significant change in the health care industry is frequently accompanied by resistance to this change. Resistance to change is the action taken by individuals and groups when they perceive that the change is a threat to them. There are generally three phases of change. First, there’s a period of inertia, when little is done. Next is a transition phase, when the change is beginning to be implemented. Once the transition is complete, the organization reaches a new steady state, with achievement of the new model. Resistance to change, at least at the outset, is inevitable because many individuals and groups tend to defend the status quo. The technology and system implementation processes should incorporate approaches for addressing staff resistance early and determining the root cause if possible.
• #15: Several strategies help overcome resistance to change. One key initial step is to involve all stakeholders before implementing the change. Another method is to create effective lines of communication. Resistance to change can also be mitigated by enlisting the aid of champions, or enthusiastic people who can help the organization push forward and overcome resistance from naysayers. Organizations can also attempt to alleviate fears that may be contributing to resistance. Individuals and groups should collaborate to solve problems during the transition, and organizations should actively elicit feedback. Sometimes, resistance to change may be the sign of a problem that has not yet been uncovered. Open communication between all parties will assist to identify these types of problems and bridge gaps of unrealistic expectations as well as identify the need for additional training and education.
• #16: The health care environment is complex, and over time clinicians develop their own work processes in addition to the training and education received in school. Clinicians are likely to use multiple tools and technologies to assist them at work. For example, a physician may use a stethoscope, and a radiology technician may use a CT scanner. Technology has become an essential component of workflow. For example, a physician may see twenty patients per day in the clinic, and now depends on the EHR to provide data, help answer clinical questions, solve problems, and aid in documentation or scheduling. New technology requires clinicians to adapt their work processes, and this requires complex and often significant adjustments. For example, a change in the EHR system means the clinician will need to master new techniques in the software in order to continue to provide the same high level of patient care and patient interaction.
• #17: The implementation of technology and the process of technological change may have unintended consequences. Changes in workflow may be a step backwards for overall system efficiency. Furthermore, clinicians may be unable to adapt to the change that is occurring around them. For example, in 2002, Cedars-Sinai Hospital in California implemented an EHR system. This led to a revolt by physicians, and Cedars-Sinai had to abandon the implementation after three months. Another potential issue associated with the implementation of complex technology is that outcome measures may not be positive. For example, Children’s Hospital in Pittsburgh implemented computerized physician order entry, or CPOE, in its intensive care unit and subsequently reported an alarming increase in mortality rates. The actual process for implementing new technology is just as important as the technology itself or the system where it’s used. The findings at Children’s Hospital in Pittsburgh could not be replicated when other pediatric hospitals implemented the same EHR system. This suggests that the Pittsburgh implementation was flawed, with devastating unintended consequences.
• #18: How do organizations manage sociotechnical change? They look for the right people to perform the right tasks to lead change at all levels—including executive leadership champions. They ensure that the people in technology work together with clinicians in a collaborative and cooperative way to ensure that technology and information systems are implemented in the most effective manner possible for achieving improved patient care, clinical outcomes, and patient safety. Organizations make a fundamental choice: either they adapt work processes to new technology, or they adapt technology to current workflow processes. New technology can be designed to improve work processes. People may need to adapt their work processes to the new technology, but the long-term advantages offered by well-designed technology may be helpful in mitigating resistance to change. Adapting work processes requires leadership to carefully manage and curate the change. However, adapting technology to current work processes is counterproductive in some cases because there’s no significant long-term improvement in care. Although this strategy may help to streamline some aspects of workflow, it’s a less agile method and less adaptable to future changes. One primary axiom of managing sociotechnical change is that new technology can be designed that will improve work processes, and work processes can be adapted to new technology. Having clinicians and technologists working together drives the appropriate balance of workflow and process change with any technology implementation.
• #19: Sociotechnical change can lead to enhancements in quality measures and improvement in clinical and operational processes. Other improvements in outcome measures can be demonstrated as a consequence of successful sociotechnical change. These include improvements in efficiency and associated enhancement of workflow, processes, and procedures. For example, improving the technology of EHR systems allows better ways to capture information and document encounters. This allows clinicians to spend more time talking with patients as opposed to documenting the visit. New technologies improve efficiencies of processes. For example, installing a newer-generation CT scanner would lower the dose of radiation required to obtain a CT scan. Improvements in patient safety and an associated reduction in errors should follow. One example of error reduction is afforded by clinical decision support; for example, the availability of information embedded in the EHR helps the clinician make good decisions at the point of patient care delivery. Medication errors are also reduced as a consequence of successful sociotechnical change. For example, barcoding for medications and for patients can prevent mistakes in medication administration.
• #20: One additional impact of sociotechnical change is in the job market. The past few years have seen changes in existing jobs and corresponding job descriptions as well as creation of new jobs requiring new skill sets. There are roles for new experts in health information technology, roles for clinicians who are technologists, and roles for technical specialists who have exposure to the clinical environment. Health care technology roles, especially for clinicians, are found across many different types of employers, including health care providers, software and technology vendors, consulting firms, insurance companies, pharmaceutical companies, and even in state and federal government. Job opportunities will continue to grow in the health information technology sector, especially with the increase of technology demands by consumers, patients, and clinicians. As in the past few years, the future may hold additional new technology jobs and career opportunities that can’t be imagined today.
• #21: This concludes Lecture c of Sociotechnical Aspects: Clinicians and Technology. This final lecture reviewed the role of technology in health care and examined the concept of social and technical resistance to change in the context of sociotechnical interdependence. Several challenges and obstacles are encountered when work processes are adapted to new technology, and changing sociotechnical processes have various influences on health care quality, efficiency, and safety.
• #22: This concludes Sociotechnical Aspects: Clinicians and Technology. In summary, this unit discussed medical errors and patient safety; the challenges of adapting work processes to new technology; and the resulting impact on quality, efficiency, and safety. This unit also examined the phenomena of social and technical resistance to change, especially among clinicians.
• #23: No audio.
• #24: No audio.
• #25: No audio.