West Virginia University and ..... Technology Education, West Virginia University, Morgantown ... Philippi, West Virginia currently undergoing his clinical.
Acceptance of Information Technology by Health Care Professionals Michael B. Moore, B.S. West Virginia University and Alderson-Broaddus College Information technology systems are not widely accepted by health care professionals. An analysis of the patterns of information systems use within health care delivery systems is instructive into the common problems faced by the application of information technology in the workplace in particular, and by society as a whole. Overview Perceived as immature technologies (Lincoln, 1994), information technology systems have been relegated to limited use, compared to other areas in which information technology has been used (Kaplan, 1985). Although the applications of information technologies to health care have been diverse, there is a common pattern of utilization. Regardless of the new technology being implemented, established patterns of education, information management, and organization remain to restrict the use of the new technology, as illustrated in the following statement by T. L. Lincoln (1994): Every new technical advance in communication, as it becomes practical, has been adopted by medicine . . . However, practicing medical professionals remain conservative in the means they use day to day to acquire medical knowledge. This may result from a prudent regard for the established way of doing things (and the fact that they work), but also there is often a lack of time to directly investigate the ins and outs of some new technological approach that may impose many demands. (p. 1955) Though Lincoln is sympathetic to the idea of increased utilization of information technology, he is skeptical of the ability of fellow health care providers to effectively utilize the technology available. This attitude toward information technologies in the health care professions contrasts sharply with the attitude shown toward other areas of technology. Intuitively, we observe that health care systems have an infatuation with new technologies, whenever and wherever they can afford them, and even sometimes when they cannot. Also, health care systems seem eager to use new diagnostic and therapeutic technologies despite the demands placed on health care providers. It seems that the demands for prudent and practical use described by Lincoln applies only to information technologies. Although this problem has affected health care delivery systems since the first efforts were made to apply information technologies to the delivery of health care, it has been exacerbated recently by the ability of other systems within our society to increase their productivity and efficiency by using information technology, and thus providing an uncomfortable model for comparison with organizations involved in health care. Additionally, the application of information technologies to other systems has also
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produced technologies that are more conducive to the type of information management that occurs in health care delivery systems. Additionally, the pressures of forced cost reductions, managed health care, and increased financial competition between segments of the health care delivery system have produced unique challenges that are forcing the entire health care delivery system to make the same attempts as other sectors of society to become more efficient and effective. These pressures have combined to produce an environment where there is a desperate need to implement information technologies to increase the effectiveness of health care delivery systems. Background and Significance of Problem Background: Information System Structure Information technology systems used by health care professionals can be categorized based on the complexity of the implementing system and the complexity of the object being handled. This model divides information technology systems into either individual or organizational systems that handle either data, information, or knowledge (Blum, 1990). Additionally, this model does not discriminate between acoustic, visual, or text data, as the type of data being managed in an information management system is not the true deciding factor on the impact of the system on the organization. Instead, it is the integration of the system into the construction of the organization and the amount that the organization relies on the system to evaluate and independently process data objects that determines the impact of the technology on the functioning of the organization. Using this model, information technology systems would allow individual health care providers, health care organizations or health care systems to manipulate data objects used in health care systems. Two prototypes explain the predominant ways that health care systems attempt to utilize information technologies. The prototype of the system that allows for the storage and retrieval of simple data at either the individual, organizational or system levels is a simple database system. These systems would range in complexity from simple financial management systems to complete integrated patient information systems that collect a wide range of data, including diagnostic and therapeutic data, about a particular patient. Although these systems have been used in the management of financial information in health care systems, relatively little use has been made of these systems in the management of diagnostic or therapeutic information management (Fitzpatrick, 1993). The prototype of the system that allows for the storage and retrieval of information or knowledge at the individual level is found in most diagnostic equipment. In the case of current electrocardiographic equipment, a preliminary diagnosis is provided along with a record of the patients electrocardiogram that reflects a degree of clinical knowledge in the area of electrocardiographic interpretation (Pipberger, 1990). Current laboratory equipment also provides a similar capability for the interpretation of laboratory results, even if it provides only for the simple recall of normal laboratory values for comparison with the reported values. From these examples, it can been seen that there has been considerable success in utilizing information technology within diagnostic or therapeutic equipment to serve individual patients, but little success in utilizing the technology to increase the effectiveness of the entire health care delivery system. Additionally, the full value of knowledge retrieval technology, which thus far has served the health care system well, will not be realized until the data produced from such systems can be
integrated into a system that provides the ability to manage the sum of diagnostic and therapeutic information for the patient in an integrated patient care record that provides the health care system the same data management capability for its basic functions as is available to other organizations (Fitzpatrick, 1993) and (Caceres, 1990). Background: Health Care System Organization The health care delivery system is unique in several respects, all of which have a direct impact on the ability of the organization and its individual members to absorb information technology and utilize it in delivery of health care. These characteristics include the unique knowledge-skill relationship within the health care system itself, the long training time and resultant knowledge fixation of physicians, and the relatively fixed hierarchy within the health care delivery system. The unique knowledge-skill relationship in health care systems impact on the utilization of information technology in these systems due to the resultant decentralization of physician activity and a change in the direct responsibilities of individual health care providers. This can disrupt the traditional cultural roles in health care organizations and systems, as well as putting individuals who are traditionally considered of a lower skill level than the physicians; for example, nurses and other skilled health care providers, in a position where they possess a superior skill in a critical area than the physicians (Hodge, 1990). The long training time of senior members of the health care system hierarchy, (physicians) as well as the resultant specialization of the majority of physicians, results in a large amount of knowledge fixation within the physician population. This knowledge fixation is aptly summarized by M. H. Hodge in a quote from a personal communication he received from a physician (1990): Most physicians do not need help most of the time to handle most situations in most of their patients. That is, the average physician sees only a limited number of different clinical situations with which he is quite familiar and which he treats in a routine manner, using a personally developed protocol which has proven successful in his hands. He generally does not need to refer to the literature for either diagnostic or therapeutic assistance. (p. 352) Hodge continues this observation from the same communication by noting the way a physician reacts to a knowledge shortfall: When he feel insecure, he uses several options: one, he muddles through, he seeks a 'sidewalk' consultation from a colleague, three, he seeks a formal consultation (frequently to document the fact that a consultation was secured for regulatory medical-legal reasons), or four, he consults the medical literature, mainly in the form of medical texts and ready references, such as the PDR. Rarely, he goes to the current medical literature. (p. 352) This sentiment reflects the greatest obstacle to the use of information technology in the clinical setting, which is the perceived lack of need. Finally, the relatively fixed hierarchy within the health care system prohibits rapid organizational or structural change. Generally, the long training time of the dominant profession within the health care system influences the ability of newer members of the profession to effect change. Additionally, the pronounced hierarchy within the dominant profession itself, that places newer members in an apprentice role with older members of the profession also subverts change. The organization or The role of the health care in the structure of society, involved almost wholly in the care of patients after they become
structural change often required for the implementation of new information management technologies must then be endorsed by established members of the profession, whose status and financial rewards are tied to the status quo (Hodge, 1990). Significance of the Problem Health care systems today require increased efficiency in providing health care delivery to highly mobile populations. Additionally, increased standards in the use of diagnostic and therapeutic technologies produces overwhelming amounts of data, that is generally recorded in an inflexible paper record (Fitzpatrick, 1993). The requirement to continually educate health care providers in a ever changing body of knowledge, as well as to provide quality health care to widely dispersed populations with an unequal distribution of health care providers (Preston, 1992) are equally challenging problems. These challenges have produced an environment where the challenges confronting the health care system are not one of a lack of knowledge and skills to confront a wide range of health problems. Instead, the problem of managing the transfer of information within the organizations that provide health care, as well as the transfer of information within the health care system as a whole seems to be the critical problem. It is this problem that seems to be especially susceptible to the application of information technology, yet remains intractable in the majority of applications (Hodge, 1990), due to the general lack of acceptance of clinical information management systems (Fitzpatrick, 1993). Summary of the Problem It appears that barriers to the use of information technology within health care delivery systems are primarily sociological, cultural, and organizational, rather than technological. An understanding of the problem in this light places the current literature regarding the utilization of information technology in health care systems in perspective. A review of the literature concerning the utilization of information technology in health care systems reveals three major factors that impede the utilization of information technology systems in health care delivery. First, the unique organizational structure of the health care system places extreme demands on the performance of information systems. Second, data quality and assurance mechanisms that would form the basis for any attempt to use information technology in improving the effectiveness and efficiency of health care delivery are blocked because of a lack of system-wide focus on the improvement of outcomes. Finally, institutional attitudes towards information technology prevent its effective utilization. The unique organizational structure of the health care system places extreme demands on new information technology systems. The health care delivery system is wedded structurally to the current overwhelming barrage of paper that surrounds health care. As Hodge states (1990): Another thing that we discovered, sometimes the hard way, was that you need to be sensitive to the cultural roles that are traditional in hospitals and health care. I've had doctors tell me, for example, that, "...entering orders is a nurse's or ward clerk's job, its not my job. You have a secretary; she does your typing. I have a nurse; she enters my orders." This attitude directly conflicts with a common goal of information technology to record data at a point that is as close to the point of origin for data as possible. ill, rather than being responsible for keeping the population healthy, has also played a role in impeding the implementation
of information technologies in the health care delivery system. This reactive focus generally prevents an outcome based approach to system management, without which information technology systems are ineffective. Changing the focus of the system to preventive care as has happened in some organizations such as health maintenance organizations, focuses the entire organization on a defined set of goals, which allows for a greater ability to refine information technology systems to support it (Collen, 1990). As an extension of this problem, health care delivery systems have resisted vertical integration of health care services, which would allow for the continuous care of patients through comprehensive services. As C. D. Flagle states (1990): . . . the non-system successfully resisted vertical integration for a long time. Only recently, under the pressures for care reimbursement--made possible by the information systems growing out of a patient classification--have we seen a trend towards hospital initiatives in comprehensive services. (p. 317) Unfortunately, it is likely that pressures from care reimbursement will only change the health care system's efforts to obtain reimbursement, not focus the system on using information technologies to improve quality of the care delivered. Additionally, as a further effect of the system's lack of emphasis on outcomes, the data normally collected and organized by the health care delivery system has been in an inconsistent, disjointed form. This data has been characterized by L. L. Weed in the following fashion (1990): The data came from a memory-based, credential oriented group of medical providers, many of whom were specialists who were not linked to one another in a highly disciplined fashioned and who, in many cases, kept sloppy medical records. (p. 236) Traditionally recorded on a partially or wholly illegible paper record, that may not even be available due to loss or transport between points of service within the health care delivery system, medical data has been of inconsistent quality. Additionally, as was stated by Hodge, the very hierarchy of the health care delivery system is geared towards the production of this record. The institutional attitudes towards information technology, especially knowledge coupling systems that allow the individual health care provider to manage the large body of medical knowledge that is now available within the health care delivery system are best summarized by L. L. Weed (1990): . . . though computerized knowledge coupling tools may have some advantages, but he, with his broad experience, would only use them on a difficult case. How would we react if we heard a person say that he thinks that the telescope is an interesting, even powerful idea, but because of his years of experience in looking at the sky, he would only use the telescope only when he sees something unusual up there. (p. 243) This attitude towards utilizing information technology in health care delivery exacerbates the problems previously discussed . Proposed Solution First, benefits from the use of information technologies in routine tasks must be clearly outlined and visible to the organization (Hodge, 1990). Second, the benefits related to the use of information technologies in knowledge coupling tasks must be integrated into health care delivery systems in such a way as to reduce the perceived threat to the established professional order (Weed, 1990). Finally, the definitive and long term solution is to change the training of health care providers in such a way as to make them more professionally
compatible with the use of information technology (Weed, 1990) and (Grigsby, Sandberg, Kaehny, Kramer, Schlenker, & Shaughnessy, 1994). In summary, an analysis of the utilization of information technology in health care delivery produces a two fold conclusion. First, information technology will continue to be utilized in transparent ways that do not fundamentally change the organizational dynamic. Second, system wide applications of information technology will continue to be hampered by the organizational structure of the health care delivery system. However, implementation of information technology systems that reinforce the extension of the health care providers abilities and structure of the health care delivery system and concurrently document the provider's activities may hold great promise for reducing the resistance of health care providers to new information technologies (Grigsby, Kaehny, Schlenker, Shaughnessy, & Beale, 1993). Providers have demonstrated a high degree of acceptance of these systems (Mattioli, Goertz, Ardinger, Belmont, Cox, & Thomas, 1992) and (Nagle, McMahon, Barbour, & Allen, 1992), and this seamless, nonconfrontational method for collecting clinical data may prove to be the best approach. In addition, rapidly converging information technologies that allow traditional professional collaboration models to be exercised while obtaining the benefit of the technologies for the health care delivery system will enable progress in this area (Crandall & Coggan, 1994). Education of health care providers in the societal value of information technology, as well as the value in improving the clinical situation of the individual patient as it improves the effectiveness of health care delivery will be crucial (Lunin & Ball, 1989). As noted by C. A. Caceres (1990), failures of information technology systems as applied to health care delivery up to this point have not been technological failures, rather they have been failures of the health care system to effectively implement the same systems that have served other sectors of society well and that we know are effective. Finally, utilizing appropriate levels of technological sophistication, as to provide the medical provider with the appropriate level of information required to make effective clinical decisions will increase provider confidence in the technological systems being implemented in health care delivery (Schnepf, Du, Ritenour, & Fahrmann, 1995). In conclusion, any limitations involved in these solutions can best be addressed in the training of providers to integrate information technologies into the practice of medicine during their formative years of professional education, and maximizing the use of converging information technologies to enhance the direct delivery of health care. Michael B. Moore is a doctoral student in the Department of Technology Education, West Virginia University, Morgantown West Virginia; and a Physician Assistant student in the Department of Health Sciences at Alderson-Broaddus College, Philippi, West Virginia currently undergoing his clinical training at West Virginia University Hospital, Morgantown, West Virginia.
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