Challenges in the Adoption of Medical Information Systems

Proceedings of the 39th Hawaii International Conference on System Sciences - 2006

Challenges in the Adoption of Medical Information Systems Marianne Maass Turku School of Economics and Business Administration / Pori Unit P.O.Box 170 FI-28101 Pori, Finland [email protected]

Owen Eriksson Dalarna University, Dept. of Culture, Media and Data SE-781 88 Borlänge, Sweden [email protected]

Abstract This paper highlights some managerial challenges encountered during the adoption of a Picture Archiving and Communication System (PACS) at Turku University Central Hospital (TUCH). The results are based on a five-year survey consisting of statistical data, cost analysis, modelling, customer satisfaction inquiries, time and motion studies, observation and staff interviews. The PACS is a medical information system, the goal of which is to allow filmless activity and improve patient care; this paper presents the curriculum of the project. As there was a lack of insight of the project being a hospital-wide socio-technical information infrastructure process, with both costs and benefits falling to all departments requiring both vertical and horizontal management at hospital level, hospital staff were unprepared for the change. Further, the technology providers did not have sufficient information or knowledge of clinical requirements. Consequently, inexperience regarding informatics, system behavior, and lack of designated expert personnel slowed down the implementation process.

1. Introduction Information Technology (IT) has had its applications within health care for decades now. Primarily, until ten years ago, IT has been used for administrative tasks, such as statistics and personnel data. Some newcomers are the Hospital, Laboratory, Pathology and Radiology Information Systems, of which the latter may be connected to a medical image database. The Picture Archiving and Communication System (PACS) is a medical information system, the goal of which is to allow filmless activity and improve patient care through the use of computerized medical patient images within and between health

units, and ultimately to enable diagnosis and treatment decisions, the so called teleconsultations, from both remote, and perhaps less specialized health care units. Finland is culturally, geographically and demographically suited for IT and telemedicine. The 5.2 million inhabitants are spread over an area of 305,000 square meters. In addition to a central homogenous area, the fairly large territory consists of wide northern rural areas as well as an extensive archipelago. The population of these regions doubles during high seasons, summer in the archipelago, and winter and spring in Lapland. Culturally, there are several factors in favor of the use of IS. Firstly, illiteracy is practically nonexistent. Secondly, there is a tradition of minimal social interaction, this includes the doctor patient relationship; people’s preference is towards non-verbal, non-personal communication. The severe climate and long distances do not encourage vivid social relations. In fact, telepsychiatry trials suggest that patients prefer videoconference communication to clinical visits. Further, the telecommunications network infrastructure is solid and widespread, and the number of PCs and mobile phones per capita is high. There is already a long history of teleapplications in different fields [16]. Health care has been under scrutiny in terms of productivity and efficiency for several years now. IT solutions have been sought to assist the re-engineering of public health care services. In the cultural, demographical and geographical framework this is justified. Medical faculties, i.e. University Hospitals, have long traditions, and best practice protocols regarding patient care and interpersonal relations, which rather hinder than trigger innovations. Patient care, and responsibility issues result in a striving towards stability and error free activity. The rigid communicative and professional rules do not support individualism, enthusiasm or initiative. The organization-centred, rather than task-, or client-

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centred atmosphere and activity culture provide little room for possibilities to have influence on one’s work. The shift from industrial to information society has its phenomena in medicine. Traditionally, medicine is an information intensive branch where patient treatment is triggered by the availability of diagnostic knowledge, such as laboratory, pathology and medical imaging results. The transmission of medical images, or, teleradiology, has perhaps been the most practiced field of telemedicine so far [2, 4], and continues to be so. The goal of the PACS is filmless radiology, which means that electronic databases are used instead of film archives. Radiologists read images on monitors and clinicians may view them on PCs, and images are stored on digital linear tapes or magneto-optical discs. The PACS allows medical imaging studies to be sent instantaneously to different health care units (= teleradiology). Consequently, earlier diagnoses are possible, thus allowing immediate treatment decisions, which in some medical conditions is crucial. Regardless of the location of the patient medical expertise becomes available, which increases patient democracy and quality of care. Diagnostic data is transmitted via networks to where the expertise is, instead of transporting the patient, which might endanger the patient’s life. Recently, there has been consensus about the necessity to ensure simultaneous availability of all patient data in order to benefit from the full potentials of telemedicine. As a consequence, the idea of an Electronic Patient Record (EPR) has emerged, in which all data from various departmental databases are available timely, when needed. This implies that interoperability between different systems is required [18]. Functional EPRs embrace all departmental sources of patient information. In this scenario, the EPR is a similar system to the analogue patient record. In fact the Finnish Ministry of Health and Social Affairs proclaimed in January 2003, that by the end of 2007 the 20 Hospital Care Districts will have implemented EPRs. It is known, that currently there are hundreds of diverse health care related IS in use, but in order to realize the EPR there is a need to integrate various specific task-oriented Information Systems (ISs) within separate departments. One of these systems is the Picture Archiving and Communication System (PACS) at the Turku University Central Hospital (TUCH). The PACS is a prerequisite of an EPR, as imaging information is relevant for patient care. This implies that the PACS is an important part of the information infrastructure of the health care work practice. The goal of this paper is to describe some lessons learnt from the adoption and implementation of the

PACS in Turku University Central Hospital (TUCH). The history of this information system (IS) initiative started in 1995. The paper is structured like this. In section 2 we will look at the adoption and implementation of IS from a theoretical angle. Section 3 describes some problems experienced in the project, these problems concern: • Cost issues • Management, planning and cooperation • Software problems • Personnel related aspects We will discuss these problems in section 4 and conclude by summarizing the learning opportunities provided by this project in section 5.

2. The Implementation and Adoption of Information Systems The development, implementation and adoption of information systems (IS) is a high-risk undertaking. It is common knowledge that a number of projects fail (see e.g. [6, 7, 10]). The question is if we are able to learn from failure, and to extract knowledge from problematic projects in order to be able to prevent future failures, or at least to be able to deal with the problems that occur in a better way [5]. The main reason why many projects fail is that the implementation and adoption is still regarded as a technical effort, instead of a socio-technical process, although it is well-recognized in the IS literature that the implementation and adoption of IS has both technical and social implications. In some cases the IS contribute to drastic changes [3] in work practices. In other cases work practices are altered over time as the new technology becomes increasingly used [13]. One reason for this is that IS are systems used to perform social actions [1, 14], which means that when a new IS is implemented, it changes the work practices of the organization. This also implies that the implementation process must cover both the technical and social implementation of the system. The adoption and implementation of an IS in an organization can be seen as an innovation process [15]. Rogers [15] makes a distinction between adoption and implementation of a technical innovation. Adoption implies the activities that lead to the decision to adopt, and implementation embrace all the activities that are involved in putting the innovation into use. Rogers emphasizes that the innovation is modified by the organization and the innovation modifies the organization. In some cases

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the innovation may affect the structure of the whole organization. Rogers also claims that computerrelated innovations often leads to uncertainty in organizations which is one reason for the special difficulties that these innovations encounter. According to Gäre [7] the implementation process of an IS starts after the development or acquisition of an IS. The implementation process can be divided into two phases: Phase 1) The technical implementation of the IS and the initial training of the users. Phase 2) Activities which take place after phase 1 when the system is used by the users and they gradually integrate the system in their work practices. In this phase they learn the possibilities and the limitations of the system. In phase 1 the focus is on the technical implementation of the system and the training of the users so that they can use the functionality of the system. If the first phase is successful the technical aspects of the system are no longer of prime importance, and the work practice will be focused in phase 2. If we look at changes taking place in phase 1 and 2 it is recognized that it is more easy to foresee the changes in phase 1, although surprises can also occur in the first phase. Orlikowski [14, p.407] states “…while users can and do use technologies as they were designed, they also can and do circumvent inscribed ways of using the technologies – either ignoring certain properties of the technology, working around them, or inventing new ones that may go beyond or even contradict designers’ expectation and inscriptions”. Orlikowski claims that people enact the use of the IS in the organization by an ongoing situated use of technology which comprises the hardware, the functionality and vocabulary inscribed by the designers, and those added on by users (e.g. specific data content, customized features, or expanded software/hardware accessories). People also draw on their skills, power, knowledge, assumptions and expectations when they enact the use of the technology in the organization [14]. In the IS-field it is also recognized that the implementation of a particular IS cannot be regarded as isolated from other IS which are implemented and already there. Information systems are implemented within a structure of other information systems, social structures and technologies. This type of complex, evolving and heterogeneous installed base of ITsystems is defined as an information infrastructure [9]. This implies that the implementation of an IS wrestles with the inertia of the installed base and inherits strengths and limitations from that base. Hanseth [8] maintains that information infrastructures

are larger and more complex systems, involving significant numbers of independent actors such as developers as well as users. Information infrastructures grow and develop over a long period of time and an information infrastructure is built through extensions and improvements to what already exists – rather than from a scratch. What is implemented has to be hooked into an existing infrastructure. This implies that the implementation of an IS can never be a fully planned and controlled activity, based on technological determinism. The implementation process is a socio-technical process where the actions of many actors in different phases of the implementation process will shape the way the system will be implemented as a part of the information infrastructure. This also implies that if we want to study the implementation process of an IS we have to study the process for a long time which makes a longitudinal research strategy the most appropriate one. The results presented in the paper are based on a five-year survey consisting of statistical data, cost analysis, modeling, customer satisfaction inquiries, time and motion studies, observation and staff interviews.

3. A historical overview of the TUCH PACS Radiology has evolved into medical imaging during the past 30 years, due to non-radiological techniques, such as ultrasound and magnetic resonance imaging. The first attempts to store radiological images in magneto optical discs date to the 1970s. The initiative was challenging in terms of technology and costs. In the late 1980s the first digital archives were adopted in clinical environments. Early on it became evident that the only obstacle to overcome was not just the image size and the media costs, but also the configuration of adjacent imaging equipment and information systems [17]. Today, most imaging equipment provides digital data. Digital archiving of images has been seen a logical solution to handle the extraordinary digital growth of the branch. At a yearly level, some 5 Terabytes (TB) of image data is produced in the Medical Imaging Centre in Turku University Central Hospital (TUCH). This data is exploited, stored, and sent back and forth between radiologists, archives, wards and clinics. Also, teleradiology is practiced between other distant hospitals. TUCH is an 800-bed teaching hospital offering specialized health care services to south western

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inhabitants. TUCH operates within a framework of a 240 million euro budget, and a 10 % increase in costs p.a. In this study we examine the curriculum of the PACS project. TUCH was the first Finnish hospital to adopt a PACS. In 1995 a 0.5 TB digital archive was installed. Recently, it has been upgraded to 12 TBs. In 2004 a paper-and filmless annex building was inaugurated. The Medical Imaging Centre is one of the many departments in a hospital competing with other departments for investments. It is allocated only 10 % of the total hospital budget because it does not provide over-night patient care. From one point of view its activity may be considered ancillary, although diagnostic information is indispensable in treatment decisions. Imaging is a technology driven faculty. Its equipment is constantly developing, expensive and quickly depleted. The life span of imaging equipment is from 5 to 10 years. Therefore the department often proposes investments in the range of 100,000 euros to even 300,000 euros. The PACS represents a new investment area which needs to be justified.

3.1. Cost Issues In 1995 the administration of the Medical Imaging Centre presented a plan of filmless activity to the board of the hospital. Some facts of film archiving costs compared to those of digital archiving were considered. The board shared the view of the administration that it was time to turn digital. At the time, there were two hospitals in Europe, the Danube hospital in Vienna and the Hammersmith Hospital in London, which were making serious efforts to achieve filmless imaging. The initial proposal to the hospital board was simplistic, including only indications of drastic film cost reductions. This motivated the investment costs for a small local digital archive. A fraction of funding was granted at a time, and the project suffered as a whole from insufficient funding. There was not enough money to provide the necessary PCs, not to mention training or human resources. The granted resources were not enough to create a filmless network. Therefore the expected cost savings did not arise. The maintenance costs were considerably higher than internationally reported or locally assumed, i.e. 26 % of the hard and software investment costs [11]. Also unexpected costs appeared in the form of archive updates, which included image data migration from the old to the new archive. The savings were overestimated, and indirect or unexpected costs were ignored. The project was one

of a kind. There was no previous experience or evidence of drawbacks; hence, they were not anticipated. The newness of the effort created unique problems and solutions to be resolved as they emerged, and one solution in one place created problems elsewhere. Also, due to the large extent of the project it was difficult to identify the sources of the problem. The busy staff was involved in their primary jobs, patient care and teaching, and secondary issues received minor attention.

3.2. Management, Planning and Cooperation The project was comprehended as a technological matter, and managed as such, if at all. It was not understood that the project was a socio-technical one, which would profoundly change working habits. A number of open-minded and keen hospital professionals were called to discuss and execute the installation and adoption of the PACS. However, there was a lack of technical and business knowledge. There was no plan of what exactly was to be installed, how and when. The majority of personnel actually dealing with patients had not even heard of a PACS. On the other hand, the investment prospects were not large enough to motivate the technology providers to seriously commit to research and development. In reality, two professional groups, hospital staff and technology providers, were discussing an ill defined topic. Technological terminology was way over the head of the personnel, and medical terminology was unknown to technology providers. As the software was in English, language skills created an obstacle in understanding the software options for nursing staff, who had to deal with obscure concepts, the IT vernacular, in a foreign language. In addition technology providers were unable to understand the prerequisites of clinical activity, and the use of medical terminology further complicated communication between medics and manufacturers. There was a multi vendor policy in order to encourage development and competition. There was a great need for co-operation between all manufactures, between manufacturers and personnel, between medical and nursing staff in radiology, and between each professional group and clinical wards. It soon became evident that the benefits of filmless imaging could only be achieved if the use of films was renounced at least at hospital level, but preferably also at regional level. Patients often recieve an imaging examination at several sites, including the private sector, and therefore the use of dissimilar data sources creates double work. The large size of the project in terms of bytes, buildings, people and technology involved would

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have required a well-defined commitment from all parties: top management as well as field workers. There was a need for information dissemination to personnel, not only to media. The consequences of adopting diffuse technology were not recognized. Therefore at contractual level liability issues were not accounted for. This created confusion as to who was responsible for what, which eventually led to a lawsuit against one of the technology providers.

3.3. Software Issues The digital archive software was developed in the United States. It lacked some Finnish letters, which were replaced with similar letter (a for ä, o for ö, etc.). Also, the Finnish Personal Identification Numbers (PIN) were longer than the given space in the software options, and were entered incomplete. When the software was updated all misspellings and PIN had to be re-entered into the IS manually. Magnetooptical discs and digital linear tapes were used for the storage of images, both media were slow, and also loss of images were observed [12]. Further, the diagnostic image viewing software was at first clumsy.

3.4. Personnel Related Issues Although some managerial staff were satisfactorily informed about the goals of the digital activity, the staff in general had to cope with insufficient information and guidance. At department level staff had to deal with the extra workload, and find out for themselves how software worked, or why images did not arrive at their destination. Often film prints were needed. Staff were irritated by the overly positive articles in the newspapers about the University Hospital being filmless and saving money and personnel resources, when this was not the case. There were no extra personnel hired to manage the project or the digital archive in the first 5 years of the project. Enthusiastic radiology technologists assumed learning tasks related to the management of the digital archive software, and passed on their experiences to the rest of the personnel. However, system back-up was available from 8 am to 4 pm, whereas the hospital operates 24 hours a day. The technology provider was located in Helsinki, 180 kilometers from Turku, reachable with a mobile phone. University hospitals mostly deal with patients with complicated health problems, sent from health centers or local hospitals. Patient care situations are demanding and require immediate uninterrupted attention. IT considerations are secondary.

4. Discussion One of the major causes of the problems described above was that less than 1 % of the hospital budget was dedicated to the implementation of the system, which suggested insufficient funding. Insufficient funding had its impact on the acquisition of hard and software, training and hiring of personnel, thus the implementation process was cumbersome. Another reason to the problems were that hospital staff were unprepared for the change. Technology providers did not have sufficient information or knowledge of clinical requirements. Inexperience regarding informatics, system behavior, and lack of designated expert personnel slowed down the implementation process. In 1995 there was no previous experience of digital archiving available at national level. News about the latest technological advances was brought from Japan or the United States by management or technology providers. Training was available at medical scientific conferences, such as the conference of Radiological Society of North America in Chicago, Computer Aided Radiology and Surgery, or telemedicine conferences. Staff were privileged with this education occasionally. These conferences were impregnated by wishful thinking on the part of medical professionals and fiction on the part of technology providers. Audiences did not ask relevant questions, because there simply was not enough knowledge of how to implement IS amongst medics. Another major cause was that in the beginning of the project the actors did not look at the project as the implementation of an important part of the sociotechnical information infrastructure of the hospital. For example, the failure to replace the old infrastructure based on film with the new filmless infrastructure. The PACS was expected to eliminate the use of film- and paper prints, but it led to increased costs, due to the operation of parallel systems. The same amount of personnel pursued both traditional and filmless activity, which led to dissatisfaction. Efficiency improvement was documented five years after implementation, when filmless activity was reached between the Medical Imaging Centre and Intensive-Care Unit (ICU). Availability of imaging related information improved from 87-88 % to 100 %. However, manual interference was still required, and film consumption costs were not reduced as anticipated. On the one hand, personnel tasks will reduce as paper and film prints are renounced, on the other new tasks will emerge due to the PACS. The configuration issues are now dealt with routinely, whilst interoperability

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questions arising from different information systems remain to be resolved. Software issues are resolved to some extent: the image viewing software and monitor resolution are sufficient. The archive software still needs some fine tuning to suit the activity.

5. Conclusions The implementation of the PACS challenged the management of change, including new type of cooperation between technology providers, medical, nursing and administrative professionals. By establishing a group of experts, coordinating activities and having enough contact with operating personnel the management problems were solved. It has now been understood that adequate investments were needed together with organizational re-engineering of service processes, in order to create a functional network providing filmless activity. A long term cost projection based on accrued direct costs including a hospital-wide network was provided 4 years after the project start. At this point it was understood that intra- and inter-hospital IT solutions trigger not only direct but also indirect costs, as well as benefits and drawbacks. Today, all clinical departments are working filmless. The idea of the PACS being a subsystem of the EPR and needing to co-operate with all hospital systems, is clear. Appropriate training is provided, and a PACS engineer is hired. Better planning of the project would not have solved all the problems in the project; however the lack of a comprehensive project plan, funding and trained IT personnel resulted in the prolonging of the project. Although in principle it is easy to understand the benefits of a PACS, it is a risky decision with unpredictable financial consequences, because the consequences of investments in information infrastructure are difficult to foresee and predict. The PACS imposes many question marks to hospital board members, including questions about finance, radiology and software, including the activity, which the PACS is supposed to cover. It may well be concluded that the project was a great learning opportunity. The early stage in which the hospital jumped on the digital train had its disadvantages. Also, changes take time, and development is the fruit of previous attempts, some unsuccessful and others successful. Learning is a process, rather than an overnight miracle. The fact that an institution takes responsibility for being the first implementation site is valuable.

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