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Case Studies in 
Health IT Implementation 
Part 1 (September 19, 2014) 
Nawanan Theera-Ampornpunt, M.D., Ph.D.
2 
H.I.T. or Miss: Lessons Learned from Health 
Information Technology Implementations 
Leviss (Editor) 
(2010)
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 
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)
Sociotechnical 
Aspect of 
Health Informatics 
Nawanan Theera-Ampornpunt, MD, PhD 
September 19, 2014 Except where 
citing other works
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 
People-Process-Technology 
Technology 
People Process
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 
“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 
Health IT Successes & Failures 
Kaplan & Harris-Salamone (2009)
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 
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 
Health IT Change Management 
Lorenzi & Riley (2000)
14 
Health IT Change Management 
Lorenzi & Riley (2000)
15 
Health IT Change Management 
Lorenzi & Riley (2000)
16 
Health IT Change Management 
Lorenzi & Riley (2000)
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 
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 
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 
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 
The “Special People” 
Ash et al. (2003)
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 
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 
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 
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 
Unintended Consequences of Health IT 
Ash et al. (2004)
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 
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 
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 
Unintended Consequences of Health IT 
Campbell et al. (2006)
31 
Unintended Consequences of Health IT 
Campbell et al. (2006)
32 
Unintended Consequences of Health IT 
Koppel et al. (2005)
33 
Unintended Consequences of Health IT 
Koppel et al. (2005)
34 
Unintended Consequences of Health IT 
Some Risks of Clinical Decision Support Systems 
• Alert Fatigue
35 
Unintended Consequences of Health IT 
Workarounds
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 
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 
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 
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 
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 
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 
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 
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 
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 
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.

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Case Studies in Health IT Implementation & Sociotechnical Aspect of Health Informatics

  • 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
  • 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
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