Managing the cultural and technical aspects of complex health care systems can be daunting. Some helpful tools are scientific theories of organizational behavior, communication and the evolving discipline of sociotechnical theory.
Applying the open-system theory, some researchers see sociotechnical systems in much the same way biologists view living things: as highly complex organisms that constantly interact with their environments.
And every habitat is different. For example, a nurse in a hospital’s surgical unit might care for three to five patients per shift and administer 15 medications, whereas his or her peer in an oncology ward might see two or three patients and administer 100 medications per shift.
“Just because a technology works on one unit doesn’t mean it will work well in another,” said Ben-Tzion Karsh, an associate professor of industrial and systems engineering at the University of Wisconsin-Madison.
But it will have an impact. “Any time you put in a technology, it is necessarily going to change things in your organization whether you planned on those changes or you didn’t,” he added.
Open-system theory also has implications for employees’ attitudes toward information technology implementations.
“Leaders need to create a sustainable focus on constant change,” said Terry Paulson, a Los Angeles-based change management consultant. “When your people ask you, ‘When are we going to be through this?’ tell them the truth: ‘We are not.’”
“The world wants to make things a movie,” he added. “IT is more like a soap opera.”
— John Pulley
To reduce preventable medical errors, a large hospital acquired a fleet of computers on wheels at a cost of millions of dollars. The goal was for nurses to keep an electronic record of patient interactions — for example, by logging vital statistics and recording the dispensation of medications.
However, soon after buying the computers, the hospital replaced the sinks in patients’ rooms with larger models that blocked nurses from wheeling the computer carts into the rooms. With computers parked in hallways, nurses could not see data or hear the electronic beeps that warned them of potential dosing errors and other mistakes.
“Plumbing tripped up technology,” said Ross Koppel, an adjunct sociology professor at the University of Pennsylvania who conducts research for the university’s Center for Clinical Epidemiology and Biostatistics.
When such interactions among seemingly unrelated events lead to unintended consequences, they are called systems failures, and they underscore the complex environment in which health information technology must operate. Moreover, such stories signal a growing awareness of what some researchers are calling the sociotechnical dimensions of health IT.
“How can you get people and nonhuman elements to work as team players and to work for each other, in contrast to the historical technological determinism in which an organization puts in technology and everything has to adapt?” asked Ben-Tzion Karsh, an associate professor of industrial and systems engineering at the University of Wisconsin-Madison.
As the technology matures, users are refining the way they judge its success. Technology that performs well during vendors’ trial runs won’t necessarily pass muster in the real world.
“Health care technology usability is growing, but usability of technology is not sufficient,” Karsh said. “You have to consider how it integrates with other systems.”
Increasingly, successful applications are those that fold seamlessly into complex health environments and function well under constantly changing conditions.
“My gut instinct is that we are making progress,” Karsh said.
Three-part harmony
The notion of sociotechnical systems has been around for decades. In 1951, for example, researchers in the United Kingdom found that the introduction of new technologies into coal mines had a big impact on communications and the coordination of work and workers, said Pascale Carayon, a professor of industrial and systems engineering at the University of Wisconsin-Madison and director of the university’s Center for Quality and Productivity Improvement.
“It is almost impossible to think about technology on its own because it interacts with the social system,” she added.
The three primary components of sociotechnical systems are the social and technical subsystems and the environment in which they operate. That trinity comprises various parts, including the organization, its people, their tools and the tasks to be accomplished.
“The system works best when the three parts are in harmony,” said Michael Harrison, senior research scientist at the Agency for Healthcare Research and Quality and its lead on organization and systems design. Fine-tuning a system for peak performance “is very different from an engineer coming in and saying, ‘How can I make this IT system run faster and cheaper?’”
Moreover, sociotechnical systems often fail at the points where people interact with technology. For example, research shows that doctors and nurses will work around technology that disrupts their workflow.
“You’ve got to ask whether the technology fits with the tasks people need to do,” Harrison said.
Cautionary tales
There is no shortage of stories about health IT systems’ sociotechnical failures. For example, one computerized physician order entry system “was so badly designed that it took up to 22 screens to see all of a patient’s medications,” Koppel said. “By the time you’ve been through 22 screens and are about to order meds, what is the probability that you remembered all of the medications” the patient is already taking?
Furthermore, some systems require nurses to remove and scan the tab on a drug’s packaging before administering it to alert caregivers to potential adverse drug interactions and other complications. However, a nurse who must administer a dozen meds might try to save time by scanning the tabs en masse before administering the drugs. But what happens if the patient throws up or the nurse is called away after eight medications are administered? The system will show that the patient received all 12 drugs — a discrepancy that is not easily resolved.
Elsewhere, a physician using an electronic system to prescribe medications might opt to use timesaving workarounds. When prompted to enter a patient’s weight, for example, the doctor might respond with an estimate if the drug isn’t weight-sensitive. Later, another doctor viewing the electronic record might assume that the patient’s weight is accurate and order the wrong dose of a weight-sensitive drug. In some cases, the proper dose of such drugs is calculated down to the last pound of a patient’s weight.
The second doctor “doesn’t know that the first weight was entered into a forced field,” Koppel said. “If the first doctor had the option of saying, ‘I don’t know and it doesn’t matter,’ then the second doctor would not have made that mistake.”
One of the most dramatic and well-documented sociotechnical snafus was a debacle at Cedars-Sinai Medical Center in Los Angeles. In 2002, the hospital installed a $34 million electronic health record system, but within months, physicians were so exasperated with the poor usability of the system that they revolted.
“The doctors were there with pitchforks and torches demanding that the system be pulled,” Koppel said. “It was pulled. The issue wasn’t that the software was bad per se. [The problem was that] the way it was used didn’t make sense in the way doctors were practicing.”
Health care culture
Not long ago, about half of all health IT systems failed to meet users’ expectations, and they frequently went over budget. The success rate has improved, but the failure rate remains alarmingly high.
“If you don’t spend time thinking about the sociotechnical impact of health IT, it’s probably going to bite you later on,” Carayon said. Newspapers and medical journals “are littered with examples of institutions that didn’t look at how technology would integrate with the physical environment and workflows. They had to throw systems out or spend additional millions to make modifications afterward because they hadn’t done their homework.”
To increase the odds of success, experts advise medical providers to choose vendors carefully because, from a sociotechnical perspective, off-the-shelf, plug-and-play applications don’t work.
“You are not buying a system,” Koppel said. “You’re buying a system within your organization. You need a company that takes seriously the need to understand that system within your organization and work with you on some long-term level and make it work and do this not only on your dime.”
However, not all vendors are up to the task of integrating health IT into your sociotechnical system.
“The vendors understand implementation and their systems, but there are very few implementation people who understand the [health care] culture,” said Carolyn Hartley, president and chief executive officer of Physicians EHR, a health care consulting firm and publisher. “There is a big need for people who understand culture, people management and workflow change.”
To a large degree, managing sociotechnical change often requires redesigning tasks along with IT implementation. “If a task is not being done well to begin with, just putting technology into the mix to make it faster won’t make it better,” Harrison said.
Making IT upgrades while maintaining the integrity of a sociotechnical system is also a matter of finding the sweet spot where goals and technology overlap.
The key “is to have a vision big enough and steps small enough that you can make progress, said Terry Paulson, a Los Angeles-based change management consultant. “Every change looks like failure in the middle.”
From the battlefield to the home front: Managing medical data
Government Health IT presents Col. Claude Hines Jr., program manager for the Defense Health Information Management System, in this recent InSight eSeminar. Col. Hines discusses the health information technology and tactical challenges faced by the military medical community in Iraq, Afghanistan and other areas of conflict. In doing so, he describes the current information technology solutions for transferring clinical data between battlefield care givers to health care personnel at military treatment facilities worldwide.
