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From the January 2003 Issue 11th-Hour HIPAA: How Can You Meet the Deadlines? |
Viewpoint
Instructive Resistance
The pages of trade journals are filled with stories reflecting on the difficulties of introducing state-of-the-art clinical systems into our old-world institutions. There are many barriers to success that are cited as issues to navigate and hurdles to overcome. Nearly all lists of such obstacles mention physician resistance as one of the most daunting. There is no question that in many institutions, IT leadership, not clinical leadership, has taken the mantle for introducing these new systems. Whenever an outsider (read: nonuser) leads, suspicion follows. This lends credence to the idea that IT and clinical leadership should partner to champion these new clinical initiatives. Yet even when such a partnership exists, we often hear war stories of the stultifying effect of physician resistance. I offer a different interpretation. As a (non-physician) CIO, I do not accept that physicians, as a group, are resistant to technology and change. There are few other professions that rely so heavily on the regular and steady introduction of new science and technology. Physician Pushback Long before we thought of introducing point-of-care software or automated decision support, clinicians were embracing new scientific evidence to change their entrenched treatment protocols. Decades before automation appeared in hospitals, physicians were pursuing CME courses to keep up with the ever-evolving thought and practice advancements. These behavioral characteristics are not consistent with those who would, carte blanche, resist technology and change. Maybe something else is going on? I have had the good fortune to be involved with two very different CPOE implementations, a self-development initiative at Brigham and Women’s Hospital and a vendor-supplied solution at Boston Medical Center. Both projects resulted in the successful housewide use of CPOE. Both initiatives included extensive discussion, negotiation, arguing, compromising, cajoling and general haranguing with all users, including physicians. It would be self-serving to label all of this activity as resistance, creating a contrived sense of absolute right and absolute wrong. If we label all disagreement that we encountered as resistance, then that seems to suggest that what we offered was unquestionably worthy of immediate acceptance. IT leaders need to accept physician pushback as a challenge to deliver better products. There is no doubt that all of us, on both sides of the CPOE discussion, could do a better job of explaining ourselves to each other. Looking beyond the presentation style (or lack of style), there is almost always a valid concern being voiced. Often this is not resistance to change, but reluctance to embrace the wrong change. Pushing further, digging deeper, one can almost always find a productive suggestion to remediate and improve the product or process. Nearly all the physicians with whom I have worked understand and embrace the promise that automation has the potential to improve care. Nearly all of them also realize that the solutions we offer today are still relatively immature and fall short of that goal. When they push back, it is to force us to dig deeper, think smarter and come closer to delivering on that promise. To label this behavior as resistance is an oversimplification of where we are and where we must go as an industry. Most of us working in IT understand that the best of the technology still lies in its potential. All our implementations are works in progress. The truth is that we should be delivering better products. Incremental Steps The clinicians with whom I work are willing to accept the products that move us incrementally forward and lay the groundwork for continued improvement. The physician critique is required to ensure that we don’t settle for what we have today. For the minority of physicians who are genuinely resistant to change for no good reason, the Darwinian process will prevail. Our colleagues’ critiques present us with several learning opportunities. Perhaps top on that list is “ease of use,” which impacts training time, use time and productivity. While our first-generation systems were impressive just by virtue of the fact that they worked when their predecessors failed, we must now develop systems that are slick and easy. Savvy users are demanding a sort of ROI that they can feel, if not empirically measure. Time on the computer must feel like time well spent. While there may not yet be common language to describe the problems, expressions like “clunky,” “slow” and “not intuitive” let us know that we do not yet have it right. Clinicians may not be able to define the best interface, but they will know it when they see it. We need to continue to work with them on this initiative. Today, a community clinician practicing in many hospitals is able, without training, to make productive use of the paper processes and charts; the same is not true of the computerized records, and we need to do better. We do not need a single system, but we need a replicable, logical approach to design that supports easy first use and rapid mastery. To continuously retrain clinicians in systems and processes as their careers take them to new institutions will neither enhance safety nor decrease the administrative expense of healthcare delivery. The introduction of incremental improvements is key to our ability to improve the quality and efficiency of care through the application of technology. None of us, nor those we serve, can afford to sit on the sidelines and wait for the fully mature products to arrive on our doorsteps, perfectly designed and affordably priced. The never-ending cycle of implementation-experience-improvement is required to generate better products. It is the physicians who loathe the systems the most who need to get more involved in the game to influence the outcomes. The core lessons of resistance are likely to be instructive. Critique, regardless of the temperament that surrounds its delivery, is valuable input to our shared goal of safe and efficient clinical products. Meg Aranow is vice president and chief information officer of Boston Medical Center, Boston, MA. © 2003 Nelson Publishing, Inc |
By
Meg Aranow