11/15/07nachc fom/it1 new approaches to technology adoption for healthcare organizations david...

11/15/0711/15/07 NACHC FOM/ITNACHC FOM/IT 11

New Approaches to Technology Adoption

for Healthcare Organizations

David Hartzband, D.Sc.Director of Technology Research

RCHN Community Health Foundation, &Research Scholar, Engineering Systems Division

Massachusetts Institute of Technology


We all know that….We all know that….• Close to 20% of the GDP of the U.S. will

be spent on healthcare this year

• Within 10 years, this figure will be equal to the total $$ spent in the U.S. on all goods & services today (~50% of the GDP)

• This rate of increase is not sustainable by our economy (or any other country’s economy)


& We Also Know That…& We Also Know That…• Health Information Technology (HIT) is

predicted to be one of the major factors in controlling healthcare costs & improving productivity & outcomes

• RAND predicts $10s of billions saved from the adoption EHR technology & $100s of billions saved if healthcare could be as efficient in its use of technology as other U.S. industries (aerospace, auto)


I Previously Reported…I Previously Reported…• My research at MIT has shown that such

cost savings & productivity improvements can not be realized unless new technologies are not only acquired (i.e. purchased) but also adopted & effectively used.

• Even when systems such as Practice Management, EHR, etc. are bought, they are most often ineffectively deployed & utilized


The Question Really Is…The Question Really Is…

• How can technology such as software & hardware systems be more successfully adopted by healthcare organizations?


& The Answer is…& The Answer is…• Co-evolutionCo-evolution, but we’ll get to that

• My previous work has also shown that technology is much more likely to be adopted if it is:– Well aligned with the cultural environment & work

processes of the people in your organization who actually do the work it is supposed to facilitate

• The technology should fit the actual work (be useful in real ways) & potentially allow people to do things that were difficult or not possible to do without it


This Gets Us to BarriersThis Gets Us to Barriers• Four types of barriers to adoption

– Technical • System complexity & lack of interoperability,

– Social & Cultural• Unprepared workforce, training & knowledge issues• Privacy & confidentiality issues

– Cost• Initial investment cost• Lack of funding for ongoing expenses (upgrade,

maintenance, etc.)• Unclear return on investment

– Alignment• System not well matched to workflows & work styles of users• System not useful to users


Collaboration Breaks Through BarriersCollaboration Breaks Through Barriers• Co-evolution is a collaboration between the

organization(s) & the people actually using the technology; & the organization(s) & people developing it

• Some time ago, I did a study with colleagues at Stanford that tried to determine what criteria organizations needed to meet in order to collaborate with each other. These included:– Shared goals– Similar asset & skill availability– Similar reward structures

• In other words, organizations must actually be peers, otherwise a relationship other than collaboration is established (parent/child, teacher/student etc.)


¿¿Co-evolution?Co-evolution?• Current research indicates that this might be an

answer to more effective technology adoption• Co-evolution is the idea that in order to actually

be aligned with the work done in an organization, the technology has to be evolved (or modified) by a process of iterative improvement while it is being used in an organization

• It is ‘co-evolution’ because the organization is often changed during this process as well


How Is Technology Developed?How Is Technology Developed?• In most cases, software (& hardware devices) are

developed by engineers & technology designers who are not experts in whatever work the technology is aimed at facilitating

• In the last 10 or so years, it has become ‘fashionable’ to include human factors & usability ‘experts’ in these design teams– This often results in technology that is technically usable, but

not useful… this is an important distinction– In some recent cases anthropologists have been used to try to

align with the cultural aspects of work (& in a very few cases of specific organizations, more later…)

• The extent to which this has been successful is debatable • Current dogma centers around users developing their

own applications (mainly on the web)


How Does Co-Evolution Work?How Does Co-Evolution Work?• A finished product (not a Beta or test version) is

deployed into an organization• The development team commits to a regular schedule of

interaction with the people actually using the product (not a management team)

• The development team discusses modifications that are suggested by the experience of using the product with the work team, makes decisions on product evolution & makes changes in a rapid development mode so that the modified product can be deployed back to the work team

• This is iterated until both teams are (mostly) satisfied • In the course of this interaction, the organization often

changes in relation to the technology


What Does This Really Mean?What Does This Really Mean?• The developer organization designs & implements a

product that is highly configurable (as opposed to customizable), this team includes people who have actually done the work they are trying to facilitate– The idea is to change the code only as a last resort

• The developer organization & the user organization collaborate with each other over a period of time while the product is being used in production

• The developer organization & the user organization configure the product to align more closely with the workflows & workstyles of the users

• These iterations continue as quickly as feasible with respect to testing & quality assurance practices until both organizations agree that the goals of the collaboration have been met


Where Has It Worked?Where Has It Worked?• Two examples (that I’ve been involved with):

– General Motors C4 Program: a very complex paperless design system was deployed to about 15 GM design & manufacturing groups (1999-2002)

• The technology development team interacted with the GM groups over about 12 months to modify the system as it was used

• Program also included an anthropological study, results were used to structure the interaction & modify the product

– Small drug discovery company (Cambridge, MA) (2006)

• Very complex process modeling & management software deployed into R&D & Marketing/Sales groups

• Development team interacted with these teams over 6 months to modify product


GM DetailsGM Details• Very complex quasi-collaboration between GM C4 ‘car

company’, Digital Equipment & IBM to develop a complete paperless design system (requirements definition, CAD/CAM, design notebook, engineering-manufacturing translation, BOMs), $1.5B budget

• Only part of the system ever delivered– Anthropological study used to guide tech development &

adoption work– Development teams worked sequentially in design/development,

review, use cycle– Organizations (GM & vendors) siloed culturally & technically

(DEC dev on VMS, IBM on Unix) so very little real collaboration acheived

• Mosaic adoption by organization & function• Parts of the system used for several car programs until

2004


Drug Company DetailsDrug Company Details• Not exactly GM, 200 people in company, 120 Ph.D. level

scientists• Development work was primarily process model

development & integration of several existing products (that the company was already using) to provide a new approach (workflows) to automated support for early stages of drug discovery

• Collaboration between scientific teams (3 teams, 17 total people) & 2 developers (DJH + 1 programmer)

• Iteration over about 6 months produced an integrated product suite with a single database & visual UI that closely matched to workflows designed by the combined team


What Happened?What Happened?• The GM product was never fully deployed. Cultural

inertia was a large part of why, but the product set was judged to be a better fit than anything they had previously used (including several products developed by the GM teams themselves)

• The drug discovery process manager is still in daily use. The company has several times looked at commercially available products, but stayed with the co-evolved one because it matched what they did much better. The company actually redesigned their R&D group during the course of this process as the product evolved


What Does It Mean For You?What Does It Mean For You?• There are currently only a very few technology

companies that work like this, but there are some… look for them

• If you can’t find one, talk with your current vendors to see how closely they can/will commit to this kind of process

• Your actual work process must be understood in order to have a target for alignment. Process documentation helps, but often you have to actually go through & chart it as it actually is.

• Co-evolution will present opportunities to change both your work processes & organizational structures. Don’t be afraid to take some of these opportunities as this will create even closer alignment of the technology & your organization


The Final Word (kinda…)The Final Word (kinda…)• Technology can substantially improve

operational effectiveness & clinical outcomes, but only if it is actually adopted & used by the people that do the work

• Technology will only be adopted & used if it is well aligned with the work being done

• Co-evolution is one technique for allowing the technology to align with the work & the people doing it. Part of the process may be that the work process & organization change as they interact with the evolving technology


The Final Word… for nowThe Final Word… for now• There are many ways for CHCs to adopt new

technology• There is no magic bullet. Technology adoption is

HARD work that must be done by the people who will use the technology

• There is no RIGHT way!

• Evolution, of any kind, is a dynamic process that modifies its participants as it progresses


remember – entropy requires no

maintenance


Questions?Questions?

David Hartzband, D.Sc.

[email protected]

[email protected]

617-501-4611 (mobile)

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