Adoption and Use of Handheld ComputersIn Clinical Practice A Qualitative Study of Innovation Diffusion

Ann Scheck McAlearney, Sc.D.The Ohio State University

AcademyHealth Annual MeetingJune 2004

Presentation Agenda

Introduction

Methods

Results

Summary

Significance for Policy, Delivery, Practice

Introduction

Project Background Project Investigators

Ann Scheck McAlearney, Sc.D. (Co-PI) Ohio State University, Division of Health

Services Management and PolicyMitchell Medow, M.D., Ph.D.

Ohio State University Medical Center, Division of General Internal Medicine

Sharon B. Schweikhart, Ph.D. (Co-PI) Ohio State University, Division of Health

Services Management and Policy

Project FundingCenter for Health Management Research

Overall Findings… Diffusion of HHCs as a technology innovation is

affected by how the technology is introduced, demonstrated, and promoted, as predicted (Rogers):

Ability to experiment

Judgment-free training

Low cost of technology

Forums with other physicians

Use of clinical change agents

Organizations can help with innovation diffusion Develop strategies to accommodate, support MD use

Leverage HHC use to build user confidence

Rationale for Study: Why Study Handheld Computers? Little research has explicitly examined:

Organizational management of HHC Clinician use of HHC in patient care

Proliferation of HHC use by physicians had not been qualitatively evaluated

Physician use of HHC use likely to be influenced by organizational decisions

Research Objective

To develop a rich and useful understanding of organizational strategies for the use of handheld computers, and of the needs and concerns of physicians using these devices for patient care delivery

Research Questions What specific applications and uses exist

for handheld computers (HHCs) in clinical settings?

What strategies and tactics are hospitals using to integrate HHCs into their patient care delivery practices?

What are the attitudes, expectations, and needs of physicians with respect to the use of HHCs in clinical practice?

Methods

Study Design Literature review and market research

Seven case studies in healthcare organizations 67 key informant interviews with organizational,

physician informants

Eight physician focus groups (54 MDs) At healthcare organizations (6 groups)

At national meetings of physicians (2 groups)

Interviews and focus groups transcribed and analyzed using deductive, inductive methods

Conceptual Framework: Handheld Computer Adoption as Diffusion of Innovation

Adopter categories and characteristics Nature of social system Extent of change agents’ promotion

efforts Perceived attributes of innovation

Results

Handheld Computer Adoption as Diffusion of Innovation

1. Adopter Categories

2. Perceived Attributes of HHCs

3. Factors Promoting HHC Use

4. Role of Change Agents

1. Adopter Categories Rogers’ Adopter Categories:

InnovatorsEarly AdoptersEarly MajorityLate MajorityLaggards

What we characterized…

Handheld Computer User Patterns

0%

10%

20%

30%

40%

50%

Non-Users Niche Users

RoutineUsers

Power Users

2. Perceived Attributes of HHC Relative Advantage

Compared to paper, PCs Compatibility

With other technologies, with workflow Complexity

Personal perspective Trialability

Availability of pilot projects, free devices Observability

Growing number of peer users

Relative Advantage… The Convinced: “For me, to be able to sync

my Palm before I make rounds and have all that information with me. Then I don't have to run around and ask the nurse who says, ‘I'm not a nurse, I'm a respiratory therapist’.”

The Unconvinced: “I'm using paper during the day. Because if you take notes, it's much more practical to take notes on a paper print-out and keep your to-do list on that than it is on a palm. Because you can just do it quicker and it's all right there.”

Compatibility… The Convinced: “I feel that I can make

decisions right there at the bedside versus stepping out of a room and saying ‘OK, I will talk to you about this at the next visit.’”

The Unconvinced: “I used it, but I have not found it convenient enough to go and buy one. Where I work we have computers everywhere and I prefer using a keyboard.”

Complexity… The Convinced: “It has got to be reliable. It

can't be going down all the time. It has got to be simple. For example, the Palm is pretty simple.”

The Unconvinced: “My partner tried to get it synched, took it home, tried to get it to work the first night. Couldn't do it, quit.”

3. Factors Promoting HHC Use

Ability to experiment Judgment-free training Low cost of technology Forums with other physicians

Forums to Learn from Others... Physician 1: I still look up my drugs in Harriet Lane. It's easier for

me to just open a book and find it, than to look for it on the palm, because the drug formulary that I have just in mine, you have to scroll through a lot to come to the part where it tells you how much each dose is and what kind of pills you can get.

Physician 2: You can jump.

Physician 1: You can?

Physician 2: Yeah. …I can show you.

Physician 1: You can? Okay... I think it's a lot easier, when you can scroll down it is, it takes a long time.

Physician 2: I mean it actually remembers. Like the ones you visit the most so if you do that over like two dosage forms, like usual dosage is always there, it's just there.

Physician 1: Okay. Never mind.

4. Importance of Change Agents

Clinical peers Constant availability Non-threatening individuals

Help from a Clinical Peer… “It's gotta be something where you can go back

and dialogue with people and say I'm having a problem here or I'm not getting the full advantage of this thing.”

“And you know, when it doesn't, when it stops working for some reason, there has to be someone who can do it...”

“Somewhere I can go to, sit down and say this is what I'm trying to do. Why can't I do it? What did I do wrong? How can you help me make it right?”

Summary

Conclusions Success of HHC diffusion affected by approach

to introducing, promoting, and supporting technology

Organizational strategies to accommodate and support physician use of HHC can help improve care and service to patients

Organizations can leverage HHC use:

Build user confidence in technology

Demonstrate success with technology implementation, adoption

HHCs Help to Build User Confidence in Technology…

“Maybe even made us ready for COE, just in terms

[that] we got used to using a digital means of

[working with] information and looking things up.

I mean it's very different [from] COE, but it is still

the idea of using a computer, using a handheld

device to do medicine. You know, five years ago

here there were no palms and it was all paper

orders … I think it kind of just helps scooch us in

that direction.”

Significance

Significance for Management Commitment to support HHCs

characterized by budget commitment to personnel (training, user support) rather than heavy capital investment

More visible use of HHCs by senior medical leadership will help expand physician use

Potential to effectively use HHCs in clinical settings for non-physician care processes is largely untapped but large

Three Organizational Strategies1. Active promotion, facilitation, and support for

broad-based HHC applications How? Broad infrastructure investment; user support;

equipment purchase (synching, printers) Why? Option to make point of care information

available; access to organization’s clinical data systems

2. Active support for HHC niche applications How? Applications tied to specific projects Why? Expectation for specific outcomes; benefit of

organizational learning about PDA technology

3. Basic support for individual HHC users How? IT-based user support Why? Need to ensure PDA use is appropriate,

compliant with security and privacy policies

Implications for Management, Delivery, and Practice

Clinical change agents and peer champions can help promote and expand technology adoption and diffusion

Understanding findings about HHC can help with other technology implementation efforts

Expectations for the Future…“And the requirement of precision is much greater. So I'm not really allowed anymore to get the drug interactions wrong. So, I have to have a device that makes it right... So, if you're going to be held to that standard, then you have to have the tools to be held to that standard. … So, whether you’re in medical school and everyone has their Palm Pilot and they're whizzes at it, as opposed to somebody like me who's struggling and wants learn to be able to access and to benefit from this technology, we have to do it. …writing illegibly is not going to do it anymore.”

Questions?