Change

TMHG 526
CHANGE
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Faculty of Medicine Ramathibodi Hospital
Mahidol University
October 10, 2014
http://www.slideshare.net/Nawanan

Introduction
2003 M.D. (1st-Class Honors) Ramathibodi
2009 M.S. (Health Informatics) University of Minnesota
2011 Ph.D. (Health Informatics) University of Minnesota
Currently
Faculty of Medicine Ramathibodi Hospital
• Instructor, Department of Community Medicine
• Deputy Executive Director for Informatics (CIO/CMIO)
Chakri Naruebodindra Medical Institute
Contacts
nawanan.the@mahidol.ac.th
SlideShare.net/Nawanan
www.tc.umn.edu/~theer002
groups.google.com/group/ThaiHealthIT

Outline
• Change & IT
• Theories on Change
•Change Management
• Change Management & Sociotechnical
Issues in Informatics
• Bad Changes: Unintended Consequences
of Health IT
• Usability & Human Factors
• Case Studies

Change Management References
Lorenzi & Riley (2004)

Change Management References
http://www.ncbi.nlm.nih.gov/pubmed/10730594

“The only constant is
change”
Heraclitus

Class Exercise #1
Discuss with your neighbor:
• What changes does an
IT implementation bring about?
• What are the risks of those changes?
• What are the implications of those
changes for implementers?

Reasons for Change
•Fix existing problems
•Add more desirable features
•Process improvement
•Address a specific policy/strategy
•Business needs
•Keep up with new technologies
•Regulatory compliance
•Could be internal or external

“To improve is to change...”
Winston Churchill

IT Implementation Failures

Theories on Change
•First-order change
• “A variation in the way processes and
procedures have been done in a given
system, leaving the system itself relatively
unchanged.”
• E.g. creating new reports, new ways to
collect same data, refining existing
processes
Watzlawick, Weakland, & Fisch (1974), cited in Lorenzi & Riley (2000)

Theories on Change
• Second-order change
• The system itself is changed
• Usually a result of a strategic change or a
major crisis such as a threat against system
survival
• Involves redefinition or reconceptualization
of the organization’s business and how it’s
conducted
• E.g. changing from paper to electronic
medical records, automated teller machines
Watzlawick, Weakland, & Fisch (1974), cited in Lorenzi & Riley (2000)

Theories on Change
•Middle-order change
• “Represents a compromise; the
magnitude of change is greater than first-order
change, yet it neither affects the
critical success factors nor is strategic in
nature.”
Golembiewski, Billingsley, & Yeager (1976), cited in Lorenzi & Riley (2000)

Theories on Change
• Lewin’s Field Theory: 3 fundamental types of
conflict situations in a person (“force fields”)
• Standing midway between 2 positive goals of
approximately equal strength
• When there are 2 good systems to purchase
• Standing between 2 approximately equal negative
goals
• Make a choice of a system that will not completely
meet the needs
• Opposing positive and negative forces
• System users vs. IT people

Change Resistance in the News
Washington Post (March 21, 2005)
“One of the most important lessons learned to date is that the complexity
of human change management may be easily underestimated”
Langberg ML (2003) in “Challenges to implementing CPOE: a case study of a work in progress at Cedars-Sinai”

Cost of Change in IT
• Time & effort to learn
• Sense of control / sense of belonging of
workers
• Sense of control of middle managers
(information systems increase ability of
executives to know what’s going on and have
more direct control)
• Loss of position, power, networks
“Power shift”

“The changes we dread
most may contain our
salvation”
Barbara Kingsolver, in Small Wonder

Change Management
•“The process by which an organization
gets to its future state, its vision.”
•Starts with creating a vision for change
and empowering people as change
agents to achieve the vision.
•“Change management encompasses
the effective strategies and programs
to enable those change agents to
achieve the new vision.”

Change Management Process
•Assessment
•Feedback and Options
•Strategy Development
•Implementation
•Reassessment

Types of Change
• Operational changes
• Changes that affect the way the ongoing business
operations are conducted
• Strategic changes
• Changes in strategic business direction
• Cultural changes
• Affect basic organizational philosophies by which the
business is conducted (e.g. implementing CQI)
• Political changes
• Staffing changes, primarily for political reasons

Types of Change
• Microchanges
• Differences in degree
• E.g., modifications, enhancements, improvements, &
upgrades of information systems
• Megachanges
• Differences in kind
• E.g., a new system or a very major revision

The Special People
Ash et al. (2003)

• 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
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
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
The Special People

Change Management and
Sociotechnical Issues in
Informatics

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

People-Process-Technology
Technology
People Process

“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

“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

Health IT Successes & Failures
Kaplan & Harris-Salamone (2009)

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

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

Considerations for a successful CPOE
implementation
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

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)

User Involvement in Health IT:
A True Story

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)

The Missing Piece in IT Adoption
Theera-Ampornpunt (2011)
Technological Sophistication
Functional Sophistication
Integration Sophistication
Managerial Sophistication
Proposed Addition

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

Theory of Hospital Adoption of
Information Systems (THAIS)

Gartner Hype Cycle
Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle
http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp

Rogers’ Diffusion of Innovations:
Adoption Curve
Rogers (2003)

Leading a Change
http://www.ted.com/talks/lang/th/derek_sivers_how_to_start_a_movement.html

Bad Changes: Unintended
Consequences of Health IT

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)

Ash et al. (2004)

• 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)

• 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)

Campbell et al. (2006)

Koppel et al. (2005)

Some Risks of Clinical Decision Support Systems
• Alert Fatigue

Workarounds

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

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;
64
mappings; constraints; affordances

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
65

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

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

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

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

HCI & Usability Resources
• Usability.gov
• Useit.com
• Edwardtufte.com
• National Institute of Standards and Technology
(NIST)
• http://www.nist.gov/healthcare/usability/index.cf
m
• 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

Summary (1)
• All IT implementations are change
• Changes differ in nature, scale, and magnitude
• Change resistance is common and natural
• Overcoming change resistance requires a good
change management strategy
• Pay attention to the “POI” or sociotechnical aspect
• Balance between People, Process, & Technology

Summary (2)
• Shared vision & commitment, user engagement,
communication, workflow considerations, &
training are key
• Understand the Adoption Curve
• Health IT can have unintended consequences:
bad changes, requiring change management &
project evaluation
• Attention to usability & human factors will help
manage changes

Case Studies on Change Management
Leviss (Editor)
(2010)
Leviss (Editor)
(2013)

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.

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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