1. Habits and Organizational Routines:
Preliminary Evidence of Habit
Disruption in Telehealth
Implementations
Elena Karahanna
Jennifer Claggett
Christina Serrano
Greta L. Polites
GPT Conference
March 17, 2011
MIS Department

2. Study Context:
Nursing Home Telehealth Project
NH 1 NH 2
Attending Physicians
Parent NH 3 NH 4
Nursing
Home NH 5 NH 6
Company Specialists
(dermatology, psychology)
NH 7 NH 8
NH 9
Remote
Emergency Room
Telemedicine
Provider
(Non-Profit)

4. Usage or non-usage of telemedicine occurs through two routes
-Deliberate Processing
-Automatic Processing
DELIBERATE
REASONING
•Relative Advantage
•Fit
•Power/Politics
•Self-Efficacy
•Relationships CHOICE OF
•Social Norms CONSULTATION
•Materiality
ORG ROUTINE
Habit
Habit
Nurse
STATUS Habit
Habit
Nurse
Habit
Nurse
QUO Physician Habit
Nurse
Nurse

5. Study Objectives
 Examine how habits and organizational routines
influence usage or non-usage of telemedicine
 Examine habit disruption interventions to encourage
usage of telemedicine
 Examine organizational routine development to
encourage usage of telemedicine
 Examine the interplay between individual habits and
organizational routines
 Focus is on situations where individuals
involved view use of telemedicine as
appropriate yet system is not used.

6. The Embeddedness of IS Habits
Polites, G and Karahanna, E. (2010)
The Embeddedness of Habits in Organizational Routines

7. Disrupting IS Usage Habits
•Action slips (Norman, 1981)
•Script disruption techniques (Schank & Abelson 1977)
Interference Distraction
(obstacles, errors)
Polites, G and Karahanna, E. (2010)
The Embeddedness of Habits in Organizational Routines

8. Interference
Techniques
(A) Eliminating Triggers
by Changing
Business Processes:
B
 “Pull the plug”
 Change sequencing and timing of steps
 Develop new organizational routine
 Automation / “push” vs. “pull”
Polites, G and Karahanna, E. (2010), The Embeddedness of Habits in Organizational Routines

9. Distraction
Techniques
Manipulating the
Context for Existing
Business Processes:
 Monitoring and feedback
Polites, G and Karahanna, E. (2010), The Embeddedness of Habits in Organizational Routines

10. Training
• Eliminating knowledge barriers vs.
retraining responses to situational cues
• Knowledge levels (Olfman et al. 2006)
Command-Based
Tool Procedural
Business Procedural Training in the context
Tool Conceptual of actual work routines
Business Conceptual and situational triggers
Motivational
Meta-Cognitive
Polites, G and Karahanna, E. (2010)
The Embeddedness of Habits in Organizational Routines

11. Case Studies
• Currently an ongoing multiple case study
• Approximately 30 individuals interviewed
– Multiple stakeholder groups
• Nursing home staff (site coordinator, director of
nursing, nurses)
• Physicians (attending physicians, specialists,
consulting physicians)
• Nursing home Parent Company Administrator
• Telehealth company staff (Director, Administrators, IT
support personnel, trainers)

12. Research Design
• Embedded NH1 NH2 NH3 NH4 NH5 NH6 NH7 NH8 NH9
Case Study
Attending
Design: 9 Physician
sites and 3 Specialist
different ER
telehealth
uses
Data analysis underway
Results based on preliminary findings…

13. Evidence: Action Slips
• Attending physician very strong proponent of
telehealth. Yet, no use:
– “I should probably be more proactive in, um,
encouraging its use. And part of it is you don’t think
about it. You’re in a routine, and you don’t think about
it…” (physician)
– Nurses describing routine: “[Dr] tells us off the top of her
head ‘call so-and-so’ and make an appointment”
– A few days after the fact: “We could have used the
system for this…” (nurses describing physician’s
comment on a case)

14. Disruption and Development of
Habits and Org Routines
Status Quo New
Organizational Routine Organizational Routine
Disruption Development
Interference Repetition
Distraction Satisfaction
Training-in- Stable Context
Context
Individual Individual Individual New Individual New
Habit Physician Habit Nurses Habit Physician Habit Nurses

15. Evidence: Interference
• Psychiatric Consults • Site 1
– State withdrew funding for – Heavy use of Telemed for
PASSR program Psych
– Strong satisfaction(better than
old)
• Site 2
– No use
– Substitute with existing org
routine - psych who already
ORG ROUTINE
Habit
visited some patients
Habit
X
Nurse
Habit
Nurse CHOICE OF
Habit Habit
Nurse
Physician Habit
Nurse CONSULTATION
Nurse

16. Prompting
Evidence: Distraction
• Deliberate reasoning by nurse – disrupts physician
habit and automatic performance of org routine.
• “We just asked him if we could and he said “yes.”
DELIBERATE
REASONING
•Relative Advantage
•Fit
•Power/Politics
•Self-Efficacy
•Relationships
•Social Norms CHOICE OF
CONSULTATION
ORG ROUTINE
Habit
Habit
Habit
Nurse
Habit Habit
Nurse
Nurse
Habit
Nurse
Physician
XNurse

17. Deliberate Processing by Nurse
• “We had a need with a patient and we had
usually transported them to […] but we saw it as
a perfect opportunity to use our telemedicine
and to do a rather quick appointment. And that
was able to be made happen and so we did it.
Because this was a patient that wouldn’t have
had a family member that could go with them.
And so it worked out great. The patient liked it.
The doctor was very efficient. She was nice.”
(Nurse at nursing home)

18. Evidence: Distraction
Monitoring and Feedback
“But really, it’s just a good review for me to be able to look back and
say, why didn’t we telemed that? Do we need to do some more
training with the nurses? Or physicians? Or something like that”
(Director of Nursing)
“We have a 24 hour book at our nurses’ station, where everybody is
constantly writing something in that book that they want to
communicate to the management team. We read those books every
morning in this room. We call it a stand up meeting. We read
everything they wrote. So if can see, if we pick up something going
on with a patient, where they have given us some information, we
will discuss at that time, first thing in the morning, should we call the
doctor and possibly see if he wants to do a telemed consult?”

19. Training in Context
• Excellent training offered on technology.
– Repeated training. All uniformly satisfied
– Excellent support – tech a phone call away and willing
to come in and help set up any consultation
• No training in context
– Not able to recognize when and how to involve telemed
use
– Continue with status quo org process
• Exception
– ‘we’re encouraged and I think the biggest thing I see in
us is that “Ok, we know which road we can take when
we have a problem.”’ (nurse)
– Wound care and psych

20. Development of New
Organizational Routine
• New Org Routines or scripts have to be
developed to replace old org routine: How?
• Over time and repetition these will become
habituated at the individual level
• Psych and wound care consults
OLD ORG NEW ORG
ROUTINE Habit ROUTINE Habit
Habit
Nurse Habit
Nurse
Habit
Nurse Habit
Nurse
Habit
Nurse Habit
Nurse
Habit Habit
Nurse Habit Habit
Nurse
Physician Nurse Physician Nurse

21. Development of New
Organizational Routine
• “… because the nurses don’t think, “Is this a
telemedicine person?” They’ve got to change their
mindset. They’ve got to think, “You know, this might be a
person I need to be thinking about.” Get that system
ready. Get it…You know in an acute care setting, when
you’re admitted, in [ER], you have this team that comes
in, everything gets done. I think you’re going to have to
build that team. Let’s get that telemedicine unit up when
you’re getting the patient down there, you’re going to
have to have everybody on board to accomplish it.”
(Physician)

22. Development of New
Organizational Routine
• “But what happens is, they call you too late in the
process. They call you when it’s not—you don’t have
time to do it. You have to get the patient out. You know?
So, part of that I think, is their reluctance to do it. We’ve
done it a few times. Several times in the middle of the
night I’ve suggested that we do the ER through Augusta.
And they’ve said, “Well, we don’t know how to do it.” And
by that time, you’ve got a patient that’s maybe going bad
on you. You’ve got thirty minutes to get—by the time the
ambulance gets there and gets back to the hospital,
that’s 30-40 minutes, so you can’t take a whole lot of
time.” (Physician)

23. How are New Organizational
Routines Sustained
• Satisfaction
• Repetition in a stable context
– Repetition opportunities
– Same time (on a schedule)
– Same actors
– Same setting

24. Example of Failed New Routine
• New Org routine developed but failed
• Attending Physician set up once a day
(12-1) telemed consult with nursing home
• Discontinued after a month or so
• Dissatisfaction with new routine
– Trivial cases presented
– Not effective or efficient use of physician’s
time
• Never habituated

25. Examples of Successful New
Routines
Wound Care and Psych
• Satisfaction with new routines
– Clear benefits
– Comfortable interactions with consulting physicians
– Benefits of knowledge exchange
– Less set up time for patient data entry
• Stable context
– On set schedule
– Same physicians
• Frequent repetition
• Hybrid mode

26. Fatigue and Stress:
Relaxing Performance Goals
• “…when I go to work Monday, next Monday, you’re on a
treadmill. It’s a harrowing experience. And between
Monday, when I show up at the hospital at 5:30/6:00 in
the morning, and Friday night at 7:00, I have absolutely
no free time. That sounds self-serving, but it’s really,
even if you get off a little early, and get home before
dark, there’s always the potential for somebody to go
bad or something. So, you don’t really have any time to
that you can say, “Yeah, Thursday afternoon, I’ll do
something.” So, you know, I need it to work without my
involvement. And I should be a little more proactive in it.”
(Physician)

27. Disruption and Development of
Habits and Org Routines
Status Quo New
Organizational Routine Organizational Routine
Disruption Development
Interference Repetition
Distraction Satisfaction
Training-in- Stable Context
Context
Individual Individual Individual New Individual New
Habit Physician Habit Nurses Habit Physician Habit Nurses

28. Contributions
• Examine implementation of new systems
from the lens of habits embedded within
organizational routines
• Reciprocal effects of habits on
performative and ostensive aspects of
organizational routines and vice-versa
• Different relationships between habits and
routines in the disruption of incumbent vs
the development of new routines