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

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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 Meeting
• June 2004

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Presentation Agenda

• Introduction
• Methods
• Results
• Summary
• Significance for Policy, Delivery, Practice

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Introduction
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Project Background

• Project Investigators
• Ann Scheck McAlearney, Sc.D. (Co-PI)
• Ohio State University, Division of Health
  Services Management and Policy
• Mitchell 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 Funding
• Center for Health Management Research

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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

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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

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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

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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?

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Methods
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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

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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

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Results
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Handheld Computer Adoption as Diffusion of
Innovation

• Adopter Categories
• Perceived Attributes of HHCs
• Factors Promoting HHC Use
• Role of Change Agents

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1. Adopter Categories

• Rogers Adopter Categories
• Innovators
• Early Adopters
• Early Majority
• Late Majority
• Laggards
• What we characterized

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Handheld Computer User Patterns
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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

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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.

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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.

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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.

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3. Factors Promoting HHC Use

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

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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.

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4. Importance of Change Agents

• Clinical peers
• Constant availability
• Non-threatening individuals

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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?

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Summary
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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

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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.

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Significance
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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

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Three Organizational Strategies

• 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 organizations clinical data
  systems
• Active support for HHC niche applications
• How? Applications tied to specific projects
• Why? Expectation for specific outcomes benefit
  of organizational learning about PDA technology
• 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

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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

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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 youre 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.

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Questions?