facilitating adoption of telemedicine disrupting habits and organizational routines
TRANSCRIPT
Habits and Organizational Routines: Preliminary Evidence of Habit
Disruption in TelehealthImplementations
Elena KarahannaJennifer ClaggettChristina SerranoGreta L. Polites
GPT ConferenceMarch 17, 2011
MIS Department
Study Context:Nursing Home Telehealth Project
NH 1
NH 5
NH 3
NH 2
NH 6
NH 4Parent NursingHomeCompany
TelemedicineProvider
(Non-Profit)
Attending Physicians
Specialists(dermatology, psychology)
Remote Emergency Room
NH 7 NH 8
NH 9
CHOICE OF CONSULTATION
DELIBERATE REASONING
•Relative Advantage•Fit•Power/Politics•Self-Efficacy•Relationships•Social Norms•Materiality
ORG ROUTINE
HabitPhysician
HabitNurseHabit
NurseHabitNurseHabit
NurseHabitNurse
STATUSQUO
Usage or non-usage of telemedicine occurs through two routes-Deliberate Processing-Automatic Processing
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.
The Embeddedness of IS Habits
Polites, G and Karahanna, E. (2010) The Embeddedness of Habits in Organizational Routines
Disrupting IS Usage Habits
Interference(obstacles, errors)
Distraction
•Action slips (Norman, 1981)
•Script disruption techniques (Schank & Abelson 1977)
Polites, G and Karahanna, E. (2010) The Embeddedness of Habits in Organizational Routines
B
InterferenceTechniques
“Pull the plug” Change sequencing and timing of steps
Automation / “push” vs. “pull”
(A) Eliminating Triggersby ChangingBusiness Processes:
Polites, G and Karahanna, E. (2010), The Embeddedness of Habits in Organizational Routines
Develop new organizational routine
DistractionTechniques
Manipulating the Context for ExistingBusiness Processes:
Monitoring and feedback
Polites, G and Karahanna, E. (2010), The Embeddedness of Habits in Organizational Routines
• Knowledge levels (Olfman et al. 2006)
Command-Based
Tool Procedural
Business Procedural
Tool Conceptual
Business Conceptual
Motivational
Meta-Cognitive
Training• Eliminating knowledge barriers vs.
retraining responses to situational cues
•
Business Procedural
Business Conceptual
Training in the context of actual work routines and situational triggers
Polites, G and Karahanna, E. (2010) The Embeddedness of Habits in Organizational Routines
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)
Research DesignNH1 NH2 NH3 NH4 NH5 NH6 NH7 NH8 NH9
Attending Physician
Specialist
ER
• Embedded Case Study Design: 9 sites and 3 different telehealthuses
Data analysis underwayResults based on preliminary findings…
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)
Disruption and Development of Habits and Org Routines
New Organizational Routine
Individual New Habit Physician
Individual New Habit Nurses
Status Quo Organizational Routine
Individual Habit Physician
Individual Habit Nurses
DisruptionInterferenceDistractionTraining-in-
Context
DevelopmentRepetition
SatisfactionStable Context
Evidence: Interference• Psychiatric Consults
– State withdrew funding for PASSR program
• Site 1– Heavy use of Telemed for
Psych– Strong satisfaction(better than
old)
• Site 2– No use– Substitute with existing org
routine - psych who already visited some patientsORG ROUTINE
HabitPhysician
HabitNurseHabit
NurseHabitNurseHabit
NurseHabitNurse
CHOICE OF CONSULTATIONX
Evidence: DistractionPrompting• Deliberate reasoning by nurse – disrupts physician
habit and automatic performance of org routine.• “We just asked him if we could and he said “yes.”
CHOICE OF CONSULTATION
DELIBERATE REASONING
•Relative Advantage•Fit•Power/Politics•Self-Efficacy•Relationships•Social Norms
ORG ROUTINE
HabitPhysician
HabitNurseHabit
NurseHabitNurseHabit
NurseHabitNurseX
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)
Evidence: DistractionMonitoring 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?”
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 telemeduse
– 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
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 consultsOLD ORG ROUTINE
HabitPhysician
HabitNurseHabit
NurseHabitNurseHabit
NurseHabitNurse
NEW ORG ROUTINE
HabitPhysician
HabitNurseHabit
NurseHabitNurseHabit
NurseHabitNurse
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)
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)
How are New OrganizationalRoutines Sustained
• Satisfaction• Repetition in a stable context
– Repetition opportunities– Same time (on a schedule)– Same actors – Same setting
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
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
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)
Disruption and Development of Habits and Org Routines
New Organizational Routine
Individual New Habit Physician
Individual New Habit Nurses
Status Quo Organizational Routine
Individual Habit Physician
Individual Habit Nurses
DisruptionInterferenceDistractionTraining-in-
Context
DevelopmentRepetition
SatisfactionStable Context
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 vsthe development of new routines