Ann Scheck McAlearney, Sc.D. The Ohio State University AcademyHealth Annual Meeting June 2004

1. Adoption and Use of Handheld ComputersIn Clinical PracticeA Qualitative Study of Innovation Diffusion Ann Scheck McAlearney, Sc.D. The Ohio State University AcademyHealth Annual Meeting June 2004

2. Presentation Agenda • Introduction • Methods • Results • Summary • Significance for Policy, Delivery, Practice

3. Introduction

4. 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

5. 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

6. 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

7. 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

8. 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?

9. Methods

10. 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

11. 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

12. Results

13. Handheld Computer Adoption as Diffusion of Innovation • Adopter Categories • Perceived Attributes of HHCs • Factors Promoting HHC Use • Role of Change Agents

14. 1. Adopter Categories • Rogers’ Adopter Categories: • Innovators • Early Adopters • Early Majority • Late Majority • Laggards • What we characterized…

15. Handheld Computer User Patterns

16. 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

17. 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.”

18. 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.”

19. 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.”

20. 3. Factors Promoting HHC Use • Ability to experiment • Judgment-free training • Low cost of technology • Forums with other physicians

21. 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.

22. 4. Importance of Change Agents • Clinical peers • Constant availability • Non-threatening individuals

23. 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?”

24. Summary

25. 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

26. 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.”

27. Significance

28. 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

29. 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 organization’s 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

30. 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

31. 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.”

32. Questions?