Professor Trish Greenhalgh Acknowledging critical conversations with Professor Rob Stones and Dr Deborah Swinglehurst

1. 4th International Workshop on Infrastructures for Health, Tromsø, June 2013 Rethinking ‘resistance’ to big IT programmes in healthcare Professor Trish Greenhalgh Acknowledging critical conversations with Professor Rob Stones and Dr Deborah Swinglehurst

2. The problem“Most [healthcare ICT] implementations fail because, despite high investments in terms of both time and financial resources, physicians simply do not use them.”Rodriguez & Pozzebon 2005

3. Standard ‘resistance’ argumentCritique A new theory of resistance ‘Expert systems’MethodologyEmpirical exampleGeneralizability?Discussion

4. Standard ‘resistance’ argument: Resistance = stupidity + skill deficit + fearSolution = behaviourist tactics (incentives, training, encouragement, ‘leadership’, ‘good management’)

5. “People who have low psychological ownership in a system and who vigorously resist its implementation can bring a ‘technically best’ system to its knees. However, effective leadership can sharply reduce the behavioral resistance to change--including to new technologies--to achieve a more rapid and productive introduction of informatics technology.” Lorenzi & Riley: JAMIA 2000; 7: 116

6. Standard ‘resistance’ argument: Technology Acceptance Model (DeLone and McLean

7. Critique of the behaviourist argumentPro-innovation bias: ‘New is always better’Means /ends: [Alleged] efficiency of process > ultimate goalsHumans are social beings who make meaning and enact roles

8. Critique of the behaviourist argumentHuman agents think and feel and care

9. A new [normative] theory of resistance Grounded in the ethics of professional practiceAsks ‘What is excellence in medicine / nursing?’ and ‘How does this IT help me achieve excellence?’

10. The theoretical background: strong structuration theory (enhanced from ANT) Humans act differently in the network because they have agency

11. A normative theory of resistance to big IT Clinicians are usually professionally motivated. They seek to provide excellent care. They resist five things: Policies that interfere with excellent care Technologies that interfere with excellent care Interference with the [symbolic] roles and relationships that define and constitute professional practice Encroachment of ‘the system’ into the clinical situation Cost

12. What is excellence in clinical care? Medicine’s ‘internal goods’ (Alasdair MacIntyre) Good doctoring is “a relational competence, where empathic perceptiveness and creativity render doctors capable of using their personal qualities, together with the scientific and technologic tools of medicine, to provide individualized help attuned to the particular circumstances of the patient.” EdvinSchei: Perspecives in Biology and Medicine 2006; 49: 393

13. The ‘expert system’ (computer science)A way of capturing expert knowledge into rules and protocols so as to deliver this knowledge to the non-expert

14. The ‘expert system’ (sociology)“[a] system of technical accomplishment or professional expertise that organize[s] large areas of the material and social environments in which we live today” Anthony Giddens ‘The Consequences of Modernity’

15. The ‘expert system’ (sociology)Classification systems “describe the way things are” (Mary Douglas, anthropologist)Embedded rules and protocols impose a distant set of values and priorities on local situations, hence ‘empty out’ their detail

16. HypothesisClinicians’ resistance to big IT systems can usually be explained as rejection of the rules and classification systems embedded in an expert system because they conflict with the internal goods of professional practice

17. Critical ethnography: A methodology for studying resistance to expert systems Empirical ethnography: Careful observation to document tasks and processes  “implications for design” Critical ethnography “… has the potential to rework a set of critical epistemological concerns around reflexivity, voice, stance and standpoint” Dourishand Bell: ‘Divining a Digital Future’

18. Critical ethnography: examples of questions Who makes the rules? What assumptions have been built into the software? Who will gain and who will lose if this IT system is used? Whose voice is notheard and why? What does someone gain by ‘forgetting’ their password?

19. Ethnography of infrastructure (Star) • Guiding methodological principles in the study of infrastructure and its ‘frozen discourses’: • Surface master-narratives (over-arching discourses / logics that shape actions) e.g. ‘Patients come first’ • Surface invisible work e.g. ‘articulation work’ done by secretaries and administrators • Study paradoxes (e.g. why one more keystroke makes the whole system unworkable)

20. Empirical example: Choose and BookRemote booking of outpatient appointments by the GP or the patient (from home using a password and booking reference)Introduced in UK in 2004 to support a policy of ‘choice’ (of hospital) by informed, empowered patients

21. Empirical example: Choose and BookEthnographic observation in 4 GP practices over 2 years, including 29 GP consultations + 58 ‘admin’ referrals Video and screen capture data on 12 consultationsNaturally occurring talk and ‘on the job’ interviewsDocuments, letters, email exchanges

22. Choose and BookLinked to a wider government-led ‘modernisation’ agenda: measure doctors’ work, make performance ‘transparent’, drive up quality through ‘informed choice’.C&B was adopted and then abandonedin most GP practices, despite financial incentives:“I was a pioneer user but I no longer use it at all” - GP

23. Resistance to Choose and Book 1:The ‘choice’ policy“patients don’t want a choice of where they are seen, they just want to attend the hospital nearest to them” - GP“I’m supposed to offer you [local hospital] or Timbuktu” - GP to patient“we should not use C & B because to do so would be to collude in a lie with the government that choice was actually being given…” - GP

24. The ‘choice’ myth: A person can manage their health effectively by rationally choosinga health-promoting lifestyle, a preferred treatment option and a particular GP or hospital (no mention of social determinants of health e.g. effects of poverty)

25. “How can I compare hospitals? • The Find and Choose Hospitals function [hyperlink] is the most sophisticated hospital comparison system in the UK. It allows you to compare hospitals on a wide and growing range of factors, including: • overall quality of service mortality rates • other patients’ views waiting times • infection rates food quality • parking facilities disabled access •  For example, you could search for hospitals within 50 miles of your home that offer hip replacements. You can then compare them in an easy-to-read table, according to the factors above and many more.” A library service for people to use NHS Choices to chose their hospital had no takers in 6 months

26. Resistance to Choose and Book 2:The technology-in-use“hopeless”“like flogging a dead horse”“a minefield”“a complete shambles”“Creak and Break” Crashing Freezing Running slowly Asking for manual data entry e.g. of patient’s phone number Giving wrong password Allocating to wrong clinic Referrals getting lost in the system No appointments available

27. Resistance to Choose and Book 2:The technology-in-use

28. Resistance to Choose and Book 2:The technology-in-use

29. Resistance to Choose and Book 3:Altered roles and relationships“We seem to be moving away from curing, caring and comforting to robotic automata” - GP“I need to save this [letter] in Choose and Book …now what I’m going to do in my capacity as ‘absolutely nothing’, I’m going to attach it….” - Receptionist with 30 years’ experience

30. Resistance to Choose and Book 4:Interference with contextual judgements“The choice is only of the crudest kind” -- GPGPs have rich local knowledge (names, styles and interests of local consultants; names and scope of clinics; how to work round local administrative problems). They also know the patient (personal history, personality, family support).The Choose and Book system containsa different kind of knowledge: depersonalised, abstracted, generic (e.g. ‘quality scores’). It is more rationalbut less useful.

31. Good doctoring is “a relational competence, where empathic perceptiveness and creativity render doctors capable of using their personal qualities, together with the scientific and technologic tools of medicine, to provide individualized help attuned to the particular circumstances of the patient.” EdvinSchei: Perspecives in Biology and Medicine 2006; 49: 393

32. Conceptual commodification of medical work by expert systems “External control over medical care requires something more than literal commodification. Rather, it requires conceptual commodification of the output of the medical labour process: that is, its conceptualization in a standardized manner. Such commodification facilitates control over the production of services, not just over the arrangements for their exchange…. The basic strategy of commodification is to establish a classification system into which unique cases can be grouped in order to provide a definition of medical output or workload.” Stave Harrison, Public Administration, 87, 184

33. Resistance to Choose and Book 4:Interference with contextual judgements

34. Resistance to Choose and Book 5:Cost“we realise what a waste of time and effort [Choose and Book] is. Our intention is to utilise resources to provide the best possible care for our patients despite the [policymakers’] best efforts to reduce these resources, all in the name of efficiency i.e. cost cutting!” - GP

35. A generalizable theory of resistance to big IT? Clinicians are usually professionally motivated. They seek to provide excellent care. They resist five things: Policies that interfere with excellent care Technologies that interfere with excellent care Interference with the [symbolic] roles and relationships that define and constitute professional practice Encroachment of ‘the system’ into the clinical situation Cost

36. Example 2: Telehealthand telecare Limited adoption & abandonment can also be explained by five kinds of resistance: To policies that interfere with excellent care To technologies that interfere with excellent care To altered [symbolic] roles and relationships To encroachment of ‘the system’ into clinical situations To cost Paper in press for SocSci Med

37. Standard ‘resistance’ argumentCritique A new theory of resistance ‘Expert systems’MethodologyEmpirical exampleGeneralizability?Discussion

38. Thank you for your attention! Professor Trish Greenhalgh @trishgreenhalgh