Abstract
Many unintended and undesired consequences of healthcare information technologies (HIT) are generated by interactions between newly introduced HIT and the existing healthcare organization’s sociotechnical system--its workflows, culture, social interactions, physical environment, and technologies. This chapter presents and illustrates a model of these interactions that we call interactive sociotechnical analysis (ISTA). ISTA places special emphasis on recursive processes (i.e., feedback loops that alter the uses of the newly introduced HIT) promote second-level changes in the social system, and sometimes lead to changes in the new HIT systems themselves. We discuss ISTA’s implications for improving HIT implementation practices and suggest how clinicians, IT specialists, and managers can better anticipate likely consequences of introducing HIT; more effectively diagnose unforeseeable consequences which emerge during implementation; and better respond to these emerging consequences.
TopBackground
Studies of Unintended Consequences
A growing body of research and user reports reveals many unanticipated and undesired consequences of implementation (Aarts, Ash, & Berg, 2007; Ash, Berg, & Coiera, 2004; Campbell, Sittig, Ash, Guappone, & Dykstra, 2006; Han et al., 2005; Koppel et al., 2005; Rosenbloom et al., 2006; Schneider & Schneider, 2006; Silverstein, 2006; Wachter, 2004, 2006; Wears & Berg, 2005). Unanticipated and undesirable consequences, which are usually just called unintended consequences (Ash, Sittig, Dykstra et al., 2007), often undermine patient safety practices and occasionally harm patients (Weiner, Kfuri, Chan, & Fowles, 2007; Campbell, Sittig, Ash, Guappone, & Dykstra, 2007; McAlearney, Vrontos, Schneider, Christine R. Curran, & Pedersen, 2007). Unintended consequences also lead to cost escalations, resistance to implementation, and sometimes to failures of HIT projects (Silverstein, 2006).
The literature on HIT’s unintended consequences documents these interactions and contains several typologies and conceptual frameworks that help guide research and practice (Ash, et al., 2004; Ash, Sittig, Dykstra et al., 2007; Campbell et al., 2006). Our previous paper (Harrison, Koppel, & Bar-Lev, 2007) provides a detailed comparison of the ISTA model to the best-known typologies (Ash, et al., 2004; Campbell et al., 2006). One of the most important differences concerns the typologies’ usability. Conceptual frameworks are usually more helpful when they represent important empirical variations through just a few distinctive types.
To enhance ISTA’s usability we sought to encompass the diverse sociotechnical sources of unintended consequences within just five types, and we characterized these types in terms of a very limited set of concepts. Moreover, we placed greater emphasis than previous studies did on consequences resulting from emergent interactions and containing recursive feedback loops among elements of the sociotechnical system – for example, effects of HIT on clinical practices and relations, which in turn shape the way that HIT is used.
Key Terms in this Chapter
Ergonomics: Also known as human factors, ergonomics is the development and application of knowledge of human capacities to the design of systems, organizations, jobs, technologies, and products. The aim is to enhance safety, efficiency, and usability.
Ergonomics: Also known as human factors, ergonomics is the development and application of knowledge of human capacities to the design of systems, organizations, jobs, technologies, and products. The aim is to enhance safety, efficiency, and usability.
Sociotechnical Systems: An approach to organizational research and development that treats organizational behavior and performance as emerging through interactions and alignments among the technical subsystem, social subsystem, and the organization’s social and organizational context.
HIT-in-Use: Refers to actual uses of Health Information Technology, in contrast to those that were intended by HIT designers or managers.
Unintended Consequences: Unanticipated side effects of interventions into organizations. When used without a modifier, the term usually implies undesired effects.
Sociotechnical Systems: An approach to organizational research and development that treats organizational behavior and performance as emerging through interactions and alignments among the technical subsystem, social subsystem, and the organization’s social and organizational context.
Unintended Consequences: Unanticipated side effects of interventions into organizations. When used without a modifier, the term usually implies undesired effects.
Sociotechnical Interaction: Mutual influence among the technical and social subsystems and among their components (e.g., interaction of technologies and physical setting of work – both of which are part of the technical subsystem).
Recursive Interaction: Refers to system feedback loops that alter the uses of the newly introduced HIT, promote second-level changes in the social system, and sometimes lead to changes in HIT configurations
Emergent Processes: Social and organizational processes, such as an altered forms of communication or work flow among clinicians, that gradually develop and become apparent during implementation of HIT -- rather than being present and apparent before implementation.
HIT-in-Use: Refers to actual uses of Health Information Technology, in contrast to those that were intended by HIT designers or managers.
Recursive Interaction: Refers to system feedback loops that alter the uses of the newly introduced HIT, promote second-level changes in the social system, and sometimes lead to changes in HIT configurations
Sociotechnical Interaction: Mutual influence among the technical and social subsystems and among their components (e.g., interaction of technologies and physical setting of work – both of which are part of the technical subsystem).
Emergent Processes: Social and organizational processes, such as an altered forms of communication or work flow among clinicians, that gradually develop and become apparent during implementation of HIT -- rather than being present and apparent before implementation.