Facilitating adoption of telemedicine disrupting habits and organizational routines

Habits and Organizational Routines: Preliminary Evidence of Habit Disruption in Telehealth Implementations Elena Karahanna Jennifer Claggett Christina Serrano Greta L. Polites GPT Conference March 17, 2011 MIS Department

Study Context:Nursing Home Telehealth Project NH 1 NH 2 Attending PhysiciansParent NH 3 NH 4NursingHome NH 5 NH 6Company Specialists (dermatology, psychology) NH 7 NH 8 NH 9 Remote Emergency Room Telemedicine Provider (Non-Profit)

Usage or non-usage of telemedicine occurs through two routes -Deliberate Processing -Automatic Processing DELIBERATE REASONING •Relative Advantage •Fit •Power/Politics •Self-Efficacy •Relationships CHOICE OF •Social Norms CONSULTATION •Materiality ORG ROUTINE Habit Habit Nurse STATUS Habit Habit Nurse Habit Nurse QUO Physician Habit Nurse Nurse

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 HabitsPolites, G and Karahanna, E. (2010)The Embeddedness of Habits in Organizational Routines

Disrupting IS Usage Habits •Action slips (Norman, 1981) •Script disruption techniques (Schank & Abelson 1977) Interference Distraction (obstacles, errors)Polites, G and Karahanna, E. (2010)The Embeddedness of Habits in Organizational Routines

Interference Techniques(A) Eliminating Triggersby ChangingBusiness Processes: B “Pull the plug” Change sequencing and timing of steps Develop new organizational routine Automation / “push” vs. “pull”Polites, G and Karahanna, E. (2010), The Embeddedness of Habits in Organizational Routines

Distraction Techniques Manipulating the Context for Existing Business Processes: Monitoring and feedbackPolites, G and Karahanna, E. (2010), The Embeddedness of Habits in Organizational Routines

Training • Eliminating knowledge barriers vs. retraining responses to situational cues • Knowledge levels (Olfman et al. 2006) Command-Based Tool Procedural Business Procedural Training in the context Tool Conceptual of actual work routines Business Conceptual and situational triggers Motivational Meta-CognitivePolites, 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 Design• Embedded NH1 NH2 NH3 NH4 NH5 NH6 NH7 NH8 NH9 Case Study Attending Design: 9 Physician sites and 3 Specialist different ER telehealth uses Data analysis underway Results 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 RoutinesStatus Quo NewOrganizational Routine Organizational Routine Disruption Development Interference Repetition Distraction Satisfaction Training-in- Stable Context Context Individual Individual Individual New Individual NewHabit Physician Habit Nurses Habit Physician Habit Nurses

Evidence: Interference• Psychiatric Consults • Site 1 – State withdrew funding for – Heavy use of Telemed for PASSR program Psych – Strong satisfaction(better than old) • Site 2 – No use – Substitute with existing org routine - psych who already ORG ROUTINE Habit visited some patients Habit X Nurse Habit Nurse CHOICE OF Habit Habit Nurse Physician Habit Nurse CONSULTATION Nurse

Prompting Evidence: Distraction• Deliberate reasoning by nurse – disrupts physician habit and automatic performance of org routine.• “We just asked him if we could and he said “yes.” DELIBERATE REASONING •Relative Advantage •Fit •Power/Politics •Self-Efficacy •Relationships •Social Norms CHOICE OF CONSULTATION ORG ROUTINE Habit Habit Habit Nurse Habit Habit Nurse Nurse Habit Nurse Physician XNurse

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 telemed use – 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 NEW ORGROUTINE Habit ROUTINE Habit Habit Nurse Habit Nurse Habit Nurse Habit Nurse Habit Nurse Habit Nurse Habit Habit Nurse Habit Habit Nurse Physician Nurse Physician Nurse

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 Organizational Routines 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 RoutinesWound 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 RoutinesStatus Quo NewOrganizational Routine Organizational Routine Disruption Development Interference Repetition Distraction Satisfaction Training-in- Stable Context Context Individual Individual Individual New Individual NewHabit Physician Habit Nurses Habit Physician Habit Nurses

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 vs the development of new routines

Facilitating adoption of telemedicine disrupting habits and organizational routines

by Lloyd Sirmons on Mar 15, 2011

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