Physicians\' Opinions on Information Technology: Using Preference Profiles for Market Segmentation

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Physicians' Opinions on Information Technology: Using Preference
Profiles for Market Segmentation
Thomas J. Muscarello, Ph.D.
Director of External Programs and Research
School of Computer Science, Telecommunications and Information Systems (CTI)
DePaul University
Ulrike Wigger, Ph.D.
Senior Analyst
First Consulting Group
David R Donohue, M.A.
Qualitative Technologies, Inc
Northwestern University, Evanston, IL
Olena M. Marshall
Research Coordinator
School of Computer Science, Telecommunications and Information Systems (CTI)
DePaul University
This work was motivated by the need to develop a marketing strategy to establish physician buy-in for a
new enterprise-wide information system. Researchers in Health Information Management and Information
Systems from the University of Illinois and DePaul University, Chicago, used a combination of qualitative
and quantitative methods to prepare a novel survey instrument. Study participants included primary care
physicians and medical students from the greater Chicago area.
The findings from this study will enable information management professionals to plan system
implementation and training interventions more effectively. In particular, this study shows that physicians’
opinion types on use of information technology (IT) can be differentiated into (a) those who are largely self-
motivated and will likely need only minimal training interventions, (b) those who need additional training in
computer skills, and (c) those who are likely to require motivational interventions that are beyond the reach
and jurisdiction of information systems departments. Interventions should thus be type-specific and not
solely based on physicians’ demographics or specialty membership.
Problems of Implementing Health Care Information Systems
One of the most pressing problems in the healthcare industry is the lack of integrated clinical databases and
decision support tools. Many organizations are now attempting to address the following problems:
1. Lack /non-availability of clinical data with the following consequences:
• Waste of time and energy (physicians, nurses, clerks)
• Duplication of tests (e.g., an MRI costs $1,000 plus)
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• Legal liability/malpractice risks (e.g., mammography or skin biopsy results can quot;become
lostquot; because outstanding tests are not flagged and thus escape attention.)
2. Data integrity problems with the following consequences:
• Incomplete and/or multiple partial records
quot;Where is the EKG? Where is the chart? [Nowhere is it to be found.] When was the last
admission? Did he have an old chart? Does he have a new one?quot;
OR
quot;Do we have an old chart?quot;
quot;Yeah, but not herequot;
3. Lack of easy to use networked systems with the following consequences:
• Problems in coordinating longitudinal care (problems in communicating and obtaining
information from other units inside and outside the hospital -- especially crucial for
primary care gatekeepers, who are responsible for costs incurred outside their clinic.)
quot;Still flying by the seats of your pants half-the-timequot;
• No reminders for preventative measures e.g., tests, immunizations, drug interaction checking.)
• Impact on patient education (not having easy access to appropriate materials and not being able
to print them out right on the spot.)
Once an organization has invested in the technical infrastructure, system hardware and software,
information systems/support personnel, and training programs the systems may still fail. These failures may
seem to result from end user indifference, lack of use, or outright resistance. However, the underlying cause
for failure lies, not so much in the failures of the end users, but in a lack of understanding of how those end
users solve problems and what their true system needs are. We can use medical terminology to simply
illustrate this problem. By not properly “diagnosing” the “patient” an improper or incomplete “treatment
plan” is designed and implemented. The “patient” is then blamed for her own worsening condition.
Substitute quot;analyzingquot; for quot;diagnosingquot;, quot;system end userquot; for quot;patientquot;, and quot;system implementation and
rollout planquot; for quot;treatment planquot; and we have described the IT problem which this paper addresses.
The three main components of an information system are hardware, software, and people. It is the last
component that is frequently given the least attention by the developers, with the consequences described in
the analogy illustrated above. A system designed without input from end users or without a knowledge of
how they do their jobs (basically in their case - how they make decisions) will not be useful to them. Even if
these issues are addressed, it may be hard or even impossible to convince them to use the system if their
attitudes and opinions toward the technology, how it is used, and how it will affect their work has not been
assessed and addressed in rollout and training.
Implementation of medical information systems involves more than training of health care professionals in
system functionality. This is, however, what most training in this domain consists of. In most cases, training
is delivered to most or all personnel of a department or a rotation at one time.
Usually this training is provided using a standardized approach (One size fits all.) This method ignores the
fact that the practitioners have different opinions and attitudes toward the uses and usefulness of information
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technology in medical practices. We cannot be sure what kinds of attitudes are held; nor can we be sure of
which individuals or types of individuals share certain attitudes solely by looking at specialty.
Building a Survey Tool for Assessing Physician Opinions
This approach used a combination of qualitative and quantitative methods.
To build the survey instrument, we started with the gathering of primary data via observations, interviews,
and focus groups. This process produced a broad range of issues and opinion statements regarding the topic
of interest. (Some key questions were: quot;What do you think about the use of information technologies in
health care? What do you like/dislike? What do you see as advantages/disadvantages?)
The survey instrument consisted of a selection of representative statements to be rank-ordered (not rated) in
terms of preference. Survey participants included primary care physicians and medical students. Data
analysis was performed with correlation and by-person factor analysis (grouping of participants based on the
various ways in which they rank-ordered the issues). This approach did not produce one average opinion,
but segmented the audience into several groups, based on differences in preference profiles. It also enabled
us to identify issues that are highly preferred in all segments as well as those that clearly differentiated
between them.
Physicians’ Preference Profiles on the Use of Information Technology
We found six different opinion profiles. These are described in the following subsections. Highly ranked
statements from the survey instrument are provided to illustrate the flavor of each opinion type.
1. Full-Range Adopters embraced a wide range of uses for information technologies. They saw the value of
IT to improve the quality of patient care and to increase efficiency in patient management activities and also,
to facilitate communications across their own office sites as well as with colleagues, insurers, and social
service agencies. Full-Range Adopters did not display any concerns about possible negative impacts of the
use of such technologies.
“Automatic reminders for routine scheduling and preventative care would make my life a lot easier.”
“Computer-based information networks will improve longitudinal care by providing coordination
between specialty and primary care physicians.”
“Computers will increase efficiency in handling patient management issues such as drug
interactions, flow sheets, etc.”
2. Skills-Concerned Adopters saw a similar range of uses, but expressed concerns about their own computer
skills.
“Computers could be useful, but I wonder whether I could ever take full advantage of their capabilities.”
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3. Technology-Critical Adopters also saw a wide range of uses, but were highly concerned about record
confidentiality and computer monitoring of their own actions.
“Confidentiality and security are bigger problems with computer records than with paper records.”
“Assessing performance is best done by directly observing the physician, not by computer monitoring.”
4. The Independently-Minded and Concerned showed a different scope of envisioned uses. Next to office
management and communications with colleagues, they emphasized literature access and personal research.
And they were highly concerned about record confidentiality, their own computer skills, and performance
assessment via computer monitoring. Their opinion profile appeared to stress the specialness of medical
knowledge, trust in the doctor-patient relationship, as well as professional autonomy and self-regulation.
“I will use computerized journals and article data bases to expand my medical knowledge.”
“I am interested in clinical information systems and data repositories to further my own research.”
5. The Inexperienced and Worried saw only a few benefits from the use of information technologies. These
included some for office management, personal research, and access to electronic journals and article
databases. But, they did have numerous concerns. They worried about performance assessment via
computer monitoring, record confidentiality and security, their own computer skills, depersonalizing effects,
and over-standardization of medical care. Their opinion profile appeared to emphasize worries about
professional autonomy, trust in the doctor-patient relationship, and the possibility that computers would be
catalysts for the degrading of medicine from a profession into a mere technical occupation. These people
worried about such things as quot;cookbook medicinequot; or “having medicine in a vending machine.quot;
As one participant stated during a focus session, quot;If computers can do it all, then why are we going to
school. Then the physician would not be needed. It would just be the patient in front of the computer.quot;
Other comments included the following:
“Physician’s knowledge, experience, and critical thinking abilities will decrease with reliance on
computers.”
“Information technologies will allow for too much standardization in medical care.”
6. The Business-Minded and Adaptive saw benefits from the use of information technologies. But, when
compared to the other opinion types, they emphasized a different scope of uses. Aside from patient
management and connecting with colleagues, they thought these technologies particularly useful to obtain
patient eligibility data and to consolidate insurer rules and regulations. Furthermore, they found the use of
computer-based records essential to compete for HMO and business contracts. Their only concerns were
record confidentiality and security, and that computer vendors might be able to manipulate them. This
perspective suggests a business mind that is adaptive to the requirements of managed care.
“Computer-based information networks will be useful to obtain patient eligibility data and to
consolidate insurer rules and regulations.”
“The use of computer-based patient records is essential to compete for HMO and business
contracts.”
These group profiles and the differences between the different groups are more easily understood when
visualized.
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Figure 1 is a chart depicting the preference profiles for the opinion types recognized. This allows a
comparison of how strongly each type ranked the preference items sorted. The items fall into two basic
categories: items of concern shown in the front half of the list, and items of utility shown in the back half of
the list. The X axis (columns) is labeled with the opinion types (1 through 6) corresponding to the type
descriptions above. The Y axis (rows) represents the composite rank intensity (+4 to -4) which was
assigned each item by the opinion group. It can be seen that opinion group 5, the Inexperienced and
Worried, is very much different from the others. This table also allows us to easily narrow down a small set
of differentiating statements that can be used to profile a physician's attitudinal type.
Factor Title 1 2 3 4 5 6
Pt Care Improvement 4 0 2 0 -2 1
Personal Tool 1 0 -3 3 1 -2
(Research)
Assets
Office Management 2 3 3 2 0 1
Share Data w/Peers 3 2 1 2 -2 3
Comm - Soc Srv 2 1 2 -1 0 -3
Comm - Insurer 1 1 1 1 0 4
Business/HMO 0 -1 0 -3 -3 2
Contracts
Computer Skills -2 4 1 4 2 0
Performance -1 0 2 3 4 0
Liabilities
Assessment
Critical Thinking -4 0 -2 -4 3 -4
Confidentiality, Security -3 -1 4 4 3 2
Depersonalizing -3 -3 1 -2 4 0
Too Much -2 -3 -1 -3 3 0
Standardization
Figure 1. Most important differentiating characteristics by type.
Figure 2 is a mapping of the same values, but comparing only the two main groups of adopters, the Full-
Range versus the Skills-Concerned. Here we see how closely these two adopter groups ranked most items,
with two main exceptions. First, the Full-Range Adopters value the utility of information systems in
providing patient care improvement. More important, from an implementation/training viewpoint, the
Skills-Concerned are very worried about their ability to use computers.
Figure 3 represents a map of ranked items comparing Technology-Critical Adopters with the Independently-
Minded and Concerned group. Once again we see certain similarities. Major differences occur in the views
of these groups regarding the utility of information systems as personal research tools. The Independently-
Minded and Concerned values this capability, while the Technology-Critical Adopters see no need for doing
research using a networked system. On the other hand, the Independently-Minded and Concerned sees less
value in using systems for business contacts and communications with Social Service agencies.
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Figure 4 is a comparison of the Full-Range Adopters versus the Business-Minded and Adaptive. Here we
see the low emphasis placed on issues of confidentiality, depersonalization, and standardization of care by
Full-Range Adopters. The Business-Minded and Adaptive ranks these items as moderate to important. On
the other hand the Business-Minded and Adaptive has little concern about communication with Social
Service agencies via the system while Full-Range Adopters rank this item highly.
Patterns and Issues of Concern
The following overall patterns emerged from the study. Members of all groups were in general agreement
on some issues. There were also findings that go against the commonly held wisdom.
Literature research versus office and patient management: This study showed that using computers to
access electronic journals and article databases is not the most desirable application for all physicians.
Instead, the common denominator in this study was the use of information technologies to improve patient
care and increase efficiency in office management activities. This is the one issue that all types agree on. In
particular, the three Adopter types wanted automatic reminders for preventive care and help in drug
interaction screening.
Confidentiality and performance assessment: The three opinion types that were highly concerned about
computer record confidentiality and security showed at the same time strong reservations about the use of
computers for monitoring their own performance. This was the case for Technology-Critical Adopters, the
Independently-Minded and Concerned, as well as for the Inexperienced and Worried. This co-occurrence of
concerns suggests that, for these participants, problems with information technologies might be less rooted
in the technology. Resentment of a particular health care ideology, not the technology, might be the reason
for the appearance of “cultural obstacles” during system implementation. Although many in the field
propound that confidentiality is a primary concern of all practitioners, the majority of this study’s
participants did not rank this issue highly.
In summary, for three of the opinion types identified in this study, the use of information technologies
appears to fit within their image of medical practice and health care delivery. In this study, they were
identified as: Full-Range Adopters, Skills-Concerned Adopters, and the Business-Minded and Adaptive. It
should be noted that age and gender were not consistently related to the type of opinion expressed. For the
other three opinion types, the use of information technologies appears to collide with their image of medical
practice philosophy. In this study, they were identified as: Technology-Critical Adopters, The
Independently-Minded and Concerned, and The Inexperienced and Worried.
Use of Physician Profiles during Systems Implementations
Findings from this study have been used successfully during enterprise-wide systems implementations of
computer-based patient record (CPR) systems in the USA and Germany. The implementation teams and
trainers first familiarized themselves with the different types of opinions, common patterns and underlying
issues of concern. The teams were prepared to expect and handle a wide range of physician opinions and
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concerns, some of which had to do with changes in workflows, others with resistance to becoming
“trackable” and having one’s actions standardized and monitored by computers. Taking this information
into account, implementation plans were phased to first focus on improving patient care and increasing
efficiency in office management activities (typical first-phase applications included: results viewing, orders
management, as well as admissions, transfer, and discharge documentation). Throughout all project phases,
great care was taken to address and clarify confidentiality and security measures time and again. In training
sessions (group and one-on-one), heightened awareness of physicians’ needs and concerns enabled the
training teams to quickly recognize, address and resolve underlying issues. These measures contributed to
system adoption by end-user physicians at American and German implementation sites.
Even more possibilities for strategic interventions arise, when the survey instrument is used and
administered in an organization that is about to implement an enterprise-wide information system. Survey
results will provide an overview of physicians’ needs and concerns, as well as existing opinion types and
their distribution within the organization. Based on the results, potential physician champions can be
identified and asked to participate in systems implementation, configuration, and training activities. System
roll-out can be structured to first convert and go-live in clinical departments with high percentages of
physicians who are likely to adopt the system. Planning of training sessions and activities can be based on
real needs and physician data; extra sessions can be used to target type-specific needs and interests (i.e., to
improve computer skills, or to focus on literature access and personal research). Training can also be geared
toward the physician's standard learning methods (quot;see one, do one, teach onequot;) and tight time schedules
rather than the usual classroom sessions. It is also possible to administer the survey instrument pre and post
implementation. This strategy assesses changes in physicians’ attitudes and enables the implementation
team to track and document implementation progress.
Recommendations
Being able to identify these different opinion types allows information management professionals to make
informed strategic decisions in implementation planning, communications, training, and roll-out.
The following steps are recommended when using this methodology:
• Segment your physician audience by preference profiling all physicians.
• Identify profile groups and individual members of each group.
• Identify Full-Range Adopters who are highly respected as well as educationally and clinically
influential. They can serve as system champions to help motivate their more reluctant
colleagues, such as the Technology-Critical Adopters.
• Incorporate preference profiles in roll-out planning and phasing. If possible, start roll-out in
departments that have the highest numbers of potential physician champions. Also, start with
system applications that are likely to achieve the greatest buy-in from physician endusers.
On the whole, regardless of the segment, level of computer skills, or types of desired functionalities,
physicians’ concerns (such as: quot;What is going to be done with the data you will be collecting on me and
my patients? Who will see it? What will be done internally? What goes externally? And if so, in which
format? etc.quot;) should be consistently incorporated in all communications and training interventions. This
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would include extra meetings, extra efforts to involve physicians in systems configuration (i.e., in flowchart,
forms, and document design), extra issues of newsletters (with articles written by physicians on how they
will use the system in their daily work), one-page fliers and other forms of communications. To achieve true
physician buy-in and system ownership, the training of medical practitioners - many of whom have not
regularly used information systems – is most usefully approached not only as an educational issue, but also
as a marketing and motivational challenge.
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Full-Range vs Skills-Concerned Adopters
Pt Care Improvement
4
Too Much Standardization Personal Tool (Research)
2
Depersonalizing Office Management
0
-2
Confidentiality, Security Share Data w /Peers
-4
Critical Thinking Comm - Soc Srv
Performance Assessment Comm - Insurer
Computer Skills Business/HMO Contracts
Full-Range 1
2
Skills-Concerned
Figure 2. Differentiation of Full-Range vs. Skills-Concerned Adopters.
Technology-Critical Adopters vs Independent & Concerned
Pt Care Improvement
4
Too Much Standardization Personal Tool (Research)
2
Depersonalizing Office Management
0
-2
Confidentiality, Security Share Data w /Peers
-4
Critical Thinking Comm - Soc Srv
Performance Assessment Comm - Insurer
Computer Skills Business/HMO Contracts
3
4
Figure 3. Differentiation of Independently-Minded vs. Independent & Concerned.
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Full-Range Adopters vs Business-Minded & Adaptive
Pt Care Improvement
4
Too Much Standardization Personal Tool (Research)
2
Depersonalizing Office Management
0
-2
Confidentiality, Security Share Data w /Peers
-4
Critical Thinking Comm - Soc Srv
Performance Assessment Comm - Insurer
Computer Skills Business/HMO Contracts
Full-Range Adopters 1
Business-Minded & Adaptive 6
Figure 4. Differentiation of Full-Range Adopters vs. Business-Minded & Adaptive.
David R. Donohue, Editor
Qualitative Technologies, Inc
Waukegan, IL 60085-4663
Copyright Qualitative Technologies, Inc. 2005