Facilitating adoption of telemedicine disrupting habits and organizational routines

Habits and Organizational Routines: Preliminary Evidence of Habit

Disruption in TelehealthImplementations

Elena KarahannaJennifer ClaggettChristina SerranoGreta L. Polites

GPT ConferenceMarch 17, 2011

MIS Department

Study Context:Nursing Home Telehealth Project

NH 1

NH 5

NH 3

NH 2

NH 6

NH 4Parent NursingHomeCompany

TelemedicineProvider

(Non-Profit)

Attending Physicians

Specialists(dermatology, psychology)

Remote Emergency Room

NH 7 NH 8

NH 9

Presenter

Presentation Notes

STOP AND TALK ABOUT CURRENT SITUATION So, before I get too far into the project, I want to explain the situation at these homes. You’re in rural GA, with a population of aging patients where medical treatment is a common necessity. Homes are staffed with nurses, but no doctors. Each patient has an attending physician – which is usually a family practioner – the first point of contact and who is responsible for managing their total health care. However, just like the ER numbers you saw on the last slide, the attending physician may be several town over, as well. It would be normal practice for them to come in and do rounds once a month – so what do you do if the patient develops some severe symptoms between visits? Currently – the nursing staff would call the doctors and describe the situation. Voluntary! Process difference and role difference Transition: So, just to further explain our research design…

CHOICE OF CONSULTATION

DELIBERATE REASONING

•Relative Advantage•Fit•Power/Politics•Self-Efficacy•Relationships•Social Norms•Materiality

ORG ROUTINE

HabitPhysician

HabitNurseHabit

NurseHabitNurseHabit

NurseHabitNurse

STATUSQUO

Usage or non-usage of telemedicine occurs through two routes-Deliberate Processing-Automatic Processing

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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 Habits

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

Presenter

Presentation Notes

Many behaviors are performed repeatedly at work, but not all are habits. An organizational routine may involve one or many people. mortgage loan example? change request example? new employee example? Each individual follows a specific sequence of steps that, over time and with adequate repetition in a stable performance context, may become truly automatized or habituated. *** Since organizational routines (and in turn, habits) are a form of cognitive script, we can look to the script literature for insights into how to disrupt IS usage habits. ***

Disrupting IS Usage Habits

Interference(obstacles, errors)

Distraction

•Action slips (Norman, 1981)

•Script disruption techniques (Schank & Abelson 1977)


B

InterferenceTechniques

“Pull the plug” Change sequencing and timing of steps

Automation / “push” vs. “pull”

(A) Eliminating Triggersby ChangingBusiness Processes:

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

Develop new organizational routine

Presenter

Presentation Notes

Introduce my BI background here; use BI examples as needed.

DistractionTechniques

Manipulating the Context for ExistingBusiness Processes:

Monitoring and feedback

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

• Knowledge levels (Olfman et al. 2006)

Command-Based

Tool Procedural

Business Procedural

Tool Conceptual

Business Conceptual

Motivational

Meta-Cognitive

Training• Eliminating knowledge barriers vs.

retraining responses to situational cues

•

Business Procedural

Business Conceptual

Training in the context of actual work routines and situational triggers


Presenter

Presentation Notes

PER ELENA: RETRAINING NEEDS TO BE DISCUSSED BETTER. *** DRAW IN A DISCUSSION OF SCRIPTS HERE !!! *** (May also want to briefly mention training to build self-efficacy and change attitudes, as well as just to eliminate knowledge barriers. Keep in mind that meta-cognitive training is designed to impact self-efficacy.)

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)

Presenter

Presentation Notes

We’re studying a set of telehealth projects being implemented inside nursing homes. This is an ongoing study – what I’m presenting is just our preliminary findings based on initial impressions. Interviews / stakeholders -> Missing patients?

Research DesignNH1 NH2 NH3 NH4 NH5 NH6 NH7 NH8 NH9

Attending Physician

Specialist

ER

• Embedded Case Study Design: 9 sites and 3 different telehealthuses

Data analysis underwayResults based on preliminary findings…

Presenter

Presentation Notes

This is an ongoing project, and we’re currently coding our interview data to thoroughly analyze it. However, I do want to share some preliminary findings based on our initial impressions from all of these interviews… Transition: My first pass at a model that starts to pin down some of these antecedents to primary appraisal

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 Routines

New Organizational Routine

Individual New Habit Physician

Individual New Habit Nurses

Status Quo Organizational Routine

Individual Habit Physician

Individual Habit Nurses

DisruptionInterferenceDistractionTraining-in-

Context

DevelopmentRepetition

SatisfactionStable Context

Evidence: Interference• Psychiatric Consults

– State withdrew funding for PASSR program

• Site 1– Heavy use of Telemed for

Psych– Strong satisfaction(better than

old)

• Site 2– No use– Substitute with existing org

routine - psych who already visited some patientsORG ROUTINE

HabitPhysician

HabitNurseHabit


NurseHabitNurse

CHOICE OF CONSULTATIONX

Evidence: DistractionPrompting• Deliberate reasoning by nurse – disrupts physician

habit and automatic performance of org routine.• “We just asked him if we could and he said “yes.”

CHOICE OF CONSULTATION

DELIBERATE REASONING

•Relative Advantage•Fit•Power/Politics•Self-Efficacy•Relationships•Social Norms

ORG ROUTINE

HabitPhysician

HabitNurseHabit


NurseHabitNurseX

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 telemeduse

– 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 ROUTINE

HabitPhysician

HabitNurseHabit


NurseHabitNurse

NEW ORG ROUTINE

HabitPhysician

HabitNurseHabit


NurseHabitNurse


• “… 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)


• “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 OrganizationalRoutines 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 Routines

Wound 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 Routines

New Organizational Routine

Individual New Habit Physician

Individual New Habit Nurses

Status Quo Organizational Routine

Individual Habit Physician

Individual Habit Nurses

DisruptionInterferenceDistractionTraining-in-

Context

DevelopmentRepetition

SatisfactionStable Context

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 vsthe development of new routines

Facilitating adoption of telemedicine disrupting habits and organizational routines

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