Professor Trish Greenhalgh @trishgreenhalgh Technology adoption: whats the problem? Teddy Chester Lecture 1 st October 2013

Professor Trish Greenhalgh

@trishgreenhalgh

Technology adoption: what’s the problem?

Teddy Chester Lecture 1st October 2013

Unlearning

Structuration theory

The technology dimension

‘Contemporary’ ST

Example: Choose & Book

Extended theory

Empirical data

Conclusions

Unlearning





Extended theory

Empirical data

Conclusions

We need to unlearn some stuff

Theories of individual adoption, based on cognitive psychology, explain a TINY % of technology adoption problems in the NHS

Simplistic

Individualistic

Devoid of context

Positivistic

Stereotypical

Value-laden

Pro-innovation bias

Flawed conceptual model of ‘resistance’ Resistance = stupidity + skill deficit + fear

Solution = behaviourist tactics (incentives, training, encouragement, ‘leadership’, ‘good management’)

Flawed behaviourist solution

“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

Standard Iowa corn (1950s) Hybrid corn (1950s)

The original diffusion of innovations study

“Back in 1954, one of the Iowa farmers that I interviewed for my PhD rejected all of the chemical innovations that I was then studying. He insisted that his neighbours, who has adopted these chemicals, were killing their songbirds and the earthworms in the soil.

I had selected the new farm ideas in my innovativeness scale on the advice of agricultural experts at Iowa State University; I was measuring the best recommended farming practice of that day.

The organic farmer in my sample earned the lowest score on my innovativeness scale, and was categorised as a laggard.”

Everett RogersDiffusion of Innovations, 5th Edition, 2003

Everett Rogers unlearns

Technologies and work practices are best co-designed using participatory methods in the workplace setting, drawing on common-sense guiding principles such as

• staff should be able to access and control the resources they need to do their jobs

• processes should be minimally-specified (e.g. stipulating ends but not means) to support adaptive local solutions

Chearns 1987

Popular alternative 1: Socio-technical systems theory

Limitation: The ‘socio-technical system’ does not include a rich theorisation of either people (e.g. doctors) or society (e.g. political context of NHS IT)

Humans and technologies are linked in networks

These networks are generally dynamic and unstable

To introduce a technology you need to stabilise the network

Latour 1986

Popular alternative 2: Actor-network theory

Limitations: Views humans and technologies as ‘symmetrical’. Views ‘agency’ as a product of the network – hard to integrate a theorisation of professional ethics or identity. Flat ontology.

Unlearning





Extended theory

Empirical data

Conclusions

“People are not passive recipients of innovations. Rather (and to a greater or lesser extent in different individuals), they seek innovations out, experiment with them, evaluate them, find (or fail to find) meaning in them, develop feelings (positive or negative) about them, challenge them, worry about them, complain about them, work around them, gain experience with them, modify them to fit particular tasks, and try to improve or redesign them—often through dialogue with other users.”

What society sees as correct, reasonable, affordable, legal

Script atTime t+1

SOCIAL STRUCTURES

INDIVIDUAL AGENCY

Script atTime t

Script atTime t-1

What individuals actually do

Structuration theory (Giddens)

SOCIAL STRUCTURES

INDIVIDUAL AGENCY

Birthdayparty 1950


Structuration theory (example)

Birthdayparty 1980

Birthdayparty 2013


Unlearning





Implications

Summary

DIscussion

SOCIAL STRUCTURES

INDIVIDUAL AGENCY

Imaging a patient


Technology structuration theory (Barley)

Imaging a patient

Imaging a patientX-ray

machineCTscanner

MRIscanner


Technology structuration theory (Barley)

HOSPITAL A

Technician takes X-ray, doctor interprets X-ray

Technician takes CT scan, doctor interprets CT scan

CTscanner

HOSPITAL B

Technician takes X-ray, doctor interprets X-ray

Technician takes CT scan, and helps doctor interpret it

CTscanner

Barley’s model of technology as an “occasion for structuring”

Script at Time t - 1

Script at Time t

static technology

upgrade upgrade upgrade upgradeupgrade

Problem: software is an evolving technology!

Unlearning





Extended theory

Empirical data

Conclusions

t1

t2

t3

And what are the outcomes of this action?

What configuration of people, technologies and wider influences (cultural, economic, legal etc) is producing what action?

Contemporary adaptation of Giddens / Barley’s theories to accommodate evolving technologies(Greenhalgh & Stones)

To understand the macro and meso, we must zoom in to the micro and look through the eyes of front-line actors

An ‘actor-network’ in which human agency is richly theorised (i.e. humans act, technologies don’t really) and we assume a ‘layered ontology’

Meso-level: the organisation’sset-up, resources and ways of working

Macro-level: the social, political, economic and technological context of wider society

Micro level: the people, the technologies and the front-line, as-it-happens detail

Micro-level (e.g. clinical encounter)

People’s identities, roles, knowledge, skills

What the technology can and can’t do in a particular situation and setting

Meso-levele.g. organisation

Job descriptions, training, work routines

IT systems and in-house knowledge

Culture and support for innovation/risk-taking

Macro-level

National and regional policies and priorities

Economic climate

Technological developments

Social movements

Professional norms and standards

Person A sees the strategic terrain in a particular way. S/he is more influenced by some social structures than others, and sees more potential in some technologies than others

Person B sees the strategic terrain, and the potential of technologies, differently

Technology X came from somewhere. Inscribed in it are ‘scripts’ (intended by its designers) and also potential uses that the designers did not anticipate

The clinician

What is my background, identity, values, education, skills, IT-literacy etc?

How do I see the strategic terrain (e.g. what do I see as ‘the Royal College view’ and ‘the way things are done in this organisation’)?

What is my clinical assessment of this patient and priorities for managing them?

What do I think the patient thinks – and what do I think the technology can do?

The patient

What is my background, identity, values, education, skills, IT-literacy etc?

In what way am I sick – and how does this affect my interest and capacity?

What do I desire (my‘presenting complaint’ and my‘hidden agenda’)?

What do I think the clinician thinks, and what do I assume about the technologies?

The technology

What was I designed to do – by whom, and for what?

What standards and assumptions have been built into me as codes, options or decision models?

With what other people and technologies do (and don’t) I connect?

What are my material properties and how do they play out in this situation?

Action in this situation

What is actually done?

What is the short-term impact in this clinical situation?

What is the longer term impact on the way people think and behave?

Unlearning





Extended theory

Empirical data

Conclusions

Choose & Book

Remote booking of outpatient appointments by GP or 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

Choose & Book: Empirical study 2007-10

Ethnographic observation in 4 GP practices over 2 years, including 29 GP consultations + 58 ‘admin’ referrals

Video and screen capture data on 12 consultations

Naturally occurring talk and ‘on the job’ interviews

Documents, letters, email exchanges

Choose & Book Linked 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 abandoned in most GP practices, despite financial incentives:

“I was a pioneer user but I no longer use it at all” - GP

Choose & Book (8 years on…)

Meso-level: 4 GP practices with different cultures, IT infrastructure and ways of working

Macro-level: Neoliberalism, ‘choice’ policy; regulatory bodies (CQC); economy (& specific incentives); professional norms/values

Micro level: The clinical encounter and admin work

Unlearning





Extended theory

Empirical data

Conclusions

Human agents think and feel and care

A new [normative] theory of resistance

Grounded in the ethics of professional practice

Asks ‘What is excellence in medicine / nursing?’ and ‘How does this IT help (or stop) me achieving excellence?’

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.”

Schei: Perspecives in Biology and Medicine 2006; 49: 393

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

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”

Giddens ‘The Consequences of Modernity’

The ‘expert system’ (sociology)

Classification systems “describe the way things are”.

Embedded rules and protocols impose a distant set of values and priorities on local situations ‘empty out’ their detail.

Mary Douglas, ‘How Institutions Think’, 1986

Hypothesis

Clinicians’ 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.

Ethnography (qualitative observation) can tell the story about people doing work with technology

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”

Dourish and Bell: ‘Divining a Digital Future’

Critical ethnography: examples of questionsWho 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 not heard and why?What does someone gain by ‘forgetting’ their password?

Ethnography can even help us study infrastructure

What is infrastructure?

Infrastructure is the “technical stuff” that supports our work. Its characteristics include:

• Embedded (=> it’s ‘in’ things)• Learned as part of membership of a community• Embodies standards• Becomes visible when it breaks down

An ethnography of infrastructure (Star)

Guiding questions in the ethnography of infrastructure:

1. What are the unwritten rules that shape human behaviour?

2. Who is doing the invisible work to keep the show on the road?

3. What are the paradoxes and what can we learn from these?

Unlearning





Extended theory

Empirical data

Conclusions

Why did staff resist C&B? GPs and their staff were professionally motivated. They sought to provide excellent care. They resisted four things:

1. The policy of ‘choice’.2. ‘Socio-materiality’: especially material properties of the

technology-in-use (+ what it cost to install and maintain).3. Interference with contextual judgements. 4. Interference with social roles and relationships.

Resistance to C&B 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

The ‘choice’ myth:

A person can manage their health effectively by rationally choosing a 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)

“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

Resistance to C&B 2: Socio-materiality

“hopeless”

“like flogging a dead horse”

“a minefield”

“a complete shambles”

“Creak and Break”

CrashingFreezingRunning slowlyAsking for manual data entry e.g. of patient’s phone numberGiving wrong passwordAllocating to wrong clinicReferrals getting lost in the systemNo appointments available




Cost (and opportunity cost) of the technology:

“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

Resistance to C&B 3: Interference with contextual judgements

“The choice is only of the crudest kind” -- GP

GPs 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 contains a different kind of knowledge: depersonalised, abstracted, generic (e.g. ‘quality scores’). It is more rational but less useful.

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.”

Edvin Schei: Perspecives in Biology and Medicine 2006; 49: 393

Conceptual commodification“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

Resistance to C&B 3:Interference with contextual judgements

Resistance to C&B 4: 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

Resistance to C&B: Refusal of policymakers to engage with anything beyond a ‘behaviourist’ framing

No national-level response to widespread complaints about inappropriateness of choice policy, material difficulties or lack of granularity in the system.

“It’s just two or three more mouse clicks!” - PCT manager

Meso-level: resistance to socio-materiality of C&B in the work [and home] setting

Macro-level: resistance to the policy of choice and (more generally) to neoliberal ‘conceptual commodification’ of medical practice

Micro level: resistance to interference with contextual judgements from expert system and with professional identity

SUMMARY: Why did staff resist C&B?

Unlearning





Extended theory

Empirical data

Conclusions

Conclusions

The non-adoption, partial adoption and abandonment of technologies in healthcare has been overly influenced by naïve and undertheorised behaviourist models.

Much can be gained by taking a ‘layered ontology’ and studying the interactions between macro (social context – political, economic, professional etc), meso (organisational, socio-material work practices) and micro (clinical encounter) in a dynamic sociotechncial network.

Structuration theory, in contemporary form, can help in the theorisation of human agency: non-adoption can be explained in terms of how individuals [and technologies] embrace and are influenced by wider social structures.

Professor Trish Greenhalgh

@trishgreenhalgh

Thank you for your attention

Teddy Chester Lecture 1st October 2013