While other industries tend to be galloping towards information technology because of its promises of increasing market share, quality assessment and improvement and adding value, the healthcare industry is slow in the adoption of information technology. This paper focuses on one key reason why information technology is not catching up as rapidly as it should in the healthcare delivery system and that is user resistance. Using professional literature and publications, it describes user resistance, its causes and some of the management strategies that have been proven to work in dealing with such nemesis. It focuses specifically on the healthcare systems and offers solutions in reducing user resistant behaviors.
Information technology plays a vital role in the health care delivery system. Brailer D of the Framework for Strategic Action as cited by The Health Information Technology Final Report refers to Health information technology as “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision-making.” According to the Department of Health and Human Services website (http://www.hhs.gov/healthit/) health information technology (HIT) allows comprehensive management of medical information and its secure exchange between health care consumers and providers. The important role IT plays in healthcare is further stressed in the report” Costs and Benefits of Health Information Technology” prepared for Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services by Southern California Evidence-based Practice Center, Santa Monica, CA. In the report, the group points to evidence that suggests that health information technology can improve the efficiency, cost effectiveness, quality, and safety of medical care delivery by making best practice guidelines and evidence databases immediately available to clinicians, and by making computerized patient records available throughout the health care network. (http://www.ahrq.gov/downloads/pub/evidence/pdf/hitsyscosts/hitsys.pdf). These assessments are products of the crises and inefficiencies in the healthcare delivery system which HIT tend to addressed. The Department of Health and Human Services notes the broad uses of HIT as improving health care quality, preventing medical errors, reducing health care costs increase administrative efficiencies decrease paperwork and expanding access to affordable care.
Computerized physician order entry commonly known as CPOE is an example of the use of technology in health care. The system promises to improve patient safety as it radically reduces the way doctors, nurses and other hospital employee do their jobs. The November 01, 2005 edition of the CIO magazine quoting studies conducted at the Brigham and Women hospitals, where informatics leaders developed their own CPOE system in 1990s reveal that CPOE cut medication errors by 80%. The magazine also quoting a study by the Center for Information Technology leadership predicts that a nation wide adoption of the CPOE would save 44 billion a year in reduced costs from radiology, laboratory and medication errors (Patton 2005).
Because of the promises of information technology couple with increasing pressure to improve and innovate with the time and age, one would think that the deployment of IT in the health industry would be a roller coaster ride – no question asked. As witnessed by technological industries, hospitals and other health facilities are feeling the heat to gear up towards a push to purchase state-of-the art-technology which seems attractive so as to still on par with the latest advances in technology. On the contrary, the deployment of information technology solutions for health care has been riddled with problems resulting into failures and catastrophic losses. The Health Informatics Journal reports with concern that in developed nations, why productivity of service industries has increased significantly due to innovation through IT enabled processes, there is a low level of IT adoption in health (Ian England and Don Steward 2007). Quite often, when HIT failure is mentioned, minds quickly run to technical problems. In “overcoming resistance to new technology…,” Zeong Shaohong points out that flawed technology is not normally a culprit for these failures. He points out that 50 – 75% of information system failures in the behavioral health are the result of people related issues with specific reference to user resistance. (Behavior Health Management, Jan 1, 2004). Bluntly put, information technology systems are not widely accepted by health care professionals (Moore 1996). More observes that such attitude toward information technology in healthcare is wired and contrasts sharply towards the attitudes health professionals have shown towards other forms of technologies like diagnostic or therapeutic systems. What then sparks this resistance to information technology in the health field and how can it be avoided, minimized or managed?
User Resistance Defined
A JAMIA editorial states that just as patient acceptance is the final factor in successful health intervention, so is acceptance of information technology by its intended users as the final stage of health information systems implementation. Anything short of acceptance or adoption equals resistance and often results into loss of millions of dollars of investments and loss of productivity. User behavior, whether acceptance and adoption or resistance is key to the success or failure oaf any information system implementation.
In January 2003, according to a CIO magazine report, there was a high profile case that spooked the medical world and demonstrates a classical example of user resistance. Doctors at Cedars-Sanai Medical Center in Los Angeles became very much unhappy with a new CPOE system. Vexed by the extra time it took them to enter orders on the computer; they staged a rebellion against the new system. This forced the hospital to shelve the CPOE portion of a $32 million implementation project after three month of use. Naakesh A Dewan and Lorenzi NM as cited in the Behavioral Health management publication of January 1, 2004 by Shaohong Zheng, grouped resistance by end users into two broad categories: resistance to particular change and resistance to perceive changers. In the former, the resistance is directed against the actual change in the system while in the latter, resistance to the perceived changer occurs because of the negative feelings towards the organization, specific units, or specific managers. In such case, any change would be resisted because of who is behind it. Understanding these broad categories is vital in determining the management strategy to put into place to address each form of resistance.
Sources of User Resistance
Not all user resistant behaviors originate from end users. Lorenzi and Dewan as cited by Zheng identified three broad sources of user resistance to technology adoption namely technical, functional and people. They described technical source as the quality of the basic infrastructure that supports application and users such as hard ware, networking, operating systems, and support while the functional source of resistance includes acquisition of data, data storage, and information representation. People source, according to the authors, includes all who are involved in providing, managing or receiving care. It is important to know the source of resistant behavior before any management strategy can be put into place to address it. It is also important to understand the different systems and users when trying to understand user resistant behaviors. Tim et al note that some systems require voluntary usage while others are mandatory. So depending on the environment in which the system is implemented, users are going to respond differently.
Causes of User Resistance
Absence of Strategic information system planning is one major reason while users exhibit resistant behavior. “Strategic information system planning is the process of identifying and using priorities to the applications of information technology that will assist an organization in executing its business plans and achieving its strategic goals an objectives” (Austin & Boxerman 2003). Austin and Boxerman observe that with a change in IS priorities in healthcare to focus on integration of system across multiple platforms. Automation for patient records… a careful planning process to develop the proper architecture that facilitates data exchange needs to be put into place. They note that historically, information systems in healthcare organizations evolve in a piecemeal fashion rather than resulting from a careful planning process. Specific requirements for capturing data, storing them and retrieving them when needed developed on an ad hoc basis as new programs and services were added. As a result, since these technology solutions are the result of exigencies and don’t properly aligned with the organization’s strategic goals, users sometimes tend to resist since the implementation of the new solution may fall out of line of their work habits, routine, and scope.
Instead “Strategic IT Application in Healthcare, according to Ragbupathi and Tan focuses on the information requirement of ad hoc and poorly structured decision tasks. The applications concentrate on giving an organization an IT-based strategy for meeting competitive challenges.
Resistance to change has been noted as a common reason for most user resistant behavior in health IT. The application of information technology in healthcare organizations inevitable involves change in the way business is done which can be threatening to organizational stakeholders, especially employees. Fear of change is a common problem encountered in system development efforts which often results in tension and anxiety. Employees, for example may have concerns about possible effects of the new system on their jobs and possible changes in the work environment that may be required. Managers may have concerns about changes that could result in redistribution of power, greater centralization of authority, or increased demand for accountability as byproducts of the new system. Some may have concern that information system will result in more rigid and less flexible patterns of operation resulting into lack of discretion in carrying out the task. Although sometimes these concerns are unfounded and are due to the misconception of the technology, they are real and pose real problems (Austin and Boxerman 2003).
In “Acceptance of Information Technology by Healthcare Professions,” Moore observes that the barriers to the use of information technology within the healthcare delivery systems are primarily sociological, cultural, organizational, rather than technological. It’s uniqueness in several respects impact the ability of its individual members to adapt to change in the way they carry on their work by absorbing information technology (Moore 1996). He names these unique attributes as a) the unique knowledge-skill relationship within the health care system, b) the long training time and resultant knowledge fixation of physicians, and c) the relatively fixed hierarchy within the healthcare system. H. M. Hodge as cited by Moore observes that this unique knowledge skill relationship within the healthcare system often makes physicians to resist the use of information technology fearing that information technology can cause a change in the responsibilities of health care providers. The adoption of information technology “can disrupt traditional cultural roles in healthcare organizations and systems, as well as putting individuals who are traditionally considered as lower skill level than the physicians” (Moore 1996).
Physicians fear this change because it will have the propensity to put power and authority in the hands of lower leveled healthcare workers like nurses who may possess superior skills in the use of information technology. Some of these long standing traditions and cultures in the healthcare system sometimes run contrary to the core traditions and values of information technology and as a result, users will resist. As Hodge experienced as quoted by Moore, “I have had doctors tell me, for example. That entering orders is a nurse’s or ward clerk’s job. ‘You have a secretary who does your typing. I have a nurse; she enters my order.’ This attitude as Moore noted conflicts with the goal of information technology to record data at the point of entry” (Moore 1996).
The long training time of physicians resulting in a large amount of knowledge fixation, according to Moore is another reason why user will be resistant to information technology. Because of this long training time, physicians are so comfortable in the way they do things and know where to go to find help when they are in doubt. Adopting the use of information technology in their field is seen as an interruption because in their view what they are used to, still works and therefore there is no need for retraining to learn how to use information technology or re-teach them new ways to do their job. Also as noted by Moore, there is a relatively fixed hierarchy within the healthcare system which prohibits rapid organizational or structural change. In the healthcare profession physicians with long years of service play the dominant roles while newer members are in the apprentices. These newer and younger members often want to introduce change but such efforts always hit the rock because such change must be endorsed by older and dominant physicians. Hodge as cited by Moore reveals “the organization or structural change often required for the implementation of new information management technologies must then be endorsed by established members of the profession, whose status and financial rewards are tied to the status quo” (Moore 1996).
The technology introduced can also be a source of resistant behavior. This is when technology, as noted by Taylor in “Three Grand Challenges for Health Informatics” seems to get in the way of traditional ideas of good practice or infringe on territory that clinicians regard as requiring expert judgment. Such ambivalence to technology sometimes comes when the technology is perceived as telling the physician how to do his job or make their expertise irrelevant. For instance, “radiologists welcome new and better imaging techniques, because they believe that such development allow them to become better radiologists. Computer software that could help them interpret x-rays, however, poses a greater challenge to their belief in the value of their own expert knowledge and existing ways of working” (Taylor 2006).
Across industries, end users resist information technology due to the way the new system will impact their job or environment. In a study carried out Kalus et all examining user resistance, they found out that uncertainty, losing control, lack of input, self efficacy, workload, lack of fit, changed job, communication, complexity and technical problems (2007). Anytime, a new information system is introduced, end users are uncertain as to what will happen to them as a result of the new system. They are not sure if that is going to put them out of job or make their skill irrelevant. They also think that they are no longer in control as the technology introduced is doing the work for them and thereby affecting their worth on the job. Sometimes they feel that their work load is going to be increased by the new technology or if they will have to change their job or department altogether as they may not fit in the new role or assignment. Moreover, sometimes the complexities of the new system drive users to resist because they feel they may not be able to fully understand and utilize it. Some users are technophobic or afraid of technology and as such any new information technology is viewed as complex and impossible to learn or adapt. Others who are not afraid of technology may not want to put in the extra time and learn the new system because are consumed by their workload. The report found that users sometimes resist because of the lack of input earlier on in the development and implementation of the system. “Often, only highly interested end users are enlisted to scope out the new software; no one formally evaluates current users to determine their views on the actual technical and functional acceptability of clinical information system” (Zheng 2004). Those end users who feel that they have no input are often found to resist. Worse of all, if the new system has technical problems users are frustrated as valuable work time is wasted as IT staff try to troubleshoot and solve technical problems. Because of such nightmares, users are apt to resist. The study by Klaus and co identified additional workload as the main reason users resist, followed by lack of fit, technical problems and changed job.
User Resistant Behavior
Although user resistance is identified as a form of non-adoption but it is not clear if adoption is the opposite of resistance (Klaus et al 2007). They observed in various environments that not all system users have adopted the system willingly neither did all non-users necessarily resisted. Whether a system is adopted or not, there are certain attitudes toward information technology implementation that Klaus and co described as user resistant behaviors. It is important to identify these behaviors as each speaks of the unique source of the behavior and the management strategy necessary to avoid, stop or deal with it. To demonstrate resistance to a system, users don’t follow process, refuse to cooperate or complain, challenge the management plan, become defensive, de-motivated or less productive. In other instances, resistant users avoid using the new system, revert to the old system or find a “shadow” system to use in lieu of the new one. They may behave inappropriately, become impatient, don’t want to learn the new system, procrastinate, or quit altogether. Still others demonstrate their resistance by hacking or engaging in acts to bring down the new system. The study by Kaus and co challenging the management plan was the most representative of user resistant behaviors followed by impatience, complain, and trying to use the old system. In what ever manner a resistant behavior is demonstrated, the result is never in the best interest of the organization. The case of a healthcare delivery system makes the case even more compelling. As noted by Moore, healthcare plays a vital role in the structure of society as it involves entirely in the care of people who are ill. Rather than keeping the population healthy, resistant behaviors as such impede the implementation of information technology in the healthcare delivery system (Moore 1996). It therefore behooves management to take steps in ensuring the smooth implementation of health information technology. It leaves us with the question of how can these resistant behaviors be minimized so that information technology in the health care delivery system to can deliver on its promises?
Managing User Resistance
End user resistance is a problem that is not unique to the health care field. It is inherent in our behavior as human beings and therefore cannot be eradicated. It is not to be ignored either or treated with brute force. Kalus and co cautioned that whether or not employees are aware of the effect of user resistance, managers and system implementers must still address the issue in a manner that produces favorable results. Aladwin as cited by Klaus et al “discusses the need for management to proactively and constructively deal with user resistance rather than reacting when it arises. It is important for managers to have strategies into place to minimize the negative effect of user resistance” (Klaus et al 2007). Failing to put into place adequate strategies to deal with resistance can have undesirable consequences. One way is for management to take no action to address the resistance which will lead to chaos. Another management demonstrates lack of strategy according to Klaus et al is to “errantly search for resister, punish the compiler and promote the uninvolved. A careful and adequate strategy in place will find the source of the resistance, the reason behind it and take the appropriate steps to address it. Zheng advised that by identifying the type of resistance, then can the change agent determine which management strategies are appropriate. For example if the resistance is to a specific change of new technology, a more direct orientation or training can be started.
Managing end user resistance starts with planning. Gabler as cited by Austin and Boxerman points out that governing boards and healthcare managers are increasingly concerned about the business value of investments in information technology and wants assurances the information technology will deliver strategic benefits to the enterprise which put puts strategic IS planning in the fore front. When a technological solution is proposed for a business problem, strategic planning allows for that proposed solution to be in line with the company strategic goals. Historically, hospitals and other healthcare organizations employed information technology to support day-to-day operations. That has changed as Austin and Boxerman observed. Increasingly, healthcare managers are recognizing the role of information systems in increasing market share, supporting improvement, and adding value to the organization. To accomplish this and make users embrace the technology, IS planning must be closely aligned with the strategic plans of the organization. It should also be reviewed to ensure that both remained aligned.
Strategic IS planning is the foundation upon which other management strategies can be based. This will make employees know where the organization is going and the tools needed to get there. Such will precipitate the Involvement of users earlier in the entire life cycle of the system development. As a first step, Zheng suggests that managers and sytem planners determine which system meets the needs of end users not financial people as failure to do so will not be costly but discourage users and developers alike. One way to do it is to conduct a formal evaluation of user satisfaction with a system they would like to purchase or design. Such an evaluation will direct those responsible for purchasing and implementing the system to ensure that end users’ input is considered rather than sampling few technologically savvy employees. Such evaluation will also gauge the organization’s needs and determine its own readiness for new technologies or systems before implementation. In other words, managers need to determine if the organizational culture or climate will easily support changing the use of information technologies Zheng 2004). These determinations can easily be made with careful information system strategic planning.
Fear of change is a common problem encountered in system development efforts which often results in tension and anxiety. Employees, managers and other staff have various concerns about their job and functions when a new technology is introduced. Effective change management requires a deep understanding of behavioral and cultural factors in information system development. Austin and Boxerman offer the following suggestions in effective change management:
1. Avoid been secretive; open communication is essential
2. Provide a comprehensive program of staff orientation and training prior to initiation of major project
3. Structure the project in such a way that users will be active participants and will buy in from the beginning
4. Make top-level support visible and reinforce that support regularly. (p 270)
According to the planned organization change theory as cited by Saleem,
an organization needs to introduce change in three distinct
categories: unfreezing, moving, and freezing. The first phase
unfreezing involves establishing an accepted need for change,
as well as reducing the forces which are likely to resist the change.
The second phase moving or changing comprises designing or
implementing the change. During this phase, employee participa-
tion is strongly recommended because employees are the most
knowledgeable about practical implications and functions of
change… the third phase unfreezing, entails stabilizing the
change through supporting mechanism such as modifications in
organizational policies as well as changes in organizational struc-
tures and group norms. POC approach is expected to result in
change acceptance through intervening mechanisms such as re-
duced resistance to change, feelings of change ownership, trust
in management and integration of knowledge (Saleem 1994).
In introducing a new information technology, Zheng notes two key factors that need to be taken into consideration. These will put management in a better position in how to deal with any resultant resistance. First is the technical quality of the information system previously implemented and the quality of the process used to implement the previous system. This is vital because the successes or failure of the previously implemented system can be remembered and users’ resistance or acceptability can be based on their previous experience. As Zheng observed, such knowledge will not stop resistant behavior but will serve as first step in facing incoming challenges (Zheng 2004).
Klaus and co after conducting a study to examine the acceptance of an enterprise system implementation listed the following management strategies: communication, feedback, providing support, training, incentives, clear plan, expertise and customizations (Klaus et al 2007). When the goal of the organization is communicated to employees and the importance of a new information technology to their work, end users can feel part of the system. End users need to know before hand what benefits of the new systems are and how positively it is going to impact their work. It starts with a clear plan of what management wants to do and a continual involvement of users. Wagner and Piccoli refer to the involvement of users in the design of applications that they will be working on as a good practice. They agreed that practicing participatory design is clearly expedient inn minimizing user resistance and offers many benefits. It is expected to help mediate the power relations among different state holders and facilitate organizational learning by producing valuable information about the organizational change process. On the contrary, lack of user participation can spark user resistance which has the propensity to derail millions of dollars worth of IT projects. (2007). In addition to involving users in the design process, user feedback must be sought and support provided on a continuous basis. In an event when users cannot fully utilize a system to their benefit, it must be customize to meet the specific needs and purposes of users.
Big bang versus a gradual approach: While the joy of using a new system can propel systems administrators to roll out a new system in one shot, specialists have found that a gradual approach may find users accepting and adopting a new system. Benjamin R. Williams, CIO and senior Vice President of strategic innovation was quoted in November 1, 2005 edition of the CIO magazine relating his experience in CPOE roll out. Taking lessons from another hospital where the computerized order entry system was rejected, he decided to phase the CPOE rollout over a period of several years and encourage doctors to use it rather than forcing them to do so all at once. Besides helping to reducing user resistance, the CIO found that doing so also allowed his team to make fixes and respond to doctors’ concerns about the system design.
In the specific case of the healthcare organizations, Moore proposes the following solutions in dealing with user resistance. First, more suggests that the benefits from the use of information technology must be clearly outline and made visible to the organization. Second, the benefits related to the use of information technologies in the knowledge coupling tasks must be integrated into health care delivery system in such a way as to reduce the perceived threat to the established professional order. Finally Weed, as cited by Moore suggests that the definitive long term solution is to change the training of healthcare providers in such a way as to make them more professionally compatible with the use of information technology (Moore 1994).
The application of information technology in the health field is vital as IT plays a key role in transforming the healthcare delivery system. From computerized order entry systems to telemedicine, information technological has played a pivotal role assuaging the many inefficiencies and bottlenecks that have been part of the health care system. However, implementing information technology in the health field has run into many problems not primarily due to technological issues but due to user resistance as a result of sociological, organizational, and cultural issues. Many healthcare professionals are afraid of change because of the perceived disruptions it poses and the concerns of uncertainty as a result of the change among others. To demonstrate such resistance, users may complain, not use the new system, quit, stage protest actions, or engage in more subtle but dangerous behavior like hacking. To tackle these many resistant behaviors, the strategic goal of the organization must be align with its IT initiatives; Managers must not rush to the use of technology because such is an attractive option but must determine if the organization is ready for such change. Effective change management strategies must be put into place as proposed in the Planned Organizational Change theory (POC). Users must be involved earlier on in all phases of the design process or the decision to buy and training/support must be provided before implementation and throughout the entire process. While a brand new field of Health informatics has emerged to bridge the gap between healthcare providers and Information Technology personnel trying to implement complex information technology solutions for doctors, nurses and other health care professionals to utilize, a lot rests on managers to devise strategies in dealing with resistance to technology. While a checklist of management strategies may be helpful, each resistant behavior must take into account the technology used, the environment in which it is implemented, the types of users involved and the organizational needs before picking a particular strategy to combat it. When these behaviors are anticipated and strategies are put into place even before forehand, dealing with any user resistance that seeps through the crack can be relatively easier to manage and can provide valuable information in dealing with future crisis. One thing which is certain is user resistance cannot be eradicated. It cam be managed.
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