EPtalk by Dr. Jayne 5/21/15

I received a large number of comments and emails in response to my post about Windows 8. Except for one, all were supportive or empathetic with several offering specific suggestions to improve my user experience. The one that I found most thought-provoking, however, was the response blaming the user:

From Cynical: “This post is indicative of the larger problem in the Health IT space. Users are reluctant to embrace change – why not try peeking your head out from underneath a rock once or twice a decade and change won’t be so hard. I won’t say that Windows 8.1 isn’t without flaws, but the majority of the whining in this post is likely attributable to user error or someone who’s 50+ who is terrified of technology. In an age where I can SMS my coffee maker in the morning to start brewing, start my car from my smart phone and adjust the climate control in my home from half a world away we’re at a point where the internet of things is here, and here to stay. “You can’t do anything without being online” isn’t a new concept and it’s not a bad concept either, but maybe that’s the view in healthcare where there are still attitudes that connectedness and sharing information may blow someone’s competitive advantage. Posts like these remind me why it seems like a losing battle to try and advance tech in the healthcare space. Users who have no desire or aptitude to learn and embrace new tools, a generation of technology leaders who think innovation is implementing Epic. A leading HIT blog like HIStalk should be embarrassed to post this.”

Reading through this, I wondered if my former CIO was stalking me. It was actually pretty funny to read, having been on the bleeding edge of healthcare IT during my time as a CMIO and doing extensive change management work to help a large health system do EHR well before everyone else was doing it (and successfully so). Let’s talk about some of the themes:

Users are reluctant to embrace change. Yes, they are. Most health IT users are concerned about the patient in front of them and the care they need to deliver. If they’re not, then they should be. When technology interrupts that, serious patient harm can result. The point of the piece was illustrating the challenges faced by someone who is reasonably tech savvy (and decidedly younger than 50) but still can’t “get it” and runs into problems executing what should be simple workflows. Having studied change management and usability for a long time, one can attribute user resistance to several things including fear, inadequate training, poor system design, and more.

Over the last several years, I’ve become more aware of the role of learning styles in regards to stalled change processes. Although we hope that systems are intuitive, sometimes they’re just not. Sometimes vendors fail to hire actual healthcare usability experts. Sometimes they hire no usability experts. Sometimes users do not have the capability to learn on their own or intuit how something is supposed to work. Learners process information in many different ways and for us as IT professionals, we need to recognize that and offer solutions that meet their needs. As more people enter the workforce with documented learning disabilities and that may require accommodation under the Americans with Disabilities Act, we’re going to need to adapt. These weren’t diagnosed as often 20 years ago and they’re changing the demographic of the workforce. We also have traditional learners with their own needs, as well as an aging workforce with specific physical requirements (increased contrast, larger fonts, etc.).

I’ve seen the assumption that everyone is keeping up with the relentless push of technology turn into a fatal flaw for multiple implementations. If valuable (but non-tech savvy) staff are to be retained, it might require sending an intern to teach them solitaire so they can develop mouse skills. It might require longer periods of elbow support. It might require a user psychology intervention. We can’t just throw away workers because they can’t pick up the latest and greatest on their own. And we need to understand that people learn differently. Webinars are highly distracting for some, who may do much better in a classroom setting. Some people need 1:1 training. Others need multiple solutions and methodologies to be successful.

Users choose not to keep with the times. Cynical’s premise is that failure to embrace new technology is a result of intentional isolation or resistance. In my situation, I’ve spent the last decade leading a major organization with a specific technology portfolio. While working a full-time CMIO job and a part-time clinical job (as well as writing for HIStalk), I didn’t have the free time to explore new pieces of technology that came out unless they directly impacted my livelihood in one way or another. Although my work situation is unique in that I choose to work multiple jobs, it’s representative of most of my workforce. The majority of our clinical end users are running on the treadmill of life faster than they ever have. In addition to increased work demands, they’re trying to be parents, children of adults that need care, spouses, little league coaches, and volunteers. Some are indeed working multiple jobs due to the part-time-ization of work. Sometimes things have to be prioritized and I can completely understand how someone winds up “under a rock” because they’re just trying to get by every day. Whether my post is agreed with or not, blaming users isn’t a strong position and it’s up to us as IT people to help them through when they’ve gotten behind.

You can’t do anything without being online. Although the Internet of Things is here to stay, it’s not everywhere. Right now, I’m working a locum tenens assignment in a community that does not have universal access to broadband. Yes, you heard me right. No high speed Internet. In 2015. The hospital is connected and a couple of businesses offer free wi-fi, but the community is rural and people can’t afford satellite service or it’s not a priority for them. Non-smart phones abound. I find it hard to criticize hard working people because they don’t message their appliances or tweak their thermostat from afar. There are people out there who use healthcare technology all day, every day, who may never leave the state where they were born. I agree the world is increasingly global, but that’s the reality here.

There’s also the reality of downtime. I’d like to be able to use my computer when I’m on a plane without wi-fi, or somewhere with a poor signal, or when the sewer company cuts Verizon’s line while doing a repair. Although being online is great (as I celebrated with my online shopping), sometimes it’s not available. We’re also in a destabilized world where we don’t just have to worry about natural disasters or weather events. Civil unrest is a real consideration and many organizations can’t afford the redundancy solutions needed for business continuity. That doesn’t make it right, but it’s a reality.

The view in healthcare is that connectedness and sharing information may blow someone’s competitive advantage. I agree this attitude is out there but there are equal numbers of us fighting to open the doors. I stood up the first HIE in my state (although it was a private one – we were tired of waiting for the state to catch up with us) and worked to lobby for legislation protecting physicians from liability around data sharing when it was done for the right reasons. Given the recent breach culture however, more patients are becoming concerned about privacy and security and want to minimize online exposure and sharing. They want to control who receives their data and when. I support that is a key tenet of patient autonomy, but it certainly makes my job as a physician harder when I don’t have all the pieces of the puzzle.

Additionally, our friends in government have solidified some of the problems around competitive advantage. A mere five to seven years ago, I had the autonomy to refer to whoever I wanted to and to whoever I thought would give the best care to the patient in front of me based on their unique situation. Now, thanks to narrow networks and ACOs, I’m forced to refer to a subset of providers who are cost-effective rather than to those that are the best for my patients. As a physician, I know that’s not necessarily the right thing to do for patients but most patients can’t afford to go out of network. The healthcare free-market economy is over and done with, at least until we get payers and government out of the business of dictating clinical care. I could write a month’s worth of blogs on those topics but I have to start rounding on real live patients in a few minutes.

Users don’t have the aptitude to learn and embrace new tools. My thinking as a CMIO is that if my users (who are often smart, college-degreed or highly experienced workers) can’t learn a new tool that maybe there is something wrong with the tool rather than with the user. Assuming that a tool is one size fits all is another fatal mistake. Tools are not always scalable and don’t always fit the user culture and workplace. Following the crowd and selecting a system because everyone else seems to be doing it may not be the right decision for your customers, and I agree with Cynical that the sometimes unthinking adoption of Epic is a problem.

Tools can also be frankly broken (like the sticky “I” key on my keyboard). I’m sure I would have had an entirely different experience getting used to Windows 8 if the keyboard worked. But instead, that particular hardware failure marred the entire experience. Imagine if you were an end user who didn’t understand the statistics (that if you buy 2,000 PCs for your staff, there’s odds that a certain percentage will malfunction) and that faulty one was your PC and you had no recourse. And there we get to the entire point of the post:

Everyone experiences technology changes differently. We all come from different experiences and different places of knowledge. Some of us are just trying to get through the day and others are more contemplative about the big picture. In my case, I researched for months and selected the device I thought would most meet my needs. Money was not a constraint. I’m an experienced IT person who has personally trained hundreds of end users and supervised the training of thousands more. I’m an early adopter for the most part and I understand the psychology about adoption. I understand the risks and benefits of the change and the limitations of my old technology and the benefits of the new. I was ready to make a change, excited about the change, and had a plan to embrace it slowly and in a non-threatening way, yet it still slapped me in the face. I literally had to put the technology aside because I physically could not do my job with it.

The story is indicative of what our end users face every day and I wasn’t embarrassed to share it. I’ve learned in the CMIO trenches that empathy and humility go a long way towards making things better.

Email Dr. Jayne.