Healthcare is changing. We hear this from many sources. One change that you have probably already seen is the use of the computer for at least some documentation of care. However, at this writing, there are very few healthcare agencies that are already paperless, which is the ultimate goal of the move to electronic records. Thus most of us are involved in situations in which we, willingly or unwillingly, are doing some documentation on the computer while still maintaining paper records, printed reports, or both. In reality, the technology to make all of our healthcare agencies paperless exists today. This prompts the question: why have we not moved more rapidly in this direction?
The usual answers relate to the lack of resources, both time and money. However, a more important reason, although also a more hidden reason, has to do with organizational culture, which is defined informally, as “the way we do things around here” (Deal & Kennedy, 1982, p. 4). Anyone who has ever tried to implement a new system has found that the most difficult part of the implementation is not software, but "peopleware," i.e., "us"! We often resist the new way of doing things, attributing this resistance to a poorly designed system or our own temperamental shortcomings. We assume that the new system is value neutral (Hodas, 1993). Although occasionally this resistance is a result of poorly designed systems, even good systems are often slow to be accepted.
Mr. Hodas, in his 1993 article, described the difficulty in getting teachers to accept a new technology, and noted that “schools (read healthcare organizations) are themselves a technology.” They are a way of behaving towards a specific goal, usually a tacit one, in which we abide by certain behaviors and values without fully understanding them. These behaviors preserve authority and maintain certain practices and values while minimizing or eliminating others. In healthcare we have optimized our agencies to the mission we believe society has assigned to us.
The 1999 Institute of Medicine (IOM) report To Err is Human has brought to our attention the high incidence and unfavorable outcomes of medical errors. Greater use of informatics, which for many users means entering into and retrieving data from computers, is often promoted as one of the methods to decrease these errors. It is assumed that our organizations, desiring to provide excellent patient care, will adopt this rational, deductive approach by using electronic records to reduce the number of medical errors.
This assumption misses the point that organizations do not always behave in a rational manner. We all seek our own perpetuity, whether of the organization or our place in it. Hence, we may experience the introduction of electronic charting as not just a challenge, but rather a disruption of our work. Given that these systems will, indeed must, create changes in work flow, this is not an irrational response. As a result our behaviors are often aimed at relieving the pressure created by these changes, rather than advancing a rational approach to solve a defined problem. The change from paper to electronic documentation appears to those outside of nursing, who too often may be administrators or information technology (IT) specialists, as an improvement. For clinicians, however, the introduction of the electronic record too often means disrupting our values and habits to accommodate this new technology.
Healthcare organizations have clearly defined lines of power, authority, and flow of information. They remain hierarchical organizations in regard to this power, authority and flow of information. This writer, when visiting the PROMISE system at the University of Vermont in the early 1980s, was told by a physician who was promoting the system, that one of the reasons for its failure was that “physicians did not want nurses to have access to this much information.” The information in question concerned not only the patient problem list, on which other disciplines were expected to chart, but also the costs of various tests and procedures. Although this particular statement singles out physicians, it could easily apply to other healthcare professionals, including nurses. We, too, guard the power that privileged information gives us. Sharing a patient’s chart with a patient, which is the ultimate goal for electronic health records and electronic personal health records, is still threatening to healthcare providers. Some of us remember the days when so much as telling patients their temperature or blood pressure was cause for a reprimand. Even today, think about how comfortable you feel about charting in a patient’s presence or reading the chart with a patient. Yet these changes are coming.
Before we can accept these changes we need to work through the fact that our values and habits will be challenged by electronic and point-of-care documentation. We need to consider our values and habits in regard to sharing information with patients. We need to reconcile our current habits and values with the changes that are coming. We need to prepare ourselves for true patient-centered care and partnerships. These changes will upset the balance of power throughout our organizations. Physicians, many of whom acknowledge this, will no longer have a monopoly on disease information; nor will we as nurses. Already research has demonstrated that many individuals get more information regarding their medical condition from the Internet than from their own physician (Skiba, 2009).
Healthcare for years has been provided within accepted hierarchical lines of authority. This often puts the various healthcare disciplines, with their associated power structures, at odds with one another. Staff nurses, who are the bedrock of nursing, the raison d’être for the existence of nursing, too often find that these hierarchies leave them with few rights of self-definition and/or discretionary use of their time and other resources. To survive they have devised strategies for gaining information that provides a sense of power. These strategies may disappear with the introduction of electronic records. For example, in the past a nurse may have had to initial an order before it was implemented, theoretically acknowledging that it had been seen, but in reality providing power and a sense of importance. Many of our valued behaviors will be changed with the introduction of the electronic record.
New technologies change both power structures and practices in an organization. These changes can either reinforce or subvert existing lines of authority, as well as introduce new authorities, such as IT personnel. A clinician’s mandate is to provide high quality patient care, while the mandate of IT personnel is to provide a workable system. If the inevitable conflicts between these two aims are not addressed, a new system, such as an electronic record system, will not achieve its goals of reduced medical errors and improved patient care. Supporting the need to consider more than the system itself, it has been documented that system success requires a mix of organizational behavioral, cognitive, and social factors (Kaplan, Harris-Salome, 2009).
Thus, it is imperative that those considering a new system consider both the value of the change and the magnitude of the disruption that the new system, or even an upgrade, will engender. This does not mean that these changes should not occur — they must. Rather it means that both the organizational culture and the technology must be considered when introducing a new system. Any system, whether well designed or poorly designed, accents or obviates certain values, some of which may be an ingrained part of our organizational culture.
I recognized, after recently re-reading Mr. Hodas’ 1993 article describing teachers’ resistance to adopting new technologies, that there were strong parallels to such resistance often seen in healthcare. I un-apologetically acknowledge the use of some of Mr. Hodas’ ideas in this column.
Linda Thede, PhD, RN-BC
© 2009 OJIN: The Online Journal of Issues in Nursing
Article published June 15, 2009