Adoption and Use of
Handheld Computers
In Clinical Practice
A Qualitative Study of
Innovation Diffusion
Ann Scheck McAlearney, Sc.D.
The Ohio State University
AcademyHealth Annual Meeting
June 2004
Presentation Agenda

Introduction

Methods

Results

Summary

Significance for Policy, Delivery, Practice
Introduction
Project Background

Project Investigators
 Ann

Scheck McAlearney, Sc.D. (Co-PI)
Ohio State University, Division of Health
Services Management and Policy
 Mitchell

Ohio State University Medical Center, Division of
General Internal Medicine
 Sharon


Medow, M.D., Ph.D.
B. Schweikhart, Ph.D. (Co-PI)
Ohio State University, Division of Health
Services Management and Policy
Project Funding
 Center
for Health Management Research
Overall Findings…

Diffusion of HHCs as a technology innovation is
affected by how the technology is introduced,
demonstrated, and promoted, as predicted (Rogers):
 Ability
to experiment
 Judgment-free
 Low
cost of technology
 Forums
 Use

training
with other physicians
of clinical change agents
Organizations can help with innovation diffusion
 Develop
strategies to accommodate, support MD use
 Leverage
HHC use to build user confidence
Rationale for Study:
Why Study Handheld Computers?

Little research has explicitly examined:
 Organizational
management of HHC
 Clinician use of HHC in patient care
Proliferation of HHC use by physicians
had not been qualitatively evaluated
 Physician use of HHC use likely to be
influenced by organizational decisions

Research Objective
To develop a rich and useful
understanding of organizational
strategies for the use of handheld
computers, and of the needs and
concerns of physicians using these
devices for patient care delivery
Research Questions
What specific applications and uses exist
for handheld computers (HHCs) in
clinical settings?
 What strategies and tactics are
hospitals using to integrate HHCs into
their patient care delivery practices?
 What are the attitudes, expectations, and
needs of physicians with respect to the
use of HHCs in clinical practice?

Methods
Study Design

Literature review and market research

Seven case studies in healthcare organizations
 67
key informant interviews with organizational,
physician informants


Eight physician focus groups (54 MDs)
 At
healthcare organizations (6 groups)
 At
national meetings of physicians (2 groups)
Interviews and focus groups transcribed and
analyzed using deductive, inductive methods
Conceptual Framework:
Handheld Computer Adoption as
Diffusion of Innovation
Adopter categories and characteristics
 Nature of social system
 Extent of change agents’ promotion
efforts
 Perceived attributes of innovation

Results
Handheld Computer Adoption
as Diffusion of Innovation
1.
2.
3.
4.
Adopter Categories
Perceived Attributes of HHCs
Factors Promoting HHC Use
Role of Change Agents
1. Adopter Categories

Rogers’ Adopter Categories:
 Innovators
 Early Adopters
 Early
Majority
 Late Majority
 Laggards

What we characterized…
Handheld Computer User Patterns
50%
40%
30%
20%
10%
0%
Non-Users
Niche
Users
Routine
Users
Power
Users
2. Perceived Attributes of HHC

Relative Advantage
 Compared

Compatibility
 With

other technologies, with workflow
Complexity
 Personal

perspective
Trialability
 Availability

to paper, PCs
of pilot projects, free devices
Observability
 Growing
number of peer users
Relative Advantage…

The Convinced: “For me, to be able to sync
my Palm before I make rounds and have all
that information with me. Then I don't have to
run around and ask the nurse who says, ‘I'm
not a nurse, I'm a respiratory therapist’.”

The Unconvinced: “I'm using paper during the
day. Because if you take notes, it's much more
practical to take notes on a paper print-out and
keep your to-do list on that than it is on a palm.
Because you can just do it quicker and it's all
right there.”
Compatibility…

The Convinced: “I feel that I can make
decisions right there at the bedside versus
stepping out of a room and saying ‘OK, I will
talk to you about this at the next visit.’”

The Unconvinced: “I used it, but I have not
found it convenient enough to go and buy one.
Where I work we have computers everywhere
and I prefer using a keyboard.”
Complexity…

The Convinced: “It has got to be reliable. It
can't be going down all the time. It has got to
be simple. For example, the Palm is pretty
simple.”

The Unconvinced: “My partner tried to get it
synched, took it home, tried to get it to work the
first night. Couldn't do it, quit.”
3. Factors Promoting HHC Use

Ability to experiment

Judgment-free training

Low cost of technology

Forums with other physicians
Forums to Learn from Others...


Physician 1: I still look up my drugs in Harriet Lane. It's easier for
me to just open a book and find it, than to look for it on the palm,
because the drug formulary that I have just in mine, you have to
scroll through a lot to come to the part where it tells you how much
each dose is and what kind of pills you can get.
Physician 2: You can jump.

Physician 1: You can?

Physician 2: Yeah. …I can show you.

Physician 1: You can? Okay... I think it's a lot easier, when you can
scroll down it is, it takes a long time.

Physician 2: I mean it actually remembers. Like the ones you visit
the most so if you do that over like two dosage forms, like usual
dosage is always there, it's just there.

Physician 1: Okay. Never mind.
4. Importance of Change
Agents
Clinical peers
 Constant availability
 Non-threatening individuals

Help from a Clinical Peer…

“It's gotta be something where you can go back
and dialogue with people and say I'm having a
problem here or I'm not getting the full advantage
of this thing.”

“And you know, when it doesn't, when it stops
working for some reason, there has to be
someone who can do it...”

“Somewhere I can go to, sit down and say this is
what I'm trying to do. Why can't I do it? What did
I do wrong? How can you help me make it right?”
Summary
Conclusions

Success of HHC diffusion affected by approach
to introducing, promoting, and supporting
technology

Organizational strategies to accommodate and
support physician use of HHC can help improve
care and service to patients

Organizations can leverage HHC use:
 Build
user confidence in technology
 Demonstrate
success with technology
implementation, adoption
HHCs Help to Build User
Confidence in Technology…
“Maybe even made us ready for COE, just in terms
[that] we got used to using a digital means of
[working with] information and looking things up.
I mean it's very different [from] COE, but it is still
the idea of using a computer, using a handheld
device to do medicine. You know, five years ago
here there were no palms and it was all paper
orders … I think it kind of just helps scooch us in
that direction.”
Significance
Significance for Management
Commitment to support HHCs
characterized by budget commitment to
personnel (training, user support) rather
than heavy capital investment
 More visible use of HHCs by senior
medical leadership will help expand
physician use
 Potential to effectively use HHCs in
clinical settings for non-physician care
processes is largely untapped but large

Three Organizational Strategies
1.
Active promotion, facilitation, and support for
broad-based HHC applications


2.
Active support for HHC niche applications


3.
How? Broad infrastructure investment; user support;
equipment purchase (synching, printers)
Why? Option to make point of care information
available; access to organization’s clinical data systems
How? Applications tied to specific projects
Why? Expectation for specific outcomes; benefit of
organizational learning about PDA technology
Basic support for individual HHC users


How? IT-based user support
Why? Need to ensure PDA use is appropriate,
compliant with security and privacy policies
Implications for Management,
Delivery, and Practice

Clinical change agents and peer
champions can help promote and expand
technology adoption and diffusion

Understanding findings about HHC can
help with other technology
implementation efforts
Expectations for the Future…
“And the requirement of precision is much greater.
So I'm not really allowed anymore to get the drug
interactions wrong. So, I have to have a device that
makes it right... So, if you're going to be held to that
standard, then you have to have the tools to be held
to that standard. … So, whether you’re in medical
school and everyone has their Palm Pilot and
they're whizzes at it, as opposed to somebody like
me who's struggling and wants learn to be able to
access and to benefit from this technology, we have
to do it. …writing illegibly is not going to do it
anymore.”
Questions?