4th International Workshop on Infrastructures for
Health, Tromsø, June 2013
Rethinking ‘resistance’ to big IT
programmes in healthcare
Professor Trish Greenhalgh
Acknowledging critical conversations with
Professor Rob Stones and Dr Deborah Swinglehurst
The problem
“Most [healthcare ICT] implementations fail because, despite
high investments in terms of both time and financial
resources, physicians simply do not use them.”
Rodriguez & Pozzebon 2005
Standard ‘resistance’ argument
Critique
A new theory of resistance
‘Expert systems’
Methodology
Empirical example
Generalizability?
Discussion
Standard ‘resistance’ argument:
Resistance = stupidity + skill deficit + fear
Solution = behaviourist tactics (incentives, training,
encouragement, ‘leadership’, ‘good management’)
“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
Perceived
system
quality
Use
Individual
impact
Perceived
information
quality
Organisational
impact
User
satisfaction
Standard ‘resistance’ argument:
Technology Acceptance Model (DeLone and McLean
Critique of the behaviourist argument
Pro-innovation bias: ‘New is always better’
Means / ends: [Alleged] efficiency of process > ultimate goals
Humans are social beings who make meaning and enact roles
Critique of the behaviourist argument
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 me achieve excellence?’
The theoretical background: strong
structuration theory (enhanced from ANT)
Historical and
social forces
Network of
position-practice
relations
Humans act
differently in
the network
because they
1.
have agency
Technology-in-focus
Agent-in-focus
General dispositions
2. Conjuncturally-specific
knowledge of external structures
3. Actions (practices)
4. Outcome on position-practice
relations
1. Material properties and inscribed
social structures (e.g. decision
models, access privileges etc)
2. Conjuncturally-specific
functionality in a particular case
3. Actions (functions-in-use)
4. Outcome on position-practice
relations
A normative theory of resistance to big IT
Clinicians are usually professionally motivated. They seek to
provide excellent care. They resist five things:
1. Policies that interfere with excellent care
2. Technologies that interfere with excellent care
3. Interference with the [symbolic] roles and relationships
that define and constitute professional practice
4. Encroachment of ‘the system’ into the clinical situation
5. Cost
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.”
Edvin 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”
Anthony Giddens ‘The Consequences of Modernity’
The
‘expert
system’
(sociology)
Classification systems “describe the way things are” (Mary
Douglas,
anthropologist)
Embedded rules and protocols impose a distant set of values
and priorities on local situations, hence ‘empty out’ their
detail
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
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 questions
Who 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 of infrastructure (Star)
Guiding methodological principles in the study of
infrastructure and its ‘frozen discourses’:
1. Surface master-narratives (over-arching discourses /
logics that shape actions) e.g. ‘Patients come first’
2. Surface invisible work e.g. ‘articulation work’ done by
secretaries and administrators
3. Study paradoxes (e.g. why one more keystroke makes
the whole system unworkable)
Empirical example: Choose and Book
Remote booking of outpatient appointments by the GP or the
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
Empirical example: Choose and Book
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
Documents,
talk
letters,
and
‘on
the
email
job’
interviews
exchanges
Choose
and
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
Resistance
The
to
Choose
‘choice’
and
Book 1:
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
other patients’ views
infection rates
parking facilities
mortality rates
waiting times
food quality
disabled access
A library service
for people to use
NHS Choices to
chose their
hospital had no
takers in 6 months
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.”
Resistance
The
to
Choose and Book 2:
technology-in-use
“hopeless”
Crashing
“like
flogging
a
“a
“a
“Creak
complete
and
Freezing
dead
horse”
Running slowly
Asking for manual data entry e.g. of
minefield”
patient’s phone number
Giving wrong passwordshambles”
Allocating to wrong clinic
Referrals getting lost in the system
Break”
No appointments available
Resistance
The
to
Choose and Book 2:
technology-in-use
Resistance
The
to
Choose and Book 2:
technology-in-use
Resistance to Choose
Altered
roles
and
and Book 3:
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 Choose and Book 4:
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 of medical work by
expert systems
“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 Choose and Book 4:
Interference with contextual judgements
Resistance
to
Choose
Cost
and
Book
5:
“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
A generalizable theory of resistance to big IT?
Clinicians are usually professionally motivated. They seek to
provide excellent care. They resist five things:
1. Policies that interfere with excellent care
2. Technologies that interfere with excellent care
3. Interference with the [symbolic] roles and relationships
that define and constitute professional practice
4. Encroachment of ‘the system’ into the clinical situation
5. Cost
Example 2: Telehealth
and telecare
Limited adoption & abandonment
can also be explained by five kinds
of resistance:
1. To policies that interfere with
excellent care
2. To technologies that interfere
with excellent care
3. To altered [symbolic] roles and
relationships
4. To encroachment of ‘the
system’ into clinical situations
5. To cost
Paper in press for Soc Sci Med
Standard ‘resistance’ argument
Critique
A new theory of resistance
‘Expert systems’
Methodology
Empirical example
Generalizability?
Discussion
Thank you for your attention!
Professor Trish Greenhalgh
@trishgreenhalgh