Clinical Information and Sociotechnology

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Recent studies conducted in England and Australia developed a theoretical concept called sociotechnology. Think about it—how can an electronic system possibly be successful unless the people who use the technology are sufficiently involved with the planning and implementation? Technical expertise is indispensible in the design of both hardware and software, but as much as technology is shaping society, society is also shaping technology.¹

When you think of how much our current society depends on technology and the number of technological advances we are bombarded with each day, it is important to remember that these advances are enabled by human expertise. In our healthcare settings, a great deal of historical precedence guide practices. With advances from evidence-based practices, technology's function must be to support and enhance these practices.

Organizations need a positive relationship between human and nonhuman systems.¹ Fortunately, our new generation of healthcare providers grew up in a computer-literate world, and the interface between human and technology factors are both intrinsic and practiced. However, our workplace is a microcosm of our larger society, and a good deal of today's workforce is not part of this newer generation. We still have to fix today's problems and recognize that top-down design of electronic systems is not conducive to smooth implementation. In the sociotechnical view, the emphasis is on bottom-up participation and work-group autonomy.¹

As sophisticated as technology is, success is incumbent upon the people involved in the design and delivery of the new information system. The term sociotech is new, but the concept is not. Without the full backing of the people involved, success is not within reach. Sociotechnology defines people as the key resource for a successful implementation. At the same time, we know that a leader's greatest resource is human assets. Therefore, the design and implementation of new systems require that both the social and technical systems be jointly optimized.

The expertise required of our computer gurus cannot be understated, but it is people that convert computer technology into useful information. Unfortunately, computer system implementation is frequently a nightmare when the systems go live. From my experience, and the experience of others reported in the literature, the lack of input from and education of clinical staff who are required to use the system are severely lacking. Even at its best, the process is in need of a complete overhaul. Systems are often implemented without a complete analysis and redesign of the very work processes that enable the efficiencies and effectiveness expected in a new system. So we implement a broken or overextended process, and now the same cumbersome processes used in the past are expected to support the new software system. What do we accomplish?

I often hear the phrase from staff nurses and front-line managers that electronic documentation systems are adding to the work of the professional nurse and that implementation requires far more preparation than they actually receive. The management concept of 80% planning and 20% implementation is a rare occurrence in the most complicated of all settings, hospitals. Why is this? The usual villain is the lack of dollars required to effectively train the very people that need to use the system to ensure smooth sailing at the time of go-live.

The common rule of thumb for system implementations is to budget 15%-20% of the total cost of the system for training. Although this is a significant figure, the cost of a poor implementation is more onerous than organizations believe. Poor implementation not only leads to a significant decrease in productivity for long periods, but it adversely affects morale, causes increased turnover, and worst of all, can affect patient safety and care quality. Too often, the focus of a system implementation is to get across the line, to “go live.” However, the benefits expected from the system cannot be realized without a commitment to a continuous process of learning and adoption for the people who need to use the system. I have noted the following:

I believe there is much more that can and should be done, and multiple ways of solving this dilemma. One of my consistent beliefs is that design and implementation of healthcare information systems should be the purview of clinical leadership. I particularly observed this as a chief executive officer (CEO); when the chief information officer (CIO) was totally responsible for success, clinical buy-in was not there.

Ideally, electronic documentation system projects need to be directed by clinical staff. At a minimum, the clinician leadership needs to work in a collaborative process with the CIO and technology staff to design and deliver the system. Such arrangements are far more feasible today than in the past since nurses, physicians, and pharmacists (just to mention a few clinical experts) have significantly more preparation in basic technical skills than at any time in the past. Ideally, the ultimate situation would allow an excellent clinician with the appropriate skills and training to direct the planning and implementation of healthcare information systems.

Maintaining a close tie with clinicians will ensure the strong relationship between the society (people) and the technical. Without that close tie and involvement, the marriage of the clinical and the technical will continue to languish, accounting for a failed and costly implementation. One of the worst outcomes of this failed relationship is nurses, staff, and physicians duplicating work processes by maintaining both paper and electronic charts, requiring excessive documentation and costly work-arounds.

Defining the structure and processes of the healthcare information system plan to include the roles of the CEO, CIO, chief nursing officer (CNO), and chief medical officer (CMO)—and the involvement of staff from the beginning—will make electronic records a reality faster and less costly in both human and financial terms.

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Reference 

1. Rollag K . Socio-technical systems . http://faculty.babson.edu/krollag/org_site/encyclop/socio-tech.html Accessed March 17, 2009.
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