Physician Leadership in Clinical Information System Projects

2. How do theoretical models such as Diffusion of Innovation theory support and inform recommendations to engage physicians in leadership roles in CIS projects?

3. Introduction/background Leadership for innovation adoption Methodology Review methodologies and special considerations Search query and protocol Findings Discussion Technology diffusion as context for leadership Clinical leadership in CIS adoption Effective clinical leadership Recommendations Training and facilitating physicians for CIS leadership Conclusion/summary Structure

4. Institute of Medicine, 2001: “…information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved over the coming decade.” Introduction/background

5. However… Difficulties exist Failures occur Reality falls short of the promise Physician leadership, however, is cited as one of the most important factors in CIS success. Introduction/background

6. Introduction/background

7. Poon EG, et al. Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. Health Aff (Millwood). 2004 Jul-Aug;23(4):184-90. “Identifying physician champions: Physician champions, typically well-respected clinicians, were key to successful CPOE implementation.” Introduction/background

8. Ahmad A, et al. Key attributes of a successful physician order entry system implementation in a multi-hospital environment. J Am Med Inform Assoc. 2002 Jan-Feb;9(1):16-24. “Hospital administration realized the importance of having physicians take an active and meaningful role in system design. To this end, a formalized physician consultant team was established.” Introduction/background

9. Ash JS, et al.A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc. 2003 May-Jun;10(3):229-34. “The institution has identified and enrolled the support of physician leaders and clinical champions, respected by their peers, who can communicate the shared vision.” Introduction/background

10. Adoption Decision to use a new and/or innovative technology Innovation diffusion Speed and extent of permeation of innovation Diffusion vs dissemination Opinion leadership Extent to, and frequency with, which an individual influences others Change agent An opinion leader who influences in the desired direction Leadership Guidance and influence of others in direction of a shared goal Leadership for innovation adoption

11. Diffusion/dissemination is the process wherein… An innovation Is communicated Over time To the units of a social system Technology Diffusion Model

12. What are the effects of clinical leadership/ engagement, in the context of CIS adoption and diffusion, on wider organisational adoption and use? What constitutes effective clinical leadership and engagement within clinical IT projects and programmes? Based on the recommendations in, and derived from, the review of research, what pragmatic ways exist for physicians to become (better) leaders, and what skills should be sought and/or taught for them to learn to be able to lead? Methodology

13. Methodology How do theoretical models such as Diffusion of Innovation theory support and inform recommendations to engage physicians in leadership roles in CIS projects?

14. Literature on success factors pertaining to CIS implementations: Preponderance of case studies/case series Dearth of controlled trials ‘Physician leadership’ more often considered as one of many variables Special considerations

15. Search query and protocol

16. 78 articles, 3 broad categories Consensus reports and expert panel recommendations Case studies, case series, or proxies such as surveys and questionnaires Analyses that link tranformational IS & IT sociological and behavioural frameworks Findings

17. Findings

18. Technology diffusion as a context for leadership

19. Technology diffusion as a context for leadership

20. Technology diffusion as a context for leadership

21. External factors (innovation factors) Affect adoption Internal factors (“social contagions”) Perception of innovation Personal characteristics of target audience Contextual factors – management, leadership, communication channels, incentives Technology diffusion as a context for leadership

22. Ongoing “leadership” is required. Innovators Highly risk tolerant Early adopters Opinion leaders; well connected Early majority Take cues from early adopters; rely on social network over external sources Later majority Act when new technology becomes status quo Laggards Traditionalists – stick to the “tried and true” Clinical leadership in CIS adoption

23. Ongoing “leadership” is required. Innovators Highly risk tolerant Early adopters Opinion leaders; well connected Early majority Take cues from early adopters; rely on social network over external sources Later majority Act when new technology becomes status quo Laggards Traditionalists – stick to the “tried and true” Clinical leadership in CIS adoption

24. What constitutes effective clinical leadership and engagement within clinical IT projects and programmes? Effective clinical leadership

25. CMIO job description (Leviss et al) Manage project expectations. Determine and govern the cultural tone of IT projects. Instantiate and lead the clinical IT department, including the recruitment of appropriate physician champions for specific projects. Lead vendor assessment and selection processes. Perform a lead role ensuring communication with other clinicians. Direct training and support, and multidisciplinary process redesign efforts. Effective clinical leadership

26. Distributed leadership (Mountford and Webb): Institutional leader Service leader Frontline leader Effective clinical leadership

27. Identify & support physician innovators Cultural change programme leadership awards evidence base demonstrating leadership value Job descriptions and performance evaluation Sessional time for dual roles Financial incentives Route back to clinical practice Earned autonomy Recommendations (General)

28. Physician leader should include being seen as a credible clinician, not just an IT/computer expert. Should have knowledge of hospital administration and operations, the ability to communicate at multiple levels, and with other functional groups within the organisation, and efficacy in the task of consensus building. The physician leader, should receive support and collaboration from the hospital’s executive team, including the Chief Executive Officer. For a significant project or large organisation, a formal CMIO role, or equivalent, should be created as part of the physician executive leadership team. Relevant continuous professional development should be made available to physicians in formal “bridging” leadership roles. Training and facilitating physicians for CIS leadership

29. Management and executive leadership content for medical informatics programmes Medical informatics content for health management programmes Leadership development theory and practice for undergraduate health disciplines Multidisciplinary research Establishment of relevant Chairs (MRG) Training and facilitating physicians for CIS leadership

30. Call-to-action to incorporate clinical leadership in CIS implementations Diffusion or Innovation theory, and research on leadership in CIS adoption, highlights the need for ongoing and different style of leadership Actively seek to overcome scarcity of physician opinion leaders Leadership roles should be more than just nominal titles Training initiatives can be incorporated in to existing education Conclusion/summary

31. Physician Leadership in Clinical Information System Projects Matthew J Glasgow Karen J Day HINZ Conference & Exhibition, November 2010

Editor's Notes

In 2000, the IOMs “To Err Is Human” report quantified the impact of medical errors in the US due to potentially avoidable errors. Similar literature has been published locally. The financial burden came as a surprise to many. The recommendations in the follow-up title “Crossing the Quality Chasm” catalysed investment in the direction of CIS innovation and implementation.This impetus was driven by such explicit statements from the IOM as their belief that “information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved over the coming decade”.
Despite this, and the trend of steady and progressive uptake of IT and CIS by many other professions and industries, with demonstrable benefit and positive RsOI, reality has often fallen short of the promise. Difficulties have led to low utilisation, and even outright implementation failure or rejection.The mere provision of electronic systems engineered to constructively transform healthcare fails to incorporate the sociological complexity of such a process.There is good evidence that using CISs such as CPOE systems does reduce medication errors, for instance, but when it comes to implementation, a number of factors influence their effectiveness. When analysing effective projects, physician leadership is cited as one of the most important factors in CIS success
Adoption looks at the decision to use a new and/or innovative technology, either at the organisational or individual level. Innovation “diffusion” describes the speed and extent of the permeation of ideas, practices or tools throughout an organisation. “Opinion leadership” is the extent to, and frequency with, which an individual is capable of positively influencing the behaviour and attitudes of others. An opinion leader is deemed a “change agent” if their influence is parallel to the direction deemed desirable by the change agency. Thus, “leadership”, including clinical leadership as it applies to information system projects and information technology transformations in healthcare, is guidance and influence of others in the direction of a shared goal .Information system implementation is an example of technology adoption. The adoption process has been classically defined as that wherein a decision-making unit (individual or organisation) progresses from the initial knowledge of an innovation, through attitude-forming, to an adopt-reject decision node, then on to decision confirmation . Subsequent spread of adoption of an innovation within a social system is referred to as diffusion or dissemination – overlap exists between the acts of adoption and diffusion, as diffusion is the higher-level, accumulated result of individual acts of adoption and utilisation, subsequent to an organisation’s decision to adopt a specified technology.
Diffusion (or dissemination) of an innovation is described as the four-step process, wherein 1) an innovation 2) is communicated 3) over time, 4) to the units of a social system.The terms “diffusion” and “dissemination” are sometimes employed as synonyms. Sometimes a distinction has been made. “Dissemination” refers to the deliberate, planned, and often centrally driven, spread of innovation. In contrast, diffusion refers to an informal evolution that is more likely to be driven as a horizontal process than one that is governed by vertical hierarchies. The Institute of Medicine refers to this semantic difference, and notes that the adoption of information systems and technology as a means to addressing deficiencies in healthcare quality is too urgent to leave to the process of gradual diffusion.The hypothesis drawn from these definitions is that leadership, specifically by physicians, can assist in the goal of achieving and disseminating adoption of an innovative technology (a clinical information system) in the complex environment of a healthcare institution or enterprise. Diffusion of Innovation theory provides a framework within which recommendations for physician leadership can be analysed for validity and supplemented with relevant detail.
A systematic literature review was undertaken to explore the role of physicians during the implementation of information systems directly related to the physician’s patient care workflow. The wider objectives of that parent review were to: - Elaborate on the effects of clinical leadership/engagement, in the context of CIS adoption and diffusion, on wider organisational adoption and use; - Examine the constituents of effective clinical leadership and engagement within clinical IT projects and programmes, and - Identify pragmatic pathways for physicians to become (better) leaders, including elucidation of the skills that should be sought and/or taught for them to best be able to lead.
This paper focuses on and presents a subset of the primary output of that review, addressing the question: How do theoretical models such as Diffusion of Innovation theory support and inform recommendations to engage physicians in leadership roles in clinical information system projects?Because this presentation is a secondary output of the review, I don’t want to dwell on the methodology too much, but I will make a few points.A modified systematic review approach was utilised to elucidate recommendations pertaining to physician leadership, which were then analysed and extended in terms of the Diffusion of Innovation model and framework.
We’re likely all familiar with the definition of a systematic review - “the application of scientific strategies, in ways that limit bias, to the assembly, critical appraisal, and synthesis of all relevant studies that address a specific clinical question” It is acknowledged that review methodologies may need to be adapted based on the evidence landscape pertinent to the study question, but the consequences of, for example, the inclusion of low-level evidence, may be less robust recommendations drawn from the review. Preliminary analysis of the literature on success factors pertaining to CIS implementations revealed a preponderance of case studies/case series, and a dearth of controlled trials .Further, it was apparent that focused articles (relative to the study question) were rare, with “physician leadership” more often being considered as one of many variables worthy of consideration and analysis during CIS design and roll-out.((Tricia Greenhalgh, who many of us heard from this morning, has undertaken systematic review of comparable topics, and has described the relevant body of evidence as “complex”,noting that the primary literature is not constrained by a unifying theoretical taxonomy. In the context of such heterogeneous literature, she has employed a meta-narrative review approach, which involves an exploratory phase, followed by “snowballing” – a manual process of reference searching and appraisal. “Snowballing”, as employed in their review, retains the hallmarks and benefits of a traditional review, but allows the targeted pursuit of conceptual threads and ancestral publications, often beyond the databases initially searched.))
Sensitivity was strived for, at the relative expense of specificity, due to the anticipated ambiguity in meta-data describing the physician’s role, specifically, in CIS projects.
A total of 78 articles made up the final pool of relevant articles. The literature accumulated in this review falls in to three broad categories. - Consensus reports and expert panel recommendations; - Case studies, case series, or proxies for case analyses such as surveys and questionnaires of those involved in information system projects; and - Analyses that link transformational information systems and technology to sociological and behavioural frameworks such as those that model technology adoption or innovation diffusion
Ash et al typify the content, particularly of the consensus report class of articles, in “A consensus statement on considerations for a successful CPOE implementation”. Although they focus on a subset of healthcare information technologies, the lessons learned are transferable. They present nine condensed themes - under the section title of “CPOE Vision, Leadership, and Personnel” the recommendation is made that, prior to CPOE implementation, enrolment of physician leaders and clinical champions is completed. Characteristics deemed relevant in choosing candidates are listed as the ability to communicate the shared vision, and the capacity to hold the respect of their peers. Pare et al, in “Prioritizing the risk factors influencing the success of clinical information system projects”, come to a similar conclusion about the importance of clinical champions. Their focus encompassed all CIS implementations, and the risk factors were spread across 7 dimensions: technological, human/user, usability, project team, project, environmental/organisational, and strategic/political. The factor that rose to the top of the rank list as the item most deserving of attention was “the lack of a project champion”.The literature has discussed the topic of physician leadership during the adoption of CISs from a number of perspectives, using a number of different research approaches. There appears to be a growing consensus that the success of CIS initiatives can be enhanced by placing physicians and other clinicians in leadership roles.
Research and conceptual frameworks exist that can be leveraged to guide the understanding of CIS implementation, and validate and extend the recommendations presented in the literature and strategic documents. Clinical leadership, defined as the capacity to influence others and guide them towards a shared target, intuitively fits into the four-step diffusion process.Diffusion of Innovation theory describes the patterns of diffusions of new technologies, and the parameters and variables that shape these patterns. Rogers published the earliest models, built on previous work, describing an S-shaped curve of technology uptake, and...
...a progression of adoption that highlights the concept that leadership and communication are necessary beyond the initial introduction of a new technology.Rogers’ model has innovations spreading across a social system, with uptake sequentially taking place in population subgroups: innovators (or first adopters) lead the way, with early adopters, the majority (grouped as early and later majority) and laggards following, in turn, the lead of the subgroup that precedes them. The proportions of these subgroups within the overall population describe a bell-shaped curve, with the bulk of the people falling in to the early and late majority groups. Critics of Rogers note that the assumption that this adopter curve is normally distributed is not always born out in reality. Derivation of a time-to-adoption profile based on other well-established diffusion models, such as the Bass diffusion model, demonstrates that the proportion of the population falling in to each of the adopter categories exist as ranges, and are therefore not identical for all innovations
Derivation of a time-to-adoption profile based on other well-established diffusion models, such as the Bass diffusion model, demonstrates that the proportion of the population falling in to each of the adopter categories exist as ranges, and are therefore not identical for all innovations
Extension of Rogers’ model (notably, research by Bass), incorporates and elucidates the factors (internal and external influences) that further shape diffusion patterns, and consequently can inform attempts to predict and optimise adoption. The boundary between internal and external factors is the social system in to which the innovation is being introduced. External factors (also known as “innovation factors”) are from outside the subject social system and facilitate or impede the adoption of new technology, e.g., economic factors. Internal factors (or “social contagions”), within the subject social system, appear to be the primary drivers of new product dissemination – the adoption behaviour of individuals within the social system are governed by behaviour, shared knowledge, or implied attitudes towards to innovation in question.Amongst the internal variables that predict the rate of innovation spread, three main categories of factors have been shown to correlate with diffusion patterns: 1) perceptions of the innovation; 2) personal characteristics of the innovation’s target audience; and 3) contextual factors, which include management, leadership, available communication channels and modalities, and incentives to adopt
Leadership is relevant at multiple points in the diffusion process. With different population subgroups progressively encountering and utilising the new technology in question at different times, leadership, and different styles of leadership, is required to draw people in to the pool of adopters. A key example is that the “early majority” take their cues, and garner knowledge from, early adopters, via local social interactions. Early adopters tend to be opinion leaders who are particularly well socially connected. However, some authors caution against mistaking all early adopters for opinion leaders – opinion leaders may adopt technology in advance of the mainstream, but generally do not risk getting too far ahead. While not as tolerant of risk as the “innovator” group, early adopters do tend to seek new technologies to test and evaluate.The early majority, on the other hand, garner knowledge of potential technologies from their social network rather than from theoretical or external recommendations. The late majority, in turn, tend to accept new technology when it becomes the status quo, again relying on local information, but seeking a higher threshold of “proof”. Laggards follow on, accepting technology when it has been proven across time – they are not dismissive of new options per se, but prefer to employ methods and technologies that are “tried and true”.These distinctions can inform the leadership styles necessary to optimise dissemination over diffusion.
There exists, however, a dearth of physician opinion leaders with the capabilities and competencies to perform guidance roles in the area of clinical information system design and implementation. The repeated reference to the social networks in which potential adopters exist as being important for communication implies that opinion leaders should be drawn from within these communities. Although there may be room use of third-party leadership, the suggestion is that physician leaders are ideally recruited from within their organisations, in order to make use of their pre-existing contacts and positions within their peer groups.In addition to the explicit leadership contextual factor, and the personal characteristics that make up the innovation adoption subgroups, several other variables inform us in the task of selecting, recruiting and training physician leaders to carry forward information system innovations. One of the more significant components of a potential user’s perception of an innovation is their assessment and understanding of relative benefit. Rogers speaks, and others reiterate, of reducing uncertainty through the dissemination of knowledge about anticipated consequences. It is also recognised that innovations must be seen to fit in to existing practices and cultures. These aspects of the technology diffusion framework are compatible with repeated recommendations to include physicians and other clinicians not only in the leadership team to facilitate product roll-out, but as advisors during the development (or customisation/implementation) phases.
What constitutes effective clinical leadership and engagement within clinical IT projects and programmes?Disappointingly, the literature remains largely mute on the specific skills a physician should possess, or seek to attain, in order to be an effective leader. Similarly, the actions a health system can take in order to enable successful physician leadership are not frequently nor adequately articulated.
Leviss et al suggest a job description that outlines a formal health IT leadership role, the Clinical Medical Informatics Officer (CMIO), to create physician ownership,and foster physician participation, in health IT projects. The subcomponents of this, at a more actionable level, include: - Manage project expectations, e.g., through the creation and execution of a relevant strategic plan. - Determine and govern the cultural tone of IT projects. - Instantiate and lead the clinical IT department, including the recruitment of appropriate physician champions for specific projects. - Lead vendor assessment and selection processes. - Perform a lead role ensuring communication with other clinicians (physicians and nurses). - Direct training and support, and multidisciplinary process redesign efforts.
Mountford and Webb present a hierarchical framework of distributed leadership that is useful in conceptualising the leadership skills that can contribute to healthcare provider functioning in general, and by extension, specific initiatives such as CIS and other information technology implementations. Three levels of leadership are described: - The institutional leader (who acts at the organisational level, and likely has little direct patient contact), - The service leader (one who drives a service for which they hold passion, and through which they maintain some direct patient contact as well as financial and performance-related responsibility), and - The frontline leader (one involved in a high level of direct patient care, who is focused on continual patient care quality improvement). This hierarchy also frames the sources of power, and the knowledge and skills required for a physician to be able to lead. The institutional leader draws power from their credibility as a physician, and their ability to communicate a high-level vision. The service leader has a tolerance for risk, and thus fits in to the role of innovator or early adopter when considering the technology diffusion framework. They are typically seen, amongst peers, as being a highly credible clinician, and, by virtue of being well connected, can draw on the skills of others in their network who demonstrate aptitude in project or operational tasks. The frontline leader, by virtue of their proximity to patient care, will be aware of opportunities for operational improvements, will have a skill set that includes an appreciation of systems- and quality-improvement techniques, and will be both a self-starter and effective team member.
Identify and provide concrete support to physician innovators. Help innovators to remain abreast of new developments (and feed back to other decision makers). Allocate time and funds for physician innovators to attend meetings and user conferences, supporting their development as CIS innovators, specialists or experts. Note that innovators, unlike early adopters, may not be deeply invested in local social networks. They may be deemed in some ways to be difficult to manage (e.g., may be demanding of latitude). Early adopterslead by communicating with early majority, but this needs to be via facilitating social networks rather than via media channels, and nominated leaders must be visible and observable – they must lead by example.Establish a cultural change programme that recognises and supports health care leaders. The MRG suggest a meritocratic approach with features such as an annual leadership award programme to draw attention to outstanding health care leaders.Mountford and Webb identify three main issues that hold clinicians back from participating in leadership roles: 1) scepticism about the benefit of allocating time to leadership tasks, at the expense of performing clinical functions, 2) the presence of weak incentives only, or even disincentives (including financial), to take on organisational leadership roles, and 3) an absence of systems and culture to foster physician leadership skills and advancement. In direct response to such lists of obstructions, the recommendations have been made that formal leadership positions have agreed-upon job descriptions, with declared annual performance expectations and leadership development plans. Basic performance data, against which progress can be assessed and comparisons can be made, has been shown to spur transformations that encourage leadership activities amongst physician. A supportive route back to fulltime clinical practice at the end of any leadership appointment should be specified, and that the allocation of sessional time during the working week should form part of the role definition. It is recognised that clinical practice and leadership roles may overlap to varying extents, so these transitions and allocations should be structured to facilitate the required balance.
Adapting and extrapolating from the CMIO-specific recommendation set of Leviss et al, the following are considerations relevant to appointing a physician to a leadership role in a clinical information system implementation project: - Personal attributes of a physician leader should include being seen as a credible clinician, not just an IT/computer expert. - Relevant skill sets include having knowledge of hospital administration and operations, the ability to communicate at multiple levels, and with other functional groups within the organisation, and efficacy in the task of consensus building. - The CMIO, or similar nominated physician leader, should receive support and collaboration from the hospital’s executive team, including the Chief Executive Officer. - For a significant project or large organisation, a formal CMIO role, or equivalent, should be created as part of the physician executive leadership team. - Relevant continuous professional development should be made available to physicians in formal “bridging” (i.e., those that cross the boundaries between clinical and information technology/systems domains) leadership roles.
A case can be made for better equipping doctors to be effective leaders by incorporating relevant training in to their various education paths. At all stages of the innovation diffusion curve, doctors lead doctors, and in turn, learn about (technology) innovations from their peers. Medical informatics programmes should include instruction on management and executive leadership.This would, of course, only reach doctors who engage in postgraduate study in these areas, so the case can be made that this cross-discipline integration could occur at earlier stages in medical training. The New Zealand Ministerial Review Group, put forward the recommendation that all undergraduate health disciplines should include formal attention to leadership development theory and practice, and that this should be incrementally instantiated throughout the curricula. The MRG goes so far as to recommend the establishment of relevant Chairs as a component of supporting multi-disciplinary research and the formalisation of academic achievement.Prior to the establishment of professional development pathways, or the integration of leadership components in to existing training, clarity must be sought on the skills required from clinical leaders in healthcare organisations. The benefits to elevating the leadership capabilities of the New Zealand clinical workforce go beyond the facilitation of information system implementations, of course, and the practical concerns associated with the more pressing issues and policies must be balanced.
** The call-to-action to incorporate clinical leadership as an integral component, at a number of levels, during the multi-stage process of CIS development, implementation, and as a component of ongoing support and evaluation, is supported by many authors and stakeholder authorities. ** The nexus between Roger’s Diffusion of Innovation theory and research on leadership in CIS adoption encapsulates the need for ongoing and different styles of leadership. The Diffusion of Innovation models speak to the importance of opinion leaders and other individuals who adopt innovations and technology at a pace ahead of the organisation’s median rate. ** In contrast to this theoretical ideal, a scarcity of physician opinion leaders exists in the hybrid domain of clinical information system design and implementation. In the absence of an abundance of physician opinion leaders in the territories of health information technology and clinical information systems, early adopters that fit the characteristics of opinion leaders must be actively identified and fostered. ** Physician leadership roles should be more than just nominal titles – they will require definition and description, evaluation and incentives. ** Training initiatives can be incorporated in to existing educational schemata.There is a presumption that physicians are already well equipped with management and leadership skills, despite a lack of formal training in these areas – a disconnect that can be remedied by integrating leadership training in existing educational pathways, and by establishing new professional development programmes. Ultimately, in order to increase the effectiveness of physician leaders in general, and in roles related to the complex scenarios of clinical information system projects, cultural change will need to be instituted that removes obstacles and incentivises selected candidates to take on such tasks.

Physician Leadership in Clinical Information System Projects

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Physician Leadership in Clinical Information System Projects

Editor's Notes