Computers and Medicine Bruce I. Blum, Editor Computers and Medicine Information Systems for Patient Care Bruce 1. Blum (Editor) Computer-Assisted Medical Decision Making, Volume 1 James A. Reggia and Stanley Tuhrim (Editors) Computer-Assisted Medical Decision Making, Volume 2 James A. Reggia and Stanley Tuhrim (Editors) Expert Critiquing Systems Perry L. Miller (Author) Use and Impact of Computers in Clinical Medicine James G. Anderson and Stephen J. Jay (Editors) Use and Impact of Computers in Clinical Medicine Edited by James G. Anderson and Stephen J. Jay With 21 Illustrations Springer-Verlag New York Berlin Heidelberg London Paris Tokyo James G. Anderson Stephen J. Jay Professor of Sociology Senior Vice President for Academic Affairs Purdue University and and Information Services Methodist Hospital of Indiana Methodist Hospital of Indiana Indianapolis, Indiana 46202, U.S.A. Professor of Medicine and Assistant Dean Indiana University School of Medicine Indianapolis, Indiana 46202, U.S.A. Series Editor Bruce I. Blum Applied Physics Laboratory The Johns Hopkins University Laurel, Maryland 20707, U.S.A. Library of Congress Cataloging in Publication Data Use and impact of computers in clinical medicine. (Computers and medicine) Includes bibliographies and index. 1. Medicine-Data processing. 2. Information storage and retrieval systems-Hospitals. I. Anderson; James G., 1936- . II. Jay, Stephen J. III. Series: Computers and medicine (New York, N. Y.) [DNLM: 1. Computers. 2. Medicine. W 26.5 U836] R858.U84 1986 610'.28'5 86-13072 © 1987 by Springer-Verlag New York Inc. All rights reserved. No part of this book may be translated or reproduced in any form without written permission from Springer-Verlag, 175 Fifth Avenue, New York, New York 10010, U.S.A. Softcover reprint of the hardcover 1st edition 1987 The use of general descriptive names, trade names, trademarks, etc. in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Typeset by Huron Valley Graphics, Inc., Ann Arbor, Michigan. 9 8 7 6 5 432 1 ISBN-13:978-1-4613-8676-6 e-ISBN-13:978-1-4613-8674-2 DOl: 10.1007/978-1-4613-8674-2 Series Preface Computer technology has impacted the practice of medicine in dramatic ways. Imaging techniques provide noninvasive tools which alter the diag nostic process. Sophisticated monitoring equipment presents new levels of detail for both patient management and research. In most of these high technology applications, the computer is embedded in the device; its presence is transparent to the user. There is also a growing number of applications in which the health care provider directly interacts with a computer. In many cases, these applica tions are limited to administrative functions, e.g., office practice manage ment, location of hospital patients, appointments, and scheduling. Nev ertheless, there also are instances of patient care functions such as results reporting, decision support, surveillance, and reminders. This series, Computers and Medicine, focuses upon the direct use of information systems as it relates to the medical community. After twenty five years of experimentation and experience, there are many tested ap plications which can be implemented economically using the current gen eration of computers. Moreover, the falling cost of computers suggests that there will be even more extensive use in the near future. Yet there is a gap between current practice and the state-of-the-art. This lag in the diffusion of technology results from a combination of two factors. First, there are few sources designed to assist practitioners in learning what the new technology can do. Secondly, because the potential is not widely understood, there is a limited marketplace for some of the more advanced applications; this, in turn, limits commerical interest in the development of new products. In the next decade, one can expect the field of medical information science to establish a better understanding of the role of computers in medicine. Furthermore, those entering the health care professions al ready will have had some formal training in computer science. For the near term, however, there is a clear need for books designed to illustrate VI Series Preface how computers can assist in the practice of medicine. For without these collections, it will be very difficult for the practitioner to learn about a technology which certainly will alter his or her approach to medicine. And that is the purpose of this series: the presentation of readings about the interaction of computers and medicine. The primary objectives are to describe the current state-of-the-art and to orient medical and health professionals and students with little or no experience with com puter applications. We hope that this series will help in the rational transfer of computer technology to medical care. Laurel, Maryland BRUCE I. BLUM Preface Bruce Blum pointed out in the Preface to the Computers and Medicine Series that although there are many medical computer applications that could be implemented economically, there is a gap between current prac tice and the state-of-the-art. On the one hand, information systems have been developed that can assist health care institutions with cost reduction, operations, and patient care. On the other hand, surveys have consis tently indicated that despite the development of an enormous number of computer-based medical information systems, their dissemination and utilization are limited. What accounts for this limited implementation and underutilization of clinical computing systems? At present, the process by which computer applications are adopted and diffuse and become part of the clinical prac tice of physicians is poorly understood. Effective public policies in the form of incentives, subsidies, and regulations, however, cannot be devel oped without a better understanding of the process through which com puter systems are implemented in various practice settings. Moreover, a clear understanding of this process and the factors that influence it is essential for those professionals who are developing the next generation of medical computing systems. Computers have the potential to extend dramatically the physician's ability to provide health care. At the same time, computers may signifi cantly alter the physician's professiona role, the nature of the doctor-patient relationship, and the organization of the health care delivery system. The challenge for the future is to develop organizational arrangements and incentives designed to enhance humane values while capitalizing on the advances in medical computing. The objective of this book is to bring together papers that provide major research findings concerning the factors that affect the adoption, diffusion, utilization, and impact of computers in clinical medicine. Areas of needed research will be highlighted. The book is aimed at the growing viii Preface number of practitioners, researchers, and students in medicine, the bio medical sciences, engineering, and computer science who use or assist in the development of medical computing systems. The chapters that follow deal with clinical information systems. Blum has defined these systems as applications that manage clinical data by creating a database that can be used by clinicians in providing health care. In this book, we have focused on large systems, most of which are hospital based. We have excluded financial systems that do not include clinical data, embedded computer applications that are largely transparent to the users, laboratory systems, and physiological monitoring systems. Also, we have chosen not to deal at this time with the growing number of microcomputer-based systems. Factors that affect the adoption, diffusion, utilization, and impact of microcomputer based systems may not be the same as for mainframe systems. However, there are few reported studies of microcomputer-based clinical systems to draw upon at this time. Most of the computer applications reported in this book have been introduced into hospitals. This practice setting is important for several reasons. Until recently, information systems have been implemented in hospitals largely because of their cost. Second, the hospital has become an institutional workplace for significant portions of the time for the majority of physicians. Not only are hospital services administrative units, but also they are organized around specialties. Consequently, physicians on a particular hospital service share common medical education experi ences, types of patients, practice patterns, professional norms, and expec tations. There is more formal and informal interaction among physicians on these services. Hospitals, then, are important practice settings in which to study the diffusion and use of clinical information systems by physicians and their effects on medical practice. We wish to thank the many contributors to this volume. Grant HS 04774 from the National Center for Health Services Research and Health Care Technology Assessment helped to support the research that resulted in a number of the contributions to this book. We also wish to thank the house staff and medical staff of Methodist Hospital of Indiana for their generous participation in our research effort and Marilyn Anderson who assisted us with the data analysis and the preparation of this book. Fi nally, we with to thank Bruce Blum for his encouragement and the edi tors and staff at Springer-Verlag for their assistance in producing this volume in the Computers and Medicine Series. JAMES G. ANDERSON STEPHEN J. JAY Contents Series Preface V Preface Vll Contributors xiii I. Introduction 1. The Diffusion of Computer Applications in Medical Settings 3 James G. Anderson and Stephen J. Jay 2. What Makes Doctors Use Computers?: Discussion Paper 8 D.W. Young 3. Medical Technology: Assessment, Adoption, and Utilization 15 Ann Lennarson Greer II. Adoption: The Physician's View of Computers in Medicine 4. The Influence of Medical Values and Practices on Medical Computer Applications 39 Bonnie Kaplan 5. What do Professional Persons Think About Computers? 51 Elizabeth Zoltan-Ford and Alphonse Chapanis 6. An Analysis of Physician Attitudes Regarding Computer-Based Clinical Consultation Systems 68 Randy L. Teach and Edward H. Shortliffe 7. Physician Attitudes Toward Applications of Computer Database Systems 86 Joseph Singer, Henry S. Sacks, Frank Lucente, and Thomas C. Chalmers x Contents 8. Why Doctors Don't Use Computers: Some Empirical Findings 97 James G. Anderson, Stephen J. Jay, Harlan M. Schweer, and Marilyn M. Anderson III. Diffusion of Medical Computer Applications 9. Diffusion of Innovations: An Overview 113 Everett M. Rogers 10. Embracing or Rejecting Innovations: Clinical Diffusion of Health Care Technology 132 H. David Banta 11. Computers and Clinical Judgment: The Role of Physician NetWorks 161 James G. Anderson and Stephen J. Jay 12. Physician Communication Networks and the Adoption and Utilization of Computer Applications in Medicine 185 James G. Anderson, Stephen J. Jay, Harlan M. Schweer, Marilyn M. Anderson, and David Kassing IV. Utilization of Clinical Computer Systems 13. Clinical Computing in a Teaching Hospital 205 Howard L. Bleich, Robert F. Beckley, Gary L. Horowitz, Jerome D. Jackson, Edna S. Moody, Caryn Franklin, Sandra R. Goodman, Michael W. McKay, Richard A. Pope, Timothy Walden, Saul M. Bloom, and Warner V. Slack 14. Implementing Computerization in Hospitals: A Case Study of the Behavioral and Attitudinal Impacts of a Medical Information System 224 Michael A. Counte, Kristen H. Kjerulff, Jeffrey C. Salloway, and Bruce C. Campbell 15. Evaluation of a Computerized Drug Review System: Impact, Attitudes, and Interactions 238 Carole Siegel, Mary Jane Alexander, Yosef D. Dlugacz, and Susan Fischer 16. A Structural Model of the Impact of Physicians' Perceptions of Computers on the Use of Hospital Information Systems 257 James G. Anderson, Stephen J. Jay, Harlan M. Schweer, and Marilyn M. Anderson