Digital diffusion in the clinical trenches : findings from a Telemedicine Needs Assessment

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Architecture, 2002.Includes bibliographical references (leaves 105-110).Broadly stated, this dissertation focuses on how practitioners and provider organizations integrate the computer and web into healthcare delivery. The opportunity that afforded this research was a Telemedicine Needs Assessment commissioned by a Massachusetts-based provider organization, consisting of two hospitals and 29 community group practices (CGP). The Telemedicine Needs Assessment incorporated qualitative and quantitative research programs to include: 1. cross-sectional, institution-wide, in-depth interviews; 2. participant observation at administrative and clinical day-to-day operations, and lastly, 3. a 68 item, closed-ended survey distributed to all 586 clinical practitioners to assess the access, use, and perceived needs of current computer, web, and telemedicine technologies. Data from the survey, (72% response rate), established a computer and web enablement baseline against which the success, failure, or potential usefulness of any future medical informatics implementation would be evaluated. Findings included: 1. Computer and web enablement within the organization is not ubiquitous. Access is high, use is low; 2. Practitioner status, practice location, and gender affect enablement. Non-MDs, CGP-based practitioners, and female practitioners report lowest access and use. 3. No differences were reported specific to home access to computers and use of e-mail. 4. Hospital-based practitioners report greater access and use. CGP-based practitioners report greater perceived needs for teletechnologies.(cont.) 5. Hospital-based and CGP-based male MDs emerge as the most polarized subgroups due to differences in computer and web use and perceived needs. 6. Female practitioners are more successful than male practitioners securing tech support at home and at work. 7. With regard to technology uptake, female MDs constitute a more homogeneous group than male MDs. Also, four products emerged from the Telemedicine Needs Assessment: 1. a needs assessment theory and methodology derived from Process Architecture which promulgates that discussions specific to the end users' work must always be inextricably linked with their work practice; 2. a typology of barriers to the integration of computer and web-based technologies into healthcare delivery stratified by practitioner, administration, organization, and industry; 3. a framework which defines and integrates real and virtual healthcare delivery services, products, and technologies, and finally; 4. a systems-based model of clinical and telecommunications integrated delivery networks providing IS, IT, and administrative infrastructure support for the framework.by Verlé Margaret Harrop.Ph.D

Primary care practices by default or by design : case study of a physician

Thesis (M.S.)--Massachusetts Institute of Technology, Dept. of Architecture, 1998.Includes bibliographical references (leaves 83-84).Dr. Meaford, a prominent internist in a PMO ambulatory unit says that he is overwhelmed by his medical practice. He attributes the state of being overwhelmed to the fact that he is unable to implement systems of support for his practice that he has designed. The thesis starts with an overview of the systems of support in Dr. Meaford's primary care practice. In doing so identifiable default practice patterns emerged. In the process of fleshing out a context for those patterns it became apparent that organizational policy can either stress or support medical practice. In Terence Meaford's case it was very much the former. What constituted a practice-specific, workflow-based system of support for him did not constitute a support priority for the organization. This is essentially why his implementations of support for his practice failed. In the process of coming to this realisation, it seemed obvious to ask how much more successful a system implementation might be if it were coming from "the top down". To that end we looked at what might transpire when the PMO attempts to implement its system of support, the integrated electronic medical record system. It soon became obvious that there was a profound conflict of frames of reference: ABMII supports primary care practice: Meta Systems supports managed care business. The only place where the two frames of reference intersect is efficiency. If Terence can improve the efficiency of his practice he won't be so overwhelmed: If the organization can improve his efficiency then he will be able to increase his panel size and generate more revenue. The implementation of these electronic medical record systems signals the end of an era in healthcare: Meta Systems confirms the supremacy of organizational values right down to the essence of medical practice itself the physician-patient encounter. Jane Jacobs, in her 1992 book, "Systems of Survival A Dialogue on the Moral Foundations of Commerce and Politics", lays out 2 value systems: the guardian syndrome (Dr. Terence Meaford) and the commercial syndrome (Health right Plus the PMO). Her point is that the espoused self interests of these two groups will always be in conflict because their value systems are antithetical. In her analysis however, there is no mention of the role that technology plays in wrestling these two to the mat. I propose that technology could be the "zipper" that pulls these two sides together and that input at every level to the policy governing this technology is absolutely essential if quality of care is to remain a priority for the practice of medicine.by Verlé M. Harrop.M.S