IT acceptance in health care can only succeed via magically balanced developer-decision maker-user triangle

Brussels 28 March 2000At the occasion of the MediMedia workshop on medical imaging, DG13 Officer at the European Commission, Dr. Ilias Iakovidis, shared his vigorous viewpoints on the indispensable need for user acceptance to create a market for IT in health care. On the other hand, the dynamic speaker drew a vivid picture of the future e-health scene in Europe where policy makers try to cuddle the citizen with general Internet access to personal health data by the end of 2000 in exchange for a vote at the elections. In the meanwhile, health experts are panicking with the thought that such tremendous speed of implementation will simply be impossible to realise. Dr. Iakovidis strongly insisted on careful manoeuvring between the Scylla and Charibdis of these two extreme scenarios and urgently pleaded for a tight collaboration between users, decision makers and developers within health care IT projects.

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Scientific studies in the United States have shown that 40% of the IT initiatives in health care are boycotted by the users. This is due to the fact that developers pay far too little attention to the user-friendliness of the systems, according to Dr. Iakovidis. Health care system designers ought to understand that health care providers can spare little or no time at all for an extensive training. Yes, they want to be educated about the new system but just for two minutes in the corridor while they are running from one patient to another. And, please, do not expect a physician to go to another room to use the computer system. If you are not able to provide portability nor any user-friendly human-computer interaction at the point of need, doctors will simply not use your carefully designed system.

This is the reason why Dr. Iakovidis stressed the importance of targeting the user profile and analysing the different contexts of IT use within the clinical routine. From a user's point of view, there are three main priorities: speed, speed and SPEED. Since the average user doesn't exist, the idea of a single interface constitutes a somewhat naive objective. Instead of a health provider having to adapt himself to the system, the computer has to adapt itself to the user. This calls for intuitive solutions. The first layer of such an IT interface can be speech recognition. In a second step, speech has to be transmitted into free text but this is insufficient. To be manageable, the system should deliver a structured text representation. This is one example presented by Dr. Iakovidis, of how IT can be successfully implemented within the hospitals.

Another aspect forms the health care market, where the role of the decision maker should not be omitted. It are not just users and developers, who make the scene. In the present situation, decision makers are very sceptical about ICT implementation, which they tend to consider as just another expense. It is not particularly high on their priority list. Dr. Iakovidis also senses a deep mistrust and misunderstanding between the different parties. Clinical users accuse industrial companies of cheating, and there are project co-ordinators who stated they never again want to know about such thing as a user group. Health authorities do not want to be bothered with the problem and delegate the issue to their IT specialist.

However, the recent experiences that Dr. Iakovidis encountered in the United Kingdom, seem to provoke drastic changes in the policy makers' attitude. An e-hype has conquered the mind of the authorities and e-health is pasted into the picture. The British government is investing in e-technology to make the citizens' health records available on the Internet by December. Although not really understanding the field, the authorities think it a good voting strategy, since people are growing excited about e-commerce. The industry is following the big dream and starts installing systems everywhere, submitting the user to what is called "SHIT", a Special High Intensive Training for the public. In turn, experts nostalgically will remember the good old times when the government didn't care and they had all the time to design the system.

The danger in all this is the lack of a solid developer-user relationship so one will boycott the other. Dr. Ilias Iakovidis predicts that hard times are coming unless this partnership slowly starts to develop. In medicine, things are not happening fast. It usually takes six years to make an idea for implementing a system actually work in a clinical environment. While showing the familiar chasm scheme, Dr. Iakovidis tried to convince the developers to nurture the so-called crazy doctors, who have innovative IT and computer knowledge but are treated as less qualitative physicians by their colleagues. Most of the IT systems never reach the market since they don't survive the chasm between these innovators and the early majority. However, once you have succeeded in selling one system, you can sell more.

For the developers, it is of crucial importance to ensure themselves from the beginning of the commitment of the health care leaders in the hospital or the region. The system will never exactly meet the initial requirements but one or two leaders are able to bridge the critical moment between disillusionment and faith, and still revive the system. Commitment means involvement which again relates to commitment. In Dr. Iakovidis' eyes, they are the same words. In conclusion, the message is very clear: the three parties of users, decision makers, and developers have to be brought together. System implementation cannot be done by one out of three, not even by two out of three. Each party needs the other one to make the magic work.

In 1995, this major principle was applied to medical record standardising in the PROREC project. In each country, government, users' associations, and developers united on a national level to standardise features of the electronic record. The results were quite satisfying. The same thing happened in the EHTEL project, which established a forum for Health Telematics Solutions in Europe. Other European examples are MSHuge and TOMELO. In Canada, there is the CIHI project whereas in the United States, the Computer Patient Record Institute (CPRI) has been founded in a similar spirit. If all of the three parties constructively work together and concentrate on user-friendliness in the first place, we are already halfway there, according to Dr. Iakovidis' firm conviction.

More information about the EHTEL project is available in the article European Union soon to have its Forum for Health Telematics Solutions which has appeared in the November 1999 VMW issue.


Leslie Versweyveld

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