Health Information Technology and Physician Leadership

In 1982, Paul Starr noted that technology increased physician power: “ . . . the most influential explanation for the structure of American medicine gives primary emphasis to scientific and technological change and specifically attributes the rise of medical authority to the improved therapeutic competence of physicians.”(1)

In the years after Starr’s analysis, not only have the advancements made through technological change enabled many of the industry’s breakthroughs and life-saving accomplishments, but they also have challenged physicians’ professional control. Robotic surgery changed the capital requirements of hospitals, decreased recovery time for patients, and required new technical skills for surgeons. Likewise, population management strategies dependent on “Big Data” information technology in the community setting altered medical practice’s historical facility-based episodic business model.

Just as patients have gained access to better information to improve their own decision-making, so too have the tools improved for physicians to support clinical diagnosis recommendations and orders for better-quality medical care. Using the best knowledge to identify what to do and how to make it part of routine practice may appear obvious. Still, studies indicate it takes up to 15 years for medical knowledge to become incorporated into routine medical practice.

Unexplained variation in clinical practice is prevalent throughout clinical settings to the extent that the integration of content and context is seldom ideal. Evidence-based medicine provides the practicing physician a bridge between science and bedside application that can serve as a pathway to transition practice guidelines to a more precision-based and scientifically rigorous methodology.

The introduction of new technology within the clinical work environment always alters processes and has unintended consequences.

The practice of evidence-based medicine should ensure that patient care adheres to clinical best practices and improves the health of communities. However, with evidence-based medicine and evidence-based management come perceived threats to autonomy and control in clinical decision-making, difficulty accessing the evidence base, and difficulty differentiating useful and accurate evidence from that which is inaccurate or inapplicable. Integrating evidence-based medicine practices into clinical guidelines requires physicians who can draw upon the evidence to improve the quality of care being delivered.(2)

The introduction of new technology within the clinical work environment always alters processes and has unintended consequences. A classic example of unintentional consequences is the 2006 study by Campbell, Sittig, Ash, and colleagues identifying a set of nine unintended adverse consequences that result from the introduction of computerized physician order entry systems. The authors note an unintended power structure shift from physicians to others based on their loss of control over information.(3)

A deeper understanding of the technologies’ role in healthcare power shifts is the interactive sociotechnical analysis (ISTA) introduced by Harrison and Koppel in 2007.(4) Computerized provider order entry and other health information technology systems all involve transforming the clinical workflow processes within organizations as they are implemented. Throughout the process of design, test, implementation, and eventual future-state use of a new application, clinician, ancillary, and administrative team members are engaged with physicians to ensure that benefits are realized from the new tools to meet goals for improving outcomes, cost, quality, and safety of patient care.

Harrison and Koppel indicate that, throughout this process, relationships and communication are impacted by the dynamics involved with changes in workflow and the new systems. New triggers, alerts, and in some cases, workarounds(5) can emerge that inadvertently result in shifts of roles and actions that can impact quality and safety in patient care operations. Harrison’s and Koppel’s ISTA model can be applied to manage resources needed to accommodate new workflows, approvals, communication patterns, and roles of various professionals in the healthcare system.

The shift in control of information brought on by health information technology improvements has led to an increase in leadership roles held by nurses and other non-physicians in the care delivery process and administration of healthcare organizations. Nurses make up the largest segment of the healthcare workforce. As their responsibilities have grown to accommodate the needs of delivering patient-centered care, academic initiatives are focused on strengthening the education level of the national nursing workforce. As a result, a growing number of nursing leaders are working in partnership with physicians to redesign the healthcare delivery system and processes.(6) Several factors are driving this change:

• The social architecture and fabric of healthcare organizations have changed. Nurses are increasingly being called upon to shape health policy, implement new systems, and serve as change agents throughout the healthcare ecosystem.

• Health information technology tools have increased the need for shared responsibilities in managing health information at the patient and population levels.

• The patient population continues to increase through demographic and socioeconomic changes that will drive the need for additional collaborative clinical leadership in managing care delivery programs and organizations.(7)

Team-based care is inevitable and crucial for improving patient outcomes as technology continues to accelerate changes in the healthcare delivery system. Team-based healthcare includes collaboration among team members and the patient and family; shared goals across healthcare settings; and coordinated, high-quality, patient-centered care.(8) However, who and how leadership and authority are distributed in healthcare teams remain controversial. The American Medical Association supports legislation that maintains the authority of physicians in patient care and advocates for physician-led team models,(9) but with the worldwide shortages of primary care physicians, non-physician healthcare professionals are taking an increasing role in leading teams in order to maintain access to primary care across the world.

Artificial intelligence-driven algorithms may supersede the seven years of medical training traditionally required to train a primary care physician and permit the design of high-functioning healthcare teams built upon non-physician professionals with a different skill set and training from that provided by medical personnel schools. Regardless of authority structure, team-based care requires shared accountability for patient care and timely information that is shared comprehensively among the team members.(10) Improvements in health information technology can optimize team-based care.

References

1. Starr P. The Social Transformation of American Medicine. New York: Harper Collins; 1982:359.

2. Shannon D. Did you get an ‘A’? Physician Executive. 2007;33(6):4-8.

3. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13:547-556.

4. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care-an interactive sociotechnical analysis. J Am Med Inform Assoc. 2007;14:542-549.

5. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008;15:408-423.

6. Institute of Medicine. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. Summary. In: The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011:221-225.

7. Hsiao W. Abnormal economics in the health sector. Health Policy. 1995;32(1-3):125-139.

8. Physician-led Team-based Care. American Medical Association. www.ama-assn.org/practice-management/scope-practice/physician-led-team-based-care .

9. Models of Physician-led Team-based Care. American Medical Association. American Medical Association, 2015. www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/cms/team-based-models_0.pdf .

10. Freund T, Everett C, Griffiths P, et al. Skill mix, roles and remuneration in the primary care workforce: who are the healthcare professionals in the primary care teams across the world? Int J Nurs Stud. 2015;52:727-743. doi: 10.1016/j.ijnurstu.2014.11.014. Epub 2014 Dec 19.