Fresh on the heels of my recent bar coding epiphany comes another “unintended consequences” article. It turns out that the whipsawing that accompanies the adoption of new technologies is completely foreseeable, the “Why doesn’t this thing work right?” phase is as predictable as the seasons.
Thanks to Dr. Mark Wheeler, Director of Clinical Informatics of PeaceHealth, for introducing me last week to the “Technology Hype Cycle” concept. The Cycle, originally described by the IT consulting firm Gartner, is comprised of an all-but-inevitable series of phases that technologies tend to traverse after they are introduced. The five phases are:
You can chart the course of virtually any
health information technology on the Hype Cycle curve. In the case of
computerized provider order entry (CPOE), the trigger was the
development of the technology in the 70s and 80s (the first CPOE system
was implemented at El Camino Hospital during Nixon’s presidency). The
Peak of Expectations was turbo-charged by the research in the 1990s by
Bates demonstrating its value in one highly unusual organization
(Brigham & Women’s Hospital), working with a homegrown system. The
apogee was the endorsement of CPOE by the Leapfrog Group in 2002.
My colleagues and I may have helped initiate the Trough – our 2001
report on evidence-based safety practices gave CPOE a relatively low
mark on “strength of the evidence,” leading to significant
consternation (“you’re holding back implementation”) among some safety
experts and advocates but opening the floodgates of skepticism. Further
Trough-digging came from studies that identified all kinds of
unexpected consequences from CPOE – culminating in the Mother of all
Excavators, the paper by Han from Pittsburgh Children’s Hospital
demonstrating that CPOE increased the mortality rate.
As more and more organizations enjoy successful CPOE deployments, we
are now trudging up the Slope of Enlightenment. And, with improving
systems (some of today’s commercial systems aint half bad), we are
probably about to scale the Plateau of Productivity.
Bar Coding and Smart Pumps, being less well-established technologies in
healthcare, are probably a phase or two behind. So expect
ecstasy-agony-realism cycles for these technologies as well.
The reason I find the Hype Cycle concept to be so illuminating is its
explanatory power and predictive value. The Cycle allows one to
pinpoint the stage of any technology at a given time (for an example,
here’s Gartner’s 2006 report on Web-based technologies outside
medicine). In the health care world, the thoughtful and prudent CIO or
CMIO will use his or her knowledge of the Cycle to help prepare the
organization for the trauma that is about to be visited upon it. For
example, a hospital gearing up to implement CPOE or bar coding would be
well advised to ready its troops to read about – and possibly
experience – the Trough of Disillusionment. This nadir (“Whose idea was
this damn thing anyway?”) is much easier to stomach when you know that
the final, happier, phases are just around the bend.
Of course, none of this is new. Even before there was a Technology Hype
Cycle, implementing new technologies was not for the faint of heart.
Consider this quote:
“That it will ever come into general use, notwithstanding its value, is
extremely doubtful because its beneficial application requires much
time and gives a good bit of trouble, both to the patient and the
Was the writer speaking of CPOE?
Bar coding? Well, no. This is a quote from the 1834 London Times,
referring to a new contraption called the stethoscope. You’ll be
pleased to know that it eventually reached its Plateau of Productivity.
Robert Wachter is widely regarded as a leading figure in the modern
movement. Together with Dr. Lee Goldman, he coined the
term "hospitalist" in an influential 1996 essay in The New England
Journal of Medicine. His most recent book, Understanding Patient
Safety, (McGraw-Hill, 2008) examines the factors that have contributed
to what is often described as "an epidemic" facing American hospitals.
His posts appear semi-regularly on THCB and on his own blog "Wachter’s World."