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 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:
- “Technology Trigger” – the initial launch; a new technology reaches public or press attention.
- “Peak of Inflated Expectations” – A few successful applications of the technology (often by highly selected individuals or organizations) help catalyze unrealistic expectations, often aided and abetted by hype driven by word of mouth, the blogosphere, or vendor spin.
- “Trough of Disillusionment” – Virtually no technology can live up to its initial PR. As negative experience mounts, the balloon is pricked and air rushes out. The press moves on to cover another “hotter” technology, like a moth flitting to the light (see Phase II).
- “Slope of Enlightenment” – A few hardy individuals and organizations, seeing the technology’s true potential, begin experimenting with it unencumbered by inflated expectations. Assuming that the technology is worthwhile, they begin to see and demonstrate its value.
- “Plateau of Productivity” – As more organizations ascend the “Slope of Enlightenment,” the benefits of the technology (which by now has improved from its initial clunky phase) become widely demonstrated and accepted. The height of the plateau, of course, depends on the quality of the technology and the size of its market.
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 healthcare 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 practitioner.”
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.