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Chapter 5

Information Technology Can Drive Transformation

Ronald W. Manderscheid, Ph.D.
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration

Introduction to Modern Information Technology

From the perspective of 2004, it seems difficult to recall that practically all of what we consider to be modern information technology (IT) has been introduced and implemented broadly only during the past 10 years. In 1993, for example, fewer than 50 Web sites were operational, and President Clinton was attempting to introduce personal computers into schools! In the present era, probably no other technological innovation has diffused as rapidly or as broadly as IT has. Alvin Toffler predicted this almost 25 years ago (Toffler, 1980).

Principally through the medium of the Internet, modern IT has become ubiquitous in government, business, and personal communication. E-mail, on-line purchases, filing of tax forms, sharing of photos, transmittal of health information, student “library” research, and on and on, all occur with the lightening speed of an electron.

All of this gives rise to a need for reflection. What impact does this new IT have on our work life, our organizations, our social life, and our community life? Does it drive organizational change? Can we direct it toward positive social change? Depending on how we answer these questions, IT may be able to play a pivotal role in transformation—the continuous process of quality improvement required to achieve desired effects. This role may modify management and business processes within both government and the private sector; alter interorganizational relationships; and extend our concept of community, particularly around our people-oriented institutions, such as health care.

The purpose of this chapter is to explore these questions. Potential applications from the field of mental health are highlighted in hypothetical
examples.

Characteristics of Modern IT

Unlike any other technology from the past, modern IT changes the essential nature of interpersonal communication. All previous technologies simply mitigated the space and/or time constraints of interpersonal communication. Originally, all human communication occurred on a face-to-face basis in real time. Writing allowed space/time constraints to be transcended in a narrow way; mail and the telephone allowed them to be transcended on a much broader basis. However, in earlier technologies, one communicated with others who were known to, and who generally shared a common language and culture with, the communicator.

Modern IT has introduced several essential changes into this traditional communication paradigm:

Acceleration. Because communication through IT is instantaneous, interpersonal communication using this technology is extremely rapid, and much more networking and interaction can take place per unit time. For example, in less than a minute, a person can broadcast e-mail to several thousand (or million) people, and they can read it and respond. As a result, interactions can proceed very rapidly, and negotiations and decisions can occur with equal speed. A sociologist would say that social time is being compressed. Norms governing propriety in such interactions are currently being developed through trial and error.

Equalization. Modern IT fosters communication through a network rather than a hierarchical structure. As a result, it has the capacity to eliminate social and rank distinctions among participants. With modern IT communication, a homeless person and a president of a large corporation are “equal.” Traditional boundaries between people of different social ranks, cultures, and even societies simply do not exist. Organizational boundaries between private businesses, professional disciplines, governmental units, and countries can be reduced or eliminated in favor of broader patterns of communication and interchange.

Disintermediation. Probably one of the most threatening features of modern IT is its capacity to eliminate intervening persons, groups, and organizations (i.e., “middlemen”) from communication and decision loops in favor of direct communication between end users (e.g., purchaser and producer, constituent and elected official, or health care consumer and physician).

This chapter applies these concepts to different structures within the health care system, with particular attention to mental health services. “Pre”-IT and “post”-IT scenarios are described at the interpersonal, interorganizational, and sector levels.

Transforming Human Relationships

Context. Sociologically, all interpersonal interaction is “staged.” This does not mean that interactions are duplicitous. Rather, it means that participants each play roles (albeit imperfectly), that they have expectations for the roles that others will play, that they usually enter and exit on cue, and they generally respect the cultural norms that define conduct appropriate to the situation.

Pre-IT. Previously, when one visited a physician (or other health care provider), one first made an appointment with a scheduler. Then, one arrived at an office several minutes before the scheduled time of the appointment, saw the physician for a very short period, tacitly agreed to follow the physician’s advice or prescription, and usually arranged a follow-up visit with the scheduler before departing. The entire transaction was very sequential and orderly. (If you do not fully appreciate the cultural force of these everyday features, just try to deviate from them—for example, schedule an appointment on a Sunday morning.)

Post-IT. E-mail between health care consumers and physicians can circumvent the social structures and cultural norms that define the office visit. E-mails can be sent 24 hours a day; the recipient can respond anytime; and other physicians and health care consumers can be copied and made part of specific transactions. For example, health care information can be exchanged rapidly among caregivers. Professional associations are just beginning to evolve norms regarding appropriate electronic interactions between consumers and professionals.

At a slightly more complex level, the physician can incorporate modern IT into an office visit. A health care consumer may interact with a computer to answer a series of questions about personal symptoms and health status before seeing the health care provider. The physician may use computer programs to assist with diagnosis; the treatments given or the drugs prescribed may be monitored through IT; and the charge for the transaction may be generated and mailed automatically.

Other features of modern IT also can shape this service relationship. Tests, such as for blood pressure or depressed mood, can be self-administered at home and the results transmitted immediately via the Internet to a physician. E-mail can be replaced by video streaming that more closely approximates the features of human interaction. The physician can be replaced by a “smart system” programmed to interact with health care consumers and to “learn” how to react and impart advice depending upon the pattern of consumer responses.

It is immediately obvious from these examples that modern IT can change dramatically the relationship between health care consumer and provider. The scope of the relationship can be broadened, better tools can be used for diagnosis and treatment, and treatment plans and these effects can be monitored more closely and accurately.

One of the major deficits of modern mental health care, the failure to develop and to follow carefully a recovery-oriented individualized treatment plan for every mental health consumer, can be overcome with modern IT. The mental health consumer, the mental health provider, and all other professionals who provide allied services (e.g., housing and job training) can jointly develop the plan through a series of interactions on the Internet, and modern IT can be used to check milestones, progress, and effects.

Transforming Interorganizational Relationships

Context. Interorganizational relationships are typically governed by elaborate boundary maintenance efforts designed to preserve the integrity of each organization. In terms defined by the sociologist Talcott Parsons more than 50 years ago (Parsons, 1951), these efforts can be described as pattern maintenance functions. With economic globalization, organizations are forced to hire more part-time, -temporary, and contract employees to remain competitive. As these people enter an organization, it becomes progressively more difficult to define organizational boundaries. Yet, paradoxically, as organizations feel more threatened by globalization, they are likely to devote relatively more of their total effort to boundary maintenance. This results in the classic problem of “stovepipe” organizations—the inability to effectively interact with the environment or to effectively protect boundaries.

Pre-IT. Previously, interorganizational communication occurred according to a hierarchical protocol based on norms that dictated the appropriate persons to engage in such interaction. For example, a staff person in company A would generate an inquiry for company B. The inquiry would be prepared in the form of a letter (or memorandum) from the president of company A to the president of company B. Subsequently, the president of company B would pass the inquiry down to the appropriate staff person who would prepare an answer. Then the communication process would be reversed. It seems very clear that such communication sacrificed efficiency for control and boundary maintenance. It was also very time-consuming, burdensome, and costly.

Post-IT. How does this pattern change with modern IT? The staff person in health care organization A can communicate directly by e-mail with a staff person in health care organization B. This communication could be about a health care consumer the two organizations share in common, about a common billing problem, or a myriad of other issues that could arise between either collaborators or competitors. In fact, many dyadic (or larger group) electronic interactions may exist simultaneously between health care organizations A and B. Acceleration, equalization, and disintermediation can all be in play. Usefully described as a “web” of communication, such patterns can progressively blur interorganizational boundaries and loyalties.

In 2003, President Bush’s New Freedom Commission on Mental Health found widespread fragmentation in mental health services that leads consumers to “fall through” interorganizational “cracks” (New Freedom Commission on Mental Health, 2003). As a result, consumers do not receive appropriate care, positive health outcomes are diminished, and overall care costs are high. The development of electronic interorganizational linkages to permit all mental health, health, and social service organizations in a local area to constitute a “virtual” system of care could go far to overcome this fragmentation. Initially, this might be as simple as crafting an Internet-based electronic information source on all services available in a local area. At a slightly more sophisticated level, it could take the form of identifying a single electronic point of entry into a virtual system of care, so consumers are not confused by a complex interorganizational environment. It would also be possible to link physicians, other providers, and consumers, so they can consult electronically about the consumer’s individualized recovery plan, or maintain consumer records in a single electronic health record, so that care is coordinated across
organizations.

Simultaneously, mental health consumers could develop Web sites that provide information to help them negotiate complex systems of care. Such information as where to go (physically or electronically), whom to see, and how to seek reimbursement is fundamental. Electronic evaluations by consumers of the services provided by different organizations and consumer-operated therapeutic chat rooms also could and should be developed in the short term.

Transforming Institutional Sectors

Context. Institutional sectors, such as the national health care system, are sustained by several key interrelated components. These are longstanding patterns of financing, human resource deployment, routine practices and services, and accountability mechanisms to control deviation. The reverse is also true. Signifcant change in any one of these components could
result in sector change and transformation.

The Institute of Medicine (IOM) of the U.S. National Academy of Sciences has issued a series of landmark studies between 2001 and the present, the Crossing the Quality Chasm series (IOM, 2001). This series calls for the transformation of health care in America. In IOM’s view, the quality of most health care in the United States is suboptimal because it is fragmented and based on outdated knowledge.

Pre-IT. Antiquated financial practices, use of clinical practices with undocumented effects, failure to use modern IT, and lack of accountability have all contributed to poor-quality health care and suboptimal outcomes for consumers. IOM has identified transformation of each of these factors as crucial to achieving true reform. These factors, plus the existence of many thousands of “stovepipe” health care delivery organizations that do not collaborate, have also caused very rapid escalation in health care costs. The United States has the most costly health care system on earth, as measured by expenditures per capita, yet only mediocre effects are being achieved.

Post-IT. Clearly, modern IT can be an essential ingredient in implementing the necessary transformation strategies identified by IOM. High-quality practices and services are contingent upon the successful deployment of well-trained human resources. The only economical way to train the mental health workforce, which currently numbers about one million providers ranging from psychiatrists to pastoral counselors to consumers, is to employ distance training strategies over the Internet. Similarly, transforming financial practices in mental health care will require moving away from encounter-based claim systems to medical savings and spending accounts that span all institutional sectors necessary for successful care. In mental health, these sectors may include mental and physical health care, psychosocial and vocational rehabilitation, housing, employment, and self-care strategies, among others. The only feasible way to create medical savings accounts across these diverse programs is to employ modern IT, which could be used to record the accounts and to issue vouchers to consumers for needed care. In addition to spanning diverse institutional sectors, this approach could have the advantage of promoting empowerment for mental health consumers, who could control how the vouchers are spent. Finally, modern IT seems to be ideally suited to promote accountability through electronic submission of program performance measures and online evaluation of care by consumers.

Some Observations

Lest we get too far afield, I would like to return to the questions that prompted this chapter in the first place. It seems very clear that modern IT can be a major force for transformation at the interpersonal, interorganizational, and sector levels. This means that it can foster and promote needed changes in behaviors and norms, which can lead to larger scale social and cultural change. I have explored these notions within the context of health and mental health care; similar analyses could be prepared for other institutional sectors, including business and education.

It also follows that this technology can be used to solve problems that were previously intractable, such as fostering communication and collaboration between two or more competing “stovepipe” organizations. Examples of this type of positive adaptation have been presented for each of the three levels analyzed here.

Acceleration, equalization, and disintermediation can have salutary effects if modern IT is applied in a thoughtful manner. The health care system, including the mental health care system, will require the thoughtful application of modern IT if it is to be transformed in accord with the vision for the future articulated by the President’s Commission and IOM. An urgent need exists to apply modern IT to these problems. Our future health may well depend on it.

Because of the potency of modern IT, executive and managerial training and practice will, as a matter of course, need to include consideration of its role in organizational leadership and operations. Because many current American executives and managers were educated in the pre-IT era, distance training will need to be implemented to overcome current deficiencies in knowledge. Anecdotal information suggests that the public sector lags far behind the private sector in integrating modern IT into leadership and operations.

Finally, a major secondary effect of such applications of modern IT is fostering interpersonal relationships that take shape and grow through communication mediated by technology. In this sense, modern IT also extends our concept of community far beyond the local workplace or neighborhood. Such broader communities are required in order to narrow the differences among us as humans.

References

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. (Also available at www.iom.edu.)

Parsons, T. (1951). The social system. New York: Free Press.

The President’s New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report. DHHS Pub. No. SMA-03-3832. Rockville, MD: U.S. Department of Health and Human Services. (Also available at www.mentalhealthcommission.gov.)

Toffler, A. (1980). The third wave. New York: Morrow.