31 May Physician mindset slows adoption of electronic health records
If you are a resident of Wisconsin and insert your card in an ATM in San Francisco, the system will immediately recognize you, your bank, and your financial records. But if you find yourself in an emergency room you’ll likely need that same card to pay for an extensive series of tests because your medical record is a piece of paper sitting in your hometown doctor’s office.
Information technology baffles users with ever-growing capabilities, including instant global transfer and tight security around our finances and livelihoods. In a medical setting, it would literally save lives. Fatal allergy and drug-interaction mistakes due to lack of information contribute significantly to the almost 100,000 deaths per year from medical errors.
Yet the technology slogs over a stifling set of adoption barriers.
The United States is the biggest information technology exporter in the world, and according to the Health Information Technology Leadership Panel Final Report, 96 percent of physicians use computers. However, the same report showed that 49 percent of physicians surveyed do not intend to use electronic health records, or EHR.
The leadership panel in the report included CEOs from nine companies including FedEx, General Motors and Wells Fargo, who assembled as some of the largest investors in the nation’s health-care system – General Motors alone pays more than $1400 per vehicle on health-care costs.
The investors assembled for the Department of Health and Human Services contractor The Lewin Group to brainstorm about technology’s adoption throughout the U.S. medical community. Most often, their suggestions emphasized cooperation and a resolution of technology’s role in a complex and sophisticated system.
Unlike in other developed countries that may operate under a unified system, the United States medical industry exists as an emerging web of competing private and public businesses.
“We know that [EHR] is slow to enter health care practices because our healthcare is delivered by mostly private, small practices made up of six-physicians or less, unlike the U.K. with its centralized single-payer system,” said Barry Chaiken, Associate Chief Medical Officer at BearingPoint.
Doctors would like to see established standards and interoperable systems before they further embrace EHR, which now manifests as anything from basic word-processing documents and e-mail to sophisticated clinical messaging, decision-support and related activities, according to Larry Clifford, director of product and member development at the Rural Wisconsin Health Cooperative.
“At present, adopting EHR is a considerable risk for medical practitioners because standards around design and use are still blurry,” Clifford said. “Once regulations become clear, some of the initial technology may be non-compliant.”
While the sense of independence and competition among medical facilities may drive healthcare into sophisticated territory, the collaboration of these efforts is key to what is now the latest stage of technological development in health care.
“For things to happen with EHR, providers need to work collaboratively with other providers,” Clifford said. “This will ultimately lead to be better patient care and clinical outcomes.”
It’s a way to consolidate information not only from physician visits, but also from lab tests, emergency room visits and individual medical history notes and then mobilize it for immediate, approved access. One major barrier to adoption is that these features are not very lucrative in every-day practice.
Who pays?
“The doctor is paid not based on quality but rather quantity. The fact that they failed to perform a test or ordered a test twice doesn’t help them to cash in, but it’s the beauty of EHR [to note this],” said Seth Foldy, project leader for the Wisconsin Health Information Exchange and former health commissioner of Milwaukee.
The use of EHR is nothing new around a hospital, but it’s just not rooted in quality of care. Independent clinics originally used it to document and collect reimbursement for care rather than implement clinical treatments, Chaiken said, and this sense of accountable service is still what drives practitioners.
Pressed for time and money, physicians say they work in a world where the quantity of services and visits wears a clearer price tag than the quality of care. For this reason, even the most careful doctors say they can’t afford slowing their work flow to fumble with electronic files and learn the technical skills required by interactive documents. Doctors find it stressful and expensive to change these fundamentals of their practice, Foldy said.
“Imagine if you couldn’t type – how long would it take you to enter a record? That time raises a barrier,” he said.
After making rounds and seeing hundreds of patients a week, this new technology offers little tangible benefit as it drags down their momentum.
“It’s about volume. Electronics can not get in the way of us keeping the volume going,” said Raymond Zastrow, a practitioner in Mequon, Wisconsin.
Physicians’ aversion to EHR is not a matter of technophobia, Zastrow said. It’s more about the hassle that breaks up their preferred areas of practice and income.
“Doctors are not necessarily computer phobic,” he said. “We love gizmos because they lead to procedures and money in the pocket. Doctors who make money do procedures.”
A doctor-friendly interface
No matter what the procedure, in the end, doctors just want tools they can work with, Zastrow said during a break between patient visits. So to bypass the wait for standards around EHR, he said designers could attract physicians to the technology by crafting and presenting new tools with the daily routine of doctors in mind.
One example comes up when doctors who run a general practice may not find a record template useful, because so many symptoms and patients present too much information to stuff into predetermined, labeled cells. In contrast, specialists working with specific patients and symptoms may find templates useful.
The main thing for designers to remember is how it feels as a doctor using the technology at the bedside. The program that sacrifices some “left-brain” design for “right-brain” creative software that offers feedback and “anticipatory guidance” is what doctors like Zastrow dream of adopting. It allows them to keep the part of the practice they love most: natural interaction with patients.
“I think the vendors are missing the boat on design,” Zastrow said. “They need to inject a huge amount of human factors engineering. [Otherwise,] we won’t use it because it doesn’t fit our mental mode.”
For now, many clinicians are not comfortable using many technologies in front of patients, Zastrow said. “The pen and tablet technology came a long way and will continue – it’s more natural.”