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When the Time is Right

February 1, 2009
by Anthony Guerra, Editor-in-Chief
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Physician EMR adoption will explode when doctors are comfortable with their risk calculation

My wife has owned an iPod for years. While, to her, it's always been a must-have device, I've never felt the need to get one. I'm just not that into music, preferring to listen to talk radio, despite the excessive commercials. I also thought the little devices were too expensive and complicated to be worth the trouble.

Recently, however, the iPod became a must-have device for me. First off, I ‘discovered’ audiobooks, and the high level of selection, technical sophistication and availability they have achieved. In addition, prices on iPods came down while their design became sleeker. Completing the picture was the availability of audiobooks at traditional stores such as Barnes and Noble, along with online venues such as Suddenly, it seemed, I could listen to history tomes and biographies during my commute and workouts, rather than looking out the window of a NJ Transit bus.

So, the convergence of affordability, ease of use and personal benefit, caused my risk calculation to come out in favor of purchasing an iPod. Interestingly, for me, this happened in December 2008, rather than 2007 or 2006.

Reflecting on my change of heart, I wondered if it didn't hold a lesson as to why uptake of EMRs among doctors is so low. To me, it's obvious that once the analysis is done, physicians are finding their EMR risk calculation number is simply too high.

Affordability: Physicians often cite cost as a reason for demurring on EMRs. While this objection has some validity, it's largely a red herring. I suspect upwards of 70 percent of these practices wouldn't implement an EMR if it were free. Many can get their EMRs underwritten by hospitals to which they refer patients, and, these days, vendors are in a ‘let's make a deal’ mode. Practices are balking at EMR adoption because they are scared to death of the disruption it will cause in their workflow, patient care, and, especially, revenue cycle. So while affordability is a factor, it's not a salient one.

Ease of Use: Whether it's downloading audiobooks or uploading patient information, ease of use is a critical factor in any IT adoption. And, for EMRs, the technology is either not where it needs to be, or suffering from a perception problem. And for office managers—ensconced in rooms full of manila folders and colored tabs, which they can see and touch—the idea of jettisoning them for diaphanous bits and bytes is petrifying. With that said, let's not forget the influence office managers have in physician practices. Often, it's the office managers that run the practices, meaning their imprimatur on any workflow-changing software is essential.

Personal Benefit: For this factor, let's refrain from the ‘improved patient care’ argument as a motivating factor in EMR adoption, and only consider personal benefit as the ability to make more money. Until it's clear that buying an EMR will increase the money that doctors take home, adoption will remain slow and low. P4P programs are having a small effect, but the payback must increase, just as the complexities of compliance must decrease. Personal benefit, however, is about more than money; it can also refer to spending less time at work. Everyone seems clear that, at least initially, EMRs slow physicians down, forcing doctors to either spend more time at work to make the same amount of money, or spend the same amount of time at work to make less money. Not a winning combination.

When looked at in conjunction, the risk calculation for physician EMR adoption will often be too high. There is, however, reason to be optimistic—vendors are making their products less expensive and easier to use, while physicians and office workers are becoming more comfortable with technology simply by functioning in today's society. Perhaps there will be a corollary between EMR and iPod adoption. I know when my risk calculation hit the necessary number, I was at the Apple store within a few days.

Anthony Guerra, Editor-in-Chief
Healthcare Informatics 2009 February;25(14):8


Apple rolled out four pieces together, which none of the other MP3 players did at the time:

1) iPod device - unusually very clean design

2) iTunes software - a broader thought than music players at the time like WinAmp

3) iTunes store - searching, commerce, free podcasts, ...

4) a marketing campaign - creating a cultural, social element.

The parallel's you elaborate are real: there isn't a good 'creating an appealing ecosystem' story in the EMR space (that has worked).

There are a few other paradigm shifters that also worked for the iPod which we haven't had in healthcare, such as Moore's law and magnetic storage equivalents that drove costs down, and the emergence of new audio compression standards like MP3, that made the new iPods possible and desirable.

In my mind, the great story here is that the iPod's roll out was clearly not conceived as a release of a technology product, a piece of hardware or software or a service. Competitors with every other formula failed to develop significant market-share.  

By the way, I cannot get my wife to adopt the iPod.  I suppose, when the time is right ...