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Adoption in its Own Time

February 25, 2008
by Samuel Bierstock, M.D.
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Forget about pushing physicians to adopt IT, a number of external factors will ensure technology is eventually embraced

Samuel Bierstock, M.D.

Samuel Bierstock, M.D.

With more than a decade behind us, and with hundreds of millions of dollars spent, less than 8 percent of physicians in the country enter their orders in hospitals by computerized order entry, and even a lower percentage have fully implemented electronic healthcare information systems. Regional health information organizations (RHIOs) struggle with the issue of enticing physicians to share data, and with the simple issue of maintaining financial viability. CEOs, CIOs, CMOs, CMIOs and CNOs struggle with challenges and frustrations presented in dealing with their medical staffs, and hospital trustees wonder why technologies that they have cost millions are not being utilized.

It now appears safe to predict that the challenge of physician adoption of healthcare information systems technologies is on the path of resolution. The surprising realization is that this is not going to be resolved as a result of the commonly articulated predictions. While physician adoption may be mandated in certain hospital settings, short of legislative fiat, it certainly cannot be mandated in the ambulatory world. The solution is not going to come from such drivers as physician concerns for patient safety, pay-for-performance policies of reimbursement, legislative mandates for data sharing, the development of physician-friendly workflows using existent two dimensional technologies, or from public pressure.

Such “value” functionalities as remote access, availability of order sets, guidelines, availability of content, electronic signature, etc. are attractive conveniences, but obviously not enough to create universal enthusiasm for these systems by clinicians.

The reality is that physicians do not want to be slowed down, do not want systems imposed upon them, and are generally deeply embedded inestablished workflows and thoughtflows. (I have previously defined “thoughtflow” as the manner in which clinicians access, analyze, prioritize and act upon data.)

Physician adoption, as a stagnating factor in healthcare IT implementation, is most likely to go away in the foreseeable future due to two independent, self-propagating and intersecting trends.

The first trend is one of simple attrition. Approximately 25,000 new physicians enter the healthcare system annually. These young clinicians have grown up in the computer age, and in many cases, have received their clinical training using healthcare information systems. They will seek and expect affiliation with hospitals and practices that allow them to work in a computerized environment.

At the same time, the “baby boomer” population of physicians is retiring at a rate that exceeds the number of new physicians entering the healthcare workplace. It has been predicted that by the year 2012, more than 70 percent of physicians in practice will have been trained on a healthcare information system, or will have grown up in the age of the personal computer.

The second and more exciting trend is the almost unimaginable evolution of technology itself. Current clinician adoption challenges have persisted because healthcare information technology has been stuck in a two-dimensional world that forces clinicians, who are accustomed to working with paper in hand, to adapt to an interface with a flat screen. Their mere mental visualization of what they seek to accomplish is thereby compressed, and their thoughtflow disrupted.

Data now presents itself in real time — as quickly as it is generated. In the world of real-time data, information seeks the clinician as often as the clinician seeks information. Clinicians must navigate under pressure in a new, highly complex world that neither looks nor feels natural. Hence, they resist.

Consider the difference between a physician dictating a discharge summary with a paper chart in hand, and doing a discharge summary using a computer. In one case, access to data is familiar, fast, manual and comfortable. In the other, it involves multiple clicks, changing screens, unfamiliar formats and significant time and effort to delve deeper into complex areas.

It is the evolution of technology interfaces into three dimensions that will make its use more natural for clinicians. Such technology is not only just around the corner, it is here. Its capabilities are so enormous that once implemented, it will simply engulf and absorb clinicians, becoming as fundamental to the way they work as the ability to use a stethoscope.

In 2002, Tom Cruise played the part of a detective in a science fiction thriller called “Minority Report.” In this futuristic depiction, his character stood in front of a large interactive screen. As information appeared, he simply pointed to a data point or image to delve instantaneously deeper, waved his hands to move images around, and otherwise manipulated data in a perceptual three-dimensional fashion.

Microsoft has recently released a technology known as Surface Computing. This technology, which has been quietly developed over the last five years, reproduces an environment similar to that used by Tom Cruise's detective character.


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