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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.

Multiple touch sensors allow the user to interact with the table-top style screen with many fingers at the same time, a significant enhancement to the limitation of a single mouse click. As a result, the screen can display many simultaneous images which can be manipulated, moved around, flipped, reordered, enlarged, reduced, or minimized with simple quick movements of the hands. Two hands or multiple fingertips can be used at once. Data can be called up by a simple touch and positioned within a document with a quick hand or finger touch movement. Drawing, writing or notating within a document is a breeze.

A fascinating capability of surface computing is called “domino tagging.” Using this feature, an object placed on the screen is instantly transformed to an on-screen object that can be interacted with. Imagine placing an accessible skin lesion against the screen and having it become an immediate image that can be placed within a document by simply dragging it to the document with your finger. Or perhaps a patient has brought in their own extensive history of self-documented blood pressure that they have measured on their own. No problem. Lay it on the screen for immediate capture and drag it to the appropriate document.

Applying such technology to the clinical workplace is likely to be adopted by clinicians because it is efficient and familiar. Its implementation would not involve a struggle to entice physicians to adopt, but rather, it would absorb clinicians as users simply because of its enormous impact and capabilities.

Advancing technology will provide a much needed short cut to increasing clinician efficiency in a form that is highly technical yet simultaneously familiar and individually customizable.

Time will do away with the need for specialists and consultants in “physician adoption.” The truly needed specialty and expertise lies in the availability of technically knowledgeable clinicians who have an eye on the wondrous developing technologies such as surface computing, and who, by virtue of their clinical experience, recognize the value of such evolving technology to the healthcare environment and patient care.

At the same time, it is incumbent on the key players in the healthcare industry (vendors, providers, payers and academicians) to give credence to such a “specialty” of expertise by including the input of such medical-technology “integrationists” in future planning. A partnership of these key players — integrationists and technology developers — will identify promising applications, but the integrationist will provide genuine insights as to how the technologies can best be incorporated in clinician workflow and thoughtflow.

Having been “in the trenches” as a practitioner, they will also have the insight to truly understand the value (or lack of value) of developing technologies to their practicing colleagues, and therefore the likelihood of acceptance or resistance.

Samuel Bierstock, M.D., BSEE, is founder and aprincipal officer of Champions in Healthcare, a consulting organization of physician-informaticists. His previous positions include chief medical officer of Healthlink/IBM, and vice president of medical affairs for Eclipsys Corp.

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