KENNESAW, Ga. | Oct 25, 2018

Technology holds the promise of solving even our most pressing and difficult problems. We know it can succeed. Just imagine how it took a whole day of labor in Babylonian times to produce enough light to be active for one hour at night. Today a day of labor can buy 1,000s of hours of light because of our electric systems and high-efficiency lighting. This technological promise extends to healthcare. The US government, like others around the world including China’s, has been trying for the past 10 years to get doctors to use electronic medical records (EMRs) with limited success. Though billions of dollars have been invested, the adoption rates have primarily climbed only in hospital settings. Smaller physician practices remain at about 50% adoption as of 2018 according to data from the Office of the National Coordinator for Health Information Technology. Professor Dominic Thomas in the Information Systems department studies these efforts.

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In September 2018, he published a recent analysis with his colleague Colleen Wolverton based at the University of Louisiana Lafayette entitled “The Development of an Integrated Model of EMR Adoption: Incorporating the Organization Artifact”.  Their study explored the differences organizational settings make when encouraging EMR adoption. First and foremost, they looked at the pressures physicians face in smaller practices when making these decisions. Physicians in smaller practices must not only see patients but must also manage their organizations. Often, they are the owners of the business too. For them, buying an EMR system has to make economic sense. Most studies up to now have focused solely on how EMR systems need to useful and easy for physicians to use. Thomas and Wolverton found that those factors do not adequately explain how to approach smaller practices. In these practices doctors need to understand the economics of an EMR in addition to the usefulness in care and ease of use in care.

When they analyzed current health policies for driving EMR adoption, they found that measures like “meaningful use” work fine for hospitals but undermine smaller practices. This is a larger issue for an economy in which a majority of new jobs are created by small businesses. The pressure to meet standards like “meaningful use” without sensitivity to the needs in smaller practices leads to a consolidation we now see in the healthcare industry. Smaller practices have to affiliate with the larger hospitals in order to meet all the requirements placed on them. This effectively makes smaller practices into extensions of larger hospital systems.

At the core of this work is a large body of research on factors that drive adoption of EMR systems. Thousands of papers have examined how to drive EMR adoption. Thomas and Wolverton analyze several meta-studies and develop a comprehensive framework incorporating these insights into 20 key factors grouped into six main categories. They test this framework using surveys of doctors in hospitals and in smaller practices to look for differences. As noted above, they find differences. Additionally, they find that the set of important factors is actually smaller than their initial set of 20. The public and policy-makers often believe that coercive policy pressure will be a major influence on causing people to behave as desired. That is not the case in this domain. No coercive factors played a primary role in doctor decisions to adopt and use EMR systems. They see this result as a direct reflection of the status and autonomy doctors typically have. They resent mandates. Ease of use didn’t matter either. They interpret this finding differently. Doctors have worked hard to attain their degrees and continue their practices. They are not afraid of work. Rather, they want to know that their time investment will be worth it. All factors related to effort expectancy and usefulness were supported including whether other peer doctors were adopting EMR systems.

What differentiated the hospital and small practice physicians in their study were the administrative factors. The private practice physicians worried about the vendors selling them EMR systems and how their data will be secure from collaborating hospital systems. They reported that EMR investments would cost them upwards of $50-60,000 but that the “meaningful use” incentive would provide only $15,000. The cost would fall on them without clear additional revenue. In the case of hospital physicians, efficiencies could potentially lead to savings to justify these systems. For smaller practices, these efficiencies could not be large enough to cover this cost.

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EMR systems and related healthcare technologies continue to promise solutions to the difficult and real problem of healthcare costs and quality in the US and around the world. The policy implications from Thomas and Wolverton’s work can help. Smaller practices need policy-makers to analyze and emphasize the economic value of these EMR systems for smaller practices. Innovative EMR systems include special capabilities for optimizing code identification to maximize revenue from office visits and insurance reimbursements. US policies do not mention any such features nor justify their pain to smaller practices with such a carrot. They could. Having such an emphasis would also encourage more systems to include features that would make the economic value apparent to smaller practices. Such a change would move us a step closer to lower-cost, higher-quality care delivered not only in large hospitals but also in smaller practices.

Further reading:

https://aisel.aisnet.org/jitta/vol19/iss3/4/

https://ehrintelligence.com/news/small-practices-express-concern-over-effects-of-ehr-adoption

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5004249/