The recent financial incentives offered by the government (HITECH) for EMR implementation are somewhat helpful but are also misleading. Most fail to recognize that the biggest obstacles to EMR implementation are not financial, but are cultural. EMR adoption will require cooperation between two disparate cultures: the Health IT (HIT) culture and the medical culture. One needs only to read a few of the EMR debates in any health care blog to discover that these two cultures view the health care system differently. Until the differences are reconciled, EMR implementation will continue to struggle despite the HITECH incentives.
Buoyed by its success digitizing other parts of the economy, the HIT industry sees in health care an untamed wilderness of inefficient workflows and slow, outdated data exchange. HIT folks envision a world where standardized workflows and rapid data movement ensure, for example, that a patient never has to wait 30 minutes in an exam room for test results and where day-to-day management of chronic diseases can be done remotely. An IT revolution in medicine would bring lower costs, better efficiency and improved care.
But there is a dark side to the HIT perspective. After successfully bringing so many other parts of our economy into the information age, some believe they have learned all they need to know to do the same for health care. The benefits are so clear and so obvious that anyone who would oppose EMR must be either clueless or just “protecting their turf.” I have heard HIT consultants brag about walking out on their physician the minute they saw a paper prescription pad. They mistakenly believe that health care is no different than banking or grocery stores – that there is nothing else to health care besides documentation, workflow and data exchange.
The medical culture sees it differently. To us health care is all about the doctor-patient relationship. In the physician’s world workflows and data exist only to support and execute the decisions patients and doctors make together regarding care. The art and science of medicine defy, to some degree, traditional software structure and data capture techniques. Our decisions may depend as much upon the look on a patient’s face as on any objective data. That is how it should be. The type of personality who is attracted to this kind of work is interpersonal, not technical. We got into medicine to interact with people, not machines.
The doctor-patient relationship gets attacked from all sides. Since the doctor-patient relationship drives one-sixth of our economy that comes as no surprise. The government just passed a huge piece of legislation that will have profound effects on the doctor-patient relationship. Pharmaceutical companies tell us we need to use their latest drug. Device manufacturers push the next great Magic Wand for performing a tonsillectomy, sinus surgery or other operation. Consultants tell us to run our practice like a business. When we make sound business decisions, we are accused of abandoning our moral obligation to medicine. To us the folks trying to sell us EMR are no different. They are just another group that thinks they know how to do our job better than we do.
But the medical point of view has its dark side as well. We act as if the doctor-patient relationship is so sacred as to be perfect and infallible, privileged from the need to evolve and improve, immune to the economic and performance pressures lurking just outside the exam room door. If the treatment we prescribe is not the most cost effective choice, let the system deal with it. If our paper prescription is illegible or non-formulary, that’s the pharmacist’s problem. If EMR is too inconvenient because of the learning curve, then it doesn’t matter how much more efficiently the system would run with EMR in place.
Bringing information technology to health care will be slow and painful until these 2 points of view are reconciled. The first step is to realize that both doctors and Health IT are right – and they are both wrong. Both sides need an attitude adjustment.
Health IT must acknowledge that the doctor-patient relationship is a major part of the health care machine. Workflows and data are the means, not the end. Nothing like the doctor-patient relationship exists anywhere else, so the experience gained bringing IT to other parts of the economy is not enough to write good software for physicians. Little wonder that doctors find EMR software “clunky”, inefficient and difficult to use. As one physician responding to a survey stated, “in order to contain the subtleties of the medical thought process, these systems have to be complex, flexible, and very nimble.” Health IT needs to invest time and effort developing a greater understanding of how doctors and patients interact and make decisions. Only then will the software get better.
The medical culture must understand that while the doctor-patient relationship is unique and special, it is not entitled to be rigid and inflexible. Over the past several decades the way we do our job has evolved; the evolution must continue. The doctor-patient relationship is not perfect. The shortcomings we impose on the rest of the system play a part in the inefficiency and the waste.
Remember when managed care came along 20 years ago? We dug our heels in and fought against it. We declared our methods and our high price tag to be above criticism. So the rest of the health care system created managed care without us. We are still living with the consequences.
With the impending IT revolution in health care we face a similar choice. If we refuse to accept change, the result will be the same as it was 20 years ago. If we want a better result this time we must take a leading role. We must voluntarily leave our comfort zone and bring EMR to the practice of medicine.
Can both cultures admit their shortcomings and meet in the middle?
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