Typology IX: Age and Academic Practice as Socio-demographic Variables:

In the discussion of factors that might impact the adoption of EHR/EMR by physicians we must consider some socio-demographic variables that typically affect how we behave as part of a group!

a)     Age as a definer of generational subcultures: This can be simply expressed as, “the younger the physicians, the more easily they use EHRs[1] Whether this would mean or imply that younger physicians are or will be more inclined to “meaningful use” of the EHR is to be seen!

b)    Practice in educational settings as an “academic subculture:” Physicians practicing in teaching hospitals and medical residencies are more likely to adopt the EHRs. ^1,[2],[3]

In this regard it is possible that medical students and residents, who generally spend at least some of their training in hospital settings, are functioning as catalysts for the office practices that house them to adopt EHRs and other HIT that may be more prevalent in the inpatient setting.[4]A particularly interesting experience that addresses both the education of medical students and the facilitating of the training of physicians in practice is occurring through the Florida State University College of Medicine model of community based medical education. Medical students who work in their preceptor’s office offer training to their mentors in the use of clinical decision support tools.

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[1] DesRoches, CM., Campbell, EG., Rao, SR., et al. Electronic Health Records in Ambulatory Care — A National Survey of Physicians. N Engl J Med. 2008; 359:50-60.

[2] Simon SR. et al. Correlates of electronic health record adoption in office practices: a statewide survey. Journal of the American Medical Informatics Association. 14(1):110-7, 2007 Jan-Feb.

[3] Likourezos,A., Chalfin, DB., Murphy, DG., et al., Physician and Nurse satisfaction with an Electronic Medical Record System. The Journal of Emergency Medicine, Vol. 27, No. 4, pp. 419–424, 2004

[4] Simon, SR., et al. Physicians and Electronic Health Records: A State Survey. Arch Intern Med. 2007;167:507-512

Cultural Typology VIII: Medicine as a meaningful professional practice for health care justice.

As posted before, according to DesRoches and Jha, there have been no definitive national studies that provide reliable estimates of the adoption of electronic health records by U.S. physicians and, there are large gaps in knowledge, including information about EHR use among safety-net providers.* This, they assert, poses critical challenges for the development of policies aimed at speeding adoption. It also poses and a particular challenge to a comprehensive reform process of the U.S. health care system.

In relation to physicians who practice in “safety net” clinics,* their rationale for practicing in underserved areas, rural communities, and serving vulnerable populations, is aligned with the values of social and health care justice held by many physicians that see health and medicine as a social good rather than a market commodity.

For example, the term ‘five-star doctor’ promoted by Boelen denotes the model physician for today’s society who should be able to respond to the needs of both individual patients and their community.[1] According to him, the attributes of this physician are:

• Care-provider. Besides giving individual treatment “five-star doctors” must take into account the total (physical, mental, and social) needs of the patient.
• Decision-maker. In a climate of transparency “five-star doctors” will have to make decisions that can be justified in terms of efficacy and cost.
• Communicator. The doctors of tomorrow must be excellent communicators in order to persuade individuals, families, and the communities in their charge to adopt healthy lifestyles and become partners in the health effort.
• Community leader. “Five-star doctors” will not simply be treating individuals who seek help but will also take a positive interest in community health activities that will benefit large numbers of people.
• Manager. To carry out all these functions, it will be essential for “five-star doctors” to acquire managerial skills. This will enable them to initiate exchanges of information in order to make better decisions, and to work within a multidisciplinary team in close association with other partners for health and social development. Both old and new methods of dispensing care will have to be integrated with the totality of health and social services, whether destined for the individual or for the community.

Although the five attributes described above may equally apply to any health professional, physicians in general, and primary care physicians in particular, can fulfill well the concept. HIT and EHRs, in particular, would be the best mechanism to facilitate executing these attributes. Boelen argues that optimal educational approaches should be in place to prepare future graduates and to reorient doctors already in practice to assume the new roles and responsibilities expected of them within this model. This recommendation is consistent with recommendations provided earlier in this position paper of educating future and practicing physicians in EHRs.

On the other hand, the Community and Migrant Health Centers (CHC) program and the National Health Service Corps, administered by the federal Health Resources and Services Administration (HRSA), as assessed in several studies have proved, as a safety net, to be one of the best model to enable the “five-star doctor” to respond efficiently to challenges in the health sector.[2],[3] From a policy perspective, CHC should be provided the funding to acquire the IT infrastructure needed. The Institute of Medicine, in its report, “America’s Health Care Safety Net: Intact but Endangered,” recommends to enhance and coordinate technical assistance programs targeted towards improving the operations and competitive position of safety net providers, among a number of recommendations that address the support of the safety net system.[4]  One such technical assistance that HRSA has developed is an Health IT Adoption Toolbox for health centers and other safety net providers to help plan, execute and evaluate Health IT.[5]

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* Safety net providers are providers that deliver a significant level of health care to uninsured, Medicaid, and other vulnerable patients. This safety net is neither uniformly available throughout the country nor financially secure. It is rather a patchwork of institutions, clinics, and physicians’ offices, supported with a variety of financing options that vary dramatically from state to state and community to community. The safety net has never been financially robust, but it has continued to survive.

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[1] Boelen, C., THE FIVE-STAR DOCTOR: An asset to health care reform? World Health Organization Web site www.who.int/hrh/en/HRDJ_1_1_02.pdf Downloaded on May  2, 2011

[2] Sardell, A. The U.S. Experiment in Social Medicine: The Community Health Center Program, 1965-1986. University of Pittsburg Press; 1988

[3] Heinrich, J. Health Care Access Programs for Underserved Populations Could be Improved. Testimony before the Subcommittee on Public Health and Safety, Committee on Health, Education, Labor and Pensions, U.S. Senate, Thursday, March 23, 2000. U.S. General Accounting Office Web site; http://www.gao.gov/docsearch/repandtest.html. Downloaded on May 2, 2011.

[4] Institute of Medicine. America’s Health Care Safety Net: Intact but Endangered. IOM Web site; http://www.iom.edu/CMS/3718/5502.aspx. Downloaded on May 2, 2011

[5] Health Resources and Services Administration, Health IT Tool Box. HRSA Web site: http://www.hrsa.gov/healthit/default.htm. Accessed on May 2, 20011

Cultural Typology VII: Sense of belonging to a professional class (guild member), and medical specialty

As I expressed in my post of February 11, 2011, About the Culture of Medicine & Physicians, physicians have constructed a corporative collectivity, the medical profession, more or less admired or chastised, but always cohesive in its control of their profession and trade. The profession claims to be the most reliable authority on the nature of the reality it faces.  In other words, the ailments brought by the patients, and they are the ultimate judge of their practice and conduct. One must not forget that the physician is the preeminent practitioner of medicine, and represents it par excellence. Perhaps anecdotally, physicians are sometimes characterized as “knowledge expert physicians,” or medicine expert, vs. “manual dexterity expert physicians”, or surgeons, but this needs to be further explored. In summary, and as it has been expressed earlier, physicians have historically relied on their professional peers as their primary source of information related to new technologies.

In relation to this sense of belonging to a professional class, particularly specific work in this respect is the work of Ford and Menachemi in Florida.[1] They argue that, collectively, the medical community’s social mechanisms that influence adoption decisions view EHRs as a potential threat to professional autonomy. This may be particularly true among physicians in small practices that value the freedom and autonomy these provide. Lee also argued that EHRs are not an appealing technology since it does not add to their social approval. [2] Menachemi, et al, found that physicians caring for children in Florida (Child Health Providers-CHP), and especially pediatricians, were significantly slower than other doctors to adopt EHRs as well as other important electronic patient safety functionalities into their office practices.[3]However, collectively, CHP did not differ from other physicians in Florida with respect to the use of many IT applications. On the other hand, specifically general pediatricians were significantly less likely than other CHPs and other physicians to indicate personally and routinely using an EHR system in their practice. A possible explanation given by Menachemi, et al, was that general pediatricians have the lowest median incomes of all physicians and they may not be able to overcome many of the financial burdens necessary to adopt EHR. Menachemi asserts that no previous study has specifically examined a broad group of CHPs, and the results of the current study may serve as a benchmark for those interested in charting the progress over time that pediatricians and other CHPs are making toward the widespread adoption of EHRs.

Menachemi, et al, recommend some key policy actions to address this lack of use of EHRs by CHPs:

1. Advocacy for an increase in the proportion of federal resources dedicated to EHR adoption that is child specific.
2. Increased representation by child health experts in national IT and IT standards organizations;
3. Increased attention by vendors to building pediatric specific functionalities into their products, such as weight-based dosing and growth charting; and
4. Increased involvement by practicing child health providers in on-going efforts to reward the use of clinical IT in pay-for-performance programs and to design ways to overcome the non-financial barriers as well.

From a cultural perspective, on the other hand, in order to address the guild cultural element implied in the profession as a close-knit social network, Ford and Menachemi’s recommendation of using internal influences (e.g. social contagions) appear to be more powerful for accelerating the diffusion of EHRs. They recommend an interactive educational strategy that would be likely to be most influential in penetrating physicians’ social networks, particularly those in small practices. The first, and more basic, is medical education. Ford and Menachemi assert that many medical schools and residency programs do not currently employ or train future physicians in the use of EHRs. They also assert that training the future medical workforce to rely on EHRs and their decision-support tools can only serve to accelerate universal EHR adoption. Furthermore, the acculturating of medical students and residents to EHRs during this formative period signals that the profession values EHRs.

The second potential channel for influencing physicians’ social networks is through the continuing medical education (CME) requirement. However, they explain, CME interventions have not proven to be particularly effective in changing providers’ behaviors in other clinical areas.

The third active educational mechanism recommended by Ford and Menachemi for accessing physicians’ social networks is academic detailing that involves in-depth, one-on-one training sessions with physicians and is an effective mechanism for altering physicians’ behaviors. Ford and Menachemi argue that, collectively, the interactive educational approaches hold the greatest power to hasten universal EHR adoption, but they also carry the highest price tag and require major coordination efforts to implement. Addressing the physicians’ social networks to use the social contagion influence is not a “bullet proof” strategy either. Simon, et al, found that fewer than one in five physicians in their study reported that the state medical society or specialty organizations played a role in their decision of adopting EHRs. Perhaps this reflects a sort of “passive aggressively” by these medical societies, who legitimately, represent the financial interest of the guild that feels particularly threatened by the loss of autonomy of physicians that the EHRs impose.

On the other hand, in relation to educational activities these have usually been delivered through the traditional physicians specialty groups. To this general rule there are exceptions. For example, the Clinical Directors Network, Inc. (CDN), based in New York and founded in 1985, deserves special attention. CDN was founded as a professional peer organization based on the demonstrated effectiveness of peer-initiated activities in promoting health care excellence, assuring and improving quality, and containing costs.[4] CDN operates by and for an extensive network or Community/Migrant Health Center (C/MHC) Clinical Leaders, not only physicians, in most of the states of the east coast, including Puerto Rico and U.S. Virgin Islands. Clinical directors in C/MHCs are clinicians who, usually by personal decision, accept the role of organizing and directing the clinical operation of a primary care center and are committed to make it work for the benefit of the patient. CDN offers its members access to peers who collect and share information, skills, and technical assistance. Within their communities, members introduce the latest developments in clinical and health services education, including Continuous Quality Improvement, re-engineering, managed care, practice-based research and electronic tools. CDN is the only practice-based research network in the country devoted to providing primary care research opportunities to medically underserved populations. With an extensive history in translation of clinical research into clinical practice this clinical network is a perfect example of the use of internal or social contagion factors that influence adoption decisions led by clinical directors. For example, their eClinician Project, a modest yet effective program provides free customized PDAs with clinical decision-support software to primary care clinicians working in New York City (NYC) Community Health Centers. A critical element of the project includes onsite and online training through Webcast Library to train clinicians on how to use electronic clinical decision-support tools. In addition, ongoing follow-up, new programs, e-health tools, and health alerts will be available to clinicians from the NYC Department of Health and Mental Hygiene Health Access Network.

This basic strategy of providing access to basic electronic tools and clinical decision tools, rewarding physicians for using computers to communicate with specialists and patients, and providing funding to help extend high-speed Internet access to doctors who do not have it, would be far more effective in facilitating physicians to adopt HIT than trying to “force physicians” to adopt full functional EHRs through external influences as might be the introduction of clinical reporting mandates.[5]

In relation to HIT as an industry, I would argue a most important working group is the Health Information and Management Systems Society’s (HIMSS) Physician Community (HPC). HPC was formed by the HIMSS and the Association of Medical Directors of Information Systems (AMDIS) to articulate a cohesive voice for HIMSS physicians and to provide leadership, guidance and domain expertise to HIMSS activities, industry initiatives, and collaborations with physician societies across the country.[6] The alliance between HIMSS and AMDIS formalizes all efforts with an enhanced and focused strategy for physicians engaged in HIT and management systems. HIMSS is the healthcare industry’s membership organization exclusively focused on providing leadership for the optimal use of healthcare IT and management systems for the betterment of healthcare with immense capacity to support their mission across the world. AMDIS, on the other hand, founded in 1997, is the premier professional organization for physicians interested in and responsible for healthcare information technology.[7 AMDIS Members are the thought leaders, decision makers and opinion influencers dedicated to advance the field of Applied Medical Informatics and thereby improve the practice of medicine.

Another key organization that is leading efforts in helping train clinicians and defining core competencies to develop physician medical informaticians, the American Medical Informatics Association (AMIA). As the professional home for biomedical and health informatics, AMIA is dedicated to promoting the effective organization, analysis, management, and use of information in health care in support of patient care, public health, teaching, research, administration, and related policy is a natural broker to engage as co-equal partners and collaborators physicians and healthcare practitioners in general, and other health/biomedical informatics and other relevant disciplines in an ongoing relationship to understand and solve problems of importance to health care.[8]

In relation to education and early adopters and the concept of social contagion, Geyer, in an expert opinion, presents another interesting strategy, that upon recruiting early adopters of technology to facilitate the adoption on HIT by physicians, nurses need to be trained first because they train MDs while assisting them during care duties.[9] In primary health care clinics that serve HIV/AIDS affected individuals, in multiple and diverse locations in the U.S., nurses play a critical role as early adopters of EHRs and facilitate that physicians appreciate and learn to use it most appropriately. This would be another internal influence to tap into.

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[1] Ford, EW.,  Menachemi, N., Phillips, T., Predicting the Adoption of Electronic Health Records by Physicians: When Will Health Care be Paperless? J Am Med Inform Assoc. 2006;13:106–112.

[2] Lee, FW. Adoption of Electronic Medical Records as a Technology Innovation for Ambulatory Care at the Medical University of South Carolina. Contemporary Issues in Health Information Management. August 2000;21(1):pp 1-20

[3] Menachemi. N., L Ettel, DL., Brooks, RG., Simpson, L., Charting the use of electronic health records and other information technologies among child health providers. BMC Pediatrics 2006, 6:21

[4] Clinical Directors Network Web site, http://www.cdnetwork.org/NewCDN/AboutCDN.aspx. Accessed on January 6, 2009

[5] iHealthBeat. Experts Warn Against Large Investment in Existing HER Systems. January 5, 2009. California Health Care Foundation web site http://www.ihealthbeat.org/Articles/2009/1/5/Experts-Warn-Against-Large-Investment-in-Existing-EHR-Systems.aspx?p=1 Accessed on January 6, 2009

[6] HIMSS website. http://www.himss.org/ASP/physicianCommunity.asp. Accessed on December 1, 2008

[7] AMDIS website. http://www.amdis.org/index.htm Accessed on December 1, 2008

[8] AMIA website. http://www.amia.org/ Accessed on December 1, 2008

[9] Geyer, S., Physicians: The Key to IT Success. Trustee; Feb 2004; 57, 2;

Cultural Typology VI: Provision of Quality Services

The IOM report “Crossing the Quality Chasm” was a call for action to improve the American health care delivery system as a whole, in all its quality dimensions, for all Americans.[1]  According to the report, what is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns, or toward applying advances in information technology to improve administrative and clinical processes.

Although conventional wisdom would indicate that EHRs should help improve quality in health care, this has yet to be proved. Diamond and Shirky (2008) assert that the challenge of thinking of health IT as a tool to improve quality requires serious attention to transforming the U.S. health care system as a whole, rather than simply computerizing the current setup.[2]  Computers, they say, are only amplifiers, and if an inefficient system is computerized, it will simply make it inefficient faster. The NRC Report even expresses that current implementations of health care IT do not take advantage of human-computer interaction principles, leading to poor designs that can increase the chance of error, add rather than reduce work, and compound the frustrations of executing required tasks.[3] As a result, the report explains, they can introduce new forms of error that are difficult to detect. Along these lines the IOM’s report, “To Err is Human: Building a Safer Health System,” explains that automation makes the system “opaque” to people who manage, maintain, and operate these, therefore, contributing to the accumulation of latent errors that could lead to unsuspected system failures.[4]

Likourezos, et al, surveying Emergency Medicine (EM) physicians and nurses at a large urban teaching hospital found that clinicians positively perceive the EMR as helpful in their daily work.  Despite reported potential benefits to the work environment and patient care, the clinicians in this study perceived the EMR to currently have minimal impact upon patient care.  Both physicians and nurses reported their beliefs that the EMR will not yet improve the quality of care, will not reduce costs, will not decrease waiting times, will not lessen the number of laboratory tests, will not reduce the number of emergency department (ED) visits, and will not attenuate ED overcrowding.  They also expressed fears about security, privacy, and confidentiality issues. On the other hand, Hackbarth and Milgate (2005) assert that the market does not reward quality improvement, one of the primary reasons for investing in the technology.[5] Furthermore, they state that the cost savings for better quality often accrue to the insurer, not the physician practice. For example, if better preventive care leads to fewer hospitalizations, it is the payer that reaps the benefits.

DoBias, (2006) in a joint project between the Robert Wood Johnson Foundation and the federal government’s health information technology office, entitled “Health Information Technology in the United States: The Information Base for Progress”, cited experts declaring that for doctors, EHR adoption “is not a financial play for them right now.  Most docs who do it say they do it because it’s the right thing to do.  We know that the patient gets most of the benefit, the health plans get the rest, and the doctor is the one who has to pay for it.” [6] All this only nurtures the cynicism with which EHRs are seen by many physicians while, as Ford (2006) asserts, the physician community does not, in general, have a strong grasp of the quality improvement processes that are being targeted at them.[7]

In order to address this cultural factor, Miller declares that quality performance incentives and support can, over time; help transform many physicians from inefficient, low-level EMR users to efficient, advanced users thereby increasing the likelihood of generating quality and financial benefits.[8],[9] However, for this to happen, as Miller discusses, we would have to work on at least three areas:

a) Increase communitywide data exchange: This would mean ubiquitous, secure electronic exchange of clinical data among providers that would help lessen the disruption from parallel electronic and paper-based medical record systems, and that would also allow clinicians to view all of their patients’ data, regardless of provider and care site. Miller expresses that a prime beneficiary of these initiatives will be solo/small-group practices that otherwise lack the leverage and resources to establish ubiquitous data exchange.

b) Provide financial payback to practices for achieving quality improvement through the use of full-fledged EMR or, alternatively, programs may selectively promote particular IT capabilities for quality improvement.

Miller warns about the correct use of financial incentives avoiding mandating programs that micro-manage how clinical care must occur and/or setting arbitrary short deadlines for full EMR use. Ford (2006) also warns that despite positive incentives, some physicians see pay-for-performance programs as a third-party attempt to overly influence medical practice, decrease costs, and increase profits for payers.[10]

Miller also asserts that Government or other funders may not need to directly subsidize the cost of acquiring EMR since, in their study, most practices could secure capital for purchasing the technology. As the Center for Studying Health System Change has found out, the recent federal regulatory changes geared to facilitate hospitals help physicians financially to acquire EHRs, at least initially, appear to have had a modest impact in encouraging hospitals to support physician adoption of EHRs.[11],[12] On the other hand, vendors already have strong market incentives for developing easy-to-use EMR, while physicians’ attitudes toward health IT and the EMR are already on a favorable trajectory with increasing use of personal digital assistants (PDAs) and the Internet by physicians. Miller believes that policy funds could be better used for rewarding quality improvement, for example, rather than for replacing available capital.

Hackbarth goes further asserting that additional quality payments could help shift the return on investment (ROI) calculations that practices must make when deciding whether to invest in IT. In addition to improving the ROI, he explains, focusing on quality objectives provides guidance to physicians and vendors about how the IT systems should be designed and used and ensures that Medicare achieves the desired policy intent. On the other hand, Hackbarth argues, although cost savings may result from physicians’ adoption of IT, it would be problematic to base policies on assumptions that those savings would be realized given the sizable barriers to effective implementation and use of IT. Hackbarth believes that these incentives for IT adoption should be funded without further increases in Medicare expenditures.

Ford explains that in other mature health care systems where various forms of EHRs have been widely adopted, such as Australia and Western Europe, there have been significant governmental efforts to partner with physicians or subsidize the cost of the new technology, respectively. On the other hand, the policy mechanism most commonly discussed for increasing EHRs in the U.S. is through external influences like the introduction of clinical reporting mandates. As Ford explains, while such programs may be of some use, they may not advance the goal of full EHR adoption significantly, because U.S. providers tend to respond negatively to such mandated-use policies, particularly in comparison to their international counterparts.

c) Support for complementary changes in physician practices, especially solo/small-group practices that require support to carry out the time-consuming workflow and other complementary changes needed to generate financial and quality benefits from “out-of-the-box” EHRs.

References:

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[1] National Academy of Sciences. Crossing the Quality Chasm: A New Health System for the 21st Century. Executive summary downloaded from http://www.nap.edu on December 1, 2008

[2] Diamond, CC., Shirky, C. Health Information Technology: A Few Years of Magical Thinking? Technology and standards alone will not lead to health IT adoption, let alone transform health care. Health Affairs 27, no. 5, 2008:w383–w390

[3] Committee on Engaging the Computer Science Research Community in Health Care Informatics; National Research Council. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. Willam W. Stead and Herbert S. Lin, editors. National Academies of Sciences web site. ;http://books.nap.edu/openbook.php?record_id=12572&page=R1.

[4] The National Academy of Sciences. To Err Is Human: Building a Safer Health System. 2000. The Nat’l Acad. of Sciences Web site http://books.nap.edu/catalog.php?record_id=9728. Accessed on Dec 11, 2009

[5] Hackbarth, G., Milgate, K. Using Quality Incentives To Drive Physician Adoption Of Health Information Technology. Health Affairs;24(5):1147-1149

[6] DoBias, M., EHR adoption `pitifully behind’; Study: Only 10% of physicians use IT to its fullest. Modern Healthcare, October 16, 2006:8

[7] Ford, EW.,  Menachemi, N., Phillips, T., Predicting the Adoption of Electronic Health Records by Physicians: When Will Health Care be Paperless? J Am Med Inform Assoc. 2006;13:106–112.

[8] Margalit, RS., Roter, D., Dunevant, MA., Larson, S., Reis, S.,

Electronic medical record use and physician–patient communication: An observational study of Israeli primary care encounters. Patient Education and Counseling. Elsevier 2006;61:134–141

[9] Hackbarth, G., Milgate, K. Using Quality Incentives To Drive Physician Adoption Of Health Information Technology. Health Affairs;24(5):1147-1149

[10] Ford, EW.,  Menachemi, N., Phillips, T., Predicting the Adoption of Electronic Health Records by Physicians: When Will Health Care be Paperless? J Am Med Inform Assoc. 2006;13:106–112.

[11] Department of Health and Human Services, “The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care: A Framework for Strategic Action” (Washington, D.C.: July 21, 2004).

[12] Grossman, JM., Cohen, G. Issue Brief, Findings from HSC. No 123. September 2008 Center for Studying Health System Change.

Cultural Typology V: Personal Relationship with the Patient; an Ethical Conundrum?

The personal relationship between the patient and the physician is the essence of medicine, an ethical relationship based on trust. One could argue that the EHR could challenge privacy and confidentiality, core values of the physician/patient relationship.(1,2) In particular, Rosenthal describes the perception of the physicians that the EHRs are an intrusion into the practitioner-patient relationship.(3) This has also been the case in Israel, an almost fully immersed EMR environment, where physicians use computers in the examination room and report that it can negatively affect patient centered practice. The computer became a “third party” in the clinical encounter requiring particular attention and diminishing the dialogue with the patient, particularly in the psychosocial and emotional realm.(4) In a hospital in Oman, physicians were generally satisfied with EMR, but most of them believed the system did not protect confidentiality because other physicians and nurses could access all clinical notes about patients and the physician could alter what they documented in some sections of the clinical data because it is not protected.(5)

Safeguarding the privacy and confidentiality of patients within the new IT environment, a tremendously volatile environment, poses many problems that are far from being clear, much less resolved.(6) On the one hand, as patients become tech-savvy, they will demand that their physician use current IT options.(7) On the other hand, Lupton would argue that this expectation must be seen within other conflicting expectations; first, frequently physicians are forced to deal with patients’ expectations of their “omnipotence.” Secondly, the physician often does not want to share the uncertainty of their treatment. Last, but critically important, are the demands from hospitals and payers to deal with the patient quickly and efficiently.(8)

To add complexity, the traditional paper chart in the physician’s office allows the physician to maintain certain anonymity, certain invisibility, in terms of what is his/her rationale for the treatment of a patient. The perception by the physician of a possible “oversight” by many others accessing an electronic version of “his” patient’s medical record is a powerful disincentive to the adoption of the EHRs. In addition, one aspect that has was not found addressed in the literature reviewed is that it also challenges the basis of medicine as a trade in which the value of a practice is determined in terms of the number of patient charts (confidential information the physician has of his/her panel of patients) kept in the not-so-easy-to-read paper chart, and locked in a private record room.

In order to address this cultural element, revisiting and, perhaps, redefining the social contract that throughout history society has developed with physicians seem most appropriate at this historical juncture. The EHRs is only pinpointing, like never before, the difficult issue of providing access to the patient of his/her medical information, arguably his/her property.

References:

1. Mackenzie, K., The Key to PHR Success isn’t What You Think. HealthLeaders Media Website. http://www.healthleadersmedia.com/print/content/222765/topic/WS_HLM2_TEC/The-Key-to-PHR-Success-Isnt-What-You-Think.html November 4, 2008. Accessed on November 9, 2008.

2. Simon, SR., Kaushal, R., Cleary, PD., et al. Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey. J Am Med Inform Assoc. 2007;14:110 –117.

3. Rosenthal, DA., Layman, EJ.,  Utilization of Information Technology in Eastern North Carolina Physician Practices: Determining the Existence of a Digital Divide.  Perspectives in Health Information Management 5; 3; Winter 2008 pp.  1-20

4. Margalit, RS., Roter, D., Dunevant, MA., Larson, S., Reis, S., Electronic medical record use and physician–patient communication: An observational study of Israeli primary care encounters. Patient Education and Counseling. Elsevier 2006;61:134–141

5. Farsi, MA., West Jr, DJ., Use of Electronic Medical Records in Oman and Physician Satisfaction. J Med Sys; 2006, 30(1): 17–22

6. GAO, Health Information Technology; Efforts Continue but Comprehensive Privacy Approach Needed for National Strategy. Tuesday, June 19, 2007. www.gao.gov/cgi-bin/getrpt?GAO-07-988T. Downloaded on December 18, 2008

7. Randeree, E., Exploring Physician Adoption of EMRs: A Multi-Case Analysis. J Med Syst. 2007, 31:489–496

8. Lupton, D. Medicine as Culture. Sage, 2nd ed., 2003

Cultural Typology IV: Physicians’ resistance

A strong sense of autonomy, can also be projected, and/or interpreted, as “resistance to change”.  Physician resistance is a “cultural element” that recurs throughout the literature as either physicians’ resistance to EHRs or change per se.[1] However, if as Lee argued that physicians are resistant to the social change that will result from the EMR, and as Anderson argued that although physicians support computer applications that enhance their ability to manage medical information they tend to view with ambivalence computer applications that affect their role as medical decision makers; it seems physicians have much reason if one also considers Campbell’s identified adverse consequences of HIT: [2]^{, [3]},[4],[5]

a) There will be more/new work for clinicians;

b) Unfavorable workflow issues develop as rigidly modeling work processes according to the “letter of the law”, and organizational policies and procedures are implemented that dramatically highlight mismatches between intended and actual work processes in real-world settings;

c) There will be “never-ending system demands” with the new hardware and software implementation tasks, and maintenance issues;

d) The paper persistence will be a real issue. Interestingly, in the Sultanate of Oman in the Arabian Peninsula, the persistence of paper provoked poor utilization of the system mainly during physician rounds because some physicians used both the paper and also the EMR. They worked double keeping notes that were transferred at a later time into the EMR system.[6]

e) There will untoward changes in communication patterns and practices;

f) Negative emotions will be a disturbing important issue that needs to be addressed promptly;

g) HIT is no panacea and new kinds of errors will be generated;

h) There will certainly occur unexpected changes in the power structure. This issue will require special attention because while at the same time one is monitoring clinician’s behaviors, this may induce changes in the power structure and culture of the organization. This is especially problematic in health care, as Campbell assertively expresses, where lines of authority emanate from traditional educational hierarchies, differences between general practitioners and specialists, and among others other differential factors. It is also true that traditionally, physicians report loss of professional autonomy when computerized systems prevent them from ordering the types of tests or medications they prefer, or force them to comply with clinical guidelines they may not embrace, or when these limit their narrative flexibility through structured rather than free-text clinical documentation.

i) Finally, the over-dependence on the technology poses its own challenges; As HIT diffuses and becomes entrenched within organizations, clinical care delivery becomes inextricably dependent upon it.

There is no magic bullet to address physician resistance other than to learn and implement good strategies to manage change. On the other hand, because of the physician’s preeminence in the health care system, their resistance is more evident, voiced more prominently, and is certainly more critical than that of other members of the health care team.  It is important to remember that the IOM study of patient records concluded that the majority of barriers to the implementation of EMR systems are behavioral and organizational rather than technical. Wears and Berg (2005) also remind us that roughly 75% of all large IT projects in health care fail basically due to inattention to the problems associated with the introduction of computer technology into complex work environments. One would have to remember that health care is probably the most complex enterprise of modern society.[7]  Harrison, et al, (2007) in a viewpoint paper, argue that many unintended and undesired consequences of HIT flow from interactions between the HIT and the health care organizations’ socio-technical system, its workflow, culture, social interactions and technologies.[8]  They assert that these socio-technical interactions have been richly documented in the literature but that, unfortunately, many IT users and even IT specialists are unfamiliar with it or its practical implications.

References:

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[1] Randeree, E., Exploring Physician Adoption of EMRs: A Multi-Case Analysis. J Med Syst. 2007, 31:489–496

[2] Lee, FW. Adoption of Electronic Medical Records as a Technology Innovation for Ambulatory Care at the Medical University of South Carolina. Contemporary Issues in Health Information Management. August 2000;21(1):pp 1-20

[3] Anderson, J.G. “Computer-based Patient Records and Changing Physicians’ Practice Patterns.” Topics in Health Information Management 15, no. 1 (1994): 10-23.

[4] Anderson, J.G., et al. “Why Doctors Don’t Use Computers: Some Empirical Findings.” Journal of the Royal Society of Medicine 79, no. 3 (1986): 142-144.

[5] Campbell, EM., Sittig, DF., Ash, JS., Guappone, KP., Dykstra, RH. Types of Unintended Consequences Related to Computerized Provider Order Entry. JAMIA. 2006;13(5):547-556

[6] Mohammed Al Farsi · Daniel J.West Jr. Use of Electronic Medical Records in Oman and Physician. Satisfaction J Med Sys (2006) 30(1): 17–22

[7] Wears, RL., Berg, M. Computer Technology and Clinical Work; Still Waiting for Godot. JAMA, 2005, 293(10): 1261-1263

[8] Harrison, MI., Koppel, R., Bar-Lev, S. Unintended Consequences of Information Technologies in Health Care – An Interactive Sociotechnical Analysis. JAMIA. 2007;14(5):542-549

Cultural Typology III: Professional autonomy and leadership

Medicine has assumed a preeminent position in the health care system as no other profession; Freidson defines it as the epitome of a profession.[1] It has been so successful that it has gained full control over the substance of the field of medicine. It develops its own independent conception of the problems the people bring to the profession, reinterprets the experience of this people and recreates their problems creating new social realities (nosologies) that only the profession is capable and authorized to handle. On the other hand, during the last thirty years professional practice models have evolved from a physician’s solo practice and nursing team practice in the hospital, into an interdisciplinary care model that puts into function critical paths to support care management for which computer based applications hold great promise. Ozbolt and Bakken see a 21^st Century with advanced practice nurses increasingly taking on functions previously provided by physicians while maintaining a nursing perspective on collaborative, interdisciplinary care.[2]

In order to address the cultural factors of professional autonomy and leadership, I would argue that it is incumbent upon physicians to assume the responsibility implicit in their delegation by society to define medicine. In order to do so, they would have to revisit their social contract with society so that the EHRs are used ethically for the benefit of the individual patient, and the society at large, whichever is most advantageous to the patients. This should occur irrespective of how much it infringes on the sense of control physicians believe they have on the patient’s medical information. Tang and McDonald, in Shortliffe, remind us that the greater need for leadership and action will be in the social and organizational foundations that must be laid if EHRs are to serve as the information infrastructure for health care.[3] I would argue that physician leaders in biomedical informatics have an important role to play in this area and that a broad “physicians and society dialogue” would be most appropriate to be called by physician leaders in bioinformatics. It needs to be defined who these leaders are and who brokers this initial agenda.

In relation to the cultural element of leadership, and the more immediate need of the implementation of the EHRs, the concept of “physician champion” is becoming popular in reference to that physician that has assumed a lead role in fomenting and facilitating the use of the EHRs. [4],[5],[6],[7] I would argue that the concept is used primarily anecdotally and needs clarification and specification. Simply because a physician is a “techie,” or an early adopter, does not guarantee that he/she knows management of health information. On the other hand, while it is true that “techies” and early adopters are “championing” all kind of technologies, physician’s use of IT today is rooted on practical and quite straightforward applications that serve their professional purposes. [8] On the other hand, physicians are also very critical of their own peers if these cannot produce compelling data showing the value of implementation and use of EHRs.

Having said this, Miller has interviewed several of these leaders and has been able to decipher some of their characteristics. [9] These physician champions had positive, “can-do” attitudes toward solving electronic medical records (EMR)-related problems and were vital to getting other physicians to use EMR.  They were physician—innovation “early adopters” who were willing to bear initial financial and time costs to generate benefits.  In contrast, non-champion physicians tended to be less positive toward EMR and more easily discouraged by usability problems.  Without exhortation and support from physician champions, these physicians tended to remain as lower level EMR users.  As a result, practices without physician EMR champions may flounder in their efforts to generate quality or financial benefits from EMR.  Finally, as a note of caution, I would reiterate, as Menachemi argues, that little is known about physicians who are likely to adopt EHR imminently.[10]

In relation to motivating physicians to adopt EHRs, Briggs reminds us to avoid the tendency of administrators to make decisions from the top down attempting to impose them on everyone. [11] Resistance to change is not unique to physicians, but in particular with physicians it is a huge issue.  In 1988, Kaplan compared the successes and failures in the implementation of three seminal management information systems (MIS), Technicon, COSTAR and PROMIS, and concluded that physicians’ reaction to a medical computer system was more important to system acceptance than the reactions of other user groups.[12] The experience gained with implementing these three systems showed that change cannot be forced and new computer systems cannot simply be mandated. Kaplan asserted then, and I would argue that nobody challenges it today, the fact that when change is well-managed, when the computer system does not radically challenge fundamental values and practices, and when it provides benefits that potential users easily identify as important and meaningful, the chances of success are greatly improved.(13)

References

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[1] Freidson, E. Profession of Medicine: A study of the Sociology of Applied Knowledge. The University of Chicago Press, 1988

[2] Ozbolt, JG., Bakken, S. Patient Care Systems. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:564-584

[3] Tang, PC., McDonald, CJ., Electronic Health Record Systems. In Shortliffe and Cimino, Biomedical Informatics: Computer Applications in Health Care and Biomedicine. Springer 2006:470

[4] Miller RH, Sim I. Physicians’ Use of Electronic Medical Records: Barriers and Solutions, A survey of physician practices shows slow but steady progress in adopting this new technology. Health Affairs (Millwood-Spring Hope). 2004 Mar-Apr;23(2):116-126

[5] Margalit, RS., Roter, D., Dunevant, MA., Larson, S., Reis, S., Electronic medical record use and physician–patient communication: An observational study of Israeli primary care encounters. Patient Education and Counseling. Elsevier 2006;61:134–141

[6] Geyer, S., Physicians: The Key to IT Success. Trustee; Feb 2004; 57, 2;

[7] Terry, AL., Thorpe, CF., Giles, G., et al., Implementing electronic health records; Key factors in primary care. Canada Fam Physician 2008;54:730-6

[8] Briggs, B., Doctors Sound Off on I.T. Concerns. Health Data Management.  9.1 (Jan 2001): 38.

[10] Miller RH, Sim I. Physicians’ Use of Electronic Medical Records: Barriers and Solutions, A survey of physician practices shows slow but steady progress in adopting this new technology. Health Affairs (Millwood-Spring Hope). 2004 Mar-Apr;23(2):116-126

[11] Menachemi, N., Barriers to ambulatory EHR: who are “imminent adopters” and how do they differ from other physicians? Informatics in Primary Care 2006;14:101–8

[12] Briggs, B., Doctors Sound Off on I.T. Concerns. Health Data Management.  9.1 (Jan 2001): 38.

[13] Kaplan, B. Development and Acceptance of Medical Information Systems: A Historical Overview. Journal of Health and Human Resources Administration. 1988;11(1):9-29

Cultural Typology II. Medicine as a Technological Endeavor

This cultural factor could be assessed in relation to, or in conjunction with the previous, Medicine as Art, because many aspects of both sometimes merge and become indistinguishable from one another.How medicine evolved from the exercise of the “art of healing” to the “application of technology” in treating illness and disease is not an easy endeavor, but as technology continues its impact in health care, the adoption of EHRs will depend on the impact of contextual variables identified. This debate is accentuated with the use of computers for data management because computers tend to demand conformity to data standards and definitions, and medicine is notorious for imprecision and even a lack of standardized vocabulary.

Over the last century and for the first time in human history, one medical system, Biomedicine, the medicine of the twentieth-century Western world, has come to influence the health and healing practices of human societies worldwide. I would argue that Biomedicine can be understood as the “technologization” of medicine. Biomedicine, that “particular” medicine that the Western world has invented and that the United States has primed par excellence, as a cultural system, focuses on physicians, its preeminent practitioners.

One would have supposed that as biomedicine has incorporated most of the technology and made it a substantive element so that only physicians can dispense it, the EHRs would have also been fully embraced by the physician. However, this has not happened. The reason could well be, accepting Shortliffe’s assertions, that the biomedical culture views IT as a support activity, outside of the usual foci of biomedical science, and there has been poor appreciation of IT as a strategic asset.

In order to address this difficult cultural element, embedded into the professional culture as well as into the general societal health culture, I would argue that it is incumbent upon physician leaders in bioinformatics to make the case to the general public, and certainly within the profession, that the EHRs has been introduced into American Medicine with the wrong emphasis on administrative tasks (billing and collection being the most prominent) rather than as the substantive mechanism to deliver a type of medicine that is safe and of high quality and that follows best practices that fit the “art” of medicine.

One has to remember that medicine is an information and knowledge intensive enterprise. As the National Research Council report asserts, currently IT applications appear designed largely to automate tasks or business processes often designed in ways that simply mimic existing paper-based forms and provide little support for the cognitive tasks of clinicians or the workflow of the people who must actually use the system.

References:

[1] Shortliffe, EH., Barnett, GO. Biomedical Data: Their Acquisition, Storage and Use. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:46-78

[2] Hahn, RA. Sickness and Healing; an Anthropological Perspective. Yale University Press; 1995

[3] Stein, H. American medicine as culture. Westview Press; 1990

[4] Committee on Engaging the Computer Science Research Community in Health Care Informatics; National Research Council. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. Willam W. Stead and Herbert S. Lin, editors. National Academies of Sciences web site. ;http://books.nap.edu/openbook.php?record_id=12572&page=R1. 2009. Downloaded on January 11, 2009

Cultural Typology I. Medicine as an art

In relation to the “art of medicine” the EHRs present various intrinsic problems.

• Computers and high-level processes

Shortliffe and Blois explain that medicine deals with high-level processes, in particular human processes and behaviors, and these represent serious difficulties for computers to manage.[1] They further assert that the descriptions of human beings and their activities must be sometimes so highly abstracted in computing as to render them worthless from either a clinical or research perspective. The authors remind us that artificial intelligence might be an answer to this difficulty but as an application it is today still in its infancy. Therefore, physicians can argue against using the EHRs, an IT application that is deficient or, at best imperfect, in its basic function of capturing the reality of the patient’s health and illness circumstances. The conundrum then for the computer specialist is the challenge to capture through computing the simultaneous nonlinear quality of patient care, and for the physician (and clinicians in general) to appreciate that altering some aspects of software are impossible because the rigor of the mathematical approach of computer systems will never provide the flexibility people have.[2],[3]

On the other hand a report of the Committee on Engaging the Computer Science Research Community in Health Care Informatics, National Research Council (NCR), expresses, “The health care IT systems today seem to squeeze all cognitive support for the clinician through the lens of health care transactions and related raw data without an underlying representation of a conceptual model for the patient showing how data fit together and which are important or unimportant. As a result, an understanding of the patient can be lost amidst all the data, all the tests, and all the monitoring equipment.”[4] The conundrum here for researchers would be, as the NRC report explains, to develop virtual patient models that are the computational counterparts of the clinician’s conceptual model of a patient. These models would free the clinician from having to make sense of raw data, and rather have a much easier time defining, testing, and exploring his/her own working theories.

On a more mundane note, since most physicians currently dictate their notes, some may feel that typing is a “misuse” of their professional time, while others will see it as a loss of status. [5]

• Computers and decision making

Information management is intrinsic to medical practice, and the nature of medical practice is decision making, the quintessential activity of the health care professional.[6],[7] The one mark of a good physician is having the ability to make sound clinical judgments, and the ultimate goal of a computer-based decision support systems (CDSS) should be to help the clinician make informed decisions.[8],[9], [10] Decision making implies the assessment of some sort of data and perhaps some sort of deductive reasoning.  On the one hand, clinical data are imperfect, e.g. imprecision and the lack of standardized vocabulary are particularly problematic in health care.[11] On the other hand, many decisions by clinicians, physicians in particular, often rely on empirical knowledge of associations between symptoms and disease. A decision that is based on these usually imperfect associations will be, to some degree, uncertain if not completely biased.[12] A computerized decision tool could offer aid in assessing complex problems, but the computer cannot substitute the intuition and clinical judgment about what data is relevant in any given case for the computer to analyze.

Finally, according to Friedman, most studies evaluating Clinical Decision Support Systems have emphasized the accuracy of the computer system alone without placing clinicians in the role of direct users. He studied the question of the extent to which the system improves the diagnostic hypothesis of clinicians not the extent to which its advice is correct. The results showed relatively small benefit, primarily among students rather than medical residents or attending physicians. In some instances the computer consultation was detrimental and caused the clinician to latch on to a misdiagnosis. Another alert posed by Burke and Wiell in relation to CDSS is that in a study published in JAMA examining a hundred decision support systems, the researchers found that “most of the glowing assessments of those systems came from technologists who after all had a hand in designing the systems”[13]

With the above in mind, physicians can argue that, given the actual level of development of medical computing, EHRs (and particularly clinical decision support systems) cannot, and will not, take over their role as medical decision makers and, therefore, its use is a loss of their professional time.[14]

In order to address this cultural perspective I would argue that medical computing rather than changing the practice of the art of medicine, enhances it as it facilitates accessing patients’ information and medical decision tools.  However, in order for physicians to “buy into this concept” they need formal education on how biomedical informatics deals with biomedical information, data, and knowledge. I would argue that a well-trained cadre of physicians in biomedical informatics would facilitate the design and development of EHRs, and certainly would become leaders in adopting these. As clinical knowledge and workflow, rather than financial models, become the basis for design, new EHRs will be more suited to fulfill the promises of clinical informatics.[15] I would also argue with Bria and Rydel who write assertively about achieving the physician-computer connection by having healthcare providers at the helm of system implementation.[16] In order for this to happen, all physicians must become at least knowledgeable about managing information, while some others will adopt biomedical informatics as their field of specialization. A word of caution though, this by no means insinuates that only through a “guild’s designed credentialing process” would physicians become “medical informaticians”.

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[1] Shortliffe, EH., Blois, MS. The Computer Meets Medicine and Biology: Emergence of a Discipline. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:3-45

[2] Ozbolt, JG., Bakken, S. Patient Care Systems. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:564-584

[3] Wiederhold, G., Shortliffe, EH. System Design and Engineering in Health Care. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:233-264

[4] Committee on Engaging the Computer Science Research Community in Health Care Informatics; National Research Council. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. Willam W. Stead and Herbert S. Lin, editors. National Academies of Sciences web site. ;http://books.nap.edu/openbook.php?record_id=12572&page=R1. 2009. Downloaded on January 11, 2009

[5] Lee, FW. Adoption of Electronic Medical Records as a Technology Innovation for Ambulatory Care at the Medical University of South Carolina. Contemporary Issues in Health Information Management. August 2000;21(1):pp 1-20

[6] Shortliffe, EH., Blois, MS. The computer Meets Medicine and Biology: Emergence of a Discipline. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:3-45

[7] Owens, DK., Sox, HC. Biomedical Decision Making: Probabilistic Clinical Reasoning. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:80-132

[8] Owens, DK., Sox, HC. Biomedical Decision Making: Probabilistic Clinical Reasoning. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:80-132

[9] Tang, PC., McDonald, CJ. Electronic Health Record Systems. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:447-475

[10] Friedman, C.P., et al., Enhancement of clinicians’ diagnostic reasoning by computer-based consultation:  A multiple study of 2 systems, JAMA 282 (1999), pp. 1851-1856

[11] Shortliffe, E.H., Barnett, GO. Biomedical Data: Their Acquisition, Storage, and Usage. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:46-79

[12] Groopman, G. How Doctors Think. Houghton Mifflin; 2007

[13] Burke, L., Weill, B. Medical Informatics: The Health Information Technology Decade. Information Technology for the Health Professions. Pearson Prentice Hall; 2009:21-39

[14] Musen MA., et al. Clinical Decision-Support Systems. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:698-736

[15] Ozbolt, JG., Bakken, S. Patient Care Systems. In: Shortliffe and Cimino, eds. Biomedical Informatics, Computer Applications in Health Care and Biomedicine. Springer; 2006:564-584

[16] Bria, WF., Rydell, RL. The Physician-Computer Conundrum: Get Over It! HIMSS; 2004

A Cultural Typology

A Cultural Typology

In the extensive literature that I have reviewed, cultural factors can be identified or can be inferred. Kaplan, as stated in earlier posts, captured very wisely the conundrum for the physicians when dealing with IT.[1],[2],[3] I would argue that her assessment is as valid today as it was in 1987. Therefore, based on my literature review, and exploring more details for her assessment, I have defined a cultural typology in relation to the values and beliefs that inform physicians’ behaviors and their practices in their decision to adopt or not adopt the EHRs. Although the following list is by no means exhaustive, and some factors manifest themselves in ways that could be ascribed to others, and the strategies to address these apply to others alike, a cultural typology would include:

1. Medicine as an art
2. Medicine as a technological endeavor
3. Professional autonomy and leadership
4. Physician resistance
5. Personal relationship with the patient
6. Provision of quality services reflecting professional competence
7. Sense of belonging to a professional class : i.e. Medical specialties as subcultures
8. Medicine as a meaningful professional practice for health care justice: i.e. Other socio-demographic variables and Age as a definer of generational subcultures
9. Practice in educational settings as an academic subculture

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[1] Kaplan, B. Development and Acceptance of Medical Information Systems: A Historical Overview. Journal of Health and Human Resources Administration. 1988;11(1):9-29

[2] Kaplan, B., The influence of Medical Values and Practices on Medical Computer Applications. In: James G. Anderson and Stephen J. Jay, eds. Use and Impact of Computers in Clinical Medicine. NY:Springer; 1987:39-50

[3] Kaplan, B. The Medical Computing “Lag”: Perceptions of Barriers to the Application of Computers to Medicine. Intl. Journal of Technology Assessment in Health Care. 1987, 3:123-136