Archive for March 2011

Cultural Typology III: Professional autonomy and leadership

March 9, 2011

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 21st 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


[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

March 7, 2011

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

March 4, 2011

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”.


[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

March 2, 2011

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

[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