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.


[1] National Academy of Sciences. Crossing the Quality Chasm: A New Health System for the 21st Century. Executive summary downloaded from 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. ;

[4] The National Academy of Sciences. To Err Is Human: Building a Safer Health System. 2000. The Nat’l Acad. of Sciences Web site 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.

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