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 facesIn 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.

[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, 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 Accessed on January 6, 2009

[6] HIMSS website. Accessed on December 1, 2008

[7] AMDIS website. Accessed on December 1, 2008

[8] AMIA website. Accessed on December 1, 2008

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

Explore posts in the same categories: Culture, Electronic Health Record, Health Information Technologies, Medicine, Physicians

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