Archive for May 2011

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

May 21, 2011

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.

[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.

May 3, 2011

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]

* 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.

[1] Boelen, C., THE FIVE-STAR DOCTOR: An asset to health care reform? World Health Organization Web site 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; Downloaded on May 2, 2011.

[4] Institute of Medicine. America’s Health Care Safety Net: Intact but Endangered. IOM Web site; Downloaded on May 2, 2011

[5] Health Resources and Services Administration, Health IT Tool Box. HRSA Web site: Accessed on May 2, 20011