Archive for the ‘Medicine’ category

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

April 27, 2011

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

April 22, 2011

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

April 21, 2011

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:


[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 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

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

About the Culture of Medicine & Physicians

February 11, 2011

In the initial blog (Jan 24, 2011) I asserted that culture, the basic tenet that informs who the individual is and how he/she behaves, has received little attention as to which of its factors influence or determine how physicians understand the desirability or lack of desirability in adopting the EHR. I also argue that principally, though overlooked, the lack of adoption of EHR by physicians has much to do with deep professional cultural values ingrained within a broader context of societal values in relation to health and health care.

I propose that a cultural framework that explores the customs, languages, and belief systems that have informed physicians in the U.S., particularly during the last century, is most appropriate to understand why or why not physicians would adopt EHR. A word of caution, although it is important to be curious about the values and attributes of a particular cultural group, there is an inherent risk of generalizing these values and attributes to everyone who shares aspects of that culture. This sort of stereotyping should be avoided.

The question then is, what is culture and where does it meet medicine?

Culture can be asserted as a universal whole, a creation of people that in turn informs those people as to who they are. It can be succinctly defined as “all the shared, learned knowledge that people in a society hold.”[1] It can also be defined as, “an integrated pattern of human behavior including thought, communication, ways of interacting, roles and relationships, and expected behaviors, beliefs, values, practices and customs.”[2] Culture is also “the bearer of human wisdom that includes a wealth of human behaviors, beliefs, attitudes, values and experiences of immense worth.”[3]

The assumption is that the individual is often the authority and sole representative of his/her cultural experience. This assumption is of most importance in health care because of the ways in which we interpret and perceive health and illness and our choices in providing and seeking care are informed (defined and influenced) by our culture. Since medicine is a cultural construct, a creation of people, the approach to the universal culture and medical culture is that people are constantly creating, negotiating, revisiting, internalizing, and externalizing their culture, a culture that is always a process and never a thing. [4] On the other hand, medicine informs some of those people, physicians in particular, to define and lead the construct of medicine.

Medicine is also a profession that imprints character. Throughout all epochs, physicians have constructed a corporative collectivity, more or less admired or chastised, but always cohesive in its control of their profession and trade. [5] In all cases this evolution has occurred within the historical and cultural context of each epoch, utilizing the knowledge available at each epoch, two things from which no society or group will ever be able to escape.[6],[7],[8],[9]

The profession of medicine as the epitome of a profession; an occupation which has assumed a dominant position in a division of labor, has gained full control over the determination of the substance of its own work.[10] The profession claims to be the most reliable authority on the nature of the reality it deals with. It deals with the problems people bring to the profession, develops its own independent conception of those problems and tries to manage both the clients and the problems in its own way.

Medicine is not merely one of the major professions of our time; it alone has developed a systematic connection with science and technology. Unlike any other profession, medicine has developed into a very complex division of labor, organizing an increasingly large number of technical and service workers around its central task of diagnosing and treating the ills of mankind. One must not forget that the physician is the preeminent practitioner of medicine, and represents it par excellence.[11] As a matter of fact, the very organization and practice of medicine are themselves cultural.[12]

One must also remember that Biomedicine is the “particular” medicine that the Western world has invented and, as a cultural system, focuses on physicians, its preeminent practitioners. [13],[14]

In exploring this cultural framework, I have reviewed literature to critically analyze prior research studies, reviews of literature, theoretical articles or expert opinions, and case presentations related to cultural determinants that could impact the adoption of the electronic health record by physicians.[15] Most of the literature reviewed recognizes multiple barriers for the physician’s lack of fully embracing EHRs. Repeatedly, it appears that basic organizational, economic, and financial factors are the prime reasons why the adoption of EHR is not greater in the U.S.

There should be no doubt that the costs associated with the adoption of EHR is high and that the “return on investment” is not easy to assess, or at least not clear to most physicians. This is particularly true in the case of physicians in small practices, rural areas, and safety net providers that are already having difficulty maintaining financially sound operations because of the low reimbursement by third party payers and the shrinking pool of self-paid individuals.  On the other hand, economic incentives per se are not a panacea nor easy to implement. As a matter of fact, according to the findings from the Center for Studying Health System Change’s (HSC) 207 site visits to 12 nationally representative metropolitan communities, despite regulatory changes, physicians’ disinterest tempered some hospitals’ enthusiasm in providing financial and other support to physicians. It appears that physicians’ disinterest was rooted in their having to cover all hardware costs and at least 15% of other costs, including the EMR software.[16]

It is also true that the majority of practices are finding the transition from a paper-based to an electronic-based medical record difficult even if the physicians and nurses are fully supportive[17]. We should also recognize that the government and industry should clarify its technology objectives, engage the physician community, shape the development of standards and technology certification criteria, and adopt concrete payment systems to promote the adoption of meaningful technology.[18] [19] As an important contrast, other Western countries have been much more successful (despite significantly lower overall national health expenditures) at encouraging the adoption of health information technology by physicians.(20] Data from industrialized nations suggest that a large majority (often more than 90%) of primary care physicians currently use computers in their office practices.

On the other han as technology continues its impact on health care, the adoption of EHRs will depend on the impact of the contextual variables identified. I would argue that the cultural aspects of the physicians’ milieu are mentioned in the literature only casuallyd,. [21] Therefore, specific cultural factors are not usually identified as such and not many specific solutions or incentives are presented from that particular perspective. Each of these cultural factors can be seen as a qualifier to argue for or against adopting the EHRs.

If we could identify cultural factors that influence physicians positively in adopting EHRs, then specific strategies to incentivize physicians could be explored, while factors that could have a negative effect could be modified or minimized. On the other hand, if these factors are not considered it is possible that some of the incentives proposed, or already implemented, might not be effective or could even be counterproductive.

What do you think are these cultural factors?


[1] Loustaunau, M., Sobo, E., (1997) The concept of culture. The cultural context of health, illness, and medicine. (pp. 9-19) Bergin & Garvey

[2] Taylor, T. Cultural Competence: Implications for service

delivery to children with special health needs and their families. An Interdisciplinary Approach: Nutrition Makes the Difference. Childrens Hospital. 1996, USC-UAP, Los Angeles, CA

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