Survey reveals physicians' love/hate relationship with technology.

... A huge, complicated machine, connected to the operating table, with many tubes and wires, began at this moment to go pocketa-pocketa-pocketa. "The new anesthetizer is giving away!" shouted an intern. "There is no one in the East who knows how to fix it!"

"Quiet, man!" said [Dr.] Mitty, in a low, cool voice. He sprang to the machine, which was now going pocketa-pocketa-queep-pocketa-queep. He began fingering delicately a row of glistening dials. "Give me a fountain pen!" he snapped. Someone handed him a fountain pen. He pulled a faulty piston out of the machine and inserted the pen in its place. "That will hold for ten minutes," he said. "Get on with the operation."

Faced with new technology, physicians fall into two camps.

One is made up of those like the protagonist of James Thurber's famous short story "The Secret Life of Walter Mitty" (not really a doctor but a meek daydreamer of vainglorious fantasies). They welcome innovation and quickly adapt to its intricacies and quirks.

In the other camp are those who focus on the discouraging costs, complications and inconvenience. They are wary of new ways, if not resentful and resistant.

Those contrasting views stood out clearly in the responses of nearly 1,600 members of the American College of Physician Executives who answered a recent survey of their organizations' progress in implementation of clinical information systems (CIS).

More than 400 respondents appended comments as well; over and over the theme was sounded:

* "Many physicians are not computer literate and don't want to try anything new."

* "Approximately 10-15 percent of the medical staff ... are very reluctant to use the computer...."

* "Health care is being held back by physicians who are IT illiterate and resistant to learning new technology. We have had significant difficulties simply because some docs refuse to use keyboards and cannot type."

* "The impact of technology is now upon us; however, our heads remain buried in the sand due to the indifference of physicians to acknowledge and accept what they do not understand.... They need to realize that when you are through changing--you are through!"

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* "We have had computerized records since 1996--not half as useful as they could be because the older physicians refuse to use them appropriately--still dictate their visits rather than 'checking the boxes' and keeping the computer chart updated.... The lack of desire for changing to e-mail communications with patients, when we have had phone problems/jams for three years running, remains flabbergasting."

* "CPOE (computerized physician order entry) was voluntary--and after a few months, most physicians had stopped using."

Two comments sum up the outlook from this camp. Grumped one respondent in a brusque, ostensibly sweeping condemnation of all the new tools specified in the survey (electronic medical records, computerized physician order entry, pharmaceutical bar coding, electronic prescriptions, e-mail and online communication between doctors and patients, personal digital assistants (PDAs) for clinical use, wireless portable devices): "Appear costly and too cumbersome, especially EMR."

Declared another dismissively: "We have found nothing (yet) that doesn't interrupt the physician's work flow."

New tricks

But if Walter Mitty's versatile fountain pen still represents the zenith of technology to many doctors (as one pecked out plaintively, sans capitals or punctuation: "typing is the bigest obstacal for me personally"), others have enthusiastically waded across the digital divide.

"New generation docs are far more savvy than those out in practice," suggested one respondent--an assessment widely echoed. "When I had a resident or med student spend a week with me, once given a password, the system was entirely intuitive to them. For a doc over 40, it was a three-month-to-three-year teaching curve! You have to live technology and use it everywhere, and make mistakes and learn how to cope. to fix--with a mentor. It'll take a generation!"

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"As an 'older' physician I struggle," admitted another respondent. But, he added gamely, "We all want to do the right thing."

Many comments proclaimed a sturdy commitment to the electronic future.

"I have no question that these technologies will enhance the quality of care and increase efficiencies of all members of the associate and medical staff," wrote one.

"Exciting, expensive, knowledge expander, safety risk reducer, time saver," summarized another.

"The sooner the better!" exclaimed a third.

Nor were opprobrious fingers pointed universally at Luddite colleagues:

* "I have been working as a physician in information technology since 1998. I feel that resistance from physicians is not nearly the barrier some people make it out to be. Most cases that I have seen that were blamed on uncooperative doctors turned out to be poorly presented information, processes that made the job more difficult rather than more efficient, or a solution to a problem that didn't address the root cause and didn't make sense. Physicians are well-educated, highly intelligent people. If you give them something that helps them take care of their patients, you will have their buy-in."

* "I am always amazed to hear that physicians 'won't use computers.' Physicians are always changing surgical techniques, meds, etc.--but they won't change from paper until it is clearly of benefit to them to do so--and that means faster and easier."

* "Most physicians are skeptical about newer technologies. But once they are introduced to a newer technology, they love it. Therefore, to get over the initial hump, there should be ample training opportunities and help."

* "It has taken us two years to move all our physicians into (the EMR) format, and there was at first great wailing and gnashing of teeth. Now that all our providers are on board, they see the benefit."

* "The MD buy-in was slow but now no one would wish to go back to manual records. When we have occasional server problems or power outages that take over 30 minutes to restore, we hear from the MDs quickly about when it will be up and running again."

* "Assumed efficiencies are NOT immediately apparent to docs. In fact, the switch to an EMR has been very labor-intensive for most. However, once they are past the hurdle of their learning and the staff has worked through the 'new tasks' that are driven by the EMR ... all say they would not go back."

Warned one survey participant: "The learning curve to efficient use of new software and devices exceeds the 'instant gratification' for many users. In addition, the payoff is often in improved system performance, not in individual productivity."

Nevertheless, declared another reassuringly, "You can teach old dogs new tricks"--adding a proviso, "but you need a lot of 'treats' along the way!!"

Deer in the headlights

It was the gremlins and hobgoblins, though, that most ACPE members invoked with shudders as they described the process of researching and planning, bidding, testing and implementing new clinical information system technologies. Examples:

* "Not always reliable, does not always live up to expectations, support for services lacking, time to train hard to manage in current environment of high volume work load."

* "This is a minefield. Everyone wants to offer you solutions, but nothing seems to fit the bill. There are traps at every turn. We need our professional organizations to help us out in this regard."

* "One year into implementation (of an EMR), only one of fifty users had managed to return to pre-implementation productivity levels, despite an additional two to three hours per day on record keeping. There was a limited reduction in overhead due to decreased transcription costs, but the ROI has not met expectations at the 12-month mark."

* "It continues to promise more then it can accomplish. It takes an unusual amount of time to get a system working well."

* "With the rapid advances in computer technology, I am loath to invest millions in a system that will be obsolete next month.... Electronic medical records may well be the wave of the future, but they ain't here for the little guy. Too many claim to be able to run when they can't even crawl. I am disillusioned."

* "Software companies are all too eager to push the positives and not deal with the negatives. Software is rushed to market and the user is the 'guinea pig,' even when it is past 'beta' testing phase. The software companies are reluctant to take responsibility for failings in their systems."

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* "Too much vaporware in this business and too many interface engines."

* "There are so many options it is deer in the headlights."

* "We were in the process of implementing a pharmacy bar coding and CPOE system for two years, but recently stopped the process due to the many bugs in the system. We lost confidence in the vendor so we must start again!"

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* "The systems that everyone wants are not yet developed, and the costs, both capital and personnel, that will be incurred in 'getting there' incrementally will be enormous. I'm not at all certain that the system, as a whole, will have the resources this is going to require."

The ordeal for the majority was encapsulated in this anguished wail: "Still A LOT OF PROBLEMS!!!"

In the wave

For all their hair-pulling, survey respondents reported that:

* Fully a third of the health care organizations they represented have already adopted electronic medical records and/or PDAs for clinical applications.

* Almost a quarter are using wireless portable devices and/or CPOE.

* One in five has implemented pharmaceutical bar coding and/or electronic prescribing.

* The least likely technology to have been embraced is doctor/patient e-mail, at 18.2 percent; it was also least likely to be a subject of current interest (fully 44 percent reported no development under way).

Overall, however, the CIS wave is inexorably building and has swept up more than half of all the hospitals and physician practices the ACPE members belong to. From almost two-thirds to 85 percent are at least researching or planning if not actively bidding, testing or already using EMRs, CPOE, pharmaceutical bar coding, electronic prescriptions, PDAs or wireless portable devices, the survey indicates.

Among those disinclined to catch the wave--as well as many already in the curl--cost is by far the greatest drag.

"Lack of money/resources to implement technology" was cited by nearly half the survey respondents as the greatest obstacle they faced--a far more formidable problem than "lack of support or buy-in from physicians and other medical staff."

To be sure, wrote one respondent, "Hospitals (and docs) are in the dinosaur age with respect to the use of technology in care and decision making. But given the current financial climate in health care, it is hard to see how this will change without government mandate and support."

"Our real challenge," asserted another, "is getting payers to acknowledge and step up to the bar to pay for the improvement in quality and accountability that information systems can provide. Everybody wants it, nobody wants to pay for it,"

The word mandate was recurrent.

"The need is obvious," went a typical lament, "(but) the obstacles (cost, training, time, resource support) appear insurmountable because there is no unified mandate to adopt technology."

Likewise, said another, "If these technologies were mandated by the federal government for Medicare payment, or if required for JCAHO accreditation, the system would definitely put its full weight and resources into acquiring these technologies. Right now, it is more of a wish list item, nice to have but a little too expensive--a luxury item if you will."

Frustration and rare praise

If frustration and disenchantment were widespread, so was the field of fire. Several well-known technology vendors were subjects of biting criticism by name. Satisfaction with systems (in some cases from the same vendors) tended to be expressed in less than gushing terms.

More than a few respondents scored their organizational leadership for indifference if not worse.

"We are at the mercy of 'pin head' hospital administrators who usually get a 'percentage of the profit,'" snapped one respondent who signed himself "a very bitter ED physician who tries to make a difference."

"The tragedy," mourned another, "is that what intuitively makes sense, not only in the context of patient safety and improving outcomes, but also from the standpoint of improving the bottom line, is considered forward thinking and progressive.... The tragedy of this tragedy is that real people will suffer and die as a result."

But there was one notable outlier from the nexus of negativity: the Veterans Administration. It received unwavering praise:

* "The VA is at the leading edge of technology and health care. Patient information generally follows the veteran around the system.... The use of view alerts, patient centric longitudinal data, and performance measures ensure the right information about the right patient to the right provider at the right time."

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* "If you fully involve yourself in the VA computerized record system, you would never go back to any other way of caring for patients."

* "The only health info system that I have experience with that works is the VA system. All the commercial systems are plagued with 'proprietariness' which sabotages communication."

* "The VA has developed one of the best computerized medical records and is an innovator in use of bar-coded medication administration. The software is in the public domain and free to hospitals that might wish to implement it. I personally don't understand why more don't do so."

* "The Department of Veterans Affairs is so far out in front on these issues, yet colleges and schools of medicine have not been particularly savvy in requesting that the VA share these technologies--especially since they would indeed be free!"

An active role

So what's the big take-home message from this first ACPE technology survey?

That, of course, is up to each interpreter. But here are a few final comments that suggest a consensus:

* "It will be impossible to practice in the future without the use of electronic systems, and true advancement in quality care (decreased error rates) cannot occur without these tools."

* "We have committed over $12 million to implement a (clinical information system). We have devoted a full time physician to (work) with physicians. This is absolutely the cost of doing business."

* "It's not about hardware and software, it's about people and process. Hence, we are embarking on an organization-wide clinical transformation process."

* "Key is to pilot, pilot, pilot. If the MDs won't use it or the program/device can't do what it is asked to do, more efficiently than pen and paper or the telephone/fax, it won't be used and workarounds and expensive paperweights will be the leftovers."

One chief medical information officer offered this succinct formulation: "Electronic health record systems are key to realizing our patient-safety goals and for managing health care costs in a rational manner.... Physician executives should take an active role in promoting and advocating for this important infrastructure for delivering health care in the 21st century."

Computerized Physician Order Entry (CPOE)

No development under way    349
Researching/Planning        527
Bidding                      72
Testing                     247
Already in use              364

2004 ACPE Health Care Technology Survey

Note: Table made from pie chart.

Personal Digital Assistants

No development under way    421
Researching/Planning        383
Bidding                      20
Testing                     158
Already in use              559

2004 ACPE Health Care Technology Survey

Note: Table made from pie chart.

Survey Participants Held These Titles or Positions

Department chair    159
Medical Director    506
YP or YPMA          245
CEO                  95
Board member         49
Professor            61
Other               356

2004 ACPE Health Care Technology Survey

Note: Table made from pie chart.

IN THIS ARTICLE ...

Results of the 2004 ACPE Technology Survey show physician executives and doctors in their organizations fall into two camps: those who loath technology and those who embrace it.

David Ollier Weber is a freelance health writer and frequent contributor to this journal. He can be reached by e-mail in Mendocino, Calif., at [e-mail]