Get Real: What will Draw Physicians to the Web?
* Information Technology (IT)
* The Promise of the Internet
* Physician Reluctance to Embrace Technology
* Obstacles to Adopting New Technologies
* Improving Physician Acceptance of New Technologies
* Increasing the Rate of Adoption
ASK MOST HEALTH care industry pundits and they will tell you they are convinced that information systems technology and the Internet will change how physicians practice medicine in their offices and in hospitals. Everybody loves the Web...everybody except physicians. [1,2,3]
Many physicians use the Internet, but mostly to search databases for medical information or for personal activities, like stock transactions or travel information. Although there is significant Web-enabled or Web native innovation around programs for practice management, clinical and business record keeping, and patient communication, physicians are surprisingly slow to adopt these products in their practices.  The application of new technologies has not spread extensively. Except for the 10 to 15 percent of physicians who are the early adopters of technology, the rest of us are waiting.  What are physicians waiting for? What will it take to stimulate widespread adoption of Internet medical systems?
Despite the downturn in technology stocks and the cooling of venture capital interest in Internet-related products, there is still a steady stream of new web-enabled offerings being presented to physicians to improve the efficiency of their practices and clinical care of patients. PC-based, Web-enabled, ASP, or handheld, these products offer a wide array of potential services from connectivity to payers for eligibility and authorization to prescription management and communication with pharmacies and a variety of electronic medical record systems for the doctor's office. The rationale for most of these products seems strong. The mass media and industry press are full of stories about their successful adoption by individual physicians. The stars are aligned, but adoption is slow. 
There is a great deal at stake in the speed and scope of acceptance of these new technologies. If health care services are to be improved at lower cost, adopting these technologies offers a promising tool for efficiency and standardization of process that can lead to improved clinical outcomes and increased patient and physician satisfaction. [7,8]
How can health care leaders and physicians help the technology innovators and the executives of new technology firms understand the components necessary to assure physician acceptance and utilization of the new tools? Here is some advice.
* Don't underestimate the personal nature of a physician's practice. It really isn't a "business." The average physician doesn't examine and modify his or her practice based on objective business-like evaluations and interventions. It's personal. Their practice is their identity; an extension of their "self." So, it doesn't help to start a sales presentation to a physician with the idea that "this product will make you more efficient" or "this will help you avoid making errors." Who says I'm inefficient and incompetent?! Better to start with something we agree on.
* Most physicians are not Luddites; they are just extremely pragmatic and practical. It is vital to address perceived need, not future predicted benefits. Physicians are wary and jaded, given past predictions about how computer applications were coming that would improve their practice and enhance clinical interventions. A lot of these predictions didn't pan out. 
* For the majority of physicians to adopt a new technology in their private office practice, that technology must address three major issues: (1) money, (2) hassle, and (3) patient care. And the benefits had better come in pretty much that order.
The three issues technology must address
The uproar in the health care system has led to physicians feeling undervalued and underpaid. The pressure to maintain income levels is motivating most physicians in office practice to see more patients and generate more revenues, at the same time that collections from office practice are declining, both in prepaid and fee-for-service payment systems. This is the part of their business that physicians see most readily.
If you want to get a physician's attention immediately, show him or her something that will increase billings, convert non-pay to full pay, improve collections, decrease the delays in payment, or assure payment before services are delivered. This is the front end to the business process in medicine. This is the connection to the payer, to the intermediary, to the bank. This involves the practice management system sub-functions of registration and eligibility, authorization for diagnosis and treatment, contract terms and pricing, claims submission, and claims payment.
If the technology is a replacement for other physician work, is the new work reimbursable? Asking physicians to take on tasks that don't generate revenue, absent other very impressive benefits, is a difficult sell. Few of these incentives exist to encourage physicians to adopt new technology.
Cost reduction in the practice comes in second to revenue generation, but is still important, given certain caveats. Can this system really, actually, and measurably reduce costs in the practice? How can you prove that to me? How is deploying this new technology going to decrease my cost of doing business in the short term? How will I know? Are examples of these savings referenced from other physicians like me, in my specialty? If this helps me to do more with fewer staff, does that mean that I have to do more in return?
The state of medical office automation is not strikingly uniform or complex. Most physicians do not and have not invested a great deal of money on office management systems, patient billing, or computer-based patient record keeping. From the average primary care physician's perspective, many of the innovations proposed are too expensive. The cost of systems integration and adoption in time, staff training, lost visits, and capital is more than a trivial item. Such efforts have been infrequent in most physician offices and are an unfamiliar process to physicians and their staff. They may not have confidence that they can manage the process successfully and are usually unwilling to pay for outside help.
Physicians are increasingly frustrated and fatigued by the increasing patient loads and feel overwhelmed by the burden of record keeping and administrative tasks that they or their staff have to deal with. Time is the most precious asset.
All physicians have a set of value-based rules about how they should practice and their professional and personal role in care delivery. Laws and regulations also codify many of these rules. Changing business process steps in an office or clinic practice involves not just logic, but habit and assumptions-- most of which are unconscious. These steps may appear cumbersome and inefficient (to an outside observer's view), but they are familiar. Changing the familiar comes hard to all of us.
But many practice administrative tasks are frustrated. Prescription refills, outside phone calls, managed care authorizations, utilization review, and record-keeping details can suck up time and energy without much benefit to the physician. Better ways of dealing with these necessary evils in the practice are often welcome. The physician, given attention to rule #1, will embrace new technologies that expedite these tasks. Such systems must also show that they measurably reduce the time required for the tasks without shifting the burden to other staff or surprising the physician with extra work, while assuring that the work is completed professionally and accurately.
Physicians' prime professional motivation is superior patient care. Many new technologies are designed to address aspects of care delivery or coordination that can improve patient care outcomes and standardize treatment. Information systems, Internet-based or freestanding, will change how physicians practice medicine and address complex patient problems.
Unfortunately, most physicians will not adopt a new technology "just because" it might allegedly improve patient care. This isn't because they are bad or ignorant. Embedded in familiar processes, physicians don't always see the systematic obstacles to patient care, where optimal care is increasingly defined as a process of care standardized on best practices and routine systems or procedures. They are doing the best they can, and the best they know how, in a system that doesn't support error free or consistent interventions. But remember, this is how physicians have been trained and socialized--a solo expert is responsible for care.
Physicians are reluctant to adopt electronic medical records (EMRs) or other care management systems in isolation from other significant benefits. They will only adopt EMRs as the consequence of other interventions in medical practice that address the benefits to practice economics and simplify tasks.
Additionally, physicians are concerned about the security of information, especially when using the Internet. They treasure the privacy and uniqueness of the physician-patient encounter.  The ubiquity and public nature of the Internet and the mysteries of other information technologies challenge these values. They are reluctant to use such systems until they can be assured, perhaps guaranteed, the safety of patient record information storage and retrieval, as well as appropriateness of their transfer and release. Some part of this reluctance is also related to the transparency of such information for potential malpractice litigation.
Patient e-mail is another example of physicians' reluctance to adopt beneficial technology and represents the collision of values between physicians and their patients' expectations. Most surveys indicate that more than 35 percent of patients would like to communicate with their doctors using e-mail. "Patients are intimidated by the dense technicalities of health plans and frustrated in trying to speak to their doctors."  Meanwhile, only about 10 to 13 percent of physicians are willing to use such systems.  Although most physicians are using e-mail for other purposes and about 80 percent claim their offices have Internet connections, they are generally not eager to begin e-mail correspondence with patients despite demand.
The reasons cited most often for this resistance are security and malpractice concerns. These are important, but, behind these stated concerns, physicians are worried about other issues too. They believe that e-mail with patients will increase their workload. They are afraid they will he overwhelmed with new, unfamiliar work. They are perplexed by the vagaries of such communication in the absence of the face-to-face contact and the proven information richness of the traditional patient visit. They estimate that they will lose revenue, either because of the time spent on e-mail detracting from other visits, or because this service isn't reimbursable. 
Innovations that promote or rely on patient-physician technological communication will have to address security, ease of use (like typing versus voice recognition), transparency, and appropriate reimbursement.
"The information technology revolution, exemplified by the expansion of the Internet, promises to shift the U.S. health care delivery model."  Most physicians are hopeful that this prediction will come true. But there are many obstacles to adopting new technologies that are the result of physician training and expectations and the current models of payment and revenue generation. In addition, some of these technological inn ovations are presented to physicians without sufficient respect for their knowledge of how medical practices really work. The benefits promised often don't match with the needs structure of the physicians. As a consequence, the cycle of diffusion of these new systems is extended and delayed.
To get physicians to adopt the new Internet tools, let's meet them where they are. They're waiting.
Michael B. Guthrie, MD, MBA, FACPE, is Executive Vice President of Premier Practice Management in San Diego, California.
(1.) Editorial. Doctor Apathy Stalls Dot-coms. American Medical News. September 11, 2000.
(2.) Chin, T. Physician Apathy led to WebMD's Downturn. American Medical News. November 23, 2000.
(3.) Chin, T. E-Health Fails to Fulfill Promise. American Medical News. August 21, 2000.
(4.) Physicians Unimpressed by 'E-Health.' WebSurvevMD.com. July 12, 2000.
(5.) Chin, T. The Plugged-in crowd. American Medical News. November 13, 2000.
(6.) Roniger, L.R. Learning to Love the Web. Healthcare Business. July 2000.
(7.) Goldsmith, J. How will the Internet change Our Health System? Health Affairs. Jan/Feb 2000, 19(1): 148.
(8.) Terry, K. The E-Train is coming at You. Medical Economics. December 9, 1999.
(9.) Basch, P. To Find Killer App, Look Deep into how Physicians Practice. Letter to the Editor. American Medical News. November 6, 2000.
(10.) For an excellent, more detailed description of the value of this interaction, see Kassirer, J. Patients, Physicians, and The Internet. Health Affairs. Nov/Dec 2000, 19(6): 116-119.
(11.) Medem Survey. May 2000 (Reported by Healthdatamanagement.com, Nov. 6, 2000).
(12.) As this is being written, several smaller health plans are experimenting with reimbursement for patient e-mail consultations.
(13.) Fried, B., Weinreich, G., Cavalier, G., and Lester, K. E-Health: Technologic Revolution Meets Regulatory constraint. Health Affairs. Nov/Dec 2000, 19(6).
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|Author:||Guthrie, Michael B.|
|Date:||Mar 1, 2001|
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