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Barriers That Impede the Adoption of Pediatric Information Technology
Kevin B. Johnson, MD, MS
Arch Pediatr Adolesc Med. 2001;155:1374-1379.
ABSTRACT
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Background Information technology (IT) is a critical but underused component of
health care. Many factors contribute to the inconsistent adoption of IT.
Objective To review the literature to better elucidate barriers that are likely
to affect the adoption of IT by pediatric professionals.
Data Sources Manuscripts were found using a MEDLINE search combining the terms medicine, information systems,
and technology transfer. I also obtained references
cited by relevant articles. Finally, I explored the Internet using http://www.google.com and http://www.northernlight.com.
Study Selection Articles discussing barriers or factors affecting the adoption of IT
were considered for inclusion. Articles unrelated to clinical IT were excluded.
Data Synthesis A variety of barriers exist that affect the adoption of useful technologies.
Situational barriers include challenges imposed by the current national health
environment, financial and legal risks associated with technology purchasing
and use, and access to technology. The most significant barrier is that pediatric
health care practitioners may lack the knowledge or training to use IT effectively.
Conclusions Although some barriers exist that may be challenging to overcome, other
barriers, such as the lack of knowledge about the uses of IT, are imminently
solvable. Efforts to overcome these barriers should begin in earnest and should
include educating stakeholders in the care of children and adolescents, as
well as improving the knowledge about various technologies available to support
pediatric and adolescent health care.
INTRODUCTION
THE FIELD of medicine is replete with revolutionary information technology
(IT) that may support children's health. However, these tools are not disseminated
into most practitioners' offices. For example, despite the presence of electronic
medical records in health care since the 1970s, between 3% and 20% of US physicians
use this technology1, 2, 3, 4, 5
compared with a much higher penetration of this technology among general practitioners
in other countries.6 The poor penetration of
IT contributes to the large number of laboratory tests (estimated at <11%)
that are reordered because of lost results, as well as the roughly 30% of
treatment orders that are undocumented.5 As
stated by the Committee on Quality of Health Care in America of the Institute
of Medicine,
A highly fragmented delivery system that largely lacks even rudimentary
clinical information capabilities results in poorly designed care processes
characterized by unnecessary duplication of services, and long waiting times
and delays.7(p3)
The reasons for the slow adoption of technology into pediatric practice
are varied. This article will examine the barriers that are of special significance
to pediatric health care professionals (PHCPs).
A CONCEPTUAL FRAMEWORK FOR UNDERSTANDING BARRIERS
Barriers may be grouped into 4 categories, as described by Knapp8 and modified for a discussion of information systems
issues by me:
- Situational—economic
realities and external environmental factors affecting access to or use of
technology.
- Cognitive and/or Physical—insufficient
skills or ability to use a technology.
- Legal—regulated
or unregulated practices that affect use of a technology.
- Attitudinal—behaviors
or opinions contrary to those needed to adopt a technology.
I conducted a literature search using a MEDLINE search combining the
terms medicine, information systems, and technology transfer. The resulting references
were included in this article if they discussed barriers to the use of technology.
I also obtained references cited by relevant articles. Finally, I explored
the Internet using http://www.google.com and http://www.northernlight.com and categorized the included references according to the framework
above.
Table 1 summarizes the prevalent
barriers mentioned in the medical and pediatric literature that are significant
in pediatric practices. This table also references articles from the pediatric
literature that identify specific barriers. Because the actual pediatric literature
on barriers is limited, this discussion will reference literature from other
areas of medicine that, in my opinion, augment the discussion of barriers.
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Table 1. Summary of Barriers to the Adoption of Information Technology
(IT)*
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CHALLENGES INHERENT IN THE US HEALTH CARE SYSTEM
To many medical "insiders," the inconsistent diffusion of useful technologies
is, in large measure, a by-product of problems in our health care system.
These problems include working in a delivery system that rewards time efficiency
more than the quality of care provided, and incurring the financial burden
of costly IT with a limited potential for return on investment.9, 10
Time pressure represents the most significant barrier to the adoption
of potentially useful technologies. Today's PHCPs spend an average of 17 minutes
per patient encounter and are reimbursed based on the time needed by each
patient (J. Speller, MD, written communication, May 10, 2001). Moreover, they
face an ever-increasing overhead per visit—more forms to complete, more
regulations to adopt, and more time spent with insurers advocating for patients.11 Studies have shown that time pressure clearly affects
the tolerance of providers for technologies such as immunization registries
and computer-based documentation tools.12, 13, 14
Furthermore, IT is neither a one-time nor a low-risk investment. The
sources of this risk include the financial cost of these systems to a practice
or a payer and the uncertain cost-benefit tradeoff of individual systems.15, 16, 17, 18 Even
proven technologies, such as practice management systems, represent a large
capital investment with a low initial rate of return relative to other investment
alternatives for the busy practitioner.9 Many
knowledgeable IT professionals are dissatisfied with the software they purchased
for their health care providers.19, 20
The diversity of our health care environment, in terms of policies, practice
styles, and revenue-generating activities makes it difficult to achieve consensus
about what or how technology should be applied to the field.13, 21
Therefore, the diffusion of potentially beneficial technologies moves slowly,
resulting in islands rather than waves of IT adoption.
INSUFFICIENT COMPUTER PENETRATION INTO PEDIATRIC PRACTICES
About 80% of pediatric practices have Internet access.12
Despite this, only 5% of ambulatory care practices use computer-based patient
records.2 Access to IT is influenced by the
financial situation, the location of the practice (rural vs urban),5, 22, 23, 24 the
size of the practice,25 and the average age
of the PHCPs—with older PHCPs less likely to have access to (or comfort
with) technology.26 Other environmental barriers
that are critical to primary care practices include the expense of systems9 and the cost of training personnel and customizing
systems for a PHCP-based practice.27
COGNITIVE AND/OR PHYSICAL BARRIERS
Many PHCPs have had to learn to use IT without the benefit of formal
study. For example, many PHCPs continue to struggle with using MEDLINE.28 When surveyed, PHCPs identify a lack of IT training
as a major barrier to using technologies they consider valuable.29, 30, 31
CONFIDENTIALITY CONCERNS
The adoption of IT often is impeded by questions about liability associated
with the dissemination of information, as well as concerns about what balance
between security and access is acceptable to consumers.12, 16, 32, 33
Concerns about security, patient confidentiality, and liability have affected
the PHCP's confidence in using e-mail to communicate with patients (T. Houston,
MD, personal communication, 2000).34, 35, 36, 37
KNOWLEDGE AND ATTITUDINAL BARRIERS
Perhaps the importance of this area is best summarized by Nancy Lorenzi
and Robert Riley, PhD:
As our new systems affect larger, more heterogeneous groups of
people and more organizational areas, the major challenges to systems success
often become more behavioral than technical . . . . A "technically best" system
can be brought to its knees by people who have low psychological ownership
in the system and who vigorously resist its implementation.38(p116-117)
People in this context include patients, parents, PHCPs, and other stakeholders
in the enterprise. Their lack of ownership may be due to a variety of factors,
including a lack of insight about the benefits of IT, their concern about
the magnitude of change caused by IT, and their ambivalence about the processes
that IT is designed to improve. Finally, PHCPs tend to embrace IT solutions
in health care that result in at least 1 of 3 benefits: more time, more money,
or a higher quality of care for their patients.12, 25, 39
LACK OF INSIGHT ABOUT THE BENEFITS OF IT
Caregivers who are not informed about the capabilities of IT may discourage
or fail to support its use.40, 41
For example, one study of children invited to participate in an electronic
support group found that some children accessed the site less frequently because
their parents were unaware of how they were using the Internet.42
The lack of knowledge about what is available on the Internet has affected
the PHCP's perceptions of the value of that tool.12
Similar misconceptions have affected the use of computer-generated visit reminder
cards in pediatric practices.17
APPRECIATING THE MAGNITUDE OF CHANGE
In busy pediatric practices, seemingly minor changes—changing
the form on which growth curves are plotted—may result in larger systemwide
effects, such as teaching PHCPs and patients about the body mass index, or
deciding whether to copy old patient information onto the new form. This low-techology
example begins to scratch the surface of what PHCPs face with even small IT
modifications in a busy practice. The magnitude of these effects may lead
to indecision, or worse, a wrong decision.43
Primary care physicians also may be less enthusiastic about the pace with
which benefits are realized after implementing IT. For example, physicians
have found that new systems result in increased patient waiting time and staff
workload for a while after the system is implemented.44
OVERCOMING BARRIERS
It is clear that some of the barriers, such as the impediments to home
and office computer access, may be out of the immediate control of the stakeholders
in health care, while others, such as the lack of knowledge about existing
policies and laws, are easily remedied. Table 2 summarizes possible strategies to overcome each barrier,
using the conceptual framework described herein. Adoption of ITs may be improved
by providing education about IT, additional research addressing barriers and
benefits of IT adoption, IT advocacy by experts, and collaborations among
professional societies and other stakeholders.
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Table 2. Overcoming Barriers to the Use of Information Technology (IT)
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EDUCATION
Pediatric health care professionals, patients, parents, and insurers
need to be educated about a variety of topics, ranging from overcoming situational
barriers (obtaining grants and loans to gain access to IT) to understanding
the true risks and benefits of IT in health care. Educational initiatives
targeting PHCPs and patients are among the first steps that should be taken
to eliminate barriers. As we understand more about the risks and benefits
of these technologies, we should identify approaches to disseminate this knowledge
and to enlighten both our target audience and ourselves about the issues that
are of concern. Pediatric health care professional education is best conducted
through both risk management forums in local areas and continuing medical
education offerings. Continuing medical education courses should be developed
that teach not only computer literacy skills but also cover issues such as:
- Confidentiality and security of information on the Internet, as
well as existing policies affecting the use of IT in medicine, such as the
Health Insurance Portability and Accountability Act45
- Benefits of adopting specific IT tools, such as computer-based
patient records e-mail, electronic prescribing, or immunization registries,
even in a time-pressured environment
- How to evaluate IT solutions for "your" practice
- Where to learn more about IT in medicine
Of note, the Section on Computers and Other Technologies of the American
Academy of Pediatrics receives accolades for its annual "Pediatric Office
of the Future" lectures held each fall. This lecture series is one of the
few objective venues available to the PHCP interested in learning about office
automation.
Many professional societies already have a strong commitment to IT.
Through continuing medical education courses, seminars, position statements,
scientific meetings, patient education materials, and advocacy, these groups
can provide a foundation that improves the "comfort zone" of potential adopters
of IT. Furthermore, their policy statements and advocacy initiatives will
help to educate stakeholders about various publicized issues, ranging from
improvements in office efficiency through IT to practical considerations when
implementing an electronic medical record.46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59
Although not widely known by most pediatricians, there are special peer-reviewed
journals and proceedings that often publish evaluations or demonstrations
of IT in medicine. The Web site of the American Medical Informatics Association
(http://www.amia.org/) includes a resource center that contains
a bibliography of recent articles from many of these specialty journals. Unfortunately,
it is unrealistic to assume that the overworked, underpaid PHCP will seek
out these journals or browse the Web looking for this evidence base. Rather,
to aid in the dissemination of new knowledge to PHCPs, pediatric core journals
should become familiar with the study of IT and should encourage the submission
of quality research from leading conferences such as the American Medical
Informatics Association Symposium. Articles published in pediatric journals
should be about subjects or contain data that are most relevant to PHCPs,
and may be more likely to result in organizational change than articles that
are published in journals with which PHCPs are less familiar.
The actual literature describing barriers that are unique to PHCPs is
limited. As we encourage more adoption of IT, there is much to learn from
both our successes and failures.60 Therefore,
we must encourage the publication of both successful and unsuccessful initiatives.
Journals such as the ARCHIVES and other American Medical Association publications
have been instrumental in disseminating medical informatics articles. Continued
effort within these pages and those of other journals is a critical step to
overcoming many of the cognitive barriers I have outlined.
Various professional and national groups already provide seminars and
workshops about the use of IT in medicine. Table 3 lists a few of these organizations. Their Web sites contain
information that is informative, up-to-date, and relevant to all PHCPs. We
should make PH CPs aware of these opportunities, and provide incentives (such
as continuing medical education credit) for attending these sessions.
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Table 3. Important Information Technology Organizations
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RESEARCH
A possible reason for the shortage of publications in pediatrics is
the dearth of informatics researchers within the pediatric community. Given
the unique needs of pediatric patients, it is most likely that only PHCPs
will conduct evaluative or observational studies of IT implementation projects
that will provide our specialty with generalizable results.
Researchers should address the following questions:
- What are the knowledge, attitudes, and behaviors
of PHCPs with respect to IT?
- What are the perceived barriers to the adoption
of IT by PHCPs in both academic medical centers and private practice? Is the
lack of time, lack of money, or lack of knowledge the key barrier to overcome?
- How prepared are today's IT tools for use by PHCPs,
and what future changes are needed in these tools?
- How should the curriculum of pediatric residencies
be modified to improve knowledge about IT and its role in children's health?
- What is the current state of adoption of IT by
PHCPs in both academic medical centers and private practice?
- What are the benefits and costs of using IT in
academic or private care facilities?
We must encourage academic PHCPs to evaluate IT in pediatric settings.
Of course, to carry out this research, funding needs to be available, or funding
agencies need to focus on the area of medical informatics. One of the biggest
challenges facing any researcher is how to garner financial support for important
projects. In addition to consulting the National Institutes of Health guide
(http://grants.nih.gov/grants/guide/), PHCPs interested in conducting
technology research should consult pharmaceutical, laboratory, and IT vendors—all
of whom may be able to provide support for focused efforts. Managed care companies
typically operate with a lower capital reserve, and may be less likely to
fund research unless it directly affects their revenue recovery or results
in obvious cost savings. Philanthropic organizations that have an interest
in children's health may be wonderful allies, but it is important to understand
the goals of the organization by reading their annual report, reviewing their
Web pages, and sending a letter of inquiry to the organization before seeking
funding in most cases. Finally, commercial organizations that cater to children
may have limited funds for projects. Nintendo Inc represents one such organization.
Many other sources of funding may be found by searching the Internet.
Occasionally, as has been the case for many Third World medical projects,
support of this kind funds not only a research question but also enhancements
to the infrastructure of participants. These sites can then become models
for other projects. People who work in these sites can become knowledgeable
about technology—furthering the educational mission while conducting
important research projects.
Groups such as our national pediatric practice–based research
network (PROS [Pediatric Research in Office Settings]) represent a marvelous
untapped resource for IT research. The PROS practitioners are highly motivated,
though extremely busy pediatricians. Furthermore, they have an identified
need for IT, both to improve communication with research investigators, and
to facilitate the projects themselves.50, 60
They are uniquely positioned to conduct research designed to improve the usability
and adoption of computer technology in ambulatory settings.
IT ADVOCACY
In concert with increasing the awareness about the benefits of IT, we
need to establish a network of IT advocates who can facilitate the movement
of more apprehensive colleagues with the help of other groups. The Section
on Computers and Other Technologies of the American Academy of Pediatrics
(http://www.aapscot.org), and the Medical Informatics Special Interest
Group of the Ambulatory Pediatrics Association (http://www.ambpeds.org) are 2 small groups of IT advocates in pediatrics, but these groups
are not yet in a position to fulfill this role at a regional level.
An IT advocacy network also could help PHCPs and patients find resources
such as http://www.digitaldivide.gov, or federal initiatives that
can fund the adoption of technology.21 Efforts
to publicize these sorts of resources may be most easily accomplished through
an IT advocacy network. Often, the role of an advocate may be as simple as
providing reassurance that one can trust the salesperson at a local computer
store, helping a colleague sign a maintenance contract on his or her computer,
letting a group of interested PHCPs know about resources available on personal
digital assistants, or recommending a Web site that will be of particular
interest.
Recent approaches to connect PHCPs and patients promulgated by groups
such as Medem (http://www.medem.com) and Beansprout (http://www.beansprout.com) may represent a trend that enables the adoption of IT solutions by
PHCPs that otherwise could not afford these tools.12
These small steps often reap large dividends in encouraging the adoption of
new technology.
COLLABORATIONS WITH STAKEHOLDERS
Professional societies such as the American Academy of Pediatrics and
the American Academy of Family Physicians have assumed a leadership role in
taking steps to promote the adoption of IT. These societies also have begun
to collaborate with industry, government, and consumer leaders. Collaboration
among industry, consumer groups, and professional societies is critical both
to short-term successes—such as improving the capabilities of existing
IT products for PHCPs—and for longer-term goals, including the sorts
of goals promulgated by the Leapfrog group,61
the Institute of Medicine,5, 7, 62
and our professional societies.55, 56, 57, 58, 59, 60, 61, 62, 63
Finally, these efforts should remain visible to the constituents of these
societies, whose knowledge and attitudes about IT may be altered simply by
witnessing the efforts undertaken by supporters of IT within their specialty.
CONCLUSIONS
Pediatric health care professionals have many reasons to adopt IT; however,
barriers both in and out of their control continue to slow the dissemination
of these advances in medicine. Educating PHCPs, conducting research targeting
issues of importance to PHCPs or stakeholders, and advocating for IT use and
understanding are important steps to improve the implementation of these tools.
This is the last article of a 3-part series the first
two of which were published in the September and October issues of the ARCHIVES.
AUTHOR INFORMATION
Accepted for publication August 13, 2001.
Presented at the Expert Meeting on the Information Technology in Children's
Health Care: Beginning to Ask the Needed Questions, conjointly sponsored by
the Agency for Healthcare Research and Quality and the American Academy of
Pediatrics Center for Child Health Research, Rockville, Md, September 21,
2000.
What This Study Adds
To my knowledge, to date, there have been no reviews summarizing what
stifles the adoption of IT by PHCPs. This article summarizes the findings
of other studies that have deployed IT. I also suggest some strategies that
pediatricians, as stakeholders in the provision of health care, should support
or use to help overcome many of the barriers described in the article. Finally,
for those readers interested in research in the field of medical informatics,
this article exposes some of what is not yet understood about barriers, and
suggests areas in which well-designed studies would result in valuable contributions
to the current body of knowledge about overcoming barriers.
From the Department of Pediatrics, The Johns Hopkins University School
of Medicine, Baltimore, Md.
Corresponding author and reprints: Kevin B. Johnson, MD, MS, The
Johns Hopkins University School of Medicine, Children's Medical Surgical Center
140, 600 N Wolfe St, Baltimore, MD 21287 (e-mail: kjohnson{at}jhmi.edu).
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