Achieving Clinician Buy-in to Technology

Bryan Bergeron, MD

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In This Article

Introduction

Technology vendors, hospital information systems (IS) department heads, and clinicians who have come to rely on information technology to make their practices more effective constantly contend with clinicians who resist buying in to technology. This article discusses several models that decision makers can use to understand the phenomenon -- a prerequisite to achieving clinician buy-in as quickly as possible.

Electronic medical records (EMRs), personal digital assistants (PDAs), and transcribing systems based on voice recognition are examples of some of the information technologies that are having varied success in improving the practice of medicine. Despite decades and millions of dollars invested in EMR research and development, perhaps only 5% of US hospitals have fully integrated EMR systems.[1] Conversely, PDAs, introduced a little over a decade ago, are used heavily by many clinicians in their daily practice, for tasks from keeping track of daily appointments to tracking patient records. Similarly, continuous, large-vocabulary voice recognition is now an affordable, shrink-wrapped commodity, but is rarely used by clinicians for transcription purposes.

A marketing focus group would probably reveal that the reason for differences in adoption by clinicians is because these technologies are at different stages of development or maturation. For example, the PDA is typically viewed as a solid technology, with users ranging from medical students to hospital staff, whereas voice recognition, while affordable, isn't normally considered reliable enough for clinical use. Even 1 error in every 100 words is often unacceptable in a clinical document.

The Magic-Technology Continuum.

This source of resistance to technology adoption is illustrated by the Magic-Technology Continuum,[2] illustrated in Figure 1, which depicts a continuum of product development from inception to maturity. In this context, magic is a technology or process that isn't readily reproducible, that requires special conditions to operate, and that can't be easily duplicated. Most technologies start as ideas, some in the form of scribbles on the back of napkin. Following this inception, most ideas lay fallow, but some are brought to the prototype stage to demonstrate the technical feasibility of the idea, and some of these prototypes actually become products. Many products fail, but some are successful in the market, and manage to survive into maturity. Along this continuum, the proportion of technology to magic increases, where technology is a repeatable, scalable, solid product and magic is an unstable, unreliable, and often unknown quantity. As such, the certainty of the return on investment (ROI) for the clinician's time, money, and energy increases as the relative proportion of technology to magic increases.

Although this model provides a logical explanation of why clinicians might avoid a product until it has fully matured, there is much more at work. As an illustration of the complex interaction between clinicians and new technologies, consider the technologic and social evolution of the stethoscope, the status symbol of the healthcare profession that dates back to only 1816.

From antiquity to the beginning of the 19th century, clinicians listened to the chest (stethos in Greek) in the most direct way possible -- by placing an ear directly against a patient's chest. In 1816, the French physician René Théophile Hyacinthe Laennec needed to listen to the chest of a young woman to verify his presumptive diagnosis of heart disease but couldn't do so because social restrictions prevented him from placing his ear directly against her exposed chest. Determined to listen to her heart and lung sounds, in a flash of insight he rolled up a few sheets of paper into a tight tube, forming the first documented chest listening device. He put one end in his ear and the other on the woman's chest and was delighted to be able to hear the heart sounds -- much louder and more distinctly than before.

After his discovery, he rushed to the lathe in his workshop and crafted the first real stethoscope, in the form of a hollow wooden tube. He spent the next 2 years investigating and documenting its use in the diagnosis of various lung and heart conditions. His book on the subject, published in 1819, served to inform other clinicians on not only how to construct their own stethoscopes, but how to use them in practice as well.

Laennec's invention began a revolution in the very nature of medical practice, shifting it to the objective measurement of phenomenon and placing much less emphasis on the patient's memory of heart symptoms, which tended to be poor. Because of this fundamental change, other clinicians didn't immediately embrace the stethoscope. It wasn't until 1866, when the stethoscope was endorsed by Austin Flint, an outspoken clinician of the time, that it became accepted and soon thereafter came into widespread use. The current design, based on a metal, disc-shaped diaphragm, hasn't changed appreciably since 1910.

With the invention of the electronic amplifier in 1905, it was inevitable that the technology would be applied to the stethoscope. But acceptance of electronic stethoscopes for clinical use has been very slow. Companies that focused solely on their superior technology were asking physicians to give up their status symbol -- even if it did make subtle sounds more discernable. Manufacturers of the newest models of electronic stethoscopes address the status issue -- at least from the layperson's perspective -- by encasing their digital signal processing chips and amplifiers in a shell that looks, for the most part, like an ordinary stethoscope. These look-alikes have a disc-shaped chest piece and earpieces connected by what looks like an elastic tube. To other clinicians, however, the electronic crutch is clearly visible.

The history of the stethoscope demonstrates how the initial adoption rate by clinicians is constrained by prior experiences and personal beliefs, which affect individual and group behavior. These 2 views of clinician behavior -- 1 at the individual level and 1 at the group level -- are discussed below.

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