Like It? Yes. Need It? Yes. Buy It? Nah.

When it comes to information technology, only in healthcare and only with physicians does the word “adoption” assume extraordinary significance. Physicians in hospitals and in private practice constitute a bloc that doesn’t exist in other sectors. Single-handedly, they can make or break a newly introduced technology.

In an independent survey of 300 physicians, commissioned exclusively for HMT by San Mateo, Calif.-based Epocrates Inc., respondent physicians indicated that they understand and like clinical decision support (DS) information technology—saying it makes them better, safer practitioners and that it improves overall patient safety—but electronic prescribing has a way to go before it reaches the mainstream.

Thoughts on Patient Safety
The respondents constitute part of the Epocrates Honors® panel, a select group of practitioners who have agreed to provide the company with feedback about a vast array of information technology—devices, software and utilization. At one level, these physicians represent the onboard contingent: They are already IT supporters by virtue of their prior interest, and in some cases are users of Epocrates’ products. At another level, who better to say what works, what doesn’t and why than physicians who encounter IT every day?

Of the 300 respondents, 14 percent represented solo practices, 22 percent represented practices of two to 10 providers, 10 percent represented practices of 11 or more providers, and 22 percent were hospital based. The remainder represented a variety of physician types including administrators and medical educators.

When asked if they thought patient safety had improved since the Institute of Medicine’s report five years ago, all 300 physicians responded; 46 percent said yes, but 30 percent said they weren’t sure and another 24 per said no. When asked why not, only 72 physicians answered. Of that total, 43 percent said that patient safety has received “lots of attention, but little action.” Another 21 percent said the technology to fix the problems still doesn’t exist, and 18 percent cited lack of investment in healthcare.

By the same token, physicians were quick to cite ways in which patient safety has improved. Figure 1 shows that most physicians attribute the improvement to greater physician and hospital focus.

Figure 1
In what ways do you believe patient safety has improved? (n = 139)

Try It, You’ll Like It
Of all 300 respondents who answered, a solid 80 percent said DS software plays an extremely important or very important role in patient safety. No one thought it was unimportant, and only 4 percent thought it was just moderately important.

But not all decision support is created equal, and not every physician who responded to the survey is a decision support user. In fact, 59 percent of responding physicians said they use automated decision support tools, but a surprising 41 percent do not—and that, in itself, is telling. While many physicians are interested in healthcare IT—in the software’s functionality and promised benefits—interest doesn’t automatically create a purchaser.

When it comes to acceptance and adoption, automated DS tools are like electronic medical records and speech recognition systems: Clinicians who use the tools usually end up loving them, but those who aren’t fascinated by the tools to begin with often do not become users until a precipitating event occurs. Clearly, there is a hump in the adoption and usability curve. Once physicians get over the hump, they generally accept, adopt, advocate and then wouldn’t be without one or more pieces of software. But it’s a very steep hump, and not everyone cares about getting over it.

Of the 176 physicians who said they do use DS technology, an impressive 97 percent (171 physicians) said they can and do practice safer medicine because of it—no surprise there. Many of these physicians, nearly 75 percent, run their software on PDAs, while just over one-quarter of them run it on their office desktop systems. Nearly 100 percent of these doctors use their PDAs at least once per day, and nearly 60 percent use their PDAs more than 10 times each day. But what do they use their PDAs for? Figure 2 indicates that a substantial amount of PDA use is dedicated to support for clinical decisions.

Figure 2
What are the primary reasons you use your PDA? (n = 125)

One physician who makes the most of healthcare IT is Dr. Richard Glover II, of Axtell Clinic, associated with Newton Medical Center, in Newton, Kan. Glover says he has been using Epocrates decision support software for about seven years, and it “has really helped me in terms of carrying a source of knowledge with me to help make decisions and make sure they are accurate decisions.”

Axtell Clinic also began using Practice Partner Patient Records, an electronic medical record (EMR) application, from Seattle-based Practice Partner (formerly known as Physician Micro Systems Inc.) in May. Glover uses the e-prescribing component of the EMR and says the application also has a foundation of medication data, so he gets the best of two worlds with his collection of software.

Another physician who uses DS technology is survey respondent Neil M. Siegel, M.D., medical director of UniversityCare, affiliated with University of Maryland Medicine, and assistant professor of family medicine at the University of Maryland School of Medicine. He currently uses Epocrates decision support on a PDA and calls it a “wonderful product. It really does help when patients are on multiple medications. It’s ridiculous to think you can know every possible interaction.” He uses it as a reference to double-check and evaluate dosing and potential drug-drug interactions and says, “Patients really appreciate it.”

Reasons to Believe: Integration and Money
What about that 41 percent who said they do not use automated DS technology? They represent two out of every five respondents, and that’s a sizable percentage. What is stopping them?

When asked, “Why don’t you use decision support software?” 124 physicians responded—every physician in the 41 percent. Nearly one quarter of this total, 23 percent, said that DS technology doesn’t integrate with their current systems.

Nineteen percent of respondents felt that DS software is too expensive, while 18 percent said they had no time to investigate and purchase software, and 8 percent said they had no time to learn it. Surprisingly, though, a tiny 2 percent said they felt the software would be too hard to learn, and a small 6 percent said they thought it would slow them down.

Axtell Clinic’s Glover says physicians should be aware—making the most of DS and EMR systems initially can require a little more time and effort on their part. However, he views the time spent up front as an investment in future efficiency gains. Glover himself is immersed in making sure each of his patients has a comprehensive medication list electronically recorded, and that takes time, but he adds, “Once that’s done, the amount of time I have to spend will be much less than in the past.”

All 300 physicians who responded to the survey answered the next question: What do you think it would take to get more physicians using decision support software tools (Figure 3), and they were very clear in their assessments—systems integration and more competitive pricing. More than a handful of these physician respondents also are interested in someone else helping to defray the cost, be it government, payers or hospitals.

Figure 3
What do you think it would take to get more physicians using
decision support software tools? (n = 300)

The e-Prescribing Paradox
Electronic prescribing and drug database software are related yet different animals. While the foundation of formulary, drug database and diagnosis-related software is encyclopedic in nature, the actual use of the software seems to demand little from the end-user other than pointing, tapping and exercising a healthy curiosity.

Not so with e-prescribing. The call to action with e-prescribing is clear and definite. Pointing, tapping and clicking may remain the same, but issuing an electronic prescription remains different than researching a question. Issuing an e-prescription is a user-initiated action. The physician might employ automated DS software to arrive at one of two or three possible conclusions about a medication. But to many physicians, the actual writing a paper prescription, handing it to the patient and noting that drug in a patient record is infinitely easier than pointing, tapping and clicking to generate the electronic version and transmit it to the pharmacy.

Nearly every physician who responded to the survey supports e-prescribing; 16 percent say it is an extremely important part of patient safety, 39 percent call it very important and 33 percent label it important. Only 4 percent of the total—12 doctors out of 300—said it is unimportant.

“[Decision support software] has really helped me in terms of carrying a source of knowledge with me to help make decisions and make sure they are accurate decisions.”

—Richard Glover II, M.D.
Axtell Clinic

As always, the proof is in the pudding—except when it comes to e-prescribing, there is minimal pudding. A surprising 72 percent of responding physicians—nearly three quarters of all respondents—admit that they don’t use e-prescribing technology. The 85 physicians who do use it like it, and more than 90 percent of those physicians say the technology enables them to practice safer medicine, but users were a clear minority in this survey.

UniversityCare’s Siegel surmises, “For anything new or different, some people are going to jump right in, some people are going to hang back a little, and some people are going to hang back too long. It’s hard to judge when you are being prudent and hanging back wisely, and when you are being a stick-in-the-mud.” Although Siegel’s affiliation is with a large enterprise, he says, “It’s very scary, if you’re in a small practice, to sink a large investment in both dollars and time resources into something that may be obsolete in just a couple of years.”

Figure 4 shows that e-prescribing software faces some of the same challenges and hurdles as DS software, but in larger doses. More than 200 physicians answered the question, “Why don’t you use e-prescribing software?” Their answers point decidedly in two directions: efficiency and integration.

It’s All About (Efficient) Me
Efficiency is a critical factor in physician adoption. In years of publishing case histories featuring physicians, HMT has learned time and again that physicians value software only if it makes them more productive in less time.

Conservation of time figured prominently in two survey questions that HMT designated as most significant. Figure 5 shows the perceived benefits that physicians have experienced from e-prescribing software. While benefits related to patient safety and reduction of medication errors figure prominently, the hands-down winner on the e-prescribing benefit roster is efficiency. IT that improves workflow and saves time is IT that could be purchased.

Glover from Axtell Clinic puts a premium on time savings, along with patient safety. “In the past, when a patient called me, I had to call for his chart and then check on his medications. Now I can pull it up immediately on my tablet, at the hospital or at home. Then I’m able to pull up the prescription and renew it, and I have a record of exactly when I sent it and how many refills. It takes so much less time and effort, and there is less chance of making errors.”

Time is also a critical factor for the 215 physicians who do not use e-prescribing software, too. When asked, “Why don’t you use e-prescribing software?” 33 percent said e-prescribing software wouldn’t integrate with their current systems, but an additional 29 percent cited time-related reasons. Of that total, 14 percent said they had no time to buy software, 8 percent said they had no time to learn the software, and 7 percent were convinced it would slow them down.

Time is exactly why Dr. Amy Starr of Trinity Pediatric Clinic in Tyler, Texas, likes using an EMR with e-prescribing functionality. Her practice has used the GE Centricity EMR for three years, and she values the ability to access patient data in the office, at the hospital and from home. She says the system is a tremendous help when she is on call, handling queries from the patients of other physicians in the practice, because she can view each child’s treatment history and medications. The system includes decision support for medications, if she needs to question or change a medication.

“Electronic prescribing is fast. Once you enter a drug, you just pull up the drug, hit a button and it prints my script, so I don’t have to hand-write it.”

—Amy Starr, M.D.
Trinity Pediatric Clinic

The speed of e-prescribing is exactly what Starr wants, and in fact, she wants more. “Electronic prescribing is fast. Once you enter a drug, you just pull up the drug, hit a button and its prints my script so I don’t have to handwrite it. It shows exactly what drug is involved, the dosage and how the patient should use it.” Handling refills is a snap, she says, and she looks forward to the future when “We’re going to have a fax server, so instead of printing the prescription, it will fax the prescription to the patient’s pharmacy of choice. It’s fabulous. We have seen what it’s done in our practice.” She plans on gaining even greater efficiency once the printing step is eliminated.

Leveraging the Investment
Physicians who have already invested in healthcare IT don’t want to spend more than necessary on new systems, and they certainly don’t want to sacrifice previous investment. When asked what it would take to get more physicians signing on to e-prescribing and automated medication management tools, 65 percent said more physicians would try the tools if they integrated more easily with IT systems currently in use. Literally right behind that response was 64 percent of physicians who said lower cost software would help increase adoption.

That’s not all. Greater industry standardization was cited by 57 percent of responding physicians, while 53 percent wanted products that are easier to use, 50 percent wanted lower cost hardware and 39 percent wanted financial subsidies from payers. Interestingly, 14 percent of physicians thought patients’ interest in e-prescribing was significant and only 13 percent thought that a government mandate might be a motivational factor.

UniversityCare’s Siegel is fortunate. As part of a large university and medical school, he benefits from having an equally large IT department to test, dissect and evaluate numerous EHR systems (with e-prescribing components) for possible purchase and implementation within the next year or two. But as the medical director for a moderately sized practice with four office locations, he is closer to the due diligence process. “I can’t justify the budget to get e-prescribing software and hardware, and then teach people how to use it, only in one or two years to turn around and have a [different global] system that we have to start using,” by virtue of their university affiliation.

For now, Siegel hangs back, watches and assesses. He says a couple of teaching colleagues tried e-prescribing with mixed results and eventually abandoned the software. He remains enthusiastic but judicious.

Maybe acceptance and adoption work in waves. Five years ago, EMRs were nouveau; today they’re inevitable. Decision support—drug databases, medical reference texts and evidence-based guidelines—become more everyday every day. Perhaps e-prescribing just needs to get in line and wait its two-to-five-year turn for acceptance, adoption and evangelism.

Although doctors want efficiency, time-savings, better integration, bigger bang for the buck and more bucks from external sources, one factor remains constant: All doctors want to provide the best patient care possible. From Axtell Clinic, Glover continues to herald EMRs, DS and e-prescribing technology. “Patients have been extremely impressed with…us as a progressive and efficient clinic. I think [information technology] makes you a better doctor, in terms of managing your patients’ care.” For everyone, that’s the right bottom line.