Kevin Koch, M.D., agrees with technology vendors who say their products will change the way he practices medicine. He just doesn't think the change will be for the better.
Why? Take the last time the Merriam, Kan., doctor tested an electronic patient record system for the 11-physician emergency medicine practice he heads. It was based on voice-recognition software, which allows physicians to enter data by talking instead of typing. The test did not go well.
"Every time I kept dictating, 'breath sounds,' it dictated, 'breast sounds,' " Koch says.
With results like that, Koch has no plans to purchase any sort of electronic patient record system. He's not even convinced a billing system his practice installed about six years ago is doing much good.
"I've seen examples where we have discharge plans for patients after they've been treated in the ER . . . and for nursing personnel, it would take them 15 to 30 seconds" to put the plans together, Koch says. "Now we have a computer program that looks a lot nicer, and we can attach it to the chart and that looks nice. In terms of length of time and efficiency of nursing, it takes them five minutes. No, that's an exaggeration -- three minutes.
"I think there's great potential" in healthcare information systems, he says. "It hasn't come to roost."
A skeptical audience. Koch's view that technology hasn't caught up with physicians' needs helps explode the stereotype that fear keeps doctors from using computers in their practices. They're not afraid; they're just dubious.
Koch and 967 others physician executives and group practice administrators responded to a survey sent in June by Modern Physician and PricewaterhouseCoopers. The survey included questions about the use and expense of technology at the practice level for such tasks as billing, scheduling and maintaining patient records.
One of the biggest problems with technology, especially for small practices, is computer systems are too expensive. In the Modern Physician survey, 26.5% of practices of all sizes say initial cost is the No. 1 hurdle to overcome in purchasing information systems.
Among practices of 50 physicians or fewer, 27.4% say cost is the top barrier to acquiring technology. For 22.4% of practices of 50 physicians or more, cost is the second-biggest concern, just slightly behind integration with existing technology, at 23.6%. These rankings reflect the bigger groups' greater resources and earlier adoption of technology.
However, when the question is narrowed to cover clinical systems only, 62.9% of practices of all sizes agree that initial cost is the greatest challenge of acquiring technology. (In this question and certain others, physicians could choose more than one answer. Also, some percentages don't add up to 100 because not all respondents answered the question.)
Other survey findings included:
On the other hand:
In general, respondents agree that acquiring and using technology is important but not enough for them to buy a system they have misgivings about.
"People could invest a lot of money and not get the true benefit of that investment at this time," says Alan Green, president of Pittsburgh-based Premier Medical Associates, a 65-physician multispecialty group affiliated with Highmark Blue Cross and Blue Shield. "Before an organization spends money on this, it has to be a little more than it is now."
Mervin Shalowitz, M.D., president of Skokie, Ill.-based Medical Care Group, a 20-physician internal medicine and pediatrics practice in Chicago's northern suburbs, acknowledges that acquiring technology can be prohibitively expensive, especially for smaller practices. He says the lowest rate he's been quoted for an electronic patient record system is $500,000, and that would only cover one of his group's six locations.
But Shalowitz, who says his practice mainly consists of young, techno-savvy doctors, says many physicians' lack of computer skills is hamstringing them in their search for technology. Shalowitz, who describes himself as "twice the age" of many of his doctors, has visited many practices in his other business, healthcare technology consulting.
Speaking specifically of Deaconess Hospital in Evansville, Ind., but also referring to other physicians, Shalowitz says: "They're so far behind in technology. They know they have to do something, but they haven't done it. That's because they don't understand it."
Big money. Doctors' interest in technology must be separated into two areas: business functions and electronic patient records.
At least among survey respondents, the use of billing software is nearly total; 94.2% use it. Also, 78.6% use a computer to aid in scheduling. Doctors see a link between the software and better management of their practices; 88% identify improved business performance as a primary motivator in purchasing information technology.
Industry analysts estimate there are 800 to 1,000 healthcare computer vendors. Many of those focusing on smaller practices offer mostly billing and scheduling software, says Don Michaels, a PricewaterhouseCoopers partner in Boston.
Cavanaugh says developing such business technology is relatively easy. "We understand for business management what kind of data they need to identify the health of the organization, what should be presented quickly and in what format," he says.
Shalowitz says the benefits can be tangible. He says his group's billing and automated referral software requires him to keep only the equivalent of 1 1/2 bookkeepers on staff. Without the software, his 20-physician office would require four or five bookkeepers.
Physicians and administrators also say business software makes it easier to discover and collect unpaid bills and arrange schedules, since information can be accessed more quickly than by rifling through paper records.
"That stuff is easy to do," Green says. "When you get into clinical aspects, it gets very complex."
Patients and impatience. It's not as if practices aren't looking to adapt technology into more of their clinical operations. Although few survey respondents use technology to handle tasks such as patient records, telemedicine, prescriptions and treatment alerts, the majority of them say they expect to within the next five years.
And Green says the initial cost is only the start in paying for an electronic patient record system.
"Looking at it, it's not only the hardware, it's the software, ongoing licensing costs and also the processing fees, operational costs and cost of upgrades," says Green, whose group is looking to buy an electronic patient record system. "What's the old commercial, 'Pay me now or pay me later'? What you really need to do is look at what the system will cost you over the long run."
Close behind cost as an issue affecting electronic patient record purchases is ease of utilization, which 60.5% of respondents say is a problem. Simply put, if a computer system isn't faster and easier to use than paper, physicians don't want it.
"It's like I need to wait for another generation for it to be effective for me," says Bruce Jacobson, M.D., president of Ophthalmology Consultants, a four-physician practice in Willoughby, Ohio. "A lot of times, I make drawings of where I see pathology. If I see a spot inside the eye, I can draw a picture (on a paper chart)."
While products exist that could scan Jacobson's picture onto an electronic record, that would add another step to building a chart -- one physicians don't care to take.
In some ways, ease of utilization is a cost issue. In calculating the return on investment in technology, doctors look not only at price but also at how the computer system affects work flow.
Just requiring physicians to enter data into a system is daunting enough.
"Doctors make expensive data entry personnel," Koch writes in his survey. He adds later, "I didn't go to medical school to type."
Also, telling doctors that getting clinical data will allow them to better manage their practice isn't enough to show them that money and time could be saved.
"The return on investment has not been validated" for clinical systems, says Don Jackson, vice president of marketing for Tustin, Calif.-based Quality Systems. His company sells business and clinical software to medical groups of 25 physicians or more, as well as to other healthcare organizations.
The company reported a $603,000 loss on $7.2 million in revenues for the quarter ended June 30, in part because of slow sales of clinical products. Jackson was hired in August to boost those sales.
"It's very early in the curve," Jackson says. "These systems are very expensive, and they impact work flow, which in turn impacts production. So whatever is out there had better help them in what they do today and do it better and faster. That's been the clear-cut message sent to us even in the large segment of the market. Unlike the business functions, where we do billing -- that's very well-understood. In the clinic, it's not been demonstrated. There's no value proposition that's tangible.
"I think it's tied to patient care," Jackson says. Doctors don't want to "adopt something that puts that at risk."
The advantage larger groups have in adopting both business and clinical systems is they can test a product with a core group of physicians, work out the bugs and then introduce the system as a whole.
"You just have to demonstrate that it will make their job easier (and) it will make patients better. Doctors are not dumb," says Thomas Ustach, M.D., a gastroenterologist and vice chairman of Gould Medical Group, a 136-physician practice in Modesto, Calif., that's affiliated with Sutter Health System.
Ustach is sold on his group's two-year-old clinical records system, which he says makes him "feel like I'm more on top of things. When a patient calls me on the phone, I don't have to hunt up a chart.
"If they took the computerized medical record from me, I would have a tough time practicing medicine," Ustach says. His group, with some financial help from Sutter, has spent more than $5 million on its business and clinical systems. Ustach says he regrets that his group doesn't have the money to buy systems through which it could create databases to gauge patient treatment effectiveness.
Shalowitz, who has a patient charting system similar to Ustach's, says he's already sure an electronic patient record system that included databases would save his practice money in the long run, even though a full system would cost $1 million, or one year's profits. He figures he could reduce his filing staff from five to three, or at least have the other two people handle different tasks.
Why so complex? The nature of a physician's practice makes developing technology complicated. A patient record system has to be able to record many types and varieties of ailments, but adding such options puts off doctors because they make the system so complicated.
"Maybe this is part and parcel for the fact a given disease in a certain geography can (encompass) a 500% variation," Cavanaugh says. "Computers aren't happy about that."
Another complicating factor is that some vendors are trying to create an electronic patient record system that integrates billing and scheduling systems. This way, a patient's financial and clinical information can be in one computer file. That's not easy to do, since so many people need access to one patient's information during a single visit.
"One thing the vendors are becoming more aware of and physicians are completely unaware of is the impact of the systems on the support staff," says David Chin, a PricewaterhouseCoopers partner in Boston. "People who have to check in the patient, people who have to answer the telephone, the nurse assistants -- think about those folks, in terms of how they interact with the information."
When the patient arrives, Chin says, "the record has to be there, the practice assistant or nurse would update the information in terms of writing down chief complaint, getting medications, getting basic weight, blood pressure, and then (the information) has to be put in the examining room. The doctor has to have access to that relatively easily.
"Then the doctor will have to do a history and physical, then put the information back into the medical record, then instruct from that visit -- will there be change in medication -- and you have to get transmitted back out to the expediter. The patient might be scheduled for another visit.
"A lot of systems, you think in tunnel vision about doctor-medical record interface, but in live practice, that interface is a lot larger than that."
No pressure. Certainly, some would like it if physicians just took the plunge and bought more computer systems. Payers are always looking for cost and outcomes data, and some state legislatures are beginning to require doctors to gather such information.
Benjamin Rooks, a healthcare information technology analyst at CIBC Oppenheimer in Chicago, says having technology could help a practice keep or attract patients.
"If you view it from a customer satisfaction viewpoint, you want to do the best you can," Rooks says. "This is a way to do it.
"I go to a multispecialty physician practice that uses appointment books," Rooks says. "It drives me up the wall. It takes a long time to make an appointment. It's tough to find a spot. The doctor's life is not affected by that. However, the patient's is. Or to put it another way, the customer's is. So maybe it's a market-focus issue."
Despite his annoyance, Rooks continues to go to the same clinic. Likewise, payers still contract with physicians who aren't techno-savvy.
Analysts say practices might be more willing to invest in business and clinical technology if some outside force pressures them. Judging by the results of theModern Physician survey, that isn't happening.
The survey asked what motivates technology investment, and out of six categories, the three that intimated outside pressure ranked the lowest. Payer demands are primary concerns for 48.3% of respondents; regulatory pressures, 30.3%; and requirement from business partners, 8.8%.
Also, the vast majority of respondents -- 70.6% -- buy their technology directly from the vendor, again showing that practices are making their own technology decisions. And sometimes, they decide not to buy anything.
"I don't know that everybody accepts (technology) as a great thing," Cavanaugh says. "You still have the problem in entering information and access to the computer, which is not as quick as telling somebody or writing a note."
He says there may be a misperception among some vendors and analysts that technology is a tool to help doctors in their clinical decisionmaking.
"That's not true; they make their decisions on cognitive ability, or they call colleagues," Cavanaugh says. "The computer can help (gather information), but the system isn't necessary to make those judgments."
Undoubtedly, doctors will integrate computers into their practices more as technology improves and becomes cheaper and as a new generation of physicians who rely on computers enters the work force.
Kevin Koch, the Kansas emergency doctor, says he might be more sold on using technology full time if he could use a hand-held terminal, "like the kind you see when you check in your rented car at the airport."
Koch, whose wife once sold computer systems for Hewlett-Packard, says he'll keep looking at computer systems.
"A lot of doctors know what they want or need," Koch says, "but the things they want and need aren't there yet."