Sunday, September 09, 2007

The Diffusion of Innovations

I’ve been reading a very interesting book called “The Diffusion of Innovations”, by Dr Everett Rogers. Much of what I see as currently happening with EMR is accurately reflected in his book. Making a major change like adopting an EMR is very much a social process.

Dr Rogers found that the adoption of an innovation follows an S-shaped curve; he categorized people as Innovators (2.5%), Early Adopters (13.5%), Early Majority (34%), Late Majority (34%) and Laggards (16%). The lower elbow of the S-curve, where adoption starts to take off, is where I think we are now—right in the Early Adopter stage. This means that you may be able to get a critical mass of users now, and the adoption rate then accelerates and becomes self-sustaining (sort of like an atomic chain reaction). It is an interesting stage, because pushing things along here makes the most difference to how fast we adopt EMRs (the “turbocharging effect”).

The process of starting EMR in our practices also has several stages: thinking about it (knowledge); forming an opinion (persuasion); deciding to do it (decision); starting to use it (implementation); continuing to use it and solving problems (confirmation). According to Dr Rogers, people tend to look to their peers when deciding (persuasion and decision stages). Diffusion networks (groups of people talking to each other) are also important at the implementation and confirmation stage, because you always have to re-invent the EMR at least to some degree to fit your local circumstances; we’ve certainly done that in my group (customized templates; implementing the preventive services; getting scanning going; hiring an IT person). It helps to have a group to see how others have solved problems.

Canada Health Infoway is starting a Peer-to-Peer network, together with the provincial e-Health organizations, so they are probably thinking along the same lines. They have targeted the keeners, under various names: “champions”, “super-users”, “peer leaders”—this is the early adopters. Infoway has scheduled the first national meeting next weekend, and it will be interesting to see what they want to do with us (and for us).

My new nurse is now comfortable using the EMR; it did not take long. She starts seeing patients on her own tomorrow. We had several visits where she saw pop-up alerts for patients booked in for other problems, such as a patient with a new diagnosis of diabetes who had not returned for foot examination or urine testing, or a patient who needed to have a MMR vaccination. She is getting good at providing opportunistic preventive care. The clinical pharmacist saw one of my patients at her hospital office last week, and I saw the electronic chart being opened while in my office, which was very strange. My secretary picked up an urgent message from a patient on a Saturday: the pharmacy had not filled one of her medications. She was able to log on to the record remotely, see that the prescription had been ordered (a copy of the script was on the EMR record), and she called the pharmacy to ensure that the prescription was filled correctly. This prevented an important medication error. While Team-based care is possible without EMR, I think it works better with EMR; some of the EMR tools (alerts, reminders, legible records, e-communication) can make collaboration more seamless.

I am looking for new partners for my practice. I have been now contacted by several recently graduated physicians with impressive credentials; I had looked for a new associate a few years ago, with no response. I don’t know whether the interest is due to the EMR or to the benefits of joining a Family Health Team; probably a bit of both. I have noticed that many of the ads seeking to recruit a family physician as an associate mention that the practice is computerized; EMRs are a selling point. All these changes seem to be having an impact, and I am very pleased to personally see that new family physicians are choosing comprehensive care again.



Anonymous said...

Excellent analysis of today's electronic medical records market. In the United States, I think we're fast approaching the early majority phase, when we should expect EMR adoption rates to quickly escalate.

I remember sitting at my desk in the early 1990s, think to myself that electronic mail was such a great idea, but remembering that no one I knew had an e-mail account. Literally 12 months later, it seems, everyone had e-mail and I was the guy in the dark.

I suspect the same thing will happen with electronic medical records software. Eventually, physicians without this technology will find themselves like a fish out of water, as the paradigm dramatically shifts and those without an EMR are left in the dark.

EMR Software Guy,

Michelle Greiver said...

Thank you. The value of an innovation involving communication is proportional to the number of people who use it. A good example is a fax (not of any value if no one else has one). E-mail, as you mention, is another example.

As the system becomes increasingly connected, the EMR becomes more valuable and more prevalent, increasing the likelihood of further connections. We are now seeing this with hospitals and DI providers; they want to connect.