Barriers That Impede the Adoption of Pediatric Information Technology FREE

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 technology^{1 - 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).

Barriers may be grouped into 4 categories, as described by Knapp⁸ and modified for a discussion of information systems issues by me:

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.

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 - 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 - 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.

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 - 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

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 - 31}

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 - 37}

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}

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

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

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.

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:

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 - 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.

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:

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.

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.

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 - 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.

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.

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.

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.

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@jhmi.edu).