Remember how I said I wanted to talk about organizational culture? The other day on Twitter, I overheard (overread? eavesread?) this snippet of conversation between Jason Kottke, Anil Dash, and Mike Monteiro. When I read these three comments together, I immediately thought “What about taste? What about symbolic exclusion?” Right now you’re thinking “um, what does this have to do with EHR?” Let me pull the focus way back for a second, and then we’ll focus down again.

These three comments got me thinking about something that has been an integral, central focus for me, no matter where I’ve been in my career: Culture. Culture is one of those things that often seems like the most hand-wavy, indefinable, airy-fairy - forgive me - Berkeley-esque concepts around. I mean, what is culture, right? It turns out culture is definable, although like so many things, there are many ways in which we can define it.

One of my favorite definitions comes from a scholar named Ann Swidler both in “Culture in Action: Symbols and Strategies” and in her later book Talk of Love. What I love about Swidler’s definition is she thinks of culture as a tool kit. This tool kit is essentially a set of resources, like symbols, rituals, and traditions. We’re influenced by these resources and we draw on them - selecting from our repertoire of knowledge, of symbols, of experiences - to create what Swidler calls “strategies of action.” We depend on our cultural settings in order to define not only ourselves but also to develop perceptions of and to figure out how to behave in and adapt to a wide variety of contexts and circumstances.

Now, there’s no way I could sum up Bourdieu’s Distinction here in a sentence or two - it’s long, it’s dense, and, y’know, a seminal work of great sociological importance, plus it’s in storage, along with nearly all my books - but I got to thinking about it. I also got to thinking two long-time favorites: another book (also in storage) Herbert Gans’ Popular Culture and High Culture: An Analysis and Evaluation of Taste and Bethany Bryson’s paper “‘Anything But Heavy Metal’: Symbolic Exclusion and Musical Dislikes”. Because when we ask the question ”why are people jerks about not liking sports?” we’re kind of asking “why do people draw a symbolic boundary around themselves and a particular set of cultural tastes, and then proclaim dislike about the cultural tastes outside those boundaries - or the cultural tastes of people who are not like them?” 

That second question doesn’t sound as good, I know. And maybe you’d ask a different question. But that’s what the question sounds like to me, and I hear pieces of Distinction: We have what’s called “taste,” which provides us with a ”sense of one’s place,” or a social orientation. For Bourdieu, this has to do with class, social position, and the properties of those social positions - what people buy, listen to, watch, consume, more. These tastes and preferences are ”cognitive structures…are internalized, ‘embodied’ social structures” that become natural to people. What does that mean? Your taste is something that orients you and it’s also something that becomes a “natural” part of you. That means different tastes are - you got it - unnatural, so we reject them. Bourdieu says the result is a “disgust provoked by horror or visceral intolerance (‘feeling sick’) of the tastes of others.”

Bryson’s proposition then rings in my ears: ”Individuals use cultural taste to reinforce symbolic boundaries between themselves and categories of people they dislike.”

Bryson brings up one of Bourdieu’s most famous concepts, and one a lot of people may be familiar with: cultural capital. She presents cultural capital as “cultural knowledge that can be translated into real economic gains, for example, by allowing access to elite social networks and clubs.” Of course, this cultural capital is knowledge based on consumption of culture, and in order to consume that culture, a person must have access to it. If access is restricted, because of social status, then only certain types of people can gain that type of cultural capital, gain access to elite social networks and clubs, and so on. 

So Bryson points out there are two interrelated levels of cultural exclusion. There’s social exclusion, which is based in part on this cultural and social capital (and on capital itself), and there’s symbolic exclusion. Not everyone has access to social exclusion, but we all have access in different ways to different types of symbolic exclusion. Symbolic exclusion is all about taste, like Bourdieu talks about. When we proclaim taste or distaste, when we symbolically include or exclude, we reinforce our own taste and our own self-definitions. When I state that sports are stupid, or that this aspect of pop culture is a waste of time, I’m drawing a boundary. I’m including myself and others like me, and I’m excluding you. If I can’t shut up about it, it’s because I’m expressing my disgust. I really want to reinforce that symbolic boundary.

Now, there are many perspectives on culture - not everyone agrees with Swidler, and there’s been much scholarly work that has challenged aspects of Bourdieu. In addition, the cultural landscape of the United States has shifted in ways such that - as Gans and Bryson, among others, point out - there is less cultural inequality and inaccessibility so we need to differentiate between being excluded from culture and simply not liking something. If anyone who reads this wants to offer more recent works and/or counterarguments - I’ll be delighted. But for those who have an interest in this, these are fantastic places to begin. In particular, I use Swidler in my dissertation research, so keep that in mind in future weeks as we return to the connection between electronic health records, technology, and culture.

Eat the Change You Want to See in the World

I’ll get back to EHR, ethnography, and culture next week. This feels a little more important.

Last night I watched an episode of Chopped that made me cry. Four lunch ladies - who should rightly be called School Chefs - competed against one another. I wasn’t the only one who cried, either. Guest judge and White House chef Sam Kass was totally crying, as were judges Amanda Freitag and Marc Murphy. 

The first thing you should know is that the producers managed to find the four nicest ladies in the entire country. They decided to compete, but to compete nicely. They were totally supportive and kind, and while they competed their hearts out, you could very obviously see two things:

1. They were honored - and I mean HONORED - to be on the show, to be recognized for what they do, to cook for the judges, to be treated so well, to be able to show that lunch ladies are more than just lunch ladies.

2. They care about the kids in their schools in ways I cannot begin to describe. 

I don’t want to tell you the outcome or too many details because I want you to go track down that episode and watch it, sniffling into a tissue the whole time at the incredible decency and kindness of these people who work so hard for so little money and even less respect to FEED CHILDREN. In fact, I think this episode should be required viewing for all of us, whether we have children or not. Particularly those of us who love food. Because I’ll tell you this: It made me think a lot about what it is I love about food, and realize I was missing out on one of the biggest parts I love.

When I watched it, I couldn’t help but think the following:

What’s wrong with this country? 1 out of 5 (Marc Murphy says 1 in 4) children doesn’t have enough food?

What’s wrong with this country that we don’t stop and think about this whole crazy food movement and how we’re so delighted by this restaurant or that, and this new wild ingredient or the other, while School Chefs like these women are cooking on bare bones budgets, trying to make the best with what they have, trying to change the face not only of the “lunch lady” but also of the school lunch itself?

What’s wrong with this country that we’re yelling about how broken our healthcare system is but very few of us - how many, really - are talking about fixing the whole system. And that means starting at the beginning: If we work to ensure kids have enough to eat and enough of the right stuff to eat, if we help kids develop healthy eating habits, perhaps we can encourage wellness and even preventative care at a much earlier age. Yes, healthy eating and good habits need to happen at home too, but why not work to help every kid have the chance to eat well and be healthy when they’re growing and learning and need it most? Parents are supposed to raise children, but think how much you learned in school. Not in the classroom but from your environment, from your friends and enemies and peers, from your teachers and counselors and even lunch ladies, from the people who took an interest in you and from those who were cruel or who flat out ignored you.

I know, it’s the day before Thanksgiving. It’s my favorite holiday, and the reason for that is it’s always been about two of my favorite F-words: food and family. Yes, it’s also our national stuff yourself to the max day, but the point of it is sort of to stuff yourself with a lot of love and then lie around and feel thankful about the bounty in your life. And there I was, last night, thinking about kids who don’t have anywhere near enough. Not just on Thanksgiving, but every day. Honestly, the whole fetishization of food has been bothering me for a while, but last night it felt pretty selfish. Food is best when it’s full of love. Man, food is love. Here we are, full up and those kids don’t have enough.

I don’t have children. Whether I ever will is up in the air. I’m saying this as someone who has gotten to know the healthcare system pretty well. You don’t need me to tell you it’s got some problems. I’m convinced systemic change - cultural change - is the way to fix the problem. Not just insurance, not just electronic health records, not just the relationship between doctors and patients, although all these are important. I mean the way we view health and wellness. The way we relate to our bodies and our own well-being. The kinds of foods we eat, when we eat them, how often, in what quantities. Habits are tough to form, but they’re tougher to break. There’s no way to convince kids that pizza and ice cream and all that good stuff isn’t great. But there is a way to help kids eat well, even if they may not have the resources to do so when they’re not at school. 

If you notice when you search “childhood hunger,” ConAgra pops up a lot. Where are the rest of us? Those of us who like to declare we eat organic this and local that? I know small organizations are out there, but if we’re so righteous about our own diets, let’s not be selfish. Let’s work to support, enable, create, finance networks that can bring food to kids at a price that allows smaller farmers and producers to participate and not just huge organizations that the rest of us sniff our noses at.

This is a part of the healthcare system we can fix. Those ladies - dammit, those School Chefs - inspired the hell out of me. Here are some places you can learn more about how to help. And you have more information or more resources, please let me know. I’m interested too in local volunteering opportunities. I’d like to spend Christmas with the Little Brothers Friends of the Elderly but I’d also like to get involved in volunteering with food programs for schools here in the Bay. 

First watch that episode. Go get inspired. It’s been a tough go for a lot of people, but I’m feeling a little extra thankful this year.

Feeding America: Childhood Hunger Facts

Campaign to End Childhood Hunger

Share Our Strength: No Kid Hungry

Ethnographic Research: What is it? How do you begin? And why?

About a month and a half ago, I went to a workshop just outside of Santa Barbara. The workshop was for ATLAS.ti, the software I use to code data from the qualitative research I conduct. It was a great workshop, and I highly recommend it - in fact, if I could take it again, I would. That’s how good it was.

But one of my absolute favorite moments had nothing to do with the software. Nick Woolf, the instructor, was discussing the difference between quantitative and qualitative research. I’m someone who has done quantitative work, from working on statistical analysis in SPSS to doing social network analysis in R but became decidedly more captivated by qualitative research, and ethnography in particular. So my ears perked up. How would he define them? Would he “take sides”? 

Nope. He presented the two in a completely fantastic, straightforward manner that delighted me. Quantitative research, particularly statistics, uses what are called univocal concepts or factual codes. These are unambiguous and exact, pre-defined and pre-established. We know the concepts we’re researching, but we want to measure them. Qualitative research, on the other hand, is about trying to form those concepts. We’re not trying to measure them because they don’t yet exist. We want to learn about ideas, to form these definitions that are much more ambiguous, at least when we begin. 

Ethnography or ethnographic is a type of qualitative research - there are many! - in which we want to understand the ways in which people form those concepts. The point is, in a general sense, to understand human behavior in its natural setting, like where people live or where they go to school. But it’s more than that. Ethnography is about getting the “insider” view of a culture or a cultural phenomena. 

You can probably see how this is interesting from an academic standpoint but it’s also useful for businesses. Think of it this way. Imagine you’re a big clothing company. You want to know who buys your clothing, how often they make purchases, what they buy, and who they’re with when they buy it. You could definitely do some quantitative research on that. But what if you wanted to approach if from a qualitative perspective, or even do an ethnography of shopping - or an ethnography of how people respond to brands like yours? You might be able to access behaviors, attitudes, perceptions and other phenomena that would be tough to tease out from quantitative data: Why different types of people make different types of shopping decisions; how emotional experiences influence shopping experiences in positive and negative ways; and how their shopping experiences will differ when a friend joins and when a sister joins, or vice versa. 

In order to do that the researcher (or researchers) must provide a detailed and in-depth description of the experience using a number of methods, which includes data collection through participant observation, in-depth interviews, surveys, and institutional data. We often do something that’s called “triangulation of data,” which is exactly what it sounds like: It allows you to confirm what your data tells you by providing more than two points for verification. 

So what was I interested in, back in 2007, when I started my dissertation research? A few things. I was interested in how people experience significant organizational change. I was particularly interested in the ways in which they navigate such a change, especially when the organizational change revolves around the introduction of a new technology. How do people learn about the new technology? How do they deal with conflict and problems? How do they resolve issues and make sense of the changes? Focusing on electronic health records and the healthcare industry - which is itself experiencing some fairly monumental changes - meant I could look at how individuals experienced cultural and professional changes too. 

I was introduced to an organization in Northern California that had recently formed - another major organizational change - and would be implementing an EHR system within the next year to year and a half. At the time, the two-year-old organization was a network of smaller medical groups, most of which had previously been private practices or newly-formed groups of clinicians who had worked in solo practices or in other small groups. The organization had the same structure it has today: two “halves,” a for-profit medical group and a not-for-profit foundation that provided management services and support. I can’t reveal the location of my research, so I created pseudonyms. In my research, I call the medical group is “Transitions Medical Group” (TMG) and the foundation “Concerned Physicians Foundation” (CPF). As a whole, the organization is affiliated with a larger regional medical group called “Jumbo Medical.” 

When I began my research, there were 18 medical offices. I chose six to focus on - three OB/GYN offices, two primary care offices, and one neurology office - although I would eventually conduct some observations and/or collect surveys at 15 of the sites. In total over a period of 18 months, I conducted nearly 400 hours of participant observation and a total of 49 interviews (34 clinician, 10 support staff, 5 administrator/executive). I also collected institutional data and conducted two surveys, both before and after the implementation. I conducted my research using a modified grounded theory approach. This means that I did not go in with a hypothesis that I wanted to try and support. Instead, I started with the data and let it hopefully lead me toward an explanation of the phenomena at hand. As I collected data, I coded it (using ATLAS.ti), and as I coded the data I grouped the codes into concepts and then categories.  

What categories did I find? Collectives, battlegrounds, and silos - oh my! Organizational culture is more important than you realize. 

My Research: How Did I Get There?

Today I planned to give you an overview of my research project but it occurred to me: before I get there, I should tell you how I got there. One of the first questions people ask when I tell them about my dissertation is how I became interested in electronic health records. Unlike many people who have studied health IT or work with informatics, I didn’t come through healthcare. 

I’ve always had an interest in how technology informs, shapes and changes social interactions (and by extension, culture). My first professional experience — writing an advice column for teen-aged boys with a passion for videogaming — was actually an excellent test bed for these interests. My column existed as part of media entity that was oriented around entertainment and would seem to have no interest in social good. But because I was passionate about my work, serious about helping my readers, and willing to embrace the technology available both as a writer and as someone nurturing a community, I truly believe my successes reflected the best potential of technology: positively impacting individual lives while also hopefully informing and entertaining wider audiences.

I addressed questions of love, sexual health, emotional growth — and the potentially contraceptive effects of Mountain Dew — with honesty, respect and fact, all of which were and sadly still can be in short supply for your average teen male.

After my tenure as an advice columnist, I moved back into academic work. I pursued a Master’s degree at Georgetown where I became interested in some of the more theoretical underpinnings of cultural representations of technology. I also continued to explore the ways in which technology impacts people and culture itself, specifically in organizational and business contexts, both nationally and internationally. 

At UC Irvine, I followed these threads by studying three main areas of interest: organizations, social networks, and culture. In 2007 I began work on my dissertation research. By that time, I was trained in qualitative research methods and knew I wanted to conduct an ethnography. My combined and ongoing interest in organizational change, technology, social networks, and culture pointed to the healthcare field and specifically to EHR.

But why clinicians? Why focus on physicians and other healthcare providers? Healthcare is a complicated industry with — as everyone knows — an ever-growing number of problems. Even if every solution we can come up with is oriented around patient care, the clinician should somehow be involved in those solutions in a positive, collaborative way. All I could think of was that, ultimately, happier physicians able to do their jobs more effectively might lead to better patient care. It’s simple and perhaps to some, too simple, but why not see if we could solve some problems at the physician level to see if there would be a ripple effect?

As the mandate for EHR grows, the contested landscape of healthcare will not likely calm, and there is a palpable lack of knowledge about how massive technological shifts will affect everyone along the chain of wellness. The outcome of this research is not a unified solution for how or why EHR is useful (or not), or the best way to design or implement it. Rather, it’s another milestone in a long term interest in observing and questioning how people make use of technology. I believe there are answers in those questions that can shape both the technology and ways people use it so that we can realize the best hopes of a technology-infused culture: health, happiness and security for everyone who engages. Even those lonely teen boys, looking for an answer.

So, in order to begin looking for these answers, I set out in late 2007/early 2008 to examine a networked group of ambulatory care clinics that, as a recently formed and unified organization, was poised to transition from an entirely paper record system to an electronic system. In my next post, I’ll tell you more about how I conducted my research.

It’s official!

Three weeks ago, I finished my dissertation for good and submitted it, revised and formatted, to the UC Irvine library. Two days later, on September 1, 2011, I handed over my signed paperwork to the graduate office completing the requirements for the conferral of my degree. 

As the newly-minted Dr. Reich who has a little more time on her hands now that she’s not working on revisions and meeting that crazy end-of-summer deadline, I thought it high time I got back to this space to write about what I found in my research as well as topics related to my project and qualitative research more generally. I’ll start tomorrow with a summary/overview of my research, including some of the findings and will branch out from there. Please let me know if you have questions or anything you’d like to discuss. I’m looking forward to it!

I should have posted this here! I’ll be writing about this sort of stuff too. 

Or maybe I should just consolidate and have one site. We’ll see!

ohheygreat:

thedocumentarian:

Voguing: The Message, by Jack Walworth, David Bronstein & Dorothy Low, 1989

Another good film on the gay ballrooms and drag scene of eighties NY. Predates Paris is Burning by a couple of years.

I can’t wait to watch this.

In all of the years I’ve been a graduate student, one of my absolute favorite parts has been the class I created and taught on the sociology of popular culture. It was a summer course and I taught it twice, two summers in a row. It was the first course I taught as a solo instructor, an undergraduate seminar, and I was full of enthusiasm. I got to create the syllabus! I got to prove my mettle! But more than that I loved the material, maybe more than any material I’ve loved except organization theory and critical theory the first time I came across it.

One of texts we read was Dick Hebdige’s Subculture: The Meaning of Style, which he wrote in 1979 and which is rather famous. If you haven’t read it, you should, as it’s also rather fabulous and fascinating. Certainly there are criticisms of it, but those criticisms are also fascinating, so get to reading.

Anyway, one of the points Hebdige makes in the book is that a subculture is not simply a group whose culture is different from the larger culture that surrounds them. A subculture is a group whose culture that exists in opposition to the majority culture. The subculture’s culture is deviant, a subversion of the normal culture.

Definitions are always, of course, up for debate, but I felt it was important to show how the word “subculture” has come to be used almost interchangeably with “lifestyle.” This takes power away from a concept that can show how groups in which the sub(versive) culture is threatening enough to really and truly scare mainstream culture into either squashing it or absorbing it.

I showed my class documentaries and movies about subcultures to give them an idea about how this occurred and what the results were. Yes, I showed scenes from The Filth and The Fury to give the students an idea of how scary punk had been to a conservative public that had never seen such a youth uprising before. I showed parts of Dogtown and Z-Boys, to show how a small, insane skateboard subculture had really maddened the larger mainstream culture of skateboarding and took it over, only to be itself mainstreamed.

And then I showed important parts of Paris Is Burning. I showed black and Latino drag queens having their drag queen ball, clothed and nude, at 3:00 am. I showed them looking at mainstream white culture that excluded them and subverting it by inhabiting it as black and Latino gay men in the ’80s, and then I showed the prices they paid: having a white star take over their style and make it hers or being erased by violence. For students whose closest encounter with “subculture” was often Hot Topic or being told not to skateboard at the mall, it was a huge eye opener into what a subculture could be.

If you’ve never seen Paris Is Burning, I cannot recommend it enough. 

Digitizing workflows →

And we are back! 

Sorry for the long delay, especially when things were so new around here. I made an executive decision to get the draft of my dissertation FINISHED - which I did - so my writing efforts were tied up temporarily. But there’s so much to talk about, so let’s get back to it, shall we?

chrisereneta:

leahreich:

It’s 2011. Why isn’t every single doctor in this country on electronic health records?

Because, Leah points out, the transition to EHRs will require a bit more rigorous thinking than “Technology GOOD, paper BAD.”

Right? And that’s the thing that gets to me: What a pervasive attitude and how totally - stay with me, folks - wrong. 

Of course, there are aspects of the paper system that are terrible, obsolete, unwieldy, frustrating, unnecessary, even unsafe. Small aspects and big aspects. But to dismiss the entire system as BAD and to hold up the new technology as GOOD, as Chris points out, misses some really important points.

Such as:

• Is everything about it bad? Are there good things about it you might be missing, things that are important to its users? What about things that are so familiar and ingrained in their routines that they rely on them in ways you might not have imagined? And will disrupting those routines without understanding why they’re important and why the old system facilitates them cause more problems than you realize?
• Is everything about the new technology good? Are there things about it that might be problematic in ways you haven’t thought about, because you’re excited about it for one set of outcomes and someone else might use it for a related but different set out of outcomes? Or even - do you define your goals the same way?

Here’s what I mean. One of the ideas I discussed in my dissertation is that people pattern their daily routines and practices based on the way they interpret the broader institutional logics that surround them. By “institution,” I mean the organizations and the industries that provide the backdrop for my study - so the healthcare and the health IT industries. The big health organization my research sites were a part of is also included. 

Two of the big “logics” about EHR in both healthcare and health IT are that EHR improves efficiency and patient care. This makes sense, right? Those are great reasons to implement a new technology, to go through the pain of such an enormous cultural and organizational change, if it will make your work more efficient and ultimately improve the reason you do your job. 

But what if a doctor interprets a logic in one way and an administrator interprets it in another? Take efficiency. What if a doctor wants to be able to refill prescriptions as quickly as she did before, and an administrator wants to be able to get information to billing faster than ever? What if a doctor wants to be able to enter data in the way that makes sense for quick charting the way he defines quick charting and an administrator wants to be able to have data entered in a way that streamlines charting for everyone, even if there were 50 doctors charting in 50 different ways prior to the implementation?

Either you’re going to have to come to a compromise or someone’s going to win out. In the situation we’re describing here, chances are whoever’s in charge of the implementation will win out, and I have some idea of how that’s going to work out down the line.

Oh, as for the good/bad dichotomy, let’s not forget one other important thing: The human factor. Hey, the paper system is a technology, it’s just an outdated one. One problem with the system has always been the human factor. People make mistakes. People misfile. People lose things. People forget.

The thing with new technology, particularly computerized technology, is that we see NEW! COMPUTER! and we think oh hey look, silver bullet! As if it’s the instant solution. But the EHR will still be run by humans, right? Who will have to learn and who will still make mistakes, no matter how much better the new technology may in fact be.

The new technology is an improvement. It can be even substantially better, leaps and bounds. But the good/bad is a mistake, and it sets you - us! - up for failure.

Even at the very basic level, it’s shocking to see how little people seem to know about the workflows clinicians perform now, with the charting systems they already have. Or even what a workflow is. 

What I like? Is when a management team maps out a workflow on a wall-sized chart after interviewing a few individuals on the team, and expects that by simply showing the other members of the team the chart that everyone will jettison their own individual work habits and communication channels and behave as the chart expects them to.

I watched this happen except for the part of getting shown the chart in some cases. Some people didn’t get shown workflows before implementation. Oh wait, technically they did - the DAY they implemented.

Also? When the management team spends three-plus years developing a content management system built to service the workflow that only the chart believes exists. With the aid of technology teams and UX consultants, who by referring to the chart as their functional spec never get the opportunity to realize that the core functionality/metaphor of the software might be wrong.

Because for the small group of team members whose work is redirected through the system first, meetings begin to sound an awful lot like yelling.

I love when Chris writes about this stuff. Chris, please write more. This is so true. This is what I saw and it’s avoidable. Or at least it should be.

So over the past week, while I’ve been working on edits to my dissertation and prepping for a job interview on the other coast, I’ve been thinking a lot about the great responses you guys gave to my first post here. Before I go off in another direction, I want to reply to some of them. 

healthpolitics:

Health care is a complex system. And American health care is a distinct beast from British or French or Canadian health care. We must approach it with some humility, and study the way pieces fit with each other and operate in their environments before we start changing things. There’s a reason the ACA works the way it does — stepwise efforts and pilot programs are a much more sane approach than massive delivery overhaul. The same goes for EHR.

Here’s one of the most important things to remember too: It’s not just that it’s a complex system in the way it’s used in each location. It’s also the second most decentralized industry in the country, second only to the floral industry. For much of healthcare’s history, it’s been a cottage industry. The introduction of major government oversight, in the forms of Medicare and Medicaid, and the emergence of HMOs that paved the way for the corporatization and bureaucratization of medicine have done a lot to change the landscape. But much of medicine is still practiced in those small private practices. It’s that kind of a complex system. 

EHR also presents some unique difficulties. The main one is a hold-up problem. I have written about this before. Insurers and patients benefit, as Leah points out, and the situation for doctors is a bit messier. I happen to believe that they benefit in the long-run from increased efficiency and a lighter workflow burden (administrative tasks consume massive amounts of physicians’ time and are among the chief things they complain about when discussing low job satisfaction) but are punished in the short-run because the onus of learning the new system and adapting workflow is placed solely on them, and they are much, much too busy to put up with it. I am sympathetic to their resistance. It is a clear case for a subsidy program, although this has already been tried with limited success, perhaps because physicians don’t really want extra money to spend extra time learning a new system; they value that extra time far too much.

This is such a great point: “the onus of learning the new system and adapting workflow is placed solely on them, and they are much, much too busy to put up with it.” Also, let’s not forget that physicians are a valuable resource when it comes down to it. You don’t want to keep waiting all those hours to see your doctor, right? Then we shouldn’t have systems that keep physicians doing administrative tasks and keep them away from clinical tasks. 

Here’s the way I look at it. Imagine this scenario:

Someone comes to you and says, “You need to change the way you do your job. We’re pretty sure it’s a good idea to do this change, and we think it will benefit someone - maybe you, but actually maybe some other groups - but we can’t absolutely guarantee it.” 

You say, “Well, ok. I can see the way I do my job could stand for some improvement, but the routines I have set up? I’m quick. Maybe it’s old-fashioned, but I feel I can do my work efficiently and effectively.”

The person says, “That’s nice. But times are changing. We need to change those parts. It’ll take about two years for you to feel proficient again. You’ll probably see benefit in these other areas! But just maybe not in the efficiency areas. You might not ever be that quick again.” 

How would you feel? I will hazard a guess. You’d probably feel, I dunno, not okay. Screw changing times! What is this? A punishment?

This is obviously an extreme - and extremely negative - example of how EHR implementation can be presented. But I’m not making it up. There are physicians who have been through it and still feel this way.

Of course, there are really positive examples of EHR implementation, of physicians who absolutely LOVE IT. Who feel 100 times more efficient after than before. I’ve interviewed those people. There are entire systems that are renowned for their fully successful implementations and their almost impossibly happy clinicians.

At the same time, there are also people who feel they’ve gotten lost in a maze of clerical duties, in tasks that take them away from patient care. They feel they can’t enter data in a way that properly reflects their patient visits. They feel overloaded with tasks they never had to perform before, tasks they see as administrative, tasks they feel leave them little time to perform clinical duties. They feel that what made them quick can never be regained, and they don’t feel the benefit has been worth it, because of system design or because the benefit is neither to them or to the patients but to administration.  So why change? Why go through the pain and misery when the system they have serves them well enough? These are important questions to answer.

The doctors who love it are male, female, younger, older, white, black, Asian, and work in primary care, OB/GYN, neurology, rheumatology. The same goes for those who don’t love it. It’s not just about the technology or the money, as healthpolitics points out, although both of those are important factors. Time is an incredibly precious resource. Other important issues are how people interpret patient care, and concerns regarding professional identity, division of labor, and authority. 

One big problem I think needs to be addressed - and that I plan to write on separately - is how distanced we as patients have become from physicians. As angry as we are at insurers, there’s a lot of blame and finger pointing at doctors. This isn’t to say there aren’t doctors who don’t deserve every ounce of the anger we send their way, or that the healthcare industry hasn’t made its share of missteps. Rather that after spending 18 months in ambulatory care practices, I discovered a newfound respect for just how hard many physicians work and how much they care. Transitioning to EHR is a difficult endeavor in an already tough job. I’d like to find a solution that is as much pro-patient as it is supportive of the physicians who will bear the brunt of the change. To me, that’s the only way we will be successful. Supported, happier, more effective doctors will be better equipped to take care of their patients. Whether they do so in managed care, large medical networks, or small, pay-for-service practices - doesn’t that sound like a healthier system than the beleaguered, finger-pointing, vitriolic one we have now?

One thing that isn’t mentioned in Leah’s post is hospitals. I think facilities actually lose when EHR is implemented because in the status quo they routinely replicate scans and procedures done at other facilities at significant profit. Streamlining the system means less procedures, hence the benefit to patients and insurers, but the big losers here are hospitals, which already operate at fairly low profit margins.

As I mentioned, I spent my research time in ambulatory care, so I have yet to gain expertise in EHRs in hospitals. I hope to in the future, but until then I leave this area to someone who has more knowledge. While related and connected, they are different beasts. So please, keep this info coming - I find it fascinating.

I look forward to hearing much more from this blog.

Thanks! Please, keep responding. This is such a critical dialog. 

(Source: leahreich, via )

E-H-R, where are you?

It’s 2011. Why isn’t every single doctor in this country on electronic health records?

You’ve probably wondered that at some point. When you’ve gone to the doctor and wondered why, as she flips through a manila folder, she doesn’t just get a computer system. Or why her information can’t easily be sent to another doctor and no one knows what anyone else is doing and it is so, so frustrating.

Or maybe you’ve read articles in the news or even posts here on tumblr, questioning and arguing and demanding the healthcare system get off its duff and get digitized. Some of the people who’ve written about it are policy people, some are in health care, some are doctors themselves. Many argue vehemently about how much we need EHR and how ridiculous it is that we don’t yet have it. 

Last year, Generic asked me what I thought of this Ezra Klein column in The Washington Post. In it, Klein writes:

In part, you’re dealing with the fractured incentives in the system: It’s good for patients and good for insurers if doctor’s offices spend money setting up computer systems, but it’s not necessarily going to make doctors any money, and the doctors themselves are frequently older and don’t want to learn a new system. That’s one reason why systems where the insurer and the provider are the same — think Veteran’s Affairs or Kaiser Permanente — tend to be ahead of the curve on electronic medical records.

It’s true. EHR systems are prohibitively expensive. Purchasing the software, installing it, training all the users, taking a huge hit in income due to a massive decrease in efficiency as you learn the new system. Let’s not forget transferring data over if you don’t have a legacy system. It’s not just the making money—it’s making money back. Now, under ARRA, there’s money to help smaller practices without deep pockets install these systems.

It’s also true that EHR is good for patients and good for insurers. We like things that are good for patients, and we should. We should support those. But keep that “good for insurers” part in mind. And note: There’s no “it’s good for doctors.” Can something that’s possibly not good for doctors ultimately be good for patients?  

But when Klein says that doctors are older and don’t want to learn a new system - when you read something like this, stop for a minute and think. Me, I ask this question: Are you making an assumption? Are you stereotyping doctors? Is that reallythe reason they don’t want to change? Or “part” of the reason? Maybe it is, but it would help us to know if that’s real data, or just an opinion. I’m not being a pedantic annoying academic - I’m thinking about this in terms of a real, applied, fixable problem. What if the issue isn’t that doctors are old and don’t like learning a new system? What if it’s something else, and something we can’t just dismiss outright but a problem we can try and solve?

Hey, we might be able to do something with that. 

As for Kaiser Permanente - it’s not just the fact that it’s provider and insurer all in one. It’s also the fact that KP is totally vertically integrated. Everything occurs within the KP system. How much easier is that problem to solve, systems design-wise and organizationally speaking, than a multi-site network scattered across urban/suburban locations where patients use external labs, scanning facilities, and pharmacies? And even with vertical integration and centralized medical centers, I don’t think KP would say their road to electronic records has been “easy.”

Klein also notes that it’s ridiculous the medical system isn’t digitized, while banking is. Here’s where it gets really interesting, especially if you like to think about how systems and organizations work.

Take the banking system. Set aside for a moment the fact that the banking system started on the road to computerization ago. I’m not in any way an expert on banking. In fact, I welcome anyone to explain the banking system to me, as well as most anything on financial institutions. But even as relatively not-knowledgeable as I am, I know this: The banking industry is fairly transaction-oriented, right? Transactions that move data from one spot to another, tracking and monitoring it, and sometimes moving it back. That’s something you can build a computer system around.

Think about it. What does Ezra Klein mention? He specifically mentions only that you want to go in and make a transaction. He doesn’t say that when you walk in to the bank, the teller tracks your entrance, makes a note that she spoke with you, looks up your name, logs the result, and so on. There’s basically one action she performs. 

A medical record - that big fat manila chart - is a totally different beast. Do you have any idea how it gets created? How it gets maintained? How things are sorted and filed? Then, say, if a patient needs a prescription refill, or a referral, or some kind of insurance form, or help with something regarding the nursing home, or a Medicare form, or a letter sent to an employer. Who does what? How do different people in an office communicate? What are the tasks? What are the resources? Hell, does anyone even know what a workflow actually is? 

I’m not being flip, I’m being deadly serious.So much of the conversation about EHR and why the healthcare industry doesn’t have its act together rests on issues of “the technology” or “do you know how much money they cost” or “doctors are so resistant.” These are all massively important. But does anyone know why they’re important? Why they happen? How they relate? Not really. Only sort of.

Even at the very basic level, it’s shocking to see how little people seem to know about the workflows clinicians perform now, with the charting systems they already have. Or even what a workflow is. 

Transitioning an office to an electronic medical record system is a fairly monumental task. There are different definitions for success. Me? I do not define success as “We got the technology installed and people are using it. For the most part.” I’m still working on my definition of success but I know it involves things like: implementing system that addresses pre-existing problems, tries to solve them without replicating them or worsening them, and, if it does make some tasks more difficult, provides support where necessary. 

So here’s a challenge for all you UX people out there: If you really care about UX as much as I know you do, dedicate some time to working on the user experience for something that really, really matters: the electronic health record. So many people bitch about healthcare and the state its in, but it’s not really a sexy fun industry. If doctors don’t have EHRs they can use that won’t drive them crazy - I’m talking Windows 3.0 based stuff here, folks - how do you think they’re going to implement a system that will replace this “insane paper system” that you find so ridiculous?

You want a better system? Then help me create one. I’m being serious. I’m not just talking about the computer program itself. I’m talking about the larger system. The organization in which an EHR is embedded. The healthcare system in which the medical organization is embedded. The society in which the healthcare system is embedded.

Systems. Organizations. Society. 

Call to arms. Let’s do this thing.