Sunday, September 19, 2010

Diffusion of EHR Innovation

No matter what your opinion of Electronic Health Records (EHR) is, you would probably agree that the concept of computerizing medical records represents an innovation of sorts. The spread of innovation, or its diffusion, has been researched and modeled by Rogers[1] as a bell shaped advancement through populations of Innovators, Early Adopters, Early Majority, Late Majority and Laggards (the blue curve in the figure below). At some point during this spread of an innovative solution a Critical Mass of adopters, or Tipping Point, is reached and the innovation is assured widespread diffusion (Gladwell[2]).  Adoption is usually described by an S-shaped curve of adopters vs. time, and the rate of adoption is the slope of the S-shaped curve at any given time (the red curve in the figure).

The Tipping Point occurs right after the rate of adoption assumes its largest value which will be maintained throughout most of the adoption process. It is worth noting that the diffusion of innovation model is not predictive. Many innovations linger and die within the Innovator circle. Another important aspect of the model is that the time variable is not constrained. Depending on the rate of adoption, it may take weeks, months or many years for an Innovation to spread throughout a given population. There is no question that EHR adoption is slowly moving up on the ascending side of a classic diffusion model bell curve, but is it moving fast enough? Is the tipping point visible? Are we there yet?

In order to answer these questions and assess where we are on the path to EHR adoption, we must examine the elements affecting diffusion of new ideas, objects or practices, i.e. Innovations, as they pertain to EHRs.

The Innovation – Not all things classified as Innovations are equal and this may explain why some succeed in becoming main stream and others fail. Rogers[1] suggests four defining characteristics of innovation:
  • Relative Advantage – To what degree is the EHR perceived to be better than the practice it aims to supersede – paper charts? The daily debates on the merits of EHR in various health care forums are stark testimony to the fact that potential users are sharply divided on the answer to this question. For some, EHRs are increasing efficiency and improving quality of care for patients. For others, EHRs are impediments to quality of care and an endless money pit for the practice. The biggest advertised advantage of EHRs, interoperability, is little more than a promissory note issued by EHR proponents to prospective adopters. The Government is adding an advantage in the form of stimulus incentives and future financial penalties for non-adoption. This advantage seems to be significant for hospitals and large groups, but less so for small private practices.
  • Compatibility – Are EHRs compatible with existing values, past experiences and needs of potential adopters? Here EHRs are being propelled onto the much larger stage of health care reform. They are no longer a humble replacement of pen & paper and fax machines. EHRs are instruments of change; a change from treating one patient at a time the best you can, to considering value-based strategies for the benefit of entire populations, and considering those right at the point of care. This seems to be a major departure from a value system created and enriched across many generations of medical doctors.
  • Complexity – Simplicity is always a virtue. The complexity of hospital EHRs, with their unwieldy CPOE modules, has created a perception of EHRs being rigid and unduly complicated tools, which take years to master.  The simple ambulatory EHRs available today, have failed to change these perceptions. To be fair, EHRs are inherently more complex than a piece of paper, but that should not necessarily deter adoption. After all, the wheel was more complex than walking, and making fire was extremely hard initially.
  • Trialability – Experimenting with small parts of an innovation before taking the final leap reduces adopters’ risk and anxiety. EHRs can be, and mostly are, implemented in stages, particularly in hospitals. In the ambulatory sector there was a trend to implement electronic prescribing as a trial before complete computerization. Perhaps the best exercise of Trialability for EHRs is the free trials offered by too few vendors.
  • Observability – An innovation is more likely to be adopted if its results are easily visible to others. This of course assumes that the results are positive. Unfortunately, successful implementations of EHRs are uneventful and largely anonymous, while their failing counterparts, usually associated with astronomic losses in funds and sometimes lives, are very visible, heavily advertised and frankly more interesting. There is no news in a 3 physician practice in Omaha installing a mid-priced EHR and having no problems to report.
Communication Channels – The news and evaluation of an innovation are spread throughout the community by various means, from mass media to informal peer to peer communications. As every EHR vendor knows, the latter is the most prevalent and effective method of disseminating messages amongst physicians. It is also a very slow method of creating awareness and unless the innovation is indisputably positive, much confusion is created by conflicting messages from friends and colleagues, thus slowing down the diffusion process. The Government’s intervention, with all its glorious publicity and billions of dollars in support of the innovation, is doing wonders in bypassing the conventional “word of mouth” diffusion mechanism. The downside is that EHR is now associated with Big Government and a particular flavor of politics.

Time – Time is involved in diffusion of innovation in several ways.
  • On an individual level the innovation–decision process goes through five stages known as: knowledge – persuasion – decision – implementation – confirmation. In EHR industry parlance, these translate to: research – assessment – selection – implementation – adoption. The shorter the innovation-decision individual cycle is and the more people actually complete it without dropping out in its midst and the more positive their adoption experience is, the faster an innovation is expected to diffuse. For EHRs this cycle can range anywhere between a few months for a small practice to several years for a large hospital. The Government imposed Meaningful Use schedules are shortening the innovation-decision cycle for those racing to qualify for maximum incentive. Perversely, the inadequate time allowed for implementation will also increase failure rates and adverse events, which does not bode well for long term diffusion rates.
  • Diffusion is also affected by the Innovativeness of the population targeted by the innovation. Here is where we encounter the accusations of physician being inherently opposed to technological advancements, and the counter arguments based on the number of iPhones and iPads already owned by physicians, not to mention all the advanced technologies in imaging, surgery and other medical fields, which are readily embraced by the medical community. When it comes to EHRs though, most docs don’t mind being very late adopters or even laggards.
  • The rate of adoption dictates how much time it will take for an innovation to diffuse throughout the system. Unfortunately for EHRs, the rate of adoption is heavily dependent on the 5 characteristics of an innovation and none of those are particularly stellar for EHRs. This is why the rate of EHR adoption prior to HITECH has been lingering at the bottom of a very wide S-curve. The Government intervention, which as mentioned above is increasing the financial advantage, is making a marked difference in the rate of adoption effectively pushing EHRs up the S-curve.
The Context – Innovations are diffused within the boundaries of a social system. The structure, norms and leadership of a system also affect the diffusion of innovations.  Systems whose members are similar in education, social status and beliefs (homophilous) are not well suited to rapid change and innovation. Physicians arguably do form such system. The historical low rates of EHR adoption could be attributed to lack of accepted opinion leaders in general, and those who view EHRs as a positive innovation in particular. The public personas that have an MD after their name and relentlessly advocate for EHR adoption are usually not practicing physicians and as such, are not accepted as respected opinion leaders by most practicing doctors.

The diffusion patterns described so far are assuming that the innovation is optional for any given individual. However, innovations are not always an individual choice. Sometimes the decision to innovate is Authority Driven. Authority driven innovations are faster to be adopted and depending on the level of coercion, may follow a completely different path. Up to HITECH, individual physicians in private practice considered EHRs optional. Those employed by hospitals or large groups were experiencing the effects of authority driven innovation all along, thus the much larger adoption rates in those sectors. Although EHRs are not yet mandatory, the increasing pressure exerted by Government incentives, regulations and penalties is changing the diffusion patterns of the EHR innovation.

Keep in mind that Government exertions do not need to continue until every physician in the country has purchased an EHR. They only need to ensure a critical mass of EHR adopters is created and the mythical Tipping Point is reached. The Tipping Point is usually observed at about 15% adoption under normal circumstances and is marked by the emergence of opinion leaders who adopted the Innovation. EHRs and health care in general are anything but normal and I would expect a larger percentage of adoption to be required before EHRs “take off” in a self-sustaining fashion. As to respected opinion leaders, there are none.

So are we there yet? I don’t think so, but we are awfully close.
1. Everett M. Rogers (1995), Diffusion of Innovations (Fourth Edition), New York, Free Press.
2. Malcolm Gladwell (2000), The Tipping Point: How Little Things Can Make a Big Difference, New York, Little Brown.


  1. We are in an age of EMR compliance rather than EMR innovation. The predictions posted here written soon after HIMSS 2010 seem to be still holding true.
    There is far more emphasis on Meaningful Use requirements than innovating the EMR.
    I agree with your 2nd to last paragraph. "Tipping Point" relies on un-interrupted free market bell-curve adoption. With Meaningful Use, government requirements will skew the 15% adoption rule to much higher percentages.

  2. I agree Faisal. However, for physicians who are still on paper, and most are, EHR in itself is an innovation regardless of the innovative changes to EHRs.
    It would be interesting to analyze how those curves are affected by changes to the initial innovation while it is spreading throughout the community.

  3. How is EHR in itself an innovation over paper? It's slower, easily corruptible, and prone to numerous electronic-only problems like copy-paste-itis. Electronic is not automatically better than paper.

  4. No, electronic is not automatically better than paper. I would go further than that and say that paper is, and probably will be for a very long time to come, much faster. Dictation is faster than clicking on boxes. Copy-paste, along with all the E&M mandatory boxes and "documentation-by-exception" are all creating useless confusing documentation.

    To be fair, EHRs have some good features too, mainly in the area of interoperability, such as incoming lab results and refill requests. In the future they will probably have more.

    This is by no means an easy and self evident "innovation". If it were, the Government wouldn't need to pay people to adopt it.