Doctors' tech adoption influenced by social circle
■ Studies examine "social contagion" theory to find how electronic medical records adoption is spreading -- and how it can grow even more quickly.
By Pamela Lewis Dolan — Posted Sept. 13, 2010
To figure out why physicians and hospitals are slow to adopt electronic medical records, researchers are looking at institutional and social networks to see if they can discover the key to overcoming resistance.
A study in the August Management Science posited that smaller and newer hospitals, and those that have some tech "celebrity" status, are the most likely to influence other hospitals to adopt EMRs.
An earlier report published in the May Journal of the American Informatics Assn. concluded that the most likely indicator of doctors' interest and use in EMRs is whether their friends use them. Not merely peers, but doctors they consider close on a personal or social level.
Both studies referred to something researchers call "social contagion" -- how peer networks influence someone to act, particularly when that action is done without someone perceiving any sort of influence being exerted. One person is the "carrier," who can spread the contagion to many.
Forms of social contagion research have been around since the late 1800s. In the 1960s, it was used to show how physicians, as the JAMIA study put it, "manage the uncertainty of adopting new antibiotic drugs." However, little work has been done about social contagion and EMRs until now.
Both studies looked at social contagion theory as critical to understanding EMR adoption, because the technology represents an expensive, radical change to how physicians and hospitals operate. The influence of others is necessary and important to the spread of information technology, the studies said.
"If you are an administrator, it's hard for you to tell the physician, 'Do it.' Physicians are like free agents. So our message is that adoption of anything new or innovative is likely to happen from one physician to another," said Vallabh Sambamurthy, PhD, Eli Broad professor of information technology at the Eli Broad College of Business at Michigan State University. He co-wrote the Management Science study.
Smaller affects bigger
The Management Science study ran statistical models and mathematical equations involving 3,989 hospitals to determine which would be the influencers and which would be influenced. One conclusion was that smaller hospitals' use of EMRs was more likely to influence bigger hospitals' use, rather than the other way around.
Much of the issue came down to resources. A smaller hospital might hear of a larger hospital's success with an EMR system, but it might not have the resources to purchase one. However, researchers said a larger hospital has the financial resources to act if a smaller hospital had paved the way.
"We almost used this term in our paper -- the David and Goliath effect," said Corey Angst, PhD, assistant professor of management at the University of Notre Dame Mendoza School of Business and co-author of the study. "There are a lot more David hospitals out there than Goliath hospitals."
Researchers said similar social contagion phenomena were present based on a hospital's age -- the younger it was, the more likely it was to influence. "Celebrity" hospitals, such as those that might appear on most-wired lists, also were influencers.
Physical proximity among hospitals was a factor in social contagion less in highly populated cities and more a factor in low-density areas, where hospitals were more engaged in "competition for knowledge workers" and "knowledge transfer across hospitals." However, proximity also was a factor in places where the larger and smaller hospitals were part of the same health system.
Sambamurthy said the government may want to consider pushing more funding to small hospitals that have a lot of innovation but limited funds. Often, he said, large hospitals have more capital than smaller hospitals but lack the innovation to try something new. Medicare and Medicaid "meaningful use" financial incentives, available beginning in 2011, will be paid to physicians and hospitals if their EMR systems are certified to meet certain guidelines.
The JAMIA study examined physician EMR use and showed a direct, personal connection to whether physicians adopted the technology.
The study looked at 25 residents and 15 physicians in an outpatient internal medicine clinic at Western Pennsylvania Hospital, which serves the Pittsburgh area, at the time the facility began implementing an EMR. The usage rate in the clinic was about 40% of clinical encounters.
The authors surveyed the physicians and residents to determine what social factors influenced use of the EMR, looking at the effect of professional relationships, "a friendship network based on personal intimacy," and "a perceived influence network" based on doctors' perceptions of how other people affected their decision to adopt.
The study's finding that personal relationships were the biggest influence on EMR adoption echoed the results of past studies on physician adoption of other technology. This was one reason researchers said they were confident in their results despite a small sample size.
Kai Zheng, PhD, assistant professor of health management and policy at the University of Michigan's School of Public Health and an assistant professor of information at the university's School of Information, is co-author of the JAMIA study. He said the research found that "friends" didn't have to be people who went out together after work. Influence also was shared between strangers who shared a mutual friend, or those to whom physicians feel they are "socially equivalent."
The study authors said their research should have hospitals and practices rethink the common practice of assigning a "physician champion" to promote EMR use. Rather than being the best tech person, the physician champion should be chosen and trained based on his or her personal popularity to have more capital "in the friendship/social space of a given clinical environment."
The JAMIA authors acknowledge that selecting that physician is not easy. Along with the Management Science authors, they say more research is needed on how social contagion theory affects EMR adoption to understand more about how and why influence can be spread, and how to pick those specific influencers that can spread the contagion.
Still, Melissa Rutala, MPH, acting executive director of the Arizona Health-e Connection, said the studies are relevant to the work she does trying to spread EMR adoption to primary care physicians in Arizona.
When physicians hear feedback from their peers, "they are more engaged, they are more interested, and they are definitely more willing to look at the possibilities," Rutala said.
Although social connections are helping to spur adoption, inactivity could have been contagious as well. Rutala believes that adding federal incentive money to the mix may have tipped the scales to get the influencers to act.