"It's not their fault!" says Derek Kosiorek, principal in the Healthcare Consulting Group of the Medical Group Management Association.

He's talking about the physicians – thousands upon thousands of them – who've failed to adopt information technology in their practices to the extent that many in this industry would prefer.

The slowness stands to reason, says Kosiorek. "They're the boss of the practice. And we're asking them to change the way they've done things for their entire career. They're used to having all that information in a paper chart. Now they have to shuffle that information like a deck of cards and put it back somewhere else on the computer screen."

But the fact remains that, while health information technology has seen profoundly improved acceptance at U.S. hospitals in recent years, physician practices have been much slower out of the gate – even since meaningful use.

When it comes to the outpatient space, says John Hoyt, executive vice president of HIMSS Analytics, "We still have a long way to go. We are just at the very beginning."

Just look at the numbers from HIMSS Analytics' Ambulatory Electronic Medical Record Adoption Model. As of the third-quarter 2013, while just 6.9 percent of hospitals are paper-based, a disheartening 48.9 percent of practices have yet to digitize.

And HIMSS Analytics only tracks hospital-tethered practices; rest assured the numbers for independent specialists and tiny two-doc shops would be even less impressive.

But as Kosiorek sees it, inertia and ingrained ways of thinking – to say nothing of high IT costs – mean that physicians' inaction can be explained if not excused.

"It's easy for me to feel bad about these guys," he said.

Just look at some of the data from MGMA's Cost Survey Report, published this past September. Since 2008, practices' annual spending per full-time-equivalent physician for information technology costs have climbed 27.8 percent, from a median of $15,211 to $19,439.

Practices also have to spend more on staffing as they implement more clinical and operational software, according to the study, which found that business operations staff per 10,000 patients increased 8.7 percent since 2011, from 6.56 to 7.13.

"Cost is a key thing," says Kosiorek. "In most cases, no matter how they work the numbers, it's not going to be a financial benefit for them."

Most of the benefits of EHR and practice management software "come to the front office," he explains. "The workflow is more efficient and a lot better. But that doesn't impact, directly, the doctor seeing the patient."

That, says Kosiorek, "causes a spiral of frustration."

Even when physicians try to do the right thing, they sometimes end up throwing their hands up and abandoning the project. Witness Richmond, Va.-based gastroenterologist Michael P. Jones, MD, who was recently profiled by Healthcare IT News.

He made a good-faith effort at using an EMR. But he found its tedious data entry and adverse effect on doctor-patient interaction to be aggravating. So now he's gone back to an "old school" way of doing things, as he wrote in a Los Angeles Times op-ed this past November, "I write, by hand, notes that contain the information I need to help you feel better.

"Whatever the EMR may become, right now it's mostly a receipt for a transaction, a bill of sale,” he added. “What gets entered into the 'elements of the encounter' field on the EMR determines how much the insurance company will pay, which only makes the unholy mess of electronic medical records worse."

At least Jones gave it a go. Many other physicians are simply keeping their heads down and ignoring meaningful use until it's time to bow out of the workforce.
"There are a lot of docs that are just flat out waiting to retire," says Kosiorek. "My father-in-law has an optometry practice. He's not gonna do it. He's just going to wait it out and retire."

Vendors share some blame for physicians' frustrations with their systems. But even there, Kosiorek, for one, is sympathetic.

"The thing lacking on the vendors' behalf is that they don't have more ability to do everything that everybody needs," he says. “I told you I feel bad for the doctors – also feel bad for the vendors. Far be it from anyone to say that. They're behind. But it's because they have so much on their plate that they can't focus."

That said, it's not exactly a shock that one of the most popular Healthcare IT News stories of 2013 was a report by Associate Editor Erin McCann titled "EHR users unhappy, many switching."

It found that many vendors have found themselves bogged down with backlogged implementations, and many are unresponsive to pleas for more intuitive interfaces and better connectivity. As such, according to a report by Black Book Rankings, as many as 17 percent of medical practices were planning to rip-and-replace.

As Chilmark Research analyst John Moore told me earlier this year, part of the problem has to do with meaningful use: the "artificially low barriers" of Stage 1, he said, were meant to ease in wary physicians.

But they also allowed many vendors that "frankly should have gone the way of the dodo to continue to exist," said Moore. "Unfortunately a lot of providers were just going out and buying whatever they could find that was certifiable for Stage 1. And now they're stuck with systems that really don't fit what they need."

That dissatisfaction is contagious. And it's probably a big reason physicians who otherwise might be willing to take the leap toward EMRs are still holding back.
In October 2013, a study from the RAND Corporation found that, while physicians understood the benefits of EMRs, they carped that too many of them are cumbersome, and too often interrupt their relationships with their patients.

"Many things affect physician professional satisfaction, but a common theme is that physicians describe feeling stressed and unhappy when they see barriers preventing them from providing quality care," said Mark Friedberg, MD, the study’s lead author and a natural scientist at RAND, upon the survey's release.

A November report from IDC Health insights found that a whopping 58 percent of ambulatory providers were unsatisfied with their EMRs, citing frustrations with usability and workflow.

"Despite achieving meaningful use, most office-based providers find themselves at lower productivity levels than before the implementation of EHR," said IDC Research Director Judy Hanover, in a statement. "Usability, productivity and supplier quality issues continue to drive dissatisfaction and need to be addressed by suppliers and practices."

Still, it was telling that those who did adopt were doing so, often, because they got a nudge. IDC found that among the top reasons for providers implementing EMRs were regulatory compliance (56 percent) and qualifying for meaningful use incentives (40 percent).

Indeed, without meaningful use, it's a safe bet that ambulatory uptake would be far below even the disappointing place it is today.

"I think it was gone about in the right way; I'm a fan of meaningful use," says Kosiorek. "No matter how it happened, I think it would have been a painful transition."

Prior to HITECH, the Bush Administration was "taking a more hands-off approach," he said. "EHRs were there; there was just no defined way of using them. I could take my whole chart room, scan it in as a PDF, and technically that's an electronic health record. There had to be a way to say: 'This is what an EHR is, and this is how it's properly used.'

"My opinion is that the speed at which meaningful use is implemented should be eased up a little bit," he said. "Easing of the restrictions and easing of the penalty phase would be helpful. I don't know anyone who doesn't want that, except for the government."

Ultimately, what may finally push ambulatory adoption toward critical mass is the patient.

"I'm surprised there's not more patients acting as customers – shopping around for a different practice if the one they're using doesn't have the electronic capabilities they need," says Kosiorek. "I think you're going to see market pressure start coming into play. If you went to a bank that didn't use a computer, you wouldn't go to that bank tomorrow. There is a time when the computer just makes the benefit.

No matter how it happens, something has to happen soon.

"We all know that some 80 percent of the volume of healthcare consumption takes place on the ambulatory side," says Hoyt. "Ambulatory EHRs need to get out there more ubiquitously."