Johnson KM, Chark DM, Chen QP, Broussard A, Rosenbloom STM. Performing Without a Net: Transitioning Away From a Health Information Technology-Rich Training Environment [Internet]. Academic Medicine. 2008 ;83(12):1179-1186

This article caught my eye because it’s the first look (that I’ve seen anyway, let me know if there are others) of what I have been calling the “California effect.” No, not the California effect of passing laws that limit patients access to their own medical data online (which has been ineffective). This is the California effect that was effective, around banning smoking indoors. What happened after that was that a whole generation of children grew up and moved to other places in the U.S. and asked their communities, “why is this place that allows smoking indoors so abnormal?” I saw a hint of it at Group Health Cooperative as well, where patients leaving the health system would ask their next doctor, “Where’s your EHR/PHR?”

This study doesn’t study patients, though; it studies doctors. Ones that have been trained in a technology-rich environment at Vanderbilt University, and who then begin working in a diversity of environments that use and don’t use Health Information Technology tools. The authors chose to study the electronic health record component, and not the personal health record component. More on that later.

328 physicians out of a total of 679 graduates were surveyed. The authors excluded people who had undeliverable addresses in the denominator, but I would prefer to look at “intention to survey,” so depending on your approach, at least more than a 50% response rate was obtained. It’s important to note that 54 percent of the respondents reported working at an academic medical center, so there’s a heavy sampling of AMC work environments here.

Absence of HIT was associated with lower perceived quality of care in many domains surveyed, including safety, efficiency, and system learning. Of considerable note, this group reported having less confidence in their knowledge about drug interactions and drug management than they did during their training, even months after changing institutions. Additionally, many respondents felt weakened in their ability to prescribe medications safely.

That’s the headline. However, looking deeper. There are a few curiosities:

1. Only 23 percent reported HIT as a “positive” factor in the decision to practice in the new institution. 11 percent reported it as “negative.” The luke-warmness and negativity could be dependent on the specific implementation of HIT at the “new” place, of course.
2. “I was better able to interact with patients/families” was not statistically significant, meaning that people with “Less HIT” didn’t feel that they were better able to communicate with patients and families at Vanderbilt.

And this interesting summary statement:

One implication of this study is that if HIT reduces error rates but is not yet ubiquitous, administrators at technologically sophisticated environments might need to expose their junior physicians to unsupported and less safe care environments as learning experiences.

The implication of the above is that resources should be spent on introducing physicians-in-training to paper based practice to support safety in a potentially unsafe environment.

The authors asked about the impact of HIT on communicating with patients and families, and the study shows that there wasn’t a significant one attributed to HIT in the Vanderbilt institution, a place that is advanced in the area of personal health records (from my limited knowledge, someone please add information about that if you have it).

Even if we assume that a HIT-enabled environment is always “more safe” than one that isn’t (and you could read the Health Care Renewal Blog to challenge that assumption – safety is not inherent in HIT, it’s in the system that it’s a part of), I think the resource should go to training skills that work in any environment, HIT or not. I am speaking of process improvement, collaborative/enterprise thinking, and patient centered care. This includes things like analysis of clinical workflows to look for and eliminate waste, learning how to write to patients and involve them and families in their care and understanding of their medical information, and leadership/support of entire care teams. On the process improvement work, there is much that can be done in a paper environment even before HIT is implemented. It’s likely that doing work that reduces waste and increases standardization makes HIT easier to implement. At the very least, creating a culture of looking for problems and focusing on the impact to the patient is as important within a HIT-enabled environment as one not-so-enabled.

Speaking from a LEAN (Toyota Management System), problems are gold, and this study is very helpful. I think it points to an early “California effect” with regard to HIT. It’s possible that clinicians trained in these environments will be more observant of not just HIT, but well-implemented HIT. The study also points out that we may still be thinking of Health Information Technology as a physician endeavor. I think it would be interesting for a large health system that has a fully deployed personal health record to survey patients who have left and ask about their confidence in managing their health and staying healthy.