You both make excellent points. 

Gary 's observation:

The idea of selecting an EMR and total solution is too mind boggling for most practitioners when they realize that although EMR has many merits it is a "disruptive technology".  Physicians want an EMR that learns how they practice, not vice-versa.

This is a profound! While disruptive technologies often change the world for the better, getting them understood and used requires "missionary marketing" because they require changes in people's mindsets and actions. The first step is make potential users aware that such tools exist. Then you have to demonstrate their value in terms of ROI (e.g., productivity gains, improved outcomes, cost reduction, competitive advantage, etc.). And then you have to deal with the tendency of most people to resist change, due to the learning effort, fear of the unknown, and so on.

One way to overcome these obstacles is to find early adopters, i.e., people who enjoy playing with innovations, aren't afraid to take a risk on something new and different, appreciate creative vision, and want to have input into how technologies can evolve by giving constructive feedback. The mainstream simply doesn't have these qualities and lag until successes are reported and a bandwagon effect kicks in. See Geoffrey Moore's "Crossing the Chasm."

Another thing to do is, while engaging in the step-wise approach to technology Rob mentioned, is to present the big picture clearly so providers can see where each technological component fits into a complete system and how such a system will help solve some of healthcare's most daunting problems. I suggest that this grand view, based on a blueprint we developed, depicts an affordable, fully integrated, interoperable, cross-disciplinary, patient-lifecycle HIT system with decision support, alerts/warnings, outcomes assessment, workflow/process management, biosurveillance, and business intelligence functions.

The portal is the most basic component and, as such, has minimal decision-support capabilities, which means, while it certainly has value, the benefits it delivers has a relatively minor effect on care outcomes. Sure, knowing about a patient's allergies and medical history is vital, but I'd venture to say that a tiny fraction of the poor outcomes and high costs in our country are due to doctors' lack of such information. After all, how often does a doctor not know a patient's allergies and medical history and cannot find out in a timely manner?

A greater level of benefit comes from use of EMRs having CPOE-type decision-support capabilities, such as medication monitoring. Adding these tools enables a doctor to avoid prescription errors, which improves outcomes and avoids costs associated with medication errors.

But there's another level of technology benefit not adequately recognized in the U.S. It has to do with wellness enhancement on the one hand, and diagnostic, treatment selection, and plan-of-care (PoC) execution decision support on the other. This is where the greatest health IT (HIT) value is obtained, in my opinion. For example, such an HIT system would assist with diagnostic and evidence-based treatment selection decisions, establishing and updating PoCs based on flexible evidence-based practice guidelines, aligning hospital resources with the execution of PoC orders, coordinating a patient's PoC (inpatient and outpatient) across providers and facilities, and helping consumers better manage their own health.

Such tools would also automatically deliver treatment process data (e.g., examining variance from clinical pathways) and clinical & financial outcomes data to teams of researchers/academicians who analyze and interpret the data, collaborate with subject matter experts in consensus groups to establish and evolve evidence-based practice guidelines, and disseminate the guidelines as needed.

And the tools would do several other things, including helping detect and manage outbreaks and bioterrorist attacks, assisting first responders in handling victims in an emergency, linking providers within and between RHIOs, speeding adjudication and reconciliation of claims, supporting collaboration via virtual forums, and providing knowledge management tools.

Enabling people to see this big picture brings into consciousness the full potential of HIT, while making folks aware of their current level of adoption. This may motivate them to take larger step-wise leaps.

It would also help if they had a guiding role in the development of such tools. That is, the tools should be flexible and the users should instruct the software developers to create tools that fit into their current workflows (ways of doing things) with minimal disruption and maximum streamlining of processes.

Steve Beller, Ph.D.