Original Research

If electronic medical records are so great, why aren’t family physicians using them?

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OBJECTIVE: The chasm theory of marketing states that fundamental differences exist between early adopters of technology and the mainstream marketplace, making it difficult for technology to transition to the mainstream market. We investigated possible differences in attitudes and beliefs about electronic medical records (EMRs) between current EMR users (early market) and nonusers (mainstream market).

STUDY DESIGN: Cross-sectional mail survey.

POPULATION: Active members in the Indiana Academy of Family Physicians 2000–2001 membership database (N = 1328).

OUTCOMES MEASURED: Differences in attitudes, beliefs, and demographic characteristics of EMR users and nonusers.

RESULTS: The overall return rate was 51.7%; 14.4% of respondents currently use an EMR. Electronic medical record users were more likely to practice in urban areas or to be hospital-based and reported seeing fewer patients. Nonusers were less likely to believe that (1) physicians should computerize their medical records; (2) current EMRs are a useful tool for physicians; (3) EMRs improve quality of medical records and decrease errors; and (4) it is easy to enter data into current EMRs. Nonusers were more likely to believe that paper records are more secure and more confidential than EMRs. Both users and nonusers believed that current EMRs are too expensive.

CONCLUSIONS: A chasm exists between EMR users and nonusers regarding issues that affect EMR implementation, including necessity, usefulness, data entry, cost, security and confidentiality. To reach full implementation of EMRs in family medicine, organizations should use these data to target their research, education, and marketing efforts.

  • Physicians have major concerns about data entry, cost, security, and confidentiality of current electronic medical records (EMRs), resulting in their questioning the need for EMRs and the usefulness of existing EMRS.
  • There are large differences in the perceptions of physicians who do and do not use EMRs.
  • Before EMRs will be accepted by a majority of family physicians, EMR companies must balance cost against the needs of mainstream family physicians.
“If everyone wants EMRs and the sources of patient data are so abundant, why are EMRs so scarce?”
—Clement J. McDonald, MD1

The benefits of using electronic medical records (EMRs) instead of paper records have been well documented.1-6 However, the current use (5% to 10%) falls very short of the 100% by the year 2000 recommended by a 1991 Institute of Medicine (IOM) report7; furthermore, the rate of EMR use has remained relatively unchanged (5% to 10%) over the past decade. Given this stagnant rate of growth despite the IOM’s support, it is important to analyze the needs and perceptions of physicians with regard to EMRs.

There are few articles on the use of EMRs in out-patient settings.1-20 Only 2 studies have analyzed the perceived needs and preferences for use of EMRs and family physicians.11,12 The first study found significant concerns about the ease of data entry, data confidentiality, data sharing, and initial EMR train-ing.11 The other article rated user requirements in rank order, but was limited by a 24% response rate.12 Most of the literature and information on the Internet about EMRs focuses on the needs and perceptions of current EMR users.1-20

The chasm theory of marketing (Figure) states that the early market of new product adopters (the first 5% to 10%) often has different concerns than the mainstream market. This group leaps ahead of the mainstream, creating a chasm.21 Early market adopters are more willing to endure technical difficulties and poor service to make a product work if it promises a competitive advantage, while mainstream users are more likely to look for widely used products that are inexpensive and easily assimilated into their current work environment with little organizational discomfort.21 Products engineered for the needs of the early market are often too complex to meet the needs of mainstream users; therefore, many products are unable to cross the chasm from early markets to mainstream markets because they fail to meet the needs of the mainstream users.21

This theory may explain the slow adoption of EMRs by family physicians. The purpose of this study was to investigate differences in attitudes and beliefs about EMRs between current EMR users (early market) and nonusers (mainstream market).

Chasm theory


The study population comprised active members of the Indiana Academy of Family Physicians (IAFP) listed in the 2000–2001 IAFP Membership Database. IAFP members who were practicing outside of Indiana or who spent less than 4 hours per week seeing patients were excluded from the study, leaving a study population of 1398 participants.

The authors designed a 53-item questionnaire based on the principles outlined in the 1991 Institute of Medicine report.7,18,19 Six physicians with expertise in medical informatics screened the questionnaire for content validity. Twelve academic family physicians reviewed the instrument for structure, clarity, and relevance to test face validity. Ten resident physicians generated a test–retest reliability rate of >80% for each item over a 2-week interval.


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