Association for Public Policy Analysis & Management

Responding to the Institute of Medicine’s continued recommendation that all physicians within the United States utilize an electronic medical record (EMR) as a means to improving patient care and health outcomes, Congress wrote into the American Recovery and Reinvestment Act (ARRA) of 2009 a mandate for all physicians receiving federal reimbursement for health care services use to a ‘meaningful degree’ an electronic medical record system within their practice.  Incorporated into the Health Information Technology for Economic and Clinical Health (HITECH) Act, physicians in the U.S. were now required to adopt and integrate an EMR system into their routine practice with required progress reports beginning in 2012.  However, six years have passed since the mandate went into effect and the rates of EMR adoption and integration are well below 75% of physicians across the U.S.  A significant portion of the literature into EMR adoption has focused on understanding this lack of response but has relied solely on the Rogers’ Diffusion of Innovation theoretical model to explore and explain the phenomenon.  Used to explain the diffusion of new innovations within a society, such as a new device, technique, or idea, Rogers’ diffusion model focuses on how an innovation may naturally diffuse throughout interwoven communities using innovation and societal characteristics.  In reviewing the unintended consequences that manifested after the mandate requirement of EMR usage, it becomes clear that Robert Merton’s Strain Theory can provide the needed clarity on the topic.  Merton’s Strain Theory, used to understand why individuals or groups may not embrace the prescribed societal goals using the normative institutional means, helps identify and provide insight into the variable response noted in EMR adoption.  Physician response to the cultural goal of improved patient care and health outcomes through the expected means of EMR usage can be understood using Merton’s five modes of adaptation.  For instance, physicians who accept the societal goal and believe the EMR system will improve patient care and health who also have the ability to purchase an EMR system will easily conform to the new mandate.  However, physicians who either do not agree that EMR systems will improve health outcomes or do not have the means to purchase a system can be understood as responding to the mandate through innovation, ritualism, retreatism, or rebellion.  These variable responses challenge accurate measurement of EMR adoption.  Using this insight from Merton’s theory, physicians who are non-adopters or not integrating systems they have purchased can be better understood and targeted for improved compliance.  Furthermore, a more realistic understanding of the extent to which the adoption of EMR systems are truly improving patient care or health outcomes can be achieved.