Arriving at a novel solution to a knotty problem by disregarding one's preconceived notions is what is commonly meant by "thinking outside the box." There is another kind of outside-the-box thinking that was illustrated in an episode of the "The West Wing" [Season 3, 2001, "Hartsfield's Landing"]. The story revolves around the notion of "seeing the whole board."Here, the board is a chess board. The episode interweaves a presidential primary campaign, a crisis involving Taiwan and China, and several games of chess being played concurrently by the president with members of his staff. In all three situations, individuals get so distracted by one facet of a situation that they consider actions that, when seen in a broader context, would clearly produce undesirable results.
I've talked about how critical context is to understanding anything. As an amateur chess player, I tend to evaluate my possible moves one-by-one from the perspective of each of my pieces. As I consider each piece, it determines the context within which my thought will proceed. It is rarely a winning approach. Perhaps one reason that armies often fight the last war is that the context of their thoughts is conditioned by the equipment they have, the skills of the soldiers and past battles with which they are intimately familiar. By ignoring those aspects of "now" that are different from "then," one can comfortably rely on the tactics and methods of the past that one knows well. That may explain why I, in my chess games, and some commanders in the field, are completely surprised by their adversary's action. It is simply something I/they never considered; it is foreign to our frame of reference (context).
Getting EHR right requires both forms of outside-the-box thinking. Innovation results from re-imagining specific objectives and components of EHR. "Seeing the whole board" means viewing the chess board (or EHR) differently. It means seeing interplay of the pieces and how the present state of the board after each move might play out as the game progresses; seeing the whole board in a military context means seeing your adversaries, their capabilities, objectives, and personalities. It means trying to understand their motivation and what novel or unexpected strategy they may invent.
EHR, like international relations and war, presents many facets, each of which provides a "box" of sorts that can confine thought in unique ways. There is the computer hardware that has changed little in the last 75 years and the software that hasn't changed much in the past 30 years. This is compounded by government regulations that demand compliance with rules and regulations that take precedence over patients and their care. Worst of all, EHRs are commonly seen primarily as a means of collecting and coding data.
While data is needed to satisfy specific objectives, in reality good charting is a form of journalism, not an exercise in data collection. "A progress note, whether for an office or a hospital visit, [should]... tell a story: what the patient said, what the examination showed, what the doctor thought was going on, and what the plan was to make the diagnosis or treat the problem, all of it written to help the physician take care of the patient and communicate with other physicians taking care of the patient," wrote Yul Enjnes in his piece, "English is the second language of medical documentation."
Those who develop EHRs (with a few exceptions) have yet to think outside the box — to see the whole board. This spawns computer systems, regulations, organizational policies, and business practices that frustrate the efforts of practitioners whose primary concern is to act on the patient's behalf, not to be constrained within boxes.
This leaves two questions:
1. So what? If a furniture store 40 miles from your home, instead of offering free delivery within four hours (as some do), offered to loan you an ox cart for the eight days it would take to transport your new furniture home and then return the rig, you would find the offer ridiculous. When an EHR vendor offers to sell or rent a relic of the past, a computing ox cart if you will, many not only find the offer reasonable but do not seem to appreciate the premium that is being exacted for the privilege of being confined in a box that does so little and does it so poorly.
2. What kind of EHR might we expect from thinking outside the boxes? As I have said before, a modifiable, content-neutral EHR that permits the practitioner to record the clinical encounter accurately, thoroughly and swiftly while also permitting the capture of information that may be needed in the future for fiscal and administrative management, accountability and clinical and epidemiological research.