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Current EHRs resemble early automobiles - and they will also continue to become more reliable and useful as they mature.
Industries follow a path similar to human beings: birth, growth, maturity, and decline. A physician's practice can avoid a lot of frustration with an EHR system by being aware the EHR software industry is not mature. Whether it is a toddler, in grade school, a teen, or a young adult is open for debate, the industry is clearly in the growth stage.
A quick look at the history of the U.S. automobile industry can help us understand some aspects of the current reality of EHRs and what we can expect in the future.
In 1909, there were more than 200 automobile producers in the United States. In 1907 alone, 82 U.S. producers entered the market. Rapid growth in the number of automakers continued between 1911 and 1922, adding an average of 15 automakers per year. Barriers to entry grew and between 1923 and 1966 a total of 15 U.S. automakers began production. By 1941, there were nine automobile producers in North America. GM, Ford, and Chrysler had captured more than 80 percent of the domestic market by 1930 and maintained their dominance for decades.
In mid-2012, more than 1,500 EHR modules or complete systems are certified for meaningful use. The number of market entrants has slowed and exits have accelerated, a trend that will continue as more sophisticated systems are required. Many vendors will be bought, merged, or simply leave the market. As with the auto industry, there will always be niche players and new entrants, but the market will most likely be dominated by a few behemoths. The process will confer a strong market share advantage to early EHR systems, although that does not mean they will necessarily be the best products.
Two conclusions are especially important:
1. EHR conversions are all but inevitable. An exit strategy is an essential element of each selection process.
2. Market penetration does not guarantee high quality.
Shift from Mechanics to Marketers
Early in the mass-market phase of the automobile industry, mechanical experts like Henry Ford dominated design. The focus was on the mechanical marvel itself, as opposed to the experience of drivers and passengers. Current complaints about physicians' technophobia and resistance to change echo Mr. Ford's comment that a buyer could have any color he wanted, as long as it was black.
In the 1940s, automakers began to design vehicles to accommodate drivers' wants and needs, and the trend continues. In 2012, automobiles are purposefully designed for comfort, pleasure, and safe operation. No current manufacturer would dare characterize a complaining driver as a Luddite who just does not get it.
EHRs will progress through the same evolution. Vendors will master the technology and that mastery will allow them to direct their attention to enhancing the user's experience. Competition will require a commitment to customer satisfaction. The shift will come more quickly for EHRs than automobiles, but it is still not in sight.
The principal influence on early automobile design was the horse-drawn carriage or wagon. As producers realized that the automobile was an entirely different type of conveyance, they developed a variety of approaches to free themselves from the constraints of the carriage model and leverage the unique characteristics of the automobile. The steering wheel is good example.
Current EHRs depend heavily upon the paper chart model. Since there are significant and fundamental differences in character between electronic and paper documentation, there is an inherent tension between the medium and the system design. Over time, designers will understand the EHR function in a different way and users will become comfortable with a system that preserves the SOAP note but does not resemble the paper chart.
Since frustration results from unmet expectations, we can all lower our frustration with current EHRs by being aware that they are, at best, adolescents. They will mature. And, like the automobiles of the 1930s and 1940s, full maturity will not be necessary for very significant benefits. The decision for individual practices is when they choose to commit to the new paradigm.
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