EHR - Time for a New Paradigm? (Part II)

August 1, 2011

Perhaps it is time to consider that despite the brilliance and hard work of the pioneers, the early decisions, made when their naiveté was unavoidably most pronounced, have had the effect of defining a paradigm for EHR that is not capable of yielding the results that they envisioned.

In part one of this blog post, Daniel Essin explored the history of healthcare computing and its importance at where systems are today. Here, he explains how time has advanced, but EHRs have not.

Dr. Guy Octo Barnett summarized the situation succinctly in 1968:

"Early interest in bringing the revolution in computer technology to bear on medical practice was plagued with over-enthusiasm, naiveté and unrealistic expectations. The use of computers would, it was held, allow rapid and accurate collection and retrieval of all clinical information, perform automatic diagnosis, collect, monitor, and analyze a variety of physiological signals, perform and interpret all laboratory tests immediately, and replace the telephone and the medical record by fulfilling their functions. In fact, however, attempts to apply computer technology to medicine have had only limited success, with numerous failures. The growing pains encountered in applying computer technology are not unique to medicine; the same types of experiences have been realized in all other areas of computer application. Indeed, one of the benefits of the computer revolution is that it stimulates and requires an intensity of thinking, a level of sophistication and a strictness of semantic behavior that are needed badly in the development of improved methods of delivering health care."

"The initial wave of optimism and enthusiasm generated by beguiling promises of an immediately available total hospital computer system has passed. Now, efforts are directed toward the painful, slow evolutionary process of developing and implementing modules or building blocks for individual functions. There is now a keen appreciation of the wide gap separating a demonstration project, however impressive, and an operational service system in daily use. Stringent reliability requirements and the difficulties attendant when non-technical personnel (with a high turn-over rate) use a computer system on a round-the-clock basis have been two of the key limiting factors in HIS development. In addition, the very high initial costs often stagger hospital administrators; demonstration of cost-benefit savings is difficult. If the experience of other industries is repeated in hospitals, the use of computers in hospitals will not reduce total medical-care costs, but will lead to more effective use of the resources at hand and to improved patient care."

In 1988, he said: “We are still in this painful, slow evolutionary process. We still face the reliability problems, the high initial costs. In reading these old articles I am impressed at how valid were our concerns twenty years ago, and how many of the issues we confronted then are still valid.”

Twenty-three more years have passed and an uncounted number of attempts have been made to develop EHR products that live up to expectations. None have succeeded unconditionally and Dr. Barnett's comments are as true today as they were when they were made. The systems and products developed during the past 50 years have been the experiments that tested the implicit and explicit theories embodied in the paradigm established by the pioneers. The only possible conclusion is that the accepted paradigm does not establish principles that, if followed, lead predictably to systems that do what is expected of them.

Perhaps it is time to consider that despite the brilliance and hard work of the pioneers, the early decisions, made when their naiveté was unavoidably most pronounced, have had the effect of defining a paradigm for EHR that is not capable of yielding the results that they envisioned.

Albert Einstein is reputed to have said that “Insanity is doing the same thing over and over again and expecting different results.” While it was not insane to do what has been done to date, to avoid being declared insane in the future, it is time to do something different - to concentrate on developing and validating new theory that can set EHR development on a different and hopefully more successful path.
 

References:
Barnett GO. Computers and patient care. NEJH. 1968; 279:1321-1327.

Barnett GO, Greenes RA. Interface aspects of a hospital information system. Ann. NY Acad. Science. 1969; 161:756-768.

G. Octo Barnett, History of the Development of Medical Information Systems at the Laboratory of Computer Science at Massachusetts General Hospital, www.seaislandsystems.com/Hardhats/HistoricDocs/OctoBarnett-History.pdf

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