There are great similarities - and great differences -between EHRs and the auto industry.
The automobile is the product of a series of developmental and evolutionary cycles. Today's car could not have been imagined by the pioneers in the field. Only as first-hand experience was gained with the car and every aspect of its use, maintenance, impact on society, etc., did it become possible to imagine how it might be changed or enhanced. It would not have been possible neither in 1769 when the first self-propelled vehicle was built or in 1885 when Benz built the first car powered by a four-stroke gasoline engine, to have conceived or written the specifications for a 2011 model. In fact, if they had, the automobile might have been a flop because they would not have guessed right. The success is attributable to the fact that inventors, engineers, and business people have been attuned to both the public reaction to their products and relevant scientific advances. Along the way designs and features that were not well received were eliminated. The willingness to develop and deploy innovative technology increased both the utility of the product and the public's interest.
Automotive innovation has been relatively unconstrained by regulation. The standards and regulations that exist, whether they relate to safety, fuel economy, bumper height, right vs. left-hand drive, etc., leave the manufacturers wide latitude to build whatever kind of vehicle they believe will interest their customers.
EHRs and the industry that builds them are also the products of a series of developmental and evolutionary cycles that parallel those of the auto industry in many respects although the timing and duration of the various phases differs greatly.
The design concepts that have “inspired” today's typical EHR system have a great deal in common with Henry Ford's concepts in 1900-1908 of how his factory system should be arranged. Ford’s notion of a production line represented a major step forward - the biggest since interchangeable parts, achieved in 1803 after a failed attempt a few years earlier by Eli Whitney. In order for Ford to mass-produce cars, he not only had to create a production line, he needed a source of parts - but there were none. Ford solved that problem by creating a complete supply-chain to acquire the necessary raw materials, manufacture the components necessary to assemble complete vehicles, and dispose of the waste. Ford was very religious and many of his notions of how a system of production should be organized reflect his religious zeal and ideals. He hated waste. Kingsford charcoal, made of the waste wood from the auto body plant, was a byproduct of Ford’s frugality and interest in profit.
Thus it was that the concept of an “integrated system” became firmly rooted in the American psyche. Ford's success seemed to constitute prima facie evidence of the value of a tightly integrated system functioning like clockwork with waste and inefficiency reduced to a minimum.
From the standpoint of product reliability, and usability, today's EHRs and our healthcare system itself have advanced to nearly the same level of the vehicles that Detroit was producing in the mid-1950s. There is a lot of hand-work. Things that go awry on the production line are discovered either by performing retrospective inspections of the results or when a complaint is registered. The bottom line may show a profit but the managers are aware of the high internal costs and spend considerable time and effort looking for ways to spend less on what they are doing. Attempts to increase the reliability and quality of the actual “production” (healthcare) process are frequently foiled because the EHRs lack important capabilities.
You can see these parallels to the auto industry reflected in the typical EHR and in people's expectations of what an EHR should be. First and foremost, it is commonly assumed that an EHR should be an “integrated” system that controls all sources of information, all intermediate processing, and should provide every service and function that might be needed to deliver patient care. To suggest that a system could or should operate differently is often considered to be an affront to the “religious tenets” of EHR.
Despite what “should be,” the real world does not, and never did, work this way. What Ford did was as much a matter of expediency as an expression of his social philosophy. The auto industry and many others have re-evaluated the merits of this approach as business conditions evolved. Today's industrial systems consist of flexible, distributed supply-chains involving dozens or hundreds of suppliers providing the goods and services needed to produce finished products. The job of the primary manufacturer is one of coordination and quality control; first making sure that they have a source for everything that is needed and that is shows up on time and then ensuring that at each step of the production process nothing of substandard quality is passed along the line. The easiest way to achieve this quality is to engineer each step to eliminate sources of variability and error and institute procedures that intrinsically yield the desired quality. The final step is to push this philosophy back into the supply-chain so that it is adopted by each of the component suppliers.
In the next part of this blog, we’ll explore the “integrated” EHR and how the certification process hinders the natural evolution of these systems.
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