The Key to EHR Lies in Identifying Timeless Patterns

September 9, 2013

Choosing a bad EHR … is demoralizing and breeds a lack of intellectual honesty and to a loss of respect for quality information

The Short Version

Early humans, in the movie "2001," wake one day to find an obelisk in their midst. To them, it is an enigma. They see no obvious way that it can help them in their daily lives - it is just there and must be accommodated.

As we (modern humans) modify the environment by constructing buildings, cities, and computer systems, some of our creations blend harmoniously with the natural environment and provide us with capabilities and resources that we can incorporate into our daily activities while others, like the obelisk, can neither perform useful functions, be used as implements to accomplish preexisting tasks better, nor stimulate innovation - they are just there and must be accommodated.

All these human constructions whether physical (houses, large buildings, housing tracts, and cities) or virtual (computer systems) share certain qualities. Some are satisfying to use, delight the eye, and are enduring.

They are, so to speak alive. While they may undergo changes over time, they are, at any given moment, internally consistent and well articulated; reflecting of the needs and expectations of those who inhabit the environment. Others are sterile, garish, dissatisfying to use, and seem to lack an organizing purpose. They seem alien. They are, in short, dead.

It is worthwhile to think about EHRs in this way. A rare EHR is alive.

Its users can occupy it and make it their own. Most, however, are dead - merely uninspired aggregations of functions and modules that must be accommodated.

Christopher Alexander, an architect noted for his identification of the value and importance of patterns, has made it his objective to understand why some architecture is alive. His work has had an unexpected influence on the process of software developers as they realized that software patterns could be identified. Patterns allow developers to avoid the necessity of having to reinvent the wheel every time the need for a wheel arises; they can simply adapt an existing "wheel pattern."

Alexander is not only an architect, he approaches things as would a mathematician or scientist and he is a philosopher concerned about the longevity and social implications of how things are designed and built.

In his book "A Timeless Way of Building," Alexander introduces his ideas. His ideas are more expansive and ecological than those of other famous architects such as Lewis Sullivan and Walter Gropius (The Bauhaus School) that inspired a great deal of dead architecture such as Chicago's infamous Cabrini-Green development.

In my opinion, Alexander is on to something fundamental that is transportable to the domain of EHR. He says (with my embellishments):

"We have been taught that there is no objective difference between good buildings and bad, good towns and bad, [good computer systems and bad]. The fact is that the difference between a good building and a bad building, between a good town and a bad town, [between a good system and a bad system,] is an objective matter. It is the difference between health and sickness, wholeness and dividedness, self-maintenance and self-destruction. In a world which is healthy, whole, alive, and self-maintaining, people themselves can be alive and self-creating. In a world which is unwhole and self-destroying, people cannot be alive: they will inevitably themselves be self-destroying, and miserable."

Having chosen a bad EHR is not merely expensive, inefficient and potentially dangerous, it is demoralizing and contributes eventually to a lack of intellectual honesty and to a loss of respect for quality information. By not allowing practitioners to do what they believe to be right and in the best interest of the patient, a bad EHR eventually, and in subtle ways, causes a diminution of a practitioners' bond with coworkers and with the ostensible mission of the organization, undermining its fabric.

(continued on the next page in longer form)

The Long Version

Since you are unlikely to buy his books on the strength of my suggestion that it might be worthwhile, I present that following excerpts (when reading, substitute an appropriate EHR-related word for every reference to architecture):

• "A town will only be alive to the extent ... [that it] brings order out of nothing but ourselves; it cannot be attained, but it will happen of its own accord, if we will only let it." He calls this the result of "the timeless way of building."

• "To seek the timeless way we must first know the quality without a name ... [a] central quality which is the root criterion of life and spirit in a man, a town, a building, or a wilderness. This quality is objective and precise, but it cannot be named."

• "In order to define this quality in buildings and in towns, we must begin by understanding that every place is given its character by certain patterns of events that keep on happening there."

• "These patterns of events are always interlocked with certain geometric patterns in the space. To the extent they are alive, they let our inner forces loose, and set us free; but when they are dead, they keep us locked in inner conflict."

• "The more living patterns there are in a place, a room, a building, or a town, - the more it comes to life as an entirety, the more it glows, the more it has that self-maintaining fire which is the quality without a name."

• "And when a building has this fire, then it becomes a part of nature. Like ocean waves, or blades of grass, its parts are governed by the endless play of repetition and variety created in the presence of the fact that all things pass. This is the quality itself."

• "[P]eople can shape buildings for themselves, and have done it for centuries, by using languages which I call pattern languages."

• "These pattern languages are not confined to villages and farm society. All acts of building are governed by a pattern language of some sort, and the patterns in the world are there, entirely because they are created by the pattern languages which people use."

• "Within this process, every individual act of building is a process in which space gets differentiated. It is not a process of addition, in which preformed parts are combined to create a whole, but a process of unfolding, like the evolution of an embryo, in which the whole precedes the parts, and actually gives birth to them, by splitting."

• "The [pattern] language, like a seed, is the genetic system which gives our millions of small acts the power to form a whole."

• "And as the whole emerges, we shall see it take that ageless character which gives the timeless way its name. This character is a specific, morphological character, sharp and precise, which must come into being any time a building or a town becomes alive: it is the physical embodiment, in buildings, of the quality without a name."

When people express dissatisfaction with an EHR, I believe that it is a reflection of the extent to which the EHR is "alive," the extent to which it exhibits the "quality without a name," the extent to its design aligns with the natural patterns of work and organization that are found in the healthcare setting, and the degree to which those patterns are expressed in ways that the users recognize and with which they agree.

Not only must the patterns that underlie the EHR satisfy the needs of users, they must offer some advantage to developers as well.

I introduced the subject of fractals in previous articles because patterns - self-similar, nested, recursive patterns - are the stuff of which fractals are composed. Healthcare encounters and medical knowledge can be viewed as a composition of self-similar, nested, recursive patterns. Information and medical knowledge can be represented electronically using a structure made up of self-similar, nested, recursive patterns. If this is done, it can dramatically simplify the programmers' task. Computers thrive on self-similar, nested, recursive patterns, allowing large chunks of information, or selected subsets, to be processed by the same program code while yielding different results.

Unexpected situations (exceptions), another problem that has fractal aspects, can be represented using the very structures that are used for the expected cases, also simplifying program development. These same structures, if they include metadata to make the meaning of the data clear, when the data is eventually removed from its native environment*, would represent a big step toward a platform-independent lifetime medical record.

These behaviors are difficult to effectively graft on to existing systems designed under a different paradigm, especially if those attempting the graft are not deeply imbued with the underlying theory but, as I pointed out last time, it will become necessary sooner or later to design new systems. It would be foolish to once again adhere to a paradigm that has consistently produced sub-optimal results. The time to start learning and developing under the new paradigm is now. These things take time. There is not a moment to lose.

* For example, attempting to open a PowerPoint file from 1993 with Office 2013