Medicine is about Sustainability, HealthIT Not Yet

May 25, 2015

When you look for guidance on the sustainability of technology, look to the government. No, not HHS, but instead the U.S. Department of Defense.

One major goal of medical practices is to benefit the patient by restoring and sustaining (maintaining) health in a manner that minimizes harm and suffering. Sustainability - living long and prospering - is an innate desire for people. And, they would prefer to be in control the choices that are made along the way. As a society, these things are so important that we go to extraordinary lengths to provide life-sustaining treatment. We also strive to make the environment safe and healthful (well, at least the progressives do). We worry about where our food and water will come from 100 years and more in the future. We worry about the legacy we will leave our children.

Some search for knowledge to better understand and control our destiny. Others say, "What the h...," relinquish control to their favorite deity, and pray. I'm not expressing preference for any belief system other than one that accepts that there are choices to be made and that we should choose those things that will most effectively sustain life.

The ability to receive medical care when needed is a part of sustainability as is seeing the same physician repeatedly, as opposed to seeing itinerants in an urgent-care clinic. Continuity of care requires a sustainable infrastructure. In the computer age, when information is trapped inside technological artifacts (archaeology-speak for whatever remains of your computer system when you turn off the power), the sustainability of the technology is critical to our ability to provide continuity of care.

Today's EHRs take a short-sighted view. It ignores the limited lifespan of technology. An EHR may do a great job on day-to-day tasks and be a failure in the final analysis. Remember, most of what people use EHRs for is short-lived: place an order -> get a result, record I/O tonight -> look at it in the morning; see a patient -> send a bill: here today -> gone tomorrow. The only thing that has enduring value is the medical record.

It must grow by accretion, discarding nothing. As it grows, if the entries are detailed and thoughtful, it builds a picture of each patient that facilitates effective continuity of care.

Even the military (notably the Defense Advanced Research Projects Agency, aka DARPA), which has tended to focus on short-term objectives is beginning to come around. A few weeks ago they announced (and I told you about) their interest in developing modular systems.

This will allow useful modules to be reused and/or retained while others can be discarded when they are no longer needed.

Recently, DARPA announced a new initiative, recognizing that today's computer systems are not sustainable. I've said all of this before but have not said it better than DARPA:

"Modern-day software systems, even those that presumably function correctly, have a useful and effective shelf life orders of magnitude less than other engineering artifacts. While an application's lifetime typically cannot be predicted with any degree of accuracy, it is likely to be strongly inversely correlated with the rate and magnitude of change of the ecosystem in which it executes.

"This ecosystem typically comprises the clients of the application itself, along with a myriad of sophisticated libraries and middleware, managed services, protocols, models, drivers, etc., that, in turn, interact with the outside world using other complex artifacts ... In the presence of such complexity, it is not surprising that applications typically bake-in many assumptions about the expected behavior of the ecosystem they interact with...

"Ensuring applications can continue to function as expected and efficiently in the face of a changing operational environment is thus a formidable challenge. Failure to effectively and timely respond to these changes can result in technically inferior and potentially vulnerable systems ... Consequently, the inability to seamlessly adapt to new operating conditions negatively impacts economic productivity, hampers the development of resilient and secure cyber-infrastructure, raises the long-term risk that access to important digital content will be lost as the software that generates and interprets that content becomes outdated, and complicates the construction of autonomous mission-critical programs."

This insight is brought to you by the same government that brought you obsolete, non-sustainable EHR technology. The DARPA part, not the HHS part, is what should guide your future actions, but only if you wish to have a future.