The Unsteady Connection between EHRs and Old Houses

August 11, 2014
Daniel Essin, MA, MD

Welcome to "This Old EHR," where we look at why your system is lot like older homes: built using outdated methods and in constant danger of structural issues.

The past few months, my comments have taken a backseat to other things like recovering from surgery and working around the house. My silence hasn't interrupted the stream of negative things that people have to say to me regarding their experiences with EHR, healthcare reform, re-engineering, and the "lean" virus that so many healthcare CEOs have caught from their consultants.

It's worth thinking about the lessons one can learn from houses (and buildings in general), especially old ones like mine, that apply to EHR.

The first lesson is that old technologies never die. Newer ones are adopted and used right alongside the old, creating all sorts of integration challenges and the risks that accompany the added complexity.

One popular construction technique has been the "pile." For thousands of years, people have piled up stones, air-dried mud bricks, logs, fire hardened bricks, and concrete blocks. Piles work well up to a certain height in seismically stable regions. The news provides daily reminders that if one ignores theory and science and build using piles in seismically active regions, the buildings collapse and people die. Ignorance, necessity, belief in the supernatural, and denial lead people to continue to take risks.

The ability to make and work with steel brought us saw blades and nails which led to stick (frame) construction. This is where my 1920s house enters the story. Its design was not based on theory nor was it "engineered." It was just assembled using "best" (meaning prevailing) practices - wood sticks nailed together resting on some concrete that had been poured into a trench in the ground. Long Beach, Northridge, and Loma Prieta were all years in the future. They didn't put rebar into the concrete, tie the wood structure to the concrete foundation, include shear panels, or tie the lower levels to the upper levels to resist upthrust. Each one of those major seismic events revealed a flaw in the "best practices" which, it turns out weren't best after all.

There was nothing in 1920 to prevent the identification of the kinds of forces that buildings could experience in earthquakes and devising construction techniques that would resist those forces - nothing except hubris and ignorance.

History proves that "best practices" are rarely "best." They are not even necessarily good. Instead, they are mostly a reflection of what people know how to do, complicated by the fact that many of the "doers" do not actually know what they are doing. It's obvious by looking at completed construction that only a minority of those who are employed as carpenters even know the best practices. The rest just do something that looks to them to be similar to what they see others doing.

I can "read" all of this in my house every time I have an occasion to peel back the plaster or drywall and see what is underneath. I don't like what I see. That's why I'm busy rectifying and reinforcing rather than writing.

The same situation applies to your EHR. It was just assembled by a crew of computer carpenters according to "best practices" or, more likely, only what the developers knew how to do. Parts were piled up; other parts are like sticks that were nailed together. The technological equivalents of seismic activity, wind, and flood have not been fully identified and therefore reliable techniques to resist them do not exist. The construction crew may include individuals with titles like "scientist" or "engineer" but there is little about the construction of the typical EHR that reflects scientific principles. Without a theoretical basis, there is a limit to how much can be engineered.

In the future, EHR will experience the technological equivalent of Loma Prieta and Katrina. Today's systems will collapse or suffer severe damage when those disasters occur. The wise person will attempt to identify the potential hazards and reinforce their systems accordingly although, without a clear understanding of both theory and prevailing construction techniques, this will prove challenging. The wise person will avoid committing to projects that have a high likelihood of encountering significant cost overruns. They will also avoid committing their entire available budget to a single "uber-project." They will thereby self-insure against the unknown but highly predictable disaster that awaits them in the future.