Why EHRs Fail

May 6, 2013
Daniel Essin, MA, MD

Some EHRs succeed in medical practices while others fail. There may be a root cause for the failure, but the solution is not easily embraced.

Today's EHRs mostly don't live up to expectations and sometimes they simply don't work at a particular site. Others seem to work but produce insidious, harmful effects that are rarely traced back to their true source. There are other projects that are superficially similar in scope and objectives but are extremely successful.

It is baffling to realize that some projects are successful while others are great disappointments. There must be an explanation. As people search for the culprits, they typically begin by "rounding up the usual suspects." Popular suspects include faulty requirements, poor planning, uncooperative or hostile users, lack of standards, etc. The list of suspects can be effectively reduced to one: People fail, individually or acting in groups, to do something that they "should" have done. In other words, when things succeed it's because computers are God's Gift, when they disappoint, people are at fault.

Those who develop successful systems are on average no smarter or more gifted than those who produced a flop. They all have the same technology available (hardware, programming languages, databases, etc.) Almost everyone uses the same "best practices" as they apply the technology to their problem. All face similar impediments such as bad luck, bad management, insufficient time, or resources. And yet, some succeed and some fail.

There is another possible suspect for the root cause of failure (failure being any outcome where the liabilities outweigh the benefits). The goals of some applications, and the data required to achieve those goals, are a good fit with the capabilities offered by the technology and best practices while others are not. It is no different from observing that you can't fit a square peg in a round hole without doing damage either to the peg, the hole, or both.

In agriculture, when vast tracts of land are farmed with a single genetic variant of a crop, it is called monoculture. Biologists now realize that, while monoculture may increase yields, it leaves the crop vulnerable to any unexpected disturbance, be it climate change, invading plant species, or changes in the insect populations that pollinate and despoil the crop.

Computer technology has become a monoculture that provides what are the equivalent of square holes into which people try to pound goals, data, and information of widely varying types. When the fit is good, the application is a success. When the fit is bad, it fails. The monoculture cannot accommodate or adjust to the new demands imposed by the environment. With EHR, the fit is bad and, when the unanticipated stress arrives, if one fails all will fail. That's the downside of monoculture.

If this hypothesis is correct, the current systems cannot be fixed by a "patch" or by attacking the people with harangues, incentives, or "more training." They can only be fixed by starting over, a suggestion to which most people don’t respond well, or at all. In fact, it probably sounds outlandish, but that does not mean that it is wrong. It may only mean that you are not willing to believe it or to accept the reasoning on which it is based. Unlike the regulators who insist they are right, there is no guarantee than an EHR will fail or that you will be dead in six months. There are only potential risks and benefits to consider. The following quotes illustrate that people have recommended caution and skepticism for millennia. Their advice seems as relevant as ever.

"Take time for all things: great haste makes great waste."

Benjamin Franklin

"Beware of false knowledge; it is more dangerous than ignorance."

George Bernard Shaw

"If you only have a hammer, you tend to see every problem as a nail."

Abraham Maslow

"From the errors of others, a wise man corrects his own."

Publilius Syrus

"Cleverness is not wisdom."

Euripides

"Never tell people how to do things. Tell them what to do and they will surprise you with their ingenuity."

George S. Patton

"What is not started today is never finished tomorrow."

Johann Wolfgang von Goethe

"Patience is the companion of wisdom."

Saint Augustine

"Better be wise by the misfortunes of others than by your own."

Aesop

"Knowledge is of no value unless you put it into practice."

Anton Chekhov

"Ignorant men raise questions that wise men answered a thousand years ago and nothing is more terrible than to see ignorance in action."

Johann Wolfgang von Goethe

 

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