Integrated EHRs - Has Their Time Come Or Gone? (Part II)

In the first part of this blog post, the parallels between the auto industry and EHRs, and the belief that these healthcare tools be integrated systems.

While an “integrated” system has the attraction of apparent simplicity, attempts to improve quality and efficiency are best made sequentially because each can have unanticipated ripple effects on the entire system. The full effect of each change must be assessed before moving on to the next. In practice it is easier and quicker to have a dozen component suppliers each working in parallel to improve their quality and efficiency. 

The idea of using a distributed network of services to achieve an overall result is familiar to everyone, as long as they are not thinking of EHR. Hardly anyone would consider going to law school to integrate legal knowledge into their brain so they could deal with a legal issue, most simply retain an attorney. When you need a document signed and authenticated, most people use a notary public instead of inventing a proprietary scheme of secure signing. When you need to look up a word, you don't try to memorize the dictionary, you consult a reference.

To think of it another way and at the personal level, to create your own integrated system would mean homesteading a long way from civilization. You would be responsible for growing or catching everything that you ate, wore, lived in, etc. There are a few hearty souls who may be capable of this; the rest have adjusted to, and thrive in, an interconnected society where people provide goods and services to each other. Going it alone and being interdependent each present risks, one from disruptive events, the other from always being close to the edge and having no margin for error.

EHRs face an immediate obstacle that will probably interfere with the necessary evolution from taking place. That obstacle is EHR certification. The certification criteria favor and reward integrated systems. It is much easier for a single vendor to get a product certified than it is for a group of vendors to collaborate in producing a system that employs a network of interconnecting components all working cooperatively to achieve the desired results. Certification and the economic threats that accompany it may deter innovative healthcare organizations from attempting to assemble their own network of components.

EHR certification criteria are not permissive, like the ones affecting the automobile, they are prescriptive and detailed. The very existence of the certification criteria interfere with the natural evolution of EHRs. The certification committees assert that the criteria are essential but the criteria mainly represent the consensus of a group that uses systems which meet the criteria or in which they have an economic interest. What evidence is there that the criteria promote, let alone insure, improved healthcare?

Perhaps a new, truly innovative EHR would provide the desired benefits but would lack some of the mandated features. What is important, means or ends? A strong emphasis on means (process), as typified by certification, implies a belief that the results may be unattainable. When planning for failure, process is critical. It allows everyone to demonstrate that they did precisely what they were supposed to have done and therefore that the inevitable failure was not their fault. When success is expected, the emphasis is on the results, not how they were obtained. As recommendations, a list of features or criteria can be very useful; as a mandate, they penalize those who would make serious attempts to reengineer their healthcare delivery process.

It's pretty clear why integrated EHRs have been favored over modular systems built up as a network of suppliers of specific functions and services - it is the result of a deeply ingrained cultural bias and the fact that the existing technology has made it attractive to build the sort of systems the customers seem to expect. Most major industries and business have gotten over this bias after concluding that their ability to survive depended on doing so. It's hard to say precisely by how many years healthcare is lagging industry in coming to this conclusion. One hopes that it is less than the 100 years that separate us from the inception of Ford's original idea for an integrated production system.

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