Black Swans, EHRs, and Your Medical Practice

You may be familiar with Nassim Taleb who, in 2007, put forward the concept of "Black Swans," his name for highly improbable events that exhibit three principal characteristics: they are unpredictable; they produce a massive impact; and, after the fact, we concoct an explanation that makes them appear less random, and more predictable, than they were. He calls them Black Swans because it was long believed that since no one had ever reported seeing a black swan that there were none - until one was unexpectedly discovered.

By their very nature, Black Swan events are not predictable. Taleb points to World War I, 9/11, and the Internet as examples of Black Swan events. In his new book, Antifragility, Taleb explains that making elaborate plans that depend on the future being a repetition of the past is a formula for disaster, e.g. the 2008 financial meltdown. The future is under no obligation to be influenced by the past. Such assumptions lead to fragility - things break when subjected to unexpected forces. Instead he suggests approaching the future by trial and error. When the unexpected creates options, be prepared to choose the one that is most favorable. Taleb applies the term "antifragility" to a situation in which the downside of the unexpected is minimized while providing opportunities for a huge benefit.  He cites biological evolution as perhaps the best example since natural selection provides a mechanism to profit from the unexpected. Biological processes, being imprecise, intrinsically generate random errors which, in turn, create opportunities for a species to benefit from changes in the environment.

Healthcare reform and the regulatory push for EHRs involve elaborate plans that are predicated on the future being a repetition of the past - but your future cannot and will not repeat the past. Assume that you have yet to adopt EHR but are planning to do so. The EHR will alter every aspect of your organization and work flow in ways that you cannot predict. Some of those changes may be so unexpected and dramatic that, when they occur, will be your Black Swans. Will they break you or have you approached EHR in a way that will allow you to profit?

Perhaps you have an EHR or hospital information system (HIS) and are going to replace it. In addition to the above question, there is another, equally challenging one. What is your exit strategy from the old system? Is your master patient index clean? Does the vendor provide a way to export the data in a format that can be loaded into the new EHR? How about the clinical work in process, the charts, old lab data, etc? What happens to all the customizations that you made (at great expense) to the old system? In other words, do you have an exit strategy from the old system and did you choose a new one that is compatible with it?

Assuming that some Black Swan event (either precipitated by the EHR or not) doesn't destroy your organization, the time will come when it becomes necessary to again change EHRs. Vendors come and go; even the biggest. Technology changes and vendors abandon old platforms. Your mission, expectations, and/or incentives may change. It may become necessary to treat your old EHR as a sunk cost; something that must be cleared away to adapt to the changed environment. Whatever the reason, at some point you will need an exit strategy. If you didn't consider that when you selected the EHR, you may again be confronted with the challenge of how to preserve your data and work in process.

I'm not suggesting that you can predict the future. I am saying that the need to change systems from time to time is predictable. You can either ignore it until the need is acute which will make you fragile - or you can choose systems that offer good tools for data loading and unloading which will give you options when you encounter a Black Swan event in the future. Modular systems that allow you to keep parts while jettisoning others seem to me to be an antifragility strategy.

Adopting an EHR is not simply a matter of choosing one, it involves making a sandwich: an EHR (with condiments) between two slices of exit strategy.