EHR Can't Make Healthcare a Production Line

Today's EHRs are a product of misunderstanding and miscalculation. Here's why. Can you define EHR? Probably not. It's probably one of those words that you sorta, kinda understand in context - at least you think you do - so you press on. Without a clear, shared definition, each individual imagines something different on which they base their expectations.

For some, an EHR is a medical chart with some utility functions tacked on. For others it is an order entry/result reporting tool with a charting function tacked on. Some see it primarily as a way to "capture data." (Are you sure you know what data is?)

Many seem to expect an EHR to control the clinical process, speed throughput and reduce variation, in other words, to "automate" Medicine through TQM, QA, CQI, and Six Sigma - concepts borrowed from the manufacturing sector. The idea is to improve quality and reduce cost by eliminating variation at the source, rather than after the fact - a great idea provided that is the procedures that are varying, not the patients.

These ideas gained traction in the late 1980s. Healthcare came to be viewed as an industry, inspired by the success that companies like Toyota had in improving quality while lowering unit costs. Healthcare executives and politicians wondered:  Why can't Medicine be more like Toyota?

EHR is supposed to be a big part of the answer - the means by which clinical practice will be turned into a finely tuned production line, moving patients smoothly along toward a state of glowing, good health. Using the data captured by the EHR, healthcare delivery will be analyzed. The bottlenecks and variation-inducing steps in the production line will be identified and eliminated and, as a result, everything will be efficient and cost effective.

Well …as good as these ideas are, and although there may be specific situations that might benefit from them, this approach is simply not applicable to medicine in general. Manufactured products such as cars are just mechanisms. They are built to a precise design (that can be changed if faulty) and are predictable whereas people are complicated and unpredictable. The things that can go wrong with people are only imperfectly understood.

The decision to view healthcare as an industry and to pattern the delivery of healthcare as a factory production line is a root cause of the dissatisfaction with EHR that is so common today. EHR can’t do what is expected, because what is expected is inappropriate and impossible. EHRs are constantly being made more complex in an attempt to "get control" over that pesky clinical production line that is constantly being interrupted every time reality and the patient’s needs intrude. Is it any surprise that EHRs tend to produce unanticipated, undesirable results or side-effects?

Variability between patients can never be eliminated because it cannot be predicted. Human physiology and pathology exhibit emergent properties - complex behaviors that can't be appreciated when looking at the components individually. Furthermore, what we know about pathology and physiology is dwarfed by what we don't know, making it difficult to correct a problem either on the "production line" or after a breakdown, even if one is identified.

Finally, unlike factory workers, physicians are not an abundant resource like running water that can be called forth in any desired quantity, simply by opening the tap, as many executives seem to think. While almost anyone (even a doctor) can be trained to be a factory worker, not everyone has the traits required of a good doctor - intellectual curiously, empathy, creativity, inventiveness, skepticism, compulsivity, and a commitment to ethical principles.

Not only is the effort to turn medicine into an orderly production line under the precise control of an EHR futile and misguided, 20 years of trying has only produced disappointment. It’s time for thoughtful analysis and meaningful definitions, not hype and platitudes. The dreams of usability and "meaningful use" will remain elusive until EHRs are redesigned from the ground up to focus on the needs of doctors and patients, not those of administrators, corporate boards, and politicians. Learn enough about the technology to form realistic expectations, then clearly define your terms. The process starts with you.