EHRs: Weighing Form vs. Function

From the outset, computers have followed two diverging paths. Along one path, we find efforts directed at creating special-purpose devices intended to satisfy specific needs. The fact that a computer was a component of the device was secondary. If something other than a computer could have fulfilled the role that is now fulfilled by a computer, it might very well have been chosen instead. Ovens, toasters, home furnaces, airplanes, and cars all used electromechanical components to regulate their operation long before computers were available.

Computers are now used instead because they cost less and are, for the most part, more reliable. Consumer electronics provide some of the best examples of how a computer contributes to the design and operation of a special-purpose device while remaining completely hidden from view.

Along the other path, we find general purpose computers. Within limits that I have discussed before, computers excel at certain tasks involving computation, numerical analysis, storing and retrieving information.

While these tasks can be computationally intensive, an individual task rarely occupies the computer for very long. In the early days computers were staggeringly expensive; it was imperative that they be fully utilized and the costs apportioned among the users. When I was working on my Master's thesis, computer time cost about $1,000 per minute. The requirement that they be "shared" by many users, each with their own unique set of computations, meant that the computer had to be general purpose; able to accept and carry out diverse and unanticipated sets of instructions.

By the mid-1970s, microcomputers, by-products of the Apollo program, made it possible to build inexpensive replicas of big, general-purpose mainframe computers and again, the designers had no idea how each computer would be used so they emulated the mainframe's general purpose philosophy as well as its hardware architecture.

General purpose devices stimulate creativity and innovation; special-purpose devices, if successful, primarily stimulate consumption - that is their raison d'etre.

The distinction between special purpose and general purpose is not sharp, there is a middle ground filled by a myriad of devices that could have been truly general purpose had they not been constrained in some way by their designers - perhaps to further a marketing goal or as an expression of the personal philosophy of the designer. You can probably name the most famous occupants of this middle ground: Macintosh, iPhone, and iPad. There are many that have come and gone: CAD workstations for architects, the TI Explorer Artificial Intelligence machine and dozens of others - all eventually replaced by general purpose alternatives.

It's fair to say that healthcare computing in general and EHR in particular would be nowhere today were it not for the general purpose IBM-PC and Microsoft Windows (that allowed developers to exploit multi-tasking). Without them we would still be staring at "green screen" CRTs and typing arcane commands. The Macintosh was never a player in this game, not only because that was never Apple's objective but it was and is intended to be somewhat special-purpose, and lately, has become further specialized into a kiosk through which you buy things from the iTunes and App stores.

Windows 8 may jeopardize the general purpose nature of the PC. Microsoft's new goal is, apparently, is to follow Apple by turning the PC into a consumer-oriented, special purpose device. Much of the software that is currently used in healthcare may not run on Windows 8.
Microsoft has apparently gone to great lengths to force the PC to look like and work like a Windows Phone. The user experience, according to many commentators, is confusing and can interfere with applications that must display lots of information and which require intensive user input.

PC hardware has become extremely consumer oriented. It is now unusual to find support for any display resolution higher than that needed to play a movie. The effect is to limit how much of a patient's chart you can view on one screen without scrolling and paging.

It is worth reiterating the lesson taught by Fritiof Sjostrand, my professor of cellular ultrastructure: Form equals function. You cannot materially change the form without affecting the function since it arises from physical structures and it is those same structures that are the forms you see. What you see is all there is, as Daniel Kahneman would say. If you don't like what you see, you probably won't like what it does either.

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