Freedom a Key Factor and Obstacle in EHRs' Evolution

Something happened 65 million years ago and as a result the non-avian dinosaurs became extinct. An extra-terrestrial observer at the time might have thought something like: "Those dinosaurs had better evolve because big changes are coming."

Obviously evolution is not something that organisms (the subjects, the target of the coming change) can choose to undergo. Evolution can be said to have occurred, retrospectively, if a subject exhibited characteristics that rendered it poorly adapted to changing conditions and if those characteristics were somehow replaced by others that enabled it to thrive.

To say that something "must" evolve is just another way of saying that there are problems which, absent some change, do not seem to be compatible with continued viability.

Gripes about today's EHRs often conclude that "EHR must evolve." Clearly, a large number of people believe that something is wrong with today's EHRs and that if the problems are not fixed, the continued viability of today's EHRs is questionable; a Google search for "EHR must evolve" returns approximately 12 million hits.

So EHR "must" evolve, but can it and will it? By what mechanism? Evolution results from the interaction between available internal sources of change (such as mutation) and external pressures that will cause some individuals (the better adapted ones) to become more prolific and thereby predominate in future generations. That is the essence of natural selection by means of the survival of the fittest.

Darwin's theory rests on two facts: mutations occur and environmental conditions change. Challenges to the theory question the plausibility that random mutations, often lethal or disabling, can be the source of the dramatic improvements that appear to have occurred.

Can an analog to Darwinian evolution be found in the sphere of human activity? Yes - it is the free-market.

In a free-market, individuals are free to invent, devise, or construct computer systems intended for application to the practice of medicine. The developer's goals may or may not coincide with the goals of potential users. The developer's concepts and definitions of terms may or may not be understood and shared by potential users. The designs may have characteristics that allow the system to be incrementally changed, improved, and extended over the lifetime of a patient - the potential to evolve - or they may not. The implementation of the concepts may or may not result in applications that are easy and satisfying to use and which enhance the efficiency and effectiveness of the users.

Potential users are free to evaluate their options and choose, or resume waiting for something they like better (called slow adoption by those with an agenda). While waiting, new developers may enter the marketplace, some individuals may decide to develop their own solutions or existing products may "evolve" to the point that they become desirable.

That's what a free-market would be like - but we haven't got one. What we have is what the Nobel Prize-winning economist F. A. Hayek [^1] would have described as a program, the ultimate goal of which, is to dictate the social and economic organization of healthcare. Its realization depends, ultimately, on abolishing private healthcare and private control of the means of delivering that care.

The aim of such programs, to use Hayek's words, is to "substitute totalitarian government control for the market economy. No longer should individuals, by their buying or abstention from buying, determine what is to be produced and in what quantity and quality. Henceforth the government’s unique plan alone should settle all these matters. 'Paternal' care of the 'welfare state' will reduce all people to the status of bonded workers bound to comply, without asking questions, with the orders issued by the planning authority." The evolution of EHR, so desperately hoped for, is next to impossible under such a program as it eliminates both creative latitude and the financial incentive to innovate.

If "EHR must evolve" then evolution must be given time and opportunity. It depends on the freedom to make mistakes and the willingness to suffer the consequences. Planning authorities take away that freedom, disrupting the normal mechanisms of change and thereby preventing the very changes upon which they depend - the quintessential unanticipated consequence. "Live Free or Die" [^2]

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[^1] Hayek, FA: Socialism: An Economic and Sociological Analysis, Preface To The Second English Edition, 1922. http://oll.libertyfund.org

[^2] http://en.wikipedia.org "the official motto of the U.S. state of New Hampshire… speaks to an assertive independence historically found in American political philosophy."