Long-term Fixes to EHR Systems Require More Than Workarounds

Every craft, manufacturing, construction, or professional activity such as aircraft, high-rise buildings, weaving, dentistry, cooking, or home building, is based on theoretical principles derived from fields such as chemistry and physics. Specialized tools and materials have been developed for each activity. The best practitioners have not only the skill (training plus experience) necessary to use those specialized tools and materials effectively, they are artists.

Some activities, such as cooking and home construction/remodeling are deceptively simple, allowing amateurs to dabble in a domain also inhabited by professionals. Five-star chefs can prepare elaborate meals for larger numbers of diners with greater consistency than the amateur cook, but food prepared by an amateur is often satisfactory for their needs. An architect working with skilled craftsmen can produce a more pleasing and perhaps more structurally sound home in less time than a weekend "do-it-yourselfer," but either structure can provide shelter.

Many people dine out and commission custom-designed buildings and homes because they desire the value that a professional has to offer. While professionals will almost always do a better job than amateurs, they can only do their best when they have access to the "right" tools and materials, but such access is not always possible.

If a home needs an emergency repair late on Sunday, there is only going to be one source of supply - the Home Depot or some store like it. If the repair calls for a specialized tool or supply, the Home Depot probably won't have it. They cater to those working at or near the amateur end of the spectrum (people who don't know about or can't afford specialized stuff) and it only stocks items that it can sell in high volume. The professional may be able to devise a wider range of solutions to the problem than the amateur, but both will be limited by what is on the shelf. Whatever the pro does, he/she will probably classify it as a workaround that can hopefully be put right as soon as possible. The amateur may end up with the same solution but not appreciate that it represents a workaround. Workarounds are familiar to virtually everyone. Scraping the charcoal off of burned toast is a workaround. It’s better than nothing, but not ideal.

There is a lesson for EHR in these prosaic examples. When something is discovered that an EHR should do, but doesn’t, the response is to devise a workaround. Only rarely is the response to have an architect remodel or rebuild the EHR.

Dietary restrictions end up on the allergy list because there is no special place for them. A new paper order form is introduced for X-rays because the order entry module of the EHR doesn’t collect information that the radiology department demands. Some workarounds are quite inventive but they have an effect on the EHR that is much like the plaque that accumulates in people's (not yours of course) coronary arteries. They gradually impede the work flow and make the system more susceptible to a fatal attack.

The need for workarounds is not limited to systems that have been implemented. When it comes to development, most EHR programmers are amateurs. Few have any specific training and are constantly asked to devise workarounds to features they may not fully understand. Like the do-it-yourselfer, they may not recognize a workaround even as they create it. It comes up so often that it seems to be part of the normal development process rather than an extraneous step needed to compensate for limitations and obstacles imposed by the system design, the tools or the programmers themselves.

The number of workarounds and the rate at which they accumulate is a good measure of the robustness of an EHR’s design and implementation. The best systems exhibit extremely low workaround rates and users may go for years without encountering a need that was not anticipated or could not be accommodated by the original design.

What differentiates systems that require frequent workarounds from those that don’t? The design - especially the extent to which it incorporates fundamental principles drawn from medical information science that are known to facilitate flexibility and usability.

Next week - how the Home Depot phenomenon contributes to the emergence of workarounds.