Paradigms are Local, Paradigm Shifts are Personal (Part II)

In Part I of this post, Daniel Essin detailed his own personal breakthrough in the design and use of EHRs. Here, he continues as to the difference in paradigms vs. paradigm shifts.

So why hasn't my personal paradigm shift become everyone's paradigm shift? Because it only occurred to me and all paradigm shifts are local. Each individual or organization has to change their own thinking and decisions like that are heavily influenced by the community within which they operate. It's not quite social pressure, but when contemplating a big step like purchasing or changing an EHR, it is comforting to have the approval of your peers and that is obtained by doing what they do. It's like Bill Murray's character says in Stripes: “Now, do what I do ... and say what I say ... and make me proud.”

A reader, Lehr Eel, noted that a "paradigm shift involves an abrupt change that brings about a radically different world view with new rules” and questions whether healthcare can make an abrupt change. He certainly won't get any argument from me when he warns about the unintended consequences that can result from incentives or that legacy systems are an impediment to any change.

Abrupt change is difficult enough if the community of interest is small, even if it is scientifically focused. The problems with Newtonian mechanics had been a topic of controversy for a considerable time but were resolved in large part and in only a few years by Einstein's Theory. The debate about the structure of DNA ended quite abruptly after the evidence for double-helix was published. In retrospect, these transitions appear to have been abrupt.

When it comes to EHR, it's not so simple. There are at hundreds of communities within three categories. There is a small group of computer scientists interested in EHR. There is a group of developers and vendors and there is a diverse group of customers including CFOs of large organizations with considerable influence over the vendor/developer group and small practices with little influence. The latter two groups are large and have primarily tangible, rather than intellectual, ties to the existing paradigm. Before it can be said that either of these groups has adopted a new paradigm, the majority of the members need to change how they act, not how they think - and that is an individual decision for each of them. Just confronting them with some “scientific” evidence is rarely enough to induce an immediate behavior change.

In the final analysis this is a “Field of Dreams” problem; no one will come if you don't build it, and maybe not even then and economic pressure being what it is, very little development takes place unless there are likely customers. Most laypeople would lump paradigms with ideology. They just want something that “works” and may not know or care that “working” can be affected the paradigm that guided the development. Until a big, politically-correct vendor chooses to build a radically new EHR that is the product of a new paradigm, there is no reason to expect the average purchaser to buy what they perceive as a “fringe” product, even if it embodies a new paradigm. It is also unreasonable to expect paradigm-shifting behavior from the average developer or vendor who puts food on the table by delivering what the customers think they want.

At the personal level, being “born again” is perhaps the best-known example of an abrupt paradigm shift. Having made the shift, there every reason to view the world differently and act accordingly. Embracing a paradigm shift can be very satisfying, rewarding and even a bit scary.

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