To Solve EHR Problems, It's Time to Get 'Real'

Virtual reality (VR) brings to mind people wearing 3D goggles and special gloves and playing "Call of Duty" or having an "immersive experience" flying like a bird.

VR is able to create simulated worlds because within a computer program, it is possible to rewrite the rules and even ignore the laws of nature. All that is needed to enter a virtual world is to suspend disbelief. The essence of VR is not the goggles, gloves, or fantasy. It is the acceptance of an arbitrary set of goals, rules, challenges, and interactions. These tend to be rigid because it's simpler. Flexibility is not necessary in a virtual world. Rules exclude the unwanted and the unexpected is simply ignored and thereby, disallowed.

Why mention VR? Because inside every computer system lurks a self-contained environment that operates on basis of arbitrary goals, rules, challenges, and interactions. That is the definition of a virtual world. Ideally, reality intrudes only occasionally; and if you believe that, I have a bridge for sale ...

Rules can detect and respond to definable situations. They cannot detect the unexpected; if it was possible to formulate such a rule, it wouldn't be totally unexpected, would it? Sometimes, like a bank stress test, the unlikely can be simulated but the truly unexpected. The "Black Swans"

(a term coined by statistician Nassim Taleb) catch every rule engine, and most people, off guard. In a game, the "fun" comes from contending with, and succeeding in the face of, rigid rules but medicine is not a game.

In fact, the practice of medicine is about as far as you can get from VR. There, the complete set of rules is knowable. The "rules" of disease are incompletely known at best. Illnesses, accidents, and injuries may be similar, but they are rarely identical. In medicine, the objective is not to win by complying with arbitrary, rigid rules; it is to win in spite of the rules, whether they are known or not. This requires flexibility and inventiveness. Rigidity is frustrating for physicians and potentially harmful to patients.

Like every computer system, each EHR creates its own VR. The danger stems from mistaking this "virtual" reality for actual "reality." Within the VR, the rules create work for physicians. The typical EHR's game cannot be played without rigid rules. The problem, of course, is that there can never be enough rules to cover every eventuality and there are not enough hours in the day to complete the "virtual" work that the rules generate. Is it any wonder that physicians get frustrated by activities like coding and other "busy work" that add rigidity and that seem tangential to patient care?

Not all computer systems have this problem. For example, Amazon.com works. The rules are neither complicated nor onerous and people are anxious to shop and buy, so they opt in and play the game. The worst that can happen is that their purchase doesn't complete or they end up with non-returnable merchandise.

EHRs don't work well at all. The rules are complex, onerous, arbitrary, and artificial. Physicians have little use for them and would prefer to opt out and not play the game, but most do not have that choice.

What would be better? A system that gracefully accommodates the unexpected. The evidence demonstrates that the recipe for a different kind of system has apparently eluded most developers. It certainly has eluded the esteemed committees that ordained the certification criteria.

The result, according to a recent physician survey: "More than 60 percent of doctors do not consider their current EHR a worthwhile investment." As well they should not, for an EHR is not an investment, it is a never-ending expense - a sunk cost that will never increase in value. Its purchase price can never be recovered by selling it because for all it costs, the customer never actually owns the system (software), they may not own their data, and the hardware depreciates rapidly.

What's the solution? Follow the lead of the Defense Advanced Research Projects Agency (DARPA) by redesigning EHR from the ground up. DARPA "has unveiled its plan for the future, and it’s a huge shift ... the biggest change is its plan to reinvent complex military systems and make them more modular ...," according to a recent article in Extreme Tech. Modularity makes it possible to better manage the unexpected because each module has a narrower scope than a complete system. The smaller the module, the fewer things it must anticipate and address. Those functions that require or benefit from rigidity can be isolated so they do not interfere with others, like charting, where practitioners need the latitude to describe actual events faithfully and without constraint.