When an EHR Meltdown Occurs, Beliefs No Longer Matter

The point of preventative medicine is to worry about (that is, pay attention to) things that we know are almost certain to cause problems for a majority of patients in the future if allowed to continue unabated. For years, many physicians believed that smoking was harmful but there was no irrefutable evidence they could cite to justify their belief. Even when doctors did recommend smoking cessation, few patients were moved by their doctor's beliefs and concerns; they believed it wouldn't happen to them. Now the evidence is available, the conclusions are irrefutable, yet many patients are still not moved by the facts: they continue to believe that it will not happen to them. Belief is a powerful thing.

Stepping back, think about the difference between science and evidence-based medicine on the one hand and the concepts behind creationism and "intelligent design" on the other. Each reflects a school of thought. Let's call them, respectively, "physical" and "metaphysical." The physical school is rooted in what can actually be seen, touched, measured, and observed, including those things that one can imagine or predict could exist, could be seen, touched, observed, etc. Regardless of what adherents of the physical school may hope or believe, they do not accept hope and belief as adequate justification for accepting something as fact, although nothing prevents them from being the basis for testable hypotheses.

In contrast, the metaphysical school of thought rests on belief and hope. Adherents of the metaphysical school regard hope and belief as "facts." They find no need to see, touch, observe, or measure. There is no need to wonder what mechanisms caused things to be the way they are believed to be. Belief explains all.

Whether the subject is something as overarching as the origin of life or something as mundane as whether a particular EHR merits an expenditure of time and money, adherents of the physical and metaphysical schools of thought will never - can never - agree. Their frames of reference differ so greatly that neither can really comprehend how anyone could hold the views that the other group appears to hold.

The conflict between the two schools of thought plays out when a large healthcare organization adopts an EHR. The procurement decision, and frequently the decisions about configuration and deployment, are made by people who are acting on their beliefs. Those within the organization who are then expected to use the EHR, whatever their initial beliefs, may find themselves seeing, touching, and observing the EHR firsthand. When thrust into face-to-face contact with reality, preconceived notions are replaced by experience. When the day is filled with experiences with the EHR that are "clunky," inefficient, confusing, etc., each user is compiling evidence of what is, not what was believed to be. There is good evidence that many users of an EHR, after they have seen, touched, and observed its behavior find that they are dissatisfied.

To work out a survival strategy, it becomes necessary to embrace the physical school of thought. It would take a very strong belief indeed for someone to deny any observation conflicting with their initial belief

The decision makers who initially selected the EHR on the basis of their beliefs may find it difficult or impossible to accept that the front-line people are dissatisfied, in whole or in part, with their choice. Their frame of reference differs so greatly that they cannot really comprehend how anyone could be as dissatisfied or that the problems that people complain about could be real.

Only when things begin to go badly with an EHR implementation on a large scale are the decision makers (those used to acting on belief), forced into the shoes of users. Only when the costs, the inefficiency, the errors caused by the system and/or the inability to implement new policies and business practices force the deciders to deal with nuts-and-bolts, do they find that the metaphysical school has nothing to offer them. They too, must see, touch, and interact with the system as they find it, but by then it may be too late.

The best way to deal with problems like this is to avoid them, but that requires an EHR decision-making process that is scientific and evidence-based, not one heavily influenced by belief. That is, of course, easier to say than to do. Acting on belief is easy. It doesn't require much knowledge or effort, it doesn't interfere with rapid action and it doesn't require decision makers to consider the possibility that their strongly-held beliefs will not be borne out in actuality by the EHRs under consideration.