My father used to tell me that if you ask for the wrong thing that it's probably what you'll get. It's rare to be told instead that it's the wrong thing. There seems to be pretty general agreement that something is wrong with the way healthcare is provided these days. If EHR was the right thing, adoption would be almost universal by now. Since it's not, and so many are complaining, I'm guessing that is because people have been asking for the wrong thing — and getting it.
If you listen to the complaints the message comes through loud and clear: demands for evidence-based medicine, concerns about patient safety, requirements that healthcare organizations conduct quality improvement programs. You hear it in complaints about unnecessary tests and procedures — unnecessary because they are not justified based on what is known about the patient's problems or did not influence the patient's outcome. You hear it in the complaints of stressed-out physicians who have trouble remembering to follow up on all the processes that they set in motion. Practitioners and organizations at risk of failing to note key results that would demand immediate attention had they appeared on someone's radar.
It's difficult to design a complex, centralized system to serve more than one master. That's why I keep urging a separation of concerns. If billing, charting, or order entry is the primary goal, then billing, charting, or order entry it will be. Everything else will be subordinated and left to chance, meaning that it will probably not perform as hoped.
Medicine does not suffer from an absence of record-keeping (seeEMR: Efficiency Mauled Repeatedly). Sure, recordkeeping could be better, but it's not non-existent. What is missing is cybernetic control of healthcare processes — the use of feedback to communicate the current state of a process to the people or devices responsible for the outcome so that necessary adjustments can be made. The concept of intelligently adjusting the details of a process to achieve the desired result is neither new nor foreign. It's not new because the word cybernetic derives from the Greek kybernetes meaning steersman or navigator; Plato used applied the term to regulating the function of government.
It's familiar because homeostasis and feedback mechanisms keep our bodies functioning smoothly. Without cybernetic control, life as we know it would probably be impossible. Cybernetics is behind the military concept of C3I (Command, Control, Communications, and Intelligence) that I previously mentioned at the beginning of this series. Command and control refers to the ability to manage complex sequences of events, including gathering information, marshaling resources, and directing or controlling processes. Communication is, of course, the means by which the feedback signals are able to have their effects.
If you accept the notion that the root cause of what ails medicine is the absence of effective feedback and control mechanisms, one must ask: “Why force the entire nation to implement outdated EHR systems that were designed to serve billing and record-keeping goals?”
The billions that are committed to “incentivize” adoption of EHR will not have the desired effects on the healthcare system because EHR is not what is needed. What are needed are cybernetic control systems that can be easily implemented and that can be tailored to different clinical settings. There must be bi-directional communication with the medical record but the control systems should be implemented as separate components. They are too important to be “bit players” in an EHR for the reasons discussed above. Products like this don't exist today but I'm guessing that a mega-buck incentive would yield interesting options in very short order.
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