EHR: A Cautionary Tale

EHR is such a funny thing for me. I can obviously see the power in the data, but after speaking to my son’s doctor a few times about it there is a darker side I’d like to caution us about. As my doctor puts it “we started teaching doctors how to click with their finger and they forgot how to think with their brain”.

The context of this conversation was around the first visit we had to the office after my son was born. Glancing through his folder I could see the printout which had come over electronically from the hospital where he was born. I thought that was totally cool, but when the doctor came in he only took a brief look at it and then dove right in to asking questions.

I don’t know what I thought was going to happen when medical records started going electronic, but this wasn’t it. As a healthcare focused technologist I’ve certainly romanticized the day when large data sets can pinpoint and and forecast problems enabling much needed supplies to be re-routed and all the best doctors from around the world working together like they’re in the same office to cure the world. And here was something different.

After the appointment I couldn’t help myself. Here was an opportunity to interview someone not only in the field, but on the front lines. I know he is only one doctor and this is only his opinion, but it certainly changed the way I think about data. Here’s the gist of what he said:

There’s no doubt EHR is a good thing that will, overall, be a positive in the healthcare community. But until it’s had some time to mature a bit there’s still a few kinks to be worked out. In my particular case he pulled out the record and showed it to me. There’s a lot of stuff there, he said. But it’s not telling me anything.

In the “olden days” of the mid 2000’s, back when doctors still took notes by hand the was a context and depth to what they wrote about their patients. Word choice is important when it comes to taking notes for someone you don’t know that will have to pick them up and understand what you ‘re thinking and feeling about your patients. You could spend a little more time on something perplexing or serious and use slightly stronger or more descriptive words for things out of the ordinary. Today we click a box or select from a menu. It’s not the same. Or to put it more plainly, it’s all the same. Exactly the same. Your record doesn’t differ much from the last ten I looked at.

When I started coding for websites it was in notepad and we didn’t have fancy JavaScript libraries. Heck, we barely had JavaScript because Netscape just invented it and was still trying to get some traction against Microsoft.  I know this sounds a lot like walking to school uphill both ways, but stay with me. We didn’t have XMLHttpRequest (that’s was makes ajax possible for all you younglings), we had the img tag and we changed out the src.  And today’s smartphones have stronger processes, more memory, and better CPUs then our desktops at the time did.

So what’s the value in suffering through life without the innovative technologies of today you ask?  It taught is something about coding. What we lacked in technology we made up for in thinking about things and grew our skills along with the innovations we take for granted today.

So why is that important?  Because it’s as important to know where you came from as it is to know where you are and where you’re going.  Today’s coders are good.  Really good.  We can quickly do things I used to dream about or agonize over.  But there’s a blindspot.  A hole in the knowledge of core foundational operations on which technology as we know it is based.

That’s what EHR is for me after seeing it for the first time through the eyes of a healthcare professional who’s been around since before I was coding in notepad. EHR is the jQuery, dojo, and prototype of our healthcare system. It’s the next evolution ultimately leading to the Web 2.0 doctrine of healthcare which will result in amazing advances in practiced healthcare. But at what cost?

Where’s the risk, and what can we learn from history?

For one, I caution schools and doctors to not lose that edge, that complexity, that difficulty of expression which forced us think about the solution per patient.  Don’t be stopped short and perplexed by a concept which was trial 10 years ago like the young developers of today who are stopped short when the pre-packaged, wrapped up in a bow, libraries don’t offer an out of the box solution.  Remember EHR is only a tool and its base is in traditional healthcare.

Second, and lastly for now, don’t get lazy. When processors got fast and memory got cheap we forgot how to architect and design efficient applications.  Sure the 3D HD THX games were amazing, but then mobile happened and we were set back at least a decade in processing power and storage — the first iPhone had a 412 MHz processor with 128 mb RAM. Almost over night those skills we learned developing in C and perl on 2400 modems were important again.

Speaking of C, what do you think Objective-C (the core language for iOS — iPhone & iPad — development) is based on?  That’s right, C is a language which has been around for over 40 years and today it’s all the rage.

I don’t know what the future of EHR holds, but if it’s anything like Web 2.0 we’re in for a wild ride. But while we are living it up, remember to pay homage to those skills that got us there because they’re still at the root of everything we do and there is a good chance you’ll need them again.