Anti patterns in EHR implementation, part 1: addiction to perfection.

I’ve been writing some stuff about the things that I keep seeing in the healthcare IT world, especially regarding EHR implementation. Most of it is in draft from now, but I wanted to write down about a particular one, the addiction to perfection.

My PhD is in a way focusing on the lack of perfection in certain domains, and accepting  it as it is, for better decision support. In the last 13 years or so, I’ve been involved in thousands of conversations with people demanding solutions, and a particular pattern in healthcare is becoming more an more obvious for me.

Almost all the stakeholders in the demand side of this discussion, always have very high expectations, and almost zero tolerance about what a proper EHR solution would look like.  We have a raining set of documents with tens of thousands of pages arriving in our mailboxes everyday. Everyone, and everyone is so diligent when it comes to providing opinions about what should an EHR implementation provide.  That’s good of course, seeing that attention to details. The only problem is, everybody, but everybody takes this huge amount of requests as indispensable. We must have perfect security, perfect performance, perfect simplicity, ease of use, you name it. And if you can’t provide these to the level we want you to, then this is not a successful outcome.

Really? I mean really? Let’s take a look at the level of imperfection in the processes and tools in healthcare. Any text about patient safety will tell you that walking into a hospital carries some incredible risks, even if it is only for a very simple procedure. What is the response to this? Well, it is a problem, and we need to do better. Good, but you are not shutting down the whole healthcare system because there are mistakes. Take a look at the tools. There is a sensitivity and specificity for many medical tests. There are gold standards of course, but you don’t get to use gold standards all the time, as they are sometimes too expensive, or invasive, or slow etc. The practice of medicine accepts this fact. Clinicians and administrators will explain to you the reasons behind false positives, and false negatives, and for those who are having trouble, check out this excellent paper from BMJ. Medical devices have their rate of error. Medical tools are imperfect, tests have their error rates, and yet, the practice of medicine is not grinding to a halt due to this. The very people who demand perfection in IT systems are running their operations everyday, accepting other deficiencies, and saying that they are continuously being improved. Whenever someone says that “but without proper <insert your favorite aspect of EHR implementation here>, the results would be disastrous!”, they should be reminded of the already existing disastrous results which is not stopping what they are doing. Believe me, they are not that hard to find.

So why is it the case that when it comes to EHR systems everyone keeps demanding perfection as a starting point? The world is full of huge projects soaked in vision and pan fried in indispensable principles. When they usually fail, the creativity which does not exist in the project itself is usually there to provide a perfect explanation for the failure. In fact, in many of the large scale projects, perfection only exists in justifying the mess.   This is mostly because the bar is always so high, and the scope is so wide. Demand side of things is always evolving into this outcome, and supply side is mostly happy about it, who would not love a millions of pound/dollars contract?

I am in no way defending lousy outcomes here. I am trying to understand why perfection is an absolute starting point, or a shiny frictionless base on top of which we should build everything, rather than being taken as a goal, arrived to in steps.  Iterative approaches can help a lot here, but people seem to avoid them passionately. Perfectionism is good, but how come you accept lack of it in almost every other aspect of your practice and demand it for EHR systems?

I’ll keep posting more on the anti patterns and I’ve got a lot to say about supply side of things too. Till then, take care.