A Health IT Developer’s Confession: How Bad Software Is Made and What to Do About It

It was a dark and stormy night. My computer didn’t catch fire while typing the previous sentence. No alarms were triggered warning me about the quality of such opening. I wasn’t prompted to select subjects and predicates from dropdown lists. I typed the entire sentence, letter by letter, not at all dissimilar to its first rendering back in 1830. Computer software in general, and Microsoft Word in particular, magically removed the hassles of quills, ink, paper, blotters, sharpeners, ribbons, whiteout, carbon paper, dictionaries, and all the cumbersome ancillary paraphernalia needed to support authoring, but made no attempt to minimize the cognitive effort associated with writing well.  Authoring great literature today requires as much talent and mastery as it did in the days of Edward Bulwer-Lytton.
For several decades, software builders have tried to help doctors practice medicine more efficiently and more effectively. As is often the case with good intentions, the results turned out to be a mixed bag of goods, with paternalistic overtones from the helpers and mostly resentment and frustration from those supposedly being helped.                 
Whether we want to admit it or not, the facts of the matter are that health IT and EHRs in particular have turned from humble tools of the trade to oppressive straightjackets for the practice of medicine. Somewhere along the way, the roles were reversed, and clinicians of all stripes are increasingly becoming the tools used by technology to practice medicine.A common misconception is that EHR designers produce lousy software because they don’t understand how medicine is practiced. The real problem is that many actually do, and the practice of medicine is precisely what they aim to change. These high clerics of disruptive innovation would have you believe that “resistance to change” is equivalent to the resurrection of paper charts, thick ledgers, and medical information coded in secretive hieroglyphs. The truth is that physicians want to use modern computers, but they resent being used by computers. And the truth is that if we shed the orthodoxy imposed on us by self-serving “stakeholders”, computer software can indeed help address various problems in health care, some in the here and now, most in a distant future.

One thousand and one elements

This may sound strange to some, but the first step towards putting EHRs back on the right track should be to stop trying to help physicians practice medicine. Clinical decision “support” in the form of alerts, disease specific templates, mandatory checklists, required fields and rigid workflows are some of the things that must be removed from EHRs for two reasons. First, most of these “features” don’t work very well anyway. Second, more often than not, the real purpose of said support is not clinical in nature. For example, alerts about generic substitutes for brand name medications, data fields that must be filled and checkboxes that must be clicked to satisfy billing codes, PQRS or Meaningful Use, and the wealth of screens to be traversed before an order can be placed, have no clinical value.  And in most cases the opposite is true.

Some experts argue that EHRs are failing because they are nothing more than an old paper chart rendered on a computer screen. Many others are outraged by the fabled lack of interoperability (dissemination of information) or the lack of EHR usability, i.e. number of clicks, visual appeal, color schemes and ease of information retrieval. I would suggest that these dilemmas are peripheral to the one foundational problem plaguing current EHR designs – the draconic enforcement of structured data elements as a means of human endeavor.

When Google mapped the Earth, it did not begin by mandating how to build and name roads and buildings. When we indexed and digitized books and articles, we did not require that authors change the way they write prose or poetry. When we digitized music, we did not require composers and performers to produce binary numbers at equidistant time intervals, and we did not make changes to musical instruments to allow for better sampling.  We built our computerized tools to ingest, digest, slice, dice and regurgitate whatever humanity threw at us, without inconveniencing anybody. This is why good technology seems magical.

EHRs on the other hand, are obnoxiously demanding that people change how they think, how they work, and how they document their thoughts and actions, just so that the rudimentary software prematurely thrust upon them can function at some minimal level of proficiency.  People don’t think in codified vocabularies. We don’t express ourselves in structured data fields. Instead of building computers that elegantly adapt to the human modus operandi, EHRs, unlike all other software tools before them, demand that humanity adjust itself to the way primitive computers work. The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.

All the pretty horses

What is the purpose of EHR documentation templates? There is practically no EHR in use today that does not include visit templates. Visit templates are a list of checkboxes, some with multiple nested levels, which allow documentation by clicks instead of by typing, writing, drawing or dictation. Visit templates are created for each disease and contain canned text for findings judged pertinent to that condition by template creators. In all fairness, many physicians like documentation templates because with just a few clicks you are able to generate all the documentation required nowadays to get paid for your work, pages and pages of histories, review of systems, physical examination, assessments and plans of care. Do doctors like templates because they believe this extensive documentation is necessary, or do they like templates because the checkboxes alleviate the pain of typing thousands of meaningless regulatory words? I suspect the latter.

Clinical templates, along with the automated clinical decision support they enable, are advertised as time savers for physicians. The time saved is the time previously spent with patients, and most importantly the time spent thinking, analyzing, and formulating solutions. For most, it’s also the time spent rendering thoughts in a manner that can be understood by another person. Furthermore, when your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say. Even in “efficient” practices where staff does the clicking and physicians have the luxury of asking “open ended” questions, the patient story, the quirky details that are irrelevant to the template, are not documented (highlighted, circled, noted on the margins, etc.) anymore. Is this a good thing?

If we proceed on the assumption that IBM Watson and the likes are eventually going to be artificially intelligent enough, and big data are eventually going to be big enough, to respectively analyze and represent a complete human being, then yes, we can safely dispense with old fashioned human expertise. However, we are most certainly not there yet, and regardless of industry rhetoric, we are not certain that we will ever be there, and we are not even sure that we want to ever be there. While this utopia (or dystopia) is portrayed by interested parties as “inevitable”, chances are that for at least several generations we will be forced to contend with imperfect digital renditions of medicine, instead of allowing EHRs to follow the growth of underlying technologies. This is akin to summarily confiscating and shooting all the horses, on the day Henry Ford rolled the first Model T off his assembly line. Where would America be today, if we did that on October 1, 1908?

Furthermore, what type of doctors are we producing when we teach medicine by template, supported by clinical decision aids based on the same template, and assessed by quality measures calculated from template data? Medicine does not become precise just because we choose to discard all imprecise factors that we are not capable of fitting into a template. Standardization of processes and quality does not occur just because we choose to avert our eyes from the thick edges were mayhem is the norm. Dumbing physicians down is not the optimal strategy for bringing computer intelligence closer to human capabilities. EHRs should not be allowed to become the means to stifling growth of human expertise, the barriers to natural interactions between people, or the levers pushed and pulled at will by greed and corruption.

Bildungsroman style

Instead, EHRs could be the scaffolding for IMB Watson and other emerging contraptions to grow and become truly useful tools for both doctors and patients, and yes, also for legitimate and beneficiary secondary uses of clinical information. Instead of mandating that doctors think and work in ways that serve Watson’s budding abilities, we should require that Watson learns how to use the normal work products of humans. Instead of enforcing templated thought and workflows, whether through direct penalties for doctors or indirect certification requirements for software, we should work on teaching Watson how to parse and use human languages in all their complexity. Watson should grow up to be the multi-media scribe behind the computer screen, the means by which the analog music composed by physician-patient interactions is digitized into zeros and ones without loss of fidelity and without interference with actual performance.

Billions of years of evolution endowed the lowliest human specimen with cognitive abilities that machines will most likely never attain. The glory is in the journey though. We need to accept delayed gratification, and we need to accept that the challenge will span centuries, not just one boom-bust cycle of a fleeting global economy.

We need to accept the fact that we will all die long before the ultimate goals are achieved, instead of declaring victory whenever each negligible incremental step is taken. If we are going to create a new form of intelligent life on earth, we need to assume the same humility Nature, or God, has been exercising since the dawn of time and counting. Otherwise, we are all just a bunch of hacks looking to make a quick buck on the backs of our fellow men and women.

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30 replies »

  1. The problem with these organizations is that they are like politicians:
    They were for it before they were against it. Once the horse is out of the paddock, it’s hard to get it back.

  2. I think both the AMA and AAFP have some initiatives, and both are making some efforts to scale back the CMS carrots & sticks program…

  3. Agreed. While not knowing the players, I speculate that those who sit on the certification boards are mostly “all in” on the hyped promise of EHRs…..and that it will be very very difficult to change their outlook.

    ……just as it will be very difficult to counter the legions of lobbyists who will argue for continuation of the CMS subsidies/penalties/incentives for EHR adoption.

    Do you know of organizations that are working to fix the EHR mess?

  4. Nice post, Margalit. You’ve done an excellent job describing the implosion caused by EHRs at ground zero—the clinician/patient relationship. The collateral damage has been horrific too. Expert docs retiring prematurely, billions of dollars wasted, serious errors made by trusting the EHR info, significant drag on health care productivity. It may take the perspective of a generation to fully comprehend the disaster.

  5. Yes, and we have to be careful here, because just discontinuing incentives/penalties for docs is not sufficient. We need to remove EHR certification requirements, since that’s how all the cavalier design decisions are essentially being made and enforced.

  6. The source of the EHR damage to the doctor patient relationship and the fiscal damage to our health care system was HiTech incentives (CMS “These incentive payments are part of a broader effort under the HITECH Act to accelerate the adoption of HIT and utilization of qualified EHRs.”

    Without these incentives EHR’s would likely have developed in a manner in which they were helpful to physicians and not encumbered with all the population management and administrative bells and whistles that most “thought leaders” love.

    A necessary step in correcting the EHR disaster must include ending the Hitech incentives/subsidies…..unlikely to happen until after the 2016 Presidential election.

  7. Some things should be open to discussion, but IMHO the guiding design principle must be shifted away from data collection for the sake of data collection.

  8. Thanks Dr. Carter and thanks for the links to those great articles.

  9. Terrific post, Margalit. Hope those in position to change the misguided rules and agenda care providers have been forced to follow, read it!

  10. Great post!

    Health care consists of processes. Taking a history, examining a patient, ordering a test— all are processes. EHR systems were conceived and designed to be systems that capture and present data to clinicians, not support processes and the attendant decision-making. MU then tried to take data-focused systems and retrofit them to be process-focused systems by kludging on even more data collection requirements. That did not work, so the follow up has been to emphasize usability. However, the architectural differences between data-centric and process-centric systems will ultimately limit the ability of any user-centered design initiatives to bring about significant changes. Clinical care is process-based, systems that support clinical care must support processes. Providing data is simply not enough.

    (See Is the Electronic Health Record Defunct? http://ehrscience.com/2014/04/28/is-the-electronic-health-record-defunct/ and Liberating the EHR User Interface http://ehrscience.com/2015/10/19/liberating-the-ehr-user-interface-part-ii-workflows-and-widgets/)

  11. I would respectfully disagree in a few areas (or submit the following for consideration):

    “Clinical decision “support” in the form of alerts, disease specific templates, mandatory checklists, required fields and rigid workflows are some of the things that must be removed from EHRs for two reasons.”

    There are some checklists put in to help both clinician and client. Verifying medications is a good thing (but should be part of the patients’ computer time, not the doctors). There are still patient safety issues when doctors don’t or refuse to follow the guidelines.

    “For example, alerts about generic substitutes for brand name medications, data fields that must be filled and checkboxes that must be clicked to satisfy billing codes, PQRS or Meaningful Use, and the wealth of screens to be traversed before an order can be placed, have no clinical value.”

    It does have value to the patient. Maybe changed to be given to the patient or yes, the doctor does need to be aware now of other substitutes that cost less to the patient. With the list of doctors & admin who have been caught for fraud, this is unfortunately done because of “bad” people.

  12. There really isn’t much good currently. The rationale seems to be that this is like a paying it forward sort of scheme, and there will be some kind of reward at the end of the line, if we integrate computers into the cognitive process of medicine. There is no empirical proof for any of this though, so you either believe, or you don’t. A bit strange for a largely scientific endeavor….

  13. Having watched every Star Trek episode dozens of times, I can convince myself that at some point in the 24th century, if all goes well after the “eugenics wars”, we will reach a level of scientific development where computerized holographic (or otherwise) physicians will be fully capable of treating patients.
    On a more serious note, dreams are great, but what I do resent, is the attempt to shape today’s (sticks and stones by comparison) medicine as if we already have acquired Star Trek technology, or will certainly have it by next Tuesday.

  14. You say, “The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.” But you imply that there will be clinically meaningful clicks in our future when self-appointed thought leaders learn to digitize the multivariate, interactive, inexact, unreliable and temporally varying factors that comprise the idiosyncratic predicaments of life. Really? Ever? https://thehealthcareblog.com/blog/2014/07/11/missing-the-forest-for-the-granularity/

  15. I just reviewed EMRs on a patient who is getting a return to work evaluation. Unless I knew in advance what he was being seen for, I would have had very little clue from looking at the records. And the med list is horrible, it continues to list meds, but then below it says certain ones have been discontinued.
    The flow and discontinuity of these records makes them essentially useless unless there’s a good narrative in addition.
    I just don’t see anything good about it.