Infrastructure lock-in, Innovation lock-out

Peter JonesWu Wei

Experienced systems and design professionals have increasingly raised their concern for the poor design of eHealth Records (EMR, EHR) systems for the last couple of years. The rapid increase in adoption and deployment, spurred by US government stimulus spending, has pushed vendors to roll systems to market in unrepentant haste. With interaction design that would make a 1980’s mainframe designer cringe (like me, I worked on AT&T’s TIRKS as well as with their Labs AI group).

People working directly in the EMR world are building workarounds, add-ons, patches, and alternative displays to fit the data systems to their work contexts and institutional needs.While EMRs are enterprise information systems, they are tightly controlled by their vendors and generally not extensible.

The ad hoc design/development process is unsustainable, could lead to communication and data breakdowns between the EMR and the multiple add-ons. Future maintenance of the workarounds is not guaranteed -a major EMR vendor upgrade could wipe out a year’s worth of work on integrated applications that were rendered incompatible .

There are two huge issues at stake: 1) That poor design or mission critical systems could lead to loss of life and investment, and 2) the institutional lock-in of poorly designed enterprise IS platforms cripples the ability of the organization to innovate with their own data resources.

Current proof? Consider this news article from Pittsburgh two weeks ago, keeping in mind that no “bad news” that could suggest liability will ever emit from a hospital IT representative:

Switch to electronic records alarms Jefferson Regional physicians
By Walter F. Roche Jr.
Friday, October 30, 2009

Jefferson Regional Medical Center’s attempts to convert to electronic medical records have some doctors concerned about patient safety.

In a memo issued this month, the hospital’s Health Information Technology Committee announced the 373-bed facility in Jefferson Hills would revert to printed versions of patients’ consultant reports “due to patient safety concerns from the majority of physicians.”

Jefferson executives downplayed the memo and said they found no evidence that patient safety has been impacted, arguing a small group of physicians expressed concerns and not a majority, as the memo claimed.

“It was a very small number that were concerned. It wasn’t the majority,” said Dr. Richard F. Collins, Jefferson’s vice president for medical affairs. “To this point, we haven’t identified any issue of patient safety.”

I credit and point you to the excellent Health Care Renewal blog, which found and deciphered this disclaiming bit of news (their highlighting was maintained here). A UX designer (and full-time EMR workarounder) also noted this brilliant bit of satire that is (he assures us) quite an accurate representation. See Extormity and prepare to laugh, and cry.

Innovation often occurs at the edges of infrastructure, as new adopters are found within the existing ecosystem built around the platforms. Technical standards beget systems beget services, then beget workarounds and new services. Twitter and other social connection services emerged from the rough-laid brick of the simple RSS feed. Linux exploited the original open O/S BSD, then open source desktop applications grew to fill the consumer need. As Health Care Renewal also finds, and I agree, World VistA could be the Linux of EMRs. But in the meantime, EMR lock-in may lead to innovation stagnation in the secured and highly regulated healthcare enterprise.