As many of you are aware, I am the editor of Electronic Health Records: Second Edition. I will not be editing a third edition. At first, I was ambivalent about the publisher’s decision to let the book go out of print – it was well received. However, after a while, I realized that the time for it had passed. There will always be clinical care systems, but they will not be today’s EHRs – we are at the cusp of a generational change.
The book’s first edition was published in 2001, having been conceived a few years earlier. In the late 1990s, when the idea for the book arose, EHR systems (or more correctly computer-based patient record systems) were considered the ultimate in clinical care systems. No one had (has) ever built a computer-based patient record. They were a wish. The terminology shift from computer-based patient record to electronic health record occurred in 2003 when the report, Key Capabilities of an Electronic Health Record, was released. As part of that terminology change, EHR systems were defined to be different from EMR systems, principally based on expected interoperability features. Here is how the ONC described EHR systems in 2011.
Electronic health records (EHRs) do all those things—and more. EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information. They are built to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. The National Alliance for Health Information Technology stated that EHR data “can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.”
Like the computer-based patient record before it, the EHR as described by the ONC still does not exist – interoperability as envisioned by the ONC has not yet made its debut.
The majority of EHR systems in use today were designed more than five years ago, and the largest systems used by hospitals systems date back 15 years or earlier. They were designed to fit the constraints that existed at the time.
In the early 2000s, LAN-based client/server was big and broadband Internet access, a luxury. The cloud and mobile devices with 64-bit processors, touch-based interfaces, voice-recognition, and an array of sensors were unknown. Workflow technology suitable for use in clinical systems did not exist a decade and a half ago; now many good systems are available.
Unfortunately, much of the current thinking about clinical care systems fails to acknowledge that many past constraints have been removed. Workflow issues and workarounds are widely discussed, and AHRQ and NIST have provided detailed reports that critically assess workflow issues. Yet, for some reason, workflow technology is rarely mentioned. We have new tools, good research on clinical work needs, and a new computing environment. It is time to try a new approach; it is time to start from scratch.
Two years ago, I wrote a post about EHR market changes (see Disruption in the EHR Market: Will Anyone See It Coming?). At the time, I thought it would take six years, at least, for new clinical care systems to appear that had deep support for CDS, clinical work processes, and clinician collaboration. I had no idea that so much research suitable for clinical system design would appear so quickly. Even more surprising (at least to me) has been how rapidly open source workflow technology has matured (commercial offerings are first rate). Alone, these two factors – more/better research data and workflow technology — are enough to usher in the next generation of clinical care systems. However, Apple has obliged by adding a third factor – a viable tablet computer with a 64-bit processor and, in October, a multitasking iOS 9. I never expected to see tablets with these features until 2017.
Looking back over the last 50 years, the effects of computer generational changes quickly rippled throughout society. Personal computers moved computing power from businesses to individuals, and the market for word processors and other productivity software exploded. LANs allowed small businesses to access software previously only affordable to larger enterprises. The Internet has reshaped entire domains. Amazon is in; Borders is out. Netflix is in; Blockbuster is out. The last three cars bought by my family were located online and picked up at CarMax.
Workflow technology, powerful mobile devices, and cloud data storage represent the newest generation of information technology. Provisioning cloud servers is significantly easier than just two years ago. Databases have changed as well – there are now ACID-compliant NoSQL systems.
Computing technology has moved forward much faster than I expected. So quickly, in fact, that it has been enough to change my outlook on what Informatics Squared, Inc. should be doing for the next five years. Having thoroughly enjoyed learning Swift, I will spend the next two weeks evaluating the latest iterations of two BPM/workflow development tools. Two years ago, both products were “interesting”; today they are ready for primetime.
Don’t say I didn’t tell you: The next generation of computing for clinical care software starts in October, when all the stars align. From that point forward, it will be possible to write the type of clinical systems that have been desired for so long. No, I do not expect the leading HIT vendors to abandon their current offerings and write new systems from scratch. I expect them to do the sensible thing and listen to their customers who are asking for improvements to their current systems—for faster horses.
As things stand, 18 months from now seems to be an opportune time to consider a new book on clinical care systems. By then, MU should have made its last bows, relieving me of the need to learn the latest permutation of certification requirements. It is too early to think about a book outline, but this I know for sure—there will be chapters on mobile devices and the cloud and an entire section on clinical workflow analysis and workflow technology.
Every software system is designed to fit the constraints of the environment it must inhabit, and those constraints have changed radically in 15 years. Welcome to the future—it arrived early.