I meet Dr. Koppel at the last Indivo X meeting at Harvard. After hearing about his work I realized… this man must be the one of the saddest people in the industry, it is basically his job to study the interface between people and EHR systems. He is the guy who documents just exactly how EHR systems fail. e-patient Dave is blogging about a talk that Dr. Koppel gave.
EHR software famously under-performs.
As Dr. Koppel points out, from the perspective of the clinicians, the design of the EHR systems are pretty bone-headed. The standard answer from vendors is “we cannot fix that” until they have a financial incentive (like a lost sale or contract) to get something done.
For instance, Dr. Koppel points out that there is problem with the sorting of drug dosages drop down in an EHR. For fun I can show you how it would actually look:
Hard to imagine why the options would be in that order, why doesn’t it look like this?
The reason it looks like this is because the software is sorting alphabetically by written name… you can see it more easily if you write it like this:
But why is this happening at all? Why wouldn’t the software automatically do the right thing? I could imagine several possibilities. Perhaps the dosages are stored as strings and then converted to numerals for display. Perhaps this decision was made because there is a mix of numerical and text data in the doses field of the underlying database. Something like “seven milligrams” and then “seven milligrams time release” or some such. But I do not know. More importantly, Dr. Koppel likely does not know, and the clinicians who have to carefully choose a dose using choosers like this every day… do not know why the system is designed like this. I could be wrong, Dr. Koppel could know… but if he does, it is because he has been told by someone who can read the sourcecode.
I think we should pause at the irony here. If we could name the chief endeavor that modern medicine is undertaking one might say “crack the DNA code”. Our cells are “programmed” with a code that until recently we could not read and that we still cannot comprehend. We are seeing “through the glass darkly” into our own cells for a thousand natural reasons.
However, we tolerate a situation where clinicians see “through the glass darkly” into their own health software. Why? Because the have decided to use proprietary software. Why do they make that choice? It seems so illogical that it makes me dizzy. I wanted to respond specifically to some of the things that were said in the presentation:
Dr. Koppel: Customization is a sales gimmick and not meaningful.
The only way to make customization meaningful is to have full source code access with the right to modify the code running in the hospital.
Problems could be fixed by smart 14 year old.
If and only if they have access to the sourcecode. The insight here is that is a question of “access” and not “complexity”
Let me take a close look at how open source licensing impacts each of these.
The simple reality is that the funding from ARRA will go towards installing software that will stagnate and rot in the hospitals and clinics across America precisely because clinicians do not understand the implications of software licensing. Dr. Koppel focuses on “the software contract” which is mostly an irrelevant afterthought. Unless the software license allows you to fire the software vendor and get one that will reorder your lists correctly, the contents of the software contract are irrelevant. The right to fire in an Open Source software license has teeth. It changes the power dynamic in ways that the contract cannot.
My grandfather once told me never to play another mans game. “If his game is pool, play him in chess. If his game is chess… play him in pool.” Clinicians are losing the software game again and again, they need to stop playing the game that has been setup by the proprietary software vendors.