Compressing the Curve

Last week, we explored a few ideas surfaced by Dr. Atul Gawande in his New Yorker essay, ‘Why Doctors Hate Their Computers.’   I have one more thought on this subject, this one more mine than his.  At least I am not just ripping his stuff off today.  Is that progress?

Let’s go to our imaginary white board and let me draw the old venerable bell curve to as I rip off another guy’s idea.  So much for my progress.

Back in the early 90s, Geoff Moore wrote ‘Crossing the Chasm,’ a great book about how new technologies are adopted into the market.  You’ve probably heard it referenced somewhere.  Innovators are on the far left side of the adoption curve as they go first.  Then come Early Adopters as the technology starts to gain traction.  The fat part of the distribution curve includes the Early and Late Majorities.  Finally, the right tail brings us the Laggards, the last people to get with the program.

That summary is brilliant not because it reveals some deep mystery, but because it simply and accurately captures the way things are.

The history of many new technologies – electricity, fax machines, smart phones, complex business software – shows that movement through the curve takes time, as it should.  Every different market segment plays a valuable role in advancing the technology. 

Back to last Friday’s post, there is a time when we want a lot of mutation, a lot of variety, a lot of experiments.  But then, for a technology to progress as it should, we need the big majority to bring in the power of selection, killing off the bad ideas and reinforcing the good ones.  Often, this process takes 30-50 years.

Unless the government gets involved.  Like it did with the EMR.

So, we decided we needed our entire industry automated faster.  Whether it was driven by vision, the need to cut spending, or just a politically acceptable government handout doesn’t really matter.  It happened. We first dictated it, then we bribed. 

If adoption was the goal, it worked.  In the space of about seven years, we went from near zero EMR market penetration to near 100%.  Few technologies will ever rival that pace. $30 billion of subsidies helped.

And along the way, we screwed this up big time. 

Mandated software functionality killed off early stage variation at the time it was most needed.  Subsidized purchases, compressed into a very short time frame, took away the market’s critical selection process as bad solutions that should have died persisted like Zombies.

The optimistic view is that though we forced the Laggards into the technology way too fast, we’ll eventually get it right, though we’ll probably take the rest of the normal 30-50 years before we do so. 

The pessimistic view is this jacked up process so resulted in fundamental flaws that we’ll never get it right. 

We’ll check in around 2040 to see which is right.

Miller Time

EMRs have a Reggie Miller problem.

Miller was a tall, skinny kid from LA who could really shoot the basketball.  Drafted by the Indiana Pacers in 1987, Miller ended his NBA career with over 25,000 points.  He could shoot from long range and had a penchant for making clutch shots at the end of important games.  As the kids say, ‘the boy could ball.’

But Miller had one big problem. 

He was born at the wrong time. 

Just before he joined the league, this other guy showed up.  Michael Jordan.  You might have heard of him. 

Jordan’s Chicago Bulls won six NBA championships in his 15-year career; Miller’s Pacers? None.  As good as they were, they could never get past Jordan and the Bulls.  Reggie is (unfairly) too often remembered as foil on stage while we oohed and aahed at MJ’s brilliance.

Poor Reggie.  Poor EMRs.

Like Reggie, EMRs were born at the wrong time, coming onto the scene at the same time as this other technology – the smart phone.

Few things summarize a physician’s expectations of, and frustrations with, their EMR better than the dreaded line that every EMR support person on the planet has heard too many times to count – ‘Why isn’t this dang (edited for public consumption) thing as easy to use as my iPhone?’  A rant generally follows.

I get it.  Docs, as proven by regular use of their omnipresent cell phone, are not the Luddite technophobes some believe them to be.  It is the EMR specifically they don’t like.

But there is a really critical difference between the gear Apple makes and the EMR you want to throw through a wall every day. 

As noted by Dr. Atul Gawande in his recent essay in The New Yorker magazine, the two systems have fundamentally different purposes:

‘Consumer technology is all about letting me be me. Technology for complex enterprises is about helping groups do what the members cannot easily do by themselves—work in coordination.’

 There, in two sentences, is a root of the physician’s frustration with their EMR, something that won’t be ‘solved’ even if we bring Steve Jobs back to life and outsource the whole thing to Apple.  My phone serves me and me alone.  I don’t care if even my wife finds it weird how I organize my apps on the home screen…it is MY phone.

The EMR simply has to serve many, many masters, not just the physician user.  Data sharing, connection to payers, communication with patients, billing, compliance, research – the list is endless. 

The implications of this reality are endless, resulting in a product that is beyond maddening for physicians to use.  That the correlation is high between physician burnout and the level of daily EMR-induced profanity (Can we get EIP established as a valid diagnosis?) is no surprise.

Can these be improved?  Of course…a lot.  That sermon is coming. 

But solved?  Nope.  Adjust your expectations accordingly.