Convention or Configuration in Healthcare?

One of the classical debates in computer science is convention versus configuration. This debate manifests in programming language design, product design, marketing, what hardware and software can and cannot do, and how they do it.

In the early eras of computing, configuration reigned supreme. The first computers had no security, no encryption, no rules, and very little if any software infrastructure to sit on top of. The early computers were in many ways a clean slate, akin to John Locke’s tabula rasa. Software and hardware were completely configurable. Before the Apple II, the only people who could acquire a personal computer were those who knew where to buy all of the components and how to assemble them. Assembly often times required soldering. Talk about high barriers to entry.

Apple has risen to become the world’s most profitable company because it embraces convention and eschews configuration wherever possible. Apple pioneered the first personal computer hardware that people couldn’t physically open or configure. Just as importantly, Apple makes software design decisions for its customers so that they don’t have to. It turns out that people want computers that "just work." They don’t want to deal with hundreds of settings and options.

So how has healthcare IT faired in the continuous march towards convention in favor of configuration? It’s been a mixed bag.

In many ways, healthcare IT has always been very conventional. Follow the rules, fill in the boxes, and get paid per Uncle Sam’s protocol. If you deviate slightly, you don’t get paid. Vendors reflect their customers, who in turn reflect the reimbursement system.

In other ways, healthcare technology has become far more configurable. Many EHRs boast over 500 or even 1,000 templates to expedite data entry. There’s no need for that many templates, but their existence reflects the underlying reality that most doctors would in their ideal world document according their own standards.

Epic takes a lot of heat for not being configurable enough. Many say that’s not true. Most of Epic’s practices that limit configurability are probably made in light of the fact that hospital EHR vendors are service companies, not software companies. They know that once you open the Pandora’s box of customization, it never ends. Epic focuses on the proven (and extremely difficult) training and deployment process. Cerner accommodates more configurability but has a poorer deployment record.

Which way should healthcare IT trend? Should vendors make more decisions on behalf of their clients? Because of their access and insight at other organizations, vendors may be more qualified to many decisions given how crucial IT is to most clinical functions today. Or not. Leave a comment with your thoughts.

Kyle Samani is a technology enthusiast who is passionate about healthcare, technology, and startups.

  • Zach Mortensen

    An alternate thesis is that the equilibrium between what you call convention and configuration is dynamic rather than static. That is, the optimality of convention or configuration is not determined by a static industry context but instead varies quite predictably over time as the market matures.

    Clayton Christensen has argued that “integrated” products — what you call “convention” — tend to dominate early in the market when the offerings are not good enough for most customers. But over time products become more mature to the point that they over-serve just about everyone, and the market tilts toward “disintegrated” (“configuration”) products that allow greater specialization and therefore more value creation.

    A great example of this is Apple’s early dominance of the mobile music/phone/tablet market (proprietary hardware, rigid software versioning, tight iTunes integration, walled garden of apps, etc.) followed by the recent ascent of the Android platform (open hardware specs, sloppy software versioning, buy music anywhere, loose app store integration). Is one better than the other? In absolute terms, no. But early in the market consumers clearly preferred Apple’s integrated experience and preferences are now transitioning quite dramatically to the less-integrated Android experience.

    So let’s not assume that the same won’t happen over time in the EMR market. If Epic’s bet on integration seems to be winning today, it might make sense to bet that a disintegrated model will win the next round.

  • caughtinatrap

    In healthcare the disconnect between IT and clinical causes configuration options in clinical applications such as EMRs to become a huge overhead from an implementation and maintainability perspective–as well as causing low adoption rates by clinicians Sure some configuration is needed, but in healthcare it is better to put that configuration in the hands of the clinician. By this I mean design well and you will meet 80% of the cases and for the other 20% introduce some end user flexibility that allows them to modify the system to meet their needs. Vendors need to move away from high services cost, long implementation times that cause low adoption and move to out of the box ‘it just works’ that is what clinicians need and want. Too many vendors don’t understand or utilize clinicians in their design to reach this level of functionality. Mobile is forcing this a bit lets see if the desktop solutions follow suite….

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