The Rise of the Stupid EHR

Back in the late 90s, I read an article in a trade magazine and the piece made such an impact on me that the ideas articulated have stayed with me to this day. The article, “The Rise of the Stupid Network,” was written by a man named David Isenberg who worked at AT&T Labs Research.

In the article, Isenberg describes how telephone companies of the day were basing their infrastructure decisions around key premises, including the following:

  • That expensive, scarce infrastructure can be shared to offer premium services
  • That the communications infrastructure of the day (at that point, primarily circuit-switched calls) was the only communications technology that mattered and
  • That the telephone company is in control of its network

In making these assumptions, Isenberg wrote, the telcos were tuning out several important trends, including:

  • The massive annual growth in the volume of data traffic running on the network
  • The many different types of data that had begun to travel on the network
  • The diversity of communications technologies under use that were not part of the core network and
  • The extent to which the Internet was shifting control to the end-user.

In his view, telcos like his employer should not have been blindly working to integrate features like more automatic operation and intelligent new services into the existing network architecture. Despite their efforts, he argued, their Intelligent Network was rapidly being superseded by a Stupid Network offering nothing but dumb transport in the middle and intelligent user-controlled endpoints.

While the analogy is far from perfect, many ideas here could be relevant to the EHRs of today. What I see happening is a shift to putting the most critical functions providers use at the edge of its network or even in completely independent hands.

As with the Intelligent Networks of the 90s, EHRs are being designed and built with the assumption that using powerful centralized technology they will manage the data their customers used, and that if customers had any other needs the relevant technologies would merely be tacked onto the core EHR infrastructure.

Yeah, I hear you saying, so what? It’s not abnormal for tech vendors to build a ring of related applications around it that integrate with its core platform and share data with end-users. In this scenario, the EHR is still the hub of all data activity and decidedly the controlling partner in the mix.

Still, EHR vendors are beginning to recognize that some of the most important capabilities they need to deliver can’t be put into place casually on their infrastructure.

Among the most recent examples of this are the deals both Epic and Cerner have recently made with digital health vendor Xealth, which offers centralized digital ordering and management of digital tools on an independent platform.

What we really need, however, is to move beyond systems that create point-to-point, EHR-to-EHR connections between data sources to creating a web of health information. These sources will include a much more robust system making sense of data from well-equipped smartphones, sophisticated, medical-grade wearables, tablets, voice assistant data and far, far more.

And while the EHRs housing this data today will likely never become completely obsolete, the job may increasingly become a “Stupid EHR” whose job is more to switch information from user to user in much the same way telephony systems do.

The truth is, thinking of EHRs as virtual versions of the paper and file cabinets providers once used is already out of the question. What we haven’t decided, but need to soon, is how far the critical functionality supporting digital health must be pushed to the edge of the network.

My feeling is that the trends relegating EHRs into just a part of a data universe are unlikely to move quickly until the pandemic truly begins to loosen its grip. When that happens, though, it could be that today’s EHRs will have a far different role to play in data sharing’s future.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.


  • Agree with your analogy, but it’s more than an analogy. The situation is the same.

    The health care community has a communication issue. Communications needs and expectations are changing, but day to day methods and processes are not.

    Like customers at the edges of the AT&T switched telephone network who were exchanging information and messages, we have health care organizations at the edges of the health care ecosystem exchanging information and messages about individuals’ personal health information. Most of the personal health information messages going back and forth between organizations are old fashioned analog as opposed to today’s digital.

    Despite all the advances in EHRs, they still don’t electronically communicate personal health information well — unless it’s going to a payor for payment of charges being billed. That somehow works.

    The analog nature of personal health information is serious issue because the health care community’s missing out on valuable information. If the messages were digitized and flowing over a “stupid” network we’d have an understanding what types of messages were flowing, between what types of organizations, when they were flowing, and why.

    Information flows are the pulse of an ecosystem and until those flows are digitized and can be measured, we’re spending most of our time in the dark.

    To ameliorate this situation we’ve constructed a framework/model for a national health IT infrastructure. This enhanced health information infrastructure would be open to all individuals or organizations that send or receive personal health information, be based on community defined principles and objectives, and be vendor and technology neutral.

    To that end, we’re planning to give our research results and the framework/model to a community based organization to support future enhancements and use.

    We’re in final stages now and plan to release our framework/model by the end of January.

  • The Stupid EHR analogy woks for me. I like to think in terms of ‘API Neutrality’ where neither the EHR vendor nor their hospital customer can control who connects what and offers what service on the network. We saw that with phone networks first with the end of all handsets had to be sold or approved by AT&T. The second change was even more important, when regulators literally enabled the Internet by forcing AT&T to be neutral on the use of digital modems on top of the voice infrastructure without charging extra.

    We have the information blocking regulations and API mandates in place. However, EHR vendors with app orchards and their would-be middlemen heirs in CARIN Alliance are lobbying hard to keep the choice of device and services out of he hands of individual patients and their doctors. The jury is still out on how TEFCA will restrict patient-directed use. The fact that patient / physician advocates like me are not considered a core participant in the RCE is shameful but can be changed by ONC.

    API Neutrality is the only way to a Stupid EHR. Let’s see if the ONC and CMS regulators are aggressive to enforce the power they already have or whether the “self-preserving silos” of incumbency prevail.

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