By JORDAN SHLAIN, MD

Chief information officers (CIOs) and chief medical information officers (CMIOs) have spent the better part of two decades on a quest for interoperability; yet, their Achilles heel lies in the “information” part of their titles. If information is the sole beacon of efficiency and value, the invaluable contours of human suffering, personal preferences and humanity itself are lost.

Information is the first step to developing knowledge and understanding, but what physicians and patients rely on in the real clinical setting, rife with changes, are knowledge, understanding and empathy. The cold, hard calculus of a=b does not always apply when dealing with people because they are much more complex and complicated than binary machines with screens. If it were so easy, there would be no problem reaching 100% compliance with medication or a plan of action.

Sadly, all data lives in a database; which might as well be called a wait-a-base; after all, the data just sits there and waits for someone to look at it.

The fundamental problem with today’s information architecture is that all data are not created equal. Data, information and knowledge degrade with each new doctor that becomes involved. In addition, systems design lacks an understanding of how the human computer works in the context of illness, anxiety or uncertainty. Healthcare is a people business in need of data, not a data business in need of people. Data are the means; people are the beginning and the end.

Today’s environment is laden with an emphasis on revenue, cost and quality, while big data, mobile devices and the Affordable Care Act also bring promise. The follies of contrived informatics harm the system it serves and the patients (and doctors) that rely upon it.

A brief look at history reveals that the origin of “data” in healthcare is borne out of the medical claim, whose original purpose was to unlock the cash register, not create a knowledge system for understanding what matters most to doctors and patients. Instead, it was a system that wanted information to adjudicate cash. When the claim became the center of gravity, the ability to navigate knowledge and understanding devolved into a world where structured data and interoperability became the prizes.

Recalling the childhood game of “telephone” will illuminate part of the problem with informatics.

Today’s environment is laden with an emphasis on revenue, cost and quality, while big data, mobile devices and the Affordable Care Act also bring promise. The follies of contrived informatics harm the system it serves and the patients (and doctors) that rely upon it.

A brief look at history reveals that the origin of “data” in healthcare is borne out of the medical claim, whose original purpose was to unlock the cash register, not create a knowledge system for understanding what matters most to doctors and patients. Instead, it was a system that wanted information to adjudicate cash. When the claim became the center of gravity, the ability to navigate knowledge and understanding devolved into a world where structured data and interoperability became the prizes.

Recalling the childhood game of “telephone” will illuminate part of the problem with informatics.

“…the origin of “data” in healthcare is borne out of the medical claim, whose original purpose was to unlock the cash register, not create a knowledge system for understanding what matters most to doctors and patients.”

Getting a patient to agree to a care plan requires a belief in that plan and as with belief systems, there is an expectation of trust (or blind faith). Trust and communication are the bedrock of relationships; EHRs value transactions of data, not relationships.

Medical decision making requires the use of knowledge, experience and data; however, the current paradigm relies almost solely on the latter. It may be useful to look at the works of Heinz Von Forester, an Austrian American scientist and the father of second-order cybernetics (they investigate the construction of models of cybernetics), to appreciate the critical role of knowledge-based systems and the influence of those that create them.

Each new doctor that gets a hand-off from another doctor is often given the homogenous data file of the continuity of care document. Similar to the telephone game, the data have already changed once they have been received, and there is no data set for what has historically worked (knowledge) and for what patients’ preferences are (U-data). Furthermore, the feedback loop does not exist to ensure fidelity of understanding.

The American College of Physicians recently published a position paper (1) that basically states that all electronic medical records were built for defensive medicine and billing while adding unnecessary complexities to the lives of doctors and patients. The article says:

“Electronic health records should be leveraged for what they can do to improve care and documentation, including effectively displaying prior information that shows historical information in rich context; supporting critical thinking; enabling efficient and effective documentation; and supporting appropriate and secure sharing of useful and usable information with others, including patients, families and caregivers…Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach to the detriment of patient care.”

Health is a foundational attribute of  life; it is existential and important. Information about what happened to us, what is happening to us and what could happen to us is all wrapped into a non-linear, non-local model. Different data types are often simultaneously dependent and independent on other data types; they interact with each other in non- linear and often non-obvious ways.

It’s time to take a deep breath and think more holistically about what needs to be accomplished for people, both proactively and reactively. If zeal for efficiency and cost containment drive strategy, they might result, but an amazing opportunity will have been missed—the opportunity to design a system to enable actionable information, wrapped in the context of the data types elucidated above; to use mobile technology whenever possible; and to teach how to observe, listen and respect the powerful nature of U-data.

The art of medicine in the context of religion, beliefs, fears, suffering and socio-economic status cannot be homogenized by data architecture. There needs to be a move towards integrating what matters to individuals with what is the matter with them. A recent study in the Harvard Business Review elucidated why people trust human judgement over algorithms; To err is human, but when an algorithm makes a mistake we’re not likely to trust it again. Furthermore, algorithms are unable to factor in the concept of the ‘benefit of the doubt’.

Healthcare has many interfaces where systems, subjects and organizations meet and interact. These multitudes of connections lend themselves to hyper-complexity; yet when boiled down to a functional unit, there is a human being in need of care. Losing sight of this element fails the entire system.

According to Sir William Osler, M.D., a Canadian physician often called the “father” of modern medicine, “The practice of medicine is an art, not a trade, a calling, not a business, a calling in which your heart will be exercised equally with your head.”

1 – Kuhn T, Basch P, Barr M, et al. “Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians.” Annals of Internal Medicine. Published online Jan. 13, 2015.

2 – https://hbr.org/2015/02/heres-why-people-trust-human-judgment-over-algorithms