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  • Clinical Decision Support

    In reading about clinical decision support (CDS) and evidence-based medicine, I am inclined to think as much change needs to happen in the social system as in any information system.  We seem to be at a stage in medical research where there is too much information to process, not enough people to process it, and not enough time. Furthermore, it’s not clear that more funding would improve the system at a foundational level. This last is almost a moot point, since greater funding than we already have is unlikely to be forthcoming.

    No matter how well-designed your system, information overload is information overload.  The requirements of medical specialization are so great, that each provider can only be expected to master a tiny portion of the field.  This leaves a huge gap between the primary care provider (PCP) and the specialist, so much so that it may be difficult for a PCP to know where to send a patient.  And since most illness and disease crosses these knowledge boundaries, the type of integrated approach necessary for true healing is usually not happening. It seems like we are doing more harm than good by trying to do more than we can.

    Until we develop effective AI, HI is simply a tool.  It can’t give you greater brain capability.  There is so much new information being put into the system, that sorting through evidence-based guidelines is a job in itself.  Improving the information system certainly helps.  But at the same time, doctors should be seeing fewer patients, taking more time for an accurate assessment and diagnosis, and having someone whose job it is to assist them in consolidating the knowledge that the information system provides.

    In law, attorneys have paralegals. In politics, politicians have aides.  Both these jobs essentially require contextualizing vast amounts of data for the person who has to make the ultimate decision.  While some medical practices may have physician assistants (PA) who fulfill this function, often a PA is discharging an entirely different type of responsibility by simply seeing less complex cases. In an ideal world, each physician should have a clinical medical librarian to research and digest the evidence-based research.

    The problems of this information overload are illustrated by the example of pharmacists overriding medication warnings.  Apparently the fix in this case was to reduce the number of warnings.  But assuming the warnings were valid, this opens the door for liability.  If you know there is a risk in a medication (no matter how low), and you choose not to share it because your providers can’t process that amount of information, you are essentially withholding information from the patient.

    At the end of the day, there is too much information in the system for providers to process. IT systems organize, disseminate, recombine, reshuffle, and perform a whole host of services.  But they can’t think for us, and more thinking, with more time to think, is what’s required here.