Tuesday, June 11, 2013

Informational Asymmetry

Accurate, timely, relevant information is a prerequisite for effective delivery of healthcare services at the individual and population level. A healthcare provider uses information, consumed in a myriad of forms, and filters the filters the new information through a framework of experience, to arrive at a conclusion and a plan of action. Jerome Groopman has detailed many of these thought patterns of doctors in How Doctors Think. The book describes numerous limitations to informational processing at the individual level.

An example clinical encounter is described:

A 28 year old female develops a painful rash on her left forearm. It starts without any apparent cause to the patient. The young lady has no other chronic medical issues and takes no regular medications. There has been no travel, no recent contact with any sick persons, and no change in her regular routine as a consultant. For several days the rash progressively worsens, and pain increases.  She schedules a visit with a dermatologist. In the medical encounter with the health professional a broad list of possibilities is considered. It could be one of several types of infections, it could be an allergic reaction, it could be underlying chronic skin condition that is just manifesting at this time. Tests of the skin are obtained, and treatment was prescribed.

Informational input needs to be accurate. The best thing in medicine is the people, the patients. Patients know the most about themselves and how they are feeling at any particular time. The challenge is in the details. For those not familiar with medical language it is not easy to remember the specific terminology, or names of medications. Was it ciprofloxacin or levofloxacin? What was the result of the heart test? Was there any particular exposure to the skin, or any new detergent, or perfume? Many times details of exposure and chronology stand out in peoples’ minds, often times they do not.

At the level of the professional, clinical information is filtered through an information mesh-work to pull out the important pieces of data in order to arrive at the conclusion/diagnosis. The process of training physicians in the U.S. system involves a high volume of exposure to individual patient care in an appropriately graduated structure. The broad experience base generates a mental framework that subsequent information is processed through. This is what Groopman discusses as heuristics; the experience-based technique for problem solving. The challenge in medical training is that is often hard to infuse more wisdom than their experience allows. Certainly, information acquired through reading builds and expounds the mental framework. That is how a medical student can know someone has appendicitis before they have ever seen or diagnosed their first case. The modern challenge is that there are now (as of 2010) 75 medical trials, and 11 systematic reviews of trials, per day.(Ref) All of that newly created information adds layers of nuance to the diagnostic and treatment processes. The human body and its ailments have not suddenly altered, but the highest value testing and treatment practices do change over time. This is the modern challenge, the smartest individual in the world does not have the capacity to consume and retain all of that information. An internet connected provider, speaks to a potential of leveling the playing field, by having access to up to date information. This ultimately will be a good thing. 

Asymmetry is the disunion that happens when the processing framework fails to properly connect and add value during the throughput of individual data. Miss-connections include:  the drug was X, not Y as the patient had originally remembered it. The previous electrocardiogram (EKG) was not available to compare for any change. From the provider perspective: that type of case, with similar type symptoms, lab results, and outcome has not been encountered before. Is this a new presentation of a new disease, or an unusual combination of symptoms for a common disease. Or from a dermatology perspective - a specific type of skin rash has not been seen before.

Facilitating a more open posture for informational flow, such as producing open source medical databases, offers a potential to augment the processing framework. At the individual level an open-source dermatology database (adequately marketed) could be searched, just like I have observed Attending physicians search Google Images for skin diagnosis. The open data could be accessed to augment the providers information mesh-work in order to decrease the probability of asymmetry. The leverage of computers/screens/phones is informational connection. This rationale assumes that the answer is out there somewhere. Finding the answer is a matter of reducing the asymmetry. When we open informational networks it is not immediately clear how commercial value will be derived. However, connecting people to the right information at the right time is one of the challenges we have taken on as we try and keep ourselves and our society healthy

The young lady described above is my wife. After time, testing, and contact with multiple medical professionals, she was ultimately diagnosed with phyto-photo dermatitis. That term was coined by Klaber in 1942.(Ref) It is a skin eruption caused by exposure to certain plants and their extracts and then being exposed to sunlight. Kelly reviewed the literature and reported that various authors make mention of the fact that the condition was probably known of in countries such as India, Arabia and Egypt many centuries before Christ.(Ref) The rash resolves over time, and with some steroid cream. She is doing well. Reducing the asymmetry in our own lives would have helped us avoid such an arduous process for a rash that has been around and known for such a long time.