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.
