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Part 4: Blind Spots Can Kill Patients -- Meaningful use and semiconscious conclusions

February 16, 2011
by Joe Bormel, M.D.
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Meaningful use and semiconscious conclusions

When I started this series (link to Part One), I began with the question of whether ARRA/HITECH, and specifically implementing certified solutions and evolving through Stage 1 of Meaningful Use, would improve care. As shown in the graphic, this was then separated into three sequential questions: 1) does HIT operationally deliver the improvement (see text in the "A Promise of HIT" above); 2) would improving the informational quality of the content delivered play a small or large role; and 3) when doctors and other providers, "working at the top of their license," receive data, information, decision and knowledge support, does that translate into better care?

Spoiler alert! If you haven't read the earlier parts of this series, I'm about to ruin the suspense for you. Easily a dozen different investigators, working independently, have documented in peer review literature that the rate of cognitive errors resulting in harm maybe as high as 15 percent. My earlier posts outline the types of errors and what to do about them, with valuable, authoritative links. To a person, these folks are frustrated. Since the general percentage of perfect care delivered is rarely better than 50 to 80 percent (see the oft quoted Elizabeth McGlynn et al work (NEJM 2003: The Quality of Health Care Delivered to Adults in the United States), or for the more recent numbers behind these estimates for hospital care), the reasons for this, and the role of HCIT may need to be rethought. Or at least, reprioritized.

Attention to cognitive errors, and the potential for improvement with HCIT, is always a second, third, or last place item on the performance improvement agenda, as well as the research funding agenda. Addressing cognitive errors is not on anyone’s critical path to attesting to nor delivering sustainable Meaningful Use. This is elaborated in Parts Two and Three of this series, with references and recommended solutions to the problem of cognitive errors from the leading experts.

In this post, we are going to look briefly at how people (including doctors) make decisions and what that means in regard to making errors. Then, in Part Five, the final post in this series, we are going to pull all that together in terms of the "Four Individual Determinates."

Based on my reading and discussions with several of the leaders in the clinical cognition field, there are three ways we make decisions. Two of them are both necessary and require different kinds of support, be that human coaching, process redesign, or HCIT-enabled cognitive enhancement:

1. Conscious, rationale, and often procedural approaches to problem solving.

2. Semiconscious, automatic thinking that may involve pattern recognition, gut, intuition, where the brain is clearly involved but has little or no ability to explain how it reached the conclusion.

3. Instinctual or reflexive thinking of the sort that animals can do that doesn’t involve higher, more evolved parts of the brain. We're not going to discuss this category any further here.




Thanks Mark, both for your kind words and your extensive work on this topic. Some of your comments were independently voiced by Dr James "Larry" Holly of SETMA in contemporaneous blog post, "Steps Toward Creating a PcMH" .  His post starts out with "The only care which benefits a patient is the care which they can access" and gets better and better from there.

Your comment picked up that same, compassionate dimension, specifically in your comment "It may all depend on whether one can actually GET to an expert or not."  Holly's post elaborates the subsequent access issue, accessing the prescribed therapy.

There's now a link to a great resource presentation to patient care hand-offs, here: , by Drs Arora, Frankel, Johnson, and Barach. 

(Depending on how your browser is set up, it may open for reading, or be directly and silently stored in your downloads folder.)

Hi Joe,
You’re really having a good time with this, aren’t you !  The blogs are terrific.  I especially enjoyed your "Butler Model" post on the importance of delivering guidance intelligently.
Access to expertise is going to be a HUGE issue going forward, because we’re moving away from the gatekeeper model so quickly.  People get their diagnostic advice these days on the internet, from their pharmacist, the NP at Walmart, you name it.   Does this improve the timeliness or reliability of diagnosis or retard it ?  You already know my bias – I want to get to an expert opinion ASAP, but I can imagine there are many circumstances where using all these different intermediaries is really beneficial.  It may all depend on whether one can actually GET to an expert or not;  For many people the Walmart NP maybe plenty expert enough, or the better than they would otherwise do.
So its really an open and unstudied issue, and I  phrased it as something that needs study as a research question in the attached publication, published in the same proceedings issue as the “Educational Strategies paper you’ve been working from. The relevant paragraph is copied below. 

Access to experts
An interesting discussion centered on access to expertise as a factor in error generation. Are patients better off having quick and easy access to expert subspecialists, or is the primary care model better, where generalists deal with common issues and just refer the mysteries? Does the error rate change if physician extenders act as front-line diagnosticians? Do 'curbside' consults prevent or promote diagnostic error? Should we encourage patients to use the internet for self diagnosis? Do online resources lead to earlier diagnosis, or delays?

Thanks for your kind words. I agree with your sentiment that emerging approaches are going to be critical to progress. It is critical that companies like yours and leading healthcare providers build processes that are more effective than those they replace.

I was not discounting semi-conscious mental processing. It is an important aspect of pattern detection, as well as method to deal with our uncertain world.

Thanks again for sharing your perspective.

Dr. Bormel,

Running a small company doesn't leave me much time these days to find true wisdom on the Net, and by chance came across your blog this AM. Can't wait to catch up on the trail!
I was blessed to be in the Interoperability Showcase at HIMSS this year. A small team of technology collaborators, including myself, showed the world that PCAST is reality now! The industry needs to allow clinicians to maintain their normal provider work flow in lieu of force feeding them the latest techno gizmo to capture data which, based on adoption rate just isn't working, we can start to move forward in a meaningful way. Pay for performance has turned to pay for reporting, and the world of certified EHR's expecting clinicians to live with fixed templates, has resulted in the watered down clinical note. Right click copy and paste is not what we had hoped for. At HIMSS the world saw exactly what Dr. Blumenthal so eloquently stated in Oct, 2010, "Once we get information into electronic form — all kinds of uses will be possible. But we can't get there until the information is digitized."

At HIMSS Dr. Frisdma echoed these sentiments when in his interview he stated "Once we get the information electronic, we start moving it around, we start to be able to do meaningful things with it.."

By no coincidence, I read your words and reminders and continue to believe - supporting and encouraging care providers to use ANY technology they are comfortable with and embracing all devices equally seems to be logical to the ends of accomplishing Dr. Blumenthal's and Dr. Frisdma's visions. Perhaps if we do then providers will do what they do best, practice medicine and when adjusting or recommending care plans they will do so with a Conscious, rationale, and procedural approach to problem solving (diagnosis and treatment). At HIMSS we presented a single end to end solution that empowered all users in the health care chain of trust. With complete disregard to the device they chose to use to capture clinical data elements. Voice dictation, handwriting, mouse keyboards, hard and soft, iPads and whatever else tech can throw at us. All of these devices, at the point of care, Digital Pen to iPads and Tablets, showed they can all move health data real time, provide quality checks, present to humans in multiple formats, we even took the simplest hand written progress note, communicated it direct from a digital pen and populated the patient chart with discreet transcribed text inside of a certified EHR. To WOW the researchers (and those who would like to be rationale in decision support) we concurrently populated a Natural Language Processor for Semantic Interoperability and atomic search - this was all accomplished by users at the kiosk without any training - only doing what they already do on a day to day basis, deliver care and document accordingly. Medical documentation should and can be available real time across the health IT enterprise, if my marketing budget was 10% of the large EHR Company's the world would know PCAST is reality now, but as always, some of the best and disruptive innovations come from the little guys and are many times reduced to "best kept secrets" not what you want if you are in the business of delivering on policy and thought leaders visions.

When I find free time from today forward I will be back and I hope to catch up at least looking back for 60 days worth of the wisdom that clearly is available from your words I read this AM and others who are contributing. Thank you for allowing me to start the day with continued hope!

Thanks and please keep up the great enlightment and thought provocation.


Joe Bormel

Healthcare IT Consutant

Joe Bormel