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 hospitalcompare.hhs.gov 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.