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Do Today's EHRs Interfere with Critical Thinking?


With EHRs, physicians have two choices: gather their own information or act on the simplified, perhaps misleading caricature that is provided by their system.

Critical thinking has been considered important since the time of Plato and still attracts considerable attention. Critical thinking is a three-part process that involves: systematically gathering information by various means including observation, experience and reasoning; assessing it’s clarity, accuracy, precision, consistency, relevance, fairness, etc.; and then using the information to formulate concepts and as a guide belief and action.

Critical thinking cannot be done it if you don’t have the facts. You also can’t do it if you don’t understand the context and the concepts behind the topic under consideration. Of course the language used must be adequately understood and sufficiently expressive but even then it may be difficult to express some complex thoughts.

Critical thinking would be less important if the real world and the decisions that one needed to make were all black and white and involved only one variable, but such is not the case. Very few things are either true or false. More often something is true, false or unknown.

Mathematicians write that as: {true, false, unknown} and call it three-valued logic. Some situations require four-valued logic: {true, false, unknown, conflict} while others require higher-order multi-valued logic. In 1965, Lotfi Zadeh extended this to include fuzzy logic in which the truth value could be any number within a specified range: {value is in the interval [0,1]}. This is also how probability is described, as a value within the interval [0,1] so, in fuzzy logic a truth value of 0.8 is more likely to be true than false, and a truth value of 0.2 is more likely to be false than true.

The ideal way to store information requiring three-valued logic would be to use a memory cell that could represent three states. Four-valued logic would be a natural fit with a memory cell that could represent four states. Fuzzy values would require a memory cell that could represent any numerical value, since there are an infinite number of possible values between 0 and 1. Digital computers provide little direct help when it comes to storing information like this. They are all based on the binary code which only requires and can only represent two states: {true, false}.

The developers of computer programming languages are likewise of little help because they tend to be lazy. To represent multi-valued or fuzzy logic information in binary memory cells requires the invention of a scheme for using multiple memory cells to store a single piece of information. Programming languages have built-in support for {true, false}, so programmers have little reason or incentive to implement anything more complex. Instead of tackling an ambiguous situation directly, there is an incentive to simplify the problems the computer is expected to tackle, as in: “Let’s assume that we can get away with {true, false}. It’s pretty close to {true, false, unknown}. I don't think that {unknown} will occur very often or that there will be any harm in ignoring it.”

So there you have it. Medicine, a field that could benefit greatly from fuzzy and multi-valued logic, is being crammed into applications that prefer everything to be black and white.

No matter what your critical thinking instincts may be and how well you may have been trained in critical thinking, that skill will eventually become dulled if the only information that you have available has been stripped of its ambiguity. Every computerized step in the process of using today’s EHRs removes some of the ambiguity that was inherent in the real-world situation and replaces it with yes/no decisions (This is the same phenomenon that makes X-ray copies reveal fewer shades of gray than the original. Individual silver grains or pixels act a binary memory cells, effective turning gray areas of the original into either black or white. The copy displays a stark combination of black and white areas instead of the gray-scale of the original.).

What is left provides an inadequate substrate for critical thinking. Physicians have two alternatives. Either they gather their own information "from scratch" so that they can discover and consider the inherent ambiguity or they believe and act on the simplified, perhaps misleading caricature that is provided by the EHR.

In answer to the opening question: Yes, EHRs interfere with critical thinking for two reasons: 1.) computers creates a false sense that the information they display is precise and complete; and 2.) as they are designed and constructed today, they make it difficult to accumulate information that is clear, consistent, relevant, accurate and of known precision -- all of which are prerequisites of critical thinking.

Now for a multi-valued quiz:
Since effective critical thinking is one of the bases of good medicine, the statement that today’s EHRs will improve quality and lower cost is:
a) true
b) false
c) somewhat likely to be true
d) somewhat likely to be false
e) highly likely to be true
f) highly likely to be false
g) indeterminate
h) refused to answer

As you probably guessed, the diagnosis code for this visit ought to be:
“EHR Problem Not Elsewhere Classified and Not Otherwise Specified.” The closest ICD-9-CM Diagnosis Code is “999.9 - Other and unspecified complications of medical care not elsewhere classified.” Close is probably good enough - if we don’t insist on thinking too critically.

What do you think?

Find out more about Daniel Essin and our other Practice Notes bloggers.

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