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EHRs Only One Victim of Reaction vs. Reason in Healthcare


Sometimes, such as with EHRs, it is not the decision-making process, but those making the decisions that create bad results.

At this time of the year, one's thoughts are more likely to turn to consideration of altruism and the well-being of others. In previous articles I've alluded to various problems that commonly afflict the process of making decisions about EHRs. The simple fact is that, while a lot is now understood about how a decision-making process can go wrong, most people that are cast into the role of decision maker, are not educated or trained in decision making. The result is that sub-optimal decisions abound. Why is that?

Nobel Prize winner Daniel Kahneman, in his new book “Thinking Fast and Slow,” provides some insight. He teaches that we all have two built-in decision-making capabilities: a fast one (System 1) and a slow one (System 2.) The fast one is automatic. It operates below the surface and is intimately linked to our sensory functions. When its inputs suggest danger, it triggers automatic reactions like "fight or flight." For example it monitors facial expressions and automatically informs us about the state of others, be it anger, fear, surprise, etc. It also handles the interpretation of simple written and spoken words in our native language.

System 1 can't reason; it uses inborn and learned patterns to match new input to things that it already recognizes. This sets the stage for biased reports. If a previously unknown set of inputs arrives, System 1 is not able to appreciate the novelty; it simply identifies what it can and then tries to match that subset to something familiar.

System 2 is slow. It has the time and the capability to reason, calculate, and question, but it must be careful because most of its input has already been filtered and categorized by System 1. Unless System 2 becomes skeptical of its inputs and initiates other measures to improve the quality of the data, anything that it evaluates, calculates, or plans will be colored by the biases that System 1 introduced. One obvious defense against this is to educate System 2 about the various biases that commonly occur so that it can take care to detect and counteract them.

Decisions about EHRs are not the only ones to suffer at the hands of System 1. There is very little that is rational about conflict between Muslim sects, ethnic and racial subgroups of a population, or the political disputes between the Republicans and the Democrats - but rationality has little to do with it. System 1 has already identified a threat, categorized it in some biased way and framed the problem for System 2 as one calling for an elaborate plan of territorial defense. How can you think clearly or negotiate productively when under that sort of perceived threat?

So it goes for regulation. The recent NTSB recommendation on cell phone use in cars is a contemporaneous example. Let me be clear that I do not approve of any activity that takes a driver's hands off the wheel or their eyes and attention off the road. Nevertheless, the circumstances of the crash that prompted a the call for new regulations were so startling and egregious that the committee member's fast systems have engendered such a strong avoidance response that they have proposed what would prove to be draconian measures if implemented as stated. Numerous commentaries, while agreeing that a problem exists, have identified a number of ways in which such a blanket proscription would be unworkable and/or unnecessary, and then there is human nature. How much intrusion into personal privacy and behavior do you think people will tolerate before they decide that regulation itself is the biggest threat? Do we want a totalitarian state, and all that implies, just to keep someone from using a hands-free phone or a car navigation system?

The world could benefit from more goodwill between men, so when you find yourself challenged in some way, or needing to make a big decision, take a deep breath, relax a bit, and give your System 2 a chance to strut its stuff. Encourage it to deliberate, consider options, question the input and make good use of you intellectual powers.

Best wishes for the holidays.

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

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