What can the Cooperative Principle teach us about better using EHRs? A lot actually.
Technology is so great, so captivating, and so compelling, it has spawned a kind of irrational exuberance which blinds people to the enduring principles and values that really matter. It’s a phenomenon that’s not unique to computer technology.
Alan Greenspan coined the term irrational exuberance during the dot-com bubble of the 1990s and Robert Shiller wrote a book, “Irrational Exuberance,” that analyzed the phenomenon. In terms of data and information, our current enthusiasm for data in healthcare displays all the features of a speculative bubble.
In the race to provide better care at lower cost, we have been assured that data will win by a head and distracted physicians won't harm anyone in the process. We are collectively gambling billions on this race in which the patients are the guinea pigs, being experimented on without their informed consent. Unknown to most people in healthcare and the government is the troubling lack of credibility in the quality of research being done on the computer science behind medical information and medical records. And this says nothing of the clarity and accuracy with which it is communicated to the public. Shiller said: "Some of this so-called research often seems no more rigorous than the reading of tea leaves." This comment would be relevant to healthcare if a lot of research was actually being done.
Shiller continues, to paraphrase: The answers to these questions are critically important to private and public interests alike. How we value data, now and in the future, influences major economic and social policy decisions that affect not only doctors and patients, but also society at large. If we exaggerate the value of data, then as a society we may invest too much in collecting and storing it, and too little in education, patient care, and other forms of human capital. We might deplete those resources that will be needed to devise new solutions to those conditions that influence the health of the world's population such as Ebola, Dengue and Chikungunya.
The buzz that surrounds technology is not conducive to thinking about principles and values. These are topics that concern ethicists and philosophers and that should help us to remember that:
• Data alone never saved a life. It takes people to do that. Data may help them but knowledge and experience are more important.
• One should not take any risk that is out of proportion to the potential benefit. Whenever possible let the patient decide which risks they prefer.
• One way to avoid doing harm is to be aware of what has happened and what was done before. Remember, insanity is doing the same thing over and over, while expecting a different result. Quality medical records, not data elements, are necessary if physicians are to be adequately informed about the patient's course.
EHRs have drawn the physicians’ focus away from the patient and the task of creating quality medical records, forcing them instead to function as data entry clerks and coders. This creates an ethical dilemma for physicians. Time pressures increase the likelihood that chart notes will be skimpy and uninformative. Both templates and copy/paste increase the chance that the notes will "document" things that were not done or not true, while failing to document things that were done (because it was too difficult to include them). People lose the potential to be informative because the context in which the data arose has been stripped away. It has either been discarded, or scattered in multiple, generally inaccessible locations. Without the relevant context the meaning, the information physicians need to understand their patient's cannot be reconstructed.
This is why the emphasis should be placed not on data, but on the faithful and complete recording of the information that physicians glean from their interactions with patients. In this regard, there is a branch of philosophy called “Pragmatics.” HP Grice (1913-1988), a British philosopher of language proposed the Cooperative Principle that he believed governed linguistic communication. His maxims provide a template, of sorts, that can guide physicians in creating informative, meaningful entries in the medical record. They are:
Maxim of Cooperation.Contribute what is required by the accepted purpose of the conversation.
Maxim of Quality. Make your contribution true; do not convey what you believe false or unjustified.
Maxim of Quantity. Be as informative as required.
Maxim of Relation. Be relevant.
Maxim of Manner. Be perspicuous; avoid obscurity and ambiguity, and strive for brevity and order.
To which should be added the calculability assumption:
Calculability Assumption: Whatever an utterance or narrative implies (though not stated explicitly) must be capable of being worked out.
Unfortunately, people apparently believe that technology can insure that a medical record will be accurate, complete and informative and that, if it isn't, big data will come to the rescue. I wouldn't bet on it.