Distinguishing the not-good-enough

by Bernie Cohen

A reaction of one reader to my pragmatics blog was that, pragmatically speaking, it was still possible for a shared EHR to add value, but that it was certainly important to down scope the problem of sharing meaning across an enterprise, knowing full well that artificial boundaries are being drawn within the overall enterprise as a consequence. He goes on to say: “It may be a case where the perfect is the enemy”.

Maybe. But my own view is that this line – that the best may be the enemy of the good – doesn’t take into account the real harm that can be done by the not-good-enough.

Consider another aspect of Healthcare, the Clinical Practice Guidelines (CPG) which is strongly promoted by WHO and supported internationally. The potential benefits are enormous, not just for the patient, who should expect to be treated with best practice by any clinician who has the CPG CDs, but for the practitioner, who will be able to defend against any accusation of negligence by demonstrating adherence to CPG, and, most importantly, for the payer (government or insurance company) who will have the philosophers’ stone: the ability to predict, given the cost profile of the CPGs and the statistical distribution of complaints, the future cost of healthcare.

Unfortunately, this all depends on the ability to demonstrate the mutual consistency of the CPGs, which have been, and are being, drawn up by panels of specialists who have their own ontologies. For example, suppose a patient presents symptoms suggestive of both asthma and angina (both of which already have CPGs), which is not uncommon, and a clinician decides to follow one, or the other, or both CPGs, will the treatment plan, outcomes etc. be similar in each case? And who will take responsibility for damages caused by inconsistency? And how, and by whom, can all compositions of CPGs be so checked?

And while we’re on the subject of insurance companies, we already know that their ontologies differ markedly from those of both practitioner and patient, as demonstrated by the classic Kaiser Permanente example: a researcher who did a longitudinal study of post-partum complications using a large KP anonymised data set discovered that a significant proportion of those complications occurred in male patients, this being due to the fact that KP recorded the gender of the payer, not the patient!

When it comes to sharing meaning, before making the best the enemy of the good, we first need to know how to distinguish the not-good-enough. If we are to develop a care-centric approach to the patient in meeting the challenge of Health Care Reform, we are going to need to share meaning by reference to the patient situation itself and not just by reference to the treatment protocols involved.

One thought on “Distinguishing the not-good-enough”

  1. Perfection and ‘the best’ are not in the same register.

    One is an imaginary absolute while the other is a vector. Hence, striving for the best is workable, whereas perfectionism cripples any working proposition that must include the scope for error.

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