To Succeed with an EHR, Understand the Information Economy

Another word for information is facts. Facts describe the state of events, objects, etc., at a particular point in time and space using values. They even describe opinions (e.g., it's a fact that your opinion is…). Facts are immutable. They don't un-happen. An object that was blue yesterday will always have been blue at that time.

Data are not facts. They are ephemera derived from facts and people's conclusions about how facts should be expressed or encoded for a particular purpose. A multitude of data elements can be derived from one fact but the reverse is impossible. Data cannot be reverse engineered to recover the information that gave rise to it.

In the information economy, facts and bundles of facts are the currency, the raw material, out of which things can be made or that allow things to be done.

Things got off track in medicine about 25 years ago. The operational side decided that medicine was some kind of health factory that needed to be run like any other mass-production business, such as Toyota. The factory needed data. Facts were too messy, too individualized to suit the needs of the robotic production line. So instead of thinking through the subject and realizing that the medical record was or could/should be the source of that data, data collection was born.

The medical record is simply a record of the medical problems and concerns for which someone has sought or received care, the doctor's assessment of the nature and significance of those problems, what plans were made to address them and the outcome.

The facts about a patient's medical care originate in association with events that involve interactions between medical professionals and a patient or interactions between medical professionals and specimens or information associated with the patient.

Events, defined in this way, are virtually the only source of information about the patient. During an event, more facts are knowable than become known. The practitioner selects, from the "universe" of knowable information, a subset considered relevant and records a subset of that in the chart. To the wide world, the entirety of what will be knowable in the future is only those facts that are memorialized in the record.

The medical record is a concept, not a technology. It can be realized in many ways, any of which is appropriate if certain basic requirements are satisfied, but it cannot be implemented using a database in the way databases are typically conceived - as containers to store and organize a bunch of data elements.

If you have expended time and money on an EHR that collects data, the thought that what you have collected has little or no value outside of the purpose for which it was collected is too uncomfortable. You fall victim to the "sunk cost" fallacy and try harder to make the unworkable work. Realizing the intended use of the data may be confounded by the all-too-frequent difficulty in determining the denominator correctly, in other words, being able to select the appropriate records for comparison. Accurate data is definitely useful in a medical-care setting but how do you get accurate data? Not from data-collection applications. They force users to discard or corrupt the information in their possession in order to enter something that the application developers chose to allow.

It is a fool's errand to make the collection of data the overriding purpose of an EHR. Data that seems to be of interest today will not be of interest tomorrow. New elements will be considered essential tomorrow that were not conceivable today. If, at any time, the data that is needed is or can be extracted from the information (facts) in the chart, then the only factor that limits the availability of data is the quality and level of detail of what is in the chart.

In the information economy, those with good information are rich and have the advantage while those with only data flounder. If you want good data, focus your effort on creating detailed, high-quality records. Devote your effort and resources to helping practitioners create those records. DO NOT dissipate your efforts on data-collection systems while ignoring the value and potential of the chart as the single, definitive source of information.

Keeping data is not the law; only being able to produce it when asked. Keeping a medical record IS the law, whether the information is used for other medical-care-related purposes or not. Why not make the most of it?