Health Information Management: Integrating Information Technology ...

92 MEETING THE CHALLENGE
improvization is crucial. Flexibility implies that the system is not more detailed
than required, not more stringent than necessary, not more imperative than
usable. A flexible PCIS or care path can be smoothly integrated in daily health
care work. It implies not detailing thirty steps when three suffice; no choice of
five thousand diagnostic categories when four hundred are sufficient. It implies,
as illustrated above, that it should be possible, at each moment, to modify a
standardized care path for an individual patient, or to take the patient out of the
path. At that moment, the patient becomes one of the 20 per cent of patients that
will be dealt with in the traditional fashion: step by step, with decisions taken at
every turn, to optimally fit this specific patient’s problem.
Flexibility also implies that the standard can be easily revised and adapted to
local demands or to new scientific insights. Compared to Danish GP systems, for
example, the coding schemes used in British primary care systems are easily
adaptable, rendering the entire system more meaningful and acceptable to GPs
(Winthereik in press). In addition, it should be possible to adapt standard care
paths to newly emerging insights, for example based on feedback from
aggregated health data tabulated from the support systems themselves.
This might sound obvious and simple but it is not. The importance of local
adaptability, for example, clashes with the demand that a standard is just that:
standard. Everywhere applicable, everywhere similar. And simple, pragmatic
standards that do not standardize more than necessary might lead to an unwieldy
patchwork of overlapping and contradictory standards. Many standard
developers abhor such disorder, and much effort is spent on attempts to develop
(inter)national, all-encompassing models in which data, decision criteria and
work processes are ordered in formal, unequivocal and universal ways. Both
within several European countries and at the European level, many resources
have been wasted at attempts to create the ‘ultimate’ model of the health care
process. Likewise, much work has been—fruitlessly—invested in the quest for a
modern Tower of Babel to resolve the vagueness and multiplicity of medical
language. Such standards are inevitably very elaborate and complex, and contain
a logic opaque to everyone except the designers themselves. Because these
standards are so far removed from daily practice, they become difficult to
implement and lead to manifold frictions in the care work. And once those
standards are implemented, finally, they are very rigid and hard to change. Any
proposed change to the complex whole has to be carefully investigated for its
consistency and logic; any such proposition has to follow a long trajectory of
(inter)national consultation rounds and committee meetings.
The success of a redesign of the care process according to the first two
principles is crucially dependent on the opportunities given to the professionals
(and other users) to skilfully integrate the demands of the care paths and the
PCIS in their work practice. Even for simple triage situations as described above
(the outpatient clinic secretary categorizing a pregnant patient), decision support
systems, when left to their own devices, are remarkably ineffective. Worried
patients end up worrying more, and the tool’s answers more often than not fail to