To the Editor: In their Commentary, Drs Duncan and Evens1 are correct that before the wholesale adoption of health information technology, a profound re-evaluation of the designs of current systems is needed. However, their emphasis on explicit algorithms warrants refinement, and their dismissal of subjective input deserves reconsideration.
Medical research has been overwhelmingly about pathophysiology and has generated few answers to practice-based questions. Most practical decisions currently have little or no evidence to support an algorithm or guideline. Even if all of the research to sustain the necessary guidelines were affordable, however, there would be a more profound problem. Explicit algorithms presuppose that a singular target point exists. Yet optimal outcomes for individual patients require the reconciliation of multiple targets, including statistical evidence that may or may not apply; patient and system resources; patient, family, and professional preferences; and the individual's intersecting disease states. The balance of competing forces creates entire landscapes of possibilities, in which optimization is relative to a field of solutions rather than the linear migration toward a single global minimum.