Bulletproof Expert Systems:

Quality improvements in health care will have the greatest impact when they address systemic sources of error and risk. Demands for improvement in individual performance are not likely to improve outcomes or lower costs. Individual health care providers are already working at their physical and cognitive limits. To better the system we have specifically recommended adopting computerized Clinical Decision Support systems in outpatient physical therapy clinics. More generally, we have recommended a quantitative, over a narrative approach, to documenting physical therapists' clinical findings.204,227,247 Any approach that standardizes and automates functions now performed by humans will be criticized by some therapists and physicians who fear that computers and algorithmic rules will replace skilled physical therapy performed by physical therapists. Their fears are unwarranted since, as this book will show, managing the complex, interconnected web of evidence that defines and describes patients' disabling experience is a skill that will define physical therapists' practice now and in the future. Skilled physical therapist practice can be quantified as the rate that physical therapists adhere to clinical decision support reminders, suggestions, alerts and guidelines. When therapists have a low rate of adherence, their skill will be determined by how they document their objections to the standard recommendation. If they do not justify their objections to evidence based guidelines then they can then be criticized for failing to practice evidence based physical therapy. According to Weed: “Individual freedom to exceed the minimum - to take into account information above and beyond that which is assembled externally - must be preserved. But no one should be free to fall short of the minimum by relying on inaccurate, incomplete or biased information.”471 Clinical Decision Support tools can also quantify intuitive physical therapy - that part of physical therapy that is outside the limits of science. Using the information we learn from CDS systems, we can state decisively where the “art” of physical therapy begins and ends.256 Physical therapists are the most qualified professional to direct societies' resources in patients' rehabilitation. Physical therapy is increasingly being delivered by doctors of physical therapy (DPT) who will need high levels of data density to justify care decisions: “The doctors' role in cases of this type may well be likened to that of an analogue computer, which plots specific points on a curve as a function of the time and type of input and the shape of the curve is not known until the input stops.”255 However, no computer can replace the human ability to apply caring professional judgment and inquire into the patients' needs. We should remember Reilly's admonishment that, “…in medicine, good science is not the sole determinant of the right things to do.”227