Expert Voice: David Gelernter on Knowledge Management - ' Applying a Narrative Sequence '

Applying a Narrative Sequence to Healthcare

Can you think of a thorny problem that might logically be reduced to narrative sequence?

Sure—healthcare. Here's how the vast majority of people deal with a doctor: The doctor sits down and he's got a folder, and that folder is a heterogeneous bunch of notes and X-ray images and copies of prescription forms and lab test results. It's absolutely clear that the first step in putting medical records online has got to be based on that folder.

I've got to be able to open that folder up and—working from the bottom because it's arranged chronologically, like a stream—take the oldest document and scan it in, take the second oldest document and scan it in, and so forth. Just feed each item in the folder into software.

And what do I want to have happen to it? I want it to turn into a stream because this is a chronological record of my encounters with this particular doctor, and it's heterogeneous. I've got to be able to deal with handwritten stuff, so I'll look at that in the form of images. And I've got to deal with X-ray images as well, and so forth. Anything more complicated—say, translating everything in that folder into a certain database format—is never going to be launched because it's just too expensive. It's too hard, and it's too massive an issue.

If I deal with three doctors, or whatever my medical world consists of, I have access to three streams. I can shuffle them together, and that's a medical record. That's a first step, and in many ways I think it'll be a very useful step toward ending the discussion about formats and saying we'll use the current format and put it online in the obvious, natural, intuitive, neutral way.

But then there are questions about controlling access to this and how to make parts of it available. I may want one doctor to see the whole thing, but the insurance company may only need access to certain parts of it, and so forth. I can do that automatically by saying, "Permission all documents of this sort to the insurance company."

And that way, instead of preparing a separate database or a separate presentation for the insurance company, the insurance company just looks at my stream when it needs to deal with my case. The insurance company has access to everyone's stream, but only a limited view, only the parts I've chosen to permission to it.

So, ultimately, I control my medical records. That's another aspect of medical records that the online effort hasn't really grasped: Ultimately, my medical records belong to me. They're not the private property of the hospital or the insurance company. They're my records and control ultimately needs to be in my hands.