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The question embodied by the individual patient doesn't have a statistical answer. Evidence-based protocols are derived from statistical syntheses of research findings about general populations. Medical research produces generalizations, then EBM generalizes about those generalizations. Even if a statistical probability is accurate for the relevant population, it tells a practitioner nothing about the patient in front of them. A protocol directs the practitioner to do what works most of the time, regardless of its appropriateness in a particular case. In this way, CDSS substitute knowledge of statistical norms for knowledge of the individual patient. But statistics can only say, "Look here first"; they can't answer the question presented by any particular patient. EBM isn't medical science but merely a dubious statistical synthesis of research findings. Science addresses the causal questions "Why?" and "How?" EMB doesn't even attempt to explain causation, but only shows statistical correlation—"If this, then that." Unlike statistics, medicine is a human science, constituted by human choices and full of ambiguity. Human judgment is necessary at every step along the way. • Researchers exercise judgment in deciding what questions to ask, how to generate relevant data, and how to interpret that data. • Practitioners exercise judgment in choosing their tools (both material and conceptual) and deciding when and how to use them. Progress has never been made in any scientific field by following protocols. Without judgment, there can be no science. Evidence-based medicine eliminates science from clinical practice, replacing it with obedience. In summary, EBM confuses what's most easily measured with what's most worth knowing. Not everything can be measured. You can't reduce a human patient to a collection of zeros and ones,and you can't put human thought in a bottle and sell it. I s a patient jus t a s tatis tic? Ca n a n y thing new ev er b e learned from followi ng a proto col? 3. tHe HeAltH infoRMAtion excHAnge (Hie) AnD tHe coRe tecHnology loop orientation A health information exchange is the Internet-based communication of electronic data among nonaffiliated organizations. The HIE isn't fully developed, but the expectations of promoters are ambitious. It will begin as a repository of research data from which clinical decision support systems draw evidence-based protocols. Eventually the HIE will also collect and analyze patient data from electronic medical records and continually redesign CDSS protocols to assimilate this raw data. Thus the core technologies will feed each other in an electronic loop with troubling implications. © Copyright IHSP 2009. All rights reserved. HIE EMRs CDSS III