Partial Intelligence: Why Data Alone Can't Make a Good Health Decision
Most patients assume their doctor makes decisions about their care freely, in the room, based on their individual case. That assumption is wrong more often than anyone tells you, and the reasons why are not conspiratorial. They are structural, documented, and, in several cases, a matter of public regulatory record. This piece walks through four separate mechanisms that leave every patient holding partial information rather than a complete picture, and explains why partial information, however much of it you manage to collect, still produces the same problem it was meant to solve: decisions made without the full picture.
Part One
The Formulary Wall
In Costa Rica, physicians working within the CCSS system prescribe from a centrally defined list of medications, the Lista Oficial de Medicamentos (LOM). This is not a suggestion or a general reference. If a physician wants to prescribe something outside the LOM, they must file a formal, written justification through the Área de Medicamentos y Terapéutica Clínica before that medication can be dispensed. The process exists, it is documented in CCSS's own institutional literature, and it is a genuine constraint on clinical decision-making, not an exaggeration of one.
This matters because the LOM, like every national formulary, is built to serve population-level cost and access goals. It has to work for the majority of people with a given diagnosis, at a sustainable cost, across an entire national system. It was never designed to be optimized for any single patient's specific combination of conditions, medication history, and physiology. A physician operating inside this system is not failing you when they reach first for what is on the list. They are working exactly as the system was built to have them work.
Private insurers operate on a different mechanism, prior authorization requirements, tiered formularies, network restrictions, but the underlying principle is the same: the decision is being made inside a framework built for a population, not for you individually.
Part Two
The Evidence Gap Nobody Mentions
The clinical guidelines your doctor is trained to follow, and the protocols that inform lists like the LOM, are built from clinical trial evidence. The uncomfortable fact, well documented in the pharmacology literature, is that the patients most likely to actually need these medications in real life are frequently the same patients excluded from the trials that generated the evidence behind them.
65.7%of eligible diabetes drug trials excluded participants using an arbitrary upper age limit.
76.8%excluded people for having more than one health condition.
29.5%excluded people specifically for being on multiple medications at once, the clinical definition of polypharmacy.
Source: Marum et al., "Underrepresentation of the elderly in clinical trials, time for action," British Journal of Clinical Pharmacology, 2020.
The researchers behind this data are candid about why this happens. Including people with multiple diagnoses and multiple medications makes a study population messier and more variable, which means a larger, more expensive sample is required to detect a clean result. Multimorbidity is, in the language of trial design, inconvenient. So it is frequently excluded, not out of malice, but out of methodological convenience.
The practical consequence: if you are over sixty and managing more than one diagnosis, the evidence base underlying your treatment protocol was very likely generated by studying people who do not resemble you.
Part Three
The Record Is Curated, Not Complete
Costa Rica's patient-facing digital health record, EDUS, lets insured patients view their own prescribed medications, diagnoses, allergies, and appointment history. It is a genuine step forward in patient access, and every patient should be using it. But it is worth understanding what it is: a curated summary, not the full operational file.
There is a documented phenomenon in clinical ethics literature called defensive medicine, in which physicians working inside institutional systems, more so than physicians in private practice, shape what they record out of concern for how that record might later be reviewed, disputed, or used in a complaint. A 2018 clinical ethics paper published through SciELO describes this directly: institutional physicians sometimes withhold or shade information precisely because institutional records face more scrutiny than private ones. This is a recognized pattern in the medical ethics literature broadly, not a Costa Rica-specific study, but the mechanism it describes applies wherever a physician works inside a large, exposed institutional system.
A note on precision here, because it matters: this source describes a documented pattern across institutional medicine generally. It does not constitute a study proving this occurs at CCSS specifically. The distinction is worth holding onto, both because it is intellectually honest and because it is the more defensible claim to make publicly.
Separately, CCSS maintains internal administrative and statistical systems, using standard diagnostic coding, that operate alongside EDUS but are not part of the patient-facing view. This is not unique to Costa Rica. Every health system, public or private, runs coding and administrative infrastructure the patient was never meant to read directly. The point is not that something sinister is being hidden. The point is that the patient-facing app was never designed to be the complete record, and treating it as though it were is a mistake with real consequences for anyone managing a complex, multi-year, multi-provider case.
Part Four
The Clock Was Never Yours to Set
In July 2022, the CCSS Junta Directiva formally approved fifteen minutes as the standard scheduled time for a general consultation at an EBAIS clinic, with up to thirty minutes allotted for a first-time visit. This was not an informal norm that emerged organically. It was a regulatory change to Article 108 of CCSS's own operating rules, negotiated between CCSS management and the national medical unions, including the Unión Médica Nacional.
What CCSS proposed: Reduce standard consultation time from 15 minutes to 12 minutes, increasing throughput from four patients per hour to five.
What happened: The Ministry of Health formally intervened and recommended against the reduction, citing international evidence that consultation length varies from five to twenty minutes across countries, and specifically noting that post-pandemic mental health needs required more time, not less. The Colegio de Médicos y Cirujanos, the physicians' own professional body, formally objected to the proposed reduction as well.
CCSS's own language is careful to describe the fifteen-minute figure as a scheduling reference average, not an absolute ceiling on any individual visit. Some consultations run shorter, others longer, depending on need. The accurate, defensible version of this finding is not that a doctor is forced to end a conversation the moment fifteen minutes elapses. It is that an entire day of care is scheduled around fifteen-minute blocks, built on the operating assumption that most visits will fit inside one, in a negotiation where the ongoing institutional pressure has consistently pushed toward less time, not more.
What This Means for You
None of these four mechanisms, the formulary, the evidence gap, the curated record, the scheduled clock, are secret. All four are documented, in some cases in public regulatory decisions with named officials attached. But almost no patient has ever had them explained together, as a single system, rather than as four unrelated frustrations experienced separately over the course of years.
Once you see them together, one conclusion becomes difficult to avoid: no part of this system was built to hold your individual story. It was built, reasonably and defensibly, to serve a population, manage cost, and protect institutions from legal exposure. That is not a failure of any single doctor. It is the honest description of what a national health system is engineered to optimize for, and it is not the same thing your care requires.
This is the argument for owning your own health record, not as a replacement for medical care, but as the necessary starting point no institution is positioned to provide. A record that travels with you across providers, across borders, across the fifteen-minute blocks, that reflects your actual response to treatment in your own words, updated by you, is the raw material your care depends on. But raw material is not the same thing as a plan.
The Part Ownership Alone Doesn't Solve
Here is where the argument usually stops, and where it needs to go one step further. Downloading the EDUS app, requesting your visit notes, keeping your own symptom log, all of this is necessary. None of it is sufficient. A patient holding forty pages of lab results across three providers and two countries does not have intelligence. They have data. Those are not the same thing, and the difference between them is exactly where bad decisions get made, just by a different person than before.
Intelligence requires three things raw data does not provide on its own: cross-referencing, does this new symptom connect to that old lab value from eighteen months ago, in a different clinic, under a different doctor. Trend-tracking, is this marker actually worsening, or is this one data point being read in isolation without the pattern around it. And translation, what does a functional-range interpretation of this thyroid panel actually mean for a decision you have to make this month, not in the abstract. A folder of documents does none of these things by existing. Someone, or something, has to do the work of turning the folder into a picture.
This is the actual argument for a service built specifically to do that work. Not because patients are incapable of holding their own documents. Because holding documents and synthesizing them into an actionable, coherent picture are two entirely different skills, and the second one is the one the system was never going to teach anyone, including most physicians operating inside fifteen-minute blocks with no incentive or bandwidth to do it for you.
This is the gap Strata exists to close, and it is not the same gap as "you should have your own file." It is the gap between having your data and having intelligence built from it, coherent, cross-referenced, and translated into what to actually do next, across every provider, every country, and every fifteen-minute appointment you will ever sit through. Ownership is step one. Synthesis is the work.
Sources
Caja Costarricense de Seguro Social. Lista Oficial de Medicamentos (LOM) and associated normativa, including the exception request process through the Área de Medicamentos y Terapéutica Clínica. binasss.sa.cr/farmacologia/NORMATIVALOM.pdf
Marum, A. et al. "Underrepresentation of the elderly in clinical trials, time for action." British Journal of Clinical Pharmacology, 2020. bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.14539
"Medicina defensiva. ¿Evitable?" Clinical ethics commentary, SciELO México, 2018. scielo.org.mx (S1405-00992018000100054)
CCSS App EDUS, official patient-facing record access. ccss.sa.cr/appedus
"CCSS aprueba 15 minutos por paciente para consulta en Ebáis." La Nación, July 2022. nacion.com, July 2022
"CCSS y sindicatos acuerdan que pacientes tengan 15 minutos por consulta." Observador CR, July 2022. observador.cr, July 2022
"Salud recomienda atender 4 pacientes por hora y no cinco, como pretende CCSS." La Nación, January 2023. nacion.com, January 2023
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