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Health Care Processes and Decision Making Lecture 2_slides
- 2. The Culture of Health Care Health Care Processes and Decision Making Lecture b This material (Comp 2 Unit 4) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 3. Health Care Process and Decision Making Learning Objectives • Describe the elements of the “classic paradigm” of the clinical process (Lecture a). • List the types of information used by clinicians when they care for patients (Lecture a). • Describe the steps required to manage information during the patient-clinician interaction (Lectures a, b, c). • List the different information structures or formats used to organize clinical information (Lecture b). • Describe different paradigms and elements of clinical decision making. (Lectures a, b) • Explain the differences among observations, findings, syndromes, and diseases (Lectures a, b, c). • Describe techniques or approaches used by clinicians to reach a diagnosis (Lectures a, b, c, d, e). • List the major types of factors that clinicians consider when devising a management plan for a patient’s condition in addition to the diagnosis and recommended treatment (Lecture e). • Describe the role of EHRs and technology in the clinical decision making-process (lecture a, b, c, d, e). 3
- 4. My Ankles Are Swollen Example case: A man who came to the clinic because of ankle swelling. The clinic assistant says, “Blood pressure 225 over 140,” as she brings in a man with his shoes untied and loosened and with his ankles bulging over the top. He looks healthy enough, but he’s a little pale. He says he’s a little short of breath after walking in from the parking lot, but his lungs sound clear, and he’s only breathing 12 times a minute. “Do you smoke?” you ask. “I used to,” he replies, “but I quit three years ago.” He says he’s been gaining weight lately, and his clothes are fitting tight. You check his heart, which has an S4 gallop but no murmur. You ask about his clothes—first his shoes, then later his pants, felt too tight. You check his abdomen, which shows no tenderness, masses, or enlarged organs. Then he recalls that he was on medication for blood pressure a few years ago but stopped taking it because he felt “slowed down.” You check his pulse, which is 120, and on his legs you notice a two- plus pitting to the mid-shin. “Have you ever been sick before?” you ask. “No, never in all my thirty-nine years, except once when I got a rash from aspirin. Oh yeah, and to have my tonsils out,” he replies. 4
- 5. Clinical Process: The Myth • History Physical Assessment Plan • The “complete” history and physical – Discrete – Linear – Orderly – Structured 5
- 6. Clinical Process: The Reality 4.5 Chart: Depiction of an iterative reasoning clinical process 6
- 7. “Disease often tells its secrets in a casual parenthesis.” -Wilfred Trotter • Getting the story o Open-ended questions o Enabling the person to tell his or her story o Including/excluding family, others • Filling in the details o Closed-ended questions o Comprehensive checklists, review of systems • The tools affect the process • Collection ≠ Documentation 7
- 8. Analyzing Findings - 1 Part 1: Giving Structure to the Data 8
- 9. Structured Data Organization • Source identification • Chief complaint • History of present illness • Past history – Allergies/adverse reactions – Medications/treatments – Past medical problems – Past surgeries – Menstrual/obstetric history – Immunization/preventive care • Family and social history • Review of body systems • Physical examination – Appearance/vitals/skin – Head and neck – Lungs/heart – Abdomen/genitalia – Extremities/back – Neurologic • Ancillary data, diagnostic test results 9
- 10. Select the Important Information • The clinic assistant says, “Blood pressure 225 over 140 (blue),” as she brings in a man (blue) whose shoes are untied and loosened, with ankles bulging (blue) over the top. He looks healthy (blue) enough, but a little pale (red). He says he’s a little short of breath after walking (red) in from the parking lot, but his lungs sound clear (blue), and he’s only breathing 12 times a minute (blue). “Do you smoke (red)?” you ask. “I used to—I quit (red) three years ago.” He says he’s been gaining weight (red) lately, and his clothes are fitting tight (red). You check his heart, which has an S4 gallop, but no murmur (blue). You ask about his clothes: first his shoes, later his pants (red), felt too tight. You check his abdomen, which shows no tenderness, masses, or enlarged organs (blue). Then he recalls he was on medication for blood pressure (red) a few years ago but stopped taking it because he felt “slowed down” (red). You check his pulse, it’s 120 (blue), and on his legs you notice 2+ pitting to mid-shin (blue). “Have you ever been sick before?” you ask. “No, never in all my thirty-nine years, except once when I got a rash from aspirin (red). Oh yeah, and to have my tonsils (red) out.” 10
- 11. Providing Structure to Data History • History of present illness: progressive weight gain; tight shoes, then pants fit tight; exertional dyspnea • Allergies: aspirin (rash); hypertension medication (“slowed me down”) • Patient medical history: hypertension • Social: quit smoking • Surgical history: tonsillectomy Physical • General: pale, healthy M • Vital signs: BP: 225/140; pulse 120; respirations 12 • Head and neck negative • Lungs clear • Heart: S4 heard, no murmur • Abdomen nontender; no hepatosplenomegaly • Extremities: 2+ pitting to mid- shin 11
- 12. Analyzing Findings - 2 Part 2: Finding Patterns and Meaning in the Data 12
- 13. Hierarchy for Clinical Data Clinical Data Hierarchy Observations Global complex Syndromes commonly seen together Diseases Specific conditions that cause syndromes Syndromes Constellation of symptoms and signs Facets Groups of findings related by pathophysiology Findings Subset that is relevant to the patient’s care Observations (may fit one diagnosis, multiple diagnoses, or no diagnosis) Everything the clinician noticed and noted (the complete history and physical) Empirium Description of clinic, staff, lighting, sound, etc. 4.6 Table: Hierarchy for clinical data (Evans, D.A., and Gadd, C.S., 1989) 13
- 14. Man with Edema Clinical Data Hierarchy Observations Global complex None so far Diseases Hypertension? Alcohol? Ischemic heart disease? Toxin? Syndromes Heart failure? Anemia? Facets Weight gain + edema; 225/140 + S4; pallor; tachycardia Findings Weight gain, DOE, Hx HTN, former smoker, pallor, clear lungs, S4, normal abdomen, edema Observations HPI progressive wt gain; shoes, then pants, fit tight; exertional dyspnea; allergy: aspirin (rash); HTN Rx (“slowed me down”); PMH ? HTN on ? Tx SOC quit smoking; SURG tonsillectomy GEN pale; healthy M VS 225/140 120 12 LUNGS clear HEART S4; no M ABD nontender; no HSM EXT 2+ pitting to mid-shin Empirium Clinic environment, staff, distance to parking lot 4.7 Table: Depiction of how the hierarchy for clinical data might work for man with edema, or swelling, of the ankles 14
- 15. Creating a Problem List • Weight gain + edema • Exertional dyspnea but clear lungs • Pallor • High blood pressure + history of hypertension • Tachycardia • S4 gallop • Risk factors for coronary artery disease • Ex-smoker To-Do list for patient care • Grouping – Group related items – Don’t group if unsure • Include – Items that need attention or action – Tonsils? Smoking? Male? • Expression – At level of understanding but no more – Problems with persistence, precision of coding 15
- 16. Health Care Processes and Decision Making Summary – Lecture b • Information gathering and processing were examined • The structure of the history and physical were discussed and correlated to a hierarchy • Through the context of a case study, the levels of the hierarchy were examined 16
- 17. Health Care Processes and Decision Making References – Lecture b References Croskerry, P. (2013) From Mindless to Mindful Practice — Cognitive Bias and Clinical Decision Making. New England Journal of Medicine 368:2445-2448 June 27. Elstein, A. S., & Schwartz, A. (2002) Clinical problem solving and diagnostic decision making: Selective review of the cognitive literature. BMJ 324 (7339):729–732. Retrieved from http://www.bmj.com/content/324/7339/729 Evans, D. A., & Gadd, C. S. (1989). Managing coherence and context in medical problem-solving discourse. In Evans DA, Patel V. L. (Eds.), Cognitive science in medicine: Biomedical modeling. Cambridge, MA: MIT Press; 211–255. Kannampallil, T. G., Jones, L. K., Patel, V. L., Buchman, T. G., & Franklin, A. (2014). Comparing the information seeking strategies of residents, nurse practitioners, and physician assistants in critical care settings. Journal of the American Medical Informatics Association 21 (2): e-249–e256. Retrieved from http://jamia.oxfordjournals.org/content/21/e2/e249 Trotter, W. (n.d.) Quotation. “Disease often tells its secrets in a casual parenthesis.” 17
- 18. Health Care Processes and Decision Making References – Lecture b Continued Charts, Tables 4.5 Chart: Depiction of an iterative reasoning clinical process 4.6 Table: Hierarchy for clinical data. Evans, D. A., & Gadd, C. S. (1989). Managing coherence and context in medical problem-solving discourse. In Evans DA, Patel V. L. (Eds.), Cognitive science in medicine: Biomedical modeling. Cambridge, MA: MIT Press; 211–255. 4.7 Table: Depiction of how the hierarchy for clinical data might work for man with edema, or swelling, of the ankles 18
- 19. The Culture of Health Care Health Care Processes and Decision Making Lecture b This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. 19
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- No audio. Recording preparation.
- Welcome to The Culture of Health Care: Health Care Processes and Decision Making. This is Lecture b. The component, The Culture of Health Care, addresses job expectations in healthcare settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
- The Objectives for Health Care Processes and Decision Making are to: Describe the elements of the “classic paradigm” of the clinical process. List the types of information used by clinicians when they care for patients. Describe the steps required to manage information during the patient-clinician interaction. List the different information structures or formats used to organize clinical information. Describe different paradigms and elements of clinical decision making. Explain the differences among observations, findings, syndromes, and diseases. Describe techniques or approaches used by clinicians to reach a diagnosis. List the major factors that clinicians consider when devising a management plan for a patient’s condition in addition to the diagnosis and recommended treatment. Describe the role of EHRs and technology in the clinical decision-making process.
- This lecture discusses the clinical process as it unfolds between the patient and clinician, focusing on the process of gathering data. Consider the story depicted on this slide. This is the case of a man who came to the clinic because he felt his ankles were swelling. The clinic assistant says, “Blood pressure 225 over 140,” as she brings in a man with his shoes untied and loosened and with his ankles bulging over the top. He looks healthy enough, but he’s a little pale. He says, “I’m a little short of breath after walking in from the parking lot,” but his lungs sound clear, and he’s only breathing 12 times a minute. “Do you smoke?” you ask. “I used to,” he replies, “but I quit three years ago.” He says he’s been gaining weight lately, and his clothes are fitting tight. You check his heart, which has an S4 gallop, but no murmur. You ask about his clothes: “First my shoes, then later my pants, felt too tight,” he says. You check his abdomen, which shows no tenderness, masses, or enlarged organs. Then he recalls that he was on medication for blood pressure a few years back, but stopped taking it because he felt “slowed down.” You check his pulse, which is 120, and on his legs you notice significant pitting to the mid-shin. “Have you ever been sick before?” you ask. “No, never in all my thirty-nine years,” he replies, “except once when I got a rash from aspirin. Oh yeah, and to have my tonsils out.”
- While trying to understand the clinical process of taking care of patients such as this man with leg swelling, one danger is that creating a model can accidentally introduce attributes that are not part of the process itself. These may be artifacts of the model. To further illustrate this point, consider that the clinical process is often described or initially learned as depicted on this slide, beginning with the patient’s history, followed by the physical examination, then followed by a step in which all the data are gathered to form an assessment, and concluding with the creation of the patient’s management plan of care. This so-called “complete history and physical” appears to be a discrete, linear, orderly, and structured process. Although it can be performed this way, observation of clinicians in real life suggests that the process often does not follow this rigid pattern at all.
- Because the complete history and physical is not really linear and orderly, clinicians often employ an iterative hypothetico-deductive [hi-puh-thet-i-koh-dee-duhkt-iv] reasoning process. In this process, the experiences reported by the patient, which are called symptoms, and the observations made by the clinician, which are called signs, are gathered simultaneously, not one after the other in a linear fashion. Furthermore, making sense of this information, assessing it, and formulating hypotheses about it, begin not after gathering all the data but within a very short time after the initial process begins—in as little as 20 or 30 seconds. Symptoms and signs are uncovered, and a set of working candidate diagnoses are considered. These hypotheses are then tested with further questioning, which can eliminate some or corroborate others. The process proceeds in an iterative hypothesis-testing cycle until enough certainty has been reached that the clinician can take action. Elstein [el-steen] described some of the cognitive properties of this process, such as narrowing of the cognitive space of possibilities. For simplicity, however, it’s sufficient to say that the clinician uses an iterative, cyclical process of information gathering and assessment that doesn’t follow the linear, orderly sequence noted earlier. This nonlinear process has implications for the development of information systems, which should function as a support tool for clinicians during this iterative patient data collection process. Information systems should ideally be flexible to support the clinician’s practices, processes, and workflow. They should function as an effective tool that captures, displays, and reports patient data in a manner to facilitate clinical practice with the assessment, diagnoses, and treatment of patients.
- As mentioned earlier, data gathering uses a combination of open-ended and closed-ended questions. Initially, clinicians try to get the story from the patient using open-ended questions that allow the person to tell the story in his or her own words. The clinician may include or exclude family members and others as historians, depending on the patient’s ability to communicate, the sensitive nature of the information, and other factors. Once this initial story is told, the clinician may proceed with more closed-ended questions either to pursue specific hypotheses or to ensure that the information is complete. Clinical documents refer to this approach as a review of the patient’s 11 major body systems (nervous system, integumentary system, respiratory system, digestive system, excretory system, skeletal system, muscular system, circulatory system, endocrine system, reproductive system, and lymphatic or immune system). It’s important to understand that the tools used to gather, record, and analyze information may affect the process of obtaining this information and that collection of information is different from documentation. Clinical information systems and EHRs can facilitate the clinician’s data collection through use of prompts and questions that display according to the patient’s identified signs, symptoms, and diagnosis.
- Once the data is gathered, it needs to be given some structure. In medical practice, physicians use a highly structured methodology of arranging information that has been used for generations, called the history and physical, or H&P. Clinical information systems and EHRs may be set up to support a template structure for clinicians to use with their data collection and entry. These templates can be set up not only for history and physicals but also for assessments, clinical notes, and treatment plans.
- Medical students learn and memorize a comprehensive history and physical format as a cognitive structure that gives organization and meaning to information that otherwise might be disjointed or difficult to comprehend. Through repetition and practice, this format becomes second nature and provides an efficient scaffolding for thinking and communication. Once the novice has acquired sufficient expertise, it becomes necessary to tailor and individualize the process to the patient and the context. The novice might know the rules, but the expert knows the exceptions. This slide shows a very brief overview of the structure and organization of data in the history and physical. Most textbooks that teach clinical skills contain an example of this arrangement. The organizational scaffolding begins with data that identifies the patient and also the source of the information, which may be the patient, a family member, old records, or another source. This is followed by what is called the chief complaint, or the reason for the hospital admission or office visit. Clinicians are typically encouraged to use the patient’s own words when recording the chief complaint. Following this is the history of the present illness. This is usually a chronologically ordered narrative, in a paragraph or more, containing the details of the patient’s current problem as explained to the clinician. Next is a summary of the patient’s past history. This summary has a substructure that includes specific information about allergies, current medications and treatments, past medical and surgical history, vaccinations and preventive care, and for women, their menstrual and obstetric history. This section is followed by a social history, which includes occupation, habits, and healthy or risky behaviors, and then by a family history, which includes any illnesses that may run in the family, such as cancer, heart disease, and hypertension. The next area of the history and physical contains a complete review of the body systems. A detailed review of each organ and body system may elucidate important symptoms that have not come to light through other means. The history and physical then proceeds to the findings upon physical examination, which also has a highly structured format. Ancillary data such as laboratory test results, x-rays, and other diagnostic test results are included. Once these results are recorded in the history and physical, the data collection phase is complete. Next, the patient assessment and the patient’s plan of care are addressed by the clinician. It may be worth noting that this order of information is analogous [uh-nal-uh-guh s] to, or somewhat parallels, the structure of scientific papers and scientific argument. A statement of the problem precedes the description of the methods and findings, and these sections precede the interpretation of the findings and the author’s conclusions.
- Knowing this structure, we can return to the story presented earlier, of the man who came to the office with swollen ankles. In this slide, the key elements of the story are highlighted, indicating the symptoms reported by the patient, which are colored red, and the observations of the clinician, colored blue. Having selected these key elements, the next task in the clinical process is to reorganize the information into a conventional format.
- This slide gives structure to the data by placing selected items in the conventional order of the history and physical. This is the first step in processing the information to make sense of it. The next step in analyzing the findings is to look for patterns and meaning in this data. Clinical information systems and EHRs ideally should facilitate the data collection process, resulting in the display of patient data in a structured format.
- The first step in analyzing the clinical data is to give it some structure—to rearrange the information to fit the standard format of the history and physical. The next step is to try to find patterns and meaning in the data, connecting the patient’s symptoms and signs to what the clinician knows about the pathophysiology [path-oh-fiz-ee-ol-uh-jee] and manifestations of disease.
- One way to understand how clinicians organize and reduce clinical information to make sense of it is to use a hierarchy of clinical data. One such hierarchy was described by Evans and Gadd [gad]. Moving from the bottom of this table to the top, information is aggregated into progressively higher-level groupings. Starting at the bottom is what has been called the “empirium” [em-peer-ee-yum], which includes all of the available information at the time the patient was assessed, including information about the patient, the staff, and the clinical setting. A lot of this information is often unimportant, but some of it may be relevant under the right circumstances. For example, the level of lighting in the room is not usually mentioned, but when the clinician walks into an examination room and encounters a patient lying down on the exam table with the lights off, it may suggest certain medical conditions that cause a person to avoid light, such as migraine or meningitis. So most of the information in the empirium may be ignored, but a subset of this information must be taken into account to understand the patient and the problem. This information is called observations. Observations are everything that the clinician noticed and documented by recording a complete history and physical. These include the signs and symptoms that are part of the current problem as well as the many pieces of information collected in a standardized fashion from patients, such as blood pressure and pulse. Moving up a level in the hierarchy, a subset of these observations is selected by the clinician on the basis of their relevance to the patient’s care for the current active problems that the clinician or the patient has identified. These are referred to as findings. Whereas a comprehensive history and physical contains all the observations a clinician has made, the story told to a colleague is likely to contain only the findings. The relevant findings are highly dependent on context; what is relevant to the psychiatrist may be less important to the orthopedist; what is relevant in the primary care setting may be less important in the emergency department. It’s not entirely predictable which of the available observations will be considered to be findings, except by knowing and understanding the context. The next analytic step is to consider facets, or groups of findings that are related by the underlying pathophysiology or disordered biologic process. For example, in a serious infection, the body is stimulated to warm itself above normal temperature. As body temperature increases, a person experiences uncontrollable shaking chills, called a rigor. Once these chills have raised the body temperature, the person experiences a feverish feeling and may notice that his or her skin is hot. Later, when the body resets its temperature set point, perhaps by the benefit of aspirin, the body attempts to cool itself, and the skin may become flushed and sweaty. Therefore, shaking chills, high fever, and sweats are connected by a common pathophysiologic [path-oh-fiz-ee-uh-la-jik] process that can be grouped into what Evans and Gadd call a facet. Not all findings can be grouped with other findings, but by grouping some of them, the clinician can reduce the total amount of information and make it more manageable while giving it some meaning. A still higher level of organization is called a syndrome. This is often a grouping of findings and facets; for example, fever, chills, and sweats, taken together with the report of cough and sputum production, pain on one side of the chest that is worse with coughing or breathing, and abnormal findings on that side of the chest when listening with a stethoscope suggest the syndrome of pneumonia. A syndrome is a constellation of findings that tend to occur together, usually because of mechanistic or pathophysiologic connections. It’s important to understand the difference between a syndrome and a disease. The findings already described suggest the possibility of pneumonia, a syndrome. If the clinician can further determine which kind of pneumonia it is—for example, streptococcal [strep-tuh-kok-uh l] pneumonia caused by bacteria called Streptococcus [strep-tuh-kok-os], the disease will be known. The key here is that many diseases can produce the same syndrome. Many different germs can cause the pneumonia syndrome, which produces the same symptoms in the patient regardless of the germ that triggered the syndrome. Many kinds of heart damage can cause heart failure syndrome, which results in the same symptoms regardless of the causative disease. Therefore, disease is a more precise term than syndrome because disease implies that the clinician understands not only what findings are present but also what the cause is. Finally, at the top of this hierarchy is what Evans and Gadd call a global complex, which is a combination of syndromes or diseases that tend to occur together in the same patient. A common example is portal hypertension from alcoholic cirrhosis [si-roh-sis], which is a global complex involving a whole host of syndromes that affect many different organ systems and cause many different symptoms, all connected to one underlying pathophysiologic process. Clinical discourse contains many examples of communications about patients at various levels of this hierarchy, indicating the varying degrees of understanding or certainty about what is wrong.
- This slide depicts how this hierarchy might work for the man who had swelling in his ankles. Starting at the empirium are all the observations the clinician might have made, which are too numerous to mention here. In the second level from the bottom are the observations, including the man’s history of weight gain, the tight-fitting pants, his high blood pressure, and so forth. The clinician often uses a specialized shorthand to note observations, usually to save time. For example, HTN [H-T-N] is hypertension, VS [V-S] stands for vital signs, and EXT [E-X-T] refers to extremities. Moving up another level, the findings include a subset of those observations that seem to be key to understanding his problem, specifically his weight gain, shortness of breath when he exerts himself (dyspnea [disp-nee-uh] on exertion, or D-O-E), and history of high blood pressure. The category of facets allows a grouping of some of the findings. For example, his weight gain seems to go together with edema [ih-dee-muh], as shown with his fluid retention. The high blood pressure goes together with an abnormal heart sound, called an S4, which occurs in patients with hypertension. His pale skin might be connected with his rapid pulse, but it’s dangerous to decide that two things are connected when they might not be, so those findings are left separate for now. Next, the clinician can try to group these findings and facets into syndromes. For example, pale skin suggests that the man might be anemic, so he may need a complete blood count to test for anemia. His history of high blood pressure, weight gain, shortness of breath on exertion, and swelling in his ankles all suggest that he may have the syndrome of heart failure. The next level is to consider diseases. If the patient has heart failure, it could be due to high blood pressure, alcoholism, coronary artery disease, or perhaps the ingestion of some toxin. This leads to what clinicians call the differential diagnosis. At this stage, the clinician has begun to make sense of the symptoms and signs, reducing the data by organizing it into meaningful groupings. Now the clinician can begin treatment and diagnostic testing.
- After the data is structured using the history and physical, then organized into meaningful groups, a problem list, shown here in the left column, can be created. A problem list is essentially the clinician’s to-do list for patient care. The problem is expressed as a disease when a specific disease is known. It is expressed as a syndrome when the exact cause of the syndrome is unknown. In some cases, only symptoms or problems are listed because the clinician has insufficient information to say any more than that the patient is, for example, short of breath. Of course, the problem list evolves over time as more information becomes available; the problem list created at the first patient visit may be different from the list that exists after examination and treatment and from the list that’s used with discharge of the patient. On this slide, the patient’s symptoms listed in the left column form the basis for a problem list. In the right column are some rules for creating problem lists. First, related items that don’t need to be listed separately should be grouped if (but only if) they are part of the same process. Second, items should be included that need attention or action, but items that do not need further attention should not be included because they clutter the page and the mind. Should the tonsillectomy be recorded in the problem list? Should the patient’s gender or the fact that he smoked be included? Whether or not to include information depends on the context of the clinical visit. Third, each problem should be expressed at the level at which it’s understood and no more. To do otherwise can lead to the diagnostic error of premature closure, whereby the clinician stops pursuing a cause before really understanding it. Premature closure can lead to inappropriate diagnosis and treatment.
- This concludes Lecture b of Health Care Processes and Decision Making. In summary, this lecture examined information gathering and processing. The structure of the history and physical was discussed and correlated with a hierarchy. Levels of the hierarchy were examined in the context of a case study.
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