Comp2 Unit4b Lecture Slides
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Transcript of Comp2 Unit4b Lecture Slides
The Culture of HealthcareHealthcare Processes and
Decision Making
Lecture bThis material (Comp2_Unit4b) 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
Healthcare Process and Decision MakingLearning 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 (lecture a,b,c).
• List the different information structures or formats used to organize clinical information (lecture b).
• Explain what is meant by the 'hypotheticodeductive' reasoning process (lecture a,b).
• Explain the difference between observations, findings, syndromes, and diseases (lecture a,b,c).
• Describe techniques or approaches used by clinicians to reach a diagnosis (lecture 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).
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The Culture of Healthcare Healthcare Processes and Decision Making
Lecture b
My ankles are swollen• Example case: a man who came to the clinic because of ankle swelling. The clinic
assistant says “blood pressure two-twenty-five over one-forty” as she brings in a man with his shoes untied and loosened, with 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 twelve times a minute.
• “Do you smoke?” you say. “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 back, but stopped taking it because he felt ‘slowed down’. You check his pulse, which is 120, and notice a two-plus pitting to the mid shin. “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.
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Lecture b
Clinical Process: the Myth
• History Physical Assessment Plan
• The “complete” history and physical– Discrete– Linear– Orderly– Structured
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The Culture of Healthcare Healthcare Processes and Decision Making
Lecture b
Clinical Process: The Reality
4.5 Chart: Depiction of an iterative reasoning clinical process
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The Culture of Healthcare Healthcare Processes and Decision Making
Lecture b
“Disease hides its secrets in a casual parenthesis”
• Getting the story• Open ended questions• Enabling the person to tell their story• Including/excluding family, others
• Filling in the details• Closed ended questions• Comprehensive checklists, review of systems
• The tools affect the process• Collection ≠ Documentation
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Lecture b
Step Two: Analyzing Findings
Part 1: Giving structure to the data
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Lecture b
Structured Data Organization• Source ID• Chief Complaint• History of Present Illness• Past History
– allergies/adverse reactions– medications/treatments– past medical problems– past surgeries– menstrual/obstetric history– Immunization / preventive
care
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• Family and Social History• Review of Systems• Physical Examination
– appearance/vitals/skin– Head and neck– lungs/heart– abdomen/genitalia– extremities/back– neurologic
• Ancillary data
The Culture of Healthcare Healthcare Processes and Decision Making
Lecture b
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 say. “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 back, but stopped taking it ‘cause he felt ‘slowed down’ (red). You check his pulse, it’s 120 (blue), and notice 2+ pitting to mid shin (blue). “Ever been sick before?” you ask. No, never in all my 39 years, except once when I got a rash from aspirin (red).” “Oh yeah, and to have my tonsils (red) out.”
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Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Processes and Decision Making
Lecture b
Providing Structure to DataHistory
• History of present illness;: progressive weight gain; shoes, then pants fit tight; exertional dyspnea
• Allergies: aspirin (rash); hypertension medication: “slowed me down”
• Pat medical history: hypertension
• Social: quit smoking
• Surgical history: tonsillectomy
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Physical • General: pale, healthy M
• Vital signs: 225/140 120 12
• Head and neck negative
• Lungs clear
• Heart: S4 heard, no murmur
• Abdomen non-tender; no hepatosplenomegaly
• Extremities: 2+ pitting to mid shin
The Culture of Healthcare Healthcare Processes and Decision Making
Lecture b
Step 2: Analyzing Findings
Part 2: Finding Patterns and Meaning in the
Data
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Lecture b
Hierarchy for Clinical DataGlobal 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)
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Lecture b
Man with EdemaGlobal 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, 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
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Lecture b
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 CAD• Ex-smoker
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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
The Culture of Healthcare Healthcare Processes and Decision Making
Lecture b
Healthcare 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.
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The Culture of Healthcare Healthcare Processes and Decision Making
Lecture b
Healthcare Processes and Decision Making
References – Lecture bReferences• Elstein et al. (1981); Medical problem-solving. Academic Medicine.• Elstein AS, Schwartz A. (2002 Mar 23); 324 Clinical problem solving and diagnostic decision making: selective
review of the cognitive literature. BMJ. (7339):729-32.• Evans DA, Gadd CS. (1989); Managing coherence and context in medical problem-solving discourse. In: Evans
DA, Patel VL, eds. Cognitive science in medicine: Biomedical modeling. Cambridge, MA: MIT Press; 211-255.• Gorman, PN. (1998); Information seeking of primary care physicians: Retrieved from conceptual models and
empirical studies at http://informationr.net/isic/ISIC1998/98_Gorman.pdf.
Charts, Tables, Figures• 4.6 Table: Hierarchy for clinical data . Evans, D.A., and Gadd, C.S.,(1989); Managing coherence and context in
medical problem-solving discourse. In: Evans DA, Patel VL, 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
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The Culture of Healthcare Healthcare Processes and Decision Making
Lecture b