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).

2Health IT Workforce Curriculum Version 3.0/Spring 2012

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.



Lecture b

Clinical Process: the Myth

• History Physical Assessment Plan

• The “complete” history and physical– Discrete– Linear– Orderly– Structured



Lecture b

Clinical Process: The Reality

4.5 Chart: Depiction of an iterative reasoning clinical process



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



Lecture b

Step Two: Analyzing Findings

Part 1: Giving structure to the data



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


• Family and Social History• Review of Systems• Physical Examination

– appearance/vitals/skin– Head and neck– lungs/heart– abdomen/genitalia– extremities/back– neurologic

• Ancillary data


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.”

9Health IT Workforce Curriculum

Version 3.0/Spring 2012


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


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


Lecture b

Step 2: Analyzing Findings

Part 2: Finding Patterns and Meaning in the

Data



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)



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



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


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


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.



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



Lecture b

http://informationr.net/isic/ISIC1998/98_Gorman.pdf

Date post:	06-May-2017
Category:	Documents
Upload:	health-it-workforce-curriculum-2012
View:	213 times
Download:	0 times

Comp2 Unit4b Lecture Slides

Documents