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Health IT Workforce Curriculum Version 4.0

2. The Culture of Health Care
Health Care Processes and Decision Making
Welcome to The Culture of Health Care: Health Care Processes and Decision Making. This is Lecture e.
The component, The Culture of Health Care, addresses job expectations in health care settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
Lecture e
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 IU24OC 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

3. Health Care Processes 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. (Lectures a, b, c, d, e).
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

4. Keeping Track of Care
“Never ask a new patient a question without note-book and pencil in hand....” Sir William Osler (1849–1919)
This final lecture discusses communication of the management plan to all those who might need the information.
It’s not clear how far back the practice of keeping medical records goes, but it dates at least to this quote from Sir William Osler [ohs-ler], who advised medical students, [quote] “Never ask a new patient a question without notebook and pencil in hand” [end quote].
(Corner, PD-US)

5. Problem List: Building Relationship, Negotiating Plans
Diabetes
Polyuria, polydipsia, polyphagia
Hyperglycemia
HTN
High BP x 3
EKG shows left ventricular hypertrophy
Hyperlipidemia
LDL 194
Triglycerides 250
Body Mass Index 34
To begin this discussion, consider a patient who has come to see a clinician to establish care. In the course of the visit, a problem list has been generated that includes diabetes causing frequent urination, excessive thirst, an increased appetite, and high blood sugar. The list also includes high blood pressure based on three previously recorded blood pressures that were abnormal and evidence on an electrocardiogram that the heart is being affected. Furthermore, low-density lipoprotein [lip-oh-proh-teen], or LDL [L-D-L], levels are far above the goal at 194, and the triglyceride level is high based on a test result of 250. The patient is also overweight, with a body mass index of 34.
As the clinician develops a management plan with the patient for each of these problems, it becomes important to communicate these problems and the evolving plan to others.

6. Who Is the Audience? What Is the Message for Each?
Patient
Family, friends, the public
Clinical staff—nurses, lab staff, x-ray, therapists, pharmacists, dietician
Yourself—now and later
Colleagues
Consultants
Insurance companies
Lawyers (plaintiff and defendant)
Compliance officers, regulators
Researchers, data miners
Performance measures
The audience for these messages will include people and entities that play a role in the patient’s care. The patient, of course, needs to receive this information, but also on occasion family, friends, or even the public need to be informed. Physicians and other clinical staff may be involved, including nurses, laboratory technicians, and therapists who treat the patient.
The clinician is part of this process in terms of keeping notes for his or her own future actions and communicating with colleagues and consultants when a diagnosis is uncertain or a referral is needed. One or more insurance companies will also need some information in order to provide payment or, in some cases, to authorize services or review services not normally covered by the insurance plan.
There’s also the possibility—although we hope it’s never realized—that attorneys may need to review the patient’s record for information to support their client in the event of a conflict.
A variety of governmental and professional regulatory agencies have an interest in making sure the health care system is functioning and health care professionals are acting appropriately.
In addition to these entities, researchers may use the information in the clinical record for data mining and for performance measures in quality improvement.
The patient record created by the clinician therefore will be used by a diverse set of audiences, each with a different focus and different goals. The next question is to determine the appropriate message for each of these audiences.

7. Communicating with Patient
Patient education—what’s wrong
Instructions—what to do
Reassurance—what will happen
Motivation, hope
Acknowledgment, acceptance
“I’ll be there for you”
First on the agenda is communicating with the patient and potentially with the patient’s family or significant caregivers. Patient education is necessary to explain what’s wrong, how it came about, what can be done, and if applicable, ways to prevent recurrence in the future. Patients need specific instructions about what to do and what not to do, and these instructions must be put in a language and format that the patient can use effectively. Often patients need reassurance about what will happen, motivation to become more engaged in their care, or a sense of hope when the prognosis is grave. Whatever the problem, whatever the prognosis, patients may need acknowledgment, acceptance, and a clear understanding that the clinician will be there for them. Communicating the plan to the patient may involve any or all of these goals.

8. Family, Friends, the Public
What do they need to know?
What will be best for the patient?
What will be best for the family member?
What can I legally tell?
What can I ethically tell?
Very often, other individuals, such as significant others, parents, children, siblings, best friends, and possibly even the landlord, are interested in or need to know about the patient’s problem and the treatment plan. Which individuals are given information depends on the patient and his or her relationships. Several questions arise. What does each of these individuals need to know? What is best for the patient in terms of information sharing with his or her family and friends? What is best for the family members? What information can legally be disclosed? What can ethically be disclosed? Privacy laws clearly define limits that help answer some of these questions; however, in clinical practice, the answers are often individualized depending on the needs and the condition of the patient and the needs of his or her loved ones.
Therefore, the second part of the communication plan is figuring out what to communicate to the patient’s family and friends and how to do so. Disclosure can be an important part of patient management and may have a significant impact on outcomes.

9. Clinical Staff Nurses Pharmacists Dieticians
Therapists: Physical, occupational, respiratory, massage, acupuncture
Lab technicians
Diagnostic imaging staff
There’s also often a whole host of clinical staff who need differing amounts of information about the patient, the problem, and the management plan in order to carry out their roles in the process. Staff members may include nurses, pharmacists, dieticians, physical therapists, occupational therapists, respiratory therapists, laboratory technicians, x-ray technicians, and more. Each of these people will need information specific to their task because they can contribute more effectively when they have an understanding of the patient’s condition. An x-ray technician who understands the suspected problem will make better decisions in performing x-rays or radiation therapy. Physical therapists will be able to provide effective treatments and provide consideration to the patient with an understanding of the clinical goals, the patient’s diagnoses, and level of mobility. A dietician will need information about the patient’s various diagnoses, habits, and social background as well as the clinical goals in order to ensure the patient receives the most appropriate diet and nutrition education. All members of the team need some, but not necessarily all, of the patient information to help them contribute. There has been an increased emphasis on care coordination in health care, which can lead to better health outcomes for patients as well as increasing efficiency.

10. Oneself
“Nothing clears up a case so much as stating it to another person” (Sherlock Holmes, fictional character of Sir Arthur Conan Doyle, 1893)
Processing effect of recording case
Effect of structure and order
Impact of recording technology
Prospective memory—notes to myself, a la “memento”
A less obvious person with whom the clinician must communicate is himself or herself. As Sherlock Holmes said, “Nothing clears up a case so much as stating it to another person”; this comment refers to the cognitive processing that occurs as we organize and articulate information. Even if the clinician doesn’t verbally explain the case to another person, he or she understands the case better by creating a written or documented record. Cognition is aided by imposing structure and order, and may also be impacted in some way by the methods and technology used in the documentation process, such as dictating, writing, typing, or using macros and smart text.
Creating clinical notes not only aids the clinician’s processing of the case, but it’s also a means of communicating with himself or herself in the future as well as sharing valuable patient information with other clinicians and caregivers. Today’s note, if well written, becomes an excellent basis for reestablishing the state of affairs at the next patient encounter, which may be many months or even years away.

11. Other Clinicians Colleagues Consultants
Future responsibility for patient
Format
Content
Detail
“Experts share knowledge not only of their domain, but of the structure and goals of their discourse” (Evans, 1989)
Consultants
Ask a clear question—get a much better answer
What to share—what to leave out
Neurologist
Psychiatrist
Cardiologist
Radiologist
Clinicians often need to communicate about the patient with other colleagues or consultants. Discussions with colleagues, for example, may involve signing out a patient over the weekend or transferring the patient to another person’s care for the future. The communicating clinician needs to consider the format, content, and level of detail of the communication, which will vary depending on the purpose. On-call, overnight coverage requires less information and detail than the permanent transfer of patient care responsibility.
“Experts share knowledge, not only of their domain but of the structure and goals of their discourse,” according to Evans. This shared knowledge can make communication between colleagues quite efficient. When calling upon consultants to address specific issues, it’s essential to ask a clear question, which facilitates a useful reply. How much information and which information to share depends on who is being consulted; for example, neurologists, psychiatrists, cardiologists, or radiologists each need different information to address the problem in their specialty. Simply communicating every piece of data will force the consultant to find a needle in a haystack of irrelevant information.

12. Insurance Companies Documentation of the illness
ICD10
Documentation of the procedure
CPT
Documentation of supplies, injections, services, etc., to Medicare beneficiaries
HCPCS
Documentation of the process
Details to support diagnosis, treatment plan
SNOMED CT
Another group that the clinician must inform about a patient’s diagnosis and management plan is the insurance companies. In most cases, before payment is authorized, insurance companies require a diagnosis expressed as an International Classification of Diseases, or ICD-10 [I-C-D ten] code, even if the diagnosis is not yet known. They also require a description of the services provided or procedures performed expressed as a Current Procedural Terminology, or CPT [C-P-T] code. Based on CPT, the Health Care Common Procedure Coding System, or HCPCS [hick picks], is a set of health care procedure codes used for Medicare billing for the Centers for Medicare and Medicaid Services (or CMS) as well as for Medicaid billing and some insurance companies.
Beyond these codes, which may not always describe exactly what the clinician is thinking, there’s frequently a need to provide certain details that support a given diagnosis or treatment in order to justify payment.
Electronic clinical documentation may also use other classifications, such as SNOMED CT [snow med C – T]. [quote] “The Systematized [sis-te-me-tized] Nomenclature [no-men-klay-cher] of Medicine, is a systematic, computer-processable collection of medical terms, in human and veterinary medicine, to provide codes, terms, synonyms, and definitions which cover anatomy, diseases, findings, procedures, microorganisms, and substances.” [end quote]

13. How Much Detail, in What Form?
Lawyers
Regulatory agencies
Data mining
Clinical and outcomes research
Quality and performance improvement
Patient safety
There are still other audiences with whom the clinician may communicate. Although the hope is that it won’t be necessary, there may come a time when lawyers examine the patient record to look for information that supports their client, and the clinician should keep this possibility in mind as he or she creates the record. Government and private regulatory agencies may use the medical record to determine whether the clinical processes of care are appropriate and for other various audits. Others may use the medical record in aggregate for data-mining purposes to learn about diseases, treatments, or practice patterns. Still others will use the record in aggregate to perform clinical or outcomes research, quality and performance improvement reviews, and patient-safety studies. A major challenge for the clinician is to create appropriate communications for all of these audiences at the same time.

14. Health Care Processes and Decision Making Summary – Lecture e
This lecture examined
How clinicians gather patient data
How they analyze it and utilize specific techniques to reach a diagnosis and formulate a plan
How clinicians communicate their plan with the patient and others who need information
This concludes Lecture e of Health Care Processes and Decision Making. In summary, this lecture examined how clinicians communicate their plan with the patient and others who need the information.

15. Health Care Processes and Decision Making Summary – Lecture e Continued
This unit examined the process of diagnosis and determination of a care plan:
Role and nature of a clinician; classic and alternate paradigms
Information gathering, process, analysis
Diagnostic thinking and techniques
Models used to choose therapy and formulate a management plan
Communication of the management plan
This concludes the unit Health Care Processes and Decision Making.
This unit described the process used by clinicians to gather patient data, analyze it, use distinct techniques for reaching a diagnosis, and develop a plan to treat the patient.
The role and nature of a clinician were defined, the classic paradigm of the clinical process was outlined, and some alternate paradigms were discussed. Information gathering and processing were examined along with a discussion of the structure of the history and physical, correlated with a hierarchy.
Diagnostic thinking was then examined with a focus on techniques for making a diagnosis, such as using a systematic or pathophysiologic approach. This discussion expanded to topographic, temporal, and clinically contextual patterns of data for use in diagnosis; the use of heuristics; and mathematical approaches to assist in clinical decision making.
Models that clinicians use to choose therapy and formulate a management plan were discussed, closing with an examination of how clinicians communicate their plan with the patient and others who need the information.

16. Health Care Processes and Decision Making References – Lecture e
American Hospital Association. (n.d.) Communicating with patients. Retrieved from
Doyle, A. C. (1893). Silver Blaze. In The memoirs of Sherlock Holmes. London: George Newnes Pub.
Evans, D. A., & Gadd, C. S. (1989). Managing coherence and context in medical problem solving discourse. In D. A. Evans & V. L. Patel (Eds.). (1989). Cognitive science in medicine: Biomedical modeling. Cambridge, MA: MIT Press. (p. 214).
Feldman M., & Christensen, J. (2014). Behavioral medicine: A guide for clinical practice, 4th ed. New York: McGraw-Hill Medical
International Health Terminology Standards Development Organization. (2016). SNOWMED CT. Retrieved from
Systematized Nomenclature of Medicine. In Wikipedia. Retrieved from
TechTarget. (2016). Definition: SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms). Retrieved from
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Images
Slide 3: Corner, T. C. (1905). Retrieved from Category:William_Osler#/media/File:Sir_William_Osler.jpg. Public domain image (PD-US).

17. The Culture of Health Care Health Care Processes and Decision Making Lecture e
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 IU24OC This material was updated in 2016 by Bellevue College under Award Number 90WT0002.
No audio.
Health IT Workforce Curriculum Version 4.0