1. The Culture of Healthcare
Healthcare Processes and Decision Making
Welcome to The Culture of Healthcare: Healthcare Processes and Decision Making. This is Lecture b.
The component, The Culture of Healthcare, 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.
Lecture b
This 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

2. Healthcare 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 (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).
The Objectives for Healthcare 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.
Explain what is meant by the 'hypothetico-deductive' reasoning process.
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.
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The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

3. 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.
This lecture will discuss 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, with his ankles bulging over the top. He looks healthy enough, but he is 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 twelve times a minute. “Do you smoke?” you ask. “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 notice significant pitting to the mid-shin. “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.”
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The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

4. Clinical Process: the Myth
History  Physical  Assessment  Plan
The “complete” history and physical
Discrete
Linear
Orderly
Structured
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, 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 a management plan. 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.
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The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

5. Clinical Process: The Reality
Because the “complete history and physical” Is not really linear and orderly, clinicians often employ an iterative [it-er-uh-tiv] hypothetico-deductive [hahy-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 [hahy-poth-uh-seez] about it, begin not after gathering all the data but within a very short time after the initial process begins – in as little as twenty or thirty 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 is sufficient to say that the clinician uses an iterative, cyclical process of information gathering and assessment that does not follow the linear, orderly sequence noted earlier. This process may have implications for the development of information systems.
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

6. “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
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 has been told, the clinician may proceed with more closed-ended questions, either to pursue specific hypotheses [hahy-poth-uh-seez] or to ensure that all bases have been covered. Clinical documents refer to this approach as a review of systems. It is 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.
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7. Step Two: Analyzing Findings
Part 1: Giving structure to the data
Once the data has been 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.
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The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

8. 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
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 some other 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 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.
Following this is a summary of the patient’s past history. This summary has a sub-structure 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; followed by a family history, which includes any illnesses that may run in the family such as cancer, heart disease, and so forth.
The next area of the history and physical contains a complete review of systems. A detailed review of each organ 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; this, too, has a highly structured format.
Ancillary data such as laboratory test results, chest x-ray, and other reports are included. Once these results are recorded in the history and physical, the data collection is complete and sections for the clinician’s assessment and plan follow. 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 these findings and the author’s conclusions.
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9. 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.”
Knowing this structure, one 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 have been highlighted, indicating the symptoms reported by the patient, which are colored in red, and the observations of the clinician, colored in blue. Having selected these key elements, the next task in the clinical process is to reorganize the information into a conventional format.
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The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

10. Providing Structure to Data
History
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/
Head and neck negative
Lungs clear
Heart: S4 heard, no murmur
Abdomen non-tender; no hepatosplenomegaly
Extremities: 2+ pitting to mid shin
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 out of it. The next step in analyzing the findings is to look for patterns and meaning in this data.
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11. Step 2: Analyzing Findings
Part 2:
Finding Patterns and Meaning in the Data
The first step in analyzing the clinical data was 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.
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12. Hierarchy for Clinical Data
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.
One way to understand how clinicians organize and reduce clinical information to make sense out 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. Often a lot of this information is 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, this suggests certain medical conditions that cause a person to avoid light, such as migraine or meningitis [men-in-jahy-tis]. So most of the information in the empirium [em-peer-ee-yum] may be ignored, but a subset of this information must be taken into account to understand the patient and the problem, and this information is called observations. Observations are everything that the clinician noticed and documented by recording a complete history and physical. This includes 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 will be 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 [awr-thuh-pee-dist]; what is relevant in the primary care setting may be less important in the emergency department. It is 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 [fas-its], or groups of findings that are related by the underlying pathophysiology [path-oh-fiz-ee-ol-uh-jee] or disordered biologic process. For example, in a serious infection, the body is stimulated to warm itself above normal temperature. To raise the body temperature, a person will experience uncontrollable shaking chills, called a 'rigor.' Once these chills have raised the body temperature, the person will experience 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 will attempt 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-ol-aw-jik-uhl] 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, together suggest the syndrome of pneumonia. A syndrome is a constellation of findings that tend to occur together, usually because of mechanistic or pathophysiologic [path-oh-fiz-ee-ol-aw-jik] connections. It is important to understand the difference between a syndrome and a disease. The findings already described suggest the possibility of pneumonia, a syndrome. If one can further determine which kind of pneumonia this 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. Many kinds of heart damage can cause heart failure syndrome, which results in the same symptoms despite having multiple causative diseases. Therefore, ”disease” is a more precise term than ”syndrome” because the term 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. This refers to combinations 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 pathophysiological [path-oh-fiz-ee-ol-aw-jik-uhl] 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.
4.6 Table: Hierarchy for clinical data (Evans, D.A., and Gadd, C.S., 1989)
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The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

13. Man with Edema Global Complex Diseases Syndromes Facets Findings
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/ LUNGS clear HEART S4; no M ABD nontender; no HSM EXT 2+ pitting to mid shin
Empirium
clinic environment, staff, distance to parking lot
This slide depicts how this hierarchy might work for the man who had swelling in his ankles. Starting at the empirium [em-peer-ee-yum] are all the observations one might have made that are too numerous to mention here. In the second level from the bottom are the observations, including his 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 is hypertension, VS stands for vital signs, and EXT 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 DOE), and history of high blood pressure.
The category of facets allows a grouping of some of the findings. For example, the weight gain seems to go together with edema [ih-dee-muh] if he has been retaining fluid. 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 is dangerous to decide that two things are connected when they might not be, so those findings will be left separate for now.
Next the clinician can try to group these findings and facets into syndromes. For example, his pale skin suggests that he might be anemic [uh-nee-mik], so he may need testing for that. His past history of high blood pressure, weight gain, shortness of breath when he exerts himself, 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, or alcoholism, or 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, and can begin treatment and diagnostic testing.
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

14. Creating A Problem List
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
Weight gain + edema
Exertional dyspnea but clear lungs
Pallor
High blood pressure + history of hypertension
Tachycardia
S4 gallop
Risk factors for CAD
Ex-smoker
After giving structure to the data with the history and physical and analyzing that data by organizing it into meaningful groups, one can create what is called a problem list, depicted here in the left column. A problem list is essentially the clinician’s to-do list for patient care. In some cases, the problem will be expressed as a disease when a specific disease is known. In other cases, it may be expressed as a syndrome when the exact cause of the syndrome is unknown. In still other cases, only symptoms or problems will be listed because there is not enough information to say any more than that the patient is, for example, short of breath. Of course, the problem list will evolve 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.
On this slide, the symptoms of the patient 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 do not 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 not items that do not because they clutter the page and the mind. Should the tonsillectomy be recorded in the problem list? Should the fact that the patient is male, and that he smoked? It all depends on the context. Third, each problem should be expressed at the level at which it is 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. This can lead to inappropriate diagnosis and treatment.
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The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

15. 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.
This concludes Lecture (b) of Healthcare Processes and Decision Making.
In summary, this talk 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.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

16. Healthcare Processes and Decision Making References – Lecture b
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):
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;
Gorman, PN. (1998); Information seeking of primary care physicians: Retrieved from conceptual models and empirical studies at
No audio
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;
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