1. The Culture of Healthcare Healthcare Processes and Decision Making 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). 2 Health IT Workforce Curriculum Version 3.0/Spring 2012 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. 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 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 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

5. Clinical Process: The Reality 4.5 Chart: Depiction of an iterative reasoning clinical process 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 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 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

7. Step Two: Analyzing Findings Part 1: Giving structure to the data 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 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 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 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

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.” 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 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 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 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

11. Step 2: Analyzing Findings Part 2: Finding Patterns and Meaning in the Data 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

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. 4.6 Table: Hierarchy for clinical data (Evans, D.A., and Gadd, C.S., 1989) 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

13. Man with Edema 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, 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 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture b

14. 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 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 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

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. 15 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 References 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.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 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture b