1. The Culture of Healthcare Healthcare Processes and Decision Making Lecture a This material (Comp2_Unit4a) 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 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. (Lecture a, b, c) List the different information structures or formats used to organize clinical information. (Lecture b) Explain what is meant by the 'hypothetico-deductive' 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 a

3. The Classic Paradigm Classic paradigm assumes a single patient interacts with a single clinician Patient has a single problem Care is provided during a single episode Various tools mediate this process –Medical records –Computers –Clinical decision support 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

4. Classic Paradigm Evolution of tools that support the task "Central Theorem of Health Informatics" –human + computer > human alone Classic Paradigm in Health Informatics –one patient –one problem –one clinician –one visit Technology supports this 1:1:1:1 paradigm 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

5. Attributes of Clinician Possesses specialized knowledge Received experiential training Has direct relationship with patient and makes decisions about patient care Acts in patient’s best interest Integrates diverse types of information Functions within time & resource constraints 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

6. Types of information Patient Datarefers to one person patient, family, records, observation Population Statistics aggregated patient data colleagues, public health dept, EHR Medical Knowledge generalizable to many persons textbooks, journal articles, MEDLINE Logistic Information how to get things done people, policy and procedure Social Influence how others get the job done observe and discuss with colleagues 4.1 Table: Types of information that clinicians utilize when making decisions 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

7. Organization How clinicians organize information? Narrative structure Rearranged into a history and physical format Further rearranged into a hierarchy Reformulated into a computable structure for utilization by clinical information systems 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

8. “Disease hides its secrets in a casual parenthesis” (Tumulty, Philip A., nd.) 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

9. How stories fit into health system Part 1 Communication between patient and clinician –Facts embedded in story (meaning to clinician) –Meaning of the illness to the patient –Communication and relationship building –Therapeutic value –Important aspect of quality of care 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

10. How stories fit into health system Part 2 Among Clinicians –Efficient communication among experts –Values and ethics are communicated through stories How do modern healthcare systems (and HIT) affect stories? –Eliminate or alter them –Lose context 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

11. Interpretation How clinicians understand clinical data Disciplinary differences Different approaches to clinical data interpretation Development of social construction Contextual interpretation of data 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

12. 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Beyond the Classic Paradigm Collaboration in Surgery Multiple disciplines with different roles and tasks Short time horizon Requires advance planning, resource rich 4.2 Table: Comparison of the classic paradigm with the operating room. Patientsproblemscliniciansvisits classic paradigm 1111 operating room 11many1 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

13. 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Beyond the Classic Paradigm Uncertain, complex, high stakes Complex acute illness - multiple disciplines, roles, tasks Short time horizon, unplanned events, uncertain data 4.3 Table: Comparison of the classic paradigm with the operating room and acute complex illness. The Culture of Healthcare Healthcare Processes and Decision Making Lecture a patientsproblemscliniciansvisits classic paradigm 1111 operating room 11many1 acute complex illness 1many 1 or more

14. 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 Beyond the Classic Paradigm Uncertain, complex, high stakes Simultaneous care of multiple acute and non-acute - very short time horizon Planning for the unexpected, resources are often constrained Coordination, cooperation, collaboration 4.4 Table: Comparison of the classic paradigm with the operating room, acute complex illness and emergency dept. The Culture of Healthcare Healthcare Processes and Decision Making Lecture a patientsproblemscliniciansvisits classic paradigm 1111 operating room 11many1 acute complex illness 1many 1 or more Emergency dept many 1

15. 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Steps in the Classic Process What is the matter? –diagnosis What can be done? –treatment What will happen? –prognosis Gathering data Analyzing findings Making a diagnosis Choosing treatment Communicating the plan The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

16. Healthcare Process and Decision Making Summary – Lecture a Looked at types of information that clinicians use in the course of managing patients Defined the role and nature of a clinician Examined the classic paradigm of the clinical process and also looked at some alternate paradigms 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a

17. Healthcare Processes and Decision Making References – Lecture a References Evans, DA and Patel, V. (1989) Cognitive Science in Medicine: Biomedical modeling. MIT Press, Cambridge, MA Retrieved from http://portal.acm.org/citation.cfm?id=575722http://portal.acm.org/citation.cfm?id=575722 Friedman, CP. (2009). A “Fundamental theorem” of biomedical informatics. Journal of the American Medical Informatics. Retrieved from http://jamia.bmj.com/content/16/2/169.shorthttp://jamia.bmj.com/content/16/2/169.short Gorman, PN. (1995) Information needs of physicians. Journal of the American Society for Information Science and Technology Hunter, KM. Doctors' (1991) stories: The narrative structure of medical knowledge. Princeton University Press (1991) Kassirer, P and Kopelman, I. Learning clinical reasoning‎. pp. 332. Tumulty, Philip A., (nd.) Quotation. “Disease hides its secrets in a casual parenthesis” 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture a Charts, Tables, References 4.1 Table: Types of information that clinicians utilize when making decisions 4.2 Table: Comparison of the classic paradigm with the operating room. 4.3 Table: Comparison of the classic paradigm with the operating room and acute complex illness. 4.4 Table: Comparison of the classic paradigm with the operating room, acute complex illness and emergency dept.