The Culture of Health Care

2. The Culture of Health Care Health Care Processes and Decision Making Lecture b 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 IU24OC000015. 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 http://creativecommons.org/licenses/by-nc-sa/4.0/.

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

4. My Ankles Are Swollen Example case: A man who came to the clinic because of ankle swelling. The clinic assistant says, “Blood pressure 225 over 140,” as she brings in a man with his shoes untied and loosened and with his 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 12 times a minute. “Do you smoke?” you ask. “I 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 ago but stopped taking it because he felt “slowed down.” You check his pulse, which is 120, and on his legs you notice a two-plus pitting to the mid-shin. “Have you 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.

5. Clinical Process: The Myth • History  Physical  Assessment  Plan • The “complete” history and physical • Discrete • Linear • Orderly • Structured

6. Clinical Process: The Reality 4.5 Chart: Depiction of an iterative reasoning clinical process

7. “Disease often tells its secrets in a casual parenthesis.” -Wilfred Trotter • Getting the story • Open-ended questions • Enabling the person to tell his or her story • Including/excluding family, others • Filling in the details • Closed-ended questions • Comprehensive checklists, review of systems • The tools affect the process • Collection ≠ Documentation

8. Analyzing Findings - 1 Part 1: Giving Structure to the Data

9. Structured Data Organization • Source identification • 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 body systems • Physical examination • Appearance/vitals/skin • Head and neck • Lungs/heart • Abdomen/genitalia • Extremities/back • Neurologic • Ancillary data, diagnostic test results

10. 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 shortof 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 ask. “I 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 notenderness, masses, or enlarged organs (blue). Then he recalls he was on medication for blood pressure (red) a few years ago but stopped taking it because he felt “slowed down” (red). You check his pulse, it’s 120 (blue), and on his legs you notice2+ pitting to mid-shin (blue). “Have you ever been sick before?” you ask. “No, never in all my thirty-nine years, except once when I got a rash from aspirin (red). Oh yeah, and to have my tonsils (red) out.”

11. Providing Structure to Data History • History of present illness: progressive weight gain; tight shoes, then pants fit tight; exertional dyspnea • Allergies: aspirin (rash); hypertension medication (“slowed me down”) • Patient medical history: hypertension • Social: quit smoking • Surgical history: tonsillectomy Physical • General: pale, healthy M • Vital signs: BP: 225/140; pulse 120; respirations 12 • Head and neck negative • Lungs clear • Heart: S4 heard, no murmur • Abdomen nontender; no hepatosplenomegaly • Extremities: 2+ pitting to mid-shin

12. Analyzing Findings - 2 Part 2: Finding Patterns and Meaningin the Data

13. Hierarchy for Clinical Data 4.6 Table: Hierarchy for clinical data (Evans, D.A., and Gadd, C.S., 1989)

14. Man with Edema 4.7 Table: Depiction of how the hierarchy for clinical data might work for man with edema, or swelling, of the ankles

15. 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 coronary artery disease • 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

16. Health Care Processes and Decision MakingSummary – 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

17. Health Care Processes and Decision Making References – Lecture b References Croskerry, P. (2013) From Mindless to Mindful Practice — Cognitive Bias and Clinical Decision Making. New England Journal of Medicine 368:2445-2448 June 27. Elstein, A. S., & Schwartz, A. (2002) Clinical problem solving and diagnostic decision making: Selective review of the cognitive literature. BMJ 324 (7339):729–732. Retrieved from http://www.bmj.com/content/324/7339/729 Evans, D. A., & Gadd, C. S. (1989). Managing coherence and context in medical problem-solving discourse. In Evans DA, Patel V. L. (Eds.), Cognitive science in medicine: Biomedical modeling. Cambridge, MA: MIT Press; 211–255. Kannampallil, T. G., Jones, L. K., Patel, V. L., Buchman, T. G., & Franklin, A. (2014). Comparing the information seeking strategies of residents, nurse practitioners, and physician assistants in critical care settings. Journal of the American Medical Informatics Association 21 (2): e-249–e256. Retrieved from http://jamia.oxfordjournals.org/content/21/e2/e249 Trotter, W. (n.d.) Quotation. “Disease often tells its secrets in a casual parenthesis.”

18. Health Care Processes and Decision Making References – Lecture b Continued Charts, Tables 4.5 Chart: Depiction of an iterative reasoning clinical process 4.6 Table: Hierarchy for clinical data. Evans, D. A., & Gadd, C. S. (1989). Managing coherence and context in medical problem-solving discourse. In Evans DA, Patel V. L. (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

19. The Culture of Health CareHealth Care Processes and Decision MakingLecture b 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 IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002.