The document discusses health care processes and clinical decision making. It examines how clinicians gather and structure patient information, including describing the levels of a clinical data hierarchy. Through a case study example of a man with ankle swelling, it demonstrates how the hierarchy can be applied to analyze findings and create a problem list. The document also provides references and examples to further explain concepts related to clinical reasoning and decision making.
We aimed to investigate the potential effects of fi x-dose atorvastatin plus amlodipine treatment and amlodipine alone treatment for 24 weeks on blood pressure, arterial stiffness and endothelial function in patients with hypertension and hypercholesterolemia. In a single-blinded, randomized, placebo-controlled and parallel design, 60 hypertensive and hypercholesterolemic patients were allocated to receive atorvastatin 10 mg/day plus amlodipine 5 mg/day or amlodipine 5 mg/day for 24 weeks. Central blood pressure was reduced significantly greater in atorvastatin plus amlodipine group than in amlodipine group after 12 and 24 weeks’ treatment. Both amlodipine and atorvastatin plus amlodipine therapy signifi cantly improved Flow-Mediated Dilation (FMD) compared to baseline (p < 0.01), the effect of atorvastatin plus amlodipine therapy was even greater after 24 weeks(p < 0.05). Atorvastatin plus amlodipine therapy signifi cantly decreased Heart Rate-Adjusted Augmentation Index (AIx@HR75), carotid-femoral and brachial-ankle Pulse Wave Velocity (PWV) when compared with baseline in both 12 weeks and 24 weeks’ administration, while amlodipine therapy not. FMD improvement was independently correlated with change in TC (β = -0.416, P = 0.004), while arterial stiffness improvement assessed with AIx@HR75 and baPWV, was correlated with change in central SBP (β = 0.772, P < 0.001, and β = 0.420, P = 0.003, respectively) in multivariate linear stepwise model. Fixed-dose amlodipine and atorvastatin treatment for 24 weeks reduced central BP and arterial stiffness, improved endothelial function greater than amlodipine therapy. Our findings suggested decrease in TC was the independent protective factor for endothelial function improvement and decrease in central SBP was the independent protective factor for arterial stiffness reduction during the follow-up period.
We aimed to investigate the potential effects of fi x-dose atorvastatin plus amlodipine treatment and amlodipine alone treatment for 24 weeks on blood pressure, arterial stiffness and endothelial function in patients with hypertension and hypercholesterolemia. In a single-blinded, randomized, placebo-controlled and parallel design, 60 hypertensive and hypercholesterolemic patients were allocated to receive atorvastatin 10 mg/day plus amlodipine 5 mg/day or amlodipine 5 mg/day for 24 weeks. Central blood pressure was reduced significantly greater in atorvastatin plus amlodipine group than in amlodipine group after 12 and 24 weeks’ treatment. Both amlodipine and atorvastatin plus amlodipine therapy signifi cantly improved Flow-Mediated Dilation (FMD) compared to baseline (p < 0.01), the effect of atorvastatin plus amlodipine therapy was even greater after 24 weeks(p < 0.05). Atorvastatin plus amlodipine therapy signifi cantly decreased Heart Rate-Adjusted Augmentation Index (AIx@HR75), carotid-femoral and brachial-ankle Pulse Wave Velocity (PWV) when compared with baseline in both 12 weeks and 24 weeks’ administration, while amlodipine therapy not. FMD improvement was independently correlated with change in TC (β = -0.416, P = 0.004), while arterial stiffness improvement assessed with AIx@HR75 and baPWV, was correlated with change in central SBP (β = 0.772, P < 0.001, and β = 0.420, P = 0.003, respectively) in multivariate linear stepwise model. Fixed-dose amlodipine and atorvastatin treatment for 24 weeks reduced central BP and arterial stiffness, improved endothelial function greater than amlodipine therapy. Our findings suggested decrease in TC was the independent protective factor for endothelial function improvement and decrease in central SBP was the independent protective factor for arterial stiffness reduction during the follow-up period.
CardiologyEndocrine Case Study Course Student Learning Outcom.docxannandleola
Cardiology/Endocrine Case Study
Course Student Learning Outcomes
Upon completion of the case study, students will be able to …
1. Apply the principles of pharmacology relative to pharmacotherapeutics across age levels including the effect of race, gender, ethnic group, and special populations.
2. Describe the uses, actions, effects and nursing implications of general classifications of drugs and selected specific drugs.
3. Investigate media resources and information technologies to enhance knowledge base of pharmacology.
4. Analyze the responsibilities of the nurse when administering drugs.
5. Apply pharmacological research to nursing practice.
Purpose The purpose of this case study is to apply concepts from pharmacology and
pathophysiology, national guidelines, and evidenced based clinical practices in the management of chronic disease. Remember this paper must follow APA guidelines for font, in text citations, reference list etc. No abstract is needed. Provide headings for the different questions in your paper.
Setting This case study takes place in a primary care setting in a small rural hospital clinic that provides health care services to predominately Latino field workers and their families. The rural clinic serves children and adults for all medical needs including well care, acute care, and chronic conditions. Some clients have seasonal insurance, state health insurance, or no insurance. Many live below poverty level according to the federal guidelines. Most do not own a vehicle. Most do not speak English; so, a translator is provided at each visit. The clinic is one hour from the nearest city where higher level of care can be offered to patients in need of specialty care. The clinic is staffed by one family medicine physician, an internist, two nurse practitioners, an RN, two LVNs, a lab tech, eight MAs and support staff. Once a week a cardiologist, podiatrist, pain specialist, orthopedist and ophthalmologist service the clinic. There is an on-site lab and a pharmacy two blocks away. There are two ambulances servicing the entire south end of the county with poor availability for emergencies.
Client
Jose is a 47 year old morbidly obese Latino male who presents to the clinic for follow up evaluation of headaches, dizziness, ringing in his ears and frequent urination. He reports having a headache that “comes and goes” with ringing in his ears and sometimes he sees spots. Jose has taken acetaminophen and states that seems to help. Due to his work schedule of six 12 hour days, Jose has not had preventive care. He reports fatigue and is depressed regarding his current income situation. Jose has just been laid off for the season and will lose his insurance in 30 days until the restart of the harvesting season in March. He is concerned about paying for any health care that may go beyond his benefit period. Jose lives with his pregnant wife, who does not work, and their seven children in a three bedroom one bath house that they share.
The new guidelines for treatment of primary hypertension. JNC 8. Samir Rafla-JNC 8-2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults.
MEDINFO 2013 Panel on Personalized Healthcare and Adherence: Issues and Chall...Pei-Yun Sabrina Hsueh
Venue: The 14th World Congress on Medical and Health Informatics will take place in Copenhagen, Denmark.
http://medinfo2013.dk
Moderator: Dr. Marion Ball (IBM Research/JHU); Panelists: Dr. Vimla Patel (NYAM), Dr. Bern Shen (Healthcrowd), Dr. Pei-Yun Sabrina Hsueh (IBM Research)
Organizer: Dr. Pei-Yun Sabrina Hsueh (phsueh@us.ibm.com)
Personalization is key to the delivery of wellness care including preventive measures and disease management regimes, where patients take on increased responsibility for
their own health. While personalized care has already taken a giant leap through genomics, it remains a challenge to understand how individual differences play a role in patient adherence and manage recommended changes accordingly.
Practical methods of creating and evaluating personalized
systems have not been fully established. In particular, the role of data-driven analytics in producing actionable insights for practitioners is unclear, and the use of behavioral data has created additional challenges to the understanding of patient adherence for effective care delivery.
The panel will discuss the challenges that face many countries around personalized care from various perspectives. These range from behavioral aspects such as maintaining good practices, cognitive aspects such as how do individuals make decisions in the lights of good evidence, social aspects such as how to engage patients in sustaining adherence behavior, to technological aspects such as how to evaluate individual applicability of data-driven analytics and personalized technological systems.
The panel is expected to contribute to the global community by presenting lessons learned from
existing pilot designs and a collective list of recommendations for pilot design of personalized services at the conclusion of this panel.
Health assessment By - Jitendra Bokha.pptxJitendra Bokha
Health assessment is defined as systematic and dynamic process by which nurse through interaction with client, significant others and health care providers, collect data about the client.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
CardiologyEndocrine Case Study Course Student Learning Outcom.docxannandleola
Cardiology/Endocrine Case Study
Course Student Learning Outcomes
Upon completion of the case study, students will be able to …
1. Apply the principles of pharmacology relative to pharmacotherapeutics across age levels including the effect of race, gender, ethnic group, and special populations.
2. Describe the uses, actions, effects and nursing implications of general classifications of drugs and selected specific drugs.
3. Investigate media resources and information technologies to enhance knowledge base of pharmacology.
4. Analyze the responsibilities of the nurse when administering drugs.
5. Apply pharmacological research to nursing practice.
Purpose The purpose of this case study is to apply concepts from pharmacology and
pathophysiology, national guidelines, and evidenced based clinical practices in the management of chronic disease. Remember this paper must follow APA guidelines for font, in text citations, reference list etc. No abstract is needed. Provide headings for the different questions in your paper.
Setting This case study takes place in a primary care setting in a small rural hospital clinic that provides health care services to predominately Latino field workers and their families. The rural clinic serves children and adults for all medical needs including well care, acute care, and chronic conditions. Some clients have seasonal insurance, state health insurance, or no insurance. Many live below poverty level according to the federal guidelines. Most do not own a vehicle. Most do not speak English; so, a translator is provided at each visit. The clinic is one hour from the nearest city where higher level of care can be offered to patients in need of specialty care. The clinic is staffed by one family medicine physician, an internist, two nurse practitioners, an RN, two LVNs, a lab tech, eight MAs and support staff. Once a week a cardiologist, podiatrist, pain specialist, orthopedist and ophthalmologist service the clinic. There is an on-site lab and a pharmacy two blocks away. There are two ambulances servicing the entire south end of the county with poor availability for emergencies.
Client
Jose is a 47 year old morbidly obese Latino male who presents to the clinic for follow up evaluation of headaches, dizziness, ringing in his ears and frequent urination. He reports having a headache that “comes and goes” with ringing in his ears and sometimes he sees spots. Jose has taken acetaminophen and states that seems to help. Due to his work schedule of six 12 hour days, Jose has not had preventive care. He reports fatigue and is depressed regarding his current income situation. Jose has just been laid off for the season and will lose his insurance in 30 days until the restart of the harvesting season in March. He is concerned about paying for any health care that may go beyond his benefit period. Jose lives with his pregnant wife, who does not work, and their seven children in a three bedroom one bath house that they share.
The new guidelines for treatment of primary hypertension. JNC 8. Samir Rafla-JNC 8-2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults.
MEDINFO 2013 Panel on Personalized Healthcare and Adherence: Issues and Chall...Pei-Yun Sabrina Hsueh
Venue: The 14th World Congress on Medical and Health Informatics will take place in Copenhagen, Denmark.
http://medinfo2013.dk
Moderator: Dr. Marion Ball (IBM Research/JHU); Panelists: Dr. Vimla Patel (NYAM), Dr. Bern Shen (Healthcrowd), Dr. Pei-Yun Sabrina Hsueh (IBM Research)
Organizer: Dr. Pei-Yun Sabrina Hsueh (phsueh@us.ibm.com)
Personalization is key to the delivery of wellness care including preventive measures and disease management regimes, where patients take on increased responsibility for
their own health. While personalized care has already taken a giant leap through genomics, it remains a challenge to understand how individual differences play a role in patient adherence and manage recommended changes accordingly.
Practical methods of creating and evaluating personalized
systems have not been fully established. In particular, the role of data-driven analytics in producing actionable insights for practitioners is unclear, and the use of behavioral data has created additional challenges to the understanding of patient adherence for effective care delivery.
The panel will discuss the challenges that face many countries around personalized care from various perspectives. These range from behavioral aspects such as maintaining good practices, cognitive aspects such as how do individuals make decisions in the lights of good evidence, social aspects such as how to engage patients in sustaining adherence behavior, to technological aspects such as how to evaluate individual applicability of data-driven analytics and personalized technological systems.
The panel is expected to contribute to the global community by presenting lessons learned from
existing pilot designs and a collective list of recommendations for pilot design of personalized services at the conclusion of this panel.
Health assessment By - Jitendra Bokha.pptxJitendra Bokha
Health assessment is defined as systematic and dynamic process by which nurse through interaction with client, significant others and health care providers, collect data about the client.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
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Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
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Providing education on nutrition, hygiene, and development.
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ACCORDING TO apic.org,
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ACCORDING TO pewtrusts.org,
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VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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Health Care Processes and Decision Making Lecture 2_slides
1.
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 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
(lecture a, b, c, d, e).
3
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.
4
5. Clinical Process: The Myth
• History Physical Assessment Plan
• The “complete” history and physical
– Discrete
– Linear
– Orderly
– Structured
5
6. Clinical Process: The Reality
4.5 Chart: Depiction of an iterative reasoning clinical process
6
7. “Disease often tells its secrets in a
casual parenthesis.” -Wilfred Trotter
• Getting the story
o Open-ended questions
o Enabling the person to tell his or her story
o Including/excluding family, others
• Filling in the details
o Closed-ended questions
o Comprehensive checklists, review of systems
• The tools affect the process
• Collection ≠ Documentation
7
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
9
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 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 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 no tenderness, 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 notice 2+ 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.”
10
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
11
13. Hierarchy for Clinical Data
Clinical Data Hierarchy Observations
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) 13
14. Man with Edema
Clinical Data
Hierarchy
Observations
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, former 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 14
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
15
16. Health Care 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
16
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.”
17
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
18
19. The Culture of Health Care
Health Care Processes and
Decision Making
Lecture 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.
19
Editor's Notes
No audio. Recording preparation.
Welcome to The Culture of Health Care: Health Care Processes and Decision Making. This is Lecture b.
The component, The Culture of Health Care, 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.
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.
This lecture discusses 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 and with his ankles bulging over the top. He looks healthy enough, but he’s 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 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 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 on his legs you notice significant pitting to the mid-shin. “Have you 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.”
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 point, 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 the patient’s management plan of care. 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.
Because the complete history and physical is not really linear and orderly, clinicians often employ an iterative hypothetico-deductive [hi-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 about it, begin not after gathering all the data but within a very short time after the initial process begins—in as little as 20 or 30 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’s sufficient to say that the clinician uses an iterative, cyclical process of information gathering and assessment that doesn’t follow the linear, orderly sequence noted earlier. This nonlinear process has implications for the development of information systems, which should function as a support tool for clinicians during this iterative patient data collection process. Information systems should ideally be flexible to support the clinician’s practices, processes, and workflow. They should function as an effective tool that captures, displays, and reports patient data in a manner to facilitate clinical practice with the assessment, diagnoses, and treatment of patients.
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 is told, the clinician may proceed with more closed-ended questions either to pursue specific hypotheses or to ensure that the information is complete. Clinical documents refer to this approach as a review of the patient’s 11 major body systems (nervous system, integumentary system, respiratory system, digestive system, excretory system, skeletal system, muscular system, circulatory system, endocrine system, reproductive system, and lymphatic or immune system). It’s 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. Clinical information systems and EHRs can facilitate the clinician’s data collection through use of prompts and questions that display according to the patient’s identified signs, symptoms, and diagnosis.
Once the data is 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. Clinical information systems and EHRs may be set up to support a template structure for clinicians to use with their data collection and entry. These templates can be set up not only for history and physicals but also for assessments, clinical notes, and treatment plans.
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 another 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 the 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.
Next is a summary of the patient’s past history. This summary has a substructure 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, and then by a family history, which includes any illnesses that may run in the family, such as cancer, heart disease, and hypertension.
The next area of the history and physical contains a complete review of the body systems. A detailed review of each organ and body 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, which also has a highly structured format.
Ancillary data such as laboratory test results, x-rays, and other diagnostic test results are included. Once these results are recorded in the history and physical, the data collection phase is complete. Next, the patient assessment and the patient’s plan of care are addressed by the clinician. 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 the findings and the author’s conclusions.
Knowing this structure, we 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 are highlighted, indicating the symptoms reported by the patient, which are colored red, and the observations of the clinician, colored blue. Having selected these key elements, the next task in the clinical process is to reorganize the information into a conventional format.
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 of it. The next step in analyzing the findings is to look for patterns and meaning in this data. Clinical information systems and EHRs ideally should facilitate the data collection process, resulting in the display of patient data in a structured format.
The first step in analyzing the clinical data is 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.
One way to understand how clinicians organize and reduce clinical information to make sense 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. A lot of this information is often 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, it may suggest certain medical conditions that cause a person to avoid light, such as migraine or meningitis. So most of the information in the empirium may be ignored, but a subset of this information must be taken into account to understand the patient and the problem. This information is called observations.
Observations are everything that the clinician noticed and documented by recording a complete history and physical. These include 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 is 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; what is relevant in the primary care setting may be less important in the emergency department. It’s 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, or groups of findings that are related by the underlying pathophysiology or disordered biologic process. For example, in a serious infection, the body is stimulated to warm itself above normal temperature. As body temperature increases, a person experiences uncontrollable shaking chills, called a rigor. Once these chills have raised the body temperature, the person experiences 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 attempts 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-uh-la-jik] 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 suggest the syndrome of pneumonia. A syndrome is a constellation of findings that tend to occur together, usually because of mechanistic or pathophysiologic connections. It’s important to understand the difference between a syndrome and a disease. The findings already described suggest the possibility of pneumonia, a syndrome. If the clinician can further determine which kind of pneumonia it 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 regardless of the germ that triggered the syndrome. Many kinds of heart damage can cause heart failure syndrome, which results in the same symptoms regardless of the causative disease. Therefore, disease is a more precise term than syndrome because 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, which is a combination 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 pathophysiologic 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.
This slide depicts how this hierarchy might work for the man who had swelling in his ankles. Starting at the empirium are all the observations the clinician might have made, which are too numerous to mention here. In the second level from the bottom are the observations, including the man’s 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 [H-T-N] is hypertension, VS [V-S] stands for vital signs, and EXT [E-X-T] 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 D-O-E), and history of high blood pressure.
The category of facets allows a grouping of some of the findings. For example, his weight gain seems to go together with edema [ih-dee-muh], as shown with his fluid retention. 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’s dangerous to decide that two things are connected when they might not be, so those findings are left separate for now.
Next, the clinician can try to group these findings and facets into syndromes. For example, pale skin suggests that the man might be anemic, so he may need a complete blood count to test for anemia. His history of high blood pressure, weight gain, shortness of breath on exertion, 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, alcoholism, 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. Now the clinician can begin treatment and diagnostic testing.
After the data is structured using the history and physical, then organized into meaningful groups, a problem list, shown here in the left column, can be created. A problem list is essentially the clinician’s to-do list for patient care. The problem is expressed as a disease when a specific disease is known. It is expressed as a syndrome when the exact cause of the syndrome is unknown. In some cases, only symptoms or problems are listed because the clinician has insufficient information to say any more than that the patient is, for example, short of breath. Of course, the problem list evolves 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 and from the list that’s used with discharge of the patient.
On this slide, the patient’s symptoms 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 don’t 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 items that do not need further attention should not be included because they clutter the page and the mind. Should the tonsillectomy be recorded in the problem list? Should the patient’s gender or the fact that he smoked be included? Whether or not to include information depends on the context of the clinical visit.
Third, each problem should be expressed at the level at which it’s 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. Premature closure can lead to inappropriate diagnosis and treatment.
This concludes Lecture b of Health Care Processes and Decision Making. In summary, this lecture 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.