1. The Culture of Healthcare Healthcare Processes and Decision Making Lecture c This material (Comp2_Unit4c) 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. The Culture of Healthcare 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 c

3. Diagnostic Thinking Weight gain + edema Exertional dyspnea but clear lungs Pallor High BP + history of HTN Tachycardia S4 gallop Risk factors for CAD Ex-smoker 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Edema – cause? –Heart –Liver –Kidneys –Nutrition Dyspnea –Heart –Lungs –Anemia –Restriction –Deconditioning Tachycardia The Culture of Healthcare Healthcare Processes and Decision Making Lecture c

4. Techniques For Diagnosis Heuristics –When you hear hoofbeats, look for horses, not zebras Mathematics –Baye’s Theorem Temporal patterns –Acute, sub acute, etc 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Systematic –e.g. VINDICATE: organ system Anatomic –e.g. Chest anatomy Pathophysiologic –e.g. Bilirubin metabolism Pattern recognition –e.g. NDM (naturalistic decision-making) Mnemonic –PT Barnum Loves Kids The Culture of Healthcare Healthcare Processes and Decision Making Lecture c

5. Systematic Approach Brainstorming To Expand Differential VINDICATE (processes) –Vascular –Infectious –Neo-plastic –Drugs –Inflammatory/ idiopathic –Congenital –Autoimmune –Trauma –Endocrine/metabolic) Organ (systems) –Neuro –CV –Pulmonary –Renal –Heme –GI –Bones –Joints –Skin 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture c

6. Pathophysiologic Approach All the causes of jaundice Erythrocyte –Disorder of erythropoiesis –Disorder of hemolysis Liver –Disorder of uptake –Disorder of conjugation –Disorder of secretion Biliary obstruction –Intrahepatic obstruction –Obstruction of the bile duct –Obstruction by the pancreas (cancer) 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture c

7. Patterns of Data in Diagnosis Especially Neurologic Diagnosis Topographic pattern –locate lesion in nervous system –peripheral nerves, plexus, spine, brain Temporal pattern –pace of appearance and resolution of symptoms –pathophysiologic process Clinical context - the company it keeps –other symptoms (e.g. fever) –comorbidities (e.g. valvular heart disease) –past Hx (e.g. smoking) 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture c

8. Heuristics: Rules of Thumb Err on the side of life When you hear hoofbeats, look for horses, not zebras (unless you are at the zoo…) You are more likely to see an uncommon case of a common disease than an uncommon disease 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Weaknesses –cognitive errors –heuristics and biases Strength: –“fast and frugal heuristics” The Culture of Healthcare Healthcare Processes and Decision Making Lecture c

9. Mathematical Approaches Bayes’ theorem –Mnemonics: SpIN and SnOUT Decision Rules –Wells criteria for pulmonary embolism –Centor criteria for strep throat Decision Analysis 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture c

10. Healthcare Processes And Decision Making Summary – Lecture c Diagnostic thinking: –Techniques for making a diagnosis systematic approaches pathophysiologic approaches –Patterns of data in diagnosis Topographic Temporal Clinical context –Heuristics –Mathematical approaches to assist in clinical decision making 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture c

11. Healthcare Processes and Decision Making References – Lecture c References Bolstad WM. (2007) Introduction to Bayesian Statistics. Wiley-Interscience; 2 edition. Elstein AS, Schwartz A. C (2002) linical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ. 324(7339):729-32. Kassirer, P and Kopelman, (1991) I. Learning clinical reasoning‎. pp. 332. 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Healthcare Processes and Decision Making Lecture c