Health Care Processes and Decision Making Lecture 4

2. The Culture of Health Care
Health Care Processes and Decision Making
Lecture d
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 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 (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.
(Lectures a, b, c, d, e).
3

4. Choosing Therapy: The Myth
• The clinical process: Patient presents with
problem  n x Diagnosis  Treatment 
Problem resolution
• Clinician may incorporate scientific
evidence to choose appropriate treatment
• This view is overly simplistic
4

5. Choosing Therapy: Reality
4.8 Figure: The complex and dynamic processes that are in play when a patient care problem has to be
translated into problem management by the clinician (Mohan, 2010) 5

6. Individualizing Management
• Coexisting conditions
• Patient preferences
• Social factors
• Economic limitations
• Scientific evidence
• Local practices
• Personal (clinician)
experience
• Organizational imperatives
• HTN in DM – choose ACEI
• PSA test – patient
preference
• Hmong beliefs about death
• New murmur, no insurance
• PPI over H2 blocker for
GERD
• Specialist availability, beliefs
• Choice of surgical
procedure
• Formulary of insurance plan
6

7. Decision Analysis
• List options available
• List possible outcomes of
each option
• Find probability of each
possible outcome
• Ask patient for utility of
each outcome (e.g., time
trade off)
• Calculate expected utility
of decision
• Toss ups
• Heuristics and biases
4.9 Chart: Decision analysis chart (Mills, 1991)
7

8. SOAP Process Model
4.10 Figure: By CAST, CC-BY
8

9. “Medical Records That Guide and
Teach” (Weed, 1968)
• Plan
– Diagnostic
– Therapeutic
– Patient education
• Three-part plan
reminds clinician of
uncertainty, patient
inclusion
• Continuity over
time
9

10. Management Plan
SOAP Format
• Problem 1: Polydipsia, polyuria
– Dx: Blood sugar, hemoglobin A1c, urinalysis
– Tx: Diabetic diet, exercise prescription
– Pt. education: Meet with diabetic educator, referral to
local diabetes group
• Problem 2: High blood pressure
– Dx: EKG, urinalysis, serum electrolytes
– Tx: Low-salt diet, exercise prescription, diuretic
– Pt. education: Hypertension handout, list of useful
websites 10

11. Management Plan Continued
GI Initial Plan Secondary Tertiary
GERD Trial of medication f/u appt for decision EGD
PUD/bleeding Labs EGD H pylori therapy
($$$)
Gastritis Education re lifestyle
changes
EGD
Non-ulcer dyspepsia (Diagnosis of
exclusion)
Gallbladder,
pancreas
CT or US
Zebras:
cancer, etc.
EGD or CT if
unimproved
4.11 Table: Evolving Management Plan (Mohan, 2010)
11
Cardiac Initial Plan Secondary Tertiary
CAD Education re lifestyle
changes
Exercise stress
testing
Aspirin?

12. Health Care Processes and
Decision Making
Summary – Lecture d
• This lecture examined
– Models that clinicians use to choose therapy and
formulate a management plan
– The process of individualizing patient management
– Techniques that assist in formulating a management
plan:
o Decision analysis
o SOAP notes
12

13. Health Care Processes and
Decision Making
References – Lecture d
References
Gawande, A. (2002). Complications: A surgeon’s notes on an imperfect science. New York:
Metropolitan Books.
HealthIT.gov. (2013). Shared decision making. Retrieved from
https://www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf
Lenert, L., Dunlea, R., Del Fiol, G., & Hall, L. K. (2014) . A model to support shared decision making in
electronic health records systems. Medical Decision Making 34 (8): 987–995.
Lown, B., & Rodriguez, D. (2012). Commentary: Lost in translation? How electronic health records
structure communication, relationships, and meaning. Academic Medicine 87 (4): 392–394.
Weed, L. L. (1968). Medical records that guide and teach. New England Journal of Medicine.
Retrieved from http://www.nejm.org/doi/full/10.1056/NEJM196803142781105
Wikipedia (2011). Decision analysis. Retrieved from http://en.wikipedia.org/wiki/Decision_analysis.
Charts, Tables, Figures
4.8 Figure: The complex and dynamic processes that are in play when a patient care problem has to
be translated into problem management by the clinician. Mohan, V. (2010).
4.9 Chart: Decision analysis chart. Mills (1991) http://www.nlm.nih.gov/nichsr/hta101/tree15.jpg.
Retrieved from the National Library of Medicine website http://www.nlm.nih.gov.
4.10 Figure: SOAP Process Model. By CAST, CC-BY.
4.11 Table: Evolving Management Plan. Mohan, V. (2010).
13

14. The Culture of Health Care
Health Care Processes and
Decision Making
Lecture d
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.
14