Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Gathering data and analyzing findings
Making a diagnosis
The impact of EHRs and technology on clinical decision-making
Slide content: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 patients 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
Slide notes: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 patients 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. Its 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. Its 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 isfor 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. 13