Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Making a diagnosis
Choosing therapy
The impact of EHRs and technology on clinical decision-making
Slide content:Management Plan Continued GI Initial Plan Secondary Tertiary GER D 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?
Slide notes:Another consideration, especially in primary or ambulatory care settings and for chronic conditions, is staging the management plan. In some cases, diagnostic tests or treatment interventions are needed only if the initial testing or initial treatment does not remedy the problem. In the hospital, with its foreshortened time horizon, staging the plan is much harder to accomplish, but in the outpatient setting its commonly done. This simple table represents an evolving management plan. Across the top are columns for the initial plan, the secondary plan, and the tertiary plan. In the first row under GI [G-I], or gastrointestinal, conditions, the patient appears to have heartburn or gastroesophageal [ gas - troh - ih - soff -uh- jeeuhl ] reflux disease. The initial plan is a trial of therapy with a proton-pump inhibitor, which works in about 80 percent of cases. If this drug is not effective, then the plan is for the patient to come back and a decision needs to be made about further workup, possibly including a diagnostic test called esophagogastric [eh- soff -uh- goh - gas - trik ] duodenoscopy [doo- awd - ehn - ah - skuh -pee], or EGD, which is usually definitive but always expensive. In the second row, peptic ulcer disease with bleeding is being considered. The initial plan is to obtain blood tests to see whether anemia has developed or theres blood in the stool. If both of these prove to be normal, then no further steps will be taken. If either test is abnormal, then the secondary plan involves an esophagogastric duodenoscopy. If that test shows the disease is caused by Helicobacter [ hell - ih - coh-bak-ter ] pylori [pie- lawr - ee ], a germ that causes ulcers, then treatment for that condition will be given. This treatment, however, may be expensive and may be restricted by some health plans. The logical procedure, therefore, is to follow this evolving plan that proceeds through stages depending on the results of the preceding stage. Again, although such a staged management plan may be the ideal, its difficult to execute in the hospital because of the very short time horizon and the need to discharge patients as quickly as possible. Its similarly difficult to execute in the ambulatory care setting because of substantial constraints on clinician time and patient access. 11