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: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
Slide notes:A more realistic view is depicted in this slide. Once again, the process begins with the patient care problem. The clinician generally tries to reach a specific diagnosis, but often the diagnosis cant be determined, or the clinician needs to begin management of the process before diagnostic testing is complete. A diagnosis isnt always available or necessary to move on to problem management. With a working diagnosis in hand, the clinician can incorporate scientific evidence and organizational imperatives to make a decision about management; however, other considerations often exist that must be taken into account. First among these are coexisting conditions, current or past illnesses, and medications that have an impact on treatment decisions for a new problem. For example, a patient with kidney disease may not be able to metabolize certain medications. In a patient with diabetes, it may be desirable to treat high blood pressure in a different way than in other patients. Clinicians must also take into account the patients preferences when devising a management plan. The growing movement toward patient-centered care and the expanded use of tools such as interactive decision aids, patient portals, personal health records, and secure electronic messaging have increased the process of shared decision making. In this process p atients and clinicians [quote] work together to make decisions and select tests, treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values. [end quote] Social factors, such as the patients job, significant others, family members, and current housing situation, may also have a bearing on treatment choices. Another set of considerations are local practices. These are relevant not just in rural areas, where resources or expertise may be constrained, but also in tertiary medical centers where local experiences or preferences for particular procedures or treatments may differ from the experiences or preferences at other institutions. Ideally, we hope a clinicians choices are driven solely by scientific evidence and the other factors discussed earlier; however, scientific evidence alone may not fully address a clinicians questions, and the experiences and preferences of local specialists may be significant factors. Furthermore, the experience of the clinician has some bearing on the best treatment choice for the patient. In general, a clinician performs better doing a procedure that he or she is familiar with than doing a new one. The same applies to prescribing familiar versus unfamiliar drugs. This issue is addressed well in Gawandes [ ga- wahn -deez ] book Complications . This doesnt preclude a clinician referring a patient to another clinician or a specialist who has more experience in a particular medical area or routinely performs a specific procedure. Last, but by no means least, are economic constraints. The most highly recommended, scientifically supported medication or treatment simply may not be available to a patient depending on his or her insurance plan or economic situation. All of these factors must be taken into account when devising a plan to manage the patients problem. 5