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: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
Slide notes:6 Listed here are specific examples of the kinds of considerations that the clinician must address to individualize management options for the patient. The first example is coexisting conditions. A patient with high blood pressure who also has diabetes should be treated first with a type of drug called an ACE [ ayse ] inhibitor because these medications have special and distinct benefits when they are used in diabetic patients. Second, patient preferences may well drive whether or not a prostate screening test called a PSA [P-S-A] should be ordered. A third example is a person dying of lung cancer who is an Hmong [ hmawng ] immigrant from Laos who would prefer not to die at home, contrary to the usual assumptions about in-home hospice provision in palliative [ pal - ee -uh- tiv ] care. Economic limitations come into play, for example, when a new heart murmur is discovered but the patient has no insurance to pay for diagnostic testing; here, a wait-and-watch approach might be taken. For a patient with peptic ulcer disease and heartburn, scientific evidence would drive the decision to choose a class of drug called a proton-pump inhibitor instead of another class called a histamine blocker; however, the better agent is more expensive, and price may be a concern. Local practices may come into play when determining referrals for procedures in specialty care. Well-trained and well-regarded specialists may have different preferences when treating certain conditions. A clinicians own experience is relevant when choosing medications or treatments because, in general, that clinician will perform better and more safely when using a familiar procedure or drug than when using an unfamiliar one, even if the new one is said to be better. Finally, organizational imperatives may drive choices beyond what the clinician and the patient think is best, such as when the formulary of a health plan or hospital restricts the choices of certain drugs within a particular category.