Arild and Tim This is clearly an issue. In the CIP project the group wanted to be able to say that a diagnosis was a working diagnosis.
We have archetyped a number of concepts that I think will enable the clinician to express these levels of uncertainty without resorting to confidence ratings on all entries in the record. Arild has shown that you could not possibly do a mastectomy without rating your certainty at 100% - or you will be sued. And not treating a pneumonia in a newborn with a certainty of only 20% will probably get you in trouble. These sort of explicit ratings are - in my opinion - very problematic. The solution lies in the recording constructs used for many years: 1. To express differential diagnoses (with or without probabilities) and to note key excluded diagnoses as well. 2. To express a diagnosis as a problem (such as lump in left breast) even if the likelihood of cancer is 100% clinically until the histology is returned. 3. To be able to label a diagnosis as a working diagnosis - ie it is likely enough to warrant the current management - but not certain. Appendicitis is a good example. So the archetypes for problem, problem-diagnosis (specialised) and differential diagnosis should meet these needs. Comments? Sam > Tim Cook wrote: > While it might be an interesting exercise for us to record how confident > a clinician was at the time of recording a diagnosis, it will have no > impact on the health care of that patient. If we were to do this would > we ask them to do so in <sarcasm>10% steps, 5% steps or .01% > steps</sarcasm>? I assert that any one of these would seriously impact > the usability of an EHR in a negative manner and would result in the > clinician taking the option that presents the least liability on their > part. > > So back to the short answer above.....is it really relevant to assert > ANY confidence factor in the EHR? > > > My opinion is that there indeed is highly relevant to assert a > confidence factor in the EHR. > > ln decision analysis one talks about treatment thresholds for diagnostic > uncertainity as "the probability of disease at which the expected value > of treatment and no treatment are exactly equal, and ne ither option is > clearly preferable." (Hunik and Glasziiou "Decision making in health and > biomedicine"). Factors influencing the treatment threshold are the > expected benefit and the expected harm of the treatment. > Example: Treatment threshold is much lower for pneumonia (treatment: > penicillin) than for cancer of the left mamma (treatment: Mastectomy) > > Thus: How confident a clinician is at the time of recording a diagnosis > has high impact on the health care of that patient. > > Comments on this? > > regards, > Arild Faxvaag - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
