P? 7. mai. 2005 kl. 15.12 skrev Thomas Beale: > Gerard Freriks wrote: > >> The EHR is not invented to describe the real actual health status of >> the patient. >> It is there to document what clinicians deemed important to say ABOUT >> the health status of the patient. >> It always is an opinion of a professional about something. > > yes, hopefully we all agree with this philosophy. > I can agree that the doctors hypothesis is an opinion, but those parts of the EHR that are pure descriptions of phenomena and symptoms, plans and descriptions of actions are not.
> But we need to add (contradict me if I'm wrong;-) that it is what > clinicians wanted to say which they deemed relevant to next steps - > either diagnostic or intervention. What to do next is not just based > on the doctor's confidence about what the symptoms might mean, but > also on: > - the urgency of treatment of that condition (cases like cerebral > meningitis, malaria...) > - the severity of the condition (e.g. cystic fibrosis) > - the severity of the consequences of the condition on others (CF, > huntington's, ...) > The issues here are - the severity of the disease - the course of the disease if not treated - the potential benefits of the intervention - the probability of the patient actually achieving these benefits - the cost and complexity of the intervention - the potential side effects of the intervention - the probability of these to develop - the patient's preferences (some patients are risk takers, others are not) one can also add - the need to convince the patient (replace the patient's hypothesis with that of the physician). - the need to maintain the patients trust in the provider (unless the patient might withdraw the care mandate / not give his consence to the plans suggested by the physician). > ...so it seems to me that the indicator of what to do next when a > differential diagnosis is recorded relates strongly to the innate > characteristics of the conditions recorded, not just the doctor's > opinion of how likely it might be. If angina pectoris is a possible > diagnosis for "burning chest pain" at 5%, with the most probable > diagnosis (in the opinion of the physician) being "gastric reflux" at > 95%, and it is a 55-yo with a family history of coronary heart > disease, I presume that the angina pectoris possibility is the one > that drives the next steps? How are the confidences really decided? > > How are we to bridge the gap between the physician-recorded confidence > factor and the total list of factors which drive the next steps? What > do we need in the EHR? Is this "just" a decision support problem > (where the physician will be performing the decision support)? Very briefly,, here are some factors (using terminology adapted from risk analysis): - Being healthy is something of high value. - Posessing a (unexplained) health problem implies being exposed to a potential threat to ones health. - When the patients seek a doctor he gives responsibility to the doctor and thereby partially transfer the risk to him (partially the health care person, partially the organisation who employs this person). - Diagnostics can be considered risk exploitation. - Therapeutics can be considered risk managment. - The patients confidence in the provider is a prerequisite for both diagnostics and therapeutics and is therefore (from the perspective of the provider) something which has high value in its own (and therefore must be maintained). - Services from health personell to patients are therefore justified for two reasons -- to maintain the patients health -- to maintain the patients trust in the provider This leads to the perspective on the EHR system as a tool for exploitation and managment of risks that can harm the patient or his trust in the provider. Can this shed new light on the issue of the confidence indicator? Arild Faxvaag -------------- next part -------------- A non-text attachment was scrubbed... Name: not available Type: text/enriched Size: 3978 bytes Desc: not available URL: <http://lists.openehr.org/mailman/private/openehr-technical_lists.openehr.org/attachments/20050509/c362aeec/attachment.bin>
