On Wed, 2005-04-20 at 08:36, Thomas Beale wrote:
> so I wonder if we can reduce all uses of uncertainty qualifiers
> ('possible', 'probable' etc) in the EHR to just 'uncertain' as Peter has
> suggested.
The short answer is; yes.
****** Caution ********
[Long winded, back to basics thought process and justification with
possible logical holes follows]
However, I think this discussion has drifted into an implementation
discussion as opposed to being about the technical model. They are so
closely related however that maybe we can't (shouldn't) separate them;
just be aware of the different aspects.
Since I am not a clinician I have had to spend a fair amount of time
interviewing them and observing them in their natural environments, <g>
so that I might gain some insight on the complexity of the job they
perform.
A clinician begins every patient contact from within a decision process
with a predisposed 'collection of possibilities' based on known facts
gathered from a variety of sources and experiences. Some of these may or
may not be based on previous knowledge of the current patient.
The thing I have concentrated on is the process of dealing with this
collection of possibilities. Each information gathering movement,
whether it be a patient question, a lab test, radiology, etc. is an
attempt to reduce the likely hood of one or more of the members of the
possibility collection. Though the goal of the clinician may be to
resolve to absolute certainty on a single possibility; that is rarely
the real world case (patients have multiple illnesses with complex
interactions) when viewing the health care needs of a patient. This
results in the chosen possibility (most probable) being only 90% - 95%
leaving room for many other minor possibilities in that 5% - 10%.
What this says is that clinicians are never 100% certain of one and only
one diagnosis.
Is this good or bad?
Depends on why we are gathering and recording the data in the first
place doesn't it?
I believe the general presumption can be made that the data is gathered
and recorded to build an information base used to make treatment
decisions for a patient, improve the overall health of the patient and
the general population at large.
If you can agree with that paragraph then we can move on to how and what
we need to implement this process of improving patient health.
The EHR is (simply?) a record of previous thought and activity. What we
are discussing in this thread is how to maximize the value or usefulness
of this data record in accomplishing improved patient health.
My belief is that one way to meet that goal is by providing data that is
computable by a decision assistance application (DAA) so that the
collection of possibilities is at once much larger than the clinician
might begin with (due to human memory and attention limitations) and
then more quickly reduced to the most probable possibilities for
presentation back to the clinician for analysis and selection.
Design of a DAA is outside the scope here but such an application should
regard all data from a patient record (EHR) as relevant but never
certain. Therefore the level of certainty (it's computability) of any
SUBJECTIVE data is irrelevant to a DAA since the DAA will compare all
recorded information to it's knowledge base of clinical guidelines. The
value of the response from the DAA is a function of it's ability to
process applicable vocabularies as recorded in the EHR.
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?
Cheers,
--
Tim Cook
Key ID 9ACDB673 @ http://www.keyserver.net/en/
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