The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Gerard Freriks]

On May 7, 2005, at 3:12 PM, Thomas Beale wrote:

> ...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?

In all cases what is recorded is the personal opinion of the  
healthcare provider.
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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Arild Faxvaag]

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
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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Karsten Hilbert]

On Sat, May 07, 2005 at 02:12:45PM +0100, Thomas Beale wrote:

> 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?

If it's "a 55-yo with a family history of coronary heart disease"
and the doctor thinks angina pectoris is at 5% while gastric
reflux is at 95% then it is either a failure of the doctor to
get his probabilites straight - or else the doctor is truly
clueful (eg knows the patient very well) - in which case, yes,
the gastric reflux would be driving the next steps.

> How are we to bridge the gap between the physician-recorded confidence 
> factor and the total list of factors which drive the next steps?
In such cases I usually record "IMO  but  not r/o
yet hence act on  but also do  to differentiate".
In clear text.

Karsten
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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[lakew...@copper.net]

Hi All,

What Gerard stated is correct regarding the objective of the OpenEHR 
effort. What Thomas stated is
equally important.

On the Patient side positions become reversed, i.e., Importance is 
attached to Thomas's position and
Gerard's position re 'what clinicians deemed important to say' yields 
data and information that the
Patient can channel to another Clinician if needed.

Overall the time the Patient spends in the Clinicians office performing 
an interview is typically a small
spot on the time scale affected with uncertainty but important enough to 
yield a procedure that may
restore Health to some prior state.

On the Patient's side the need for EHRs (plural) is clear: a minimum of 
three EHRs, one for the
Clinician, one for the Patient and a meta EHR that keeps the data and 
information organized and
readily accessible.

Translated into Developer English that is and OpenEHR project for 
Clinicians (because the Patient needs
to capture the Clinician's diagnosis and course-of-treatment), and 
PatientEHR system capable of
handling Patient-provided data and information, and a meta database for 
organisation and access.

The same approach is applicable for the Patient. Recording 'what 
clinicians wanted to say' may be a
life-saving measure. Applying a meta database would organize the data 
and information and can be
considered the first level in a data mining system. The current OpenEHR 
approach minus
'what clinicians wanted to say' is an approach destined to block data 
mining, limit functionality and
produce unresolvable points in the record (simply because of recording 
uncertainty; accurate, precise
reproduction requires certainty).

The proposed approach is not easy on the Patient's side. The benefits 
include a much expanded data
capture operation that covers 24/7 Health. Reproduction is also hampered 
by uncertainty but
overall reproducibility is much better.

Being able to reproduce 'what clinicians wanted to say' is a major benefit.

Regards!

-Thomas Clark

Thomas Beale wrote:

> 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.
>
> 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, ...)
>
> ...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)?
>
>>
>> He, himself, always makes statements with varying degrees of certainty.
>> Physicians are no gods that know everything.
>
>
> What? And I thoughtoh no, my whole world is shattered...:-)
>
> - thomas
>
> -
> If you have any questions about using this list,
> please send a message to d.lloyd at openehr.org
>
>

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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Philippe AMELINE]

Hi,

I agree with Thomas, probably because we are engineers and ask ourselves 
"If they don't record this information for further action, why do they 
record it anyway ?".

I can perfectly understand the way Gerard thinks to it, in an EHRcom way 
: "I use this EHR for myself, and I can send you a part of MY EHR record 
to complete yours" (sorry Gerard if it seems over-simple).

 From my own point of view (at least for the kind of systems I am 
working on), the members of a patient's health team are contributors on 
a common working place, and, (if we don't ask them to be God) we expect 
for more involvment and accuracy in the process.

Cheers,

Philippe

Thomas Beale wrote:

> 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.
>
> 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, ...)
>
> ...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)?
>
>>
>> He, himself, always makes statements with varying degrees of certainty.
>> Physicians are no gods that know everything.
>
>
> What? And I thoughtoh no, my whole world is shattered...:-)
>
> - thomas
>
> -
> If you have any questions about using this list,
> please send a message to d.lloyd at openehr.org
>
>

-
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please send a message to d.lloyd at openehr.org

The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[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.

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, ...)

...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)?

>
> He, himself, always makes statements with varying degrees of certainty.
> Physicians are no gods that know everything.

What? And I thoughtoh no, my whole world is shattered...:-)

- thomas

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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Dr LONJON Roger]

Hello,
I read opinions expressed on the topic. This question is important in France.
The government took the decision that all citizen is going to have an
electronic medical file.personal (DMP acronym)
In principle all physicians with the authorization of the patient will have an
access to this medical file
for me it is about a medical file published a little like a weblog (to private
and controlled acc?s)
It is completely different of the electronic medical file that every physician
must create and hold up to date for his/her/its patient in his/her/its cabinet.
we call it the software profession.( logiciel m?tier in french )
This DMP should receive information exported from the software profession of the
physician.
The difficulty is to decide:
1 - what information must be published,
2 - this information is it reliable, so that another physician can use him and
not to ask for a new exam
3 - if the physician producer of information, has a space of liberty, so that
his/her/its responsibility implication is not systematically.?
The solution would be can be to differentiate well:
1 - an information validated by the physician and that gives him the opposable
information statute. He/it accepts to hire his/her/its responsibility. It is an
information that is certified by documents as the imagery, the biopsy, the
biologic analyses.
2 - an information proposed by the physician and that gives him the likely,
possible information statute, but of which the level of certainty is not
sufficient to have the opposable information statute. In this case the
responsibility of the physician, be able to not be put in reason, while using
this information no validated like proof.
It is a legislative and legal probl?me, that is different of a computer
analysis, but that is real.

Indulgence for my English and thank you.

Dr R LONJON
France















Selon Gerard Freriks :

> Sam,
>
> I agree.
>
> Suggestion
> In otherwords any clinical  (or non-clinical) concept model must be
> able to express the view of the author about certainty.
> 3 states are sufficient for starters:
> likely (as default)
> not-likely
> certain
>
> When a person attaches new information to the EHR and is of the opinion
> that whole or parts of a received  extract (or EHR) need an other
> qualifyer then via versioning he must be able to annotate this by
> adding his beliefs about certainty.
>
>
> Gerard
>
> --   --
> Gerard Freriks, arts
> Huigsloterdijk 378
> 2158 LR Buitenkaag
> The Netherlands
>
> +31 252 544896
> +31 654 792800
> On 27 Apr 2005, at 23:25, Sam Heard wrote:
>
> > 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


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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Gerard Freriks]

Sam,

I agree.

Suggestion
In otherwords any clinical  (or non-clinical) concept model must be 
able to express the view of the author about certainty.
3 states are sufficient for starters:
likely (as default)
not-likely
certain

When a person attaches new information to the EHR and is of the opinion 
that whole or parts of a received  extract (or EHR) need an other 
qualifyer then via versioning he must be able to annotate this by 
adding his beliefs about certainty.


Gerard

--   --
Gerard Freriks, arts
Huigsloterdijk 378
2158 LR Buitenkaag
The Netherlands

+31 252 544896
+31 654 792800
On 27 Apr 2005, at 23:25, Sam Heard wrote:

> 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
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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Gerard Freriks]

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.

He, himself, always makes statements with varying degrees of certainty.
Physicians are no gods that know everything.

Readers of the statements made by others necessarily don't take 
everything for granted what other have stated.
So again at the receiving side things are interpreted in varying 
degrees of certainty.

Answering your question:
> So back to the short answer above.is it really relevant to assert
> ANY confidence factor in the EHR?
>

The answer is YES

Gerard



-- 
-- 
Gerard Freriks, MD
Convenor CEN/TC251 WG1

TNO Quality of Life
Wassenaarseweg 56
Leiden

PostBox 2215
22301CE Leiden
The Netherlands

+31 71 5181388
+31 654 792800
On 27 Apr 2005, at 13:01, Arild Faxvaag wrote:

> 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 10% steps, 5% steps or .01%
> steps?  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
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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Sam Heard]

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 10% steps, 5% steps or .01%
> steps? 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
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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Arild Faxvaag]

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 10% steps, 5% steps or .01%
steps?  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
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The Uncertainty Decision was: Dr R LONJON Confidence indicator !

[Tim Cook]

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, 
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 10% steps, 5% steps or .01%
steps?  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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