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.
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?
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
-- <private> --
Gerard Freriks, arts
Huigsloterdijk 378
2158 LR Buitenkaag
The Netherlands
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 accés)
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 métier 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 probléme, that is different of a computer
analysis, but that is real.
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 thought....oh no, my whole world is shattered...
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).
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.
