Yet another OBSERVATION vs. EVALUATION issue

Gerard Freriks gfrer at luna.nl
Sat Aug 18 04:41:09 EDT 2012



On 17 Aug 2012, at 19:38, Thomas Beale wrote:

>> 
>> Decisions of medical users do not depend on the fact that an item is classified as "observation" or "evaluation".
> 
> maybe not so much on how it is classified, but on whether it can be trusted or not. Erroneous conclusions can be drawn from evidence by mis-diagnosis, and diagnoses often have to be revisited in difficult cases. Observations might sometimes be declared faulty, but it is much less often the case, and the kinds of errors are generally less problematic than errors of diagnosis.


20 something years of medical practice learned me to be humble and do not use the word Diagnosis too lightly:

- facts (e.g. measured things like lab results,or interventions/operations, etc.) are trusted much better than opinions/evaluations/inferences

- inferences are highly personal and context dependent.
(e.g. there are opinions be peers that one generally can trust more than others. Some are never trusted. Even in the case of  peers that are trusted, each time the healthcare provider must be able to create his own opinion and make his own judgement.
Personally I distrust all Diagnosis statements in the record. Even my own statements. Diagnosis is always an inference about a (disease) process inside the patient system. These processes we can no see; the only thing we can perceive are the results of that process. It is much more realistic to record in the EHR Reasons for Diagnostics and Reasons for Treatment than fuzzy things such as 'Diagnosis'. The draft EN13606 Association SIAMS document (Chapter 6) is about topics like these.
Before we can start to standardise how archetypes are produced we will have to agree on a number of notions/concepts.

Example: I know that within one day I suspected the patient to have shortness of breath because of: asthma, pulmonary infection, cardiac failure and panic attacks/hyper ventilation. These were my inferences about the process inside the patient system.
Only one was true and had to found out via trial and error diagnostics and trial treatments. I fear that the best we can do in most circumstances (as GP) is to code 'Reasons for ..' and do not use the word diagnosis too often.
A fact to think about was an scientific article where 'Diagnosis' made in an academic hospital setting were compared with the autopsy findings. In 25% of all cases the diagnosis was missed completely. The inferences and resulting treatments were wrong and sometimes dangerous. I have known too many patients that were in that category.
By the way: The 'Reason for ..' artefacts are EVALUATIONS that will result in the start of a Procedure or Clinical pathway via an INSTRUCTION.)

http://www.en13606.org
http://www.en13606.org/wiki/images/1/1c/ERS_SIAMS_%28most_recent_version%29.pdf

Gerard
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