Yet another OBSERVATION vs. EVALUATION issue
jussara.macedo at gmail.com
Sat Aug 18 08:29:18 EDT 2012
Yet we use this term a lot, as a hypothese or as a differential diagnosis, or even as a past diagnose, not forget to billing purposes and DRG calculus. Don't know how you could avoid it here in Brazil, where ICD 10 is used to code everything, actually it is the only classification used in large scale in Brazil, where even CIAP isn't used by the primary care doctors. All analytics of health status and conditions as well decisions support tools in Brazil use ICD as the clinical vocabulary, and you know what happens if you retrieve those codes without having the context. I used to work with record linkage and know how inaccurate can it be to do a query using ICD and was for that reason that we began to seek for modeling information, because it's essential to give context wherever the ICD is used. The ontologic based openEHR RM was found by experts here the model that is closer to our need. I think not only us, as international experts gathered at CIMI just came to the same opinion.
Talking on the difference of evaluation and observation, I thought we're talking on modeling not on the value of using any concept or entry. If most clinicians don't trust diagnosis or inferences, they do it everyday, because it's our jobs to make inferences! There are them which lead to the instructions we give.
Enviado via iPad
Em Aug 18, 2012, às 5:41 AM, Gerard Freriks <gfrer at luna.nl> escreveu:
> 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.)
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