Medicine, the profession struggles with its identity. Will
we be physicians in the likes of the great scientist philosophers and humanists
since Hippocrates? Or, will we succumb to the trend of commodifying the
profession? It is clear that health care planners intend to move us in the
direction of standardized care. The extent to which the profession restores its leadership, humanity and science will largely depend upon how it deals with the coming universality of computerized patient records.
Meaningful Use requirements for incentive
pay under the Affordable Care Act and various agencies will mandate certain
quality metrics in the Electronic Health Record. (EHR) Evidence of compliance
may be required by the uniform claims submission process for reimbursement. Programmers will likely build these metrics
into the software developed by various vendors of the EHR. Doctors are familiar
with Best Evidence and some of those treatment standards are already appearing
in EHRs. A new feature will be Clinical Decision Support (CDS). Best Evidence
largely deals with treatment protocols. CDC will deal mostly with diagnosis.
What follows is a discussion about how the later, CDS, deals with differential
diagnosis and the role of the physician in an electronic data environment.
The review of systems (ROS) and the differential diagnosis
lie at the heart of the data processing that attempts to deal with these two intellectual processes. Each item in the ROS, signs and symptoms
related by the patient, becomes critical data in the process to follow. The
negative response is as significant as the positive -- maybe more. Each
positive response, when confirmed by further questioning, evokes a list. The
list is critical as well and might as well be indelibly imprinted behind each
data point or on the mind of the physician. When completing the ROS, one then
has a number of responses, each with its list of etiological possibilities. One
or more diagnostic possibilities appearing on separate lists tend to point to
the underlying problem and contribute to the establishment of a tentative differential.
Here is where statistics comes into play The coupling of
signs and symptoms with a medical information database, can assure the
clinician that he or she did not overlook the less obvious problem. The more often a diagnosis appears on multiple
lists and the more completely the signs and symptoms on the ROS fulfill the
attributes of a diagnosis, the more likely you are on the right track. However,
all overlapping signs and symptoms are not equal and many illnesses have
similar symptoms. Furthermore, individual patients seem to have a limited range
of symptoms to account for a wide range of possible illnesses. Patients also react to illness in a highly individualized way.
Ongoing and
real-time statistical analysis of the differential diagnosis compared with
outcomes can validate the initial list of possibilities. Thus the coupling together of patient data with the vast store of
medical information, can assist the clinician with his or her interpretation of the data. Furthermore,
the computer generated differential can focus statistically on the more likely
candidate diagnoses. Database mining software can provide further relationships that the
mind cannot grasp or that have not previously been observed.
Playing the percentage game, however, can be risky. An old
adage states, “If you hear hoof beats in the hall, don’t think of zebras.” The
Internist might ask, “Is there a circus in town?” The problem with rare
diseases is that there are so many of them. Encountering a rare condition unexpectedly is
a common occurrence. Adding further to the dilemma,
the easy diagnosis often masks an underlying cause. Examples abound: Valvular
Heart Disease, Shingles, Atrial Fibrillation, and Duodenal Ulcer to mention
only a few of the more obvious ones all have underlying causes. Diagnosis is thus challenged on multiple levels. Physicians must peal away the layers of the diagnostic onion. Programing information technology to dig
down to those multiple levels of scrutiny may be tricky indeed.
Some would advocate a process in which the computer and pre-defined procedures defined by best evidence as written by experts, take the
prime role and relegate the physician to insuring the validity of the data
points. The rationale to this approach lies in the frequency of diagnostic
error and the never ending expansion of diagnostic and treatment procedures
that do more harm than good costing more and more.
Others would say, we need to go back to the physician as the
humanist and scientist of old with vast experience and ongoing medical education
in a professionally structured society, dedicated to excellence. Today we are
at a cross roads. The road to subordination, however, may have already been
taken. Whichever path we follow, patient safety, access and consistent in depth
handling of the data are primary. The differential diagnosis is critical to
achieving anything like the health metrics of the rest of the industrial world.
--- We are currently something like 37th in perinatal mortality and longevity.
Man thinks, the computer remembers. The physician’s mind does far
better at complex judgment and interpretation than any computer to date. The mindful and highly
experienced physician sees the above analysis and assembles a differential
diagnosis with a scanning logic. Most physicians navigate a differential
diagnosis quite well. The differential diagnosis, however, demands a high degree of commitment to the
art, medical education and extensive exposure to most every form of disease. Our mind thinks and makes individualized judgments that the computer
cannot. The computer on the other hand remembers and does statistics. We do not
remember so well and we do not manage statistics well on a large database.
For the statistical linkages between
patient data and the proven diagnosis to be valid, they must be relevant to the patient. Do you depend on statistics developed on a national scale,
an international scale or limited to a local population that might be more relative
to the patient at hand? I say might be because each patient is a one of a kind
individual. The only statistics that matter might very well be the patient's
own genomics. The individual genome, despite the nail biting, is falling in
price and will soon be ubiquitous. We need to be sure the tests are not sold
like snake oil by bathers, naturopaths, charlatans and opportunists.
The psychological or psychiatric diagnosis
proves elusive for the computer generated history, whereas, the physician may
grasp it intuitively. A ROS with phases of the MMPI covering all classes of behavioral and psychological issues could be
helpful. The biggest mistake is to tell a patient, “It’s all in your head;”
that’s not a diagnosis. Again the physician must dig down to an underlying
cause. Be suspicious. Clinical interaction must continuously measure outcome and look for errors. --- It may be difficult to teach a computer to be
suspicious.
The present day inconsistencies in both
diagnosis and treatment have lead to a movement among health care planers to
standardize care. Indeed there are many missed and wrong diagnoses. Misses are almost inevitably due to
omitting the ROS or ignoring one or two of the responses when they do not fit
the assumption. Larry Weed, the inventor of the problem oriented
record (POMR), insists that any positive, not accounted for by the diagnosis,
belongs on the active problem list. Weed further advocates that the physician’s
training is backwards and that he or she should be trained to exacting and
standardized skill in history taking, examination and technical surgical skills
while leaving the basic science and pathology to the experts delivered by
computer but with the provider guiding the patient in making the decisions in a
compassionate way. This supposes that information technology will provide the
best diagnosis, the best evidence and the best treatment leaving the decisions
largely to the patient. This sentiment is further advanced in John Wennberg’s book, Tracking Medicine.
In which he documents over treatment and inconsistent treatment
demonstrating superior outcomes in regions of less intense and less specialized
care.
Arguably, we should do the thinking and follow a strategy in
which the computer remembers the data and the physician exercises judgement
based on the individual patient and that patient’s choices. The physician
concentrates on the science, the judgment and the art of medicine. Bring the
patient to the fore of decision making. The computer tracks lists and analyses
statistically on a real-time basis. Embrace the benefits of HIT and CDS. Retain
control of the data, however, at all costs. Let the computer couple your
precise clinical data with the vast store of medical terminology, nosology, and
the salient features of each. The value here is in not missing something and
not getting stuck in a wrong assumption. The analysis should present to the
physician a credible preliminary differential. With or without assisted memory
and coupling to the vast store of medical knowledge, the ROS is key to patient
safety and care. Without extensive branching logic, though, the computer administrated ROS may create variable data. We have all experienced the patient responding differently on different occasions, to different physicians or to the nurse. I think the responsibility for securing a valid database remains with the physician. Less experienced clerical questioners may fail to elicit valid data.
Physicians and Medical Schools struggle with a conflict between physicians
in the classic role of science, art, diagnosis and a newly proposed role in
which the physician practices in a role subordinate to the computer,
algorithms, protocols, check lists and the authors of Best Evidence.
At the heart of the conflict lie the
complex process of diagnosis and the choice of individual treatment. To meaningfully
apply the dictate of Best Evidence, one needs the right diagnosis. We suggest
that the best application of computers, statistics will be achieved when the
computer applies its faultless memory and capacity for data with dynamic
real-time statistical analysis, not on mass populations, but on the internal data
at hand. This strategy provides data more relevant to the individual patient
and keeps the physician in control of the data. The strategy also leaves the
physician and the patient with the choices, the judgment and the mindfulness of
that data. The physician thinks, the patient participates, the computer
remembers.
Yogi Berra once famously said, "When you come to a fork in the road, take it!" As a profession, we should have it both ways, the physicians science and art plus the computers memory.
Agencies include: Health and Human Services (HHS), National
Institution of Health (NIH), Centers for Medicaid and Medicare Services (CMS),
Insurance companies, and regional Health Information Exchanges (HIE),
We do need to take into account the
computer’s future capabilities, however. So far the computer does not think,
but IBM's Watkins comes close.
