Part II: Solutions
While investigating, examining, andÂ evaluating multiple ontologies and coding languages, software designers and certification agencies have lost sight of the fact that clinicians transfer information in medicalese, for want of a better term. Computer to computer transmission requires transmission protocols for efficient readable transfer of data. Clinician to clinician transmission requires medicalese for efficient transfer of clinical information. Medicalese is a dialect of English and often requires translation by a qualified clinician interpreter for the confused patient and their family.
Medicalese is a logically organized jargon that allows highly specific communication. It is filled with terms like Health Maintenance Organizations, Third Party Payers, Calcium Channel Blockers, Idiopathic Hypertrophic Subaortic Stenosis, Incomplete Left Bundle Branch Block, etc. Medicalese is required for answering the four questions we ask every patientâ€”repeatedly:
- Who is going to pay?
- Are you allergic to any medicines?
- Have you had any previous diagnoses made?
- What medications are you taking?
Answers to these four questions are necessary in the care of every patient. In the absence of the answers to these questions, the attending clinician has the entire universe of possible diagnoses and treatments availableâ€”along with the entire universe of possible wrong decisions, adverse reactions and additional expense to rectify mistakes that occur. Limiting the diagnostic and therapeutic choices at the outset of the clinical encounter optimizes the decision making process.
The first question, while not obviously a clinical question, addresses limitations to treatment options. The answer dictates which hospital can be used, which specialist can be consulted, which anesthesiologists could be used for a specific operation, which drug is on the formulary and which pharmacy can be used for that particular patient, just to name a few.
The need for the second question is obvious. It limits options for testing as well as therapy and enhances the opportunity for success of proposed therapies.
The answer to the third question builds the context of the milieu in which therapeutic plans are formulated. It focuses attention on particular body systems and known disease mechanisms allowing the attending clinician to refine testing, choose appropriate consultants and more efficiently use the tools at hand for optimal therapeutic decisions. This list also gives the attending clinician the opportunity to add more than medical diagnoses to the context of patient care. Problems such as “illiterate” and “can’t drive a car” give more important contextual data to the attending clinician and allows for more precise and individualized treatment plans.
The answer to the fourth question further delimits treatment options by posing possible drug interactions and offering additional opportunities for more economical choices with change of current medications.
Clinicians spend their important time collecting old information from the patient, because the definitive source of the origin of the diagnosis of an allergy or a disease and the prescriber of a medication are usually not readily available to the treating clinician.
Context in the treatment of patients is everything. This is why so much time is spent taking histories.
DATA VERSUS INFORMATION
An important differentiation to make is the definition between data and information. Data are the unprocessed bits and pieces of the vast numbers, pictures, x-rays, visual clues, auditory hints and tactile suggestions that are processed by every clinician when involved in the care of their patient. Take, for example, an EKG. It is the visual representation of electrical impulses in three dimensions, over time, presented on a piece of paper. It is coded information, presented in a format that requires an “interpreter.” There are computers that “read EKGs”, but are not trustworthy for subtle changes in critical treatment situations. The EKG becomes valuable clinical information only after it is interpreted, processed and documented by the interpreting clinician. Its true value becomes realized only when it is available for rapid access at the point of care by the primary ordering or attending clinician.
LOGICAL DESIGN FOR ACCESSIBLE INFORMATION
When the attending clinician has ready access to the problem/allergy list and medication list, context for the current clinical encounter is provided by the reliable authority of previous attending clinicians. This contextual information affords the current attending physician the opportunity to forgo interrogation the patient and rapidly move to evaluation of the presenting complaint, collection of clinical data and ordering of laboratory testing, while refining the diagnosis and optimizing treatment plans at the point of care. And further, if the attending clinician can readily access the full text of a previous document of clinical activity, then the optimal environment of the congress of attending clinicians at the foot of the patient’s bed comes closer to being realized.
The readily available list of problems and medications becomes the table of contents of the totality of clinical information available for a given patient. It then becomes incumbent upon the attending clinician while creating a new document of the clinical activity, to update and refine the two lists and publish the updated versions, along with the new document of clinical activity, for access by other clinicians at future clinical encounters wherever the point service.
THE CONGRESS OF CLINICIANSâ€™ CLINICAL INFORMATION NETWORK
The full power of the Internet information conduit is being realized by posting the full text of the documents of clinical activity at every work site. These documents are indexed by problems, allergies and medications and published into a restricted network that only allows access to credentialed users. This network, available from any Internet connected device, will allow participating clinicians to practice medicine in an environment of optimized clinical information availability and safety. This achievable environment of readily accessible clinical information will revolutionize patient care, reduce unnecessary hospital admissions, stop redundant testing, identify fraud and reduce costs.
This is the kind of reform that clinicians can embrace.