Management of a Patient Process, Clinical Practice Guidelines and Pathways

Management of a Patient Process, Clinical Practice Guidelines and Pathways

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

April 22, 2016

In medical practice and in hospital administration, we now oftentimes hear of clinical practice guidelines, evidence-based clinical practice guidelines and clinical / care pathways.  These are tools to improve quality and safe patient care.

Clinical Practice Guideline (CPG) as defined by the Institute of Medicine, is a “systematically developed statement to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”

Evidence-based Clinical Practice Guideline (CPG) is clinical practice guideline supported by the best available evidence in the clinical literature.

Clinical / Care Pathways is an interdisciplinary plan of care that outlines the optimal sequencing and timing of interventions and expected outcomes for patients with a particular diagnosis, procedure or symptom.

Basic among the clinical practice guidelines, evidence-based clinical practice guidelines and clinical / care pathways is a management of a patient process which has not been fully explained to the max in the literature.

The management of a patient process occurs in two settings in medical practice and in hospital administration.  The first setting is in the management of the patient health problem itself without the patient getting admitted to the hospital.  The second setting is when a patient gets admitted to a hospital.  In the second setting, invariably there is the management of the patient health problem process preceded by the admitting and followed by the discharge processes.

In this manuscript, we will be discussing the management of a patient health problem process.  We will not discuss the admitting to and discharge from the hospital processes.  At the end of the discussion on the management of a patient health problem process, we will integrate or relate it to the clinical practice guidelines, evidence-based clinical practice guidelines and clinical / care pathways.

Management of a patient process is a process.  Process as defined by ISO Standards is a “set of interrelated or interacting activities, which transforms inputs into outputs”.

Management of a patient process is therefore, a set of interrelated or interacting activities, which transforms inputs into outputs, the input being the patient health problem or patient with a health problem and the output is the resolution of the patient health problem.  The set of interrelated or interacting activities are the throughputs, which essentially consist of problem-solving and decision-making on tasks to be done by the physician or any health care professional.

Again, the input or the starting point of the management of a patient process is the patient health problem or a patient with a health problem or concern.  The output is the goals of management which can generically be spelled out as resolution of the health problem in such a way that the patient does not end up dead, with disability or complications and in such a manner that the patient is satisfied and there is no medicolegal suit.

The throughput, as mentioned, consist of the processes of problem-solving and decision-making on the tasks to be done.

The tasks consist of the following:

  • Establishing rapport initially and then maintaining it throughout the course of patient management.
  • Formulating a clinical diagnosis followed by an advice to the patient on the findings and diagnosis.
  • Deciding on whether a paraclinical diagnostic procedure is needed or not; if needed, selecting the most cost-effective procedure, followed by an informed consent; if a paraclinical diagnostic procedure is done, interpreting the result and correlate it with the clinical findings to come out with a pretreatment diagnosis, again to be followed by an advice to the patient.
  • Deciding on the most cost-effective treatment procedure for the patient, followed by an informed consent; if treatment is done, monitoring the result and giving advice to the patient.
  • Maintaining health and wellness of patient and giving advice.

 

The tasks can be summarized by the following diagram:

Rapport ————————————————————————————————->

Diagnosis ———————————————————————————————>

Advice —————————————————————————————->

Treatment ———————————————————————–>

Advice ————————————————————————>

Health Maintenance ————————————————>

Advice ——————————————————–>

The quality standards to evaluate the tasks consist of rationality, effectiveness, efficiency, and humanness or compassion.

RAPPORT

Establishing rapport with the patient and his/her relatives is the best strategy for obtaining satisfaction from the patient and his/her relative.  It is also the strongest strategy in the prevention of medicolegal suit in case a physician or health professionals commit errors of commission and omission.

Here are some recommended ways to establish rapport with the patient and his/her relatives:

  • Being courteous
  • Showing respect to person and beliefs
  • Giving honest and clear advice on diagnosis, paraclinical diagnostic procedures, and treatment
  • Demonstrating humaneness and compassion
  • Being gentle in words and deeds (physical examination, procedure)
  • Showing the patient and relatives that one is trying his very best
  • Being helpful when it comes to medical expenses
  • Making the patient and relatives feel that one is approachable and easy to talk to

 

THE DIAGNOSTIC PROCESS AND THE DIAGNOSIS

  • The diagnostic process starts from the time a physician sees the patient up to after treatment.
  • A diagnosis is an identification label of the patient’s health problem.
  • The diagnostic process must be rational for it to be acceptable.
  • A diagnosis that is based on a rational process is not always correct. However, a diagnosis is more often correct than wrong if it is rationally arrived at.
  • A diagnosis is almost always an educated guess.

 

INTERVIEW AS A DIAGNOSTIC TOOL

  • Identify the chief complaint or main problem of the patient. Once identified, use it as the steering wheel in the diagnostic investigation of the patient.
    • Inquire on the circumstances associated with the chief complaint.
    • Inquire on symptoms. Symptoms are those manifestations perceived by the patient.
    • Get clues from the “circumstances and symptoms” to be used in the diagnosis of the patient.
  • Be effective. Be complete.  Be efficient.  Be relevant.
  • Know how to get cues from data; to interpret data.
  • Know which data to pursue; to put in the background; to use in the diagnosis; not to use in the diagnosis.

 

PHYSICAL EXAMINATION AS A DIAGNOSTIC TOOL

  • Use the identified chief complaint or main problem of the patient as a guide on what to examine.
  • Look for signs. Signs are those manifestations perceived by the physicians or health care professionals.
  • Get clues from the signs to be used in the diagnosis of the patient.
  • Be effective. Be accurate.  Be complete.  Be efficient.  Be relevant.
  • Know how to get cues from data; to interpret data.
  • Know which data to pursue; to put in the background; to use in the diagnosis; not to use in the diagnosis.

 

INTERVIEW AND PHYSICAL EXAMINATION

  • Interview and physical examination can be done in any order as dictated by the circumstances.
  • Interview and physical examination can be done simultaneously.
  • The goal of interview and physical examination is diagnosis.
  • Correlate data from interview and physical examination to come out with a rational clinical diagnosis.
  • If there is a question on which data to put more reliance on, choose the “sign” data over “symptom” data. Remember, however, that for the “sign” data to be reliable, they must be accurate.

 

CLINICAL DIAGNOSTIC PROCESS

  • A clinical diagnosis is one that is derived from the interview and physical examination, or put in another way, it is one that is derived from the symptoms and signs.
  • After the interview and physical examination, the symptoms and signs are analyzed to come out with a clinical diagnosis.
  • The expected output after a clinical diagnostic process is a rational set of primary and secondary clinical diagnosis (or differential diagnosis).
  • Essentially, two processes are used in coming out with a clinical diagnosis. These two processes are pattern recognition and prevalence.
    • Pattern recognition means the realization that the patient’s presentation conforms to a previously learned picture or pattern of disease.
    • Prevalence means the choice of a diagnosis is based on the frequency of occurrence of the disease in a certain locality, in a certain age and sex group, and in the affected organ and system.
  • Based on pattern recognition and prevalence, decide on the primary and secondary diagnoses. Primary diagnosis is what you think is the most likely diagnosis and secondary diagnosis is the closest second.  (see illustrations below)
  • Explain to patient how you arrive to the primary and secondary clinical diagnoses. Use the clinical diagnostic processes of pattern recognition and prevalence. May use algorithm. Use pathophysiology to support your primary and secondary clinical diagnoses.
  • Elemental steps in making a diagnosis:
    • Identify which organ or tissue or system is involved.
    • Then, identify the disease in general terms, such as inflammation, infection, tumor, trauma, endocrine, etc.
    • Then, try to be more specific in identifying the disease, if possible, such as malignant neoplasm, abscess, etc.
  • Knowing the nomenclature of diseases facilitates diagnostic labeling.
  • CLINICAL DIAGNOSTIC PROCESS – PROCESSING OF DATA – ILLUSTRATION 1

Knowing the common manifestations of 5 different diseases as follows:

Disease A – abcd (manifestations)

Disease B – fghi

Disease C – klmn

Disease D – pqrs

Disease E – uvwx

Given a patient manifesting with pqrs, your diagnosis is Disease D.

What is the process used? PATTERN RECOGNITION

  • CLINICAL DIAGNOSTIC PROCESS – PROCESSING OF DATA – ILLUSTRATION 2

Knowing the common manifestations of 3 different diseases and relative frequency of each as follows:

Disease A –  abcd (manifestations)           Least common

Disease B –  abcd

Disease C –  abcd                                              Most common

Given a patient manifesting with abcd, your diagnosis is Disease C.

What is/are processes used? Pattern Recognition but mainly PREVALENCE

  • CLINICAL DIAGNOSTIC PROCESS – PROCESSING OF DATA – ILLUSTRATION 3

Knowing the most common diagnosis of a thyroid nodule is a benign colloid adenomatous goiter, given a patient with a thyroid nodule, you gave the abovementioned diagnosis.

What is/are processes used? PREVALENCE

 

PARACLINICAL DIAGNOSTIC PROCESS

  • After the clinical diagnosis, the next step to do is to determine whether a paraclinical diagnostic procedure is needed or not. A paraclinical diagnostic procedure is a diagnostic procedure that is done after the clinical diagnosis is arrived at and its objective is to make the diagnosis more definite.
  • To decide whether a paraclinical diagnostic procedure is needed or not, a physician should consider the following factors:
    • How certain he is with the clinical diagnosis.
      • If he is quite certain or very certain, in general, a paraclinical diagnostic procedure is not needed. The quite certain clinical diagnosis becomes automatically the pretreatment diagnosis.
      • If he is not quite certain or uncertain, in general, a paraclinical diagnostic procedure is needed.
      • In general, a clinical diagnosis is said to be quite certain if it is based primarily on signs that are reinforced by the symptoms and prevalence data.
      • A clinical diagnosis is said to be uncertain if it is based primarily on symptoms or on prevalence data.
    • Whether a more definite diagnosis is needed or not for some reasons or another.
      • If the contemplated treatment procedure is mutilating, risky, etc., then a more definite diagnosis is needed.
      • If the treatment for the differential diagnosis is the same as that for the primary clinical diagnosis, then a paraclinical diagnostic procedure may not be needed. If it is different, then a more definite diagnosis is indicated.
  • PARACLINICAL DIAGNOSTIC PROCESS – INDICATION – PROCESSING OF DATA – ILLUSTRATION 1

CERTAINTY OF CLINICAL Dx
1O Dx     60% ———————————————- 99%

needed                                                                                not needed

TREATMENT PLAN FOR 1O & 2O Dx

Different ————————————————–  Same

needed                                                                                                not needed

  • PARACLINICAL DIAGNOSTIC PROCESS – INDICATION – PROCESSING OF DATA – ILLUSTRATION 2

Certainty             Plan of Treatment

Primary clinical diagnosis                               98%                        Surgical

Secondary clinical diagnosis                         1-2%                      Nonsurgical

Is a paraclinical diagnostic procedure needed? NO unless there is a strong reason to do so (exception to the rule)

  • PARACLINICAL DIAGNOSTIC PROCESS – INDICATION – PROCESSING OF DATA – ILLUSTRATION 3

Certainty             Plan of Treatment

Primary clinical diagnosis                               60%                        Surgical

Secondary clinical diagnosis                         40%                        Nonsurgical

Is a paraclinical diagnostic procedure needed? YES

  • PARACLINICAL DIAGNOSTIC PROCESS – INDICATION – PROCESSING OF DATA – ILLUSTRATION 4

Certainty             Plan of Treatment

Primary clinical diagnosis                               60%                        Surgical Excision

Secondary clinical diagnosis                         40%                        Surgical Excision

Is a paraclinical diagnostic procedure needed? NO unless there is a strong reason to do so (exception to the rule)

  • PARACLINICAL DIAGNOSTIC PROCESS – INDICATION – PROCESSING OF DATA – ILLUSTRATION 5

Certainty             Plan of Treatment

Primary clinical diagnosis                               90%                        Mutilating Operation

Secondary clinical diagnosis                         10%                        Non-mutilating Operation

Is a paraclinical diagnostic procedure needed? YES unless there is a strong reason NOT to do so (exception to the rule)

  • PARACLINICAL DIAGNOSTIC PROCESS – INDICATION – PROCESSING OF DATA – ILLUSTRATION 6

Certainty             Plan of Treatment

Primary clinical diagnosis                               70%                        Chemotherapy

Secondary clinical diagnosis                         30%                        Radiotherapy

Is a paraclinical diagnostic procedure needed? YES unless there is a strong reason NOT to do so (exception to the rule)

  • PARACLINICAL DIAGNOSTIC PROCESS – INDICATION

Which of the following statements is the strongest indication for a paraclinical diagnostic procedure?

  1. You can never be absolutely certain of your clinical diagnosis
  2. You want to confirm a clinical diagnosis which are certain of
  3. You want to document a clinical diagnosis which you are certain of
  4. When you are not certain of your clinical diagnosis

THE BEST ANSWER IS “D”.

 

  • Once a decision is made that a paraclinical diagnostic procedure is needed, the next step is to choose the most cost-effective procedure for the patient by considering the various factors (tabulate, compare, and analyze):

 

Procedures Benefit (goal) Risk Cost Availability
Option1        
Option2        
Option3        

 

  • PARACLINICAL DIAGNOSTIC PROCESS – SELECTION – PROCESSING OF DATA – ILLUSTRATION 1
Procedures Benefit (goal) Risk Cost (PhP) Availability
Option1 most direct acceptable 1000 available
Option2 indirect acceptable 1500 available
Option3 indirect acceptable 1000 available

 

Which is the most cost-effective procedure? OPTION 1

  • PARACLINICAL DIAGNOSTIC PROCESS – SELECTION – PROCESSING OF DATA – ILLUSTRATION 2
Procedures Benefit (goal) Risk Cost (PhP) Availability
Option1 accuracy 99% acceptable 5000 available
Option2 accuracy 90% acceptable 3000 available
Option3 accuracy 50% acceptable 1000 available

 

Which is the most cost-effective procedure? OPTION 1 or OPTION 2 (depending on financial resources)

  • PARACLINICAL DIAGNOSTIC PROCESS – SELECTION – PROCESSING OF DATA – ILLUSTRATION 3
Procedures Benefit (goal) Risk Cost (PhP) Availability
Option1 yield > 90% acceptable 4000 available
Option2 yield  90% acceptable 4000 available
Option3 yield  80% acceptable 3000 available

 

Which is the most cost-effective procedure? OPTION 1

 

  • After the paraclinical diagnostic procedure has been done, the next step is to interpret the result. The result of the paraclinical diagnostic procedure must be correlated with the signs and symptoms of the patient to come out with a pretreatment diagnosis.
  • If the result of the paraclinical diagnostic procedure is congruent with the primary or secondary clinical diagnosis – ACCEPT; if incongruent – MAKE A DECISION (ACCEPT or HOLD)
  • PARACLINICAL DIAGNOSTIC PROCESS – INTERPRETATION – PROCESSING OF DATA – ILLUSTRATION

Determine which paraclinical diagnosis should be accepted as the pretreatment diagnosis and which one should be put on hold for further decision-making. Write (A) for accept and (H) for hold.

  • Paraclinical diagnosis is the same as the primary clinical diagnosis. (A)
  • Paraclinical diagnosis is the same as the secondary clinical (A)
  • Paraclinical diagnosis is a clinical diagnosis least considered.(H)
  • Paraclinical diagnosis does not jibe with the clinical picture or diagnosis. (H)

 

SELECTION OF TREATMENT

  • Selection of treatment procedure is based primarily on the pretreatment diagnosis.
  • Select the most cost-effective treatment for the patient after considering the various factors (tabulate compare, and analyze):

 

Treatment Benefit (goal) Risk Cost Availability
Option1        
Option2        
Option3        

 

  • SELECTION OF TREATMENT PROCESS – PROCESSING OF DATA – ILLUSTRATION 1

 

Treatment Benefit (goal) Risk Cost Availability
Option1 greatest surv rate acceptable 5000 available
Option2 rate < 1  > 3 acceptable 4000 available
Option3 least surv rate acceptable 3000 available

Which is the most cost-effective treatment option? OPTION 1

 

  • SELECTION OF TREATMENT PROCESS – PROCESSING OF DATA – ILLUSTRATION 2

 

Treatment Benefit (goal) Risk Cost Availability
Option1 survR1 =survR2 lesser 5000 available
Option2 survR2 =survR1 more 5000 available

 

Which is the most cost-effective treatment option? OPTION 1

  • SELECTION OF TREATMENT PROCESS – PROCESSING OF DATA – ILLUSTRATION 3

 

Treatment Benefit (goal) Risk Cost Availability
Option1 as effective as 2 acceptable 8000 available
Option2 as effective as 1 acceptable 4000 available

 

Which is the most cost-effective treatment option? OPTION 2

  • SELECTION OF TREATMENT PROCESS – PROCESSING OF DATA – ILLUSTRATION 4

 

Treatment Benefit (goal) Risk Cost Availability
Option1 most effective acceptable 2000 available
Option2 effectivity <1 >3 acceptable 3000 available
Option3 least effective acceptable 4000 available

 

Which is the most cost-effective treatment option? OPTION 1

  • The final decision on the type of treatment to institute will rest on the patient (informed consent)
  • Know when and to whom to refer.

 

ADVICE AND INFORMED CONSENT

  • After the interview and physical examination and after the physician has arrived to a clinical diagnosis, the next step is to advise the patient on the nature of his health problem.
  • After the clinical diagnosis has been explained to the patient and/or his relatives, the next step is to advise whether a paraclinical diagnostic procedure is needed or not. If a paraclinical diagnostic procedure is needed, the patient is informed of the various options.  He is advised on the most cost-effective option.  Performing the paraclinical diagnostic procedure can only be carried out after the physician has secured an informed consent from the patient.
  • After the paraclinical diagnostic procedure has been performed, the next step is to advise the patient on the results.
  • After a pretreatment diagnosis has been gotten, the next step is to inform the patient on the various options of treatment. He is advised on the most cost-effective treatment option.  Carrying out the treatment procedure can be done only after the physician has secured an informed consent from the patient.
  • After treatment, the patient should be advised on the results and subsequent management, specifically follow-up. The patient should also be given advice on health maintenance.

 

ADVISING PATIENTS AND RELATIVES

  • A physician (or any health professional) deals with both patients and their relatives or guardians.
  • A successful physician-patient-relative relationship is based on the establishment and maintenance of good rapport initiated and accomplished by the physician. A good rapport basically emanates from the trust and confidence given by the patient-relative to the physician.  This trust and confidence can be gained by the physician through many ways.  The following are some qualities of the physician that will promote trust and confidence of the patient-relative:
    • Competent physician
    • Honest
    • Gentle
    • Compassion and shows concern
    • Courteous
    • Patient, persevering, and understanding
  • Advising a patient and his relatives is a major pathway through which a rapport can be established and maintained by the physician.
  • In managing a patient, advising is usually needed on:
    • clinical diagnosis
    • need for a paraclinical diagnostic procedure
    • nature of a paraclinical diagnostic procedure
    • results of a paraclinical diagnostic procedure
    • plan of treatment
    • outcome of treatment
    • prognosis of the disease
    • maintenance of health after treatment
  • Advising a patient and his relatives on any matter can make or break the physician-patient-relative relationship. Thus, it is important that the physician knows how to advise.
  • The following are tips in advising:
    • Always include the relatives of the patient in the advising, if they are available.
    • Assess the psychological make-up, the health beliefs, and the level of competency of the patient and the relatives before making any advice.
    • Make strategies that will promote rapport.
    • Be honest but not brutally frank.
    • For example, slowly divulge the diagnosis of an incurable disease or a frightening disease.
    • Use terminologies or explanations that can be easily understood by the patient and his relatives.
    • Use all kinds of strategies that will make the patient and his relatives like you.
    • Explain to the patient and relatives the processes you use in arriving to a diagnosis, recommendation for a paraclinical diagnostic procedures and treatment.

We have just discussed the rudiments in the management of a patient process.

We will now integrate or relate it to the clinical practice guidelines, evidence-based clinical practice guidelines and clinical / care pathways.

The management of a patient process should be considered the foundation or framework of all clinical practice guidelines and clinical pathways.  In fact, it should be considered the first clinical practice guidelines, evidence-based clinical practice guidelines and clinical / care pathways.  Unfortunately, it has not given much emphasis, if not recognition.

To be continued.

Advertisements
This entry was posted in Clinical Practice Guidelines and Pathways, Management of a Patient Process. Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s