Defining the Process of Medical Care
to Include Dual Situation Awareness
between Patient and Clinician
Richard A. Olson MD, FACS
Habersham Medical Center
Demorest, Georgia
dr.rich.olson@gmail.com
Why pursue a model of Dr/Pt SA?
• Better design of Electronic Health Record
– & other Health IT applications
• Improve decisions – esp. shared decisions
• Support “patient engagement”
• Support team care delivery
SOAP Note c2013
Problem Oriented Medical Record
• History (Subjective)
• Physical Exam, Lab Data (Objective)
• Problem List – working diagnoses, not final
diagnoses
• SOAP Note for each Problem
– Subjective
– Objective
– Assessment
– Plan
Problem Oriented Medical Record
System (Weed, Hurst & Walker)
Dr. Lawrence Weed, Univ. of Vermont
Problem-Oriented Medical Record
“The beginning clinical clerk, the new intern, and the
practicing physician are confronted with an apparent
contradiction. Each is asked, as a ‘whole’ physician, to
accept the obligations of meeting many problems
simultaneously and yet to give to each the singleminded attention that is fundamental to developing
and mobilizing his or her enthusiasm and skill, for
these two virtues do not arise except where an
organized concentration upon a particular subject is
possible.”
The multiplicity of problems the physician must deal with every day constitutes a principal
distinguishing feature between a physician’s activities and those of many other scientists.
These realizations led me to develop the POMR so that medical students and
practitioners could function in a structured, rigorous way more like that of workers in the
scientific community. The POMR cannot change the multiplicity of problems that
physicians face. But the POMR enables a highly organized approach to that complexity.
Medical Informatics
• Analysis / Communication / Record / Library
Dr. Eta Berner’s skeptical student
• Did we start at the right place?
• If our starting point was the medical record,
and not the patient-physician relationship,
have we picked the best path to apply
technology to improve clinical care?
Situation Awareness (SA)
Before making a choice to act, what do
we understand about the state of mind
– the perceptive and the cognitive
processes which precedes that action?
What WERE you thinking???
(If SA is missing, it becomes more apparent.)
SA -> Decision -> Action – (Endsley)
Doctor-Patient Awareness Matrix
Dual Situation Awareness
The Johari Window - 1955
“Named after the first names of its inventors, Joseph Luft and Harry Ingham,” this “is one of
the most useful models describing the process of human interaction” 1999 by Duen Hsi
Yen http://www.noogenesis.com/game_theory/johari/johari_window.html
Dr-Pt Situation Awareness
= SOAP
(1) Dual SA: Diagnosis & Dialogue
Levels of Dual SA:
3) Projection
2) Comprehension
1) Perception
Communication
George Bernard Shaw (1856-1950)
"The single biggest problem in
communication is the illusion that is has
taken place"
Places the burden on the physician, to choose the best
way to say something, to use visual aids, and to
confirm the message is correctly received by the
patient.
Each problem needs separate
consideration
• Cognitive limits of human ‘operator’ defines
one ‘panel’ of SA;
– Multiple physicians / specialists per patient
– Multiple problems per patient
• “One problem at a time”
Health Affairs – Feb. 2013
“New Era of Patient Engagement”
A National Action Plan To Support Consumer
Engagement Via E-Health
Lygeia Ricciardi, Farzad Mostashari, Judy Murphy, Jodi
G. Daniel, and Erin P. Siminerio (HHS/ ONCHIT)
(2) Decision
Who Shall Decide??
Physician
Patient
Goal: Optimal Decisions
• Defined as satisfactory to both patient and
physician
• A good decision remains satisfactory - even in
hindsight
• Timely - ideal responsiveness may require
patient monitoring and ‘decision triggers’
Barriers to Rational Choice
(besides system complexity)
•
•
•
•
•
•
•
Fear, Mistrust
Myths & Misconceptions
Youth & adolescence
Aging & dementia
Miscommunication
Psychopathology
Socio-pathology
– “Half of the people lie with their lips; the other half with their
tears,” Nassim Nicholas Taleb
(3) Action:
•
•
•
•
Diagnostic
Therapeutic
Education (patient, physician)
Management
– Hospitalize, Discharge
– Consult
– Transfer
– Follow-up
Action changes the Situation
Cycles the D.P.U. (doctor patient unit)
Pathway of Diagnosis
Initial Problem ->
Working Diagnoses -> -> ->
Final Diagnosis
Fatigue ->
Anemia ->
Gastric Ulcer ->
Gastric adenocarcinoma
Disease Trajectory
• Corbin-Strauss Model, 1991 nursing model
coined the term ‘disease trajectory’
• Abdominal Aortic Aneurysm growth & rupture
• Diabetes with progressive kidney failure
• Cancer patients with possible recurrence
LINK TO THIS COMIC: HTTP://XKCD.COM/931/
TEAM Doctoring
1994 Harrison’s
Textbook of Internal Medicine
"Increasingly patients are cared for by groups of
physicians, clinics, hospitals,
organizations." With a chief drawback being,
"the loss of the concept of the physician who is
primarily and continuously responsible."
TEAM doctoring
• Primary care (Family Practice, General Internal
Medicine, OB/Gyn) - “The Medical Home”
• Emergency Room
• Hospitalist
• Critical Care
• Cardiology & other Medical Specialties
• Surgery (all specialties) & Anesthesiology
• Medical Imaging (Radiology)
Hospital Staff TEAM
•
•
•
•
•
•
•
•
•
Nursing (including many nursing specialties)
Pharmacy
Physical Therapy
Occupational Therapy, Speech Therapy
Respiratory Therapy
Dietary – Nutrition
Case Management – Social Work
Clergy
Support (clerical, communication, transcription)
Team SA in Healthcare
Endsley, M. R., & Jones, W. M. (2001). A model of
inter- and intrateam situation awareness
Final Thoughts & Questions
• Might Dual SA be a useful model for design of
EHR & Consumer E-health Systems?
• Can EHR System design support Team SA?
• Is Situation Awareness a useful ‘buzzword’ in
healthcare, as it is in military & aviation
• Would improved Dual & Team SA lead to
better decisions and better outcomes,
including workplace satisfaction of providers?
dr.rich.olson@gmail.com