Difference between revisions of "Diagnosis"
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== Discussion == | == Discussion == | ||
| − | = Use of Diagnosis in HIT | + | = Use of Diagnosis in HIT Systems = |
== Differences in Requirements == | == Differences in Requirements == | ||
== Use in Billing == | == Use in Billing == | ||
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== Use in Disease Registries == | == Use in Disease Registries == | ||
== Use in Quality Measures == | == Use in Quality Measures == | ||
| + | |||
= Need for Consensus on a Model for Diagnosis = | = Need for Consensus on a Model for Diagnosis = | ||
= Associations between diagnosis and other key elements of an EHR, health history summary, PHR, or other HIT. = | = Associations between diagnosis and other key elements of an EHR, health history summary, PHR, or other HIT. = | ||
Revision as of 15:43, 3 March 2011
Contents
- 1 Diagnosis Topic
- 2 Use of Diagnosis in HIT Systems
- 3 Need for Consensus on a Model for Diagnosis
- 4 Associations between diagnosis and other key elements of an EHR, health history summary, PHR, or other HIT.
- 4.1 Relationship between diagnosis and a health concern (problem)
- 4.2 Link between diagnosis (indication) and therapy
- 4.3 Link between a diagnosis and other diagnosis (complications, syndromes, etc.)
- 4.4 Link between “admitting diagnosis”, “discharge diagnosis” and administrative classifications
- 4.5 Changes in Diagnosis
- 4.6 Issues in creation of a definition of a diagnosis
- 4.7 Components of a Diagnosis
- 4.8 Finalized consensus models
Diagnosis Topic
Note: this is a cross cutting concern which impacts many HL7 groups, and needs to be reviewed and vetted by SDWG, PCWG, ECWG, CIC and TermInfo.
Diagnosis Definition is Contextual
The term diagnosis, derived from the Greek term διάγνωσις (discernment), has context dependent meanings. As such, use will require formal definitions so it can be properly treated algorithmically. It is often defined as the art or act of identifying a disease from its signs and symptoms as well as the conclusion reached. (Merriam Webster). Often diagnosis is further divided based upon source of knowledge, e.g. in cancer there is a concept of the “tissue diagnosis” (the type of cancer as identified from an examination of biopsy material).
There is also a distinction made by some between the “clinical diagnosis”, i.e. the diagnosis which is determined by history and physical exam, “radiologic diagnosis” (e.g. the discovery of pathognomonic features in a diagnostic imaging procedure, “medical diagnosis” (the diagnosis by a physician) and nursing diagnosis (the concept of diagnosis used by nurses).
Medical Diagnosis
The medical diagnosis attributes a causative pathologic or physiologic process to a given set of clinical findings. Medical diagnosis typically involves multiple modes of investigation. It usually is predicated upon a history of the presenting problem, a review of systems (symptoms specific for different organ systems), a physical examination
Nursing Diagnosis
Differential Diagnosis (q.v. LOINC 56865-9)
A differential diagnosis is a set of
Rule-out Diagnosis
Salient Features
Certainty and Uncertainty
All diagnosis are associated with a non-zero probability of being wrong. While many diagnosis approximate zero, there are always possibilities of laboratory error, mix-up of specimens, errors on the part of any of the healthcare team (particularly radiologists and pathologists, upon whom great importance is placed for accuracy). This is typically most evident with clinical diagnosis.
Discussion
Use of Diagnosis in HIT Systems
Differences in Requirements
Use in Billing
Use by Public Health
Use in Clinical Decision Support Systems
Use in Disease Registries
Use in Quality Measures
Need for Consensus on a Model for Diagnosis
Associations between diagnosis and other key elements of an EHR, health history summary, PHR, or other HIT.
Relationship between diagnosis and a health concern (problem)
Link between diagnosis (indication) and therapy
Link between a diagnosis and other diagnosis (complications, syndromes, etc.)
Link between “admitting diagnosis”, “discharge diagnosis” and administrative classifications
Changes in Diagnosis
Often a patient’s diagnosis changes. This can be due to diagnostic error, error in recording or codeing the diagnosis, error introduced by use of ICD codes from billing systems, further information becoming available which further defines or corrects a diagnosis, and progression of disease.
