Henry Price – Physician Advisor at Hub Health Systems, LLC
During my years of practicing Medicine in the inpatient setting, I have encountered multiple CDI professionals asking the same questions, and I provided the same answers. One particular answer elicits an unpleasant response from some of the CDI professionals. They will ask me “why did you document undetermined.” I will respond by saying “because at this time I truly don’t know the answer to your query.”
I think it is imperative for CDI professionals to understand the process involved in determining a diagnosis. It’s like a show on Broadway that most of the hard work takes place days before the show and the audience just sees the final production. A lot goes into diagnosing a patient. The diagnostic process is a continuous process of information gathering, integration and interpretation involve hypothesis generation and updating prior probabilities as more information is learned.
Two essential considerations in the diagnostic process are diagnostic uncertainty and time.
“Absolute certainty in diagnosis is unattainable, no matter how much information we gather, how many observations we make, or how many tests we perform. A diagnosis is a hypothesis about the nature of a patient’s illness, one that is derived from observations by the use of inference. As the inferential process unfolds, our confidence as clinicians in a given diagnosis is enhanced by the gathering of data that either favor it or argue against competing hypothesis. Our task is not to attain certainty, but rather to reduce the level of diagnostic uncertainty enough to make optimal therapeutic decisions”. (Kassirer, 1989, p. 1489)
The element of time is important in the diagnostic process because most diseases evolve over time, and there can be a delay between the onset of disease and the onset of a patient’s symptoms. Time can also elapse before patient symptoms are recognized as a specific diagnosis. Some diagnoses can be determined in a very short time frame, while months may elapse before other diagnoses can be made. This is due to the growing recognition of variability and complexity of disease presentation.
Reasoning – Clinical & Probabilistic
Clinical Reasoning: The cognitive process that is necessary to evaluate and manage a patient’s medical problems. It is a dual process theory that integrates analytical and non-analytical models of decision making.
Analytical (reflective): rely heavily on the clinician’s working memory and involves hypothetical and counterfactual reasoning. Information gathered during patient’s interview, and diagnostic findings are used to generate a hypothesis. Sometimes the working memory is supplemented by clinical decision support tools.
Non-analytical (intuitive): requires very little working memory capacity. They are often triggered by stimuli or result from overlearned associations or implicitly learned activities. Broadly construed through a pattern recognition framework, it attempts to match presenting patients to their mental models of diseases (information about diseases stored in the memory).
This process involves ruling in or ruling out a diagnosis as findings are integrated and interpreted. Probabilistic reasoning is most often considered in the context of diagnostic testing, but the presence or absence of specific signs and symptoms can also help to rule in or rule out diseases. A diagnosis is ruled out in the absence of a particular sign, symptom, or negative test that is always present in a particular disease
Empiric Treatment Strategy:
Clinicians sometimes employ empiric treatment strategies or the provision of treatment with a very uncertain diagnosis – and use a patient’s response to treatment as an information gathering activity to help arrive at a working diagnosis.
Query to clarify definitive cause of – Shortness of Breath
In case of a patient that presented with shortness of breath, I employed probabilistic reasoning technique, by ruling out Acute COPD, Heart Failure, Pulmonary Embolism, and Pneumonia as the likely causes of the SOB.
Each of the differential diagnoses will undergo the entire process of confirmation or rule out to determine the most likely cause of the SOB. The goal is not to be certain but to reduce uncertainty. As a physician, my thought process is that “I don’t want to miss anything.” On my discharge summary, I indicated SOB cause is multifactorial based on information gathering, integration, and interpretation. I suspected CHF, mild acute COPD, and Pneumonia. The query from the CDI suggested I choose one likely cause as the principal reason for the admission. Again, as I explained my judgment tells me each of these conditions contributed to the shortness of breath, I will rather not exclude potential causes to arrive at a single reason for SOB for coding purposes. Clinical reasoning is a dual process involves both analysis and intuition. Sometimes we feel strongly about our differential diagnoses even after all the testing and workup. It is important to note that clinicians do not need to obtain diagnostic certainty before initiating treatment; the goal of information gathering in the diagnostic process is to reduce diagnostic uncertainty enough to make optimal decisions for subsequent care.
Some CDI specialists react by issuing unwarranted queries before carefully examining the clinical situation. I also think some CDI specialists doubt it is impossible for a particular query answer to be “unknown.” Remember one crucial factor in the diagnostic process is “time.” Some diagnoses can be determined in a concise time frame, while months may elapse before other diagnoses can be made. It all depends on the recognition of variability and complexity of disease presentation. Physicians are already under regulatory pressure to discharge patients as soon as possible. This complicates the diagnostic process and frankly one of the reasons why even at the time of discharge a physician cannot definitively confirm his or her hypothesis. When a physician responds by saying “unknown,” it could be the utmost truth. Don’t label a physician outright as uncooperative because you did not get the response you are looking for. The relationship you build with the physician is significant to your success as a CDI specialist.
National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794.