Modification of assessment and atypical presentation in older adults with complex illness. They need to select a few of their best ideas and eventually narrow it down to their absolute best. THE DIAGNOSTIC EVIDENCE BASE AND CLINICAL PRACTICE, Advances in biology and medicine have led to improvements in prevention, diagnosis, and treatment, with a deluge of innovations in diagnostic testing (IOM, 2000, 2013a; Korf and Rehm, 2013; Lee and Levy, 2012). All Rights Reserved. 2011. Middleton, B., M. Bloomrosen, M. A. Dente, B. Hashmat, R. Koppel, J. M. Overhage, T. H. Payne, S. T. Rosenbloom, C. Weaver, J. Zhang, and American Medical Informatics Association. Radiology 234(2):339–342. health care professional education and training (Kassirer, 2014; Kugler and Verghese, 2010). Provide checklists to minimize reliance on memory and directed questioning to aid in diagnostic thoroughness and problem solving. 2007. 2010. Clinical chemistry. Kassirer, J. P. 2014. The future role of radiology in healthcare. http://healthit.gov/sites/default/files/reports/info_blocking_040915.pdf (accessed April 10, 2015). HIMSS (Healthcare Information and Management Systems Society). This recommendation neither entails nor requires the disclosure of trade secrets or of intellectual property. Figure 2-3 illustrates the concept of calibration, or the process of a clinician becoming aware of his or her diagnostic abilities and limitations through feedback. www.acpinternist.org/archives/2014/11/virtual-visit.htm (accessed May 24, 2015). Because of a recent news story on a tourist kidnapping in Country “A,” we change the destination we have chosen for our vacation to Country “B.”. Annals of Internal Medicine 130(12):995–1004. Meigs, J. Journal of Continuing Education in the Health Professions 26(3):192–198. 1984. 2013. There are four CMS-designated accreditation organizations for medical imaging: ACR, the Intersocietal Accreditation Commission, The Joint Commission, and RadSite (CMS, 2015a). 2015. McGraw-Hill Professional. A smartphone dongle for diagnosis of infectious diseases at the point of care. Electronic Health Record Usability: Vendor Practices and Perspectives. B., E. Cagliero, A. Dubey, P. Murphy-Sheehy, C. Gildesgame, H. Chueh, M. J. Barry, D. E. Singer, and D. M. Nathan. If the clinician has seen the patient before, these observations can be weighed against previous interactions with the patient. Sociology of Health and Illness 31(2):278–299. Whether caused by new technology implementations, process updates, compliance initiatives, reorganization, or customer service improvements, change is constant and necessary for growth and profitability. 2011. Laboratory medicine: A national status report. Mental health diagnoses can be particularly challenging. Zhi, M., E. L. Ding, J. Theisen–Toupal, J. Whelan, and R. Arnaout. IOM. Roshanov, P. S., J. J. 2009. can improve safety during all phases of the design of their products, from requirements gathering to product testing. The New York Times, February 26. www.nytimes.com/2011/02/27/opinion/27verghese.html (accessed August 5, 2015). Quality and Safety in Health Care 19:i68–i74. Recommendation 6: The Secretary of HHS should specify the quality and risk management process requirements that health IT vendors must adopt, with a particular focus on human factors, safety culture, and usability. ACR. A. Mackay, L. Weise-Kelly, T. Navarro, N. L. Wilczynski, and R. B. Haynes. Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: A report of an AMIA special task force. Interview with Lawrence Weed, MD—The father of the problem-oriented medical record looks ahead. 1996. Possible factors contributing to failure in this phase include an incorrect interpretation of the test result by the ordering clinician or pathologist and the failure by the ordering clinician to act on the test results: for example, not ordering a follow-up test or not providing treatment consistent with the test results (Hickner et al., 2014; Laposata and Dighe, 2007; Plebani and Lippi, 2011). Smartphones have been used in conjunction with specialized attachments to make certain laboratory-based diagnostics more accessible (Laksanasopin et al., 2015). contracts and made a number of suggestions for improving health IT contract language (see Box 5-5). A. Feldman, J. R. Beshansky, J. L. Griffith, and H. P. Selker. The President’s Precision Medicine Initiative highlights the growing interest in taking individual variability into account when defining disease, tailoring treatment, and improving prevention (NIH, 2015). The use of molecular diagnostics is a rapidly developing area. Disclosure of information should not create legal liability for good-faith reporting. Medicaid.gov. www.degruyter.com/dg/viewarticle.fullcontentlink:pdfeventlink/$002fj$002fdx.ahead-of-print$002fdx-2014-0064$002fdx-2014-0064.pdf?t:ac=j$002fdx.aheadof-print$002fdx-2014-0064$002fdx-2014-0064.xml (accessed December 8, 2015). Archives of Pathology & Laboratory Medicine 135(11):1476–1481. 8 Electronics embedded in watchbands, clothing, contact lenses, or other wearable equipment. Innovation adds value to the services or goods that you provide and so you should seek to be innovative in your business. Vendors and their customers, including users, should report and make available salient information about threats to patient safety resulting from software deficiencies, implementation errors, and other causes. Mulley, A. G., C. Trimble, and G. Elwyn. are done in the background, improving accuracy and freeing up the user’s cognitive resources for other tasks” (HIMSS, 2009, p. 3). www.rcpath.org/Resources/RCPath/Migrated%20Resources/Documents/G/G026_Telepathology_Oct13.pdf (accessed May 24, 2015). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. 2013. These contractual barriers may propagate safety risks and pose significant challenges to the use of data for future patient safety and quality improvement research (IOM, 2012a). The appropriate choice of imaging modality depends on the disease, organ, and specific clinical questions to be addressed. The Joint Commission. www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/AOList.pdf (accessed November 3, 2015). Clinicians have expressed dissatisfaction about EHR screens being too busy due to a high degree of display clutter (or the high density of objects). Diagnosis 1(1):11–12. Academic Medicine 84(8):1022–1028. 2014b. www.dallasnews.com/ebola/headlines/20141206-full-transcript-dr.-joseph-howard-meier-s-responses-to-questions-from-the-dallas-morning-news.ece (accessed March 30, 2015). [Clinicians] often bypass the bedside evaluation for immediate testing” (Verghese et al., 2011, p. 550). Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: A quasi-experimental study. Lipshitz, R., G. Klein, J. Orasanu, and E. Salas. Ensure that problem lists are integrated into workflow to allow for continuous updating. For example, many comprehensive EHR systems automatically generate alerts in response to abnormal diagnostic testing results, but Singh and colleagues (2013) found that information overload may contribute to clinicians missing test results. Mangalmurti, S. S., L. Murtagh, and M. M. Mello. Problem List Guidance in the EHR. Groen, G. J., and V. L. Patel. GABHS causes about 10 percent of acute pharyngitis; thus, 90 percent of pharyngitis is not due to GABHS (e.g., viral) (Snow et al., 2001). New England Journal of Medicine 363(26):2477–2481. SOURCE: El-Kareh et al., 2013. Probability theory in the use of diagnostic tests. http://tricorder.xprize.org/about/overview (accessed May 24, 2015). CHCF (California HealthCare Foundation). ASCP certifies medical laboratory professionals. Carranza, N., V. Ramos, F. G. Lizana, J. Garcia, A. del Pozo, and J. L. Monteagudo. 2015. As molecular diagnostic testing becomes increasingly complex (such as the movement from single biomarker tests to omicsbased tests that rely on high-dimensional data and complex algorithms), there is considerable interest in ensuring their appropriate development and use (IOM, 2012). Today’s post will cover the four steps in the business process improvement cycle. Medical Care 14(10):848–856. There is a range of settings (i.e., work systems) in which the diagnostic process can occur—for example, outpatient primary or specialty care office settings, emergency departments, inpatient hospital settings, long-term care facilities, and retail clinics. Hand, S. G. Elliott, S. Kinkade, M. J. Hauan, D. K. Onion, and B. M. Sklar. Carayon, P., T. B. Wetterneck, B. Alyousef, R. L. Brown, R. S. Cartmill, K. McGuire, P. L. Hoonakker, J. Slagle, K. S. Van Roy, J. M. Walker, M. B. Weinger, A. Xie, and K. E. Wood. Washington, DC: The National Academies Press. Innovation is a process of improving a product service from its current state. Talking data with your doc: The doctors. in the diagnostic process, both within one setting and across care settings. Acting on significant laboratory results. As a clinician. 2015. Eligibility for laboratory accreditation. profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance. When a patient presents to a clinician, the initial data include symptoms and signs of disease, which can range from single characteristics of disease to illness scripts. Health Affairs (Millwood) 33(9):1672–1679. 2008. Further information gathering activities or treatment could provide greater certainty regarding a working diagnosis or suggest that alternative diagnoses be considered. 2015b. 2007. A systematic review found an increase in the appropriateness of diagnostic and treatment decisions when mobile devices were used for clinical decision support, but the researchers who performed the study noted that the evidence was limited; thus, more research will be needed to draw reliable conclusions concerning whether and how these mobile devices help and in what circumstances and how they should be used (Divall et al., 2013). Gigerenzer, G. 2013. American Journal of Roentgenology 173(5):1169–1172. Show this book's table of contents, where you can jump to any chapter by name. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Dual-process theories of higher cognition: Advancing the debate. 2011. Dallas Morning News, December 6. www.dallasnews.com/ebola/headlines/20141206-er-doctor-discusses-role-in-ebola-patients-initial-misdiagnosis.ece (accessed August 11, 2015). Diagnosis 1(1):13–17. Cognitive debiasing 1: Origins of bias and theory of debiasing. Lenzer, J., J. R. Hoffman, C. D. Furberg, and J. P. Ioannidis, on behalf of the Guideline Panel Review Working Group. Washington, DC: National Academy Press. 113–121). Accreditation. Clinicians can also recommend that the patient seek a second opinion from another clinician to verify their impressions of an uncertain diagnosis or if they believe that this would be helpful to the patient. that response rates to treatment can be highly variable, and the failure to respond to treatment does not necessarily reflect that a diagnosis is incorrect. Cosmides, L., and J. Tooby. Diagnostic error in internal medicine. However, fever occurs in 24 percent of those with GABHS and 11 percent of those without GABHS (Centor et al., 1980), so 2.9 percent have GABHS without nasal congestion but with fever (11.9 percent with GABHS without nasal congestion times 24 percent), whereas 9.7 percent have nonGABHS without nasal congestion but with fever (88.1 percent with nonGAHBS without nasal conges-. Diagnosis 1(1):79–84. 10-0098-EF. Diagnostic consultations can also be arranged through the use of integrated practice units or diagnostic management teams (Govern, 2013; Porter, 2010; see Chapter 4). Defining features versus incidental correlates of Type 1 and Type 2 processing. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Accreditation organizations/exempt states. To do so, we must define and operationalize what ‘better’ looks like and measure to know if the changes we make result in the improvements we seek.Measurement for improvement allows us to answer questions such as: 1. Complications: A surgeon’s notes on an imperfect science. Second opinions. One key feature of an effective user interface is simplicity. 2011. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. 2013. Clinicians can then decide whether to pursue additional information gathering or treatment based on an accurate estimate of the likelihood of disease, the harms and benefits of treatment, and patient preferences (Kassirer et al., 2010; Pauker and Kassirer, 1980). 09(10)-0091-3-EF. of what should or should not happen in particular situations, in order to test possible actions or to explore alternative causes of events (Stanovich, 2009). (Middleton et al., 2013). Panels of biomarkers are being developed into molecular diagnostic tests (omics-based tests) that are used to assess risk and inform treatment decisions, such as Oncotype DX and MammaPrint in breast cancer (IOM, 2012). Current market conditions create business incentives for information blocking, that is, “when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information” (ONC, 2015, p. 8). 1: The P value fallacy. The aging physician: Changes in cognitive processing and their impact on medical practice. 1996. BMJ Quality and Safety 22(Suppl 2):ii1–ii5. The CDC performs research on laboratory testing processes, including quality improvement studies, and develops technical standards and laboratory practice guidelines (CDC, 2014). New York: Russell Sage Foundation. 2007. To search the entire text of this book, type in your search term here and press Enter. Journal of the American College of Radiology 11(4):402–406. Other mHealth applications for patients, such as wearable technologies, are intended to facilitate data collection, and they offer an additional source of patient data which may improve clinicians’ ability to diagnose certain conditions. Indeed, Kassirer concluded: “Diagnosis remains fundamentally dependent on a personal interaction of a [clinician] with a patient, the sufficiency of communication between them, the accuracy of the patient’s history and physical examination, and the cognitive energy necessary to synthesize a vast array of information” (Kassirer, 2014, p. 12). Identifying patient smoking status from medical discharge records. Specifically, “some vendors require contract clauses that force [health IT] system purchasers to adopt vendor-defined policies that prevent the disclosure of errors, bugs, design flaws, and other [health IT]-software-related hazards” (Goodman et al., 2011, p. 77). 2008. A human-centered design approach balances the requirements of the technical system of computers and software with those of the larger sociotechnical system (Gasson, 2003). Disclosures made in good faith should not constitute violations of [health information technology (health IT)] contracts. 2015. Effectiveness of topic-specific infobuttons: A randomized controlled trial. Early diagnostic suggestions improve accuracy of GPs: A randomised controlled trial using computer-simulated patients. Zwaan, L., and H. Singh. mHealth applications are often designed to assist clinicians at the point of care and include drug reference guides, medical calculators, clinical practice guidelines, textbooks, literature search portals, and other decision support aids. 2010. 2010. 2015. The hope is that health IT will enhance patient and clinician communication and collaboration by, for example, facilitating patient access to health information (see Chapter 4). Laboratory developed tests. Input submitted to the Committee on Diagnostic Error in Health Care, November 5 and December 29, 2014, Washington, DC. Berger, D. 1999. American Journal of Managed Care 20(5):418–423. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. Applying Grading of Recommendations Assessment, Development and Evaluation (GRADE) to diagnostic tests was challenging but doable. Analytical reasoning models have several additional characteristics. Evans, J. S. B. T., and K. E. Stanovich. During the analytic phase, the specimen is tested, examined, or both. Overconfidence in clinical decision making. FIGURE 2-4 Number of journal articles published on health care topics per year from 1970 to 2010. 2008. A public statement outlining the lessons learned and responses to this diagnostic error included. Current evidence suggests that patients seen in the emergency department are at high risk of experiencing diagnostic errors because of the range of conditions seen, the time pressures involved, and complexity of the work system environment (Campbell et al., 2007). B. Greenbaum, P. B. Berger, C. P. Cannon, D. J. Cohen, C. M. Gibson, J. F. Saucedo, N. S. Kleiman, J. S. Hochman, W. E. Boden, R. G. Brindis, W. F. Peacock, S. C. Smith, Jr., C. V. Pollack, Jr., W. B. Gibler, E. M. Ohman, and CRUSADE Investigators. Journal of the Medical Library Association 92(4):429–437. Adaptive thinking: Rationality in the real world. An accurate history facilitates a more productive and efficient physical exam and the appropriate utilization of diagnostic testing (Lichstein, 1990). 2014. Human-centered vs. user-centered approaches to information system design. Grimes, D. A., and K. F. Schulz. Compared to physical diagnoses, many mental health diagnoses rely on patient reports and observation; there are few biological tests that are used in such diagnoses (Pincus, 2014). Stratton, C. W. 2011. Kostopoulou, O., A. Rosen, T. Round, E. Wright, A. Douiri, and B. Delaney. Evidence-informed person-centered health care (part II): Are “cognitive biases plus” underlying the EBM paradigm responsible for undermining the quality of evidence? Continuous developments in picture archiving and communication systems and radiology information systems have strengthened the overall teleradiology process, including image capture, storage, processing, and reporting. Sarter, N. 2014. Regional variations in diagnostic practices. www.acr.org/Quality-Safety (accessed May 22, 2015). As described above, the diagnostic process involves initial information gathering that leads to a working diagnosis. Contracts should contain language describing a process for timely and, as appropriate, transparent conflict resolution. 2014. Inadequate patient education and preparation for an imaging test can also lead to suboptimal imaging quality that results in diagnostic error. It's important to have a progressive digital culture without compromising the success of the new technology we choose. Improving the availability of clinical history accompanying radiographic examinations in a large pediatric radiology department. Psychology of clinical reasoning. For example, studies suggest exceptions for findings such as Kayser–Fleischer rings with other causes of liver disease (Frommer et al., 1977; Lipman and Deutsch, 1990) or Koplik’s spots with parvovirus B19 or echovirus (Suringa et al., 1970) and even for Reed-Sternburg cells for Hodgkin’s lymphoma (Azar, 1975). But if we handle this process incorrectly, it can be disastrous. www.iea.cc/whats/index.html (accessed April 10, 2015). I believe the process is a good and necessary one, and the Info-Tech reps I've spoken with on the topic have been quite helpful and knowledgeable. and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks” (HIMSS, 2009). There are a number of individual characteristics that can affect clinical reasoning, including intelligence and knowledge, age, affect, experience, personality, physical state, and gender. Moroff, S. V., and S. G. Pauker. www.ascp.org/Advocacy/Patient-Access-to-Test-Results.html (accessed March 16, 2015). The SAFER guides: Empowering organizations to improve the safety and effectiveness of electronic health records. Clinical reasoning is “the cognitive process that is necessary to evaluate and manage a patient’s medical problems” (Barrows, 1980, p. 19). The dual process theory integrates analytical and non-analytical models of decision making (see Box 2-4). The following text provides an overview of telemedicine applications in radiology, pathology, and neurology. These information-gathering processes are discussed in further detail below. An important component of usability is whether it supports teamwork in the diagnostic process. Automation bias: A systematic review of frequency, effect mediators, and mitigators. In older adults with mild to moderate dementia, such illnesses can manifest with worsening cognition. The task of selecting the appropriate diagnostic testing is challenging for clinicians, in part because of the sheer volume of choices. What can be done to increase the use of diagnostic decision support systems? 2009. Experience with implementation of a radiology speech recognition system. The difficulty with experience: Does practice increase susceptibility to premature closure? 2013. The physical exam is a hands-on observational examination of the patient. Because action research is a collaborative activity, the diagnostic data are fed back to the client, usually in a group or work team meeting. Byrnes, J. P., D. C. Miller, and W. D. Schafer. Diagnostic error: Issues in behavioral health. 2008. For instance, EHR systems may become temporarily inaccessible because of software updates or network failure. Bhan, S. N., C. L. Coblentz, and S. H. Ali. ing a working diagnosis continues. 2014a. Lau, J. K., N. Lowres, L. Neubeck, D. B. Brieger, R. W. Sy, C. D. Galloway, D. E. Albert, and S. B. Freedman. The steps of the diagnostic process fall into three broad categories: Initial Diagnostic Assessment – Patient history, physical exam, evaluation of the patient’s chief complaint and symptoms, forming a differential diagnosis, and ordering of diagnostic tests Diagnostic Testing – Performance, interpretation, and communication of test results 2012. 12-1–12-15). 2013. A cause of excessive testing. Hoffman, K. A., L. M. Aitken, and C. Duffield. 2012. Communication factors in the follow-up of abnormal mammograms. We buy a new car based on excellent reviews and tend to ignore or downplay negative features that are noticed. NIH (National Institutes of Health). Delivering high-quality cancer care: Charting a new course for a system in crisis. Box 2-5 describes how certain individual characteristics of diagnostic team members can affect clinical reasoning. Unfortunately, contractual provisions, intended to protect vendors’ intellectual property interests and liability from the unsafe use of health IT products, limit the free exchange of information about health IT–related patient safety risks (IOM, 2012a). Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text. Gunderman, R. B. Systematic review of guidelines on imaging of asymptomatic coronary artery disease. www.americantelemed.org/about-telemedicine/what-is-telemedicine#.VWHni0b9x7x (accessed May 24, 2015). Addressing overutilization in medical imaging. However, there have been a number of challenges to the development and use of CPGs in clinical practice (IOM, 2011a, 2013a,b; Kahn et al., 2014; Timmermans and Mauck, 2005). Health IT that is not designed and implemented to support the diagnostic process can increase vulnerability to diagnostic errors. evant differences between the medical imaging and pathology processes include the nature of the examination and the methods and technology used to interpret the results. USA: Createspace. Ferket, B. S., T. S. Genders, E. B. Colkesen, J. J. Visser, S. Spronk, E. W. Steyerberg, and M. G. Hunink. Family resemblances: Studies in the internal structure of categories. Croskerry, P., A. Thus, the probability of disease does not have to be equal to one (diagnostic certainty) in order for treatment to be justified (Pauker and Kassirer, 1980). Comments from the American College of Radiology. The landscape of inappropriate laboratory testing: A 15-year meta-analysis. 2015. For many conditions, it is also used to select and plan treatments, monitor treatment effectiveness, and provide longterm follow-up. Kanwisher, N., and G. Yovel. Stanovich, K. E. 2009. molecular imaging with PET (typically as PET/CT) have recently been approved for clinical use, and more are undergoing clinical trials, while PET/MRI was recently introduced to the clinical setting. list each sub-step (again, no more than 5-6 steps) under the main steps; Detailed Process Map. A. Abbass, and A. W. Wu. Croskerry, P., and D. Musson. A major goal of using data collected within EHRs for legal, billing, and population-wide health management has led to a profusion of structured clinical documentation formats within health IT tools. 2014a. Identify key challenges, articulate specific aims to address those challenges, and focus improvement efforts 5. IOM. Included in these assessments are the potential for false positives and ambiguous or slightly abnormal test results that lead to further diagnostic testing or unnecessary treatment. 2013. Analytical models (slow system 2) involve a conscious, deliberate process guided by critical thinking (Kahneman, 2011). Telemedicine Journal and E Health 16(7):818–826. Checklists are another approach that has been implemented to improve the safety of care by, for example, preventing health care–acquired infections or errors in surgical care. Safety issues related to the electronic medical record (EMR): Synthesis of the literature from the last decade, 2000–2009. Improving the identification of diagnostic errors is an important recommendation of this committee (see Chapter 6), and health IT vendors should facilitate efforts to do so by developing tools that enable organizations to more easily determine the rates of diagnostic errors, especially those that are common and that have serious implications for patients (e.g., pulmonary embolism, acute myocardial infarction, and stroke). McGlynn, E. A., S. M. Asch, J. Adams, J. Keesey, J. Hicks, A. DeCristofaro, and E. A. Kerr. This can include imaging (such as ultrasound) to localize tissue targets during biopsy. lines (Ferket et al., 2011; Han et al., 2011; IOM, 2011a; Lenzer et al., 2013; Pronovost, 2013). “Problem-oriented” has two interrelated meanings (Weed and Weed, 2011, p. 134): The problem list includes all past and present diagnoses, as well as the time of occurrence and whether the problem was resolved, and links to further information on each entry in the list (AHIMA, 2011; Weed, 1968). We see a work colleague picking up two kids from an elementary school and assume he or she has children, when they are instead picking up someone else’s children. CAP. Snow, V., C. Mottur-Pilson, R. J. Cooper, and J. R. Hoffman. Energy & Commerce Committee. Facilitate patient education about potential red-flag symptoms; track follow-up. Treat the patient, not the CT scan. A physical exam may include an analysis of many parts of the body, not just those suspected to be involved in the patient’s current complaint. Clinical documentation is used to justify the level of service billed to insurers, to collect information for research or quality improvement purposes, and to inform a legal record in case of litigation (Rosenbloom et al., 2011). Each of these includes the six components of a work system—diagnostic team members and tasks, technologies and tools, organizational factors, the physical environment, and the external environment—although the nature of the components may differ among and between settings. www.iom.edu/Activities/Research/BiomarkersforMolecularlyTargetedTherapies.aspx (accessed May 22, 2015). Throughout the diagnostic process, there is an ongoing assessment of whether sufficient information has been collected. Enhancing nursing practice by utilizing voice recognition for direct documentation. Kent, D. M., and R. A. Hayward. Journal of General Internal Medicine 20(2):143–147. There are many heuristics and biases that affect clinical reasoning and decision making (see Table 2-2 for medical and nonmedical examples). 2003. www.cqpi.wisc.edu/usability-tools.htm (accessed May 3, 2015). Journal of the American Medical Informatics Association. Washington, DC: The National Academies Press. Marois, R., and J. Ivanoff. King, V. Patel, C. J. Hsiao, J. Adler–Milstein, and A. K. Jha. BMJ 340:c291. A controlled trial of web-based diabetes disease management: The MGH diabetes primary care improvement project. Clinicians may refer to or consult with other clinicians (formally or informally) to seek additional expertise about a patient’s health problem. Intelligence refers to individuals’ abilities to engage in high-level cognitive tasks such as reasoning, problem solving, and decision making (Croskerry and Musson, 2009).