1a) A specific example of a clinical practice guideline is a set of instructions which allows a

clinician to decide whether or not to perform a tonsillectomy in a child. The guideline I am
referring to is that presented by the United States Department of Health and Human Services’
Agency for Healthcare Research and Quality.
1b) The tonsillectomy guidelines are supported by clinical evidence which can improve
outcomes by offering suggestions for perioperative orders, help clinicians to evaluate patients
who may need the procedure, and provide state-of-the-art information to families about the
benefits of the surgery. They also standardize care, which will be required in the present health
care landscape. On the other hand, guidelines themselves may be confusing or misleading at
times because the actual practice of medicine is not set in stone and there are always exceptions
to the rule. The legal department may misinterpret or overstate these guidelines if a specific case
goes to court.

2) One study demonstrated that a decision-oriented display could minimize the search for
information, make inferences through pattern recognition, and direct attention to emergent needs.
Orders were made more accurately, more timely, and using less mental effort, as a result. This
display arranges and prioritizes data by time and also reveals relationships occurring within the
data. Information technology allowed the researchers to employ statistics to determine these
groupings. It also displays the data in a manner which facilitates the clinical decision-making
process, by presenting time-dependent information using graphics and by organizing results
according to the decisions made. The authors cite evidence that graphics, such as star charts,
icons, bar graphs, and pie charts, are superior to tables and that their effects are more pronounced
under time constraints. In the case of a patient with renal failure secondary to sepsis, status post
chemotherapy, graphical representations of time verses the patient’s body temperature and other
vital signs, complete blood count, culture reports, antibiotic levels, renal function tests (including
calculated values), organism susceptibilities, and medication interaction would make enormous
differences in the following ways:
2a) Physicians would not have to keep track of multiple values from previous days and would
easily recognize trends, especially those which need to be addressed immediately.
2b) Guidelines from sources such as the Sanford Guide to Antimicrobial Therapy would be more
readily available and instantly integrated into the graphical display in an appropriate manner.
2c) Data could be compared more easily, such that major deviations could be viewed in relation
to the overall day-to-day status of the patient, which would be crucial in a critically-ill patient.
The effects of therapeutic interventions would also be more accurately interpreted, especially
during the early stages of treatment.

3a) Patients can read a great deal of information online which may leave them confused. Asking
them to print out their findings, and to bring that information to their appointment to discuss it
with the physician could resolve this issue. For instance, the symptoms of many conditions
overlap and the sub-sternal pain associated with heartburn could be mistaken for a heart attack.
One physician decided to advertise accurate information through a highly influential
organization to counter the misconceptions. Knowing one’s audience is the best guideline for an
educator.
3b) Patients can find misleading claims on many websites which can potentially lead to a
strained doctor-patient relationship. The solution is to recommend reliable websites to patients so
that they receive accurate information. Up-to-Date, or a similar reference which physicians use,
also provides information in a format understandable by patients, which can be printed and given
to patients. In the case of the misinformation regarding vaccinations as a cause of autism,
physicians can direct patients to the evidence offered by a reliable source such as
http://www.aap.org. The old adage that one should consider the source still holds true.

4a) The recipient’s identity cannot be confirmed, so this practice is in violation of Health
Information Portability and Accountability Act (HIPAA) regulations. Although e-mails are
allowed according to HIPAA, cell phones are not secure. Also, there are legal implications to
consider when using this method of communication. The best approach would be to send a
confirmatory e-mail to the recipient to verify her identity before disclosing any sensitive
information. Texts must be viewed as a limited means of communication with a patient;
questions which require more in-depth answers need to be responded to in person, especially if
the topic is serious. A good use of texts would be to send general reminders or educational links
to all of the patients throughout a practice. Physicians do need a means by which they can
communicate with their patients, but these should be made and received over secure connections.
4b) Secure apps have been developed, such as MedXCom and mRx, to encrypt text messages.
Measures should be taken to instantly delete these messages on both sending and receiving
phones, yet to document the conversation’s content as well. Precautions should be taken to avoid
sending a text message that discloses any Personal Health Information (PHI). Consent must be
acquired from the patient before sending her a text message. One benefit of texting, however, is
that anonymous texts can be very useful. It is currently possible to keep the texting and phone
functions on a smart-phone separate. The fact remains that some patients may prefer this means
of communication, and that it does save time. Photographs exchanged by clinicians through
smart-phones have improved the quality of care, especially in remote areas. Electronic
prescriptions could be transmitted this way, too.

5a) Young men like John who exercise and lack a family history of coronary artery disease
(CAD) have a low risk for CAD. Therefore, the post-test probability would need to be updated to
account for the fact that the test has a low positive predictive value, due to the low prevalence of
CAD in this population.
5b) Bayes’ theorem is used to derive the formula for positive predictive value (PPV), which
factors in the prevalence of a disease in a subpopulation.
5c) The exact prevalence of CAD in John’s subpopulation could be entered into the formula for
PPV if known. The other component of the equation is the true positive rate, also known as the
sensitivity, of the stress test. The sensitivity is important because the test result was positive,
since sensitivity measures the probability that a patient with CAD also had a positive stress test.
5d) Insurance companies probably will not pay for this test, and hospital policy would not
encourage it. I came across a similar situation in which a nurse in an emergency room wanted to
perform electrocardiograms (EKGs) on all patients because one young patient had a myocardial
infarction that was missed. The attending physician explained that more false positive EKGs
would lead to more unnecessary interventions and would place an increased workload on an
already-busy cardiac catheterization lab. Besides the unintended consequences of an incorrect
diagnosis, an exercise stress test itself is expensive and requires a cardiologist to interpret it
correctly.

6a) The Hawthorne effect occurs when subjects under observation perform better because they
know they are being monitored. It would skew the results to make it appear that the hand-
washing intervention was more effective than it normally would be, especially since no subject
would want to be accused of neglecting to wash their hands.
6b) Assessment bias refers to the phenomenon by which the researchers collecting the data allow
their personal prejudices to alter the results. As part of an infection control study, in which
different departments are being assessed to determine if their lack of sanitary practices are
contributing to more hospital-acquired infections (HAIs), the researchers may be tempted to
tamper with results to demonstrate a greater reduction in HAIs in patients discharged from either
the Intensive Care Unit or the post-operative unit, resulting from the implementation of new
hand-washing policies, to target one of these departments as the source of HAIs, and thus
promote the new practice.
6c) The checklist effect occurs when more thorough and organized data gathering, encouraged
by the use of paper or electronic forms, results in better performance. In the case of hand-
washing, Dr. Atul Gawande’s operating room (OR) checklist comes to mind. If the OR staff fill
out a form on an iPad prior to washing their hands, the use of standard formats and technology
may bias their compliance with the new protocol.

7a) The quality and specifics of the clinical training which physicians received will have an
effect on their interpretation of physical findings, as would their general familiarity with the
clinical condition. Appendicitis, for example, can present in a classic fashion or in a vague
manner. Some clinicians are astute at diagnosing it without the aid of Computerized Tomography
scans because of their excellent clinical training and expertise and are less dependent on modern
technology than others.
7b) The prevalence of appendicitis and other conditions which present with abdominal pain will
vary in different areas and subpopulations. For instance, patients demonstrate varied
susceptibilities to appendicitis which may be related to genetics or to intestinal flora. It is entirely
possible that antibiotic prescription practices or antiseptic use could create variations in intestinal
flora among a patient population, which could influence the disease presentations.
8.1) B
8.2) negative
8.3) A
8.4) prevalence
9a) independent
9b) dependent
10.1) D
10.2) C
10.3) B
10.4) A
11) Northwestern University has created the NUgene project and participates in the eMerge
network. Discuss some of the issues surrounding the inclusion of genetic information in a
patient’s Electronic Medical Record (EMR). How will this information alter the ways in which
EMRs function to impact medical practice?
Genomic data are a form of Big Data which must be stored for future interpretation, since
research is currently underway to determine the significance of these genes, their modifications,
their regulation, and their outputs. They have the potential to assist, as a reference, in decision
support modules, particularly in aspects of preventative care, and pharmacokinetics and
pharmacodynamics. Future EMRs will need to be updated regularly as new discoveries are
made. Northwestern University researchers have suggested that the five to ten Gigabytes of
genomic data could be stored separately, and perhaps their decision support system would be
independent along with it, just as is the case with radiographic images (Terry, 2013). Data
gathered by EMRs is currently available for researchers to mine to determine potential genetic
variants worthy of further study.
Genomic information included in the EMR could revolutionize health care if this data are
understood and actionable; the EMR could be the ideal platform to integrate this reference into a
clinician’s workflow. There are six benefits to making gene sequencing data available: disease
prediction, risk-based early intervention, non-invasive and accurate diagnosis, accurate drug
selection, treatment modification, and gene-based therapeutics (Berkowitz, 2007). Northwestern
University’s NUgene project is attempting to implement this paradigm in conjunction with
clinical staff, while also respecting patient privacy and securing the data.
One novel approach personalizes the process by gathering the family medical history online,
integrating it with genomic data within an EMR, and using all of this information in determining
patient risk, through a decision tree which leads to suggestions for screening; these tasks are
performed with the goal of treating families as a unit. Another recommendation is to create a
new professional known as a “preventive health care advisor” who works with the patient and
will be making use of electronic devices to monitor her health in the near-future; with this
baseline information in hand, they can then make lifestyle modifications based on her genomic
data and thereby transform the integrated EMR into a “personalized health plan” (Preventative,
2009).

References:
Berkowitz, L. (2007, February 27). Genomics, Personalized Medicine and Electronic Medical
Records. Retrieved from http://www.slideshare.net/drlyle/genomics-personalized-medicine-and-
electronic-medical-records
Cohn, W. et al. (2011, April 14). Health Heritage- Gene EMR. Retrieved from
http://www.law.virginia.edu/pdf/news/postercomp/riley.pdf
Preventive Medicine and Docs vs. Genomics. (2009, October 4). Retrieved from
http://futurememes.blogspot.com/2009/10/preventive-medicine-and-docs-vs.html
Terry, K. (2013, April 10). EHRs Aren't Ready For Genomics-Driven Healthcare. Retrieved
from http://www.informationweek.com/healthcare/electronic-medical-records/ehrs-arent-ready-
for-genomics-driven-hea/240152602