Yet another OBSERVATION vs. EVALUATION issue
heather.leslie at oceaninformatics.com
Tue Aug 14 22:49:41 EDT 2012
Some of the latest versions of existing archetypes might suit your purpose -
the most recent are currently on the NEHTA CKM and we are looking to
transport them across to the openEHR CKM.
More details below.
From: openehr-clinical-bounces at lists.openehr.org
[mailto:openehr-clinical-bounces at lists.openehr.org] On Behalf Of Koray
Sent: Tuesday, 14 August 2012 2:28 PM
To: For openEHR clinical discussions
Subject: Yet another OBSERVATION vs. EVALUATION issue
There's a CVD risk assessment tool I'm working on which prepopulates
clinical info from GP software. This includes diagnoses
[HL>] EVALUATION.problem_diagnosis -
, smoking status
[HL>] EVALUATION.tobacco_use_summary -
and checklist for certain medications
[HL>] ACTION.medication -
. Note that some of the underlying info might be coming from previous visits
(e.g. problem list type) but also can be newly entered as a result of GP's
assessment. Now, regardless of what happens in GP software, when it is
transferred onto this tool (whether automatically prepopulating and/or
manual entry) are these Observations or Evaluations?
[HL>] If you see this work as part of a broader ecosystem of data and this
could be extended, the data re-used etc, then I'd strongly advise that you
use the existing archetypes as described above. This is clearly the ideal
situation and recommended from a pure modelling perspective, maximising the
opportunity to re-use or re-purpose or extend data in the future.
Note that the GP does not make any further clinical judgement here, just
rephrase existing data for a different purpose. My gut feeling is the former
[HL>] The actual recording of risk itself will be captured using an
EVALUATION - where the evidence from multiple sources is synthesized and an
expression of risk is calculated or stated. There is a very early archetype
- EVALUATION.risk -
http://www.openehr.org/knowledge/OKM.html#showarchetype_1013.1.176_1 - on
the openEHR CKM that probably needs to be modified, but gives you a sense of
the likely structure. It has long been on my mind to scope out the 'risk
ecosystem' and devise a generic risk model, probably much as you see it now,
but with a more generic index data element (ie take away 'condition') and
probably some related specialisations for Risk of Condition etc. Yet to be
determined, I'm afraid.
Hope this helps
I know this is tricky and has been brought to this list many times here but
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