Link between goals and other clinical concepts

pablo pazos pazospablo at hotmail.com
Sun Jun 22 22:48:14 EDT 2014


Hi Ian / Thomas / Heather,
That's weird, I didn't received Heathers' response email :)
I think the idea of reusing CLUSTERs is cleaner and simpler than my idea of specializing the goal archetype. What's nice about that is if we add a slot in the current Body Weight archetype to a CLUSTER to hold the measurement record, the paths in the B.W. archetype may not change.
About Thomas proposal, I see a lot of overlapping between the Epistemic Status and OBSERVATIONs / INSTRUCTIONs, and also with the INSTRUCTION state-machine states. So, I'm not 100% sure if we need add that, maybe if we find some use cases that can't be modeled otherwise, that would help.
About using intervals for the measurements, I think that's overkill. A better idea would be just to reuse the constraints for units, magnitude and precision (if the target is DV_QUANTITY). So, if the archetype for the measurement defines constraints for those data fields, in the goal archetype I would set references to those constraints of each limit of the interval defined as goal. I don't really know if that reference can be done via SLOTs because the reference is not only to an archetype, is to a specific/fine grained part of that archetype, so we might need the path in the SLOT. 
Can this be done in ADL 1.4? Is planned to add this kind of fine-grained SLOTs to ADL 1.5?
About goals like "Reduce BP", I think goals like that have implicit numeric semantics, and what we need are numeric values to be compared with measurements. When we specify "reduce" or "increase", the next questions is how much? So we need a number. Also, if we set an x..y interval for a goal and the current measurement is z, if z > y, the goal is to "reduce", but if z < x, the goal is to "increase" (that's the implicit semantics I mentioned above). I fact to have "reduce/increase" goals was a requirement in a current project and when I mentioned the implicit semantics they removed that requirement, now we have just intervals and first measurement to now if the goal is to increase or reduce.
In general, and because this goal/measurement is really a pattern all over healthcare, I would like to find / define a "best practice" of modeling this using openEHR (maybe just a guide for ADL 1.4 but for ADL 1.5 we might propose some model changes for the IM or AOM to support this pattern as it support the HISTORY pattern and the INSTRUCTION/ACTION pattern to track state changes).
What do you think about specifying how we all model the goal/measurement today to create a pool of real use cases, and then propose some openEHR friendly way(s) of modeling it? (as you notice I'm trying to avoid Hugh's proposal to use a higher level model to link goal and measurements :)
Personally, I have a couple of experiences with this, is not much but is something: one was a complete system design to manage patients with chronic pain and the other a system to manage celiac patients. Both with goals and result tracking. 

-- 
Kind regards,
Eng. Pablo Pazos Gutiérrez
http://cabolabs.com

> From: ian.mcnicoll at oceaninformatics.com
> Date: Sun, 22 Jun 2014 13:41:47 +0100
> Subject: Re: Link between goals and other clinical concepts
> To: openehr-clinical at lists.openehr.org
> 
> Hi Pablo,
> 
> You can see an example of the Goal archetype in-use via the SHN Heart
> Failure template at
> 
> http://www.openehr.org/ckm/#showTemplate_1013.26.14
> 
> This was my interpretation, which I think aligns with Heather's but
> others may vary!
> 
> To answer Mark's point, I think the archetpye does support defining a
> range of values via the Interval datatypes.
> 
> As Thomas has said, this is the subject of some discussion in the CIMI
> world. Although some sort of epistemic status flag/mood code seems
> attractive, it works very badly for Goal/Target. It is pretty obvious
> that the contents of an archetype for Target Blood pressure is very
> different for that ob the measurement itself. The only part of the
> highly complex blood pressure measurement archetype which has any
> value in the blood pressure target archetype are the systolic,
> diastolic and perhaps MAP datapoints and  even at that level the
> original observation data point is a single value , whereas the target
> is likely to be an interval. To make an epistemic flag work we would
> need to model the original measurement as an interval, which is
> entirely possible technically but requires us to further constrain the
> measurement archetype at template level to make it useable.
> 
> As Heather has pointed out, it might be possible to re-model every key
> data point as an individual cluster or even element archetype but that
> imposes a very significant burden on the modelling work, particularly
> clinical review, where we would again effectively have to re-create
> the existing blood pressure measurement archetype as a template with
> all of the additional constraints and aggregation. I don't think the
> CIMI group have really taken this on-board.
> 
> In a sense, at least for the 'Target/Goal' scenario, all that we want
> to do is to re-use the datatype and units from the original
> 'measurement' archetype. We probably need to use different SNOMED
> bindings and convert the data type to its INTERVAL equivalent. So I
> would question whether there  is any real value in re-using the
> original constraint pattern. Arguably the only attribute which is
> actually copied intact is the unit.
> 
> I think it might actually be more sensible to use the current approach
> where an existing archetype node is pointed to for information but
> that this is then used by tools to replicate/adapt the original
> constraints. i.e this is re-use via copy/paste/edit rather than direct
> re-use/inheritance.aggregation.
> 
> I suppose it all comes down to the value of direct re-use. At least
> for the Target/Goal scenario, I suspect the overhead of doing this far
> outweighs any benefit, and I think may be another example of
> informaticians trying to construct ontologically pure and elegant
> solutions which actually just get in the way of implementation.
> 
> The eHealth record is fundamentally anti-pattern.
> 
> Ian
> 
> Ian
> 
> On 20 June 2014 06:32, Heather Leslie
> <heather.leslie at oceaninformatics.com> wrote:
> > Hi Pablo,
> >
> >
> >
> > Comments inline
> >
> >
> >
> > Heather
> >
> >
> >
> > From: openEHR-clinical [mailto:openehr-clinical-bounces at lists.openehr.org]
> > On Behalf Of pablo pazos
> > Sent: Friday, 20 June 2014 10:09 AM
> > To: openEHR Clinical
> >
> >
> > Subject: RE: Link between goals and other clinical concepts
> >
> >
> >
> > Hi Heather!
> >
> >
> >
> > Yes, I was evaluating the goal archetype. Great, now I get what the "Target
> > archetype node" is for.
> >
> >
> >
> > About that I have a question, what's the role of the "Target measurement"?
> > My understanding was that's the value set for the goal (e.g. target body
> > weight),
> >
> > [HVL:] Agreed. Perhaps we should refine the name/description to make that
> > clearer.
> >
> >
> >
> > not the measurement to be evaluated against the goal (e.g. current body
> > weight).
> >
> > If that value is the measurement, where should the value for the goal be
> > set? Or the idea is not to set a value like quantity but set a text in
> > "Target".
> >
> >
> >
> > My question was focused on the relationship between the value set for the
> > target goal and the archetype used to record the measurements to be compared
> > with the value of the goal. Because the goal and the measurements should
> > comply the same constraints (magnitude, units, etc)
> >
> > [HVL:] Understood . That is what I was referring to with my comment
> > “correlation with magnitude and unit constraints would be nice to have, but
> > is not currently easy to achieve.” We would currently do that manually in
> > the template. Alternatively we could specialise the goal archetype for each
> > measurement, but that has lots of overheads as well.
> >
> >
> >
> > If we were to look at changing the modelling patterns to allow for a common
> > CLUSTER to be used within both the measurement OBSERVATION and the
> > EVALUATION.goal then we could achieve what you asked for. In the current ADL
> > 1.4 world that would be an enormous modelling overhead as then no
> > measurement model is standalone and ready to go but needs to be combined
> > with others in order to be used in every modelling scenario.
> >
> >
> >
> > It is not clear that the requirements for goal justify the changed modelling
> > pattern scenario. The value and clarity of the standalone OBSERVATIONs is
> > huge.
> >
> >
> >
> > Also, what about when you have a goal for the BP and you need to specify a
> > value for systolic and diastolic? Should I create two instances of the goal?
> > (One for systolic and one for diastolic).
> >
> > [HVL:] Depends on what you are trying to achieve. You could do it the way
> > you describe, and then reaching each goal can be assessed independently. Or
> > if you want to reduce the BP as a whole, you could set a goal of ‘Reduce BP’
> > and have two targets, one for Systolic and the other for Diastolic
> >
> >
> >
> > Thanks!
> >
> >
> >
> >
> >
> > --
> > Kind regards,
> > Eng. Pablo Pazos Gutiérrez
> > http://cabolabs.com
> >
> > ________________________________
> >
> > From: heather.leslie at oceaninformatics.com
> > To: openehr-clinical at lists.openehr.org
> > Subject: RE: Link between goals and other clinical concepts
> > Date: Wed, 18 Jun 2014 03:13:09 +0000
> >
> > Hi Pablo,
> >
> >
> >
> > Is it safe to assume that you’ve seen the current archetype for Goal? It is
> > here: http://www.openehr.org/ckm/#showArchetype_1013.1.124
> >
> >
> >
> > In it we have a data element that specifically identifies the archetype and
> > path of the specific node that should be used to capture the actual
> > measurement, eg the weight or height or systolic blood pressure.
> >
> >
> >
> > This combination of the EVALUATION.goal archetype with various target
> > OBSERVATIONs for recording the actual data is being used in implementations
> > in Australia as part of a personalised care plan, as Hugh has indicated. The
> > correlation with magnitude and unit constraints would be nice to have, but
> > is not currently easy to achieve.
> >
> >
> >
> > Regards
> >
> >
> >
> > Heather
> >
> >
> >
> > From: openEHR-clinical [mailto:openehr-clinical-bounces at lists.openehr.org]
> > On Behalf Of pablo pazos
> > Sent: Saturday, 14 June 2014 5:21 AM
> > To: openEHR Clinical
> > Subject: Link between goals and other clinical concepts
> >
> >
> >
> > Hi, if I want to establish a goal for body weight, I think there's a need of
> > linking the goal concept with the body weight concept, but the body weight
> > archetype is for measuring the weight not to specify a goal for it.
> >
> >
> >
> > I understand the difference between a goal (what you want to achieve, fixed
> > value) and the measures (to control your progress and compare with the goal,
> > variable value through time).
> >
> >
> >
> > Also, I think the target measurement from the goal archetype will depend on
> > the specific concept I'm creating a goal for (body weight), I mean the
> > magnitude and units constraints should be inherited someway from the concept
> > I'm measuring (body weight) into the goal archetype.
> >
> >
> >
> > Does anyone has an idea of how will be a good way of modeling a goal related
> > to another concept like weight or BP?
> >
> >
> >
> > Thanks!
> >
> >
> > --
> > Kind regards,
> > Eng. Pablo Pazos Gutiérrez
> > http://cabolabs.com
> >
> >
> > _______________________________________________ openEHR-clinical mailing
> > list openEHR-clinical at lists.openehr.org
> > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
> >
> >
> > _______________________________________________
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> > openEHR-clinical at lists.openehr.org
> > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
> 
> 
> 
> -- 
> Dr Ian McNicoll
> office +44 (0)1536 414 994
> fax +44 (0)1536 516317
> mobile +44 (0)775 209 7859
> skype ianmcnicoll
> ian.mcnicoll at oceaninformatics.com
> 
> Clinical Modelling Consultant, Ocean Informatics, UK
> Director openEHR Foundation  www.openehr.org/knowledge
> Honorary Senior Research Associate, CHIME, UCL
> SCIMP Working Group, NHS Scotland
> BCS Primary Health Care  www.phcsg.org
> 
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