BMI archetype

GF gfrer at luna.nl
Tue Apr 11 03:15:11 EDT 2017


Sam,

I reserve Observation for all that can be observed by the five human senses.
All that is derived by, for instance, a calculation, or rules, or a thought process, is an Evaluation.

This means that sometimes BMI is read or heard and therefor an Observation.
Or derived using observed values like Weight and Body length and there for an Evaluation.

I disagree with the definitions as provided by Silje.
Each item in the EHR has an associated point in time, since life unrolls in time as does documentation.
A definition that is based on exclusions only is not correct.
E.g. 'Something is a bee, because it is NOT a lion, Not a tulip, and NOT a mosquito’ does NOT qualify as a correct sensible definition.

What are the formal definitions of Observation and Evaluation in the context of an EHR?

Gerard   Freriks
+31 620347088
  gfrer at luna.nl

Kattensingel  20
2801 CA Gouda
the Netherlands

> On 10 Apr 2017, at 23:12, Sam Heard <sam.heard at oceaninformatics.com> wrote:
> 
> HI All
>  
> The fact that BMI is derived from two other measurements does not make it an evaluation. It is objective and when it was measured, max, min, average etc are all of interest.
>  
> An evaluation is a clinical statement of persistent relevance. Silje’s example of Obesity or Malnutrition are good examples.  There may be a date of onset but there may not be. Personality disorder is an example of the latter. Dates in evaluation archetypes tend to be specific to that concept.
>  
> Cheers, Sam
>  
> Sent from Mail <https://go.microsoft.com/fwlink/?LinkId=550986> for Windows 10
>  
> From: Bert Verhees <mailto:bert.verhees at rosa.nl>
> Sent: Tuesday, 11 April 2017 4:52 AM
> To: For openEHR clinical discussions <mailto:openehr-clinical at lists.openehr.org>
> Subject: Re: BMI archetype
>  
> Thanks Silje,
> 
> to my personal opinion, I think this is the best answer, at least the first part. The second part consist of negation, I would like a more positive description about when to use an evaluation. That is per example in the third part of your answer.
> 
> I like to thank all for your considerations shared on this mailinglist.
> 
> Best regards
> 
> Bert Verhees
> 
>  
> 
> On 10-04-17 09:46, Bakke, Silje Ljosland wrote:
> I think this is a case of putting too much weight into the names of the archetype classes. <>
>  
> Basically:
> ·         OBSERVATIONs are used when you need a point in time event (or series of them) or an interval event with or without a math function, ie want the same thing done over and over again with the same protocol, or you need to specify the patient state.
> ·         EVALUATIONs are used when you don’t need any of the above, and the use case doesn’t fit with ACTIONs, INSTRUCTIONs or ADMIN_ENTRY either.
> 
>  
> BMI is evidence that is reached by calculation of measurements, it’s not a clinical assessment. Based on the BMI, you could draw a conclusion that the person is obese, which would be recorded in an EVALUATION archetype (typically EVALUATION.problem_diagnosis).
>  
> Regards,
> Silje
>  
> From: openEHR-clinical [mailto:openehr-clinical-bounces at lists.openehr.org <mailto:openehr-clinical-bounces at lists.openehr.org>] On Behalf Of GF
> Sent: Monday, April 10, 2017 9:33 AM
> To: For openEHR clinical discussions <openehr-clinical at lists.openehr.org> <mailto:openehr-clinical at lists.openehr.org>
> Subject: Re: BMI archetype
>  
> My ‘definitions'
>  
> Observation: a result obtained by an author using human senses
> Calculation: a kind of Evaluation by a human or device using Observations and knowledge (rules, formula)
> Evaluation/assessment: Interpreting observations caused by processes using existing knowledge
> Diagnosis: Special case of Evaluation. The process pertains to processes in the Patient system.
> 
> Gerard   Freriks
> +31 620347088
>   gfrer at luna.nl <mailto:gfrer at luna.nl>
>  
> Kattensingel  20
> 2801 CA Gouda
> the Netherlands
>  
> On 10 Apr 2017, at 09:10, Pablo Pazos <pablo.pazos at cabolabs.com <mailto:pablo.pazos at cabolabs.com>> wrote:
>  
> from ehr_im
> 
> OBSERVATION (for all observed phenomena,including mechanically or manually measured, and responses in interview)
> My interpretation is automatic calculations are included in "mechanically measured".
> Also
> 
> EVALUATION (for assessments, diagnoses, plans, risks, recommendations)
> I don't see an evaluation in the execution of a numeric formula, but I can see it in the recording of an evaluation in terms of the result of executing the formula. Similar case the calculation of the mean systolic BP based on a series of events = 140 mmHg (is OBS), and stating "high BP" or "hypertension" is EV).
>  
> On Mon, Apr 10, 2017 at 3:55 AM, Bert Verhees <bert.verhees at rosa.nl <mailto:bert.verhees at rosa.nl>> wrote:
> Op 10-4-2017 om 8:52 schreef GF:
> I would say one needs both:
> Evaluation: when calculating by the author the BMI-number using existing weight/height data
> Observation: when reading/copying by the author aa a BMI-result from a source
> 
> Also a good argument ;-)
> 
> A good solution would then be, put it in a cluster, so it can be sticked into whatever is right for the situation.
> 
> 
> Bert
> 
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> 
> 
> --
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