thomas.beale at openehr.org
Wed Apr 26 11:58:37 EDT 2017
On 12/04/2017 08:07, GF wrote:
> So briefly, the types are:
>> * Observation - data gathered, including what is called
>> 'subjective' data, e.g. patient-reported pain. It is assumed that
>> both manual and machine means are used to gather data, and that
>> the data may be of unlimited complexity. However, the data are
>> 'about' the one individual, i.e. the patient (patient's kidney,
>> skin, CV system, etc)
> This analogous to my definition of Observation.
> It has the next set of characteristics:
> - data obtained
> - using human senses
presumably you agree that use of instruments is included as augmenting
human senses. Not forgetting that many instruments these days can
generate data that the physician doesn't even see until it is in the
EMR, and they only see it as the result of a query on the EMR.
> - about phenomena as the result of processes in the patient system
> - in addition observations, evaluations, plans, orders and actions can
> pertain to other processes also, including administrative processes
> This implies that sources (third parties other that the author)
> produce data about the patient system that potentially can be
> observed by the author.
> Until observed this existing data exists in the EHR as observable.
> When the author really observes it the status is transformed from
> ‘observable' into ‘observed’. Meaning that there was a conscious
> action by a person to admit it to the patient record.
if I understand correctly, you are talking about some sort of 'signing
off' by the physician of data generated by devices and/or other people?
I think that in general, the act of committing data to the EHR by the
physician performs this task. ANd he/she can add an attestation in
openEHR, if they really want to say that so-and-so agreed with the data.
Otherwise you are talking about data coming from different sources like
the patient and direct data pathways from devices into the EHR. In the
case of the patient it may be that the physician will attest to some of
it, but I think it is unrealistic to require that in all cases -
generally, patients who collect data on themselves do so more reliably
than doctors. The audit trail always marks it as patient-supplied data,
so it can always be filtered out.
>> * Evaluation - inferences made by human mind or machine, by
>> comparing the individual data to the current knowledge base -
>> i.e. standard medical knowledge, diagnostic guidelines, etc - any
>> knowledge that is 'about' categories, e.g. 'patient with high
>> BP', 'patient with raised blood glucose 2h after challenge', etc.
>> These can be understood as some kind of 'opinion', since there
>> can always be errors in matching the observation to the
>> knowledge, or even knowing which observations matter and so on
>> (think: episodes of House). Typical clinical words for Evaluation
>> are 'assessment', 'diagnosis', but even just identifying a
>> 'problem' is a kind of evaluation. An evaluation that has been
>> made can be considered some kind of clinical decision on which
>> actions can be based.
> I agree, but extend it to the execution of rules, algorithms, using
> observed data. I consider it an assessment of existing data.
I think that's reasonable, and that's generally what protocol should be
used for on the EVALUATION class in openEHR.
> Many times just the result of an Evaluation is used and therefor will
> be observed as Observation.
I don't understand this - how can an Evaluation 'be observed'?
> The Evaluation will document the calculation documenting the method used.
> The Observation will document the noticing of he result only.
> References might point at the calculation
again I think you are talking about an attestation of some kind, not an
>> * Instruction - request to various actors to perform specific
>> actions, based on the Evaluation(s), typically medications, other
>> therapies, education, further observation.
> I have as additional Entry the Planning of Instructions and Actions
right. We aren't currently modelling this as a kind of ENTRY but there
is now a draft model
of it for openEHR.
>> * Action - record of actions actually performed.
>> * Admin_entry - record of administrative statements recording
>> passage of patient around the care system
> I see no need to have this kind of Entry since all kinds of Entry
> pertain to processes and/or phenomena of processes, among which the
> processes in the Patient System.
if you mean Admin_entry, well it has proven to be very useful to have
separately from the clinical process Entries in the EHR.
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