Clinical Context

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Introduction

Clinical data always is obtained within a complex clinical context. Knowledge of the clinical context is essential to safe, accurate, and otherwise appropriate interpretation and understanding of the data. Clinical data, when properly associated with its context, becomes clinical information.

For example, interpretation of even a simple clinical data entry requires extensive knowledge of the complex to interpret. Consider an observation of heart rate collected 2013-07-02@1446 of 68 BPM. It is impossible to know the meaning of this (normal, abnormal, too high, too low) without the surrounding context of patient age, clinical condition, interventions (e.g. IABP, dose of epinephrine or esmolol), rhythm, orientation in regards to gravity, methodology (surface ECG, auscultation, pulse oximetry, arterial line, non-invasive oscillometric BP cuff, or palpation of a peripheral artery). In particular, the various methods can, and do, yield different results, esp. in patients who are not in sinus rhythm. Noting any discrepancy would be of great importance, but not evident from the single value. Even noting a second reading 2013-07-02@1451 of 148 BPM doesn't tell you much other than you can note a change. This change may represent a recovery from a serious bradycardic episode in a 6 week old, a sudden tachycardia in an elderly person with an esophageal variceal bleed, variability in someone w/ non-rate controlled atrial fibrillation, or a change in method where poorly conducted beats not appreciable at the radial pulse are evident on surface ECG.

Plan

This will be part of the work done with the Care Record project, which should be scoped and a PSS created in conjunction with the Sept 2013 or Jan 2014 WGM.