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Project Summary

Concern Tracking and Care statements provide a framework for tracking and managing health concerns, however there are many undefined relationships and representations that remain to be defined. Issues identified include.

  • Standard representation of how observations should be characterized (eg diagnosis vs problem)
  • Standard representation of distinction and linkage between provider roles in problem lists (eg nursing problems vs physician problems).
  • Standard representation of common attributes about a problem (eg clinical status, problem severity, etc)
  • Methods for adding diagnosis specific attributes (eg Cancer Stage, CHF Class,...)
  • Correct representation of problem modifiers and negation. (eg rule out MI, or history of MI vs AMI)
  • List maintenance issues in messaging. (eg send full list including history, send full list, but no history, only send updates for a concern)
  • Correct relationships terms for episode links and sub-concerns.
    • Multiple Related Episodes
      • Repeated Acute problems (eg, 2 bouts of community acquired pneumonia)
      • For exacerbations and remissions (eg, chronic asthma with multiple acute exacerbations )
    • Different levels of Granularity (eg, internist calls "CAD s/p CABG", cardiologist calls "2 vessel disease with LIMA to mid LAD, SVG to RCA")
    • Causality
      • Assumed in Term (eg Gestational Diabetes <- Pregnancy )
      • Manually Asserted (eg Diabetes & ESRD)
      • Therapy related (GI bleed while on Coumadin for Afib)
    • Others??

Artifacts and related modeling

todo:

  • add related articles
  • links/pointers to info from campbell, chute, elkin, va, terminfo

Use Cases

Implementors

Canada Infoway

Participants

  • Larry McKnight
  • John Kufuor-Boakye
  • Jim Campbell
  • Tom Oniki
  • Bob Dolin
  •  ? Kevin Coonan
  • William Goossen

Meetings/T-Conn's

The discussion from the list is deferred to this spot.

Discussion Area from the Patient Care list on Diagnosis label

Larry McKnight asked to make a summary, this is not the summary but William's start to make one.

May I suggest that all of you look back at your initial mails and include the questions, the answers and the discussions in this?


John stated the following:

"Since I started the thread, I like to recap (more than summarize) the various options and suggestions that have been put forward. First, I like to re-state the use-case that triggered a search for this label/name. It was to come up with a unifying concept for diagnoses, symptoms, and any other recordable finding that can be referenced by a healthcare provider (doctors, pharmacists, dentists, nurses, etc) as a reason for performing (indication) or not performing (contraindication) care provision activity on/for a patient.


Here is a list of names/labels that have been suggested for the concept:

- Problem - CareIndication - CareActivityIndication - CareActivityReason - CareProvisionReason - ClinicalFinding - ClinicalAssertion - Condition - ClinicalCondition - HealthIssue - HealthState

So far, there hasn’t been a consensus on the list as to which of the suggested name/label best describes the perceived concept domain. Personally, I tend to lean towards ‘CareProvisionReason’ (though the observation may be referenced as the reason for provisioning or not provisioning care) as an all-encompassing label for such a concept, but then, this is in the purview of the clinical domain experts.

Regards,

John Kufuor-Boakye"

Hi John,

I'm not thrilled with anything that has the word Reason or Indication in the name. Reason/Indication is the name of the relationship between the observation and the intended action. It's not a name for the observation itself. The observation is simply a statement of "The patient has X".


Lloyd

This is one discussion brought to our attention nov 3 08 by prof. Pieter de Vries Robbe from Nijmegen, NL:

Since the introduction of the problem oriented medical record by Weed in 1968 there are discussions about the term 'problem'. In our view the term is used by Weed for non medical 'diagnosis', for 'intermediate' diagnosis and for aspects of worry. For the intermediate diagnosis one can think of the evolving idea about the underlying problem. The worry things are just a list of things you want to pay attention to. For one doctor this can be another list than for another doctor. The underlying problem is patient specific and is of interest for one or more doctors.

The evolving idea of the underlying problem is modeled in HL7 by the ELNK. This evolving idea is not between different worries! Therefore we used the ELNK between different Conditions. About a condition or about a labtest result or about a procedure one can have a Concern. These concerns are doctor specific. Furthermore one can have an assertion about an underlying problem. This assertion is an idea on a specific moment. In that sense it is like a test result. Therefor we use Observation to represent assertions about Conditions. So in our view we need Observations, Conditions and Concerns with heir specified relationships. End quote:

Then Tom de Jong answered:

I agree about the ingredients (conditions, observations, concerns), but  with some comments:

* I would like a better definition of what a condition is and how it  relates to the other concepts. It is the most ambiguous term of the  three, which leads to recurring discussions.

* I would like a split between two broad branches of observations:  tests versus assertions. I agree that an assertion is an observation,  but so is a condition (in the current RIM). Yet, I do feel they are
semantically distinct enough to warrant a separate class code.

* I disagree with your statement that a Concern is doctor-specific. In  the way Concern is used in the current Patient Care materials, it is  specifically overarching, linking the observations (and other acts)
from different doctors to a common underlying problem.

So it seems we disagree about the hierarchy between Condition and  Concern... I think if we would ask 10 Patient Care gurus, they would  give 5 different definitions of both, and they wouldn't agree on the  hierarchy either. That is exactly where we need consensus...fast.

End Tom's quote.

Comment by William:

We have agreed already that a Concern is not an observation. And we have agreed that a Concern is not professional specific. However, one question would then be: how does a concern start? Well that is the perspective of one clinician starting the thread because she/he worries.

In the DSTU it is now an R-MIM A_ConcernTracking(REPC_RM000300UV01)for which Concern is defined as: "....Concern Class as result of harmonization work: An interest or focus of attention that tends to persist over time and has as a subject a state or process. The subject of the interest or focus of attention has the potential to require intervention or management."

This implies not only Pieter's 'worrying', but also the imperative for the health professional to 'do something about it'.


"

Project Committee Overlaps and Dependency

  • Orders and Observations
  • Structured Doc
  • Term Info
  • M&M