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This is a work in progress and frequent changes are likely.  This should NOT be taken as final or the actual direction with workgroup is taking.
 
This is a work in progress and frequent changes are likely.  This should NOT be taken as final or the actual direction with workgroup is taking.
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''Please use the discussion tab for commenting, questions, and the like.  Edits to this page should focus on content which is expected to be balloted.'''''
 
''Please use the discussion tab for commenting, questions, and the like.  Edits to this page should focus on content which is expected to be balloted.'''''
  

Latest revision as of 17:28, 31 October 2013

This is a work in progress and frequent changes are likely. This should NOT be taken as final or the actual direction with workgroup is taking.


Please use the discussion tab for commenting, questions, and the like. Edits to this page should focus on content which is expected to be balloted.


Definition

A condition is an Observation about the patient or

Types of Conditions

Previous discussions have been principally focused on specific uses of a Condition, rather than the general concept of the Condition itself. The concept of a Condition has broadened as new use cases are examined which use the Clinical Statement.

Disorder

This is the prototypical Condition. It is an instance of an Observation Event, typically with a healthcare provider as author. If active, these provide a good deal of the content for a Problem List, which is a dynamically generated list of active Health Concerns (or perhaps their naming Conditions?) based on specific criteria. There is no restriction that it must be a disease (or the concept of disease could be expanded to include a wide range of abnormal situation). Family and social issues would be represented using the disorder model. In addition, it need not be an identified disease. It could be a sign, symptoms, or abnormal screening or diagnostic study. There is also no reason why a patient, cannot create a new disorder-type Health Concern.

It typically, but not always, represents some identified disease process in a patient. The Disorder need not be in the record target. For example, the subject may be a fetus in utero. It could be a family member with some health related (including psychosocial issues) problem which impacts the patient (record target), e.g. pertussis in the the sibling of an infant. (In all likelihood this would include the disorder with the sibling as the subject, and a 'risk for pertussis would be a related naming condition. [see below])

There is an identified need to be able to specify the clinical status of a condition. This is distinct from the status of any model element in an EHRS (i.e. Condition.statusCode isn't used for this).

In prior discussions, there was a need to name the reason for some health care action. Names suggested included: - Problem - CareIndication - CareActivityIndication - CareActivityReason - CareProvisionReason - ClinicalFinding - ClinicalAssertion - Condition - ClinicalCondition - HealthIssue - HealthState

To this one might add 'Diagnosis'.

Once a disorder has resolved, it is still maintained as a Health Concern. The information regarding it remains the same. However, conditions with a clinical status of "resolved" would likely appear in the generation of a Past Medical History

Infectious Disease

Communicable diseases have specific aspects (e.g. contacts, isolation precautions, etc.)

Exposure or Ingestion

Exposures (ingestions, inhalation, etc.) to toxic substances requires specifications to represent the dose, agent(s), duration, etc.

Injury

Injuries have detailed specifications regarding the mechanism of injury, use of safety measures/equipment, estimation of forces, etc.

Malignancy

Cancer is a diverse family of complex disorders requiring detailed assessments of disease stage, functional status, response to therapy, associated symptoms (either from the neoplasm or from therapy), and estimation of tumor burden

Therapeutic Immunosuppression

There are a wide range of agents used to selectively inhibit the immune response used for a host of disorders. Often the level of immunosuppression is variable (e.g. asthmatic who requires several days of corticosteroids a few times a year). There are details of associated risks of malignancy, endocrine disorders, and opportunistic infections which often are distinct for each regimen. These specific items would be represented as Risks.

Therapeutic Anticoagulation and Antithrombosis

Another example of a treatment resulting in what otherwise would be considered a disorder. Often laboratory testing is done to monitor status, and relationships to bleeding episodes.

Propensity to Adverse Reaction to Substance

Medication allergies and allergies to shellfish, latex, tape adhesives, as well as adverse reactions which are expected to recur with repeated exposure require monitoring. These fall under the broader scope representing a propensity to adverse reactions to a substance. This has an associated Risk (i.e. what is expected to happen if exposed to the substance, or other substances sharing some critical similarity). Documentation of specific reactions would follow the general pattern for a Condition, but would have a link as the manifestation of the chronic Propensity to Adverse Reaction to Substance. See the Allergy Project for current work on domain analysis, and progress on RIM-based information modeling.

Symptoms (Including Pain)

Symptoms follow the same general pattern for disorders and have similar requirements for tracking the current degree and frequency of a symptom. There is a growing awareness of the need for palliation of these, often managed as a separate issue with its own Care Plan from any underlying etiology. Chronic pain is a major cause of disability, and careful monitoring is essential for proper care. The extremes of pain management (e.g. the recognition of oligoanalgesia in the 1990s to the widespread use of opioids for pain control for non-cancer pain currently causing great alarm due to the associated increase in fatal overdoses) demonstrate the need for careful documentation. In addition, many symptoms have an associated impairment of functional status. This association is crucial for determination of a Care Plans therapeutic endpoints and for assessing response to therapy.

Presenting Problem and Chief Complaint

This can include specific items such as the Chief Complaint, Presenting Problem, but not the Reason for Visit. These have been defined [ref]. The Chief Complaint is the narrative account of what a patient stated (or perhaps even entered themselves) as the symptoms or other disorder related aspects. It may include translations. An encounter will have [0..*] chief complaints. Some encounters are specifically based on a healthcare process (i.e. some procedure) in a patient without any complaints. E.g. immunization of a healthy patient or medical clearance for incarceration/jail. These procedures are the Reason for Visit and would not be maintained as part of a Health Concern, as they are part of a Care Plan. They typically will have another Condition as the reason. The Presenting Problem and Chief Complaint also has specific links to patient encounter(s) not typically found in other conditions. This isn't to say that something which is a chronic condition cannot be the reason for visit--it just needs to be identified as such.

Risk

One type of Conditions, very similar to disorders, is an assertion that the subject (patient, fetus, family, etc.) is at risk for some specified undesirable stat (Observation Risk). This is not an assertion of a risk factor (these typically are disorders), but it likely will have associations (interpretation) with risk factors which support the determination of some risk.

Future systems may in fact have hundreds, if not thousands, of risks which are tracked and quantified. One can envision a design where a system instantiates a list of risks faced by every person (likely customized by a clinical decision support system, and hopefully quantified, when possible) simply by nature of being born, e.g. risk of traumatic brain injury, risk of pneumonia, risk of diabetes, risk of meningitis, risk of athlete's foot, risk of malaria, risk of child abuse, risk of fatal or disabling motor vehicle collision, etc. etc In practicality, implementer would likely limit the risks to those which will have some sort of associated Care Plan.

E.g. there is considerable attention paid in childhood to educating the child and parents, as well as adolescent and adults, about measures to mitigate risks, e.g. use of helmet whenever the child is on a bike, skates, or using any other self-propelled wheeled device; immunization against HiB, pneumococcus and meningococcus; keeping patient active and on a healthy diet; initiation of malaria prophylaxis based on individuals travel plans (or seasons when EHRS is used in endemic regions); discussions on parenting skills, education on risks associated with shaken baby, and assessment for maternal depression or significant stressors in any adult caring for an infant; and counseling patient on use of proper restraints in motor vehicles. While human clinicians may have difficulty navigating hundreds to thousands of risks, an EHRS could be designed to automate the monitoring of these, capture needed data (from patient record, public health reports, etc.) and maintain vigilance. If the risk of some disorder reaches some threshold (likely based on the severity of the disorder as well as the probability) it could be surfaced in a problem list by the EHRS software.

The actual value of a Risk would be expressed as a probabilistic or uncertain range. Even if the probability isn't known, or is only approximate (e.g. low v. high), then terminology can help specify the qualification.

Specific Risk Circumstances

Many disorder risks are routinely monitored, screened, and prophylaxed. Many of these have distinct aspects and requirements of subsequent information models (i.e. have a known pattern of specific associated information) which warrant discussion and consideration. Not all of these may result in a different model at the RMIM level, but would have distinct requirements for implementation (e.g. specified as templates).

Risk for Complication of Therapy

There are many therapies which have specific, known, risk of complications. Each of these will require monitoring and surveillance. This includes surgical procedures, medications, radiation therapy and other interventions on the patient's behalf. It is likely that all Care Plans have one or more risks of complications or adverse outcomes.

Risk of Infectious Disease

All humans have a risk of a wide range of infectious disease. Traditionally, these are not accounted for in patient record systems. As mentioned above, it is well within the capability of an electronic health record system to monitor and track the specific risks for a relevant set (which may be quite large) of infectious disorders. These risks would vary upon a host of patient behaviors, travel, occupation, avocation/hobby, active and passive immunization, chemoprophylaxis, barrier measures, disease prevalence, population size and activity of vectors, diet, and countless other aspects of human life and clinical care. Ongoing estimation of these risk could be calculated regularly (daily?) if one assumes that patients will be able to supply the needed detail (e.g. via a personal health record system which communicates with an electronic health record system), along with inputs from public health officials, local infection control, "flora" of a given facility or community, and possibly even news feeds.

Risk of Cardiovascular Disease

Cardiovascular disease (including, but not limited to, stroke, myocardial ischemic disorders, cardiomyopathies, heart failure, valvular disease, peripheral vascular disease, aortic aneurysms) are the leading cause of death in developed countries. Great efforts are made within the healthcare system to reduce these risk. Primary and secondary prevention are specific types of Care Plans which address the specific risks.

Risk of Cancer

In the US, malignant neoplasms are the second leading cause of death. Various cancers have different risk factors and many are actively screened for via a range of methods (usually exam and diagnostic studies).

Risk of Injury

Injuries are the major cause of death in children, adolescents, young adults and adults. Each age group, along with other factors (substance use, occupation, sports, avocations/hobbies, domestic violence/abuse) and diseases, has a pattern of common injuries. Interventions (Care Plans) to mitigate these risks are common and useful. Addressing risks of injury is a routine component of pediatric anticipatory guidance, as well as being a topic commonly addressed with the elderly.

Barrier to Care

Patient Preference

Pregnancy

Health Maintenance

Child Development

Transplant

Monitoring a graft, be it bone marrow, pancreatic islet cells or solid organs require a range of specific monitoring as well as being the reason for one or more transplant specific Care Plans.