Intentionality of Act and the Future of Observations
There were discussions at the last few HL7 modeling harmonization events regarding a revision on the way we think about acts.
Here is a fragment of the Act Definition:
Acts are the pivot of the RIM; all domain information and processes are represented primarily in Acts. Any profession or business, including healthcare, is primarily constituted of intentional actions, performed and recorded by responsible actors. An Act-instance is a record of such an intentional action. Intentional actions are distinguished from something that happens by forces of nature (natural events). Such natural events are not Acts by themselves, but may be recorded as observed (Observation).
Some questions that came up are:
- Is an accidental administration of insulin to a patient a SubstanceAdministration, can it be called an "intentional action"?
- Is a snake bite or bee sting a SubstanceAdministation, can it be called an "intentional action"?
- Is a gun-shot bullet a SubstanceAdministration?
- An abdominal surgecy is a Procedure, is someone stabbing a knife performing a procedure? Is it an intentional action?
- Is a car accident an intentional action?
The Proposal has been to remove the requirement for Acts to be called intentional, and instead say that a snake bite can be called a substance administration, someone stabbing me with a knife is performing an Act, and a gun-shot hitting me in a cross-fire is also an Act. Car accident is an act as well and so is me being hit by a lightning strike.
So, all distinctions between acts that are ordered scheduled and billed for vs. those events of nature would go away. When the Act class was still called "Service" this kind of change was unthinkable, now it is a notion that is seriously entertained.
The reason why people want this change is that it allows them to use the Act attributes and participations (time, performer, etc.) to describe any incident just like acts.
Points of Concern
The downside of this is that it causes a great shift in the modeling of Observations. In the past, people would use Observations to describe events of nature, and unintended incidents such as gunshot wounds or car accident injuries. In fact there is still a sizable group of people who would like to think of procedure history (e.g., appendectomy 20 years ago) as an Observation in a collection of "patient history" Observations. I think the RIM was trying to make that appendectomy a Procedure regardless of whether it is recent and known from first hand reports or if it is only known through patient recollection or even hearsay. But now we would be moving even more information items that used to be understood as Observations over into being other specific Acts such as Procedures or SubstanceAdministrations.