Revise, Clarify and Fix the Goal, Outcome, and Intent Relationship Types and Moods

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PROPOSAL STATUS: NEW (in draft process)

Recommendation for HL7 RIM Change	RECOMMENDATION ID:
Submitted by: Gunther Schadow	Revision (# and date): 1
Date submitted: 20060314	Committee status: open
Submitted by: Gunther Schadow
NAME: Revise, Clarify and Fix the Goal, Outcome, and Intent Relationship Types and Moods

Stewards Position

REQUIRED - This table should contain one row for each Steward Committee affected by the recommendation.

TC	RECOMMENDATION APPROVAL STATUS	AFFECTED ENTITIES OF INTEREST TO TC (responsibility level: S=Steward; I=Interested)
O&O	Unknown	I
MnM	Requested	I

Issue

There is broad misunderstandings about Goals, Risk, Expectation, Prognosis, Intents in both the ActMood code as well as in the ActRelationship type code. Recent change actions have aggravated the problem rather than solve it.

The main questions are:

(1) What is the difference beteen a Goal and an Intent?

(2) What is the difference between a Goal and an Objective?

(3) What is the difference between the Goal relationship and the Goal mood?

(4) Isn't there some funny dependency between relationship types for Goal and Risk and moods of Goal and Risk?

Original State

ActMood

*ActMoodIntent	*INT	intent	An intention or plan to perform a service. Historical note: in previous RIM versions, the intent mood was captured as a separate class hierarchy, called Service_intent_or_order.
**(PRMS)	**PRMS	promise	An intent to perform a service that has the strength of a commitment, i.e., other parties may rely on the originator of such promise that said originator will see to it that the promised act will be fulfilled. A promise can be either solicited or unsolicited.
**(PRP)	**PRP	proposal	A non-mandated intent to perform an act. Used to record intents that are explicitly not Orders. Professional responsibility for the 'proposal' may or may not be present.
**(RQO)	**RQO	request	A request or order for a service is an intent directed from a placer (request author) to a fulfiller (service performer). [...]
ActMoodPredicate			Any of the above service moods (e.g., event, intent, or goal) can be turned into a predicate used as a criterion to express conditionals (or queries.) However, currently we allow only criteria on service events.
*(EVN.CRT)	*EVN.CRT	event criterion	A criterion or condition over service events that must apply for an associated service to be considered.
*(GOL)	*GOL	Goal	Expectation to make a specific observation with a desired value at a predefined future time
*(OPT)	*OPT	option	An option is an alternative set of property-value bindings. Options specify alternative sets of values, typically used in definitions or orders to describe alternatives. An option can only be used as a group, that is, all assigned values must be used together. Historical note: in HL7 v2.x option existed in the special case for alternative medication routes (RXR segment).

ActRelationship Type

*ActRelationshipOutcome	*OUTC	has outcome	An observation that should follow or does actually follow as a result or consequence of a condition or action (sometimes called "post-conditional".) Target must be an observation as a goal, risk or any criterion. For complex outcomes a conjunction attribute (AND, OR, XOR) can be used. An outcome link is often inverted to describe an outcome assessment.
* ActRelationshipObjective			The target act is a desired outcome of the source act. Source is any act (typically an intervention). Target must be an observation in criterion mood.
**(OBJC)	**OBJC	has continuing objective	A desired state that a service action aims to maintain. E.g., keep systolic blood pressure between 90 and 110 mm Hg. Source is an intervention service. Target must be an observation in criterion mood.
**(OBJF)	**OBJF	has final objective	A desired outcome that a service action aims to meet finally. Source is any service (typically an intervention). Target must be an observation in criterion mood.
*(GOAL)	*GOAL	*has goal	A goal that one defines given a patient's health condition. Subsequently planned actions aim to meet that goal. Source is an observation or condition node, target must be an observation in goal mood.
*(RISK)	*RISK	*has risk	A noteworthy undesired outcome of a patient's condition that is either likely enough to become an issue or is less likely but dangerous enough to be addressed.

Answers to the Questions Till Date

In the literature on Artificial Intelligence, Agents, and Planning, one finds the word "Goal" used as a state in the system that the system needs to achieve by planning and eventually executing actions. These agents work by working on goals until the goal is reached, and then removing the goal from the list of outstanding goals.

Intentions and promises have been proposed for Multi-Agent Systems as such system states too, so they are on the goal list and once they have been accomplished they are removed from the goal list.

Clearly there are different kinds of goals, such as the goal of a classical blocks-world planning problem vs. goals that are asserted by means of a promise. In HL7 we distinguish these different kinds of goals. On the top level we distinguish outcome goals from process goals. Process goals are what we want to do, and outcome goals are what we want the world to look like. The outcome goals may be related to our actions. When speaking of goals, we also realize that we can speak of risks (undesirable situations) and expectations (predicted situations), which are not goals. In the sense of AI agent planning they might be thought of as penalties for possible actions or avoidance-goals.

The following hierarchical list attempt to map out the space completely:

• outcome goals

situation (target) which may arise from actions or a prevalent situations (source)

• • outcome of actions

situation (target) which may arise from an action (source)

• • • objectives of action

situation (target) which is desired to arise from an action (source)

• • • • final objective

situation (target) which is desired to arise at the end of an action (source) example: provide ambulation training until ambulation level is restored

• • • • maintenance objective

situation (target) which is desired to arise from continuing the action (source) example: administer dobutamine to raise blood pressure to 90 mmHg

• • • [expectation of an action]

situation (target) which is expected to arise from an action (source)

• • • [risk (adverse effect) of an action]

situation (target) which is un-desired to arise from an action (source) example: administering drug X may causes agranulocytosis

• • outcome of situations

situation (target) which may arise from a prevalent situations (source)

• • • outcome goal regarding a situation

situation (target) which is desired to arise from a prevalent situations (source) example: hemiparesis for which we have a goal of ambulation at a certain level

• • • [expectation regarding a situation]

situation (target) which is expected to arise from a prevalent situations (source) example: permanent hemipareis from cerebral infarction

• • • [risk regarding a situation]

situation (target) which is un-desired to arise from a prevalent situations (source) example: acute myocardial infarction with risk of ventricular tachycardia

• • outcome goal independent of action or prevalent situation

situation which may arise (without regards to any action or prevalent situation)

• • • outcome goal independent of action or prevalent situation

situation which is desired to arise example: increase patient mobility to a certain level

• • • [expectation independent of action or prevalent situation]

situation (target) which is expected to arise example: increase patient mobility to a certain level

• • • [risk independent of action or prevalent situation]

situation (target) which is un-desired to arise example: patient is suicidal

• process goal

• • process goal

action which is desired to be performed

• • • process plan

action which is desired to be performed example: plan intubation (to manage pCO2)

• • • process request

action which another agent is asked to perform example: order intubation (to manage pCO2)

• • • process promise

action which is committed to be performed example: confirm consultation

• • • process proposal

action which is considered to be performed example: propose intubation (to manage pCO2)

• • • [process expectation]

action which is expected to be performed example: we probably will intubate (to manage pCO2)

• • • [process risk]

action which is un-desired but nevertheless may have to be done example: we might unfortunately have to intubate (if we cannot improve pCO2)

Recent Changes to Act Mood

*(GOL)	*GOL	Goal	Definition: An observation that is considered to be desirable to occur in the future. The essential feature of a goal is that if it occurs it would be considered as a marker of a positive outcome or of progress towards a positive outcome. Examples: Target weight below 80Kg, Stop smoking, Regain ability to walk, goal is to administer thrombolytics to candidate patients presenting with acute myocardial infarction. Discussion: INT (intent) reflects a plan for the future, which is a declaration to do something. This contrasts with goal which doesn't represent an intention to act, merely a hope for an eventual result. A goal is distinct from the intended actions to reach that goal. "I will reduce the dose of drug x to 20mg" is an intent. "I hope to be able to get the patient to the point where I can reduce the dose of drug x to 20mg" is a goal. EXPEC (expectation) reflects a prediction rather than a hope. RSK (risk) reflects a potential negative event rather than a hope.
*(RISK)	*RISK	Risk	Definition: An act that may occur in the future and which is regarded as undesirable. The essential feature of a risk is that if it occurs this would be regarded as a marker of a negative outcome or of deterioration towards a negative outcome. Recording a risk indicates that it is seen as more likely to occur in the subject than in a general member of the population but does not mean it is expected to occur. Examples: Increased risk of DVT, at risk for sub-acute bacterial endocarditis, Discussion: Note: An observation in RSK mood expresses the undesirable act, and not the underlying risk factor. A risk factor that is present (e.g. obesity, smoking, etc) should be expressed in event mood. INT (intent) reflects a plan for the future, which is a declaration to do something. This contrasts with RSK (risk), which is the potential that something negative will occur that may or may not ever happen. GOL (goal) reflects a hope to achieve something. EXPEC (expectation) is the prediction of a positive or negative event. This contrasts with RSK (risk), which is the potential that something negative will occur that may or may not ever happen, and may not be expected to happen.
*(EXPEC)	*EXPEC	expectation	Definition: An act that is considered likely to occur in the future. The essential feature of an act expressed in expectation mood is that it is likely to occur. An expectation may be desirable, undesirable or neutral in effect. Examples: Prognosis of a condition, Expected date of discharge from hospital, patient will likely need an emergency decompression of the intracranial pressure by morning. Discussion: INT (intent) reflects a plan for the future, which is a declaration to do something. This contrasts with expectation, which is a prediction that something will happen in the future. GOL (goal) reflects a hope rather than a prediction. RSK (risk) reflects a potential negative event that may or may not be expected to happen.

Recommended Action Items

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