BMI archetype

Clinical (archive)
21

Good story. Thx
Bert

22

see below

Gerard Freriks
+31 620347088
gfrer@luna.nl

Kattensingel 20
2801 CA Gouda
the Netherlands

For those who are interested in the background…

the underlying design of the Entry types were the result of an epistemological analysis of kinds of information that could be generated in clinical work. That required an analysis of the ‘clinical cognitive loop’ as I now think of it, which is similar to a scientific investigation (theory building), but goes further and then intervenes in reality, based on the theory of what is going on.

So briefly, the types are:

  • Observation - data gathered, including what is called ‘subjective’ data, e.g. patient-reported pain. It is assumed that both manual and machine means are used to gather data, and that the data may be of unlimited complexity. However, the data are ‘about’ the one individual, i.e. the patient (patient’s kidney, skin, CV system, etc)

This analogous to my definition of Observation.
It has the next set of characteristics:

  • data obtained
  • using human senses
  • about phenomena as the result of processes in the patient system
  • in addition observations, evaluations, plans, orders and actions can pertain to other processes also, including administrative processes

This implies that sources (third parties other that the author) produce data about the patient system that potentially can be observed by the author.
Until observed this existing data exists in the EHR as observable.
When the author really observes it the status is transformed from ‘observable’ into ‘observed’. Meaning that there was a conscious action by a person to admit it to the patient record.

  • Evaluation - inferences made by human mind or machine, by comparing the individual data to the current knowledge base - i.e. standard medical knowledge, diagnostic guidelines, etc - any knowledge that is ‘about’ categories, e.g. ‘patient with high BP’, ‘patient with raised blood glucose 2h after challenge’, etc. These can be understood as some kind of ‘opinion’, since there can always be errors in matching the observation to the knowledge, or even knowing which observations matter and so on (think: episodes of House). Typical clinical words for Evaluation are ‘assessment’, ‘diagnosis’, but even just identifying a ‘problem’ is a kind of evaluation. An evaluation that has been made can be considered some kind of clinical decision on which actions can be based.

I agree, but extend it to the execution of rules, algorithms, using observed data. I consider it an assessment of existing data.
Many times just the result of an Evaluation is used and therefor will be observed as Observation.
The Evaluation will document the calculation documenting the method used.
The Observation will document the noticing of he result only. References might point at the calculation

  • Instruction - request to various actors to perform specific actions, based on the Evaluation(s), typically medications, other therapies, education, further observation.

I have as additional Entry the Planning of Instructions and Actions

  • Action - record of actions actually performed.
  • Admin_entry - record of administrative statements recording passage of patient around the care system

I see no need to have this kind of Entry since all kinds of Entry pertain to processes and/or phenomena of processes, among which the processes in the Patient System.

23

So briefly, the types are:

  • Observation - data gathered, including what is called ‘subjective’ data, e.g. patient-reported pain. It is assumed that both manual and machine means are used to gather data, and that the data may be of unlimited complexity. However, the data are ‘about’ the one individual, i.e. the patient (patient’s kidney, skin, CV system, etc)

This analogous to my definition of Observation.
It has the next set of characteristics:

  • data obtained
  • using human senses

presumably you agree that use of instruments is included as augmenting human senses. Not forgetting that many instruments these days can generate data that the physician doesn’t even see until it is in the EMR, and they only see it as the result of a query on the EMR.

  • about phenomena as the result of processes in the patient system
  • in addition observations, evaluations, plans, orders and actions can pertain to other processes also, including administrative processes

This implies that sources (third parties other that the author) produce data about the patient system that potentially can be observed by the author.
Until observed this existing data exists in the EHR as observable.
When the author really observes it the status is transformed from ‘observable’ into ‘observed’. Meaning that there was a conscious action by a person to admit it to the patient record.

if I understand correctly, you are talking about some sort of ‘signing off’ by the physician of data generated by devices and/or other people? I think that in general, the act of committing data to the EHR by the physician performs this task. ANd he/she can add an attestation in openEHR, if they really want to say that so-and-so agreed with the data.

Otherwise you are talking about data coming from different sources like the patient and direct data pathways from devices into the EHR. In the case of the patient it may be that the physician will attest to some of it, but I think it is unrealistic to require that in all cases - generally, patients who collect data on themselves do so more reliably than doctors. The audit trail always marks it as patient-supplied data, so it can always be filtered out.

  • Evaluation - inferences made by human mind or machine, by comparing the individual data to the current knowledge base - i.e. standard medical knowledge, diagnostic guidelines, etc - any knowledge that is ‘about’ categories, e.g. ‘patient with high BP’, ‘patient with raised blood glucose 2h after challenge’, etc. These can be understood as some kind of ‘opinion’, since there can always be errors in matching the observation to the knowledge, or even knowing which observations matter and so on (think: episodes of House). Typical clinical words for Evaluation are ‘assessment’, ‘diagnosis’, but even just identifying a ‘problem’ is a kind of evaluation. An evaluation that has been made can be considered some kind of clinical decision on which actions can be based.

I agree, but extend it to the execution of rules, algorithms, using observed data. I consider it an assessment of existing data.

I think that’s reasonable, and that’s generally what protocol should be used for on the EVALUATION class in openEHR.

Many times just the result of an Evaluation is used and therefor will be observed as Observation.

I don’t understand this - how can an Evaluation ‘be observed’?

The Evaluation will document the calculation documenting the method used.
The Observation will document the noticing of he result only. References might point at the calculation

again I think you are talking about an attestation of some kind, not an observation.

  • Instruction - request to various actors to perform specific actions, based on the Evaluation(s), typically medications, other therapies, education, further observation.

I have as additional Entry the Planning of Instructions and Actions

right. We aren’t currently modelling this as a kind of ENTRY but there is now a draft model of it for openEHR.

  • Action - record of actions actually performed.
  • Admin_entry - record of administrative statements recording passage of patient around the care system

I see no need to have this kind of Entry since all kinds of Entry pertain to processes and/or phenomena of processes, among which the processes in the Patient System.

if you mean Admin_entry, well it has proven to be very useful to have separately from the clinical process Entries in the EHR.

  • thomas