Hi,
I am working on building a basic progress note with archetype data
elements. I am looking for the most appropriate archetype for the
standard 'Chief Complaint' that the patient presents with, perhaps in
the patients words, perhaps defaulting with the registration reason
for visit.
The best I can find is the "Clinical Description" under
openEHR-EHR-CLUSTER.health_event.v1
Let me know if this is not the right place for basic mapping questions
thanks!
Greg
We have used plain text: Queixa Principal is Chief Complaint in Portuguese.
ontology
term_definitions = <
["pt-br"] = <
items = <
["at0000"] = <
text = <"Queixa Principal">
description = <"*">
>
....
BEatriz
Greg Caulton wrote:
Hi,
I am working on building a basic progress note with archetype data
elements. I am looking for the most appropriate archetype for the
standard 'Chief Complaint' that the patient presents with, perhaps in
the patients words, perhaps defaulting with the registration reason
for visit.
The best I can find is the "Clinical Description" under
openEHR-EHR-CLUSTER.health_event.v1
Let me know if this is not the right place for basic mapping questions
thanks!
Greg
We have used plain text: Queixa Principal is Chief Complaint in Portuguese.
ontology
term_definitions = <
["pt-br"] = <
items = <
["at0000"] = <
text = <"Queixa Principal">
description = <"*">
>
....
BEatriz
Hi Beatriz,
Thanks for the reply. Was that plain text "Queixa Principal" field in
an archetype that you designed locally? Or is it in one of the
existing archetypes in the subversion/online repository?
As I build out my system I am importing the repository archetypes,
keeping the full path of each data element as a 'pointer' to the
archetype. As I understand it In order to support AQL and exchange
data we need to use the same archetypes in the same context.
thanks!
Greg
Sorry I forgot to mention that - it's an observation:
openEHR-EHR-OBSERVATION.triage_main_complaint.v1ao
included in one section:
openEHR-EHR-SECTION.emergency_triage.v1ao
that is part of our template of emergency assessment.
We have specialized and/or created several attributes to cope with our
needs.
I plan to write back to the group the modifications we did - just a
matter of finding time to do that. Most of what we've done it's to
change in the template either the combo content or to make a bind with a
local terminology.
Again that is the part we do not like in the model - since it's just an
URL - this is not enough to guarantee the semantic interoperability!
Where are you using it?
We have it deployed in a HIS running in Angola.
Cheers,
Beatriz
Greg Caulton wrote:
Date: Fri, 03 Oct 2008 09:45:30 -0300
From: BeatrizdeFariaLeao <bfleao@terra.com.br>
Subject: Re: Chief Complaint
To: For openEHR clinical discussions <openehr-clinical@openehr.org>
Message-ID: <48E613EA.4050107@terra.com.br>
Content-Type: text/plain; charset=ISO-8859-1; format=flowedSorry I forgot to mention that - it's an observation:
openEHR-EHR-OBSERVATION.triage_main_complaint.v1ao
included in one section:
openEHR-EHR-SECTION.emergency_triage.v1aothat is part of our template of emergency assessment.
We have specialized and/or created several attributes to cope with our
needs.I plan to write back to the group the modifications we did - just a
matter of finding time to do that. Most of what we've done it's to
change in the template either the combo content or to make a bind with a
local terminology.Again that is the part we do not like in the model - since it's just an
URL - this is not enough to guarantee the semantic interoperability!
Where are you using it?
We have it deployed in a HIS running in Angola.Cheers,
Beatriz
Right, I am writing an open source HIS which hopefully will start
hospital deployments in the spring. I am loading the official
archetypes to provide the core content and then anything I cannot map
I will assign a LOINC or SNOMED code and then map it to an archetype
later.
thanks for the info !
Greg
Hi Greg
I would have thought that it would be better to do it the other way around i.e. map everything to archetypes and worry about the coding later? Its a mistake to think that archetypes are just another way of coding things and that archetypes and coding systems are interchangeable,
regards Hugh
Greg Caulton wrote:
Hugh
When making the archetypes you use information from many different sources.
I believe that SNOMED CT is one of the sources that should be consulted.
It is useful to see how specific concepts are modeled in SNOMED CT in order to avoid incompatible modeling in the archetypes. Mapping to SNOMED CT does not necessarily have to be done in the first place, but attribute name and attribute value binding to SNOMED CT should be anticipated.
I believe that the combination of archetypes and a terminology is very powerful.
Knut
Hi Knut
I completely agree with you. I was pointing out that archetypes and terminology are not interchangeable, but that you need both for a complete solution to interoperability.
regards Hugh
Knut Bernstein wrote:
I agree. For countries that use Snomed indeed it's very useful. That is
not the caes of Brazil, or Angola or Mozambique..
B.
Knut Bernstein wrote:
SNOMED is also not very strong in Austria. I agree and also consider it to
be one of the major powers of archetypes to be a means of different
communities for capturing agreements on how to translate content from one
world to the other.
These agreements will be difficult to establish, but at least there is a
way.
See you,
Stefan Sauermann
Well, my point is not whether SNOMED CT is used in one country or another.
I am suggesting that when we are making the MODELING of archetypes, we
should look into SNOMED CT as one of the sources for understanding how the
modeling could be done.
A lot of effort has gone into the clinical modeling of SNOMED CT and it
seems unwise not to get inspiration from this work.
And - as a second point - when we eventually want to bind archetype
attribute names and values to a terminology, it will be much easier if the
archetype structures and the terminology structures are compatible.
Regards
Knut
-----Oprindelig meddelelse-----
Hi Knut
I think that SNOMED is one place to look for inspiration about modelling of archetypes, however I think that we need to remember that openEHR is an ontology of information and SNOMED is an ontology of reality. Each needs the other, however they are not always the same thing. We will get into a lot of trouble if we decide to create try to re represent SNOMED in archetypes.
regards Hugh
Knut Bernstein wrote:
Further to Hugh's point about "coding", I have posted an article on
Codes, EHRs and Semantic Interoperability at:
http://www.openehr.org/wiki/display/healthmod/Codes%2C+EHRs+and+Semantic+Interoperability
I suspect most clinicians equate coding with choosing terms from a
pick list from some vocabulary.
As an engineer, I have spent too much of my last 35 years wading
through (and sometimes drowning in) codes - from punched cards and
paper tape in the 70s, tracing machine instructions and data through
microprocessor circuits in the 80s, micro-formatting documents and web
pages in the 90s, and trying to fathom the madness of HL7 v3 codes
this century. From this experience I have, perhaps, a different
perspective.
I assume that the article is biased by my experiences. I welcome
others to contribute their perspectives or correct my errors.
regards,
eric browne