# [Dcm] terminfo meeting room requirements/Planning for Phoenix **Category:** [Clinical (archive)](https://discourse.openehr.org/c/clinical-archive/153) **Created:** 2008-06-04 15:19 UTC **Views:** 2 **Replies:** 40 **URL:** https://discourse.openehr.org/t/dcm-terminfo-meeting-room-requirements-planning-for-phoenix/14983 --- ## Post #1 by @Stef_Verlinden1 Dear all, The way I see it DCM could be very useful is when it truly separates clinical domain knowledge from technical issues such as the modelling to a certain reference model and/or standard. Which doesn’t mean that these technical aspects shouldn’t be addressed as well. Only it should be a separate discussion. From the health care professional (HCP) perspective it’s important to have an, as broad as possible (and independent of technique), agreement on: - what is the relevant information per clinical domain that needs to be stored and shared between all HCP involved - the cardinality for each information item that could be acquired - the constraints for that information - which coding/ value sets are to be used? - If and if yes, which codes (Snomed, ICD, IPC, OID, etc.) are attached to each information item In order to avoid “double entrance”(i.e. similar data is captured in more than one archetype/ (clinical) template/ etc.) guidelines should be present to determine how large/small each clinical domain should be. With regard to this issue, one should clearly separate the separate findings, from the protocols or methods used to interpret these findings (see my second question below). Another important issue is whether these clinical domains could be used for decision support and/or to support workflow management. In order to do so it’s essential that free text entrance is avoided as much as possible. This than could lead to a method and tools to verify, validate. asses the quality and/or perform quality control. Separately agreement should be reached on (and supersets should be created which can be used for) harmonising the standards/ reference models, which could be used to model the ‘independent’ clinical domains. First question: do others share this view? My second point is about the optimal ‘size of a clinical domain. My feeling is that we tend to create clinical domains that are ‘too large’ which can lead to more or less similar information that is stored in two different archetypes/(clinical)templates/ DCM’s. Let me try to explain this with an example. While looking at the ZIM website (which is unfortunately only in Dutch), the following struck me. There are 2 separate ZIM’s which are used to record more or less similar information. One is the Barthel index the other one the ADL (activities of daily life) index. (So far I only could find an observation.barthel archetype and here one can see the same as in the Barthel ZIM but since there seems to be no ADL AT the double recording issue is less clear). The Barthel index ZIM or AT is used to register what the capabilities of a patient/client are. The ADL ZIM is used if one wants to register in more detail what these capabilities are. For example in ADL incontinence can be registered (yes/no), in Barthel there are separate entrances for bladder and bowel, for which on a 3 point scale can be scored whether there is incontinency and how severe it is, if present. Another example is dressing and undressing. In ADL undressing the upper and lower body is scored separately as well as dressing of upper and lower body, with an extra entrance for socks/ stockings, shoes and zippers, all on a 5-point scale. In Barthel there is one item dressing/ undressing which is scored on a 3-point scale. If one chooses to use these 2 ZIM’s side be side data about the same observation will be scored in 2 different locations and what’s worse: healthcare providers type A would use f.i. the ADL ZIM, because it suits their needs, and healthcare provider type B would use the Barthel ZIM and both wouldn’t know from each other that valuable information is already present in another location. My point is that both the Barthel index as well as the ADL index are ‘protocols’ which can be used to assess a complex clinical situation and as such are too large to see as one clinical domain. Ideally one should have one observation for urine incontinence, one for bowel/stool incontinence, and one for dressing and one for undressing. This separate observation should be defined in such a manner that they both can be used for a Barthel index and an ADL assessment, which in themselves would be (clinical) templates. Only then all relevant aspects for each specific observation are present at one location where they can be re-used and shared independent of the ‘protocol (ADL of Barthel in this case), that one choose to interpret/ assess the situation. So my second question is, are there published methods/guidelines to determine how to deal with this issue? Just out of curiosity a last question about the Barthel ZIM. For each separate ‘observation’ there is a well-defined 5-point scale to score that observation. Still, as an extra option, it is possible to score that observation as free text as well. Is there a specific reason to choose for this ‘dual strategy’? Cheers, Stef --- ## Post #2 by @system Hi Stef I believe that your response is universal on first confronting this issue - we need to get things modelled in a generic environment. The problem is that to model things usefully there has to be a high level of coherence between the models. The same thing has to be represented in the same way. Further, a lot of things need to be modelled over and over to get it right - such as how do we represent the average of 3 readings, the maximum, the change in a value etc. Otherwise we end up with thousands and millions of archetypes. If these things are not done the same way each time they are modelled then we will find we are in a mess very quickly. The openEHR reference model is designed to model the things that are not of concern to clinicians but are essential for processing. The section does not alter the meaning of an entry, the source of the information, who is the information about and in what way are they related to the subject of the record, who committed the record and when, was it part of this record at the time or at another location, when was it visible in this record etc, etc. We find pretty quickly that the models get about as useful as word documents - they have lots of text about them, the boundaries of the modelling are not understood clearly and we have a problem. More over, it is a problem that has been experienced by health authorities around the world - especially those preparing for or using HL7 v3 - how to get these models written? No, how to get these models formally expressed. UML is a modelling language, but it does not solve the problems any more than paper does in this space. My point is, you have to commit to a reference model in order to make the clinical modelling work. openEHR has been developed over 15 years of experience to get to the point where the models can be expressed AND the software can be implemented independently. A generic approach cannot deliver this. Further, if the environment is sufficiently expressive, you should be able to express the combination of the constraints in the openEHR RM and the archetypes and templates in a single statement in that formalism. Just want to head off what has taken the DCM group a long time to discover - generic clinical modelling cannot be done except as a feeder to openEHR or HL7 - you have to have a formal outcome and I argue that the word document is as useful. It is not so intuitive but it is correct. If people are not convinced, think about why it has not been done to this point, and look at the outcomes of efforts to cope with the complexity of health information - they both have reference models as starting points. Cheers, Sam Stef Verlinden wrote: [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #3 by @williamtfgoossen Stef, Sam, I just heard that the DCM proposal was accepted by HL7 steering devision. This means we can now formally work on this. I followed the thread a little and want to pinpoint to one particular misunderstanding in your comments. I copied in the particular line: In a message dated 6-6-2008 16:40:10 W. Europe Daylight Time, stef verlinden in copied message by sam heard writes: > Ideally one should have one observation for urine incontinence, one for bowel/stool incontinence, and one for dressing and one for undressing. This separate observation should be defined in such a manner that they both can be used for a Barthel index and an ADL assessment, which in themselves would be (clinical) templates. Only then all relevant aspects for each specific observation are present at one location where they can be re-used and shared independent of the ‘protocol (ADL of Barthel in this case), that one choose to interpret/ assess the situation. Stef, this would do for a generic observation. However, the value sets applied render it different observations. Perhaps some could be done via defining different options for Likert Scales. Now we have the harmonised ISO datatypes almost worldwide available, the key CO (Coded Ordinal) especially for likert scales is available with the explicit option to calculate with it. So a starting point. However, the reference to Barthel score items and comparing them to a single observations is not comparing apples with pears, which still could be a nice fruit salad, but it is comparing nails with silk. No relevance to each other, and silk could be destroyed by a nail so to speak. The simple reason is that the Barthel index individual item has only meaning in the whole context of the 10 other items, belonging together and allowing the explicit summation of the mandatory ten scores (not nine, nor six, that would be meaningless). The simple reason for this is that the Barthel index (and the thousands of other scales, indexes of measurement instruments) are tested for validity and reliability in particular populations under specific circumstances, with the specified wording of total, variables and valuesets. I have had a student analysing the 4 different scores for pressure ulcer risk in order to go the path you describe ( **[Helleman J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Helleman%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)**, **[Goossen WT](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Goossen%20WT%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)**. **Modeling nursing care in health level 7 reference information model.** Comput Inform Nurs. 2003 Jan-Feb;21(1):37-45.). (With hindsight the titel should have been detailed clinical modelling nursing care for use in HL7 messaging). We found that it could be doable on the observation level (similar as you suggest), but that it is impossible to go the value set harmonization path. Therefore I believe we can do what you suggest for a single observation of e.g. urine incontinence type stress incontinence, or type urge incontinence, or functional incontinence etc. But we cannot do as you suggest for a 'normal' single observation of clothing as one part of the clinical template for ADL (activities of daily living, not archetype def. language). But we cannot include the Barthel, because due to the strict meaning, purpose and context it is completely different and MUST be stored separately. these two are not comparable entities! Also I believe the Barthel should mandatory be the smalles atomic archetype possible (but still some complexity in it), where the ADL observations can be less complex archetypes that allow the many reuses as you suggest and constrain them on clinical template level. I also would like to point you to this publication, that handles the same issue on terminologicial side to include scales into LOINC. [White TM, Hauan MJ.](http://www.ncbi.nlm.nih.gov/pubmed/12386110?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum) Extending the LOINC conceptual schema to support standardized assessment instruments. J Am Med Inform Assoc. 2002 Nov-Dec;9(6):586-99. Hope to have clarified the difference. Sincerely yours, dr. William TF Goossen director Results 4 Care b.v De Stinse 15 3823 VM Amersfoort email: Results4Care@cs.com phone + 31654614458 fax +3133 2570169 www.results4care.nl Dutch Chamber of Commerce number: 32133713 --- ## Post #4 by @system Hi, Ordinals are peculiar things. I agree that (perhaps) there are ordinals at the data types level. But ordinals at the archetype (concept) level are different kinds. ('Fikkie is a dog but not all Fikkies are dogs', as a Dutch proverb goes) Ordinals at the concept level act as modifiers to a noun or verb. A severe headache. A mild hypertension. No digestion. High level of exertion. Ordinals at the concept level are preferably a code from an external coding system. Defined for a specific ever changing context. Ordinals at the data type level are mostly unneeded when we accept my view. Gerard Freriks > Now we have the harmonised ISO datatypes almost worldwide available, the key CO (Coded Ordinal) especially for likert scales is available with the explicit option to calculate with it. So a starting point. -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #5 by @thomas.beale with apologies for daring to tread the waters of the medical professional \.\.\.\.\. Williamtfgoossen@cs\.com wrote: > > \.\.\. > However, the reference to Barthel score items and comparing them to a > single observations is not comparing apples with pears, which still > could be a nice fruit salad, but it is comparing nails with silk\. No > relevance to each other, and silk could be destroyed by a nail so to > speak\. > The simple reason is that the Barthel index individual item has only > meaning in the whole context of the 10 other items, belonging together > and allowing the explicit summation of the mandatory ten scores \(not > nine, nor six, that would be meaningless\)\. The simple reason for this > is that the Barthel index \(and the thousands of other scales, indexes > of measurement instruments\) are tested for validity and reliability in > particular populations under specific circumstances, with the > specified wording of total, variables and valuesets\. I believe this is correct as well \- there are many such evidence\-based scores that I think we have to consider as 'pre\-fabricated' content molecules in our system of content definition\. If we accept this, then we have a modelling environment that could be thought of as follows: \- all archetypes     \+ archetypes that are molecules of atoms constructed by archetype modellers as a way of standardising some aspect of medical data recording     \+ archetypes that wrap pre\-fabricated molecules already standardised by medicine There may be a score for urinary incontinence in an ADL score 'molecule' and also a separate observation \(described by an archetype of the first kind\) that describes urinary incontinence in some detail\. Both of these possibilities should clearly exist\. The interesting design problem that this throws up is how querying should react\. \- thomas beale --- ## Post #6 by @Stef_Verlinden1 > Stef, Sam, > > I just heard that the DCM proposal was accepted by HL7 steering devision. This means we can now formally work on this. Congratulations > I followed the thread a little and want to pinpoint to one particular misunderstanding in your comments. > > I copied in the particular line: > > In a message dated 6-6-2008 16:40:10 W. Europe Daylight Time, > stef verlinden in copied message by sam heard writes: > > > Ideally one should have one observation for urine incontinence, one for bowel/stool incontinence, and one for dressing and one for undressing. This separate observation should be defined in such a manner that they both can be used for a Barthel index and an ADL assessment, which in themselves would be (clinical) templates. Only then all relevant aspects for each specific observation are present at one location where they can be re-used and shared independent of the ‘protocol (ADL of Barthel in this case), that one choose to interpret/ assess the situation. > > Stef, this would do for a generic observation. However, the value sets applied render it different observations. Perhaps some could be done via defining different options for Likert Scales. Now we have the harmonised ISO datatypes almost worldwide available, the key CO (Coded Ordinal) especially for likert scales is available with the explicit option to calculate with it. So a starting point. > However, the reference to Barthel score items and comparing them to a single observations is not comparing apples with pears, which still could be a nice fruit salad, but it is comparing nails with silk. No relevance to each other, and silk could be destroyed by a nail so to speak. > The simple reason is that the Barthel index individual item has only meaning in the whole context of the 10 other items, belonging together and allowing the explicit summation of the mandatory ten scores (not nine, nor six, that would be meaningless). The simple reason for this is that the Barthel index (and the thousands of other scales, indexes of measurement instruments) are tested for validity and reliability in particular populations under specific circumstances, with the specified wording of total, variables and valuesets. > > I have had a student analysing the 4 different scores for pressure ulcer risk in order to go the path you describe ( **[Helleman J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Helleman%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)**, **[Goossen WT](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Goossen%20WT%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)**. **Modeling nursing care in health level 7 reference information model.** Comput Inform Nurs. 2003 Jan-Feb;21(1):37-45.). (With hindsight the titel should have been detailed clinical modelling nursing care for use in HL7 messaging). Thanks, unfortunately I don't have access to the whole article. Is it possible to send a copy of it? That would be great. I think I see your point partially but I'm still struggling with it. From my point of view there is still something missing. Let's try if I can explain it in another way: The underlying observations (in this example for both Barthel and ADL) are generic: for example the (in)ability to control urine excretion. In order to score if there is, and if present what the severity of urine incontinence is, one should create a dedicated urine excretion (observation) archetype/ DCM/ etc. This one would probably have a lot of extra parameters that are not necessary for the Barthel of ADL assesment. Scoring a Barthel or an ADL index is actually an interpretation of those specific observations and attach those interpretations to different scales. This is where I agree partially with you. The difference is that from your viewpoint the whole Barthel score is one observation as such and therefore all underlying observations should be stored as one and separately form other observations. From my viewpoint those are different interpretations of (more or less) the same set of observations. For example, the Barthel looks at both urine and faecal incontinence separately. In the ADL it is scored whether there is either urine or faecal incontinence. Nevertheless the underlying 'observations' are identical and that why I think those should only be registered once in a specified archetype/ DCM per generic observation. From this line of reason (if I understand it correctly) the Barthel index en the ADL index should be separate archetypes, where the underlying generic observation archetypes serve as source for the evaluation/interpretation of the situation leading to a (calculated) score. In that case both indexes can remain their own scales and their own rules to calculate the score. This also provides the opportunity to solve another issue: the Barthel index provides an evaluation of the actual situation. According to which protocol? From literature I can find at least 3 versions of the Barthel index (the original from 1965, a modified version from 1985 and an extended version from 1979). It seems important to know which version is used for the evaluation. This is something you would like to add with the protocol section of your evaluation archetype. In that manner it would be very well possible that there will be 2 different Barthel archetypes both using a different protocol for the evaluation/ calculation of the Barthel score. In this respect I'm also in doubt whether such an archetype should be an observation or an evaluation AT. At one hand it doesn't seem to fit the definition of an evaluation AT on the other hand it seems to me that it is the evaluation of a multifactorial situation. How do others see this? --- ## Post #7 by @Stef_Verlinden1 > > with apologies for daring to tread the waters of the medical > professional \.\.\.\.\. Well the other way around, for one or another reason I seem to get caught up in discussions that are far to technical for me:\-\) I guess we do need both sides of the medal\.\.\.\. >> \.\.\. >> However, the reference to Barthel score items and comparing them to a >> single observations is not comparing apples with pears, which still >> could be a nice fruit salad, but it is comparing nails with silk\. No >> relevance to each other, and silk could be destroyed by a nail so to >> speak\. >> The simple reason is that the Barthel index individual item has only >> meaning in the whole context of the 10 other items, belonging >> together >> and allowing the explicit summation of the mandatory ten scores \(not >> nine, nor six, that would be meaningless\)\. The simple reason for this >> is that the Barthel index \(and the thousands of other scales, indexes >> of measurement instruments\) are tested for validity and >> reliability in >> particular populations under specific circumstances, with the >> specified wording of total, variables and valuesets\. > > I believe this is correct as well \- there are many such evidence\-based > scores that I think we have to consider as 'pre\-fabricated' content > molecules in our system of content definition\. If we accept this, then > we have a modelling environment that could be thought of as follows: > > \- all archetypes >     \+ archetypes that are molecules of atoms constructed by archetype > modellers as a way of standardising some aspect of medical data > recording >     \+ archetypes that wrap pre\-fabricated molecules already > standardised > by medicine I'm not sure but I have the feeling that we're referring to the same principle \(see my previous response to Williams answer\)\. Is that correct? > There may be a score for urinary incontinence in an ADL score > 'molecule' > and also a separate observation \(described by an archetype of the > first > kind\) that describes urinary incontinence in some detail\. Both of > these > possibilities should clearly exist\. The interesting design problem > that > this throws up is how querying should react\. The interesting question is how should we solve that? Cheers, Stef --- ## Post #8 by @Stef_Verlinden1 Since this response bounced because it was too large, I resend a shorter version > Hi Stef Hi Sam, Thanks for your response\. > > My point is, you have to commit to a reference model in order to > make the clinical modelling work\. openEHR has been developed over > 15 years of experience to get to the point where the models can be > expressed AND the software can be implemented independently\. A > generic approach cannot deliver this\. Further, if the environment > is sufficiently expressive, you should be able to express the > combination of the constraints in the openEHR RM and the archetypes > and templates in a single statement in that formalism\. > > Just want to head off what has taken the DCM group a long time to > discover \- generic clinical modelling cannot be done except as a > feeder to openEHR or HL7 \- That was the idea behind the initial mail\. To discuss if it's useful to have an generic clinical modelling which is 'independent' of the underlying reference model \(openEHR or HL7\) which stays away \(if possible\) from the technical discussions especially wrt the harmonization of those 2 reference models\. harmonized reference models and widely accepted clinical models \(archetypes/ templates/ DCM's\) and these should be available as soon as possible\. By separating those two discussions we can work in parallel and gain a lot of time\. Now it seems \(to me:\-\)\) that solving the technical issues has a higher priority \(which is of course essential\) but in the meantime al lot of technique independent clinical modelling issues \(F\.I\. is the Barthel index a molecule build form atoms or is it an atom in itself\) can be discussed and agreed upon\. Since these agreements should have nothing to do with the RM used in the end I wondered if this DCM platform could be a place to share out knowlegde and experience and boost the harmonization in clinical modelling\. Also there is a lot of work to be done and the sooner we can create clinical models that are widely accepted the better\. Cheers, Stef --- ## Post #9 by @system -1- There is the question. Many clinical models in the Dutch ZIM's and the topics of the DCM's, are they Evaluations based on observations or Observations? It can be argued that they are Observations that are transformed via an algorithm into something else that is an abstraction of reality: the Evaluation. Evaluations are the same, almost. But in this case there is no algorithm, but only the experience and knowledge in the mind of the documenter. -2-Without any doubt we get archetypes that document the same concept but are different internally. Because other codes are used, other ways of measurements and units, other ways to express (quantitatively, semi-quantitatively, qualitatively), etc, etc. But all document the same concept. This situation calls for a type of 'Archetype Ontology' so we can document that these archetypes documenting the same concept are 'synonyms'. And that when querying we know what archetypes to use in order to collect all documented information about a clinical topic. Gerard > - all archetypes > + archetypes that are molecules of atoms constructed by archetype > modellers as a way of standardising some aspect of medical data recording > + archetypes that wrap pre-fabricated molecules already standardised > by medicine > > There may be a score for urinary incontinence in an ADL score 'molecule' > and also a separate observation (described by an archetype of the first > kind) that describes urinary incontinence in some detail. Both of these > possibilities should clearly exist. The interesting design problem that > this throws up is how querying should react. -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #10 by @thomas.beale Gerard Freriks wrote: > Hi, > > Ordinals are peculiar things\. > I agree that \(perhaps\) there are ordinals at the data types level\. > But ordinals at the archetype \(concept\) level are different kinds\. > \('Fikkie is a dog but not all Fikkies are dogs', as a Dutch proverb goes\) > > Ordinals at the concept level act as modifiers to a noun or verb\. > A severe headache\. A mild hypertension\. No digestion\. High level of > exertion\. > Ordinals at the concept level are preferably a code from an external > coding system\. > Defined for a specific ever changing context\. > Ordinals at the data type level are mostly unneeded when we accept my > view\. > \*Gerard, what would we do with urinalysis ordinals then: trace, \+, \+\+, \+\+\+, etc? \- thomas beale --- ## Post #11 by @williamtfgoossen In a message dated 7-6-2008 7:22:07 W. Europe Daylight Time, gfrer@luna.nl writes: > Ordinals at the data type level are mostly unneeded when we accept my view. Gerard, here you sure have a point: we would not need them in the ideal world. however, medical and psychological and nursing scientist in health care have been making such scales for decades. They are just there as part of our domain reality and therefore we need to handle them as intended. William Sincerely yours, dr. William TF Goossen director Results 4 Care b.v. De Stinse 15 3823 VM Amersfoort email: Results4Care@cs.com phone + 31654614458 fax +3133 2570169 www.results4care.nl Dutch Chamber of Commerce number: 32133713 --- ## Post #12 by @system Thomas, There is an attribute in Observations where we can 'store' the result. Attached to it there is a Modifier Attribute that indicates whether it is a Quantitative result or a Semi-Quantitative or Qualitative result. Semi-Quantitative is a link to an accepted published code list with (trace, +, ++, +++, ++++) As indicated by the urine analysis strip. Quantitative indicates the present or not-present state. Using this way of thinking we are able to express: - Urine stick measurement xyz: Yes or No - Urine stick measurement xyz: (trace, +, ++, +++, ++++) - Urine stick measurement xyz: 7.4 mmol In an Evaluation we could express: - It is my opinion that: Urine stick measurement xyz: is (low, moderate, high) Low is defined as ..., moderate is defined as ...., high is defined as ... Problem to solve: How can we standardize these Modifier Code Lists Is SNOMED enough? > what would we do with urinalysis ordinals then: trace, +, ++, +++, etc? > > - thomas beale > > * -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #13 by @thomas.beale Gerard Freriks wrote: > Thomas, > > There is an attribute in Observations where we can 'store' the result\. > Attached to it there is a Modifier Attribute that indicates whether it > is a Quantitative result or a Semi\-Quantitative or Qualitative result\. I am not sure what attribute you are talking about here \- do you mean somehting in the OBSERVATION, HISTORY, or EVENT classes? Or do you mean DV\_QUANTIFIED\.magnitude\_status? > Semi\-Quantitative is a link to an accepted published code list with > \(trace, \+, \+\+, \+\+\+, \+\+\+\+\) As indicated by the urine analysis strip\. > Quantitative indicates the present or not\-present state\. > > Using this way of thinking we are able to express: > \- Urine stick measurement xyz: Yes or No > \- Urine stick measurement xyz: \(trace, \+, \+\+, \+\+\+, \+\+\+\+\) > \- Urine stick measurement xyz: 7\.4 mmol > > In an Evaluation we could express: > \- It is my opinion that: Urine stick measurement xyz: is \(low, > moderate, high\) Low is defined as \.\.\., moderate is defined as \.\.\.\., > high is defined as \.\.\. we could but this isn't a clinical opinion in the normal sense of the term \- it is a 'cognitive' opinion, like trying to say what small writing says in an eye test\. Any such measurement should be objectively reportable, regardless of whether the values come in bands or not\.\.\.\. --- ## Post #14 by @heather.leslie Hi Stef, I’ve been travelling\. My belated comments inline… Cheers Heather --- ## Post #15 by @system Dear all, Some detailed thoughts. Reading recent e-mails about Terminfo, DCM and knowing the discussion topic 'severity' here my mental ruminations. - Always there will be various ways to express the same meaning. How much one tries to limit this there will be good and bad reasons to have these separate forms of expression. The only solution is a management Tool to deal with it. When making queries via the tool 'synonyms' (archetypes with different names and internal models, but expressing the same topic) must be found. This implies an ontology about Archetypes so we can record and find those synonyms and include them in queries. This is a way to deal with the 'grey zone' between ways to express things as code or structure. - When we try to express things there are variable levels of abstraction/aggregation we use. E.g. Observation: Ability to put on socks: No/Yes Observation: Ability to put on socks: +, ++, +++, ++++, +++++ Observation: Ability to put on socks: 30 seconds Observation: ability to put on left sock: 30 seconds; right sock: 5 minutes Observation: Systolic pressure: No, Yes Observation: Systolic pressure: 0, +, ++, +++, ++++, +++++ Observation: Systolic pressure: no, Low, Normal, High, very high Observation: Systolic pressure: 120 Observation: Systolic pressure: 120 ± 1 Observation: Systolic pressure: 119.9 ± 0.3 All (most) observations can be transformed from very precise to generic/aggregated. The are all about the same topic (ability or measurement) Are all examples of the same nature? - A measurement by a device is it the same as an observation by a human? - A liver that is palpable by a human is this an observation or an subjective interpretation and therefor an Evaluation? So far any documentation about the patient system as a whole is an observation. I think this is correct. - But 'Systolic: High' isn't this an Evaluation with implicit or explicit classification criteria? The Evaluation is an expression of a professional opinion. To document Blood pressure as low or high is this no longer an observation but an Evaluation or both? - When we document Systolic pressure: +++, don't we need to have in the cluster archetype (pattern) a facility to express what we mean by +++ or high in order to interpret correctly the information? In other words is an ordinal at the archetype level not a pattern in itself? A pattern that defines a semi-quantitative observation or evaluation? - When there are patterns for qualitative, semi-quantitatve and quantitative observations and evaluations, does this mean that these cluster archetypes as patterns will be expressed no longer as ordinal data types but a collection of quantities and codes? Gerard > [Heather Leslie] Additionally, and very importantly, once these archetypes > are in the archetype repository, then searching breathing should display > both the Apgar plus the 'breathing-related' archetypes; and searching for > mobility should display both the generic mobility archetype plus the Barthel > – then the user can use which archetypes suit their purpose, or query > appropriately. The Repository will play an important role here due to the > ontology basis behind it. -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #16 by @thomas.beale Gerard Freriks wrote: > > Observation: Systolic pressure: No, Yes > Observation: Systolic pressure: 0, \+, \+\+, \+\+\+, \+\+\+\+, \+\+\+\+\+ I want to meet the GP who measures BP like this ;\-\) > > Are all examples of the same nature? > > \- A measurement by a device is it the same as an observation by a human? yes: just a question of the statistical accuracy band\. > \- A liver that is palpable by a human is this an observation or an > subjective interpretation and therefor an Evaluation? > So far any documentation about the patient system as a whole is an > observation\. I think this is correct\. observation: it is a procedure, taught to professionals to be repeatable and reliable, without which they would need some other observational method to establish problems in the liver\. The fact that it is in use shows that it is an adequate and useful observational method, and generates results that are statistically acceptable\. > \- But 'Systolic: High' isn't this an Evaluation with implicit or > explicit classification criteria? > The Evaluation is an expression of a professional opinion\. > To document Blood pressure as low or high is this no longer an > observation but an Evaluation or both? Here we get into linguistic challenges\. If the understanding of 'high' is derived from the following: low: < 90 mmHg normal: 90mmHg \- 140mmHg high: > 140 mmHg then assuming there is an instrument available to generate the value 'high' it is an observation \(at a very coarse precision\), since it is a repeatable and objective\. If the 'instrument' is in fact a human being reading from a normal digital or analog device, then it may questionable as to whether the more precise measurement should not be recorded\. If however, the word 'high' is being used by the clinician to mean 'this patient is hypertensive', i\.e\. the BP is too high, then it is an evaluation\. And that's why words like 'hypertensive' exist\. In this second case, the band of values that correspond to 'high' may vary with the patient, e\.g\. sex, weight, age, pregnancy, diabetic, or just plain personal variation\. So the use of the word 'high' in this circumstance indicates an assessment by the clinician that the observed blood pressure is \_higher than normal\_, i\.e\. \_too high\_ for the given patient\. > \- When we document Systolic pressure: \+\+\+, > don't we need to have in the cluster archetype \(pattern\) a facility to > express what we mean by \+\+\+ or high in order to interpret correctly > the information? > In other words is an ordinal at the archetype level not a pattern in > itself? > A pattern that defines a semi\-quantitative observation or evaluation? I think we only need to do such things if a physician is realistically going to use them\. I would have thought that 'high' would never be used as a primary observation, but only in the evaluation sense, and I did not know that \+\+\+ was used at all for BP\. > \- When there are patterns for qualitative, semi\-quantitatve and > quantitative observations and evaluations, > does this mean that these cluster archetypes as patterns will be > expressed no longer as ordinal data types but a collection of > quantities and codes? well, if we want to use 'high' according to the first sense I describe above, and \+\+\+ likewise, then we would use ordinals, because the latter supply a means of defining the bands of terms like 'low', 'normal', 'high' etc, but if you want to use them as diagnostic terms, then they need to be coded and bound to things like Snomed::hypertension etc\. We have to remain ever\-vigilant to the intricacies of natural language\! \- thomas beale --- ## Post #17 by @Tim_Cook2 What GREAT reply\. I have been thinking all day about how to properly, respectfully reply to Gerard's email\. I only wish I could have assembled the thoughts and put them into writing the way you did\. Cheers, Tim --- ## Post #18 by @Karsten_Hilbert > Gerard Freriks wrote: > > > > Observation: Systolic pressure: No, Yes > > Observation: Systolic pressure: 0, \+, \+\+, \+\+\+, \+\+\+\+, \+\+\+\+\+ > I want to meet the GP who measures BP like this ;\-\) Not sure about the \+, \+\+ but No/Yes may well occur in a reanimation situation\. Karsten --- ## Post #19 by @Andrew_Patterson >> > Observation: Systolic pressure: No, Yes >> > Observation: Systolic pressure: 0, \+, \+\+, \+\+\+, \+\+\+\+, \+\+\+\+\+ >> I want to meet the GP who measures BP like this ;\-\) > > Not sure about the \+, \+\+ but No/Yes may well occur in a > reanimation situation\. They can do this now? I, for one, welcome our new zombie overlords\.\. Andrew --- ## Post #20 by @Stef_Verlinden1 Hi Heather, Thanks for your extensive reply, this is very helpful. Just some remarks in between your reply. > [Heather Leslie] I both agree and disagree with you, Stef!!!! > > [Heather Leslie] I always try to model each archetype as a discrete, single > > clinical content specification – designed as a maximal data set for > > universal use case. This is what I would describe as ‘PURE’ modelling, just > > as you describe. > > However there are definitely situations where there are groups of concepts > > that are only meaningful when grouped together – such as Barthel score. > > Apgar (breathing, heart rate, color etc as an assessment of an infant at > > birth) and SF-36 questionnaires are other examples which are in common usage > > but only useful and valid when cohesive and used as a whole. I guess the underlying question is, is a Barthel index score always an observation as such, or can it also be constructed from other (smaller/ atomar) observations. If for a Barthel index score means that a health care providers goes to see the patient and scores for all items on the list and that observation is only used for that purpose, I agree it could be a separate AT. If however a Barthel index could also be constructed from (previously) recorded (smaller/atom like) observations I would stay with my previous suggestion that a barthel index should be a 'superarchetype' (a molecule as Gerard nicely put it) which can be constructed from 'atoms' (see also the reply to William's remarks) > [Heather Leslie] From my point of view the clinical descriptions of > > ‘Mobility’ as defined in Barthel are only a very limited subset when > > describing mobility as a maximal data set archetype. We could try to be > > inclusive and have these attributes in part of the ‘pure’ mobility > > archetype, but I don't think that this fragment about 'mobility' is > > particularly useful, except as part of the Bartel context. I would describe > > mobility quite differently in a 'purely designed' maximal archetype. I agree that mobility as defined in Barthel is a very limited subset. Even more I would argue that the mobility score in the Barthel index is an interpretation of the actual observation of the ability to be mobile, which is captured in a 'pure' mobility AT. In Barthel you have a 5 point scale. For example a score '2' means '(needs) little help (to be mobile)'. This is not a very objective observation. Little help: According to whose/ which standard? So one would like to have be able to record the underlying 'objective' observations. These would be captured in a purely designed maximal archetype. I'm aware that this is very detailed but to give you an example. Here in the Netherlands the Barthel score is used to asses how much care one gets and this translates into money. So people could have an interest in 'lowering' the score (those who receive the care) or to make the score 'bettter' (those who have to pay for it). Only if (more or less) objective criteria can be used to generate this score a 'fair' assesment can be provided. > [Heather Leslie] These scores or indexes are well used as screening or > > assessment scores and, as William has indicated, some such as Barthel have > > been validated only when used as a whole. So my opinion is that there is > > good reason for simple and ‘PRAGMATIC’ modelling of these scores as a whole, > BUT I would also like the generic components each modeled ‘purely’ as well > > ie a maximal and generic ‘mobility’ archetype modeled as well plus the > > concept of breathing, as found in Apgar, modeled using all its component > > concepts as separate archetype components ie breathing = respiratory rate, > > chest expansion, inspection of trachea/chest, auscultation, etc etc. > > [Heather Leslie] I generally push back if there is a real or perceived > > overlap in content – but I think that in this situation the overlap is > > minimal and the intent quite different. > > [Heather Leslie] Additionally, and very importantly, once these archetypes > > are in the archetype repository, then searching breathing should display > > both the Apgar plus the 'breathing-related' archetypes; and searching for > > mobility should display both the generic mobility archetype plus the Barthel > > – then the user can use which archetypes suit their purpose, or query > > appropriately. The Repository will play an important role here due to the > > ontology basis behind it. I'm not sure if I agree with that, because that means every time one wants to create a query one have to do extensive research in the AT repository to find out of for every search item an alternative entry exists. Theoretically and technically that will work, but since it involves extra work/ somebody who loves to search for those alternatives, practically it could mean that data that is present in another location is overlooked. Although this probably can't be prevented entirely one should try to reduce this overlap as much as possible. Cheers, Stef --- ## Post #21 by @Stef_Verlinden1 Tom, Thanks for these definitions and examples, they're very helpful. > observation: it is a procedure, taught to professionals to be repeatable > > and reliable, without which they would need some other observational > > method to establish problems in the liver. The fact that it is in use > > shows that it is an adequate and useful observational method, and > > generates results that are statistically acceptable. > > > - But 'Systolic: High' isn't this an Evaluation with implicit or > > > > explicit classification criteria? > > > > The Evaluation is an expression of a professional opinion. > > > > To document Blood pressure as low or high is this no longer an > > > > observation but an Evaluation or both? > > Here we get into linguistic challenges. If the understanding of 'high' > > is derived from the following: > > low: < 90 mmHg > > normal: 90mmHg - 140mmHg > > high: > 140 mmHg > > then assuming there is an instrument available to generate the value > > 'high' it is an observation (at a very coarse precision), since it is a > > repeatable and objective. If the 'instrument' is in fact a human being > > reading from a normal digital or analog device, then it may questionable > > as to whether the more precise measurement should not be recorded. > > If however, the word 'high' is being used by the clinician to mean 'this > > patient is hypertensive', i.e. the BP is too high, then it is an > > evaluation. And that's why words like 'hypertensive' exist. In this > > second case, the band of values that correspond to 'high' may vary with > > the patient, e.g. sex, weight, age, pregnancy, diabetic, or just plain > > personal variation. So the use of the word 'high' in this circumstance > > indicates an assessment by the clinician that the observed blood > > pressure is _higher than normal_, i.e. _too high_ for the given patient. Question is, is a (part of) the Barthel index score: (needs) little help (to be mobile) (see my response to Heathers mail as well) an observation or an interpretation/ evaluation. I would say it's an evaluation. > Cheers, Stef --- ## Post #22 by @system > Gerard Freriks wrote: > > > > > > Observation: Systolic pressure: No, Yes > > > Observation: Systolic pressure: 0, +, ++, +++, ++++, +++++ > > I want to meet the GP who measures BP like this ;-) But he will use the frase: High Blood pressure, Low Blood sugar. And +++ and - are just equivalents/synonyms of High and Low. > > > > > > > > Are all examples of the same nature? > > > > > > - A measurement by a device is it the same as an observation by a human? > > yes: just a question of the statistical accuracy band. > > > > > > - A liver that is palpable by a human is this an observation or an > > > subjective interpretation and therefor an Evaluation? > > > So far any documentation about the patient system as a whole is an > > > observation. I think this is correct. > > observation: it is a procedure, taught to professionals to be repeatable > and reliable, without which they would need some other observational > method to establish problems in the liver. The fact that it is in use > shows that it is an adequate and useful observational method, and > generates results that are statistically acceptable. So we agree. > > > > > - But 'Systolic: High' isn't this an Evaluation with implicit or > > > explicit classification criteria? > > > The Evaluation is an expression of a professional opinion. > > > To document Blood pressure as low or high is this no longer an > > > observation but an Evaluation or both? > > Here we get into linguistic challenges. If the understanding of 'high' > is derived from the following: > > low: < 90 mmHg > normal: 90mmHg - 140mmHg > high: > 140 mmHg > > then assuming there is an instrument available to generate the value > 'high' it is an observation (at a very coarse precision), since it is a > repeatable and objective. If the 'instrument' is in fact a human being > reading from a normal digital or analog device, then it may questionable > as to whether the more precise measurement should not be recorded. > > If however, the word 'high' is being used by the clinician to mean 'this > patient is hypertensive', i.e. the BP is too high, then it is an > evaluation. And that's why words like 'hypertensive' exist. In this > second case, the band of values that correspond to 'high' may vary with > the patient, e.g. sex, weight, age, pregnancy, diabetic, or just plain > personal variation. So the use of the word 'high' in this circumstance > indicates an assessment by the clinician that the observed blood > pressure is _higher than normal_, i.e. _too high_ for the given patient. We agree, again. > > > > > - When we document Systolic pressure: +++, > > > don't we need to have in the cluster archetype (pattern) a facility to > > > express what we mean by +++ or high in order to interpret correctly > > > the information? > > > In other words is an ordinal at the archetype level not a pattern in > > > itself? > > > A pattern that defines a semi-quantitative observation or evaluation? > > I think we only need to do such things if a physician is realistically > going to use them. I would have thought that 'high' would never be used > as a primary observation, but only in the evaluation sense, and I did > not know that +++ was used at all for BP. What I'm hinting at is the need for patterns that express: - quantitative measurements: systolic=120 - semi quantitative measurements also called 'ordinals': systolic=high or +++ - qualitative measurements. Systolic=present When I talk about patterns it means sub-archetypes that can be re-used in other archetypes. And I'm not talking about data types. > > > > > - When there are patterns for qualitative, semi-quantitatve and > > > quantitative observations and evaluations, > > > does this mean that these cluster archetypes as patterns will be > > > expressed no longer as ordinal data types but a collection of > > > quantities and codes? > > well, if we want to use 'high' according to the first sense I describe > above, and +++ likewise, then we would use ordinals, because the latter > supply a means of defining the bands of terms like 'low', 'normal', > 'high' etc, but if you want to use them as diagnostic terms, then they > need to be coded and bound to things like Snomed::hypertension etc. > > We have to remain ever-vigilant to the intricacies of natural language! > > - thomas beale > > _______________________________________________ > openEHR-clinical mailing list > [openEHR-clinical@openehr.org](mailto:openEHR-clinical@openehr.org) > http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #23 by @thomas.beale Stef Verlinden wrote: > > Question is, is a \(part of\) the Barthel index score: \(needs\) little > help \(to be mobile\) \(see my response to Heathers mail as well\) an > observation or an interpretation/ evaluation\. I would say it's an > evaluation\. > \*could 10 randomaly chosen occupational therapists come up with the same answer to the question? If yes, it is an observation\. What does 'a little help' mean? What does 'mobile' mean? \- thomas --- ## Post #24 by @Stefan_Sauermann Hello everybody\! Just a brief introduction, as I am new to many of you: I am working at the University of Applied Sciences Technikum Wien, Biomedical Engineering, some teaching, some program directing\. Before that I had 15 years at the general hospital in Vienna, which is a university hospital, a lot of that designing software for biosignal analysis research\. I am also chairing the Austrian mirror groups to CEN TC251 and ISO TC215, and moderating the working group for "Interoperability and Standards" within the Austrian eHealth Initiative, which provided guidelines that were used to design the architecture of the Austrian national EHR \(called ELGA, see www\.arge\-elga\.at, sorry german only\)\. I am also consulting the ELGA project in the work on harmonised medical documents \(discharge information, lab and radiology report, and medication\)\. In that I am moderating a representative high level group of laboratory experts, who have been assembled to decide the medical content of laboratory reports for Austria, as an integrated part of the work on the core applications of ELGA\. I am also a founding member of IHE Austria \(www\.ihe\-austria\.at\)\. In everything I have been doing for the last 5 years, I wanted to contribute to the application of international standards in healthcare\. In this time I gradually became aware of the benefits of archetypes, and also realized the limitations that we have to accept when we want to apply this advanced technology into clinical practice\. I believe that both sides have to move, modify and learn, and meet somewhere in the middle\. This process is visibly going on, and I am here because I believe that you are a very relevant meeting point\. Especially after the discussions we had in Gothenburg in ISO TC215 WG9 two weeks ago\. At this point I would like to join in, because Stef raises exactly the question that is central to me: "Since these agreements should have nothing to do with the RM used in the end I wondered if this DCM platform could be a place to share out knowlegde and experience and boost the harmonization in clinical modelling\." They group of laboratory medicine experts whom I moderate are now in the middle of the clinical content discussion\. By the end of 2008 the content needs to be stable, and go into "clinical" tests\. If international cooperation is an issue, it should be started now, when things are still in the flow\. Similarly in other countries clinical content is slowly reaching the attention of national projects \(Denmark, Sweden, UK, \.\.\)\. \(I am putting an excel list of that together\)\. Now: The question is: Is DCM willing to accommodate this "clinical" discussion? I agree with Stef, in that it might be wise to "separate those two discussions", possibly by forming a subgroup which only addresses the clinical content questions, and does not get into RIM and technical matters\. Of course such a group would have to have a very close connection to the "RIM" group, to provide feedback and receive technical guidance, but that could be "in the background", and "hidden" from the clinicians\. I would be very happy to join such a group, and help to organize a "meeting ground" for clinicians, who are not able to contribute to RIM questions\. Are there others? How do you see that? I hope to hear from you, to cheer up a very sad Austria, which got kicked out of the European soccer championships by Germany yesterday, on home ground\. But this is another long story, see you around, Stefan Sauermann Acting Program Director Biomedical Engineering Sciences \(Master\) University of Applied Sciences Technikum Wien Hoechstaedtplatz 5, 1200 Vienna, Austria Tel: \+\+43\-\(0\)1\- 333 40 77 \- 988 sauermann@technikum\-wien\.at http://www.technikum-wien.at --- ## Post #25 by @system Thomas, We need to provide three types of patterns as sub-archetypes. One of them is the semi-quantitative expression. Gerard > what would we do with urinalysis ordinals then: trace, +, ++, +++, etc? -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #26 by @Stef_Verlinden1 > Stef Verlinden wrote: >> >> Question is, is a \(part of\) the Barthel index score: \(needs\) little >> help \(to be mobile\) \(see my response to Heathers mail as well\) an >> observation or an interpretation/ evaluation\. I would say it's an >> evaluation\. >> > > \*could 10 randomaly chosen occupational therapists come up with the > same > answer to the question? If yes, it is an observation\. What does 'a > little help' mean? What does 'mobile' mean? That's my point so in my opinion it's an evaluation\. --- ## Post #27 by @heather.leslie __*Hi Stef,*__ __*This is an issue that gets raised not infrequently. I’ve gradually been distilling it down to simpler terms and hope this can clarify.*__ · __*An observation is something measured, observed or heard – effectively covering all history and examination, including information provided/reported by the patient or third party.*__ · __*An evaluation is*__ __*information generated by the clinician eg*__ __*“On the basis of these facts (ie the observations recorded above) it is my opinion now that this patient is suffering from ....., or has risk of ..., etc”*__ __*On this basis, your Barthel score example itself is still an observation.*__ __*Heather*__ --- ## Post #28 by @Stef_Verlinden1 This I don't understand. Can you please elaborate on that? Cheers, Stef --- ## Post #29 by @Stef_Verlinden1 Hi Heather, OK, if that's the consensus it's fine with me. Although I have the idea that your definition and the one the Thomas provides are different. Thomas stated: '........ If however, the word 'high' is being used by the clinician to mean 'this patient is hypertensive', i.e. the BP is too high, then it is an evaluation. And that's why words like 'hypertensive' exist. In this second case, the band of values that correspond to 'high' may vary with the patient, e.g. sex, weight, age, pregnancy, diabetic, or just plain personal variation......' My point is that 'high' and 'little' are subjective terms (like the --. -, 0, +, ++ scale that Gerard uses as an example) and needs objective criteria (F.i. a little help with mobilization means less than 10 minutes help per 24 hours) in order to be able to provide a reproducable score between different health care providers. Where do we store the input data (how many minutes of help are provided per timeframe) for that assesment and the criteria themselves? Right now, I don't see the difference between: - spider angioma (symptom) = liver cirrhosis (interpretation) and - less than 10 minutes help per day (this seems a 'symptom' to me) = little help (this seems an interpretation to me) Does that mean that the diagnosis liver cirrhosis is an observation as well? Cheers, Stef > __*Hi Stef,*__ > > __*This is an issue that gets raised not infrequently. I’ve gradually been distilling it down to simpler terms and hope this can clarify.*__ > > · __*An observation is something measured, observed or heard – effectively covering all history and examination, including information provided/reported by the patient or third party.*__ > > · __*An evaluation is*__ __*information generated by the clinician eg*__ __*“On the basis of these facts (ie the observations recorded above) it is my opinion now that this patient is suffering from ....., or has risk of ..., etc”*__ On the basis of the fact that this patient requires 6 minutes help with his mobility /24 hours it is my opinion that this patient needs little help..... --- ## Post #30 by @system Hi, For me the constituting elements are Observations expressed following a semi quantitative documentation pattern. The Barthels Index is an Evaluation because an algorithm calculates, interprets, the observations and transform it to a new semi-quantitative value. Gerard > Question is, is a (part of) the Barthel index score: (needs) little help (to be mobile) (see my response to Heathers mail as well) an observation or an interpretation/ evaluation. I would say it's an evaluation. -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #31 by @thomas.beale Stef Verlinden wrote: > Hi Heather, > > OK, if that's the consensus it's fine with me\. Although I have the > idea that your definition and the one the Thomas provides are different\. > > Thomas stated: > '\.\.\.\.\.\.\.\. If however, the word 'high' is being used by the clinician > to mean 'this patient is hypertensive', i\.e\. the BP is too high, then > it is an evaluation\. > And that's why words like 'hypertensive' exist\. In this second case, > the band of values that correspond to 'high' may vary with the > patient, e\.g\. sex, weight, age, pregnancy, diabetic, or just > plain personal variation\.\.\.\.\.\.' > > My point is that 'high' and 'little' are subjective terms they may or may not be\. They are objective if they are always generated repeatably by a direct observational protocol that works the same for all patients \(e\.g\. 'high' is always > 140mmHg\), e\.g\. a machine or person who does some measurement and then reads off the value 'high'\. They are subjective if they are an opinion about this particular patient's state of health, based on another observed value e\.g\. a reading off the sphygmo or other BP device\. > \(like the \-\-\. \-, 0, \+, \+\+ scale that Gerard uses as an example\) and > needs objective criteria \(F\.i\. a little help with mobilization means > less than 10 minutes help per 24 hours\) in order to be able to > provide a reproducable score between different health care providers\. > Where do we store the input data \(how many minutes of help are > provided per timeframe\) for that assesment and the criteria themselves? > > Right now, I don't see the difference between: > > \- spider angioma \(symptom\) = liver cirrhosis \(interpretation\) > > and > > \- less than 10 minutes help per day \(this seems a 'symptom' to me\) = > little help \(this seems an interpretation to me\) the first is a \(presumably\) repeatable quantitative measurement, generated by a standard observational protocol, and the same answer would be generated if any other doctor or patient were to perform the measurement\. The second is probably an observation, but at a coarser grain of quantisation, assuming the word 'little' is understood in the same way by all physicians who might perform the observation, and if it would be applied in the same way for any patient\. > Does that mean that the diagnosis liver cirrhosis is an observation as > well? No, it is clearly an Evaluation \- you cannot observe liver cirrhosis, only signs and symptoms that together enable you to classify the patient as one of those individuals who match the pattern that we call 'liver cirrhosis' to which is attached a theory of underlying physiological process, which is what enables us to predict what will happen and also to try and treat it\. I think in general the way we have to look at these kinds of questions is to classify what we are trying to do in each case\. Is it: a\) to gather evidence upon which assessments can be made? b\) to make an assessment based on some measured or observed evidence? An assessment is someting that leads to action \(which might be to perform further observation\) \- thomas --- ## Post #32 by @heather.leslie We still can’t agree, Gerard;-) Barthels Index is a consistent way to gather evidence about a patient’s state – repeat it in a month’s time and you get a consistent answer that reflects the change in the patient’s state – as per Thomas’ way of describing an observation class, and a direct output from taking a history or examining a patient as per my description. The number that is the sum of all the individual constituent choices – it still reflects just the total, not an assessment or interpretation. It can be done online - [http://www.patient.co.uk/showdoc/40001654/](http://www.patient.co.uk/showdoc/40001654/) - without any clinical input, expertise or interpretation. The clinical extrapolation that follows might conclude that this patient is ‘at risk of falls’- this is an evaluation class. The subsequent plan that the patient needs interventions including a referral to a Falls clinic or a home visit by an occupational therapist for bathroom aids is characterized by an instruction class. BTW did you have a good holiday? Cheers again Heather --- ## Post #33 by @thomas.beale Heather Leslie wrote: > > We still can’t agree, Gerard;\-\) > > Barthels Index is a consistent way to gather evidence about a > patient’s state – repeat it in a month’s time and you get a consistent > answer that reflects the change in the patient’s state – as per > Thomas’ way of describing an observation class, and a direct output > from taking a history or examining a patient as per my description\. > The number that is the sum of all the individual constituent choices – > it still reflects just the total, not an assessment or interpretation\. > It can be done online \- http://www.patient.co.uk/showdoc/40001654/ \- > without any clinical input, expertise or interpretation\. > > The clinical extrapolation that follows might conclude that this > patient is ‘at risk of falls’\- this is an evaluation class\. The > subsequent plan that the patient needs interventions including a > referral to a Falls clinic or a home visit by an occupational > therapist for bathroom aids is characterized by an instruction class\. > > BTW did you have a good holiday? > \*I suspect that philosophically the truth is somewhere in between\. The Barthel, as Gerard has pointed out is something like a protocol for generating a classification of an inidividual, which is something like an assessment of some kind\. Normally \(in my understanding\) further assessments would be needed on people who come out badly on the Barthel index\. Nevertheless, it could be looked upon as a little tool that performs your observation and generates a rough assessment\. For practical purposes I think it is better to treat it as an observation though, since it is repeatable, objective \(as long as the protocol is followed\) and it is something used as evidence for a real assessment\. \- thomas --- ## Post #34 by @Arild_Faxvaag1 Maybe I repeat what numerous others have said or just add confusion, but there is a professional society dimension to this too: \- I believe some clinicians would regard it an instrument\. \- It was established by a member / members of a professional society \- It has been, and is used as a measurment instrument for scientific purposes within the professional society \- To use the Barthel index while solving the problems of individual patients can be compared to using a term in the language of the professional society \- To use the index while conducting clinical work opens up for the possibility that the patients case might become a case in a scientific publication \(e\.g\. an outcome study\)\. Arild FAxvaag --- ## Post #35 by @Stef_Verlinden1 Hi Heather, > > Barthels Index is a consistent way to gather evidence about a > > > > patient’s state – I just found out that, when looking for an 'example' in the Barthels index, I've overlooked the adjacent column in which the 'criteria' are stated (Little help is defined as ' one person for supervision or some help). Furthermore 'little help' is a score for transfer from bed to chair and not for mobility. Sorry for the confusion that I've created. So, I can see your point that, since all these parameters which are scored for are well defined, the Barthels index should be regarded as an instrument to consistently gather information about a patients state. The point I was trying to make, and I don't think we disagree on that, is that subjective scores (for example high/ low), for which there is no universal agreement upon the criteria for that score, are evaluations. In that case people can use their own criteria and/or different standards/ protocols and one needs to know according to which criteria/ standard/ protocol it is high or low. For example 'high blood-pressure' is an evaluation of a blood-pressure value based on criteria/ standard/ protocol X. Somebody else who is using criteria/ standard/ protocol Y may evaluate the same blood-pressure value as normal. What still puzzles me, is that if the criteria are universally accepted the score becomes an observation while if the criteria can vary it becomes an evaluation. The thing that immediately pops into my mind is that since there are at least 3 different versions of the Barthel index (as mentioned in a previous mail) one can wonder how universal these criteria are. So at least it should be known which version is used. Cheers, Stef --- ## Post #36 by @heather.leslie Hi Stef, I’m glad we are back in alignment again;-) Barthel Index and Apgar are pragmatic examples where the components are powerful together, but are not really suitable for the ’pure’ modeling we need to aim for in general – ie the concept of a maximal dataset for universal use case. Apgar is more complicated again as it has specific events involved as well – ie 1 min, 2 min readings etc. The issue of different criteria is a real one, and I understand that with links we will be able to connect a diagnosis back to the original evidence, which will be important – this is new territory to me, but I believe covered by the RM. Others might be able to provide more information. And re your final point, from memory the difference between some of the versions of Barthel are quite significant. If other versions are being used, then we will have to consider specialization or possibly even separate archetypes – I don’t have much of a feel for the clinical requirements here, yet. Cheers Heather --- ## Post #37 by @system Dear all, For quite some time as was confused as most of you when it comes to thinking about Observation and Evaluation. The reason is/was that most clinicians, and GPs in particular, know the Larry Weed **S**ubjective, **O**bjective, **E**valuation and **P**lan way of documenting in records. It all became very clear to me that the major differentiator to make the decision between Observation and Evaluation is to look at the 'documentation pattern' that each of these archetypes provide you. The choice is not whether it is an uttering of the patient or an observation by the documenter or whether it is an idea generated in the mind of the documenter. It is all about documentation and patterns provided by the different type of archetypes. So there are four basic 'Documentation Patterns': Observation, Evaluation, Instruction and Action. These 'Documentation Patterns' have nothing to do with Larry Weeds SOEP stuff. Gerard > I am in the process of documenting my current feelings about the > Observation/Evaluation debate and came across this alternative > definition in a different setting -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #38 by @system Observation = A Documenting Pattern to record observed facts about the state in the patient system. Leading to a pattern to document an observation at one or more points in time, describing the status of the observed object, and method used. Evaluation = A Documenting Pattern to record subjective opinions about processes in the patient system. Leading to a pattern to document a personal opinion. At one point in time, not only based on facts, but based on experience and expertise, hunches, thoughts, etc, etc. Reading the above I see some potential grey areas. Several observations done by clinicians take the form of an opinion. The auscultation of a heart murmur when documented by a device is certainly an Observation. But when a human does it, the human will take on the role of a device. He will document: I declare that I heard a murmur of a certain type in this patient using my own expertise and experience as 'device'. It looks like an evaluation. This statement is actually an observation about the patient system but expressed as a an opinion. When a human is acting as a machine to record facts (even when experience and expertise is called for) it will be recorded using the Observation Documenting Pattern not with the machine as method but the human. It is the recording of a state of something in the patient system. When facts , expertise, experience, hunches, thoughts, transform data into information in the head of the documenter the at a higher level of abstraction a notion is formulated with the character of a declaration about a process in the patient system. This declaration helps to understand the states in the patient system in the past, the present and predicts states in the future. To **document** something about the **state** of something in the **patient system,** at point is **time**, using a specified **method** we have to use the Observation Documenting Pattern. To **document** something about a **process** in the **patient system** we use the Evaluation Documenting Pattern. Gerard > In the same way, Evaluations in the clinical information cycle will > often select certain items already mentioned in Observations - but note > they are not just repeating them, they are really selecting and usually > saying something about them. E.g. that the mother's breast cancer > represents a risk for the current patient (the daughter). > > The practical upshot of this is that there will be a need to have some > archetyype elements in common with both Observation and Evaluation > archetypes. -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #39 by @thomas.beale Gerard Freriks wrote: > To **document** something about the **state** of something in the **patient system,** at point is **time**, using a specified **method** we have to use the Observation Documenting Pattern. > To **document** something about a **process** in the **patient system** we use the Evaluation Documenting Pattern. This is a very useful discussion. The above is an interesting way of looking at the problem, but we need to be careful about what it means. 1. we can only observe phenomena via the states they give rise to at points in time. We can make multiple samples if we want. 2. we can't directly observe a (temporal) process. The best we can do is to make observations of the state of something and then surmise that a particular process is present - i.e. it is an opinion based on the observed samples. Making a diagnosis or any other kind of assessment is about identifying an underlying process. It is the same as any other evidence-based scientific theory - to be 'good', it must have good explanatory power, and it must have good predictive power. But it is still an opinion. It is now interesting to think about Barthel or Apgar. They are clearly observational, at least partly, but do they contain opinions based on the evidence? One could argue that they do, since the point levels that designate different categories of babies or elderly patients are a kind of standard assessment about the meaning of the point levels. This would be the same situationn as a BP meter that has a red zone or indication when the systolic is above 180mmHg. Practically speaking I believe it is better to keep them as observations and treat the output as a kind of observation as well, which will act as the input to the next stage of proper assessment. For example, a low Apgar doesn't on its own tell what is wrong with the baby, only that something needs to be done fast; an doctor still needs to assess and act. - thomas --- ## Post #40 by @system Thomas, > > To **document** something about the **state** of something in the **patient system,** at a point in **time**, using a specified **method** we have to use the Observation Documenting Pattern. > > To **document** something about a **process** in the **patient system** we use the Evaluation Documenting Pattern. Bartel and Apgare and a lot more of those indexes are based on observations. When the observation is a measurement then this is transformed into a semi-quantitative observation using some rules. Other observations are not measured but (based on experience, expertise) clinical people produce directly the observations in that semi-quantitative way. Using an algorithm the Index is calculated. These Indexes indicate in summary the status in the patient system by observing a few aggregated phenomena. Indexes are observation that will use the Observation Documenting Pattern. Sometimes a real measurements are transformed using classification rules as method and turned into a semi-quantitative measurements. Sometimes clinicians document the semi-quantitative measurements directly. Then the human is the method. The Index is calculated using the algorithm as the method. These indexes tell us nothing about underlying processes in the patient system. Only that, based on aggregated observations of states, healthcare providers are able to see an indication of severity and the need to draw conclusions and make a plan. Gerard > Gerard Freriks wrote: > > > To **document** something about the **state** of something in the **patient system,** at a point in **time**, using a specified **method** we have to use the Observation Documenting Pattern. > > To **document** something about a **process** in the **patient system** we use the Evaluation Documenting Pattern. > > This is a very useful discussion. The above is an interesting way of looking at the problem, but we need to be careful about what it means. > > 1. we can only observe phenomena via the states they give rise to at points in time. We can make multiple samples if we want. > 2. we can't directly observe a (temporal) process. The best we can do is to make observations of the state of something and then surmise that a particular process is present - i.e. it is an opinion based on the observed samples. > > Making a diagnosis or any other kind of assessment is about identifying an underlying process. It is the same as any other evidence-based scientific theory - to be 'good', it must have good explanatory power, and it must have good predictive power. But it is still an opinion. > > It is now interesting to think about Barthel or Apgar. They are clearly observational, at least partly, but do they contain opinions based on the evidence? One could argue that they do, since the point levels that designate different categories of babies or elderly patients are a kind of standard assessment about the meaning of the point levels. This would be the same situationn as a BP meter that has a red zone or indication when the systolic is above 180mmHg. Practically speaking I believe it is better to keep them as observations and treat the output as a kind of observation as well, which will act as the input to the next stage of proper assessment. For example, a low Apgar doesn't on its own tell what is wrong with the baby, only that something needs to be done fast; an doctor still needs to assess and act. > > - thomas -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #41 by @thomas.beale A way of summarising your view is: - an observation is a record of measured/observed patient state - an evaluation is a record of a theory of underlying process. An apgar score could be considered a way of classifying patient state into 'ok' and 'not good (needs immediate care)'... or is this really a way of classifying process into 'normal' and 'something wrong'? I don't think it matters that much; Apgar and the like are used as observational evidence on which opinions and then actions are founded. But I do think this state/process way of looking at observation/evaluation is a good one, and can be used to help clarify questions people have on this. We must update the wiki pages on this. - thomas Gerard Freriks wrote: [details="(attachments)"] ![OceanC\_small.png|74x72](upload://5I367QG2SMJUp18Pt3jF6yz13Ey.png) [/details] --- **Canonical:** https://discourse.openehr.org/t/dcm-terminfo-meeting-room-requirements-planning-for-phoenix/14983 **Original content:** https://discourse.openehr.org/t/dcm-terminfo-meeting-room-requirements-planning-for-phoenix/14983