Episode of care - institution

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Hi @heather.leslie (and everybody),

I just saw that the archetype has been made visible. I’m currently working on the representation of episodes of care and encounters for HiGHmed/Nephro Digital and a case management software. I was wondering what has been the sources for the modelling. In general, I would see an encounter as the information object being created on an admission inside a particular organization and episode of care as something that exists one level above an encounter. I think it would be good to also include guys from code24 (@sebastian.iancu) and maybe also nedap in this conversation.

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and @bna

It does end up being a very complex area as the terms that are used and the understanding is very driven by whether you are working in GP type longitudinal care which really has little idea of episodes of care , community-care ( Code24) where this is around care-planning and hospitals which is much more about admissions and out patient episodes.

Teasing out the language and use=cases is actually very challenging. Bjorn and I both think that Contsys has done a pretty good job of conceptualising the space in a way that we should definitely pick up on, otherwise we will waste a huge amount of energy doing the same job. That’s not to say we should try to implement Contsys as -is but it just helps make sure that everyone is talking in the same terms.

http://www.contsys.net/non_cm/documents.htm

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I’ll have to have another look at Contsys :confounded:
Last time I looked was admittedly quite a while ago when I suggested to them that if they were too theoretical and we couldn’t model it, then it wasn’t going to be much use IRL. I had assumed it wouldn’t change much because it was an ISO standard :pensive: .
Happy to revise my view if it has. I heard rumours of a v2 since then…
@birger.haarbrandt Consider this a starting point to capture data around a single admission/separation episode in an institution. Current archetypes about admission & discharge are old & a bit of a mess, mixing clinical & admin & logistics data. Even the word discharge is incorrect eg death, discharge to home, transfer to another institution…
Starting with fairly simple & ubiquitous data points. Testing the water to see if the concept is right first.
Happy for change requests/suggestions.

Primary care episodes are considered quite differently. Not sure that outpatients have episodes, or maybe follow a primary care pattern with a series of discrete visits…

Let’s tease it out…

Heather

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I agree it was too theoretical to implement directly, but the theory is pretty good. The challenge was that the market is/was not really ready to embrace the kind of vision of cross-sector continuity of care and they were trying to force people to re-engineer their systems (openEHR included) without a clear demand or capacity.

BUT!!! I know from experience that when we start talking about encounters and episodes of care and problem lists, very quickly we will find that the meaning behind these terms is highly variable, and takes a long time to tease out. Much of the teasing out has already been done by both Contsys-1 and 2. There will be more required, of course as requirements emerge.

If we agree to start with the Contsys-2 definitions I think we may short circuit a huge amount of confusion and wasted energy.

Their concept naming may seem a bit weird and probably does not line up with anyone’s local definitions but in many ways that is bonus, since everyone starts with a clean set of as-yet implementaiyon-agnostic definitions.

Up to folks if they want to change the internal definition of e.g. ‘encounter’ to the Contsys-2 equivalent, or just map internally. I think the broader openEHR community is best served by using contsys-2 concept names as neutral start-point.For example …

period of (health) care set of contacts between a subject of care and one or more health care professionals in the framework of a care mandate
(health care) contact occasion defined by one health care professional when health care provider activities are performed for one subject of care
record contact contact restricted to the access to the professional health record of a subject of care by a health care professional for its management, out of the presence of that subject of care
(health care) encounter contact in the course of which health care provider [FM1]activities are delivered to a subject of care in her or his presence
contact element part of a contact which specifically addresses one health issue
episode of (health) care time interval during which health care activities are performed by one health care provider to address one professionally defined health issue
cumulative episode of (health) care collection of episodes of care delineated by one health issue thread

One problem is that these ISO standards are behind a firewall but Contsys is well documented here

https://contsys.org/package

NHs Digitial has als os attempted to SNOMED code parts of the model - I happen to think this is almost certainly broadly the wrong approach but there may be useful aspects.

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Ooooh, it fair does my head in.

Um - episode is theoretically fine but still extremely vague, eg difference between hospital and primary care. I’ll undertake to make my head hurt more and try to propose some practical models. But I’m suspicious we’ll still be winging it, even with these high level concepts in place. Real world is messy.

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I agree in general with @birger.haarbrandt. That would be my interpretation of an Encounter (slightly clearer concept) and Episode of Care (not as clear).

For OP an Encounter starts when the patient arrives to the clinic and ends when they leave.

For an IP an Encounter starts on admission and in most cases end on discharge. However, at least in the counties I’ve worked with encounters (Sweden and UK/NHS) IP encounters can also end when clinical responsibility changes. In Sweden a transfer from one specialty to another (represented by organizational departments) and in the UK between different consultants (consultant episodes). This means that an IP stay can consist of multiple Encounters in sequence. In the UK referred to as a Hospital Provider Spell.

The encounters (for one single OP visit) or each IP encounter are the basis for grouping costs and other information. It can answer things like “what happened during the patient’s last visit”. So I would say they primarily have administrative purpose.

Now, openEHRs Encounter does not match this concept which has confused me a bit. It seems to capture each individual encounter between a patient and an indictable healthcare professional, whereas the Encounter I am used to from SWE/UK capture the encounter between patient and an organization. Of course, during an admission to hospital the patient would have most commonly one Encounter (the admin type I am referring to) but any number of openEHR encounters.

Episode of Care I would also argue is something broader and spanning over longer periods of time. They do not require the patient to be actively engaged with a healthcare organization. These could also be more seen as “cases”, a patient could have an episode of care for a problem during which they have multiple encounters (admin ones) to the GP or hospital. Patients can be treated in home care or within psychiatry/mental health with periods of time where they are not actively being treated or seen. You still want to monitor these, I would see them as episodes of care.

We also have a concept of a “Commitment” which is a healthcare organizations commitment to treat a patient for a certain problem. Also an Episode of Care if you ask me during which the patient can have any number of Encounters.

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In some way, encounter and contact have the same meaning, i.e., interchangeable. But as ContSys defined, Episode of Care is a more broader and complex concept.

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Agree, we need a common concept system like ContSys to support our artefact authoring. Not long time ago, I informally converted the ContSys into OWL format.

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In Portugal we have the same situation described by @martin.grundberg. And as I can see, these concepts are used in more country. Shouldn’t episode of care and other concepts like “cumulative episode of care” be defined in the RM?

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Possibly, but I suspect it would be better to ‘trial’ the ideas using archetypes in the first instance. The ideas in Contsys look good to me but practically implementing them in real systems is still experimental. And what people think they want from ‘Episodes of Care’ often differs quite dramatically. For sensible reasons it takes time to have changes applied to the RM, especially something contentious and fundamental like Contsys, so my suggestion is to see how far we can try out the concepts using archetypes, at least until we have some confidence and consensus.

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This is my whole concern in this area - everyone comes to the space with quite different ideas of the meaning of Episode/ encounter based (not unreasonably) on prior experience. The terms Encounter, episode. spell, period are all hugely overloaded., The openEHR Encounter is largely from a primary-care or individual practitioner perspective, your is from an organisaitonal / reporting perspective. Neither are wrong. There have been successive efforts in various places to standardise the ideas. Contsys is the only one that feels to me to have been bold enough to take a truly holistic approach, and not be afraid to use new teminology

That’s why I would strongly suggest using Contsys as the ‘common language’ for these ideas, even if they do not fit anyone’s language properly. They are at least neutral, and sometimes phrased in a way that is a bit weird - e.g ‘Health issue thread’ .

http://www.contsys.net/documents/prEN13940-2_(E)_WD_2009-11-26khl.doc

I would map your idea of Encounter to

episode of (health) care time interval during which health care activities are performed by one health care provider to address one professionally defined health issue

spell of care to …

period of (health) care set of contacts between a subject of care and one or more health care professionals in the framework of a care mandate

openEHR Encounter does map to

(health care) encounter contact in the course of which health care provider [FM1]activities are delivered to a subject of care in her or his presence

Commitment is

(health) care mandate health mandate following a demand for care, assigned to, and accepted by, a health care provider to perform health care provider activities, and to manage a local health record

What is important (and where I disagreed with the way Contsys was trying to get adopted) is that we need to expect local organisations and practitioners to defend their local terms - just too hard to get people /systems to drop this.

So my thoughts are that we should name any Contsys artefacts using their terminology but accept that local naming will still be needed. Also that contsys alignment might be best achieved by using cluster extensions, into existing archetypes, RM constructs. The Contsys people wanted to basically build their own RM - that was just never going to happen.

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I dont have in depth experience with ContSys, but will have to check again. It is very abstract, and on a very high level, so it has been a bit difficult for me to see how to use it for any practical use case in the past.

Just looking at your suggestions:

I would map your idea of Encounter to

episode of (health) care time interval during which health care activities are performed by one health care provider to address one professionally defined health issue

I don’t think this fits due to the last part, it put’s an unnecessary constraint on what I mean with “Encounter”. It could be multiple “Health issues”, a concept that is vague in itself. And depending on what you mean with “Health Issue” it could also be no health issue.

spell of care to …

period of (health) care set of contacts between a subject of care and one or more health care professionals in the framework of a care mandate

Maybe we are getting to the point here, I don’t see that the contact is between patient and a healthcare professional, but instead between a patient and a healthcare organization of some sort. So this definition I think falls on that in terms of what I would consider a “Hospital Provider Spell” or a “Episode of Care”. I also see that an Episode of Care doesnt have to necessarily include contacts (my idea of an Encounter). Image a patient being referred and the referral being accepted, hence initiating an episode of care, but the patient has yet to have an actual contacts.

I would define it something like this.

Contact / Administrative Encounter
An interaction or encounter between a subject of care and a healthcare organization spanning over a period of time. It can be face to face, virtual or in more indirect ways such as a letter. It can be in an outpatient setting, such as a booked appointment, unplanned acute visits to A&E or admissions as an inpatient. During the contact several healthcare activities can take place, and several healthcare professionals can be involved in the patient care. The contact is often used for administrative purposes such as to group costs as well as retrospectively see what has happened during a contact. A contact can end by an appointment ending, a discharge (to home, care home etc) or a change of organizational responsibility. The latter is often that a new administrative grouping of costs is required.
During a contact a patient can have had periods where they have stayed at different locations. For an inpatient, this can mean transfers between wards and beds.
As the contact is primarily used fo administrative purposes, it is also common to have a requirement to perform administrative coding per contact, e.g. setting diagnosis and procedure codes as part of the closure and summary of the contact.

I agree that it is a good idea to start agreering on the concepts, as obviously the terms are used differently, e.g. same term for different concepts.

I also agree that this concept that me and others have in mind should be possible to model as an archetype. If there is a good pattern for handling administrative differences in different markets (have slots for market specific archetypes) I don’t think modelling such an “administrative encounter” should be impossible.