This is part of a discussion that started off the list. The need is to be able to model Episodes in openEHR, while remaining compatible with available structures.
Currently, there is no “Episode” class (although this doesn’t necessarily have to remain this way). Up to now, we have never been able to nail down sufficiently ‘standard’ requirements to satisfy everyone’s idea of an “episode”. Instead we have suggested that Folders be used as reference containers to Compositions considered to have occurred in an episode. The current EHR reference model shows this.
More recent thinking on this issue:
on my recent visit to Mayo Clinic at Rochester Minnesota, I discovered that their idea of an Episode in the MICS system is “a period of care overseen by a particular clinician”. E.g. if someone comes in with an injury, the doctor referred to (by a GP or by A&E) ‘runs’ the episode. Even if the patient sutains an MI while in hospital, and that becomes her main problem, and a cardiologist gets involved, the original clinician in almost all cases is in charge of the episode, and will make the discharge summary. An episode can be ‘closed’ on the MICS system, but can be reopened by some special operation, e.g. if erroneous information is spotted later on. I seem to remember that someone else can take over an episode - presumably if the original clinician becomes unable to continue giving care for some reason. (Someone from Mayo on this list might want to correct me if I have any of this wrong).
Maarten Spook of 2Cure, Amsterdam has some very typical requirements of an “Episode”, as follows:
We think of attributes like:
startDateTime: the date-time the episode is started (medically)
stopDateTime: the date-time the episode has ended (medically). When present this folder is closed?
createdDateTime: the date-time the episode was created (administrative)
contributers: care providers and their role (participations?) It would be clear to see who had added info and who is responsible for this episode etc
structured annotation: a short description of the content / context of the episode
My comment on this is: of the above attributes, it is the first 3, and maybe #5 which need to be associated with an episode as such. Contributors can be determined from the contributors to versioned Compositions in openEHR (remember “Contributor” is actually a class itself in the openEHR Common model). Let us consider if we could achieve this just using Folders, as a “straw man” proposal.
clinical start date time can be determined from the start_time of the first Composition in the Folder
clinical stop date time can be determined from the endt_time of the last Composition in the Folder
created date time of the “episode” - administrative. Depends on what this really means. The creation date time of the Folder representing the episode is easy - it is the time_committed in the audit attribute of the type VERSION resulting from the class VERSIONED_COMPOSITION being a binding of VERSION_REPOSITORY to COMPOSITION.
contributors - as mentioned above, these can be derived from inspecting Compositions in the Folder
structured annotation describing episode. Usually this would be in the discharge summary, itself a Composition, containing narrative and links to previous Compositions & Entries in the episode. However, does it need to be someting else?
Maarten also mentioned that in their system, they want to be able to “close” an episode, in a similar sense as the Mayo description given above. This functionality doesn’t exist in openEHR.
Lastly, I believe in CEN ENV13606 there was the idea of a Folder that could be “closed”, presumably to simulate an episode. However, some users of 13606 don’t want to use Folders at all, so where would that leave them.
Some questions:
are there other attributes or functions required in the “episode” concept?
is there any hope of standardising the idea of “episode” sufficiently to create a class in the reference model for it?
is the Folder good enough to model an episode?
over to the group…
thomas beale
If you have any questions about using this list, please send a message to d.lloyd@openehr.org
This is part of a discussion that started off the list. The need is to
be able to model Episodes in openEHR, while remaining compatible with
available structures.
Definition from this link:
/The basic record is^ a finished consultant episode of care (the time spent under^ the care of one consultant). An admission, or spell, is defined^ as a continuous period of time spent as a patient within a trust,^ and may include more than one episode. Using HES data, we contrasted^ spell based activity and episode based activity, using myocardial^ infarction as an example.
......
/Measuring hospital activity by episode could result in^ overestimates of up to 50% for myocardial infarction. In 2.9%^ of spells, vague symptoms and signs were noted in the primary^ diagnosis of the first episode with myocardial infarction in^ the subsequent episode. Overestimates carry obvious implications^ for estimating the incidence of disease and assessing healthcare^ outcomes.
Consider the following as requirements from the Netherlands.
The Dutch GP organization NHG has defined Episode as:
An Episode is a chronological collection of medical data (episode items) of one patient and describes the state changes over time concerning one health problem.
The name of the episode describes the health problem (health issue) and can be changed over time.
The episode unordered list contains all episodes, open or closed.
Episodes can have an attribute indicating "attention"
Episodes can be closed and opened.
Episodes can be joined and split
One episode consists of episode items.
Episode items are: report as the result of a contact, Prescription/Order, Diagnostic Archive, Correspondence.
Most of Marten Spook's attributes stem from these Dutch GP requirements.
I consider Episodes as an alternative view on the information collected.
It is a list consisting of links pointing to registered information that is available in the system.
The preferred place to store this list is the Folder.
And then there are our DBC's (DRG's) One DBC is almost the same as an Episode.
At Mayo Episodes of care start with any billable encounter with the health system (e.g. clinician visit, lab test, etc.) and ends when the clinician of primary record says that the episode is complete. For curable illness this often occurs after the cure. For chronic illnesses it usually ends when the patient reaches a steady state or a goal (e.g. Diabetes Mellitus with a HgA1C < 7.0 mg/dl). For surgeries it may be after the first post hospital visit. For medical hospitalizations it is often at the time of discharge. This has two important implications. One there is one clinician who is identified as the team leader of record who is charged to coordinate all of the care from any provider in the health system. Two, at the end of an episode the clinician is mandated to sum up the episode and state for the record what are the final diagnoses for this episode of care.
I hope that this helps.
Warm regards,
Peter
Peter L. Elkin, MD
Professor of Medicine
Mayo Clinic, College of Medicine
>
Defintion from this link:
The period of admitted patient care between a formal or statistical
admission and a formal or statistical separation, characterised by only
one care type.
I personally think this is not that useful, since older and complex
patients just don't have only one care type (which I take to mean
specialty).
Although you would never know it from the web page, by "care type", they
mean "acute care" versus "rehabilitation" versus "psychiatric". These
distinctions are purely administrative and have no definitive clinical
or epidemiological meaning. Nevertheless, it is teh basis of all
official Australian hospital statistics. The British definitions are
much better, I think.
I would suggest that the most meaningful defintion of "episode" is more
like the Mayo one - an admission (= acceptance by a provider institution
to undertake provision of healthcare to a patient) to the point in time
when the same institution performs a transfer of care to another
provider - a referral of some kind to e.g. the GP, aged care home,
self-care at home.
We refer to that as a "separation" - which begins with inpatient
admission to a healthcare facility and ends with discharge, transfer or
death. You also need rules for "leave" - some patients (eg long-term
psych patients, rehab patients) go on leave during the course of one
admission/separation.
But we also have to ask the question of what use is knowing where the
boundaries of an episode are. Clearly cost accounting occurs at a much
finer level of detail, which is easily supported by models like openEHR
(to our knowledge to date at least);
Hospital- and ward-level cost accounting might take place at finer
levels of detail, but hospital funding tends to use these
administrative/"statistical" definitions, as noted in the BMJ article.
An EHR repository will not curry much favour with administrators (who
tend to hold the purse-strings) if it can't give them the information
they want (which is not necessarily what they need...)
it seems to me that an episode is
more to do with a period of legal responsibility of care by a provider
(institution).
Episodes could be called "funding temporal units".
At Mayo Episodes of care start with any billable encounter with
the health system (e.g. clinician visit, lab test, etc.) and ends
when the clinician of primary record says that the episode is complete.
For curable illness this often occurs after the cure. For chronic
illnesses it usually ends when the patient reaches a steady state or
a goal (e.g. Diabetes Mellitus with a HgA1C < 7.0 mg/dl). For
surgeries it may be after the first post hospital visit. For medical
hospitalizations it is often at the time of discharge. This has two
important implications. One there is one clinician who is identified
as the team leader of record who is charged to coordinate all of the
care from any provider in the health system.
That is quite different to the model of care in Australian hospitals
(and British hospitals when I worked there 20 yrs ago - probably still
the same). Patients are the responsibility of "teams" (or "firms")
organised around a consultant/specialist (or a small group of them).
Thus, if a surgical patient is admitted to ICU post-surgery, then it is
the ICU team (and ultimately the ICU specialist in charge) who has the
final say in the patient's care (well, the patient and relatives may
have some say...) while they are in the ICU. The surgical team might
drop by to see how the patient is going and to assess te outcome of the
surgery, but the surgeon doesn't manage, for example, the haemodynamics,
ventilation and blood sugars of the patient. Responsibility for
recording what happens falls to the teams currently in charge of the
patient.
Two, at the end of an
episode the clinician is mandated to sum up the episode and state for
the record what are the final diagnoses for this episode of care.
The defect in the Australian model is that the responsibility for this
summing up falls to the last team to look after the patient prior to
separation - and that team may not be very interested or knowledgeable
about the treatment which went on before they took over the patient
(although it would be rare or unfortunate if they did not know enough to
record some sort of precis of it). However, as a GP, I often used to
receive hospital discharge summaries which devoted one line to the
extensive surgery which a patient underwent and the weeks which they
spent in ICU recovering from complications, but half a page to their
rehabilitation and functional status at discharge. Of course that is
quite appropriate for a discharge summary, and perhaps for a
community-based EHR. Less useful if some other surgeon in some other
hospital needs to revisit the patient's earlier surgery (but surgeons
prefer to look for themselves and never believe anything written in the
medical record - or EHR).
The first question, when it comes to "episodes" is to know if you are talking about "episodes of care" or "episodes of disease". Of course both concepts are very different.
To try a joke, I could says "tell me how you manage your patients over time, and I will tell you who you are".
Certainly, the choise of Episodes of disease, as described by Gerard is the vision of GPs and closely related to Problem Oriented Medical Record (POMR).
Episodes of care is either the vision of a care place or the way a group is organisd to treat a specific disease : for example the treatment of cancer is organized using a pre-determined set of Episodes of care.
you deal with continuity of care. An episodes of care is a technical concept, and often a local concept. Clearly episodes of care occur in an episode of disease.
If the Episode of disease if a worldwide clearly defined concept, through the POMR structure and the WONCA organization, you probably will find a specific definition of the episode of care in each care organization (care places or care networks) and I don't know if you can standardize it.
The first question, when it comes to "episodes" is to know if you are
talking about "episodes of care" or "episodes of disease". Of course
both concepts are very different.
Exactly!
....
If the Episode of disease if a worldwide clearly defined concept,
through the POMR structure and the WONCA organization, you probably will
find a specific definition of the episode of care in each care
organization (care places or care networks) and I don't know if you can
standardize it.
Probably true. Jurisdiction- and organisation-specific "episode of care"
archetypes are likely to be needed.
Although you would never know it from the web page, by "care type", they
mean "acute care" versus "rehabilitation" versus "psychiatric". These
distinctions are purely administrative and have no definitive clinical
or epidemiological meaning.
i.e. more or less "setting"?
I would suggest that the most meaningful defintion of "episode" is more like the Mayo one - an admission (= acceptance by a provider institution to undertake provision of healthcare to a patient) to the point in time when the same institution performs a transfer of care to another provider - a referral of some kind to e.g. the GP, aged care home, self-care at home.
We refer to that as a "separation" - which begins with inpatient
admission to a healthcare facility and ends with discharge, transfer or
death. You also need rules for "leave" - some patients (eg long-term
psych patients, rehab patients) go on leave during the course of one
admission/separation.
in your understanding Tim, does "separation" mean transfer of legal responsibility for care?
Episodes could be called "funding temporal units".
is the best way to develop a model for "Episode" in a reference model like openEHR to start with a model of funding/cost reporting? That would almost seem to guarantee that a common model of episode is going to be dificult to find, since such matters are quite dependent on how healthcare is financed in each country.
Although you would never know it from the web page, by "care type", they
mean "acute care" versus "rehabilitation" versus "psychiatric". These
distinctions are purely administrative and have no definitive clinical
or epidemiological meaning.
i.e. more or less "setting"?
No, because a patinet can stay in exactlyteh same bed in teh same hospital and change bewteen an acute care epidsode and a rehab episode. Yes, its completely artifical, but that's how the bean counters count.
in your understanding Tim, does "separation" mean transfer of legal responsibility for care?
Yes.
Episodes could be called "funding temporal units".
is the best way to develop a model for "Episode" in a reference model like openEHR to start with a model of funding/cost reporting? That would almost seem to guarantee that a common model of episode is going to be dificult to find, since such matters are quite dependent on how healthcare is financed in each country.
Yup, just pointing out that openEHr will need to accomodate these national requirements if openEHR repositories are to please the bean counters.
Clearly this discussion will run a while longer, and we can hope to hear from other clinicians, and from a variety of geographical locations and clinical cultures. At this point, can we suggest that:
1. there are "episodes of care", which are to do with a) accounting/reporting and/or b) acceptance / discharge of legal responsibility for care ("separation")
2. there are "episodes of illness", which are to do with the course of a problem/issue/disease. What about pregnancy, chronic asthma, and conditions which seem to slide from being chronic to being solved to relapses (e.g. back pain)?
I think "episodes of illness" can be modelled with openEHR (and CEN 13606; possibly CDA as well) - it is done using links between Entries, Compositions etc to create "threads" (which may be branching) of recorded items relating to each problem. Each link indicates which problem it is about. A single given recording may be multiply classified as data relating to more than one problem. Of course we need more experience with this aspect of the models to see how well it will work. Philippe Ameline's system is probably ahead of any others I have seen in this respect - maybe he wants to add some wisdom here.
I would like to know who would agree with the proposition that an "episode of care" is bounded by acceptance & discharge of legal responsibility for care provision by a given provide (institution).
Hi
I think Tim Churches is more on track. Gerard appears to be describing a
"problem" as I would understand it in POMR. An episode in natural language
implies a discreet period of time and I would make a plea that we (you?)
retain the meaning of any term that is closest to its natural meaning. An
episode is an incident in a series of events or something along those lines.
A problem can be 'active', 'inactive', or 'terminated'. An episode is
'active' or 'complete'. I propose that there can only be one episode
effecting a person at one time. You can only be in one place at one time
(except for some odd situations such as a person who takes leave from an
inpatient facility for a couple of hours for some ongoing and completely
unrelated treatment as an outpatient at private rooms. They may not even
tell the inpatient facility why they want to go out. It may be better to
call that two "concurrent" episodes for practical reasons because in this
situation, he/she is behaving semantically like two people.)
I propose the following definition: "An episode is a period of management of
a patient from the time of presentation to a medical unit (which can be
anything from the teams or "firms" in a teaching hospital to an individual
practitioner) until the unit or a proxy "discharges" the patient." The
proxy could be a unit (on the last unit) to which the patient is transferred
during the course of the episode. (An example could be general surgery =>
cardiology => cardiac surgery => rehabilitation: all one episode.)
I would be against using definitions based on legal responsibilities as that
is truly nebulous, especially in common law jurisdictions and is ultimately
at the whim of some judge.
It is not very precise and can never be as each specialty and medical
culture may have a different approach. However, almost everyone "knows"
when an episode is done. That is why I propose that the treating unit
"declare" the end of an episode. This is where the word "discharge" needs
definition. It is an active, transitive verb and that is why the intention
of the unit/doctor concerned should be the paramount consideration. It
their intention to relinquish direct responsibility that is crucial. It is
comparable to death in our jurisdiction. You are dead when a doctor says
you are! (i.e. declares "life extinct", or in the case of "brain dead", two
doctors after due deliberation but that is a special case.)
Our hospital systems speak of a "separation" which befits a hospital as
discharge is a form of separation. It might be more difficult in GP. I
think an episode has to be considered separate from say just "discharge from
hospital" which is better termed a "separation" or similar. An episode can
involve a period of inpatient and outpatient treatment.
The question of transfer between units is difficult. If a person is admitted
under the abdominal surgeons with a stomach ulcer and is subsequently
transferred to the cardiologists when it is established 24 hours later that
it is a myocardial infarct, is that one or two episodes? Most people would
consider it to be one episode in natural terms but there could be a rule
requiring that this is two separate "incidents" for the purposes of
remuneration for example. It would be up to the two units as to whether
this would be called one or two episodes and could be handled semantically
by allowing that an episode can involve semantically "seamless" transfer
from one unit to another until a unit declares "DISCHARGE" and then the
episode is done.
Cheers
CDC, Perth
Looking at the discussion it is very obvious that there are several points of view and all are reasonable and correct.
One: the patient viewpoint. The Episode (as I described): one patient, one health issue, and many healthcare parties, contacts, etc
Two: the Healthcare party viewpoint. The administrative view. One admission upto discharge for whatever reason.
Three: What is the viewpoint as seen from the third type of healthcare party? The payor.
Four: What is the viewpoint as seen from Government reporting, reserach, etc?
Each viewpoint needs its own definitions of attributes and code systems
And all must be harmonized.
I expect that work in CEN/TC251 (System of Concepts for Continuity of Care) might enlighten us.
Gerard
-- <private> --
Gerard Freriks, arts
Huigsloterdijk 378
2158 LR Buitenkaag
The Netherlands
The Dutch GP organization NHG has defined Episode as:
An Episode is a chronological collection of medical data (episode
items) of one patient and describes the state changes over time
concerning one health problem.
This is what GnuMed uses, too.
The name of the episode describes the health problem (health issue)
and can be changed over time.
Same with GnuMed. We allow any item within the clinical
narrative to be declared the defining item for the episode
name. The episode name describes the current active health
problem. The term health issue is used to describe underlying,
more general (chronic?) issues with one's health. Those are
highly likely to affect health of the entire lifetime with
differing levels of activity (eg. may be dormant for a while
but will still exist as a "threat"). Such a health issue may
show up in several episodes each of which pertains to a
different episode in time where a particular health problem
was active.
The episode unordered list contains all episodes, open or closed.
Episodes can have an attribute indicating "attention"
We consider the episode to "just be there" whether we pay
attention to it or not (and different clinicians may in fact
define the open-/closedness of an episode differently - and
they can, it's at the discreetion of the user to define their
state). Only members of it (eg. clinical items being attached
to an episode) can be "clinically_relevant" (eg. need
attention). One may want to define the deliberate association
that any episode with a clinical item that is
clinically_relevant to always be open. But this does not seem
mandatory.
Episodes can be closed and opened.
Agree.
Episodes can be joined and split
Agree.
One episode consists of episode items.
Agree.
Episode items are: report as the result of a contact,
Prescription/Order, Diagnostic Archive, Correspondence.
I consider Episodes as an alternative view on the information
collected.
Agree.
It is a list consisting of links pointing to registered information
that is available in the system.
We have that information always bound to an episode - that
which is bounded by the states the primary clinician thinks is
useful. This we can do because we target the GP/community
specialist setting. It can be redefined, however.
The first question, when it comes to "episodes" is to know if you are
talking about "episodes of care" or "episodes of disease".
Interesting distinction. We (GnuMed) never thought of that but
implicitely used episode of disease (eg. our episodes are
stored in a table named clin_episode).
At Mayo Episodes of care start with any billable encounter
with the health system (e.g. clinician visit, lab test, etc.)
and ends when the clinician of primary record says that the
episode is complete. For curable illness this often occurs
after the cure. For chronic illnesses it usually ends when the
patient reaches a steady state or a goal (e.g. Diabetes
Mellitus with a HgA1C < 7.0 mg/dl). For surgeries it may be
after the first post hospital visit. For medical
hospitalizations it is often at the time of discharge. This has
two important implications. One there is one clinician who is
identified as the team leader of record who is charged to
coordinate all of the care from any provider in the health
system. Two, at the end of an episode the clinician is mandated
to sum up the episode and state for the record what are the
final diagnoses for this episode of care.
This is quite telling. Although Mayo certainly appears to be a
wee bit larger than my surgery (GnuMed) both are served well by
pretty much exactly the same definition of (medical) episode -
even though one is in the US while the other is in Germany.
Doesn't that indicate something about the validity of the
definition ?
I propose the following definition: "An episode is a period of management of
a patient from the time of presentation to a medical unit (which can be
anything from the teams or "firms" in a teaching hospital to an individual
practitioner) until the unit or a proxy "discharges" the patient." The
proxy could be a unit (on the last unit) to which the patient is transferred
during the course of the episode. (An example could be general surgery =>
cardiology => cardiac surgery => rehabilitation: all one episode.)
I would be against using definitions based on legal responsibilities as that
is truly nebulous, especially in common law jurisdictions and is ultimately
at the whim of some judge.
Actually, I agree with that, but we still need to be precise enough for the definition to work. As you say...
... This is where the word "discharge" needs
definition. It is an active, transitive verb and that is why the intention
of the unit/doctor concerned should be the paramount consideration. It
their intention to relinquish direct responsibility that is crucial.
i.e. responsibility for providing any further care (until some later moment perhaps when you again accept responsibility for care)
It is
comparable to death in our jurisdiction. You are dead when a doctor says
you are! (i.e. declares "life extinct", or in the case of "brain dead", two
doctors after due deliberation but that is a special case.)
Our hospital systems speak of a "separation" which befits a hospital as
discharge is a form of separation. It might be more difficult in GP. I
think an episode has to be considered separate from say just "discharge from
hospital" which is better termed a "separation" or similar. An episode can
involve a period of inpatient and outpatient treatment.
So a "separation" doesn't involve follow-up outpatient treatment/monitoring?
The question of transfer between units is difficult. If a person is admitted
under the abdominal surgeons with a stomach ulcer and is subsequently
transferred to the cardiologists when it is established 24 hours later that
it is a myocardial infarct, is that one or two episodes? Most people would
consider it to be one episode in natural terms but there could be a rule
requiring that this is two separate "incidents" for the purposes of
remuneration for example. It would be up to the two units as to whether
this would be called one or two episodes and could be handled semantically
by allowing that an episode can involve semantically "seamless" transfer
from one unit to another until a unit declares "DISCHARGE" and then the
episode is done.
If we followed the Mayo model (and your definition, depending on which granularity of "medical unit" is identified), it would be one episode, but detailed EHR recording will of course provide correct coding/classification of the incidents, allowing remneratoin to occur as usual.
How common is the Mayo model, where the initial clinician is the "team leader" (as Peter Elkin explained), and shepherds the episode through from go to woe?
"Separation" in our system means departure from hospital and does not imply
anything specific about follow up. A majority are followed up but if you
have fully recovered from a simple illness, you may be discharged to the
care of your GP or even to formal no follow up at all.
In our set-up, the team leader is the clinician under whom the patient is
"admitted" at the time and will change if the patient is transferred to
another unit. We don't really speak of "team leaders". The usual question
is "Who is this patient under?" One important exception is ICU. To be
admitted, a patient must be "under" another non ICU team as well as the ICU
team involved. Thus all ICU patients are under two teams. The rational is
that the ICU can discharge anyone to the ordinary wards at will without
having to "find a team" if they need to free up a bed urgently. The outside
team has to take the patient whether they like it or not and the ICU is
never left "holding the baby". If a patient is admitted direct to ICU in an
emergency and no one else will take responsibility for them, the general
medical team of the day (of admission) is the default outside unit and then
have to try to "slough" the patient to a sub specialist or other appropriate
team, or take the patient on discharge.
These links are very helpful...particularly to show that the idea of episode is about one consultant - rather than admission. The Australian data dictionary is about an admitted patient episode.
It is clear that many types of groupings will be required. The Folders solution may be one - but I believe a 'persistent' EVALUATION which is archetyped for the purpose is more likely to be useful....as it will allow collection of whatever data is required.