We’re trying to model an operative note document - therefore we used the procedure archetype openEHR-EHR-ACTION.procedure.v1 and specialised it by adding other archetypes into the procedure details slot. Within the description of the procedure archetype it says
‘Additional structured and detailed information about the procedure can be captured using purpose-specific archetypes inserted into the ‘Procedure detail’ slot’
but
‘this archetype will be used to record only what was done during the procedure. Separate archetypes will be used to record the other required components of the Operation Report’.
I am a bit confused - we added something like specimens taken, devices, medication during surgery. Do you think it is valid to add these archetypes into the slot procedure details?
And what about elements like preoperative diagnosis, risks and anesthesia? I think these are detailed information for the surgery but they do not belong to the surgery itself - so they shouldn’t be added.
What do you think?
Thanks for your help and ideas.
Kind regards
Antje
Antje Wulff
Peter L. Reichertz Institut für Medizinische Informatik
Can you point us to the WHO checklists you had in mind ? It is worth noting that checklists are often orthogonal to operational data capture.
I would be thinking in terms of operative note as a composition , using the procedure archetype with device and detailed method in the slot.
To maximise reuse I would probably put specimen inside the relevant lab request archetype and similarly record meds using a medication order archetype. Prepping diagnosis would use the problem-diagnosis archetype.
Is it worth working this up as an exemplar template to put up on CKM?
I think it would be a good idea to have an example template. It might serve as a good starting point and reference model (not to be confused with the openEHR Reference Model :). However, our current effort is to create a template that mimics two surgery management systems at Hannover Medical School for the purpose of data integration. Therefore, the results might need some additional editing to become a good and generic example.
Thanks for sharing your ideas on modelling an operative report. I decided to use the procedure archetype in the way Ian described. Now I am thinking about how to integrate the different surgery steps, e.g. pre-operative preparation of the room/of the patient, incision to closure, post-operative preparation… for each step there is a specific date/time which has to be represented within an archetype. Do you think it might be possible to use the PATHWAY within the ACTION archetypes?
The first idea was to create a CLUSTER archetype called ‘surgical times’ in which each surgery step is represented by one data element (by using the data type date/time) but it does not feel very comfortable to me.
I suspect this is one of the situations where it feels like you have found a consistentpattern i.e. ‘surgical times’ but where each procedure and speciality may have very different ideas about exactly which times are significant. I had a similar experience when modelling metastatic cancer spread, where there initially seems to be a lot of commonality but you quickly get into a tangle with exceptions and redundant elements.
My inclination would be to create a generic cluster for operative details, including the common ‘surgical times’ but expect to have to ‘fork’ this frequently in the way that the physical examination archetypes are now modelled - i.e aim for generic patterns, rathe than true inheritance.
I don’t think these sub-events really qualify as Care steps. The only exception might be pre-op and post-op procedures/summary which perhaps merit their own archetypes but for now I would probably just include these within the operative details CLUSTER archetype.
I get involved a little late in this discussion, sorry for this but I did not know obout this forum.
The point is, we have already worked a lot on surgery and how to model the whole process.
We have implemented planning of surgery already and we did it by modelling a template for decision for surgery.
Like you we used the procedure INSTRUCTION archetype and it seems to work well. There is only one difference.
We decided to have one procedure instruction for the surgery an d one for the anesthesia. This because you sometimes you need surgery without anesthesia or anesthesia without surgery and we think that these to are so different that I makes sense to describe them as own procedure.
Than we added a lot of Clusters with details like information about priority details, special needs for surgery, plan for anesthesia etc.
That was the planning.
We are now proceeding to performing and documenting the procedure and we actually also thought of using the action care steps for registration of the different times/states during an operation.
Ian could you tell a little bit more about why do you think this would not be a good idea?
Anca, I agree with you. I think it would be better to have an own procedure action archetype for anesthesia. There are some more of these actions which can be done during a surgery, e.g. X-Ray/imaging help, blood arrest, pre-operative examination – I think it is not valid to model these concepts as CLUSTER because these are own ACTIONS, right? Unfortunately, it is not possible to add these ‘special methods’-archetypes into the details-slot of the surgery procedure archetype then (e.g. within a template) – so you can’t really represent that these actions may be a part of the surgery action.
How would be the approach to represent something like sub-actions?
May I suggest that Antje and Anca make a mindmap of their solution, showing the way the different archetypes beeing used fit together? That would clarify a lot. Would also be grate if Ian can make one of his suggestions. You can either attach it to this discussion thread, or use the openEHR/CKM general discussion feature. If the latter, please let us know by posting a link to the discussion here.
From Oslo university hospital point of view, as a customer of DIPS ASA (which delivers the solution Anca describes), we are interested in using archetypes that are thoroughly worked through and in line with an international understanding of the area.
I also agree about recording anaesthesia separately, especially if the template is being used in an operational system.
The various sub-steps could be regarded as their own ACTION/ OBSERVATIONS etc but sometimes this just makes the modelling too complicated. If the documentation is an operative note made by a surgeon after the procedure, he/she is essentially making a summary report in hindsight, rather than documenting the steps as he/she goes along. Definitely an area to explore further.
@Vebjørn - good suggestion. It is difficult to discuss these areas without clear examples. For policy reasons, this list does not accept attachments (under discussion). We could setup an Incubator on the international CKM and upload resources there. If people want to email mindmaps etc directly, I am happy to upload them to CKM.
I’m not sure we would like to continue todays practice, when the surgeon is making the operative note after the operation is over. As a general rule, data should be captured as they are produced, to avoid the extra work afterwards. (And as we know, that gives us poorer data quality and delay). So a solution that captures data as the surgery is being performed, will be very welcomed! The source of this will be from manual input from personel attending the operation, maybe from medical devices or from a third-party system (such as a charting system) in a type of combination of them all. Therefore the archetypes should be constructed to handle this.
Vebjørn
PS: I didn’t know attachments were not allowed here, my mistake. Incubator? Yes, please J
I totally agree in principle but sometimes implementers have to compromise and reflect the immediate needs of registry/reporting style recording. It is fine balance!!
For a better discussion, I will try to put together my ideas for an operative report template and the corresponding archetypes into a mindmap as soon as possible! Thanks for the link, Ian.
Yes, Vebjørn – from my work I know that there often is a combination of manual input (the documentation starts during the surgery, especially the ‘live’ documentation of the surgical times) and medical devices (e.g. scanning of implants). On the other hand, some elements are added after the surgery.
I think we have to be clear about the term ‘operative note’ – often the surgeon dictates the procedure after the surgery but there is another type of an operative document (called operative report in English, I guess). The operative report summarizes details about devices used, materials, the team and their tasks, times…This documentation often starts during the surgery (done by nursing staff). So, as Ian said there are many different needs…
Antje Wulff
Peter L. Reichertz Institut für Medizinische Informatik
I think the best solution is to repost the question on the Wiki and then point people to the CKM incubator, once we have some activity there We are still very much in discovery phase here and we need to work up the questions/ possible answers first.
