Revision of Instructions - clinical implications

Clinical (archive)
1

There is a discussion on the technical lists about handling
INSTRUCTIONS and subsequent ACTIONS in openEHR. Heather Leslie has
provided an excellent explanation of the process but there is one
comment that I feel merits some further clinical discussion.

"But: how is that change of the Instruction state recorded on the EHR?
[HL>] The INSTRUCTION for a procedure remains unchanged, unless the
clinician changes the nature of the original order and this is carried
out with a revision of the committed INSTRUCTION."

I have a current use case for modelling Medication orders, and the
situation where the original order is altered slightly e.g a minor
change of dosage or timing, where the clinicians have expressed a
requirement to have this 'seen' as a modification of the original
order, rather than a completely new order.

This would seem to accord exactly with Heather's suggestion above i.e.
simply modify the original order in the original committed
composition, updating the version.

I am not totally comfortable with this approach, since it feels to me
as if we are asserting that the original order was incorrect. This
would obviously be ok if we were indeed correcting an order which had
never been actioned but for a valid, actioned order, this does not
feel correct, since it essentially hides the original order, albeit
that the original instruction is still available for medico-legal
purposes via the original committed version.

I think would prefer to create a new order but link it to the
original to ensure that the clinical requirement to maintain a chain
of events is ensured"

Any thoughts?

Ian
Dr Ian McNicoll
office +44 (0)1536 414 994
fax +44 (0)1536 516317
mobile +44 (0)775 209 7859
skype ianmcnicoll
ian.mcnicoll@oceaninformatics.com

Clinical Modelling Consultant, Ocean Informatics, UK
Director/Clinical Knowledge Editor openEHR Foundation www.openehr.org/knowledge
Honorary Senior Research Associate, CHIME, UCL
SCIMP Working Group, NHS Scotland
BCS Primary Health Care www.phcsg.org

2

Isn’t ‘Instruction’ itself an action?

Jag

Dr. S Jagannathan
198 St Johns Road
Edinburgh
EH12 8SQ

— On Sat, 10/12/11, Ian McNicoll Ian.McNicoll@oceaninformatics.com wrote:


> From: Ian McNicoll Ian.McNicoll@oceaninformatics.com
> Subject: Revision of Instructions - clinical implications
> To: “openEHR clinical discussions” openehr-clinical@openehr.org
> Date: Saturday, 10 December, 2011, 15:44
>
> There is a discussion on the technical lists about handling
> INSTRUCTIONS and subsequent ACTIONS in openEHR. Heather Leslie has
> provided an excellent explanation of the process but there is one
> comment that I feel merits some further clinical discussion.
>
> “But: how is that change of the Instruction state recorded on the EHR?
> [HL>] The INSTRUCTION for a procedure remains unchanged, unless the
> clinician changes the nature of the original order and this is carried
> out with a revision of the committed INSTRUCTION.”
>
> I have a current use case for modelling Medication orders, and the
> situation where the original order is altered slightly e.g a minor
> change of dosage or timing, where the clinicians have expressed a
> requirement to have this ‘seen’ as a modification of the original
> order, rather than a completely new order.
>
> This would seem to accord exactly with Heather’s suggestion above i.e.
> simply modify the original order in the original committed
> composition, updating the version.
>
> I am not totally comfortable with this approach, since it feels to me
> as if we are asserting that the original order was incorrect. This
> would obviously be ok if we were indeed correcting an order which had
> never been actioned but for a valid, actioned order, this does not
> feel correct, since it essentially hides the original order, albeit
> that the original instruction is still available for medico-legal
> purposes via the original committed version.
>
> I think would prefer to create a new order but link it to the
> original to ensure that the clinical requirement to maintain a chain
> of events is ensured"
>
> Any thoughts?
>
> Ian
> Dr Ian McNicoll
> office +44 (0)1536 414 994
> fax +44 (0)1536 516317
> mobile +44 (0)775 209 7859
> skype ianmcnicoll
> ian.mcnicoll@oceaninformatics.com
>
> Clinical Modelling Consultant, Ocean Informatics, UK
> Director/Clinical Knowledge Editor openEHR Foundation www.openehr.org/knowledge
> Honorary Senior Research Associate, CHIME, UCL
> SCIMP Working Group, NHS Scotland
> BCS Primary Health Care www.phcsg.org
>
> _______________________________________________
> openEHR-clinical mailing list
> openEHR-clinical@openehr.org
> http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical

|

3

Hello

I think I have asked this question before. I always wondered why ‘instructions’ were separated from ‘actions’ as I thought an ‘instruction’ was an ‘action’ too.

I really look forward to the answer to the question.

Many thanks.

Eunice

Eunice Bamgboye

4

well version updates to persistent Compositions like medications list
are not regarded as 'corrections', just updates to bring it up to date.
'Correction' is just one possible reason for a new version of something.

- thomas

5

Instruction defines what Activities should be performed. Actions record
the execution of those activities, which might not be exactly the same
as what was ordained. So Instruction = intended; Action = actual.

- thomas

6

would it be wrong to say instruction = request; action = response ?

7

Further: an Instruction might not get performed at all. But you want a
record of it anyway.

- thomas

8

When you instruct someone do to something then it is an action.


Jag

— On Sat, 10/12/11, Thomas Beale thomas.beale@oceaninformatics.com wrote:


> From: Thomas Beale thomas.beale@oceaninformatics.com
> Subject: Re: Revision of Instructions - clinical implications
> To: openehr-clinical@openehr.org
> Date: Saturday, 10 December, 2011, 16:49
>
> Instruction defines what Activities should be performed. Actions record
> the execution of those activities, which might not be exactly the same
> as what was ordained. So Instruction = intended; Action = actual.
>
> - thomas
>
> On 10/12/2011 16:00, S JAGANNATHAN wrote:
> > Isn’t ‘Instruction’ itself an action?
> >
> > Jag
>
> _______________________________________________
> openEHR-clinical mailing list
> openEHR-clinical@openehr.org
> http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical

|

9

Hi Thomas and Seref

Many thanks for your response … this was what I thought too … but then does that not mean that all that is needed to be able to capture both under actions is an attribute of ‘type’ for ‘intended’ and ‘actual’ OR ‘request’ and ‘response’ rather than separating them to remove the confusion of thinking both are not actions.

Thanks.

Eunice

Eunice Bamgboye

10

no, because the information structure of an Instruction is in future time, so specifying it requires structures / data items that correspond to that. The model we use in openEHR is by no means the best, but it illustrates: in future time you specify what might possibly happen, including with conditional branches, as workflow engines do. Actions are in past time, and are therefore simpler to represent. On the other hand, Actions being performed usually represent transitions in a state machine. See the openEHR models of these two Entry types here.

  • thomas
11

In a trivial sense that is of course true. But the interesting part of an Instruction is what is being instructed, which is where the potential complexity lies.

  • thomas
12

Following a clinical examination/consultation a clinician may instruct, advise, prescribe, recommend etc. These are all actions which may be taken by the clinician.
Intended, proposed, actual, done, not done, are all attributes of an action.

Jag


— On Sat, 10/12/11, Eunice Ab euniceab@googlemail.com wrote:


> From: Eunice Ab euniceab@googlemail.com
> Subject: Re: Revision of Instructions - clinical implications
> To: “For openEHR clinical discussions” openehr-clinical@openehr.org
> Date: Saturday, 10 December, 2011, 17:04
>
> Hi Thomas and Seref
>
> Many thanks for your response … this was what I thought too … but then does that not mean that all that is needed to be able to capture both under actions is an attribute of ‘type’ for ‘intended’ and ‘actual’ OR ‘request’ and ‘response’ rather than separating them to remove the confusion of thinking both are not actions.
>
> Thanks.
>
> Eunice
>
> Eunice Bamgboye
>
> -----Inline Attachment Follows-----
>
> _______________________________________________
> openEHR-clinical mailing list
> openEHR-clinical@openehr.org
> http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical

|

13

Well in an HL7 modelling view of the world this would be true. But
ontologically it is not, if 'action' means something that was done,
which is what it means in openEHR. All Actions in openEHR are 'actual'.
An Action may be used to record some clinical thing being 'not done' as
well, since that is also an Action (essentially a decision by the
clinician). But Actions in openEHR can't have the classifiers
'intended', 'proposed' or similar things. This is what Instruction is
for. The data structures to represent future events and past events are
different. Simply using a classifier on a generic 'Act' model doesn't work.

- thomas

> Following a clinical examination/consultation a clinician may
instruct, advise, prescribe, recommend etc. These are all actions which
may be taken by the clinician.
> Intended, proposed, actual, done, not done, are all attributes of an
action.

14

If that is the case. then there really is no need for Instruction separately as such.
The ‘what’ can be specified and the context may be obtained by applying attributes such as for a procedure- proposed, done, not done, postponed, recommended, instructed(as well!) etc. and for drugs-prescribed, taken, dispensed etc.

Jag



— On Sat, 10/12/11, Thomas Beale thomas.beale@oceaninformatics.com wrote:


> From: Thomas Beale thomas.beale@oceaninformatics.com
> Subject: Re: Revision of Instructions - clinical implications
> To: openehr-clinical@openehr.org
> Date: Saturday, 10 December, 2011, 17:15
>
> In a trivial sense that is of course true. But the interesting part of an Instruction is what is being instructed, which is where the potential complexity lies.
>
> - thomas
>
> On 10/12/2011 17:02, S JAGANNATHAN wrote:
> > When you instruct someone do to something then it is an action.
> >
> >
> > Jag
> >
>
> -----Inline Attachment Follows-----
>
> _______________________________________________
> openEHR-clinical mailing list
> openEHR-clinical@openehr.org
> http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical

|

15

http://en.wikipedia.org/wiki/God_object

16

Hi

I thought the data structures were to support the clinicians workflow view. I just wondered why you mentioned the ‘Act’ model would not work.

As Jag explained all the things he listed including instructions are all actions … and why do we have to restrict the definition of ‘an action’ to what is done rather what it is actually… Even the models in SNOMED CT supports these as all being its term for actions … ‘procedures’.

I totally agree with Jag’s suggestions for having attributes to mark these as not done, done etc.

Thanks.

Eunice

Eunice Bamgboye

17

Marking Actions as something 'done', 'not done', etc is normal of
course. In openEHR, such actions can be matched up with states in the
abstract state machine, so that you can query afterward on what is
active, suspended, completed etc. But things like 'intended' are not
meaningful possibilities for acts already performed. You may not like
the name 'Instruction' in openEHR (we had to pick something), but it
distinguishes between what has not yet been done and what has already
been done - i.e. between future time and past time. That's a key
distinction. Most workflow engines work this way, because the structure
of something in the future can contain possible paths, whereas what was
already done doesn't, it is just a series of events that actually
occurred - there is no branching or conditionality.

- thomas

18

Those are not the semantics used in openEHR: http://www.openehr.org/releases/1.0.2/architecture/rm/ehr_im.pdf

In the openEHR RM the ACTION is the record of something done: a procedure, a study, etc. An INSTRUCTION is the record of the order of that procedure or study.

19
Not an expert on' openEHR semantics' But in simple terms it is still a matter of something + an attribute( in this case the tense) ie Procedure+ordered/instructed + done, + not done + proposed + postponed + suggested etc

I wasn’t trying to change any open ehr rules, but was just looking at it from a straightforward, logical and simplistic view to try and avoid ambiguity, confusion and duplication.

Cheers

Jag

Dr. S Jagannathan

20

But we are talking about the openEHR model, so we should consider the semantics of the terms we use based on those semantics instead of redefine them on every discussion. That’s what a standard is for: defining a common language so we have no misunderstandings for differences on interpretation (= avoid ambigüity).

The states you mention are modeled by the openEHR model already. There are 3 different concepts: the initial instruction, the actions made for that instruction, and the current execution state for that instruction, determined by the actions taken. The record of those 3 different elements should be done separately, because you want to have the execution history of the instruction, not only the current state. The execution history is recorded in the actions taken. This is needed for audit trail, for medico-legal reasons, and to detect problems on the care process.

I think storing all the information in one class doesn’t solve the problem and leaves out the historical information.