We have to be careful to develop the nomenclature that meets our needs.
An instruction can lead to actions and other things. So an instruction to do a Diabetic review may lead to a number of observations and even evaluations – but it will be the Action saying that this thing (the diabetic review) has been done that will relate to the instruction directly (workflow may link the other observations as well).
Referral is a good example of a work flow that does not really relate to the ‘actions’ one might expect. So a lab order will stay active while the sample is taken, analysed, reported, communicated, reviewed and actioned. The ‘action’ in the usual sense is the laboratory report which is a separate document.
It will take some time before these workflows are commonly dealt with as a transparent process.
Again, the nomenclature is important – as is the separation to some extent of clinical and technical. The information construct that arose from clinical requirements is that we need a way to say that something has to be done. This should have, in the future, a machine readable statement as to when.
From this point of view, anything that is to be carried out in the future is an instruction. This could be to advise, prescribe, recommend etc.
Prescibe is an excellent word to consider – is this the ‘order in the medication list’ or is it the actual order that is communicated to the pharmacy. In openEHR archetypes at the moment it is the later. It is a copy of the standing order (INSTRUCTION) that is transmitted to the pharmacy and an ACTION of prescribe is recorded in the record. This is not a trivial distinction.
This assumes that the information about the thing that is proposed is the same as the thing that is done. That was our starting point and we did reuse structures in models for a time. Then we started to see that there are quite a few differences.
What would you call a standing order for a PAP test every two years when the woman has already had two?
What is the re-issuing of a prescription?
Also, do you have write access to the information that you are acting on?
I think you will see that your proposal falls on difficulties quite quickly in a distributed eHealth environment.
This is indeed a very interesting question. I am inclined to think revision based approach seems to be more intuitive here if the update is not due to an obvious dosing error.
If revision means changing and losing the original data (the 200 value
is lost forever) then I think we shouldn't do that. As a bad
prescribed medication can harm the patient I think we need always to
be able to track the source of the problem. If revision is supposed to
store original and revised one then no problem with that
As Thomas said, the versioning of Instructions happens anyways, on the
technical implementation level. So I guess what Ian is after is more
on the clinical level - which way is more intuitive to the clinicians.
I know cases where the dose changes are anticipated, e.g. based on lab
tests, temperature etc depending on how the patient responses to the
treatment. In these cases, it seems natural to keep the original
workflow and just update the medication dose.
There is no logical difference no matter what the change. What you want to do is link an update with the previous instruction. I would suggest that this will be done by workflow or by links.
The issue is that that the 'current version' of the EHR should reflect
what is currently believed to be true and 'safe' about the patient's
record without having to trawl through previous versions.
So If I query for all medication orders, I should get back the
original order, as well as the revised order, since both were accurate
and 'true'.
If the revised order is recorded by amending the original order entry,
rather than by creating a new 'linked' order, a query will only get
back the revision, unless I specifically request older versions to be
included. If I do the latter, I will also retrieve incorrect or
erroneous orders which have been correctly amended or deleted.
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
Hi Ian
Well, the workflow link may do this but the link from an action to an
instruction is actually to the version (EHR_URI) - as this is the sensible
option.
Cheers, Sam
The precise ‘choreography’ of these things like versions, updates, error corrections, etc. can not be solved in a standard.
The standard must be so flexible that it can document whatever choices are made by the implementation.
Then it is a deployment issue for implementers to solve.
This is really a link between INSTRUCTIONS, asserting some sort of
clinical continuity, almost at a visual level i.e show me these orders
as a single entity, rather than as 2 separate lines. I am not sure it
is usefully computable beyond that.
Was 'Superceded' ever considered as one of the Action states, though I
am not sure this would be the right way to go.
I have also had an interesting conversation off-list about the
situation where a pharmacist corrects or amends the original order, in
a hospital setting i.e. the order itself, not the dispense or
administration.
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
I agree, but openEHR is not just about standards, it is about
implementation and we need to be able to think through the
implications of particular approaches, where different options are
available. The issues being discussed are directly related to the
openEHR specifications and not particular to the Ocean engine.
For those of us who are implementers it helps to establish some
ground-rules/ shared experience about how to achieve this in practice.
In a sense, we are also possibly slowly developing some standard
'norms' and good practice of clinical system behaviour, so that
cross-system querying becomes a reality.
It also opens up a wider discussion about a tricky clinical
informatics issue, which is common to all applications, dealing with
medications orders. One of the attractions of openEHR is that it
perhaps lets us establish some best practice in this area, independent
of any specific applicaiton.
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
Perhaps this explanation is too simplistic and naive!
The ‘thing’ remains the same ie PAP smear, there is no assumption about the ‘thing’.
Only the qualification of it is whether the ‘thing’ was done or whether it is proposed to be done.
Other qualifications can be applied to the same ‘thing’ such as not done, postponed,
cancelled etc.
The thing is a PAP smear:
Thing: PAP smear
Attribute: Done:
Time related Info, Time point Date and time: 1
Date and time 2
Thing: PAP smear.
Attribute: Scheduled
Time related info: frequency Two yearly 0r
Time related info: Date and time
A reissue of a prescription (thing) is still a prescription with a different date ie date of issue or a future date.
Reissue and repeat prescriptions are just descriptions of a prescription.
It is a little simplistic, since it is quite common for the recording requirements of the activity to differ significantly from that of the original order. e.g. The performer may need to record variance from the original order (drug given at a different dose/time), complications, related findings, device/materials used (which may not be specified in the original instruction).
In the example of medication there are a whole host of other things that need to be recorded around meds administration (batch number, expiry date, site) that are not specified in the original order, and similarly for dispensing.
Of course, there is considerable overlap (which we capture by using shareable cluster archetypes) but ultimately the recording requirements of an instruction may differ markedly from that of an Action.
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
Thanks for the reply Ian.
I based the explanation on the sample that Sam posed.
It is still possible to record all the other information that you have mentioned in a similar manner. The contents (things) in your original order do not change, Only additional information on the contents and perhaps some additional contents may be required.
I don’t want to divert your attention from the hard work being done by you all. May be we’ll call an end to this discussion as this can go on till the cows come home.
Regards
Jag
Dr. S Jagannathan
198 St Johns Road
Edinburgh
EH12 8SQ