A lot of our clinical data is in narrative reports form. Let’s say for EVALUATION.clinical_synopsis.synopsis there’s a DV_TEXT that contains a paragraph of text where some words in an individual sentence could be mapped to e.g. SNOMED.
e.g. :The patient has shown signs of dysuria(http://snomedct.info/id/ 49650001>) warranting a urinary sediment to exclude a UTI (http://snomedct.info/id/68566005>). "
Currently it’s only possible to map the entire DV_TEXT to a code system like SNOMED. The deprecated DV_PARAGRAPH offered the option to ‘concat’ multiple DV_TEXTs so that you could have separate DV_TEXTs like (syntax probably incorrect) :
- DV_TEXT.value = “The patient has shown signs of”
- DV_TEXT.value = “dysuria”
- DV_TEXT.value = “warranting a urinary sediment to exclude a”
- DV_TEXT.value = “UTI”
The use would be to offer the user possibly relevant similar reports or information from the EHR using SNOMED to find synonyms. Not to query based on definitive data e.g. “has UTI”
I understood DV_PARAGRAPH was deprecated in favour of markdown. But markdown doesn’t support term mappings. So what is the current advice how to achieve this. And do other implementors share this problem?
I know the proper openEHR way would be to to do fully structured data where the
entry is the smallest unit of information. So the dysuria should be a CLUSTER.symptom_sign and the UTI possibly a EVALUATION.differential_diagnoses. But I’m struggling to imagine a user interface that facilitates recording all narrative information in such a strictly structured way, without driving clinicians crazy.
(The EVALUATION.clinical_synopsis states recording (semi) structured data as misuse btw. So unless you know what your doing, don’t just implement what I described above.)