Douglas Carnall wrote:
>... > >If I see a patient who subsequently turns out to have thyrotoxicosis, but do >not record the presence or absence of certain key clinical findings (e.g. >pulse, weight, tremor), and do not order thyroid function blood tests, then >there must be doubt if I even considered the diagnosis. > >Abstracting clinical data out of context is problematic. > this is certainly our point of view. We would say: - record what is stated measured, checked etc - do it in such a way that it works a) for patient care b) for decision support c) for other uses, in that order. - assume that physicians and other health workers are thiking people, and will in general use data to make inferences leading to care decisions; don't try to record data in a way that makes presumptions about this, or prejudices the thinking process of the clinician That said, there is still the technical challenge, at the reductionist end of the data-recording spectrum, of when to try an record data items in structured form (so they are computable) and when not to. Structured data is much better for: - computation, especially decision support - interoperability, since every communicating party can agree on the one standard for what a "Quantity" etc looks like However, many people, including myself, have strong reservations about recording very unreliable data (either partially specified or from a known/suspected unreliable source) in structured form, particularly if values are synthesized to make it fit the requirements of creation of the structured data object in question. >I know it's a windup to make this statement to this list, but we now have >enough cheap gadgets and computing power at the desktop to model a paper >record graphically. Maybe this would be a good starting point for a clinical >record that truly gave first priority to the clinicians using it. > >Would the open-ehr archetypes provide the building blocks for a designer who >wanted to take this approach? > first thing to say is that CEN/GEHR/openEHR approaches do not predispose (we hope) the visual appearance of EHRs in applications to any particular model; there is no reason why the clinician's view of the record on the screen should not look like the paper record they are used to. Once you start looking at forms for recording information in the paper record, it is clear that these forms often represent a) a long-term refinement of important data items for the purpose, and b) a long-term refinement of the arrangement of the questions and way of recording answers. So in many cases, forms will be a starting point for archetypes. But I should stress that archetypes (as we have defined them in GEHR/openEHR) are constraint models of data, not models for forms as such. Now consider a form like the diabetic interview form in our current project. The first time interview form has boxes for information that clinicians recognise as being in various well-known categories, such as lifestyle (the smoking, diet and exercise questions), family history (diabetes in the family), current medications, and so on. We envisage archetypes primarily for structuring data in the record, so there will be archetypes for each of these well-known categories of information. This means that if a different clinician uses an unrelated form for the patient, which also asks for (probably different) data to do with lifestyle, family history and so on, what we want are archetypes for lifestyle, fam hist etc, which cover the data being asked for in each place. Over time, the design of such archetypes crystallises, and specialisations may be created for certain kinds of patients. Where does this leave forms? One of the reasons I / DSTC have proposed a more formal concept of "contributions" is so that data gathered on a form, whcih might well be committed to different parts of the EHR according to various thematic (data-oriented rather than scren-oriented) archetypes, can be re-assembled easily into the original form. Secondly, there are various people thinking about "visual archetypes" and stylesheets for archetypes, and I have seen a system in Europe which I think could be integrated with the GEHR archetypes to build screen forms whose elements and element groups are based on archetypes, but where the overall design of the screen form resembles something the clinicians are used to seeing. It is early days yet.... - thomas beale - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
