Dear All,
I would like to concur with Sam on these issues. i.e.
1. The natural language used in recording a set of EHR entries should
normally be specified at the Transaction/Composition level.
2. The EHR must be able to represent faithfully the use of a term from
a terminology system by an author, by being able to represent (either
as one or as multiple attributes)
a) the code value
b) a unique reference to the terminology system that issued the code
(ISO & CEN naming schemes have been defined over the years but not
rigorously or comprehensively adopted)
c) the version of that system used
d) the actual rubric as selected by the author (for safety, and for
transparency in a distributed environment)
3. The language of the Transaction/Composition should be deemed to have
prevailed throughout
However,
4. There is at times the need to include remarks (e.g. made by the
patient or a relative) in a different language to the main clinical
author. This might arise, for example, if the main author is a health
advocate working jointly with a patient and a clinician who do not
speak the same language. This is not entirely conjecture, as I have
worked in such clinical situations (but obviously, not with such
wonderful systems that can do what I am proposing here). As patients
begin to fill in questionnaires that form part of a consultation, a
need for mutli-lingual Compositions may arise in that scenario too.
This means that the EHR representation of narrative expressions should
permit a specification of natural language that differs from that of
the overall Transaction/Composition.
With best wishes,
Dipak
________________________________________________________
Dr Dipak Kalra
Senior Clinical Lecturer in Health Informatics
CHIME, University College London
Holborn Union Building, Highgate Hill, London N19 5LW
Direct Line: +44-20-7288-3362
Fax: +44-20-7288-3322
Web site: http://www.chime.ucl.ac.uk
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