Greetings: I am new to this discussion but had a couple of thoughts. I am just in the final stages (actually finished) modeling some data for oncology patients.
I would like to suggest that an "episode" be centered around a single patient illness, and not dependent on whether that patient was in or out of the hospital. This is speaking from a clinician's viewpoint which involves a continuum of care, hospitalization being one event. In regards to the Mayo model, my suggestion would be that the "episode" for the patient mentioned be the injury, the MI a second "episode" etc. The physicians associated with that patient's care are linked via connecting tables, and the lead physician designated in the linking table if that is desirable. That episode has many events associated with it, including hospital admission, discharge, tests, procedures. All of those things are housed in other linked tables. In regards to the GI ulcer and MI patient mentioned below, my suggestion would be two episodes, one of which was closed (ulcer question). Physicians need something slightly different than institutions because our focus is on responding to the disease episode, in or out of the hospital, so none of this may apply. Just thought I'd jump in a little. Regards, Sally M. Knox, MD, FACS Baylor Univ Medical Center Dallas, Tx -----Original Message----- From: Christopher Clay [mailto:[email protected]] Sent: Monday, November 22, 2004 9:45 AM To: Thomas Beale; Openehr-Technical Subject: Re: Episodes in openEHR Hi Tomas "Separation" in our system means departure from hospital and does not imply anything specific about follow up. A majority are followed up but if you have fully recovered from a simple illness, you may be discharged to the care of your GP or even to formal no follow up at all. In our set-up, the team leader is the clinician under whom the patient is "admitted" at the time and will change if the patient is transferred to another unit. We don't really speak of "team leaders". The usual question is "Who is this patient under?" One important exception is ICU. To be admitted, a patient must be "under" another non ICU team as well as the ICU team involved. Thus all ICU patients are under two teams. The rational is that the ICU can discharge anyone to the ordinary wards at will without having to "find a team" if they need to free up a bed urgently. The outside team has to take the patient whether they like it or not and the ICU is never left "holding the baby". If a patient is admitted direct to ICU in an emergency and no one else will take responsibility for them, the general medical team of the day (of admission) is the default outside unit and then have to try to "slough" the patient to a sub specialist or other appropriate team, or take the patient on discharge. Cheers CDC, Perth ----- Original Message ----- From: "Thomas Beale" <[email protected]> To: "Openehr-Technical" <openehr-technical at openehr.org> Sent: Monday, November 22, 2004 9:42 AM Subject: Re: Episodes in openEHR > Christopher Clay wrote: > > >I propose the following definition: "An episode is a period of management of > >a patient from the time of presentation to a medical unit (which can be > >anything from the teams or "firms" in a teaching hospital to an individual > >practitioner) until the unit or a proxy "discharges" the patient." The > >proxy could be a unit (on the last unit) to which the patient is transferred > >during the course of the episode. (An example could be general surgery => > >cardiology => cardiac surgery => rehabilitation: all one episode.) > >I would be against using definitions based on legal responsibilities as that > >is truly nebulous, especially in common law jurisdictions and is ultimately > >at the whim of some judge. > > > > > Actually, I agree with that, but we still need to be precise enough for > the definition to work. As you say... > > >... This is where the word "discharge" needs > >definition. It is an active, transitive verb and that is why the intention > >of the unit/doctor concerned should be the paramount consideration. It > >their intention to relinquish direct responsibility that is crucial. > > > i.e. responsibility for providing any further care (until some later > moment perhaps when you again accept responsibility for care) > > > It is > >comparable to death in our jurisdiction. You are dead when a doctor says > >you are! (i.e. declares "life extinct", or in the case of "brain dead", two > >doctors after due deliberation but that is a special case.) > >Our hospital systems speak of a "separation" which befits a hospital as > >discharge is a form of separation. It might be more difficult in GP. I > >think an episode has to be considered separate from say just "discharge from > >hospital" which is better termed a "separation" or similar. An episode can > >involve a period of inpatient and outpatient treatment. > > > > > So a "separation" doesn't involve follow-up outpatient treatment/monitoring? > > >The question of transfer between units is difficult. If a person is admitted > >under the abdominal surgeons with a stomach ulcer and is subsequently > >transferred to the cardiologists when it is established 24 hours later that > >it is a myocardial infarct, is that one or two episodes? Most people would > >consider it to be one episode in natural terms but there could be a rule > >requiring that this is two separate "incidents" for the purposes of > >remuneration for example. It would be up to the two units as to whether > >this would be called one or two episodes and could be handled semantically > >by allowing that an episode can involve semantically "seamless" transfer > >from one unit to another until a unit declares "DISCHARGE" and then the > >episode is done. > > > > > If we followed the Mayo model (and your definition, depending on which > granularity of "medical unit" is identified), it would be one episode, > but detailed EHR recording will of course provide correct > coding/classification of the incidents, allowing remneratoin to occur as > usual. > > How common is the Mayo model, where the initial clinician is the "team > leader" (as Peter Elkin explained), and shepherds the episode through > from go to woe? > > - thomas > > > - > If you have any questions about using this list, > please send a message to d.lloyd at openehr.org > - If you have any questions about using this list, please send a message to d.lloyd at openehr.org - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
